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THE CARNEGIE FOUNDATION
FOR THE ADVANCEMENT OP TEACHING
MEDICAL EDUCATION
IN EUROPE
BULLETIN NUMBER SIX
1912
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MEDICAL EDUCATION
IN EUROPE
A REPORT TO
THE CARNEGIE FOUNDATION
FOR THE ADVANCEMENT OF TEACHING
BY
ABRAHAM FLEXNER
WITH AN INTRODUCTION BY
HENRY S. PRITCHETT
PRESIDENT OF THE FOUNDATION
LIBRARY
JUL 3 1 1279
T ...-.;;0 INSTITUTE
FOi< :,VuDI;^ EDUCATION
BULLETIN NUMBER SIX
576 FIFTH AVENUE
NEW YORK CITY
1912
D. B. UPDIKE, THE MEURYMOUKT PRESS, BOSTON'
TABLE OF CONTENTS
PAGE
Introduction »,,,.,...,,. v
CHAPTER
I, Historical 3
II. The Number and Distribution of Physicians . , . , . 16
III. The Basis of Medical Education ...... 32
IV. The Preliminary Sciences: Physics, Chemistry, and Biology , , 59
V. The Medical Sciences: Germany ....... 73
VI. The Medical Sciences: Great Britain and France . . . .113
VII. Clinical Instruction: Germany ..,..,, 145
VIII. Clinical Instruction : Great Britain ...... 188
IX. Clinical Instruction: France 220
X. Curriculum and Examinations: Germany ..... 233
XI. Curriculum and Examinations: Great Britain and France . . 266
XII. The Financial Aspects of Medical Education 287
XIII. Sects and Quacks 308
XIV. Postgraduate Education .317
XV. Medical Education of Women 323
Appendix 327
Index * . 347
INTRODUCTION
In June, 1910, the Carnegie Foundation for the Advancement of Teaching published
a report on medical education in the United States and Canada.^ This report not only
dealt with the conditions of the medical schools in the United States and Canada, but
also attempted an analysis of the problem of medical education. The publication of
that report met with immediate response not only from the teachers of medicine in
America, but from the medical profession itself, and there was a prompt suggestion
that the Foundation continue the work thus begun by a study of medical education
in leading European nations. The present report on medical education in the German
Empire, Austria, France, England, and Scotland is therefore the outcome of the first
report on medical education in the United States and Canada, and is to a very large
extent a necessary supplement to it. It has been carried out under the direction of
the Foundation by Mr. Abraham Flexner, who made the previous report.
Its plan follows essentially the general plan adopted in the former bulletin. First,
there is given an historical statement, which attempts in brief compass to describe the
background upon which modern medical education in Europe is to be studied, and
the point of departure from which the present undertaking is begun. Like its prede-
cessor, this report concerns itself thereupon with the basis of medical education and
the relation of education in medicine to the general system of schools. It considers
next the laboratory branches, and following these in succession the clinical studies and
the hospital as related to the problem of practical clinical training. Adhering also
to the course previously pursued, the author has taken up later the financial aspects
of medical education, medical sects, postgraduate education, and the medical train-
ing of women. Throughout, the influence of university status on medical education is
contrasted with the influence of proprietary conditions.
There is, however, to be noted this marked difference. The bulletin dealing with
medical education in the United States and Canada was intended, among other things,
for the specific use of the medical schools in these countries. It aimed to descril^e and
to discuss in detail the conditions prevailing in each of the one hundred and fifty-
five medical schools then existing in the United States and Canada. The present re-
port is intended to give not a detailed account of the separate schools existing in Ger-
many, France, and England, but rather a picture of contemporary medical education
in these countries. The study, therefore, is based upon an examination of representa-
tive medical schools and institutions in each country, not upon the examination of
every medical establishment. For this reason, no attempt is made to include a sepa-
rate inventory of every school in the several countries discussed.
In carrvingout so extended a piece of work, the cooperation of those engagedinmed-
ical education was indispensable. The Foundation desires to express in the most hearty
1 Copies of Bulletin No. 4, entitled Medical Education in the United States and Canada, will be sent
on request.
vi INTRODUCTION
way its appreciation of the cordial assistance that hjis been everywhere given by those
who are connected with medical schools and institutes. Everywhere Mr. Flexner was
met with the most generous offers of help, and not only was there every opportunity
given to learn the strong points and the l)est facilities of each institution, but there
was also every disposition to discuss in the frankest wav the defects of the situation
as well. For this ready cooperation on the part of medical teachers, medical practi-
tioners, and educational officials the sincere thanks of the Foundation are tendered.
One word further needs to be said concerning the point of view from which this
bulletin has been prepared. It has already been explained that it does not undertake
to give a detailed view of all schools or of any one school in these countries, but rather
to portray the essential features of medical education and to set forth a contem-
porary picture of the status of medical education in each of these nations. Such
an effort cannot limit itself to mere description, but to be suggestive must also be
critical and constructive. To describe the methods and the organization of the schools
of these countries without attempting to draw forth such conclusions as the facts
themselves seem to suggest would be both short-sighted and unfruitful. The present
report,' therefore, not only attempts to picture the status of medical education in
several foreign countries, but also aims to draw attention to the strong and to the
weak points in existing organizations and in present methcxls of instruction. This
involves, of course, in some cases a critical attitude. Wherever criticism has been
made, the effort is to present it, not for the sake of criticism, but in order to obtain
a complete conception of the situation that may be useful to those who are in any
country endeavoring to realize for medical education the achievements of medical
science.
It may be added also that while the primary object of this study is the benefit of
medical education in America, it was, nevertheless, impossible to treat matters of
universal interest from a local and national standpoint. That which makes for the
highest interest of medical science and for the true advancement of humanity through
this science is common to the whole world. WTiile the work was undertaken in the
desire to improve the conditions that now exist in the United States and in Canada, it
has been written from the standpoint of the advancement of medical science through-
out the world. As the detailed chapters will show, there is to be found in the teach-
ing and in the practice of the older European countries much that these newer trans-
atlantic nations may study to their advantage, and perhaps even imitate. It is equally
clear from such a careful examination as ha.s here been made that newer countries may
profit by the mistakes that have been made, or by unexpected developments that
have occurred, in the experience of older nations. To-day, in medicine, as in all other
larger human interests, the world is in reality one, and it is a backward and narrow
national view which fails to take to heart both the successes and the failures of other
nations.
In a study covering so much ground as is here treated, it is impossible to set forth
INTRODUCTION vii
in an introductory statement the important data which are brought forward. To at-
tempt to do so is to omit many of the most significant scientific and pedagogic con-
siderations that are adduced. For most of the questions discussed are not to be resolved
upon simple lines. Many factors enter, and to obtain an intelligent picture, those who
are directly concerned either with medical education or with medical practice must
read the chapters in detail. The report contains also information and conclusions
which are of great interest not only to the medical teacher and medical practitioner,
but also to the intelligent layman. I venture to call attention to certain matters that
are of special interest as viewed from the standpoint of teaching and from the stand-
point of social development itself; in so doing, I shall treat the report as an educa-
tional document.
First of all, the teacher who examines the two reports upon American and Euro-
pean conditions will realize that medical education is an educational rather than a pro-
fessional problem. It is for this reason that the report has been prepared under the
direction of a teaching organization by a man who is primarily interested in educa-
tion rather than by one who is engaged in the practice of medicine. This distinction
is an important one, for professional education, particularly in America, has suffered
from the notion that to train a man for his profession, one must have the viewpoint
of the practitioner only, and not the viewpoint of the teacher as well. The education
of a physician is primarily an educational, not a medical question, just as the train-
ing of an engineer is primarily an educational question, not an engineering question.
This does not mean that the physician and the engineer must not recognize finallv
the point of view of medical practice and of engineering practice respectively, but it
does mean that though the content be in one case medical, in the other technical, the
methods employed in training physician and engineer involve educational procedures
and educational skill. Each of these professions calls for a high order of reasoning, and
for training in the observation of fact and in the proper marshaling of facts in order
to reach a correct result; each finally involves the acquisition of a high order of skill.
All this is education. No matter how unsuccessfully it may have been achieved in this
school or in that, however deficient the educational processes to-day employed may
be, it nevertheless remains true that improvement can come only from clear educa-
tional reasoning, and from a clear educational conception of the capabilities that are
needed and the methods by which these qualities may be developed in the student.
Whether medical education is dealt with by the layman, by the medical teacher, or
by the practising physician, it still remains true that it is at bottom an educational,
not a medical, matter.
Considering, therefore, the medical schools in the countries under discussion from
this point of view, the most striking fact that emerges from this study is the abso-
hite dependence of professional teaching in medicine upon the general educational
system of the country itself. If one admits that professional education is primarily
a question of education, this result must necessarily follow; but that admission has
viii INTRODUCTION
not generally been made. One nation after another has undertaken to erect its pro-
fessional schools upon the frailest foundations of general education. It is not too much
to say that in every such instance the result has been a failure. This does not mean
that such a system may not bring forth from time to time great practitioners. It
happens in the United States and Canada now and again that a brilliant practitioner
emerges from a most inefficient and even disreputable medical school. The genius
will work out his salvation under almost any conditions, but a svstem of education
is to be judged not by its occasional brilliant successes, but by the general level of
performance of those whom it undertakes to train. No one who faces the evidence
brought together in these two reports can doubt the conclusion that in those coun-
tries in which the elementary and secondary school system is weak, the general level
of professional education is low. Under such conditions brilliant practitioners of one
profession or another occasionally arise, — they will arise under any system; but the
average of training will be low, and the professions will be overcrowded with a large
proportion of ill-prepared men, who drag down ideals and gain their livelihood at the
public expense. Of the soundness of this conclusion there can be no more striking
example than is furnished by a comparison between Germany on the one hand and
the United States and England on the other. For the general high level of Gernian
professional training the German secondary school is mainly responsible. A sound and
well-conceived svstem of elementarv and secondary schools is a necessary precondition
to good professional training; one may go even further and affirm unreservedly that
any nation that undertakes to prepare men for the professions upon any other basis
will, in the long run, impose upon its citizens great and unnecessary hardships.
A comparison of the conditions in the counti'ies here studied throws light upon the
precise kind of secondary education which should be provided for intending physicians.
The medical curriculum, extended as it is in Europe over five years, has reached the
limits of its capacity: it can contain no more. Exactly the same process has gone on in
medicine as has taken place in the training of engineers. In fact, experience in these two
kinds of technical education during the last fifty years has been strikingly similar.
Most naturally, the medical school and the engineering school have endeavored to
include in their teaching some knowledge of the new sciences developed in the last
half century and of their application. As a result, the burden devolved upon students
of medicine and of engineering has grown enormously. Their respective curricula
have been fonned almost altogether by accretion, something more being constantly
put in, little or nothing taken out. As a result, both the medical student and the
engineering student are called upon to carry not only a heavier load, but a load made
up of more parts. Each now flies from one task to another at such a pace that little
time is left for thorough preparation or for serious consideration. Consequently, there
is a growing disposition to neglect the great underlying fundamental studies. Twenty-
five years ago, the medical student could even include in his curriculum a certain
number of literar>' studies. These have been omitted, to be sure, but he is still ex-
INTRODUCTION ix
pected in most schools to find time for elementary chemistry, elementary physics,
and elementary biology. It is clear that educationally we have come almost to an
impasse, that the load not only cannot be increased, but that for the sake of good
teaching it must be lightened and simplified. The medical student and the engineer-
ing student must each have a timely opportunity to ground himself in fundamental
studies, and to learn how to think, how to observe, how to apply. Everv pedagogical
consideration, therefore, points to the conclusion that the elementary underlying
sciences must be learned by the student of medicine and of engineering before he
enrolls himself in the professional school. A youth of twenty, — in America of twenty-
two, — who has spent fourteen years or more in preparation, ought surely to find the
time for chemistry, physics, and biology in so long a preparatory period.
A wide variation of attitude toward this question in the countries under considera-
tion is clearly set forth in the report. Strong as is the system of secondary schools in
Germany, — and the even development of German medical education is mainly due to
this, — it still remains true that the German boy may enter the medical school, if he
so desires, almost entirely without knowledge of the fundamental sciences and with
the expectation of gaining that knowledge in the medical school itself. How unsatis-
factory this is from the point of view of sound teaching has already been alluded to.
The practical disadvantages entailed are set forth fully in the chapter dealing with
this topic.
This question is warmly discussed in the United States to-day. Should the boy
who undertakes the study of medicine be expected before entering the medical school
to have obtained an elementary knowledge of chemistry, physics, and biology .'* \'ery
interesting statements have recently appeared in American educational journals,
calling attention to the fact that students who lack this preparation appear to have
made quite as good showing in certain medical schools as those who have it. ^^'ith-
out going too far into an analysis of the facts that are advanced in support of this
contention, it needs to be said that even were this true, it is beside the mark. It still
remains certain that the vouth who has not pursued these fundamental sciences does
in the medical school an entirely different thing from the one who has l)een properly
trained in them. Teachers of medicine readily admit that for students who have really
mastered their elementary physics and chemistry and biology, medical education be-
comes a wholly different thing from what it is for those who have not gained that foun-
dation, not only because the man so trained can begin at a different point, but also
because he is familiar with scientific concepts, scientific nomenclature, and scientific
methods of reasoning.
Even if we may assume that students enter the study of medicine properly trained
in the fundamental sciences, the problem of the curriculum is a serious one. The
report shows a general tendency toward overburdening. The question naturally arises.
What ought the course of study of a technical or professional school to accomplish?
The medical school cannot turn out finished doctors; it cannot teach all that it is
X INTRODUCTION
important for the practitioner to know. Under these circumstances, it does best to
accept frankly certain limitations, and so to train its students that they will be dis-
posed subsequently to remedy their own deficiencies. Inclination of this kind appears
most likely to result from a training that prescribes only the indispensable minimum,
requiring in addition more thorough performance in a few directions and leaving
opportunity for still further effort to those of greater energy, interest, or ability. The
attitude of the German university on this point is thoroughly to be commended.
Every medical faculty in Germany offers more in every department than the under-
graduate student can achieve ; every student is encouraged to exert himself beyond
the average or the minimum in some direction or other. It is therefore not surprising
that active progress beyond the point to which his education brought him is generally
characteristic of the German physician.
Those concerned for the development of right educational methods will read
with interest the discussion of the function of the clinical teacher. It has come to
be generally conceded that not only must the basic sciences of chemistry, physics,
and biology be taught by those who are primarily teachers and who give their whole
time to teaching and to research, but also that the more definitely medical sciences
of anatomy, physiology, pathology, and bacteriology must be represented by spe-
cialists. It has not been so generally granted that the clinical teacher must also be
primarily a man who devotes his life to teaching and to research. This reform is the
next great step to be taken in the improvement of medical education in the United
States and Great Britain. In Germany only has it heretofore found recognition, and
to this fact, next to the development of an orderly and efficient system of secondary
schools, is to be attributed the high level of German medical science and medical
teaching. With the more general acceptation of the view that medical education is
education^ not a professional incident, the conception of the clinical teacher must
undergo the change here alluded to. The teaching of clinical medicine and surgery
will then cease to be a side issue in the life of a busy practitioner; it will propose to
itself the same objects and conform to the same standards and ideals as the teaching
of any other subject of equal importance.
The account and discussion of the professional examinations furnish one of the
most suggestive chapters in the bulletin. While the examination cannot alone be
relied on to force a high teaching level, it is undoubtedly capable of proving a most
potent weapon in forbidding incompetent institutions. The contrast between the Ger-
man and English methods is most significant. It is clear that the German examina-
tion is not appreciably responsible for the best features of German medical educa-
tion; they must rather be attributed to the high and uniform entrance basis and
to the vigor of university ideals. For the American teacher and the American official
charged by the state with the admission of candidates to medicine, the careful and
practical form of examination carried out in England is of especial importance.
English experience clearly shows that such examinations can be administered on
INTRODUCTION xi
a large scale, that they are fair to the candidate, and that, if so administered, thev
■wall exclude the manifestly unfit and unprepared. The institution in America of state
examinations modeled on those of the London Conjoint Board would at once put an
end to schools incapable of giving their students practical laboratory and clinical
training.
This report, therefore, when studied by the student of education, carries at least
four significant suggestions which bear upon training for professional life : first, the
dependence of such training on preliminary education and the necessity for a close
relation between the secondaiy and the professional school; secondly, the part which
right lines of study in the secondary school may play in determining the quality of
the work which the student in the professional school is able to perform; thirdly,
the advantage which the average student derives from a logical arrangement of sub-
jects, provided fair scope for elasticity and election is still preserved; and finally, the
wholesome effect of an examination system at the close of the professional study
which shall at one and the same time test theoretical knowledge, ability to think,
and technical skill.
Turning aside from the consideration of the explicitly educational aspects of the
report, I now venture to call attention to certain lessons which it carries for those
dealing \nth medical education in its humanitarian and social relations. Not only is
the whole civilized world to-day bound together in the discussion of all questions of
scientific, educational, and social progress, but also the people of a given nation are
bound together by their common interest in such questions. Education in any nation
is one thing, not a series of separate and unrelated things. Under modern social con-
ditions a nation will, therefore, inevitably lack not only industrial power, but also
social contentment and efficiency, if it fails to conceive its various educational diffi-
culties as fundamentally a single problem to be worked out by institutions related in
the most vital way to one another, and representing together a national conception
of progress and betterment.
For this reason professional education is of vital interest not only to those in the
professions, but to the average citizen. In particular is this true of medicine. Perhaps
no other professional man, not even the priest, is allowed to enter so intimately into
individual and family life as the modern physician. Every person, whether he be rich
or poor, is concerned that the profession of medicine shall be placed upon the best
possible plane, that the men who enter it shall be chosen under good conditions, and
that the unfit and the unworthy shall be excluded from it.
While the average intelligent man appreciates this fact in a dim way, as a prac-
tical rule of conduct he entirely ignores it. He chooses his physician with ver\' little
more care than he chooses his coachman. It seldom occurs to him to inquire what
was his previous training and what have been his opportunities. He does not concern
himself with the question as to whether he is an educated man. He takes his physi-
cian on the recommendation of a friend, or on the basis of accidental acquaintance,
xii INTRODUCTION
and the notion that he should inquire in advance as to the fitness of the physician
and as to the quality of his training rarely enters his mind. Moreover, the ordinary
citizen fails to appreciate his individual responsibility for the betterment of the pro-
fession itself. The future improvement of the profession in such countries as the
United States depends to a large extent upon the awakening of the mass of citizens
to the importance of their own attitude toward this great profession ; for while the
progress of medical science will continue to depend primarily on those who are con-
nected with the profession, the elevation of the level of medical practice depends in
verv large measure upon the intelligence of the average citizen with respect to pro-
fessional training, and upon his willingness to assume some responsibility in the mat-
ter. The following general considerations, suggested by the two reports that have
been issued by this Foundation, are, in my judgment, of enormous importance to all
classes of citizens. First of all, these studies have served to emphasize, particularly in
the United States and Canada, the fact that medicine is a profession, not a trade.
Not only is it a profession, but it is one of such enormous importance to society,
carrying with it such opportunities for good or ill, that modern society is compelled
to regard it as a quasi-public profession. It is not jKJSsible to allow complete free-
dom of choice to any who may choose to enter it. Society is compelled to insist that
those who enter it shall qualify themselves for its quasi-public I'esponsibilities and
opportunities.
It is precisely at the point where this situation is recognized that the responsibility
of the layman begins, for not only is he interested in choosing his own physician, but
he has also to legislate upon the conditions which shall determine how candidates are
to be admitted to the profession. At the present time, in the United States the con-
ditions under which medical practice may be entered upon vary widely. Each state
is a law unto itself, and no agreement Avill prevail until the people of the various
states have come to some general conception of their responsibilities. The obligation
to enact statutes fixing reasonable conditions upon wliich the practice of medicine
may be undertaken rests not only upon the necessity for preserving a high level in
the profession, but also upon the fact that only by effective legislation can the gen-
eral public be adequately protected from exploitation by an army of ill-trained doc-
tors, quacks, and charlatans.
From this point of view, the most startling fact that stands out for us is this :
faults of one sort or another may indeed be found with the medical sc-hools of Eng-
land, Scotland, France, Germany, and Austria. But scandals in medical education
exist in America alone. In no foreign country is a medical school to lie found whose
students do not learn anatomy in the dissecting-room and disease by the study of
sick people. It has remained for the United States to confer annually the degree of
doctor of medicine upon, and to admit to practice, hundreds who have learned ana-
tomy from quiz-compends, and whose accjuaintance with disease is derived not from
the study of the sick, but from the study of text-books. These scandalous conditions
INTRODUCTION xiii
are, it is true, less widespread to-day than they were a decade ago; yet they are still
to be found in almost all sections of the country, even in the most cultivated. The
State of Massachusetts tolerates in the city of Boston, the State of New York tolerates
in the city of New York, the State of Illinois tolerates in the city of Chicago, the State
of Missouri tolerates in St. Louis, the State of California tolerates in San Francisco,
so-called medical schools that pretend to train doctors, despite the fact that they are
almost wholly without clinical facilities. In no European country is it possible to find
an educational farce of tliis description. There, every school has adequate clinical
resources under complete control. If the lowest terms upon which a medical school
can exist abroad were applied to America, three-fourths of our existing schools would
be closed at once. And, let me add, the remaining fourth would be easily and entirely
adequate to our need. Managers of feeble medical enterprises in our country pretend
that they are making great sacrifices for the public good. This hypocritical pretense
ought not to be permitted longer to damage the public interest. No medical school
that lacks proper facilities has any other motive than the selfish advantage of those
that carry it on; and no civilized country except America at this day allows such
enterprises to impose upon the public.
Likewise a matter of legislation and public opinion, as this report shows, is quack-
ery. That quackery is not the result of a high standard of professional education
is proved by the fact that it is found in all countries whose laws permit unlicensed
practice, whatever the level at which professional education begins. That level is low
in England and high in Germany. In neither country do the laws effectively restrain
quackery; in both it exists, and in the very cities where physicians are most abun-
dant. In Germany, the quack must indeed register as a quack. He cannot designate
himself as a doctor of medicine, nor can he perform certain official duties that the
legally qualified practitioner can perform; but under the permission to ply his trade
he finds a field waiting for his reaping. Of course, no law can protect the ignorant and
the credulous from all charlatans, but a rightly framed statute can make it impos-
sible for the ignorant and illiterate impostor to carry on his gainful trade, and the
exclusion of this class means an enormous protection for the whole people. In the
United States, under the laws hitherto in existence, the quack is able to provide him-
self with the degree of doctor of medicine, sometimes by purchase, but oftener by at-
tending a nominal course at some proprietary medical school, and he has not hitherto
been compelled even to spend much time in acquiring this pseudo-degree. It remains
now for the various states of the Union to enact such laws as will in the first place
make it impossible for the medical charlatan to trade in the uncertain zone of the
laws in near-by states, and will make it impossible as well for him to decei\ e the public
by a medical degree which does not guarantee genuine training. The law needs to
go one step further and prescribe a minimum of general education, — a step which
would go further toward eliminating the professional medical charlatan than per-
haps all other requirements. For such legislation those who are seeking to advance
xiv INTRODUCTION
medical education and to render more useful the medical profession must rely upon
the intelligent layman.
One more topic must be briefly, but emphatically, touched on. The reader of this
report will note the fact that legalized medical practice in Eurojje is of one type onlv.
Every qualified physician must comply with the law; having qualified, he may call
himself what he pleases. As a matter of fact, he calls himself "Doctoi-," and rarely
anything else. There are, in a word, no medical sects in Europe: the homeopath is
almost, the osteopath and the eclectic are wholly, unknown. On the other hand, in the
United States, where the medical sectarian is admitted to practice on easier terms,
sects flourish, — though decreasingly so. The lesson is plain: sectarianism in the
United States is a device that admits to practice those unable to comply with the
sounder standards; wherever all practitioner are alike compelled to comply \nth one
standard, almost no one wants to brand himself as a sectarian. Our duty in this matter
is to set up and to maintain a single standard in res{)ect to preliminary education,
laboratory and clinical facilities, professional education and examination; and this in
the public interest solely. That done, time may be trusted to settle the fate of the
medical sects.
The layman carries also another direct responsibility to medical education arising
out of the control of hospitals which are governed, as are the colleges of the United
States, by lay boards. Probably no other men have in their hands so great an oppor-
tunity to advance medicine as have the trustees of hospitals.
Hospital trustees in the past ha\ e dealt in a somewhat cautious spirit with medi-
cal schools in the United States, and this attitude is not to be wondered at, since
these schools have in most cases been proprietary concerns, and in the absence of
effective entrance requirements the class of students enrolled in them was often not
of a character that a hospital could admit to its wards. The reorganization now
going on, however, in medical education in this country makes it possible gradually
to improve clinical training, but the hands of the univei"sities seeking this progress
are tied so long as they are required by the trustees of hospitals to utilize the ser-
vices of the hospital staff of physicians and surgeons who have been chosen without
regard to their fitness for teaching or for research. As matters now stand in the United
States, it is important that hospital trustees either do more for medical schools, or
do nothing. They should do more for such medical schools as enroll a competent
student body, provide adequate facilities and staff for instruction in the underlying
medical sciences, and are prepared to assume the expenditure involved in placing
clinical education on a sound basis. For medical schools that are upon a proprietary
basis, even though they be under the shelter of a college or university, the hospitals
should do nothing. In taking this stand, the hospital trustees would not only help
the real advancement of medicine, but they would also serve the true interest of the
hospitals themselves, for wherever the medical school is in a position to comply with
the conditions just stated, the hospital will be helped in every way by close and lib-
INTRODUCTION xv
eral affiliation. It is entirely in the interest of the sick themselves that the privileges
of instruction shall be given to a good medical school. The chapters dealing with
clinical education in Germany and Great Britain completely establish the proposi-
tion that the patients will in the long run profit by such a relationship, and this not-
withstanding the fact that the right of the patient to decline to be used for teaching
purposes should be scrupulously respected. On the other hand, wherever the medi-
cal school is unable to comply with the requirements I have mentioned, it is in no
position either to aid the hospital or to advance education. The trustees of hospi-
tals in the United States in lending the scanty privileges which they now offer to unfit
proprietary medical schools are helping to perpetuate the worst education regime in
medicine to be found in any country.
There is another point that I desire to commend to the attention of hospital
trustees. This report establishes the fact that well-trained young physicians find no
difficulty in attaching themselves to the retinue of hospital staff physicians and sur-
geons in Germany, and thus procuring for themselves the opportunity to caiTy on
active scientific work. In America, this is practically impossible. Members of the hos-
pital staff retain for themselves all the opportunities that the institution affords:
if they are too busy with practice or too indifferent to science to use the material,
clinical and other, it is wasted. We witness, then, this strange anomaly : an American
graduate in medicine can, for the asking, obtain the entree to the clinics of Berlin,
Vienna, or Munich; but in his own country, the doors of the hospital are closed in
his face ! It is not a pleasant task to disclose the reason back of this unwise policy.
To some extent, at least, it is due to the fact that hospital physicians engrossed in
practice are unwilling that their prestige should be lessened by the scientific achieve-
ments of younger men working in their wards. The laymen in control of hospitals
could easily break up this selfish and unprogressive attitude, by insisting that hospi-
tal opportunities do not exist for the professional benefit of the visiting staff.
The unwillingness of the hospital trustee in America to permit the resources of
the hospital to be used for metlical education arises partly out of the fact that he
has not yet outgrown the idea that the hospital is intended only to help the man
who happens at the moment to be ill. A hundred years ago this was the case, but
to-day all disease is approached from an entirely different standpoint. Every physi-
cian, every medical school, every hospital, must deal with disease not only with the
idea of assisting and bringing back to health the patient who is stricken, but also in
the interest of all other individuals and of the community itself. The patient must
be used, with all due regard to his owti interest, to resolve the problem of disease,
and to prevent the recurrence in the community of the illness with which he has l^een
stricken. This attitude toward medicine has not yet become common amongst hospital
trustees of the United States. They are still disposed to consider that they have done
their full duty when they have given to the patients within their wards skilful medical
attention and careful nursing. As a matter of fact, this is only the beginning of their
xvi INTRODUCTION
duties, and no hospital can serve either its own patients or its own community more
efticientlv than by opening its Aicilities in the fullest way to a rightly conducted
medical school. In order that their facilities may be thus used, the staff' of the hospital
must be chosen by the university on the ground of ability to teach and to investigate,
as well as to practise, not by the board of trustees upon other grounds. No hospital
can suffer by giving this privilege to a rightly conducted university medical school.
The prosperity of German medicine and the eminence of the German hospital are,
as the report demonstrates, due to the acceptance of this point of view and all that
it implies.
So important is this point in its bearing on the development of American medicine
that I venture to call attention to the sharp contrast between the attitude of lay-
men in control of hospitals in England in the matter of hospital management and
the attitude of similar boards in the United States. In England, the trustees of the
hospitals admit most frankly their obligation to open the wards to students. They
realize that such a relationship is advantageous to their own patients and to the cause
of medical science. Throughout the United States medical education will continue to
lag unless through general discussion public opinion can be educated to the point
where the general citizen will recognize his o\m responsibilities in the choice of a physi-
cian, in the enactment of reasonable laws for admission to practice, and his respon-
sibility as a hospital trustee both to medical science and to the community in which
he lives.
AVhile hitherto little has been said to the average man in the United States as to
his responsibility for the betterment of the medical profession, certain ideas have
become firmly rooted in his mind by reason of the arguments which are continually
put forth to procure the perpetuation of proprietary medical schools. One of those
most commonly advanced for the purpose of continuing a regime long since outgrown
is the claim that a certain numl^er of cheaply trained doctors must be furnished for
the sparsely settled districts of the country. ^Vherever the proprietary medical school
is attacked, this is the claim put forward, and so often has the story been repeated
that the idea itself has now become fixed in the minds of most laymen.
The information brought forward in these two reports dealing with medical edu-
cation on the continent of America and in European countries ought permanently
to set at rest this contention. If the contention were a true one, if it really is neces-
sary" that the resident of the country must put up with a poorly trained physician, then
something should be done by society to remedy the situation. As a matter of fact, the
statistics here brought together prove that no physician, poorly equipped or well
equipped, will go where a livelihood cannot be gained. On the other hand, the experi-
ence of Germany, which educates all its physicians at a high level, shows that the
well-educated physician will settle wherever a living is to be had.
In fact, of all men who deal with human illness, the country physician needs to
be the best trained. He is far away from the specialist; he is without the facilities of
INTRODUCTION xvii
hospitals, and hence he must deal alone with situations in which in the city he would
have the cooperation of two or three men trained in different fields. It is therefore
particularly essential that the country physician should have a broad and thorough
training. The experience of Germany proves that the distribution of physicians does
not depend upon a low standard of education, and that any country can have as many
physicians as it can employ at a high, without resorting to a low, level, if proper
secondary school facilities have been provided. In other words, a country which up-
holds reasonable standards in preliminary education, reasonable standards of pro-
fessional training, and reasonable legal conditions governing admission to the pro-
fession can secure men trained at this level for every village and neighborhood that
can give a moderate support to a practising physician. There is no need to resort to
the cheap medical school in order to obtain men willing to go to the village or to the
countryside.
It remains true, however, that under any system thinly populated country districts
will lack medical practitioners. With the problem of furnishing proper medical aid
to those living in thinly settled areas, statesmen in all countries will have to deal.
The problem cannot be solved by producing a special and cheaper brand of doctor,
for the cheaper doctor will go where he can do better, precisely as the more highlv
trained man will do. A sanitary service, subsidized by the state, will alone render effi-
cient relief in the backward districts without generally demoralizing the profession.
Those who think of resorting to medicine because of its pecuniary attractions will
be reminded by the report that on the whole the profession is not financiallv prosper-
ous. Nor is there in this any cause for disappointment. Under pressure of public opin-
ion, it is becoming each year more and more a profession to which men give them-
selves from the ideal of service, recognizing that in this calling the average practitioner
is to obtain little more than a comfortable living, and in many cases not even that.
The youth or the parent who looks toward medicine from the commercial standpoint
is in most instances sure to be disappointed. In just such proportion as higher stan-
dards of admission to the medical schools and higher requirements of admission to
practice are enforced, in just such proportion will the body of men who compose the
profession come to be actuated by the ideal of service rather than by the ideal of
gain. Under certain conditions and in certain places, individual physicians and surgeons
may receive large emoluments, but the average man seldom realizes that such suc-
cesses carry with them the necessity for enormous expenditures. The man who actually
accumulates a fortune in medicine is so rare that he may practiailly l^e neglectetl.
As the commercial medical school disappears, and the profession comes to l>e com-
posed of educated men alive to the ideal of service to their communities and to hu-
manity, the opportunitv to exploit medicine for gain will disappear. The youth who
is looking for a fortune, or the parent who seeks for his son a remunerative occupation,
should look elsewhere.
It is not possible to dismiss this matter, however, without one word more concern-
xviii INTRODUCTION
ing the attitude of the profession itself with regard to fees. In Germany, as is made
clear in the report, this is a matter of state regulation. It is also clear that in Ger-
many the payment has been reduced in many cases, by the contract system, far below
the remuneration which the competently trained physician ought to receive. The
opposite evil exists not infrequently in the United States, where a commercial aspect
is given to the entire profession because certain successful physicians exact fees wholly
out of proportion to the service rendered. The physician or surgeon who levies upon
a rich man a fee of many thousand dollars simply because he is a rich man has ex-
ploited the patient at the expense of his profession. He has done what is practically
dishonest and unfair, and the exploitation of rich men in this way has worked infinite
harm both in the ideals of young men and in the attitude of the general public toward
the practitioner. Men who have been guilty of this practice are well known. Some
of them are men of great skill and high standing, but there can be no question that
in the long run they themselves will suffer in reputation from their ill-judged and mis-
taken course of action. One result in part due to this attitude of the medical profes-
sion in the United States and in England is worth mention. In Germany, medicine
has been supported by the government, and we find there medical training, medical
laboratories, and medical facilities upon a uniformly high plane. In the United States
and in England, medicine has been in the main supported by fees, with the help of
such contributions from individuals as the medical school could obtain. In the United
States, money has been poured out upon education in the last twenty-five years by
rich men with a generosity unexampled in the world's history. Almost nothing of this
flood of wealth has gone into the coffers of the medical school, and this notwithstand-
ing the fact that no class of men interested in education have such close and intimate
opportunity to influence men of wealth as the practising physician and surgeon. The
refusal of benefactors to assist medical education is in great measure due to the fact
that medical education has been hitherto largely commercial, and that the successful
physician and surgeon levy fees which the well-to-do know to be based on their wealth,
not upon the service rendered them.
Notwithstanding all the commercialism that has been mingled with medical edu-
cation in English-speaking countries, it ought still to be said that in no profession
has there been finer devotion than on the part of the representatives of the profes-
sions of medicine and surgery, and of all the men who have shone in these professions,
those who have served their generations best were the men who gave themselves
generously and unselfishly to the cause of medical education. In both England and
America, this list carries many names of those who have given the highest service
upon the most unselfish grounds. The poverty of support hitherto given, due in large
measure to the commercial attitude of the medical profession itself, ought now to
disappear. If medicine in all countries is to be placed upon a proper basis, then the
requisite number of medical schools must receive support on a scale entirely differ-
ent from that which has hitherto obtained. Business men in both America and Eng-
INTRODUCTION xix
land think to-day in millions, where twenty-five years ago they thought in thou-
sands, and yet they expect those in charge of the medical schools to conduct them
on the scale of twenty-five years ago. There is no opportunity to-day, either in Eng-
land or America, for a wiser use of money, if judiciously expended, than in support-
ing on the right foundations the comparatively small number of medical schools
needed in each country to train men to do the work of the profession. It is greatly to
be hoped that those who have means to give may clearly realize that opportunity and
their own responsibility; that they may be not only generous in their attitude toward
medical education, but discriminating as well ; that they will give their money freely,
but in the right places. Giving to educational institutions, particularly in America,
has too often been haphazard. In medical education to-day, we know what can be done
and what ought to be done. There is no field of human endeavor in which a wise giver
can do more for civilization in the United States than in this cause. The man who has
intelligently thought out the place of the physician in our social order, who realizes
the enormous service which medicine is now rendering and is to render in the future,
not alone in the cure of disease, but in its prevention, will rise to his responsibility.
It will be a serious hindrance in the work of civilization both in the United States
and in England if there cannot be found those who will avail themselves of this great
opportunity.
In the process of reconstructing medical education, which wise benefaction could now
so readily bring about, we in America are luckily free from the most serious obstacle
that reformers abroad encounter : we have so brief a history that no very stubborn
traditions have been created. Englishman, Frenchman, or German, in the effort to
improve or adapt, has to overcome the resistance of long, and in many respects ad-
mirable, usage. Plasticity is the good fortune of youth. Let us not suffer our defects
to become hallowed by time; let us not suffer the period of ready adaptability to
roll by unutilized. There is undeniable danger that we may. \\'hen it is proposed to
discontinue a medical school in an out-of-the-way place, where clinical material is
unobtainable, tlie "age" of the institution is already alleged as sufKcient reason for
keeping it up, — just as though inadequacy does not offset all possible considerations,
sentimental or otherwise. When the merging of a weak proprietary establishment in
a large city with a more promising university department is suggested, the answer
is made that the "alumni" of twenty or thirty years' standing will resent the passing
of the school which graduated them. Conservatism due to the established usfige of
centuries has doubtless its advantages; but it has also most serious disiidvantages.
At any rate, no nation needs to grow old before its time. Our educutional institu-
tions cannot yet fairly resist change in the public interest on the score of antiquity.
Let us set our house in order before it becomes a more difficult and delicate task to do
so ; and let us remain youthful and adaptable as long as we can. Science is progressing
with amazing rapidity; every advance in medical science suggests a corresponding
educational readjustment. Medical education abroad, with all its merits, lags behind
XX INTRODLXTION
niedicAl science, because habit, tradition, and vested interest oppose easy readjust-
ment. If the resourceless proprietary medical school is eliminated in America, if the
university medical departments are financially strengthened, nothing prevents us from
keeping medical education practically abreast of medical science. We can at once learn
from the Old World what we have not yet perceived, namely, the elementary condi-
tions without which medical education should not be undertaken at all ; may we not
also hope to contribute to medical education something in advance of what Europe
has at this moment to teach us.'*
Henry S. Pritchett.
Nerv York, January 1, 1912.
MEDICAL EDUCATION IN EUROPE
CHAPTER I
HISTORICAL
Medical education has only of late deliberately set out to overtake medical practice;
up to quite recent times, whatever the defects of practice, the defects of education
were decidedly more serious. This arose in the first place from the mediaeval teach-
er's veneration for authority and contempt of things, — an attitude that persisted in
education long after it had been thoroughly discredited in experience. Hippocrates,
Galen, and Pare did not disdain to use their hands; but the mediaeval university,
which on the medical side survived far beyond the Middle Ages, confined its medical
instruction altogether to theoretical exposition, and until the nineteenth century in
the Latin language at that! Drawing a sharp line between medicine and surgery, it
regarded the latter as a menial art. As a matter of fact, from the medical standpoint,
the hand is a source of knowledge as well as an instrument of relief; and medicine,
in discriminating against manual methods, lost touch with reality. Clinical educa-
tion, therefore, remained for centuries an abstract and pedantic discipline, little af-
fected by the progress making in medical and surgical practice. The same conditions
prevailed in what we now call the fundamental sciences. Prejudice against desecrating
the human body — that of the dissector, perhaps, as well as the dissected — subsisted
long after the epoch-making discoveries of Vesalius. For some centuries, anatomical
demonstrations were in most European countries so rare as to constitute a profes-
sional, and in some places a social, event. Even so, the hands of the professor were
not defiled : a prosector dissected, and a demonstrator pointed out, while the professor
read aloud and expounded the authorities. Meanwhile, the student acquired such
anatomical knowledge as he possessed by dissecting lower animals, usually a pig.
Indeed, the teaching of anatomy by actual participation on the student's part rather
than by professorial demonstration is not much more than a century old. Physio-
logy, chemistrv, and pathology were, like anatomy, substantial sciences outside, long
before they gained the laboratory footing inside, the univei-sity. Anatomy got its
first independent teaching laboratory at Breslau in 181 -t; Purkinje's physiological
laboratory at Breslau was established in 1824; Liebig's chemical lalwratory at Gies-
sen a year later; pharmacology obtained its laboratory start at Dorpat in 1849; patho-
logy, as late as 1856, when Virchow was called from "Wiirzburg to Berlin. In all these
cases, educational recognition and adjustment were distinctly tardy. Whether even
now the several sciences play in medical education a role adequate to their function
in medical art and science is a question that will be answertxl in the course of our
present enterprise.
Fortunately, on the clinical side, the meagre training of the continental universi-
ties was readily supplemented. Under the influence of the church, hospitals were freely
established, and the young doctor, having already heard his lectures and passed his
4 MEDICAL EDUCATION
examinations, easily procui-ecl in the retinue of a master an experience equivalent to
an apprenticeship. With this practical instruction the univei-sity had at first nothing
to do. Its doctor's degree was awarded on a purely scholastic basis. Practical clinical
instruction was first recognized as an essential feature of university medical training
at Leyden: there, as early as 1630, the student was expected to examine the patient
in the presence of the professor, who thereupon criticized his findings and opinions.
The sensitiveness of the students prevented the system from taking root at that time;
but early in the eighteenth century it was revived by Boerhaave, under whom the
medical clinic of the University of Leyden became the most famous in the world.
With Boerhaave's clinic, university instruction in clinical medicine may be said to
begin. His pupils transplanted his ideas and methods into fruitful soil at Paris,
Padua, Edinburgh, and Vienna.
Paris and the Italian universities had already been important centres of such
medical instruction as had been previously current ; Edinburgh and Vienna may be
fairly regarded as slips cut from the vigorous Leyden tree. Boerhaave was fifty-one
years of age when Alexander Monro, the first of his line, became, as Struthers puts
it, his "favorite and admiring pupil." ^ His relations with Boerhaave did not terminate
when, a year later, he returned to Edinburgh to become at twenty -one the professor
of anatomy. He frequently sent patients from Scotland to consult his old teacher at
Leyden; more important still, the young Scottish clinicians of Monro's time emulated
his example by repairing thither for clinical study. The medical faculty at Edin-
burgh was thus an avowed exponent of Boerhaiive's ideas. The five teachers^ under
whom John Fothergill took his degree there in 1736 had all been pupils of the illus-
trious Dutchman.' Boerhaave's clinical method was carried to V^ienna by Yan Swie-
ten in 1753; the first university clinic there was established in the Burgerspital,
whence it was transfen'ed to the Allgemeines Krankenhaus, where, thirty yeai-s later,
Joseph II consolidated the hospital charities of the city.
In the states that now constitute the German Empire, mediaevalism maintained an
especially stubborn hold. Toward the close of the eighteenth century, it was rein-
forced by the metaphysics of Schelling, which intervened like a cloud between the
physician and the phenomena it would profit him to observe and reflect upon. The
fact is that the medical faculties of the German universities were little more than
nominal as late as the beginning of the nineteenth century. In 1805, the total num-
l)er of medical students in Prussian universities was only 144. At that day, the his-
torian of the medical faculty of Tubingen can still report that students find out-
^ Struthers: The Edinburgh Anatomical School, p. '21 (Edinburjfh, 1H67).
2 Monro, Alston, Rutherford, Sinclair, and Plumnicr. Rutherford was elected professor of medicine
in 17-2fi; he pave clinical lectures at the Royal Infirmary for the first time in 171-8. (Grant : S/ory of
the Vnire.rxilxj of Edinhnrgh, vol. i, p. .'il3.) \ set of Rutherford's lecture notes in the library of" Sir
William Osier at Oxford shows how concrete and practical IJoerhaave's method was. Clinical teach-
ing in surf,'cry at Edinburgh was inaugurated by James Rac in 17fi9.
3 Norman Moore: Medicine in the British Isles, p. 154 (Oxford, 1908).
HISTORICAL 5
right theoretical instruction less irksome than being inteiTogated in the presence
of patients,^ and he quotes an apologetic suggestion addressed to the senate of the
university to the effect that "it would certainly be useful if the young doctors, who
expect to practise obstetrics, had seen at least one birth before undertaking difficult
cases where two lives are at stake."^ More than a quarter of a century later, in 1842,
to be precise, mediaevalism was still more or less rampant at Berlin : for in that year,
Helmholtz, just graduated as a military surgeon, publicly expounded "the operation
of tumors," though he had never yet seen a tumor cut.'
The fundamental difference between mediaeval and modem medicine emerges just
here. Mediaeval medicine theorizes with or without experience. It starts with a pre-
supposition, a notion, a metaphysical principle, and purports thence to deduce its
procedure. Intellectual processes of so dignified a description appear to the vitalist
to dispense with the necessity of close observation: percussion, auscultation, and the
physical measurement of temperature are, in his opinion, crude methods, incapable
of penetrating as deeply into the mysteries of disease as his own purely reflective
processes. As opposed to this predominantly deductive procedure, modem medicine
strives to be honestly and modestly inductive, — consulting the situation for relevant
facts, and cautiously drawing provisional conclusions, subject to revision whenever
the issue of experience suggests modification.
It is not possible to fix precisely the time when the scientific viewpoint was first
clearly established in medicine: it made its way by slow stages. During the course
of the eighteenth century, medicine procured an ever sounder basis in pathological
anatomy and increased diagnostic precision through the development of the arts of
percussion and auscultation.* Such innovations are inevitably associated with a general
tendency toward facts and away from "principles,'" even though at the moment men
do not suspect their significance. Indeed, nothing is made plainer by the history of
progress than man's inveterate habit of temporarily adjusting really irreconcilable
attitudes and practices. The landmarks, therefore, do not indicate the close of one era,
the opening of another. The two eras live on together, the one gaining, the other losing.
In this sense, Skoda and Rokitansky at Vienna, Corvisart, Laennec, and Louis were
the harbingers of modern medicine, which came to completer self-consciousness in Jo-
hannes Mliller,^ and finally to total self-consciousness in Rudolf ^'irchow. Xirchow's
clean-cut conception of disease as a definite disturbance of function, originating and
developing from a specific cause and cellular site, has proved a most fertile postulate
1 Schleich : Ein Stiick aus der Oesckichte der Medicin'ischen FacuUiit der UnivtrtUdt Tubingen^ p. 33
(Tubingen, 1910).
2 Ihid., p. 35.
3 Popular Addresses (translated by E. Atkinson), p. 199 (New York, 1901).
« The clinical thermometer, though known to Boerhaave, first came into general use through Traube
about 1850.
5 Called from Bonn to Berlin as professor of physiology in 1S39, at the age of thirty-one.
6 MEDICAL EDUCATION
in stimulating investigation; it has entirely expelled speculative mist from medical
thought; abnormal phenomena, their origin, course, and outcome, have become prob-
lems amenable to the methods of observation and attack that were working out in the
underlying sciences.
In consequence, the human body is now \'iewed as an item in the universe of matter
and life, without recoui-se to essences and principles. The physics and chemistry of
organic and inorganic things are recognized to be the phvsics and chemistry of bodily
movement and action, alike in health and disease, — of sight, hearing, digestion, secre-
tion, excretion ; embryology, morphology, and physiologv are conceived as comprehen-
sive sciences including the human species along with all others. Directive control of
the body in disease demands an intelligent knowledge of its structure and functioning
in health; and the sources of this comprehensive knowledge are held to lie in the
enveloping fundamental sciences above mentioned.
The scientific viewpoint involves formulation of a method and deliberate devotion to
it. As to this, a mischievous misconception is still more or less prevalent. There are
those who oppose scientific and clinical medicine to each other, regarding laboratory
methods as scientific, clinical study at the bedside as empirical. Nothing could be
more illogical. Science is indifferent as to where or how observations are made; it is
concerned only with the vigor, precision, and consistency of observation. Wherever
observation is careful, medicine is there and to that extent scientific; when this criti-
cal attitude became characteristic of the field as a whole, the scientific point of view
became dominant. The difference between modern medicine and its predecessors is,
therefore, not a difference between our laboratory methods and their bedside methods;
that is not locricallv fundamental. Nor is the distinction due to the fact that thev never
observed rigorously, while we always do; for they sometimes did and we sometimes
do not. The difference is simply this, — that unprejudiced and critical scrutiny was
with them occasional and precarious, liable to sudden irruptions of fancy or mysticism,
while with us it is deliberate, conscious, and as consistent as our mental powers can
make it. That is what is meant when the modem way of observing and experiment-
ing is termed a method.
As a matter of history, accurate clinical observation and description are found as
far bgick as Hippocrates, or further. Excellent descriptions of characteristic clinical
conditions have been made by physicians in all ages. Such instances of accurate obser-
vation form to this day integral parts of scientific medicine. Hippocrates and Boer-
haave unconsciously practised scientific method whenever they rigorously observed
and described a patient's symptoms; they abandoned the scientific method when they
resorted to metaphysical principles in description, explanation, and cure. Modern
medicine is simply more consistent, more thoroughgoing. It is so partly, perhaps, but
not largely, in virtue of the more general prevalence of skeptical habit, but mainly
because of the creation of means for experimentally simplifying the complexes which
the earlier physician lacked ways to disentangle. In truth, in the presence of com-
HISTORICAL 7
plexes that we ourselves are as yet unable to resolve, men are even now not infre-
quently as credulous and unscientific therapeutically as their forbears some genera-
tions back. The general situation, however, is better because the elemental facts, the
logical technique, and the experimental apparatus, by means of which so many knots
have been untied already, are in steady use in unraveling others. This is the whole
secret of the rapid strides made possible by the experimental method. \\'hen Harvey
and Hunter and Simpson did their utmost, they were reasoning with unresolved com-
plexes within which definite relations could not be postulated or demonstrated. Shrewd
intelligence and large experience carried them far. But, at best, they had to advance
by "hit or miss" methods or stand still. Unable to isolate causes, to fasten upon
and to exclude irrelevant factors, they had to resort to expedients. Their expedients
often availed, but they rarely knew their limitations accurately. Physics, chemistry,
pathology, pharmacology, and the diagnostic arts have gone a good distance toward
breaking up into fundamental and significant elements what to these earlier physi-
cians were inexti'icable complexes of symptoms; likewise they have made it possible
to deal practically with elements deliberately selected from an involved situation. To
the extent that this had previously been done, scientific methods were in vogue; to
the extent that it still remains to be done, medicine is not yet thoroughly and satis-
factorily scientific. In the narrower sense, therefore, only part of the medical field has
been reclaimed. More liberally taken, however, the whole field has been won. For
even where the modern physician confesses ignorance and helplessness, follows the
will-o'-the-wisp of mere symptoms, or blindly relies on empirical agencies that he
does not pretend to understand, he treads warily, with full realization of the nature
and extent of the risk that he runs. The sense of limitation with the cool, persistent
effort to pierce the barrier at its weakest spot, — this is science. Its spirit h£is thus
subtly transformed even where its arms have not yet conquered.
The German university became the home of this method and spirit early in the
nineteenth century. Before that date, scientific men had worked to no small extent
as private individuals; the main function of institutions of learning had been to
transmit canonical doctrine. The founding of the University of Berlin in 1809, under
the influence of Wilhelm von Humboldt, was an experiment by way of ascertaining
how far the mediaeval university was capable of answering the needs of the modem
spirit. Had the experiment failed, the German university would have withered away
like many another mediaeval institution ; society would have had to devise some new
agency for scientific education and investigation. Beyond question, it would not have
been made up of four coequal faculties, nor would any faculty have been created in
exactly its present form. Though the university has not proved wholly adequate to
contain all the scientific and educational activities that the hvst century has devel-
oped, Humboldt's move is undoubtedly entitled to be regarded as a brilliant achieve-
ment. The new wine was successfully decanted into old bottles, even if some new
bottles, in the shape of technical universities and research institutes, have had to be
8 MEDICAL EDUCATION
provided. Historic continuity has been preserved, while content and purpose have
been transformetl.
The adjustments forced by the invasion of the university by the scientific spirit
touch equally the faculty, the curriculum, the teaching method, the examinations, the
equipment, and the expense. Once the medical teacher rotated through the entire
curriculum. Even as late as 1850, Johannes Miillers chair at Berlin included ana-
tomy, physiology, embryology, and pathology ; the second Monro successfully resisted
the endowment of a chair of surgery at Edinburgh on the ground that surgery went
with anatomy. Amalgamation of topics persisted as long as transmission contin-
ued the main function of the school. The invention of tools — scientific tools, such
as sound fundamental concepts, efiicient apparatus, technical skill, modern logic —
has forced differentiation because a single individual now found all he could do in
a small, definitely delimited territory. First, loosely formed aggregates were broken
up. Joseph II's scheme had united in one person the teaching of surgery, materia
medica, and pathology with the teaching of other branches. These incongruous masses
fell to pieces. Next, closely allied, but yet too extensive, fields were provisionally
separated, as when physiology and pathology parted from anatomy. In our own day,
internal differentiation within each of these fields is taking place, because, as our in-
struments improve in precision and efficacy, still finer specialization is found profit-
able. Pathology splits into general pathology and experimental pathology; physi-
ological chemistry tends to become practically independent; medicine disintegrates
into inner medicine, psychiatry, pediatrics, dermatology, and inner medicine itself
tends to break up into distinct divisions: surgery splits into general surgery, gyne-
cology, orthopaedics, etc. From time to time, the curriculum and the examinations,
in the effort to overtake practical medicine and surgery, have noted these changes :
physiology was first made a compulsory study in Germany in 1856, pathological
anatomy and hygiene in 1869. Most significant of all, in the interval, the passing of
scholasticism was expressly recognized when, in 1861, formal logic and philosophical
psychology dropped out of the medical curriculum.
With the educational problems created by these progressive improvements, we shall
deal hereafter. Meanwhile, it is impossible to exaggerate the importance of the fact
that from the beginning of the scientific development just sketched, laboratory and
clinical chairs in Germany were of the same status. The salvation of German medi-
cine, as it now turns out, lay in the fact that clinical teachers and practical clinical
teaching were already safely housed in the university when the universities took up
Humboldt's ideal. Instruction and research, as they developed, were thus bound to
affect medicine, if they affected anything. \Vhen, therefore, chemistry, physiology,
and pathology developed, clinical medicine, being under the same roof, could not
escape their application and their stimulus. In the eighteenth century, the professor
of medicine and the professor of physics both talked; in the nineteenth, the former
got his hospital, the latter his " institute," and both thenceforth produced as well as
HISTORICAL 9
talked. The clinic was thus at the critical moment already included in the German
university on what we should now describe as the footing: of a laboratory. This made
it possible shortly to differentiate pathology as an independent science, without break-
ing connection between pathology and medicine. Where, as in England, the clinics
remained outside the university, pathology, on becoming a laboratory science within
the university, tended to draw away from the hospital. The German clinic threw off
pathology; but pathology remained close by, and bore steadily upon it. \'irchow
kept open his communications with the sick-bed, while attacking pathological prob-
lems thence derived, now with histological methods, now with chemical, again by
animal experimentation. When, in consequence of the cogency of his point of view, a
new type of clinician was created, the university at once had place and opportunity for
him. He was indeed born there. Thus, in a decade, the scientific method di-ove out of
university chairs of medicine the last survivors of mysticism, naturalism, and vitalism.
For the first time medicine now rested on an adequate concrete basis. This basis
has since then been enormously strengthened by developments in physiology and
chemistry, which have furnished additional standpoints from which to study and to
attack disease. In the generation immediately succeeding \'irchow's great achieve-
ments, prolonged training and some independent productivity in physiology and
chemistry became the normal basis of a clinical career : here again, medicine, being
wholly within the univei*sity, was at once fertilized, and has ever since been con-
tinuously fertilized, by the new knowledge. Three great schools of physiology have
flourished in Germany: Miiller''s at Berlin, Ludwig's at Leipzig, Voifs at Munich,
to one or another of which almost every important clinician of the last fifty years in
large measure traces back his lineage. Traube and Frerichs, the former intimately as-
sociated with Vlrchow and especially interested in the application of physical methods
to the clinic, the latter distinguished for clinical research on the chemical side, had
both been profoundly influenced by Muller. Leyden, at Berlin, Naunyn, at Strass-
burg, Quincke, at Kiel, were among their pupils; pupils of Naunyn — the third gen-
eration of this fecund line — mow fill the chairs of medicine at Wiirzburg, Bi-eslau, and
Halle. Ludwig's pupils occupy professorships in Leipzig, Heidelberg, and Berlin. From
Voifs laboratory in Munich came Friedrich Miiller, now professor of medicine there;
his pupils hold posts in Kiel, Strassburg, and Vienna. Medicine and the underlying
sciences have thus in Germany played upon each other in the most intimate fashion
during the last half century or more. The fundamental sciences have served as foci,
out of each of which a clinical school has developed, — a school not in the metliaeval
sense of a body of men succeeding each other in the pious office of handing down a
tradition, but in the sense of a succession of workei-s, applying sound methods and
fruitful ideas to the elucidation of problems left unsolved by their predecessors. Each
generation uses the preceding as its foothold. The splendid achievements of Gennan
medicine are, indeed, at bottom ascribable to the contiguity of the sciences and the
clinic in the modernized university.
10 MEDICAL EDUCATION
About university relationship itself there is no magic: its virtue depends wholly
upon the character of the university. German medicine in the eighteenth century was
worse off inside the university than English medicine outside; for the university re-
lation meant in Germany mediaeval pedantry, the non-university relation in England
meant contact with disease in hospital wards. In the succeeding century, the univer-
sity connection in Germany became valuable because the univei-sity had become the
abode of scientific ideals. Medicine inside the university was exposed to a tremen-
dously stimulating contagion that was bound to give new viewpoints and content;
medicine outside the university has nowhere succeeded in obtaining an equally inspir-
ing contact. Whether in the future the university connection will prove equally im-
portant obviously depends on the future adequacy of the universities.
The acceptance of the scientific postulate has tended to unify medical education
and practice, even while it has introduced new complexities through differentiation.
Empirical medicine lacked a broad and substantial basis; it lacked unifying concep-
tions. In consequence, the field was broken up into several non-communicating divi-
sions: medicine proper, surgery, and obstetrics were cultivated independently of one
another by doctors of different grades, the training of each of whom was limited to
his particular function. There were thus several kinds of practitioner. On the reorgan-
ization of the Prussian regulations in 1825, that is, at the beginning of the scientific
era, a distinction was still recognized between doctors who had received diplomas enti-
tling them to practise medicine, and surgeons of the first and second class, who might
by additional examination obtain the right to practise midwifery and ophthalmology.*
The doctor was required first to graduate at a Gymna.sinm ; he had then to study
for four years at a university. Of surgeons of the first class less extensive preliminary
education and only three years' study either at the medical faculty of a university
or at a medico-chirurgical school were required ; the surgeons of the second class were
extremely "practical" men, prepared for their calling by attendance on a "master,"
or by service in a military hospital. Pathology and physiology soon made division into
several species of physician and surgeon untenable. When all medication or relief was
conceived to depend on the comprehension of abnormal stinicture or disordered func-
tion, it was no longer possible to set up a fundamental distinction between extenial
and internal diseases, between diseases amenable to manual, and diseases amenable to
medicinal, relief. In consequence, the inferior disciplines were abolished in Germany ;
the surgical schools of Breslau, Greifswald, Minister, and INIagdeburg were closed in
1848 and 1849; in 1852, new regulations ordained that thenceforth there was to be
only one grade of physician, who should be obliged to pass all examinations and be
eligible to all kinds of practice. In Austria, similar distinctions had existed : country
doctors {Wunddrzte) had been bound to onlv two years of study, though a year was
added in 1810. The abolition of the inferior education was first proposed in 1848;
but it was feared that the medical faculties of the existing universities at Vienna
1 Puschmann : History of Medical Education (translated by Hare), pp. 585, etc. (London, 1891).
evo-
organic
HISTORICAL 11
and Prague were unequal to the task of producing high-grade physicians in suffi-
cient number. New faculties, therefore, were constituted at Graz and Innsbruck ; after
which inferior establishments were suppressed one by one ; but not until 1872 did tiie
medical regulations finally recognize the unity of medical science by the total abo-
lition of all inferior grades of practitioner. In England, an inferior grade of practi-
tioner was one of the consequences of the apothecaries' act passed in 1815. Thackeray
tells of "the very humble shop in the city of Bath, whence Mr. Pendennis exercised
the profession of apothecary and surgeon, and where he not only attended gentle-
men in their sick rooms and ladies at the most interesting period of their lives, but
would condescend to vend tooth-brushes, hair powder and perfumery."^ To this the
law of 1858, constituting the General Medical Council, put an end.^ The same
lution has now taken place everywhere : the human body is regarded as an
whole, to comprehend or remove a disturbance in any part of which requires, first of
all, a comprehension of its entire structure and function: for no part is, strictly speak-
ing, separable from the whole.* Specialization of function on the part of the physician
has indeed been re-introduced in later times; but it is by no means the specialization
that once permitted a surgeon to be less intelligent and more ignorant than a doctor,
because the surgeon used only his hands, while the physician must employ his brains.
The specialization of modem medicine is an extension, a wing built out upon the
basis of a common fundamental discipline: the obstetrician, the ophthalniolofnst,
the surgeon — civil or military^ — must be first of all a physician. Specialization thus
rests upon the admitted unity of medicine and sm-gery ; it is a means of securing in-
tensive cooperation. Together the modem surgeon and physician envisage the total
interest of the patient, and see each other's procedure from a single central point of
view. INIore thorough knowledge of detailed stinicture and function, increased possi-
bilities of therapeutic and mechanical relief, have suggested and justified specializa-
tion far beyond anything that had previously existed; but it remains specialization
qualified and held together by a sound and complete scientific conception of the unity
1 See Sprigge : Medicine and the Public, pp. 15, 16 (London, 1905).
2 The examinations in Great Britain continued, however, to be partial. The Royal College of Surgeons
conferred a general license to practise medicine and surgery, though it held no examination in either
medicine or midwifery; so the Apothecaries' Hall gave an equally general qualification, although its
examination contained neither surgery nor midwifery. In 1870, the Surgeons added an exaniiiiation in
medicine; some years later, one in midwifery. In 1S84, the combination of the two Roval Colleges to
form a conjoint examining board practicallyestablished the present order. Two years later, an act of
Parliament required every qualilying body to institute a complete set of examinations, by combina-
tion or otherwise.
3 The military surgeon is an important figure in continental medicine. In the first place, his training is
that of a physician. Afterwards, special provision is made for practical opportunities. In Prussia, for
example, army surgeons alone receive interneships at the Charite( Berlin), which, indeed, was loaned
to the university as an academic hospital in return for special pri\ileges in the form of interneships
tdrarzt, Leipzig, 1903 ; Klette : Das Studium der Medizin, Leipzig, 1904. Puschmann (pp. 558, etc. ) gives
the facts as to Austria.
12 MEDICAL EDUCATION
of the organism : a very different tiling from a crude subdivision of function made in
ignorance of the organic unity of the body.
I have explained the sudden rise of German medicine from its low estate by its
membei-ship in the univei-sity at the fateful time when new and fructifying ideals were
there set up. One gets negative proof of the soundness of the contention from Eng-
land and France. Both were scientifically productive long before Germany woke up
from its metaphysical trance. But in neither have jjroductive scientists been long or
consistently connected ^\'ith the univei-sities. They have labored as individuals: Davy,
Faraday, Darwin, Huxley, and Tyndall were all their lives without university sta-
tion, recognition, or even whole-hearted toleration.
Medical education, of course, had nothing to gain from the two dormant Eng-
lish universities as long as they were oppressed by ecclesiastical traditions and man-
agement. It was fortunate in its association with the hospital instead. The English
medical student was originally a sort of journeyman, who obtained a practical train-
ing through actual apprenticeship. The private pupils of the physician or surgeon
" walked" with him the hospital wards. At St. Bartholomew's (London), students thus
attended the medical and surgical practice of the hospital as early as 1662. Every
physician or surgeon had his group of followers, no little friction resulting at times
from their factious quaiTels.^ But for centuries the hospitals made no provision for
pre-clinical or extra-clinical instruction : a hundred years ago, the London medical
student picked up his anatomy at Abernethy's or the school in Great AVindm ill Street;
midwifery in Queen Street ; materia medica and chemistry in an apothecary's shop
anywhere. Lectures on medicine and surgery were also given as private enterprises,
not in the hospitals. Brodie, who came to London in 1801 at the age of eighteen,
spent almost two years before he at length entered St. George's, not even then so
much a pupil of the hospital as of one of its surgeons, Everard Home, the unhappy
custodian of John Hunter's precious manuscripts. The need of more thorough in-
struction of students and more orderly conduct of the hospital eventually brought
the student-groups together; the staff became a faculty, the apprentices became
clerks and dressers responsibly participating in the conduct of the wards. The quality
of the instruction furnished by these hospital schools varied with the character and
ability of the individual teacher. It had the merit of concreteness ; for the student
was from the first steeped in the clinical atmosphere. But despite concreteness, medi-
cine was hampered by metaphysical and abstract prepossessions. In vain John Hunter
opposed "trying"" to "thinking." "Don't think, try; be patient, be accurate,'"' he
said to Jenner. He was too far in advance of his time. His direction to "be as par-
ticular as you can"^ in observing had little meaning for a geneiation of physicians
who filled out imperfect knowledge by intellectual or imaginative exertion.
The subsequent history of English medical schools brings out clearly the weak-
» See, for example. E. W. Morris: The London IlofpUal, p. 187 (London, 1910).
2 John Hunter, by Stephen Paget, p. 123 (London, 1897).
HISTORICAL 13
ness inherent in this educational isolation. The purely theoretical clinical teaching
of Germany, far inferior at the start to the ward work of the English hospital, had,
by virtue of its inclusion in the university, the advantage of position in reference to
the future. It was able to take up the scientific viewpoint, method, and content when
in due time they were developed. Meanwhile, the English hospital itself underwent
no radical change during the nineteenth century. It was a philanthropic institution,
supported by the subscription of benevolent individuals who believed in caring for
the indigent sick, while the Germans and other impracticable folk prosecuted science
besides. There was no lack of brilliant individual performances. l"he century is dotted
with them: the two Huntei*s, their nephew, ]\Iatthew Baillie, Bright, Addison, and
Hodgkin, to select a few at random. These men all ran substantially the same course.
As unknowTi youths they became assistants in the dead-house or the out-patient de-
partment of the hospital. This was their opportunity; obscurity was their protection.
They spent years in working out, on both pathological and clinical sides, the im-
portant problems with which their names are severally associated. ^Vhen, at the close
of a decade, they had achieved scientific eminence, they were w hirled off into busy
practices. The rest of their active lives they spent as prosperous consultants, visiting
the hospital and teaching in its medical school of course, but without the leisure,
environment, or stimulus requisite to further scientific pursuit. The hospital as an in-
stitution was indifferent; other inducement there was none. Fifteen or twenty unpro-
ductive yeai*s followed. Thus men blossomed early, but they left no seed ; they had
no scientific heirs; they established no line. Suppose, for example, that Addison had
been a university professor instead of merely a hospital and consultant physician.
That explicit and dominating relationship to science and to education would have
stamped and secured him. Fame would have brought him students to maintain the
succession. English physiology was enabled to become a school because it was thus
established and protected. English medicine, on the other hand, is but a brilliant dis-
connected series of brilliant achievements flashing here and there in the skies. The
British profession, clinical on the lines laid down by Sydenham and his successors
did not as a whole, in the entire course of the century, succeed in digesting with
relish the scientific point of view.
At Edinburo-h alone was there a medical faculty within the rnivcrsity, — an in-
fluence that undoubtedly made itself felt. But with drawbacks, nevertheless: for Uie
University was itself conservative, and the medical faculty was acatlemic in name rather
than in fact. It consisted, in a word, of local practitioners, selected by the town council.
After a lively scrimmage for votes, James Simpson, for example, was chosen profi-ssor
by the close vote of seventeen to sixteen. No wonder that, at intervals, the medical
department of the Univei-sity relapsed into inactivity, so that the prcKlding of extra-
mural teachers was needed to goad it into action. For, once selectetl professor, the
demands of practice were likely to be disastrous to science and not conducive even
to vigorous teaching.
14 > MEDICAL EDUCATION
Quite recently there have l>een indications of a changing attitude, — a deliberate
attempt to bring teaching into closer relation with medical thought. Oxford and
Cambridge, for centuries a collection of colleges of secondary school grade, have
begun to develop under the eyes of the university, scientific institutes of modern type
related to all their constituent colleges. Prosperous provincial towns like Liverpool,
Birmingham, and Leeds, have realized the industrial and cultural value of modern
scientific training. In those busy centres local pride and national interest have stimu-
lated large educational benefactions: phvsics, chemistry, and physiology have been
more or less liberally endowed. Coincidentally with this scientific development within
the universities, medicine began to gi*avitate toward them : little as it had had to
gain from them in their mediaeval fonn, the moment the universities took up produc-
tive science, they became the congenial and indeed the necessary abode of medical
science and education. Oxford and Cambridge, at which chairs for theoretical lecture-
ships had long since been founded, have now provided modern laboratories for all
the fundamental scientific subjects: ^ Cambridge so successfully that it has the largest
medical school in England.
The proprietary hospital schools of the provincial towns have apparently been al-
ready forced into the local univei-sities. But integration is still far from complete. The
universities have indeed full control of the laboratory coui-ses: they possess labora-
tories, teachers, ideals, and some resources. To them the provincial hospital schools
have abandoned without reluctance the thankless and unprofitable laboratory field.
Clinical teaching is another matter. It costs little or nothing to demonstrate cases
to groups of clinical clerks; the fees amount to something; moreover, every student
is a potential source of future consultations. AMiile, therefore, the laboratory subjects
are organic parts of the provincial universities, taught with modem appliances by
teachers of modem type, the hospitals, as we shall more fully relate in a subsequent
chapter, remain outside the university, conducted not by clinicians sought out by
the university because sympathetic with scientific ideals, but by local physicians
designated by hospital boards for personal reasons.
In London, the situation is less satisfactory on the laboratory side and essentially
similar to that in the provinces on the cliTiical. King's and University Colleges are,
indeed, like Oxford and Cambridge, excellently etjuipped and manned in the laboratory
branches. Properly speaking, they are both divided schools, the laboratory half being
of academic complexion, the clinical half of a piece with the rest of London clinical
teaching. Exclusive of King's and L^niversity, the medical schools of the metropolis
are hospital schools. They have installed more or less meagre teaching laboratories
in the fundamental sciences; and they have defeiTed to the tendencies of the time by
setting up a verbal relationship to the University of I^ondon ; but as the Univei-sity
of London is only an examining board and the hospital schools have undergone no
1 For their clinical instruction, the Oxford and Cambridfre students repair chiefly to the London
hospital schools, though at both places small hospitals are associated with the medical faculty.
HISTORICAL 15
essential modification in consequence of their nominal connection with it, chnical
education in the English metropolis can hardly be said to have advanced many steps
on modern lines. The London hospital school is still essentially a proprietary insti-
tution, owned by the faculty, which is at the same time the hospital staff, and main-
tained because, directly or indirectly, it is commercially profitable. At the present
time, therefore, the first half of the medical cumculum is on a university basis at
Cambridge, Oxford, the provincial and Scotch universities, and the two London
colleges;^ nowhere in England is clinical medicine of the same status.^ In Scotland,
the University of Edinburgh possesses what appears to Ix; an organically whole medi-
cal department. However, both in theory and in practice, the clinical situation there
differs essentially from the laboratory situation. The university possesses its own
laboratories, and procures its chemist, physiologist, and anatomist where it pleases.
But, on the clinical side, it has nothing that approaches such complete control. From
a strict university point of view, Glasgow is similarly circumstanced. The univer-
sity appoints four professors at each of two large infirmaries, bound by agreement to
provide teaching w-ards under their exclusive control; but it would hardlv venture to
leave the local field in choosing a clinical professor, whereas it is free to bring in a
scientist from anywhere. Complete university texture cannot be achieved until trans-
plantation is equally easy in the clinical and in the laboratory branches. The fact that
the clinician, unlike the physiologist, having once secured a post, commonly ceases to
produce must be ascribed largely to the fact that he has thenceforth nothing to gain
— though something to lose — through scientific productivity. The same situation
exists in France, where the laboratories are within, the clinics, strictly sjjeaking, with-
out, the university. If, then, progress toward complete university status be regarded as
the normal course of development for scientific medicine in the nineteenth centurv-,
it is clear that a consistently organized and motivated university school of medicine
does not exist in Great Britain or France to-day.
1 University and King's. The London hospital schools also to some extent appoint their teachers of
the fundamental branches on university principles.
2 The professors of medicine and surgery at Oxford and Cambridge are selected on university pnni'i-
ples but neither institution has developed clinical teaching. Their medical departments arc practHrally
half-schools, their students going to London for chnical training.
CHAPTER II
THE NUMBER AND DISTRIBUTION OF PHYSICIANS
The form in which medical education is organized — university or proprietary — is
a matter of social as well as of scientific importance. The two types of medical edu-
cation involved are in spirit and method opposed to each other. Propositions look-
ing to the conversion of the latter into the former are met by the criticism that they
lose sight of weighty practical considerations. It is important, therefore, before pro-
ceeding further, to ask whether the needs of a civilized country are satisfied by the
number of physicians produced at the university basis,^ and whether such effort to
supply physicians of university type, if successful, requires the augmentation of the
number of universities beyond what would otherwise be necessary.
The statistical questions thus propounded are highly intricate. The obvious start-
ing-point would be a decision as to what is the correct ratio of physicians to popu-
lation. Unfortunately, no single solution of this problem is generally applicable; for
though one physician may be able to care for two thousand artisans in ]\Iunich,
it is quite obvious that a single physician could not render anything like the same
service to the same number of scattered peasants in Posen. But there is another diffi-
culty which lies deeper still : what do we mean by the "proper number of physicians'"?
Do we mean a number sufficient to care for all the sick of the district in question?
It might require the efforts of half a dozen men to give adequate medical attention to
two thousand scattered East Prussian peasants. There is danger, however, that even
one physician might eke out only a precarious living with the whole district to draw on.
In a well-to-do and quite densely populated region, the number of physicians that
can earn a livelihood would approximate or exceed the number required to care for
the sick ; in poor or thinly settled regions, the number that can earn a living tends
to fall below the number actually needed. Any conclusion as to the "proper num-
ber of physicians " must therefore take account of the possibilities of their earning a
living.^ As long as medicine is a vocation in which support must be earned, the en-
deavor to calculate the necessary ratio of physicians to population in a poor and
thinly settled territory is a purely academic exercise. No such ratio can ever be actu-
alized, no matter what educational facilities exist, no matter what educational stan-
dards prevail. The entire basis of the practice of medicine must be changed, for such
localities at least, before people that cannot support good doctors will be provided
with them.
Nor is the distribution of physicians even then wholly an economic problem : for
even under more or less favorable rural conditions, the current of population flows
toward the towns. The more enterprising, the more able, seek the greater prizes and
1 The problem of medical quacks is considered in chapter xiii.
2 See chapter xii.
NUMBER AND DISTRIBUTION OF PHYSICIANS 17
excitements of urban life. On any educational basis that could nowadays be proposed,
physicians are likely to be congested in cities and relatively scarcer in the country.
Finally, in comparing different countries, inferences must be drawn very cautiously.
In Germany, it is true, medical education is on a university, in England on a more
or less proprietary, basis. But the statistical situations cannot be directly compared,
as if all other factoi-s were so similar as to cancel one another. How far conditions
in one country are significant as to any other is, therefore, always dubious. For
example, before a ratio regarded as adequate in one place can be applied with cer-
tainty elsewhere, we must assure ourselves not only that people live in something
like the same proximity and have something like relatively equal means, but that
they are also in something like the same degree of dependence on the family phy-
sician: they must be in the habit of consulting or summoning him in the same sort
of emergencies, and be equally liable to such emergencies in point of seriousness and
frequency.
The general ratio^ of physicians to the entire population of the German Empire
is 1 to 1912 ;^ but this ratio is an average between extremes so divergent that it has
little significance. East Prussia, for example, is an industriallv backward district with
small toAvns, manorial estates, and thinly scattered population ; its 2,030,576 inhab-
itants, occupying 14,786 square miles of territory, are served by 694 physicians, a
ratio of 1 to 3070. In Konigsberg, its chief city, the ratio is 1 to 844; in the district
of Sensburg, the ratio is 1 to 5465; in that of Ortelsburg, 1 to 7718. Conditions are
similar in other thinly settled pro^^nces. Posen, for example, with 11,109 square
miles, has 618 physicians for 1,986,637 inhabitants, a ratio of 1 to 3214. The more
prosperous and thickly settled pro\nnces in the south and west fare better : Bran-
denburg,— omitting Berlin, — with 15,383 square miles, has 3,331,906 inhabitants
and 1366 physicians, a ratio of 1 to 2439; Hanover (14,870 square miles, 2,759,544
inhabitants, 1444 physicians), a ratio of 1 to 1910. In the district that includes
Berlin, the ratio is 1 to 849; in that including Koln, 1 to 1335. Taking the King-
dom of Prussia as a whole, the ratio of physicians to population is 1 to 1940.
1 The statistical material employed in this section is mainly derived from the following sources :
1. Preussinche Statistik. 204. (Berlin, 1908.)
2. Statistisches Jahrbuch fur den Preussischen Stoat. (Berlin. 1910.)
3. Oesterreichische Statistik der Unterrichtsanstalten, 1905-1906. (Wien. 1909.)
4. Oesterreichische Statistik der Santfdtswesen. 1906. (Wien, 1910.)
5. Medizinal-Kalendar 1910. (Berlin. 1910.)
6. Medizinal-Schematismm fiir Oesterreich. (Wien, 1906.)
7. Eulenburg: Die Frequenz der Deutschen Universitdten. (Leipzig, 1904.)
8. Lexis: IWe Deutschen Universitdten. (Berlin, 1893.)
9. Simon: Statistisches Taschenbuch — 1910.
10. Statesman's Yearbook — 190B.
11. Rabe : Aerztliche Wirthschaftskunde. (Leipzig, 1907.)
In addition to these published sources, much information has been courteously supplied by officials of
the Ministries of the Interior at BerUn and Vienna, the General Medical C^iuncil. London, etc.
2 This fails to take account of two factors which greatly abridge the field of the medical profession:
midwives, of whom, in 1907, there were in Prussia, -2(\H78. or I to every ISlo '"hab.tant.s ( / r..««^
Gemndheitmvesen, pp. 432-462. Berlin, 1909), and quacks, also very numerous. As to the latter, see
chapter xiii.
18 MEDICAL EDUCATION
The other states of the German Empire show, on the whole, similar conditions:
witness Bavaria, ratio 1 to 1925; Saxony, ratio 1 to 2015; Wiirttemberg, ratio 1 to
2130; Baden, with a ratio 1 to 1397, is somewhat more abundantly stocked. The larger
cities prove, of course, everywhere powerful magnets: Munich, with 538,983 inhab-
itants, has 845 physicians, a ratio of 1 to 637; Leipzig, 502,605 inhabitants, has
439, a ratio of 1 to 1144; Stuttgart, 205,591 inhabitants, has 229, a ratio of 1 to 898.
In Bremen, the ratio is 1 to 1093; in Hamburg, 1 to 1227; in Charlottenburg, 1 to
440; in Kiel, 1 to 696.
Whether these ratios indicate scarcity or plethora can be settled only by exami-
nation of the economic conditions prevailing within the profession. The German doc-
tors must earn their living. Do they ? I may so far anticipate a subsequent chapter
as to state here that the financial condition of the profession is distinctly unsatisfac-
tory; that is, even on the university basis, more doctors are produced than can be
supported decently. An agency is maintained at Leipzig through which physicians
seeking an opening can be directed to eligible places: in 1908, there were 898 appli-
cants and 618 openings.^ Increased output at a lower educational level would not
help mattei*s; it would only further increase the professional proletariat of the cities.
This is clear from two considerations : even in the most unattractive of the districts
above mentioned the small towns are well supplied. In the Ortelsburg district, there
is a doctor at Friedrichshof with its 2051 inhabitants, one at Mensguth with 1154,
four at Ortelsburg with 5079, two at Passenheim with 2084, and one at Willenberg
with 2382. In the Sensburg district the same holds: Alt-Ukta with 1119 inhabitants,
Peitschendorf with 1039, have one physician each ; Nikolaiken with 2287 has two, Sens-
burg with 5838 has six. In general, wherever there are people enough to maintain
a physician, one is found, despite the obvious preference for larger towns.
On the other hand, the outlying regions lack physicians simply because they are
too poor to pay for them, — a fact that is rendered clear by the income-tax returns.
Free of income tax in Prussia are those whose yearly income does not exceed 900
marks (8225). Clearly, persons who pay no income tax cannot afford to pay doctor's
biUs; not improbably many who pay the income tax are unable to pay a physician. I^et
us, however, omit this latter class. According to Rabe,^ there were in Prussia in 1903
35,114,667 inhabitants, of whom about eleven per cent — 4,217,330 — paid the in-
come tax; of this number sixty-five per cent — 2,602,092 — lived in towns, thirty-
five per cent — 1,615,238 — in the country. It is obvious that a large percentage of
the rural population — especially in East Pioissia — are economically unable to sup-
port a physician at all. No reduction of educational standards such as can be seri-
ously entertained would attach physicians to districts in which the population is so
meagre, so scattered, and so poor that medical praxitice cannot possibly yield sub-
^ AentUches VereinshJatt fur Deutschland, 1910, No. 765. As to financial conditions in the German
profession, see chapter xii.
2 Pages 67, 68.
NUMBER AND DISTRIBUTION OF PHYSICIANS 19
sistence. The solution of this problem is to be reached, as we shall shortly suggest,
by an entirely different procedure.
For the present, therefore, we may pass by those sections of the country that are
too poor to maintain a doctor in any event; in view, too, of the general prevalence of
more doctors than are properly supported, we need not try to determine what would,
after all, be the safe ratio in each of the various types of connnunity. The really in-
teresting questions from the educational point of view are: (1) as to whether university
standards of medical education are consistent with an output of doctors great enough
to fill the posts capable of sustaining them; and (2) as to whether a limited numlxr
of universities have expansive power enough to respond to such a demand.
There are now, as there have been for almost a century past, twenty-one universi-
ties in the German Empire.^ At the beginning of the nineteenth century, when the
teiTitories included in the present empire possessed about 19,000,000 inhabitants,
medical education was still so loosely organized that the universities furnished but
a fraction of those practising medicine or surgery in Germany; since the middle of
the century, they have supplied all the recognized practitioners. Twenty-one uni-
versities functioned for the whole of what is now the German Empire when the
population was some 40,000,000; they function now for the same extent of territory
with its population exceeding 63,000,000. In 1885, there were 15,764 licensed phy-
sicians for a population of 46,858,000, a ratio of 1 to 3000; in 1898, there were
24,725 physicians for a population of some 54,000,000, a ratio of 1 to 2200; in
1909, there were 30,558 physicians to 63,000,000, a ratio of about 1 to 2000. Be-
tween 1885 and 1909, a period of twenty -four years, the number of physicians had
increased almost 100 per cent — that is, about three times as fast as population in
the same interval.
In the winter semester, 1830-1831, 2355 students were enrolled in the medical
faculties, 78 for each 1,000,000 inhabitants; in the summer of 1848, — a troubled
era, — the number of students decreased to 1506 ; thenceforward it rose (gradually ex-
cept during the eighties, when the rise was very rapid), until in 1890, the registration
reached 8724, about 180 to each 1,000,000 inhabitants; it fell to 5903 in 1905;
increased to 9648 in the winter of 1908, and to 11,240 in the current semester.^ It
w^ould appear, then, that a chain of well-developed universities is capable of ver^-
considerable expansion to meet progressive conditions. ^Vhereve^ social and profes-
sional status depends on education, a powerful motive drives the more gifted into
the universities. High standards, a lengthening curriculum,' and relatively few univer-
sities thus not only involve no necessary shortage, — they are even quite compitible
with over-production,* for the drop from 8724 in 1890 to 5903 in 1905 in the face
1 Munster, however, has only two faculties. 2 Winter. 1911.
3 The student enrolment has not been kept down despite the fact that in recent years tlie required
course has been made a year and a half lon^'cr.
4 Over-production meaning not that there is an excessive number of physicians everj-where. but an
excess wherever physicians will locate at all.
20 :medical education
of an increasing population probably indicates previous excessive production as well
as automatic action in the direction of checking supply.
Let us consider the matter from another point of view. I have pointed out that
universities are elastic, that a given set of institutions can accommodate an increasing
student body. There must be, of course, a limit to such accommodation. Has it been
reached in Germany? At this day, with the largest registration in the history of the
German universities, only two medical schools are dangerously large : Munich with
2148 students,* Berlin with 1646. Three others are near the danger-point: Leipzig
with T46 students, Freiburg with 718, and Wurzburg with 617. The other sixteen
average 332 apiece, the number at Rostock falling to 172. The average attendance,
including all the universities, is 533.
WTiether or not the medical faculties are on this showing overtaxed is, however, a
question that cannot be settled by a mere inspection of numbers. In recent years, the
period of medical study has been lengthened : this extension involves an apparent
rather than an actual increase of the medical student bodv; for if every student is
detained an extra semester or two, the number of students in attendance at any one
time is greater, although the actual number of those who pass through the course re-
mains the same. If, at the same time that the course is extended, additional facilities
are provided, pressure is not increased, though the apparent student body has been.
Again, the active student body — the student body, that is, that constitutes a tax
upon the teaching resources of the university — is smaller than the enrolment.^ A
fraction — how considerable a fraction it is perhaps impossible to say — attend lec-
tures irregularly, and cumber very slightly the laboratories or the wards. Benches,
thronged in the early days of the semester, usually have room enough long before its
close. For example : clinical students are called down into the arena to participate in
demonstrations;' I have repeatedly heard anywhere from three to a dozen names called
before a response was obtained,* Moreover, the Germans make no effort to distribute
students according to semesters. The presence of 500 students does not mean that 50
are following work laid out for each semester. Students are divided only as between
those in the first half of the course, covering five semesters (the sciences), and those
in the latter half, likewise five semesters (the clinics). On either side of this line, a
given lecture course will enroll students of all the semesters in question: those in
their first and those in their fifth may attend the same exercise; those in their sixth
and those in their eighth may attend the same clinic. Moreover, on either side the
dividing line, lecture courses may and sometimes must be heard twice; not infre-
' Winter semester, 1909-1910.
2 Billroth's experience (IBftfi) seems unusually unfavorable: " About 4s50 students were enrolled last
semester in my clinic; and yet the amphitheatre was often empty; scarcely 50-60 came rejrularly,
most of these foreign physicians. If a student was called to act as ' Praktikant' and chanced to be
present, as a rule he never came again." Aphorism^n, p. 8 (Wien, 1886).
^ " Prakticieren." See page 175.
* Failure to respond may be due to either absence or timidity.
NUMBER AND DISTRIBUTION OF PHYSICIANS 21
quently they are heard still oftener. More effective organization might greatly reduce
these audiences. Preference for the more attractive lecturer, or for the professor who
is an examiner too, operates also to bring about congestion at one place, scarcity at
another, quite without reference to paper calculations aiming to prove or to disprove
the overtaxing of capacity. Undoubtedly, there is overtaxing at certain points, —
in this laboratory or that, in this clinic or that; but this may signify a defect of
organization or teaching method, as well as a defect of resources. A medical course
running through ten semesters might absorb 500 or 600 studenis without mucli
pressure at any one place ; whether any existing school could handle three or four
times that number is, of course, another question. As long, however, as the average
per school does not exceed 500 divided among ten semesters, the call for new uni-
versities may be less urgent than the call for more effective organization of those
that exist.
There is, however, a certain misconception involved in the supposed averaging of
enrolment. It would be unwise to equalize enrolment: in the first place, because,
while material and facilities are in one place inadequate to a body of, say, 250 stu-
dents in each half of the course, the facilities of other schools would t^e wasted under
such a limitation ; again, because students vary so greatly in the way they respond
to conditions that an adequate system of medical departments should contain a few
schools much smaller than others.
But whether wise or unwise, it is not feasible. The student body in Gennany can-
not be arbitrarily regulated without disturbing one of the most valuable features
of German academic life, namely, the ease with which the student wanders from uni-
versity to university. Omitting those in their first semester, more than one-half of the
entire body of German students change universities in the course of their studies,
no inconsiderable minority changing more than once.^ The motives that affect migra-
tion may not always be scholarly. The student wanders, indeed, in order to come in
contact with a great thinker or to procure larger opportunities; but not only so. Sea-
sonal and local attractions cut a figure : winter sports favor Freiburg, atjuatic in-
terests work in behalf of Kiel. The German student loves to taste a varie<l experience :
he wants to feel the contrast between the severe north, as he finds it at Greifswald.
and the lighter-hearted south of Munich and Heidelberg. He finds it worth while,
too to reckon with another sort of severity, namely, that of the examinations.* Over
and above all the big citv is the powerful magnet which nothing but autocmtic prtv
hibition could possibly offset. An increasing percent^ige of the total student body
1 Preuss. Statist. 208, p. 141, etc. .u . j » u. ,
u ,^;r.^A for rIPOTPPs are relative v much ereater than the student b<><Iy.
2 Wherever the numbers exammed for degrees are rciamc.) ^^ HcidellxrK enrolU-d S.^i
22 MEDICAL EDUCATION
is found at Berlin, Munich, and Leipzig: 83.5 per cent between 1851 and 1855, 41.7
per cent between 1896 and 1900. Since the establishment of the empire, the trend
towaixl centralization is unmistakable. One-fifth of all university students in the Ger-
man Empire are now found in Berlin.^ Eulenburg maintains that the city itself has
come to exercise a more powerful influence than the faculty.^ Mere increase of the
number of universities might have the effect of reducing enrolment at the small insti-
tutions where it is not now excessive, rather than seriously to tap the three metropoli-
tan institutions towai'd which the tide sets so strongly.
Some disparity in size, therefore, is a thing to be accepted and reckoned with.
Certain of the faculties should then not be expected to enroll over 300 or 400 students.
Should any of them be compelled or allowed to handle 1500 or 2000 .'^ That depends
on the methods of teaching. We shall have occasion to observe that the methods of
teaching now employed do not vary essentially between Giessen, where there are 331
students, and ]\Iunich, where there are more than six times as many. Mass methods are
followed in both: the lecture is in general use, irrespective of the size of the student
body. But a lecture to 30 students and a lecture to 300 are, nevertheless, very differ-
ent things. So pronounced a difference in degree almost constitutes a difference in
kind. In the smaller institutions, mass teaching is greatly mitigated by the casual
contact of student and teacher. It would be, moreover, a simple matter to introduce
improved methods into the smaller schools: is it feasible in the largest.'' The question
is extremely difficult to answer. The German professor is simultaneously teacher and
investigator; his administrative responsibilities are intended to be subordinate to his
educational and scientific activities. A small department can be so conducted that a
teacher keeps his contact with students, and conducts research because there is little
administrative detail. Are the same sort of personal contact with students and the
same active participation in research compatible with the administration of a huge
department.'' Certainly not on the part of a single chief, though a sufficiently numerous
staff — not as yet provided — might conduct the work on the whole acceptably. Lender
such conditions, there would undoubtedly be greater waste of student ability than in
smaller schools; that is, fewer students would enjoy direct contact with able instruc-
tors. On the other hand, the unusucxlly strong would undoubtedly come to the surface;
and the general level of training under the supposed conditions might still be high
enough to protect society.
A second solution of the problem of the large school is conceivable : the several
departments might be duplicated. On the clinical side, this device has had to be em-
ployed at Vienna, Munich, and Berlin, where the numljer of beds in certain depart-
ments has grown too large for a single service. The educational situation is relieved,
however, only in so far as students voluntarily disperse through the three clinics. On
the laboratory side, no such duplication occurs except partially in anatomy. We may
* Eulenburg: Frequenz, p. 262. ^ Iftid., p. 264. Billroth concurs: Aphorismen, p. 24.
NUMBER AND DISTRIBUTION OF PHYSICIANS 23
concede, therefore, that as far as gross attendance alone indicates, individual univer-
sities— Berlin and Munich, for example — are now overtaxed, while still we maintain
that the German universities as a whole have stood the strain of the last half century
well enough to prove the possession of unsuspected elastic power; we may even take
the position, as I hope to show, that over-pressure such as now exists calls for reor-
ganization of teaching before any considerable addition to the number of existing
universities is undertaken.^
We have thus far considered the question of over-pressure from one side only,
namely, that of total registration. But the total number of enrolled students in
medical faculties is in Germany less significant than the annual output of physicians,^
for, under the conditions of the German universities, part of the student body in-
flicts, as we have pointed out, no strain on its teaching capacity: they are passive
hearers, and perhaps not always that. In two semesters, 1885—1886,^ with an average
registration of 1174 medical students at Berlin, 111 doctors of medicine were there
graduated; in the two semesters, 1892-1893, with an average registration of 1149,
there were 182; in 1901-1902, only 50 (average registration 1084); in 1905-1906,
80 (average registration 991). Graduating classes of this size in Berlin would, as
such, tax nothing, — not plant, organization, or teaching method. Nor do these fig-
ures mean that the German student, taking advantage of his liberty to migrate in
the last semester, resorts in large numbers to smaller universities in the hope of get-
ting an easier examination and there overcrowds them ; the following table shows the
contrary :
Number of Graduated Physicians at Prussian Universities
Year
Berlin
Bonn
Breslau
Gottingen
Greifswald
Halle
Kiel
Konigsherg
Marburg
Total
1885-1886
111
56
20
22
55
30
20
9
14
337
1892-1893
183
64
15
29
67
32
61
20
33
503
1901-1903
61
45
53
36
41
42
113
34
38
463
1905-1906
80
41
28
35
35
40
53
25
24
361
1909-1910
108
43
38
26
34
27
73
28
20
397
That is, nine Prussian universities averaged 38 graduated doctors in 1885-1886,
56 in 1892-1893, 52 in 1901-1902, 40 in 1905-1906, 44 in 1909-1910. Taking the
entire German Empire, and counting "approbierte Aerzte" instead of "promovierte,""
the following table represents the total output in each of several years with the aver-
age per university:
1 The situation in London suggests still another solution, the creation of complete, but separate schools
federated as the university. See pages 218, 219. The plan is hardly imaginable for Germany.
2 "Approbierte Aerzte," that is, those who have passed the state examination. Whoever passes this
examination is a "Praktischer Arzt." In order to obtain the degree of doctor of medicine, a second
examination must be passed; those who pass it are "promoviert." The number of those "approbiert"
exceeds the number of those "promoviert," although for our present purposes the difference is not
material. For example, in 1889-1890, 499 were "promoviert" in Prussian universities, 564 "approbi-
ert." See Preuss. Statist., 308, p. 198, and Lexis, vol. ii, p. 406; also chapter ix.
3 Summer semester, 1885 ; winter semester, 1885-1886.
24 MEDICAL EDUCATION
Year
Total
" approliierle Aerzte"
Average per university
1877-1878
52i
25
1885-1886
9P8
4S
1890-1891
1570
75
1899-1900
1384
66
190-2-1903
1551
74
1908-1909
i)i2
45
These comparatively small totals and averages taken in conjunction with the rapid
increase in the size of the medical profession testify to the fact that a small num-
ber of universities possess surprisingly great productive capacity. Tliey suggest, more-
over, that in a course of training occupying ten semesters, the students going forward
to graduation, if fairly stratified, would not in general be likely to be excessively
numerous at any one stage. Furthermore, if graduating classes of the above sizes are
adequate, the question arises whether they cannot be obtained from a smaller stu-
dent body. These facts again suggest that no considerable increase of medical facul-
ties in Germany is called for : at most, a certain degree of reorganization may be
timely. Such reorganization might affect the enrolment in one of two ways : it might
decrease the number of students enrolled, for it would increase the severity of the
study; or it might, without increasing the total size of the student body, increase
the number who successfully achieve the medical course. Fortunately, in Germany the
creation of universities is not a matter of local pride or personal whim. Though the
present locations are due largely to historic accident,^ the government has made the
best of it, and is not likely to repeat historic misfortunes. The proposal to establish
a university at Frankfort is undergoing most careful consideration, and any institu-
tion created there will take note of the existence of Giessen, Marburg, Heidelberg,
and Wiirzburg in the \ncinity.^
The problem of the back country, however, remains. There dearth exists, and will
continue to exist on any conceivable educational standard, as long as the situation
is left to itself. It cannot be cured by lowering standards, for economic and social
interest will still impel educated men toward the towns.^ In the old days, the in-
ferior surgeon (the so-called "Wundarzt") was denied freedom of locomotion: he was
licensed to ply his art — or trade — in a prescribed locality; but democratic progress
has made this species of professional \illeinage impossible. Moreover, the ethics of the
c^Lse enter into the reckoning. " I hold it unrighteous in principle," declares Billroth,
"to give country people worse doctors than city people."* An organized sanitary
1 Eulenburg very aptly remarks : " That Koln should have lost and Erlangen retained its university
cannot be reconciled with sound policy." Freqnenz, p. ^2'l'^.
2 It is worth pointing out once more that German universities exist now in large towns, now in small.
Nowhere does one encounter the notion that a town should possess a university or a medical school
merely because it is large, well situated, or commercially important.
• In 1871, 23.7 per cent of the population of the empire was urban, 76.3 per cent rural; in 1900, 42.26
per cent was urban, 57.74 per cent rural. An occupational census tells tne same story of strong cur-
rent toward the cities; in 184.3, it is estimated that 61 per cent of all persons earning a livelihood
were employed in agriculture, forestry, fishing, etc.; by lHf»5, this haa decreased to 35. 7 per cent.
(Dawson: Evolution of Modern Germany, chapter iii, London, 1909.)
* Aphorismen, p. 55 (Wien, 1886).
NUMBER AND DISTRIBUTION OF PHYSICIANS 25
service, maintained by the state, will alone bring competent and steady medical re-
lief to those who cannot pay for it themselves.
The situation in Austria,^ while more undeveloped, follows in general the German
lines. A population of 28,000,000 is served by a profession of 13,202, — a general
ratio of 1 to 2120. Since 1905, the population has increased by 4 per cent, the number
of practitioners by 6 per cent; so that at the moment the two move fairly well to-
gether. But between 1887 and 1905, while population increased 30 per cent, the med-
ical profession increased 76 per cent. In 1889, there was one physician to 3243 inhab-
itants; in 1900, one to 2477; to-day, one to 2175. Marked fluctuations have mean-
while taken place in the numbers annually graduated — 574 in 1889—1890,759 thenext
year, 857 in 1894-1895, after which there is a steady decline until 1904-1905, when
375 were graduated ; at substantially that figui'e, the output has since remained, the
graduates in 1908-1909 numbering 393. Between 1887 and 1895, 5075 doctors were
graduated; between 1896 and 1905, 7225. This is the output of five medical faculties
employing the German language. Obviously, here as in Germany a small chain of
universities possesses great elastic power. That five medical faculties suffice does not,
however, follow, for the average enrolment is now 736. jMore than thirty years ago,
Billroth urged the creation of new medical faculties, by way of remedying the con-
gestion at Vienna, still unrelieved.
In respect to distribution, we are again confronted by the dilemma that arose in
dealing with Germany : are we to start with population and territory on the one hand,
or with the opportunity for self-support on the other? Physicians are superabundant
where a livelihood can be earned: Olmlitzhas one for 390 inhabitants, Innsbruck one
for 485, Graz one for 530, Vienna one for 670, Salzburg one for 770, Pilsen one for
950, Triest one for 1010. If the supply of doctors is to be regulated by their oppor-
tunities to earn a livelihood, Austria is thus even now probably oversupplied, for
complaints of the impossibility of making ends meet are general and bitter. On the
other hand, in the poorer country districts, medical relief is obtainable only with diffi-
culty, and as the population is both too scattered and too poor to pay for medical
service, the scarcity can hardly be relieved without governmental subvention. In the
district Gorz-Gradiska, 56 physicians must serve a population of 232,897, a ratio
of 1 to 4158; in Carniola, 100 for 508,150, a ratio of 1 to 5081. Nor is this obvious
stringency much relieved by the survival in all Austria of some 600 of the inferior
surgeons admitted to restricted practice prior to 1872. As long, however, as small
towns and country neighborhoods in which physicians of university training can earn
a modest competency do not lack for them, the problem is, here as in Germany, eco-
nomic and political, not educational; for even if lowering of educational efficiency
were ethically thinkable, there is no reason to believe that it would effect the desired
1 The Austrian situation is complicated by racial differences. The text refers only to its German-
speaking universities.
96 MEDICAL EDUCATION
object. It would be more likely to result in an aggravation of objectionable conditions
in places already supplied.
AVe have now noted in Germany and in Austria the influence of a clean-cut univer-
sity relationship on the statistical aspects of medical education ; let us see what hap-
pens in England and Scotland under conditions but partially emancipated from the
proprietary regime. The bearing of proprietary education on matriculation standards
and on the quality of medical training will be discussed presently in the appropri-
ate chapters.
First of all, as to the number of schools: with a joint population of 36,999,946
inhabitants, England^ and Scotland now possess 27 medical schools : ^ that is to say,
as compared with Germany, a population 46 per cent less maintains 29 per cent more
medical schools. In terms of output : the average annual registration of physicians in
England and Scotland during the last fiveyears^ has been 513, an average of about
19 per school, which includes some at least whose education was not received in the
British Islands. This evident dispersion of the student body among a needlessly large
number of medical schools enfeebles the stronger institutions, while enabling weak
schools to protract a useless existence. Thus in the London schools in 1905, only 18
full students entered Middlesex Hospital, 24 entered Charing Cross, 22 King's Col-
lege Hospital, 13 Westminster, and 18 St. George's. Meanwhile, the stronger schools
were not large: the entering class at the London Hospital contained 83 full students,
that of St. Bartholomew's 60, that of St. Mary's 44, that of Guy's 63. As the proprie-
tarv school must live on its fees, it is clear that improvements can be effected only by
concentrating resources; but it is precisely concentration that the proprietary interest
opposes. The London schools, for example, are said to spend £10,000 annually in
salaries for the teaching of anatomy; yet till recently only a single anatomist was paid
above £400, and not a single department is adequate to modern requirements. Mean-
while, the semi-univei*sity provincial schools are also weak in numbers and resources:
Liverpool, for instance, has an entering class of 34; Sheffield has 40 students, all
told.
It is clear, then, that the proprietary form tends to increase the total number of
schools, involving necessarily the occupation of the local field by relatively weak
competing institutions. Why not.'' If one hospital staff selected for personal reasons
finds it profitable to engage in medical education "on the side," why not another.''
The moment the university relationship is regarded as essential, competing schools
tend to consolidate. AVherever universitv ideals prevail, as in the laboratory depart-
ments of the provincial universities, unity results: witness Liverpool, for example,
1 Including Wales.
2 In this estimate. University College and University College Hospital Medical School (London) are
counted as one, although, strictly speaking, they form two half-schools ; the same is true of King's Col-
lege and King's College Hospital Medical School. Nor have I counted certain drill-schools such as still
survive.
2 Taking the last twenty-four years, the average annual registration in England and Scotland was 572.
NUMBER AND DISTRIBUTION OF PHYSICIANS 27
where the fundamental branches — chemistry, anatomy, etc. — are offered by the
university in exactly the same way as Latin or mathematics. But wherever a trace of
proprietary or commercial interest survives, combination halts. Apparent unity in
such instances needs to be probed carefully. At Livei-pool, up to 1902, aU medical
students received their clinical training at the Royal Infirmary. But there were three
other general hospitals in the town : their respective staffs offered clinical instruction
at lower rates and captured a considerable part of the trade. Peace was made by
an amalgamation which spread the name of the university over all, without modify-
ing in any wise the character of any one of them. Apparently, the three clinical
schools exist no longer; but they exist none the less. Printing the aggregated staffs of
three hospitals in one list does not alter the fact that each of the three hospitals is
a separate clinical school, over the internal conduct of which the university has no con-
trol. An identical situation exists with an even smaller student body in Sheffield.
In London, despite nominal inclusion in the University of London, the thirteen schools
remain competing proprietary institutions with all the educational and professional
demoralization consequent upon low ideals and varying personal interests. Three of the
schools ^ have indeed discontinued the laboratory branches because the income from
fees was inadequate to sustain them; but they still maintain undergi*aduate clinical
classes. As the hospital staff in London is composed, as a rule, only of consultants,
it is obvious that suppression of a medical school cuts off an important source of con-
sultant business. Supei-fluous and competing local schools are almost bound to exist
where medical education is proprietary in form. That education suffers from the dis-
sipation of resources, the scattering of students, and the ascendency of commercial
objects, the British medical student has certainly discovered. Hence, despite the mod-
ern tendency toward centralization in great cities, despite the enormous clinical wealth
of the London hospitals, the enrolment in the London hospital schools has steadily
declined: in the session of 1880-1881, 778 new medical students came up to London;
in 1890-1891, 657 ; in 1900-1901, 536; in 1904-1905, 413, a loss of 47 per cent in
twenty-five years.^ In the same period, the provincial medical schools increased from
257 to 353, — 37 per cent.^ This unmistakable demonstration of relative educational
deterioration has had no effect in diminishing the number of London schools; there
is no good reason why one business enterprise should get out of the way of another,
when, small as the business may become, an individual who does but little is still
pecuniarily better off than if he did nothing at all. Meanwhile, the situation bids fair
to remain in statu quo until there is created in London a teaching university embody-
1 Westminster, St. George's, and Charing Cross,
2 For these figures I am indebted to Dr. William Bulloch, of the London Hospital. Slightly different
totals, leading, however, to no different result, are given by the late Sir Henry T. Butlin in a memo-
randum submitted to the Royal Commission on London University. (Minutes of Evidence, p. 274.) The
late Sir William H. Allchin estimates (ibid., p. 3-24.) that from 1900 to 1905 an average of 300 men came
up to London yearly; from 1905 to 1910, an average of 276.
^Minutes of Royal Commission, p. 274.
28 MEDICAL EDUCATION
ing in medical education such ideals as would in time discredit and destroy propri-
etary education.
On a much smaller scale, Edinburgh furnishes another illustration : there medical
education is furnished by the university faculty on the one hand, the so-called extra-
mural school on the other. These two bodies have long competed for students. I have
already briefly described the university faculty as it now stands; the extra-mural
school^ is a loosely organized proprietary affair, under the nominal jurisdiction of the
Royal Colleges of Physicians and Surgeons. Not improbably, the competition of the
two schools may have been wholesome at a time when international ideals can hardly
be said to have existed. The choice between a poor instructor in the university and
a good drill-master outside may have been important when the colonial thought
he had to go to Edinburgh or nowhere. But as university education in medicine de-
velops, as English and Scotch universities enter a world-wide scientific competition,
local animosities and contentions can only lower the standard, and divide resources;
for if both the Edinburgh schools now came together under the university, the barren
extra-mural drill in anatomy and chemistry would cease to suggest false standards
of scientific teaching, and the entire Royal Infirmary might become a university
clinical department, in the manning of which local and personal considerations could
be sunk, Edinburgh, like London, therefore, proves that where the university relation
is absent or not highly developed, unnecessary schools survive on a low or obsolete
basis.^ Assuredly, this contrast is not without significance: where proprietary medi-
cal education exists, local schools multiply freely ; as the proprietary instinct wanes,
schools unite or drop off. \Miere the university status is definite, local competition
ceases entirely without as yet anywhere reducing the number of faculties dangerously
low. On the Continent, two apparent exceptions are easily accounted for: at Pi'ag,
racial bitterness compels the separate maintenance of two universities, — one, Ger-
man, the other, Czech; at Lille, religious animosities are similarly peipetuated.
It is unfortunately impossible to show statistically the effect of proprietary edu-
1 The relations of the extra-mural school and the university can be understood only in the light of their
history. In 1694, Alexander Monteath, a member of the Corporation of Surjreons, obtained from the
town council permission to use " those bodies which dye in the correction house" to teach anatomy;
during the succeeding twenty-five years, other subjects were added. The medical faculty of the univer-
sity started in 1726 with the right to confer degrees. The two schools grew side by side ; it became usual
for students dissatisfied with a university teacher to attend classes under extra-mural instructors,
though they were not thereby excused from attendance on the university. Early in the nineteenth
century, however, the extra-mural school was so much the more popular of the two, that an effort —
unsuccessful till 184-7 — was made to force the university to recognize and accept extra-mural teaching.
The tie between the extra-mural school and the Royal Colleges was snapped in 1871 ; it ha.s latterly
been reestablished. Nevertheless, the classes offered do not form a school in any proper sense. They are
practically private classes, the teacherfnrnishing the equipment and keeping the fees. The students are
in large part university students, candidates for degrees ; the remainder expect to obtain qualification
for practice by passing the "Triple Board" examination (see page 268). The university allows students
to take classes in the extra-mural school, thus recognizing work which it does not control. (See "The
Development of the Edinburgh School of Medicine," by Professor D. Noel Paton, Edinlnirgh Medical
Journal, November, 1894.)
2 At Glasgow, two extra-mural drill-schools of proprietary character still survive : Anderson's College
Medical &hool and the Western Medical School.
NUMBER AND DISTRIBUTION OF PHYSICIANS 29
cation on the size of the student body in general. Evidently, low standards tend to
swell enrolment; and the high rate of mortality at the qualifying examinations ^ sug-
gests the inferiority of no small portion of it. But total attendance statistics for a
series of years cannot be given. The schools, being largely private enterprises, furnish
no detailed information on the subject. Such figures as are published may be mislead-
ing. It is important to create the impression of prosperity; therefore, published lists
do not always distinguish full from special students : of 500 students claimed by one
school, only 380 were full medical students; of 58 entering another, only 31.
Let us, finally, consider the relation between population and number of physicians
under partially proprietary conditions. When medical education is proprietary in
character, the economic motive alone checks production. Personal fitness and adequate
previous training have little influence ; for tempting advertisements obscure the for-
mer consideration, low entrance standards dispense with the latter. Solicited to enter
professional life, the untutored boy asks only, " Will it pay ?" And the statistics show
that he takes large chances as to that. In 1891, there were in the United Kingdom
29,555 registered physicians for a population of 38,104,975, that is, a ratio of 1 to
1289; in 1898, 35,057 to 40,380,792, or 1 to 1151 ; in 1907, 39,827 to 44,100,231,
or 1 to 1107. London, with a present population of 4,536,541, had 4801 registered
physicians, a ratio of 1 to 945; at Birmingham, the present ratio is 1 to 1376; at
Newcastle, 1 to 1418. In Scotland, overcrowding is in the large cities pronounced,
though it is to be remembered that the consultants of the entire country are con-
centrated in a few towns: Edinburgh shows a ratio of 1 to 489; Glasgow, 1 to 754.
The country districts show no scarcity: omitting 39 towns containing 10,000 or more
inhabitants, Yorkshire has one physician for 2057 persons ; Devon and Cornwall, less
fourteen such towns, one for 1238 ; Cumberland, less four towns, one for 1882; War-
wickshire, less eight, one for 1139. In Scotland, Sutherlandshire has a physician for
every 1121 inhabitants; Argyllshire, less two towns, shows the ratio 1 to 799; Fife-
shire, less three towns, 1 to 1622; Aberdeenshire, less three, 1 to 1164.^ Population
being denser than in Germany or Austria, inequality between to^v^l and country is
much less marked, the country itself being so overcrowded that a livelihood is far too
precarious: not much over one-half of the profession actually achieve a fair success
or better.^ In general, in the decade 1891-1901, the population of England and Scot-
land increased about 10 per cent, the medical profession over 20 per cent. Despite
the increase in total registration, the average annual registration is now declining.
The average annual registration in England during twenty-four years was 674, dur-
ing the five years preceding 1910, 593; in Scotland, 470 and 434 respectively. This
temporary diminution in an overcrowded profession is not alarming. It is probably to
1 See chapter xi.
2 Based on Churchill's Medical Directory, unofficial but approximately accurate. How many registered
physicians have withdrawn from practice, it is impossible to say.
5 Sprigge, pp. 30-37, n
30 MEDICAL EDUCATION
be accounted for by the existence of relatively brighter prospects somewhere else. In
any event, it is no sufficient reason for leaving British medical education untouched for
fear of imperiling the necessary supply. The statistics of a larger span show clearly
that the profession may be counted on to increase; it would be unwise to let it increase
without any of the checks that higher entrance standards, higher educational ideals,
and fewer schools would supply, — checks that would certainly insure a better profes-
sion without imperiling a sufficiently numerous one.
In France medical schools of three types are found: the university faculties, eight
in number, situated at Paris, Lyons, Bordeaux, Lille, etc.; so-called schools "de plein
exercise," attached to hospitals in three cities, — Marseilles, Nantes, and Rennes, where
there are no universities; "preparatory schools," likewise attached to hospitals in
twelve non-university towns, such as Angers, Dijon, Rouen, and Amiens, and offering
coui*ses covering only two years of the curriculum.^ In all three types, the government
designates the professors; but as, with rare exceptions at Paris and Lyons, appoint-
ments go to local men engaged in practice, not even the university faculties are built
on university lines. The second and third types differ from the first in their total
isolation and in the source of support; for the state finances the universities, the
municipalities fijiance the others, — as far as they are financed at all. Only the univer-
sities are empowered to conduct examinations; hence, twice yearly, university professors
are delegated to conduct examinations at the inferior institutions. Practically, these
inferior establishments are of little importance. Of a total enrolment of 8850 medi-
cal students in January, 1911, 7652 were found in university faculties, 557 in schools
"de plein exercise,**' and 570 in the preparatory schools. Paris alone registered 4101,
Lyons 968,^ Bordeaux 732, Montpelier 659, Toulouse 412, Nancy 340, Lille 279,
Algiers 161. The non-university school at Marseilles enrolled 256, at Nantes 158,
at Rennes 143 ; of the twelve preparatory schools, Angers, the largest, had 86 students,
Besan^'on, the smallest, 32. The year's output of graduates was 883 ; Paris furnished
450, Montpelier 120, Nancy 32, Algiers 3.
The relation between the size of the medical professson and the population that it
serves, appears to resemble what we have previously encountered elsewhere. The num-
ber of registered physicians in the country increased from 14,846 in 1881, to about
20,000 in 1909, — an increase of 30 per cent in a period during which population
increased 10 per cent.^ Locally, conditions repeat those prevailing elsewhere : Paris had
^ The history of these partial schools is as follows : Prior to the Revolution, there existed in the more
important towns of France corporations of surgeons with certain educational functions. On the sup-
Eression of these bodies in 1793, the door to the practice of medicine and surgery was left wide open ;
ut the abuses of unrestricted practice soon proved intolerable. By a series of decrees, beginning in
1820, the last as recent as 1894, so-called secondary schools of medicine were established in twelve
towns. These schools consist of local hospitals, to which meagre laboratories of physics, chemistry,
biology, anatomy, and physiology are joined; their students remain for two or three years, betaking
themselves elsewhere for the rest of their work.
* Not reckoning about 200 military surgeons.
' Coriffi-h dea Practir.iens, Avril 1910, vol. i, p. 249.
NUMBER AND DISTRIBUTION OF PHYSICIANS 31
one physician to 1126 inhabitants in 1894, one to 931 in 1901, one to 767 in 1908. In
general the towns are overcrowded, the thinly peopled departments undersupplied,
because they offer no inducements. There are 15,459 phj^sicians outside Paris for
a population of 36,488,852 (ratio 1 to 2360). In the department of Ain, 122 doctors
for 345,856 (ratio 1 to 2834); in that of Alpes (Basses), 39 for 115,021 (ratio 1 to
2949); in Lozere, 40 for 128,866 (ratio 1 to 3221). In towns, by way of contrast, Mar-
seilles (population 491,161) has 378 doctors (ratio 1 to 1299); Lyons (population
472,114) has 421 (ratio 1 to 1121); Limoges (population 84,121) has 49 (ratio 1 to
1716); Poitiers (population 39,886) has 32 (ratio 1 to 1246).'
The foregoing discussion appeal's to warrant the following conclusions: overcrowd-
ing of the profession takes place in Germany and Austria on a high, university basis,
in England and Scotland on a low, proprietary basis. It is, indeed, as would be ex-
pected, more marked in the latter countries, but its occurrence in all indicates that
high standards as such do not mean a depleted profession. Wherever adequate general
school facilities have been provided, a high standard of medical education, despite its
attendant delay and expense, is entirely consistent with an abundantly, even too
abundantly, numerous profession. Low remuneration, doubtful success, excessive com-
petition, do not effectually deter. The danger of depletion cannot, therefore, anywhere
be urged against conversion of low standard proprietary education into high standard
university education as fast as proper secondary school facilities can be provided.
The reason is plain : medicine is at once an interesting and an attractive profession.
It offers powerful inducements of scientific and social nature, so powerful that addi-
tional educational barriers merely increase both its scientific possibilities and its so-
cial distinction. A surplusage may exist, whatever the educational basis. Where edu-
cation is on a university basis, surplusage is ascribable to the social prestige and
scientific interest of the learned professions; where education is on a proprietary basis,
a larger surplusage represents in no slight degree the admission of the unfit. Under
university conditions, therefore, a supply of higher quality is better adjusted to the
demand, — never so closely, however, as to exclude selection of the more capable by
wholesome competition. The sacrifice of sound educational principle, and resistance
to progress along modern university lines, profit only the individuals interested in
private ventures. Nor can proprietary education fairly plead in extenuation any in-
direct benefit to the state. It leaves society still to deal ^vith the problem of the back
country; it lowers the quality of the urban physician, embittering and demoralizing
his struggle for existence.
1 Figures taken from Guide Rosenwald, 1910. It must be remembered that raidwives, being numerous,
diminish the burdens of the profession, as do also the quacks.
CHAPTER III
THE BASIS OF MEDICAL EDUCATION
Three-fourths of the students beginning the study of medicine at the German
univei'sity are under twenty-one years of age. There, as elsewhere, the average age
has risen, while at the same time the average period of study has lengthened. In
the eighteenth century, the student came to the university in his eighteenth year;
toward the close of the succeeding century, in his twentieth. At that point the
average now remains, with an observable tendency higher: in 1899-1900, 22.2 per
cent were over twenty-one; in 1902-1903, 26.83 per cent; in 1905-1906, 26.46 per
cent. Meanwhile, the percentage of students entering under nineteen shrank from
26.72 per cent in 1899-1900 to 23.80 per cent in 1905-1906.^ A few months previ-
ously, the student has been graduated from a nine-year secondary school. All pursue
that beaten path; it forms the only approach to the medical profession. The intending
physician must have completed a regular secondary curriculum ; thereupon he must
study medicine at a university. On no other terms can he look forward to engaging
in the practice of medicine, surgery, or any medical or surgical specialty.^
During the whole of the nineteenth century, this path was alike steep and nar-
row. The recognized Gymnasium was a classical school, established in essentially its
present form in 1810, when the new conception of the university as an institution
for professional training and research necessitated the widespread organization of
secondary schools capable of supporting the academic structure. As organized they
were decidedly partial affairs, even though called institutions of general culture.
Philology in one form or another dominated the curriculum. Unable, therefore, to
find adequate expression in the crowded and hostile humanistic Gymnasium^ the
modem side, as it is aptly called in England, procured in 1859 its own establish-
ment, the Realschule, subsequently developed into the Realgymnasium. A third form,
the so-called Higher Realschule, — even more explicitly modern and scientific, —
was established in 1882. University privileges, however, were limited to the classical
Gymnasium^ which enjoyed an unbroken monopoly during the entire century. Not,
of course, without vigorous protest, in which, with characteristic outspokenness, the
youthful emperor, William II, dramatically joined on the occasion of a general edu-
^ Preuss. Statistik, 204, pp. 116, etc. See also Lexis: Deutsche Universitdten, vol. i, pp. 136, etc.
2 Excepting only obstetrics: midwives are licensed after special training. The so-called " Personal-
Verzeichniss" issued by each university, in enumerating students, sets aside those enrolled in the
medical faculty "without certificate of graduation from a gymnasium"("ohne Reifezeugniss"). These
are mere hearers, who cannot come up for examination. They are relatively much rarer in the medical
than in the philosophical faculty, as the following figures show :
Hearers in Philo- Hearers in
University Semester sophical Faculty Medical Faculty
Berlin 1908-1909 677 0
Bresl.-iu 1909-1910 284 0
Halle 1909-1910 162 82
Marburg 1909-1910 68 88
Kiel 1909 T9 0
BASIS OF MEDICAL EDUCATION
83
cational conference assembled shortly after his accession. Bitterly recalling the in-
sufficiency of the education that he had himself received in the classical Gymnofnum
at Cassel, he declared: "I believe I realize to what goal the modem spirit and the
century now approaching its close are tending, and in educating the oncoming gen-
eration, I am resolved, as I was resolved in taking up social reforms, to travel the
new paths which, beyond all question, travel we must." The concessions obtained
at the moment were slight ; ten years later, however, the emperor was able to issue
the rescript^ that affirmed the equivalence^ of the three types of secondary school.'
In this scheme the experience of a decade has disclosed certain defects that I shall
mention in passing. But they are far outweighed by its merits ; for the scheme recog-
nizes individual diversity and procures both continuity and variety, while avoiding
the dangers arising from dispersion and promiscuity.
These three types can be very readily characterized and differentiated. Alike they
consist of nine successive classes; all offer practically the same courses in history,
religion, German, and geography, some science, and some mathematics. On this
common basis, varying but slightly from state to state, the classical Gymnamim
emphasizes strongly Greek and Latin; the Realgymnasium^ omitting Greek wholly
and relegating Latin to a somewhat inferior position, stresses, particularly in the
higher classes, the modern languages and the sciences; the Higher Realschide, cut-
ting loose entirely from the ancient languages, throws itself frankly and unre-
servedly upon modem subjects. The classical Gymnasium and the Higher Real-
schnle are clean-cut embodiments of mutually exclusive ideals. The Realgymnasium
is a compromise, retaining part of the humanistic discipline, while embracing mod-
ern interests and activities.* Between the three, the youth chooses early, — as a rule
1 AUerhochster Erlass vom 26 Nov. 1900, It is given as an introduction to Lexis: Die Reform des
hoheren Schulwesens in Preiissen (Halle a. S., 1902).
2 This was, in the first instance, a Prussian, not an imperial reform : it applied to the study of philoso-
phy and law, not of medicine, since the last was left to imperial regulation. As the matter now stands,
the study of medicine has been opened to graduates of the three tjT^es of secondary school, but stu-
dents coming from the Higher Realschule are required to present evidence of having studied Latin,
which is not included in the curriculum of the Higher Realschule.
3 In Austria, the same step was taken only a year ago.
4 For all nine classes, the different subjects and the total hours of weekly instruction offered are as
follows :
Hours of Instructiox includixg all Classes
Subjects
Religion
German
Latin
Greek
French
English
History
Geography
Mathematics
Science
Writing
Drawing
Total
Gymnasium
Realgymnasium
Higher Realschule
19
19
19
26
28
34
68
49
0
86
0
0
20
29
47
0
18
25
17
17
18
9
11
14
Z\
42
47
18
29
36
4
4
6
8
16
16
269
262
262
84 MEDICAL EDUCATION
in his tenth or eleventh year; the clioice once made, little room is left for subsequent
movement within the curriculum. The risk attending so early an option has latterly led
to still another innovation, the so-called Reform Gymnasium, which aims to defer
decision by so redistributing subjects that all pupils may have from three to five years
of common discipline before reaching the fork in the gymnasial road.^ The gymnasial
course closes with the leaving-examinations, conducted by a commission consisting
of the teachers and director of the school and a government representative. With this
body, sitting as an examination board, a transcript of the student's record is filed.
The candidate then undergoes written examinations that include a German essay,
translations from and into whatever languages he has studied, plane geometry, solid
geometry, etc. The seriousness of the tests may be gathered from the time allowance:
five hours for the German essay, as many for mathematics, three hours for Greek and
French, two for Latin. For the oral tests, students appear in groups of ten. They are
questioned by their own teachers ; but other teachers present, and the inspector, are
free to interject questions. The examinations are reputed to be decidedly severe. Yet
the classes have been so carefully weeded out year after year that the percentage of
failure among candidates for the leaving-certificate is not heavy : 3.16 per cent at the
classical Gymiiamim, 2 per cent at the Higher Recdschule}
The examinations that thus terminate the secondary school open the university
career. The successful youth receives a certificate of maturity {Reifezeugniss\ which
admits without further parley to any university in the land ; ' nor can he become a can-
didate for university degrees or present himself for examination in medicine unless
he has thus entered the univei'sity. Historically, the maturity examination originated
in the desire to protect the university against unfit students. Nevertheless, it is in
theory and practice viewed not as an entrance examination in reference to the uni-
The following illustrations indicate the range of the instruction:
Gymnasium :
Latin : Oiesar, Ovid, Vergil, Cicero, Sallust, Livy, Tacitus, Horace ; in Bavaria and Saxony, Quintilian, Terence,
Plautus, also.
Mathematics : Alpebra, Plane and Solid Geometry, Trigonometry.
Science : Botany, ZoOlogy, Mineralogy, Elementary Physics, and Chemistry.
Realgymnasium :
Latin : Caesar, Ovid, Curtius or Livy or Cicero, Vergil, Horace, — the two latter limited to simpler extracts.
Mathematics: Algebra, Advanced Plane and Solid Geometry, Advanced Trigonometry, Analytic Geometry.
Science: Experimental Physics and Chemistry.
Bigher Realnchule :
Mathematics: Higher Algebra, Geometry, Trigonometry, etc., carried further.
Science : Botany, Zoology, and Mineralogy, more thoroughly. Advanced Physics and Chemistry, including Organic
Chemistry.
For detailed and complete description, see Lexis : Das Unterrichtsicesen im Deutschen Rsich, vol. ii,
pp. n9-lo2 (Berlin, 1904).
^ According to the Frankfort plan, the three lowest classes are in common ; at Hanover and Breslau,
five. The question is fully discussed by Dr. Karl Reinhardt in Die Reform des hiiheren Schulwesem
in Preiusen (chapter xx).
2 These figures have been courteously furnished by Geheimrat Reinhardt. It is to be remarked that
many pupils enter the Gymnasium with no intention of remaining beyond "Untersecunda," successful
completion of which reduces military service to one year. These students are in no wise to be reckoned
as failures.
3 This certificate is deposited with the university, where it remains as long as the student is in
residence.
BASIS OF MEDICAL EDUCATION 35
versity, but as a leaving-examination in reference to the secondary school. Second-
ary school teachers — the boy's own teachers at that — are, under supervision, the
responsible agents in the transaction. It is presumed that if the student is fit to leave
the secondary school, he is by that same token fit to enter the university : and of the
former fitness, which implies the latter, his teachers in the gymnasium are the proper
judges. The definiteness and imiformity of school values renders this arrangement
safe and convenient. Under its working, the universities are spared the necessity of
"going back of the returns;" the ReifezeugnisSy or leaving-certificate, circulates
at face value throughout the empire; and students move without let, hindrance, or
discount from one institution to another.^
In the decade that has passed since the breaking of the gymnasial monopoly, Real-
schulen have greatly increased. In 1900, there were in Prussia 295 Gymnasien as against
135 Realgymnasien and Higher Realschulen; in 1909, 336 Gymnasien, 138 Realgym-
nasien, and 85 Higher Realschulen.^ While the classical Gymnasien have increased
14 per cent, the scientific secondary schools have increased 66 per cent.^ The total
attendance in the same period was as follows:*
Tear Classical Gymnasien Realgymnasien Higher Sealschulen
1890 77,811 26,272 4,177
1900 89,257 (increase 14%) 21,433 15,134 (increase 20%)
1909 106,794 (increase 19%) 46,080 34,735 (increase 129%)
Enrolment
Classical Gymnasien
Realgymnasien
77,811
26,272
89,257 (increase 14%)
21,433
106,794 (increase 19%)
46,080
iQuates :
Classical Gymnasien
Realgymnasien
3,657
539
4,646
709
5,735
1,243
Tear Classical Gymnasien Realgymnasien Higher Realschulen
1890 3,657 539 18
1900 4,646 709 1,315
1909 5,735 1,243 1,885
The relative importance of the humanistic Gymnasium is thus gradually declin-
ing. In 1900, 59 per cent of all Prussian boys in secondary schools were studying in
the classical schools, as against 14 per cent in Realgymnasien, and 27 per cent in Higher
Realschulen and Realschulen ; a decade later, the percentages i-un 48, 21, and 31, re-
spectively.' The inherent affinity of medicine for the scientific secondary schoohng
1 For a concise account of the leaving-examination and a summary of what is to be said for and
against it, see Loos: Handbuch der Erziehungskunde, vol. ii, p. 17 (Vienna, 1908).
2 Each type also has a shorter form found in smaller communities, — the Proffymnas'mvi, Realprogym-
nasitim, and ReaUchide, respectively, each offering six years' work leading up to the seventh in the
complete school of its own type. The increase of the secondary pro-schools is reflected in the follow-
ing figures :
Year Progymnasien Realprogymnasien Realschulen
1900 60 23 132
J 909 35 45 169
3 In the same period population has increased 16 per cent, showing that gymnasial education is pene-
trating the people more deeply.
* Die Refoi-m des hoheren Schulwesens in Preussen, pp. 411-416.
5 A. Tilmann : ilonatschnft fur hohere Schulen, June, 1910, p. 298. The same article contains a highly
interesting- account of the cost of keeping up the secondary school system of Prussia. It appears that
36
MEDICAL EDUCATION
is gradually affecting the student's option. The following tables depict the progress
of the movement:
SeTtiester
(S, Stimmer: W, Winter)
Total
MafricuiTtion
in Medical Faculty
FVom
Classical'.
Gymnasien
From
Real-
gymnasien
From
Higher
Realschulen
1908 (s)
2,786
2,379 (85.3%)
3:?0(11.5%)
87 (3.2%)
1909 (s)
3.669
2,877 (78.4%)
589(16.1%)
203 (5.5%)
1910-1911 (w)
3,873
3,057 (78.9%)
597 (15.4%)
219 (5.7%)
Of students in their first semester:
Semester Total
Classical Gymnasien Realgvtnnasien
Higher RealschvJen
1910 4o3
325
86
42
The explanation of the foregoing figures is not far to seek. Only during the last few
years have the secondary schools been graduating the students who entered since the
breaking of the classical monopoly. In this brief space of time, the contribution to the
student bod}' in medicine from the scientific gymnasia has risen from 14.7 per cent to
21.1 per cent. In considering these figures, two facts must be borne in mind: general
culture, not special fitness, is still supposed to be the proper equipment for any sort of
university career; whatever special knowledge maybe needed the trained mind read-
ily picks up. This view is — as we shall see — an en*or, but an error not yet clearly
exposed. Besides, the humanistic tradition is strong in the educated classes ; and the
educated classes form a fairly well-defined caste. One-third of the entire student en-
rolment of the universities comes from official and professional ranks; the fathei*s of
one-fourth were themselves university students with humanistic training, of course.^
Although the total number of university students has greatly increased, only a
the total cost of the establishment increased from 18,419,000 marks in 1901 to 73,740,000 marks in
1910, that is, 52 per cent. The sources whence these sums (millions of marks) are derived are thus
sho\\Ti :
Year Total Fees Endotcments Municipal Taxation Contributed by State
1901 iSH 19 3 14 12
1910 73?4 31 4 24 14
1 Preuss. Statistik: Tabelhn, p. 34, etc. Eulenburg: Frequenz, pp. 258, etc. The appended tables show
the developments, including all faculties :
All Prussian UxrvEnsmES
From
From
From
Total
Classical
Real
Higher
Semester
Matriculation
Gymnasien
Per cent
Gymnasien
Per cent
Realschulen
Per cent
1901-1902 (w)
1173
1143
97.5
30
2.5
1902 (s)
1093
1028
94.
65
6.
1902-1903 (w)
2318
2230
96.2
88
3.8
1903 (s)
2103
19U6
94.9
108
5.1
1903-1904 (w)
2131
1983
93.
148
1904 (s)
2082
1920
92.2
162
7.8
1904-1905 (w)
1950
1776
91.
175
9.
190S (s)
2117
1923
90.8
194
9.2
1906-1906 (w)
2017
1806
89.6
209
10.4
1906 (s)
2176
1934
88.9
241
11.1
1906-1907 (w)
2324
2076
89.3
249
10.7
1907 (s)
2534
2216
87.5
264
10.4
64
2.1
1907-1908 (w)
2643
2289
86.6
291
11.
as
2.4
1908 (s)
2786
2379
86.3
320
11.5
S7
3.2
1908-1909 (w)
3072
2646
82.9
407
13.2
119
3.9
1909 (s)
3?86
2091
81.9
442
13.4
KvS
4.7
1909-1910 (w)
3636
2832
80.1
6.36
16.1
lf.9
4.8
1910 (s)
3669
2W7
78.4
689
16.1
203
5.6
BASIS OF MEDICAL EDUCATION 37
negligible fraction of the increment has been derived from the lower strata of society.
In truth, Germany is, and is purposely kept, an aristocratic country; and an obso-
lescent education is one way of hedging an aristocracy about. Transit from popu-
lar and technical schools into the Gymnasien which constitute the portals of the uni-
versity is none too common and none too easy. The stream that would most probably
swell the scientific enrolment is thus dammed before it gets so far. Of those whose
social position or origin destines them to the university, only the exceptionally vigor-
ous or the unconventional are likely to break abruptly with humanistic tradition.
Meanwhile, prosperity is creating another source of university recruits. The rich mer-
chant or manufacturer wants some of his sons to continue his business; but he also
wants the family prestige elevated by having a son or two in a profession. The more
downright follow inclination by approaching the university through the modern side
of the gymnasium ; those who are sensitive to the social value of humanistic association
go to the classical gymnasium, thus marrying into the educational aristocracy.^
As to the comparative value to the prospective medical student of the three
secondary disciplines respectively, there is in Germany even now nothing like una-
nimity of opinion, although the modern trend appears to be steadily gaining. At
the very beginning of the movement in favor of modem studies, the urgent needs
of medical education were made prominent; but when, in 1869, the Prussian min-
istry took counsel, the medical faculties were almost evenly divided in opinion.
The faculties of Berlin, Breslau, and Halle were squarely against a new departure;
that of Bonn refused to take a stand, for the professors were unwilling to abandon
the classical discipline, even while they admitted that "science teaching in the Gym-
nasien was shamefully neglected." Gottingen, Kiel, Konigsberg, and Greifswald were
favorable to the modern order. In the conference of 1890, even Helmholtz argued in
behalf of the supenor disciplinary efficacy of the ancient languages, especially Greek,
although he is nowadays cited by Ostwald as a brilliant illustration of their futil-
ity;^ for as he himself confessed in the remarkable address delivered at the celebra-
tion of his seventieth birthday; "Many a time while the class read Cicero or Virgil,
both of which greatly bored me, I was calculating the path of parallel rays through
a telescope under my desk." As recently as November, 1909, a conference at Munich
was still discussing the question: "What secondary school training is most desirable
for the study of medicine?"^
Nov-Prussian Universities
Semester
iVo.
Total
Matriculation
Classical
Oymnasium
Per cent
Real-
gymnasium
Per cent
Higher
Realschule
Per cent
1907-1908 (w)
1908 (s)
1908-1909 (w)
7
8
11
1896
2646
4583
1566
2061
3801
82.6
80.9
82.9
297
407
654
15.7
16.
14.3
33
78
128
1.7
3.1
2.8
(The above figures are taken from the Monatschrlft fur hohere Schulen — passim.)
1 The classics are held to be "vornehmer."
2 Grosse Manner, p. 344 (Leipzig, 1910).
3 Full proceedings are given in the Miinchener Medizinische Wochenshrift, 1910, No. 19.
38 IVIEDICAL EDUCATION
Grave diffei-ences of opinion exist in Germany, as elsewhere, respecting the method
to be employed in settling such problems. The breaking of the monopoly of the cleissi-
cal gymnasium was not itself necessarily a final solution; for it yet remains to be
decided whether the three possible paths that now lead to the medical cuiriculum are
in fact equally acceptable. How is one to decide?
One may proceed in either of two ways: from the standpoint of abstract educa-
tional principle, or from a consideration of the antecedent requirements of the object
to be attained. Partisans of the classical basis start fi"om the former. Their argu-
ment requires one to concede in advance certain highly debatable propositions as to
mental discipline and the peculiar efficacy of the ancient languages in this regard.
These propositions appeal with force only to those disposed in advance to grant
them. The intrinsic value and interest of the classics are not now in question, — merely
their educative importance to those that have no other concern with them. When
the problem is thus naiTowed, it is hardly too much to affirm that favorable causal
relations between the humanistic discipline and subsequent scientific performance
cannot be definitely made out. Nor can the argument from abstract principle be suc-
cessfully buttressed with statistics that prove, at the most, only that many men who
have worked through the classical gymnasium have also succeeded in working through
the medical faculty. The achievement of brilliant success in science proves the pos-
session of extraordinary ability, not the virtues of a classical education ; for extraor-
dinary ability attains its objects, regardless of schoolmasters. Something would be
proved for the humanistic cause if it could be established that students of mediocre
capacity from the classical schools do better in medicine than students of mediocre
ability from the Reahchulen, for mediocrity can noticeably be helped by propitious,
and hindered by unpropitious, suiToundings. But on this point statistics throw no
light. To mere argumentation the partisan of a more modern procedure, therefore,
opposes a stubborn skepticism. The needs and the problems of the medical curricu-
lum stare him in the face. From them he reasons backward.
The current of opinion flows, more strongly than surface appearances indicate,
against the classical gvnmasium as an acceptable or feasible basis. Reason and his-
tory both suggest suspicion. It is indeed the difficulty with customs and institutions,
— educational as well as others, — that they maintain in one situation prestige won
in quite another. It becomes, therefore, difficult to deal with problems on their merits.
Here is a case in point. The classics achieved their prominence under educational
conditions and for educational objects wholly unlike the conditions that now obtain
in medical education. Would it be anything less than an educational miracle, if a
form of training that came into vogue for scholastic purposes proved some centu-
ries later the fittest discipline preliminarv to sciences which represent the opposite ex-
treme in content, logical method, and attitude to life, — more fit than any alternative
that can now be devised by those battlin*; with the difficulties of a concrete situa-
tion.'* Such educational predestination seems in the highest degree improbable. The
BASIS OF MEDICAL EDUCATION 39
grounds on which classical training is now commended have, as a matter of history,
nothing to do with the causes that gave that training currency. The classical lan-
guages were originally taught largely because they were needed. They had become
a habit by the time they ceased to be needed. New reasons had then to be contrived
to explain their continued study; these were, of course, readily found: the classics
were the only gateway to superior culture; the peculiar structure of the ancient
languages made them a potent instrument for the discipline of mental faculty.
For a time, the former argument was taken to be the weightier; but it has lost in
importance with the growing recognition of the fact that boys acquire little of the
ancient culture in the course of their study of ancient languages, and what they do
acquire is of dubious adequacy or authenticity. At the moment, the case rests rather
on the formal argument: "The gymnasium has done enough even for the future doc-
tor, if it has taught the youth to think logically and has permitted his judgment to
harden and ripen."^ Long strides are lightly taken in such argumentation. To say
the least, it has nowhere as yet been proved that, as mere discipline, formal disci-
pline is superior to one that actually takes account of the normal activities of youth
or of the object toward which he strives; nor does it follow that it is feasible to
organize education thus, even were it true.
The fact is, that the passage from educational principles, so-called, to specific edu-
cational content is highly perilous. Principles in education have hitherto been mainly
pretentious warrants for doing what the schools propose to do anyway, for some other
reason; they have been neither fundamental nor comprehensive. Derived from the
imagined virtues of a certain subject-matter, they shortly reappear as its sanctions.
A specific content can be inferred from them only because it is their own source. As
a matter of fact, such principles as we can hope to establish in secondary education
are psychological and social rather than philosophical; they concern presentation
rather than content. The problem of education is relatively constant: to assist the
individual to organize himself in harmony with his environment and his purposes.
Psychology can hope to be distinctly suggestive as to procedure. But the contents
of the school plan must change with the changes of the environment and the object:
long prescription is a doubtful argument in behalf of any curriculum.
Therefore, in the construction of a course of study for a progressive society or a
progi'essing object in such a society, what may not unfairly be called opportunism
must necessarily play a large role. Suppose, for example, it were demonstrated that
formal discipline is of greatest value and that the Chinese language is the best vehicle
for formal discipline : the existence of teachers in plenty being assumed, would it then
be feasible or wise to introduce Chinese into the secondary schools? Clearly not; in
the choice of the curriculum not only formal ends, but actual content, must be re-
garded; and the practical educational problem of every age may well be, not to pro-
cure the most effective formal discipline, excluding all other considerations, but to
1 Bickel : Wie studiert man Medizir. ? p. 5 (Stuttgart, 1906).
40 MEDICAL EDUCATION
derive from a content dictated by social conditions the best discipline obtainable. For
as modern education is a function of social life widely taken, its subject-matter must
bear an unmistakable relation to the interests, activities, and purposes of the age,
and of the individual's object and environment. No single principle can then dictate
the constituents of a course of study, which must rather recognize and endeavor to
harmonize many motives. It includes one thing because it desires to communicate a
valuable content, something else in order to test or develop a particular capability,
and still another thing by way of furnishing a tool that may contribute in one case
to enjoATiient and in another to profit. The secondary school cundculum is necessarily
a compromise of this complicated character; it can, therefore, accommodate any
congenial and helpful subject that, viewed from an opportunistic standpoint, is of
value, — whatever else it may contain and for whatever reason.
The classic languages thus undoubtedly obtain a place in the secondary school
for such as choose to pursue them, — in which respect they are on the same footing as
most other subjects. The central branchesof acoui^se of study may, however, also fairly
be dictated by the goal that the student hopes to reach. He may not at the moment
himself choose to study chemistry, even though he knows he will ultimately study
medicine: he may prefer something more decorative. In that case, his eventual ob-
ject must at the proper time retroactively overrule his personal preference. In choos-
ing the end, he must submit to the means involved in it. Now and then, of course, the
student's instinctive choice will anticipate just such prescription; he will want to do
betimes the very things that his ultimate purpose would, if consulted, suggest : self-
expression and life-object neatly coincide, A Helmholtz or a Faraday thus unerringly
defines his object in life by a dominant trait; his entire spiritual and intellectual life
ordersitself spontaneously around a single burning focus. But the less highly and en-
ergetically organized individuals, of whom for the most part the world is composed,
select their objects more or less adventitiously, and remain, perhaps, permanently in
doubt as to just what use they would make of an unrestricted opportunity for self-
development, should they get it. For the genius at white heat, guidance comes from
within; for the rest, some sort of control must be exercised from without. How these
various aims and needs are to be recognized in secondary education is a problem in
adjustment not to be solved on the basis of abstract principle.
The growing preference for the scientific secondary training corresponds with
increasing acknowledgment of the urgent necessity of consulting the ultimate oljject
for guidance in this matter. Abstract educational principles cannot alone or chiefly
determine. We must analyze the situation of tlie mediail student, we must analyze
the medical curriculum, and thereupon, with full knowledge, decide how the diffi-
culties that are discovered are to be met.
The main difficulties are these : the age of entrance upon the study of medicine
is rising, — economically and educationally a distinct misfortune. To make things
worse, the cumculum has steadily expanded. Despite increased length, it is still
BASIS OF MEDICAL EDUCATION 41
packed to the bursting point, as mere enumeration of its contents will prove. The
student must now get, wholly within the university if classically trained, physics,
chemistry, biology, anatomy, physiology, pharmacology, bacteriology, pathology,
hygiene, medicine, surgery, gynecology, obstetrics, pediatrics, etc. The task, how-
ever modestly conceived, is practically impossible. But if the learning of physics,
chemistry, and biology were remanded to the secondary school, congestion would be
to that extent relieved, and the more thorough training thus procurable would also
elevate the grade of work in the medical sciences.
This, then, is the procedure suggested by a study of the object. With the increas-
ing volume of things to be learned, the professional motive must become opera-
tive farther back. At a time when medical lore could be comfortably disposed of in
the course of eight or ten semesters, it was all very well to postpone decisions and
beginnings until the university was reached; but a reasonable acquaintance with the
field now requires both an earlier start and a more prolonged endeavor.
The prudential argument just presented is strongly reinforced by pedagogical con-
siderations. Youth is plastic, suggestible, energetic. Prolongation of an unrelated
schooling confiscates its years of promise and enthusiasm. Now that medical study is
specific in its demands, as to the type, training, and information required, the second-
ary school is in position to take time by the forelock. We know in advance what in-
struments the student will need to have mastered : modern languages, for example,
which, by the way, he learns best if he learns early and informally; manual dexterity,
not to be acquired after the muscles have " set ; " keen sense perception, lost unless
engaged and fixed in childhood and youth. The eye that is not early trained to
detect slight differences, the ear that is not early habituated to distinguish sounds,
the hand that is not early accustomed to skilful evolutions, lose once for all their
educative potentiality.
The same is probably true of the inductive habit. Medicine is not an exact science:
it is none the less inductive and experimental. The fact that its data are so com-
plex, that it deals usually with probabilities rather than with certainties, does not
destroy its scientific character; it only adds a reason for greater scientific caution.
Every point that the physician observes is to him a suggestion ; he looks for other
indications whose presence will confirm his tentative diagnosis, or he tries a certain
procedure, the outcome of which will decide whether he has read the situation aright.
The shuttle-like movement of mental process from observation of the patient forward
to inference or trial and then back to the patient again is a habit to be developed in
childhood and youth. The robust scientific temperament may be somewhat indifferent
as to what opportunity the schools give for its cultivation : unpropitiously placed, it
may, without being permanently injured, prove recalcitrant like Davy, or successfully
divide attention like Helmholtz. But in case of less gifted individuals, the chances to
determine the inductive mental habit that the school neglects, subsequent life veiy
rarely indeed recovers.
42 MEDICAL EDUCATION
No opportunities afforded at the university for the study of chemistry, physics, ma-
thematics, or biology retrieve what the gymnasium loses. In the first place, there is no
time.^ The capacities themselves have been blunted from disuse.^ In consequence, the
sciences are not thoroughly acquired even in an elementary form. "To my most ghastly
experiences as a teacher," says a distinguished clinician,^ "belong the hours in which,
in order to make a sugar determination, I must train my students to use a polarization
apparatus and to read off the result on a scale. Scarcely one in ten can properly carry
out the operation. That as late as the final examinations medical students habitually
confound a polarizer with a spectroscope may be incidentally mentioned."" The content
and the level of medical education are thus seriously prejudiced: "The preparation
of our students leaves, alas, much to be desired, and precious time must be wasted in
teaching the medical student to use his senses; to comprehend what he perceives and
properly to manipulate it in thought. But that is the foundation of medicine; the
student cannot practise observation and inference early enough or often enough."*
The defect is increasingly felt, not because the gymnasial teaching has deteriorated,
but because medical study has become increasingly definite and increasingly severe
in its demands. Students as competent in observation now as their predecessors twenty
years ago appear relatively inferior. That, on the other hand, brilliant successes can
be instanced proves little. One may possibly succeed in spite of education quite as well
as because of it. The factoi"s that determine a successful educational outcome are so
complex that it is impossible to determine the precise share of a particular part of
the curriculum in the result, however prominent. The mere fact that all hitherto
successful men were classically trained does not prove that a humanistic foundation
is either a wise or a necessary preliminary. It is precisely because no headway can be
made in this direction that it is important to obtain from the end to be reached per-
tinent suggestions as to the path to be chosen in order to reach it.
From time to time, the combination gymnasium already referred to has been urged
as the proper solution. But it seems clear that sound scientific training and thorough
humanistic training cannot be accommodated within the limits of a single curricu-
lum, even though it be nine years long. The centre of gravity must lie within the one
or the other, — humanities or science; it cannot lie in both. The scientific instruction
of the classical schools is destined to remain dilettante, — an incidental exercise to
awaken or to satisfy curiosity, or to furnish the child with a superficial training that
1 " It is a gross mistake, unfortunately very widespread, to believe that there is time enough to acquire
this preparation at the university," etc. A. Nagel : Die Vorhildunq zum med. Stwlium, pp. 3, etc. (Tu-
bingen, 1890).
2 " It is a fact that nowadays these capacities are quite inadequately developed in the average student.
The science teachers generally and vigfjrously complain of the awkwardness of the beginner." E. Bern-
heim: Der Universitdta-Unterricht, p. 5 (Berlin, 1898).
3 F. von Miiller: Munchener Medizinische Wochenschri/t, 1910, No. 19.
* J. Orth : Medizinische Unterricht und AertzUche Praxis, pp. 22, 23 (Wiesbaden, 1898).
BASIS OF MEDICAL EDUCATION 43
may lend interest to a vacation trip.^ In the same fashion, the modem gymnasium
must accept its inevitable limitations. Neither form of secondary school has thus far
recognized this fact. Hence all gymnasial programs are criticized as at once too
various and too arbitrary; they are censured as containing too many subjects and
as taking too little account of psychological motive. A reform urged with great force
at a recent gathering in Munich ^ proposes that the cun-icula be so simplified that
each will embody an optional major group, to which a required minor group will be
compulsorily attached.
It is, however, an en-or to suppose that the content of the cun-iculum is the only
important consideration. For the most aptly selected and most skilfully dovetailed
course of study does not automatically produce trained minds. Good teaching is of
supreme importance; inefficient teaching will spoil the most cleverly constructed
cun-iculum. The German gymnasial teacher is a trained expert in the art. In this
respect the humanistic instructor has thus far had the advantage ; for him a method
has been worked out through lengthy experience. The science teachers are just begin-
ning to define their objects and to elaborate an appropriate procedure; their early
efforts suffered from excessive extension, and from attaching too great impoi'tance to
facts, too httle to logical process and technical method. Despite the breaking of the
humanistic monopoly a decade ago, the numbers who have preferred the scientific basis
are so small that for practical purposes medical education in Germany may be said to
have rested thus far on the basis of a classical secondary education. Undoubtedlv, the
nan'owness and inelasticity of this prescription have, as I have urged, involved hard-
ship, just as the total inelasticity and the overcrowding of each of the three gymnasial
types still do. But at the same time, definiteness of curriculum and vigor of teaching
have had advantages that must not be lost sight of. The German student of medicine,
for the most part, has known no science at the start; he has been accustomed to alien
modes of thought and application. But to thought and application he has at any rate
been no stranger. While it would doubtless have been better had the hard work been
of a kind to select, to preserve, and to train the peculiar aptitudes henceforth to be
relied on, hard work of any kind is at once a sieve and a discipline: it eliminates the
incapable, — even though some of those eliminated may have been only philologically
incapable; it hardens the fibre of those that remain. Successful passage through the
classical gymnasium is, at least, a demonstration of application and power. Like
a stern upbringing, the rigidity of the gymnasium has not been an unmixed advan-
tage; but like a stern upbringing, it has been at once formative and selective. It may
be inelastic, severe, unsympathetic, and, so far, destructive; but it is also energetic
and serious, and, so far, genuinely stimulating. All kinds of gymnasia are alike in this
1 "Many view instruction of this kind as an asrreeable entertainment that introduces a httle variety
into the monotony of language teaching." J. Pagel: Einfiihrung in das Studium der Medicin, p. 56
(Beriin, 1899).
^ Aufgabe und Gestaltung der hoheren Schulen (Miinchen, 1910).
44) MEDICAL EDUCATION
important respect. The matriculation basis has been broadened, but it has remained
tjualitatively homogeneous, — homogeneous in respect to the soHdity of acquirement
and the continuity of effort represented.^
In striking contrast with organized and systematized Germany are the conditions
surrounding secondary education in England. The national tradition is one of ram-
pant individualism ; as against it the national need of effective educational devel-
opment and organization has been increasingly felt in recent years. Up to our own
times, tradition effectively checkmated need. The earliest voice in protest was that of
Matthew Arnold, but it was a voice crying out in the wilderness. Successive commis-
sions in 1861, in 1864, and in 1894, had in vain pointed out the fact that elementary
education in England was chaotic, and secondary education practically non-exist-
ent. The Englishman, fond of doing as he pleased and ^villing to pay for the privi-
lege, heeded not. Endowment had planted a school here, religious zeal had established
one there, business enterprise somewhere else; each went its own way. The endow-
ments were largely wasted; schools conducted by religious organizations or private
individuals without central direction or control were for the most part weak and
inefficient. After a fashion, work of secondary grade was carried on by universities
and univei"sity colleges, for which expert "grinding" by tutors or special schools was
a sufficient preparation. The conception of secondary education as at once a step be-
yond the elementary school and the threshhold of the university and professional
school has not been widely entertained until very recently. Despite the efforts of a
few reformers to gain for the state a firm foothold and a definite function in that
field, little positive progress was made until 1902, when local authorities were con-
stituted for the express pui'pose of establishing secondary schools, and a special di-
vision of the national Board of Education, commanding sufficient funds, was created
1 Austrian conditions, while not so highly developed, are from the standpoint of educational attitude
so similar that they require no additional discussion. The monopoly of the classical Gymitashim lasted
in Austria until 1910; the RcaJschule has very slowly developed to full gymnasial stature. The Real-
gymnasium has a program of only four classes.
Number of Austrian Secondarv Schools
Year
Gymnasium,
Realschvle
1863
92
38
1S7S
95
74
1883
136
79
1893
156
77
1903
217
121
1906
827
131
The enrolment has been as follows :
Year
Gymnatium
Realschrde
1863
2'.I,7J8
9.087
1873
31, ITS
18..i.')9
1883
55,217
ifl.yio
I89S
56.581
22.933
1003
78.250
42,202
1906
87,*12
45,217
Loos: Hnndhnrh rier Erz'iehnnfjxhiTuh (.irticle "Rcalschule"). The Gymnasium and the Oherrpahchule
have each eight classes. For the curriculum of, and the privileges attached to, different certificates of
graduation, see Horn: Las /where Schulwesen der Staaten Europas, pp. 101-107 (Berlin, 1907).
BASIS OF MEDICAL EDUCATION 45
to cooperate with them.^ The terms upon which the contribution of the government
is made available tend indirectly to determine the type and scope of the school. They
include at this date freedom from denominational control, accessibility through the
offer of a stipulated number of free places to all classes of people,^ a four-year curri-
culum,* and governmental inspection. The course of study must include English, geo-
graphy, history, mathematics, science, drawing, and one language other than Eng-
lish. Development, though brief, has been rapid: since 1904, when the regulations
were revised and accurate statistics became procurable for the first time, the number
of approved secondary schools has increased from 491 to 802, the number of pupils
under instruction from 85,358 to 135,776; the government subvention, £200,591 in
1904, has been much more than doubled.* So quick and recent a growth cannot be of
the same texture throughout; teachers and equipment can be provided but slowly.
But, whatever may be its present defects, the nation would appear to have at last
decided in favor of the creation of an adequate national system of secondary schools.
From the standpoint of correlation with university or professional school, little
progress has as yet been made. Oxford and Cambridge are still of overshadowing
magnitude; and Oxford and Cambridge show slight inclination to take position with
reference to a national scheme for secondary or academic education. Nor do the pro-
vincial universities as yet regard the secondary school as the necessary basis of such
academic training as lies beyond it ; on the contrary, each of the several higher classes
of the secondary school is a step-off from which the student may gain academic foot-
ing at one higher institution or another, for the universities uphold no common
matriculation standard.^ A school whose sixth form admits to Oxford announces that
its fifth form prepares for Birmingham or Durham. The universities themselves —
even those situated in large cities — compete with the secondary schools by conduct-
ing elementary classes for matriculation.® That a modern university seeking to develop
^ A succinct sketch of the entire development is given in the Report of the Board of Education for
1908-1909, pp. 31-46 (London, Eyre & Spottiswoode, 1910).
2 On January 31, 1911, free places to the extent of 34 per cent were held by pupils from public ele-
mentary schools.
3 In small towns and country districts, a three-year curriculum is permissive for pupils who do not
leave school before they are fifteen years of age.
* Number of Secondary Schools in England, etc.
Number of Secondary
Number of
Amount of
Year
Scliools on Grant List
Pupils
Grant
1904-1905
491
85,358
£200,591
1905-1906
600
105.034
225,080
1906-1907
677
115,744
324,. 334
1907-1908
739
124,758
450.347
1908-1909
804
135.671
537,375
1909-1910 *
841
141,149
573,026
* Figures subject to correction.
5 The four northern English universities, Liverpool, Leeds, Manchester, and Sheffield, operate a joint
matriculation board.
« See Calendar of Victoria University, Manchester, 1910-1911, p. 213, for "Matriculation Time Table."
So at the University of Sheffield, rratriculation courses of a very elementary character are offered.
46 MEDICAL EDUCATION
research at the upper end should still be teaching the A B C of Latin and algebra
at the lower is not yet perceived to be altogether anomalous.
For the present, therefore, entrance upon medical education in England cannot
be located at a definite point in an orderly and progressive educational scheme; for
between the secondary school system and the medical school — whether of hospital or
university type — there is no educational relationship whatever. In Germany, as we
learned, the situation is characterized once for all when one says that the leaving-
certificate of a nine year school is the sine qua non for matriculation; there is no
doubt as to just what that leaving-certificate signifies in knowledge and training. In
deffiult of an organized system in reference to which the standard can be fixed, the
English prerequisite is defined in the form of certain specifications, to judge which
various bodies are competent. Before he is admitted to a medical school, an English
boy must at least produce a certificate showing successful examination by one of the
bodies in question in four subjects — three being languages: English, including dic-
tation, composition, parsing,^ and so on; Latin, requiring the study of Caesar and
some Virgil, as well as a limited experience in reading at sight;^ mathematics, includ-
ing arithmetic, elementary algebra, and three books of plane geometry; and one more
language, — Greek, French, German, or Italian, — the scope being approximately that
indicated by the prescription in Latin,
In Great Britain, the arrangements w ith respect to the conduct of these examina-
tions are somewhat complex. One cannot fully understand them without first know-
ing the method by which physicians are licensed to practise. This subject will be
dealt with fully in a subsequent chapter, which I must at this point briefly antici-
pate. As will there be explained more fully, examinations for the practice-license in
Great Britain are held by certain chartered professional corporations and by universi-
ties with medical departments: The Royal Colleges of Physicians and Surgeons exist-
ing in London, Edinburgh, Glasgow, Dublin, and the Apothecary Societies of London
and Dublin, are among the professional corporations to which the government has
delegated the privilege of "qualifying" physicians. These bodies admit candidates
after successful examination to degrees, if they be universities, to diplomas, if they
be professional associations; such degree or such diploma constitutes "qualification"
or warrant to practise. The charters of these institutions contain no limitations
whatsoever as to the educational basis on, or professional qualitv of the exami-
nations by, which they are to confer the right to practise medicine. The govennnent
has divested itself of control without exacting conditions as to how control shall be
as, for example, in Latin, Caesar, Bell. Gall., Book I : in English, Addison, Selections from Spectator,
Southey, Life of Nelson; in mathematics, algebra to progressions, etc.
1 The source of the selection to be parsed is at times indicated ; it is usually a poem like Goldsmith's
Deserted Village.
2 The University of London and the Conjoint Board do not require Latin ; they accept instead, in case
of Oriental students whose vernacular is other than English, examination in either science or a classical
Oriental tongue.
BASIS OF MEDICAL EDUCATION 47
exercised by those to whom it is delegated. It has presumed that bodies within the
profession will be sufficiently jealous of their prestige and their interests to protect
honor, dignity, and credit.
This expectation has not been wholly fulfilled. Intolerable discrepancy in point of
ideal among the examining corporations came to light coincidently with the gen-
eral rise of medical art. While the government was not even thus led to make itself
directly responsible for the character and fitness of those at whose mercy the health
and well-being of the citizen largely lie, society has nevertheless recoiled from some
consequences of the individualistic attitude. Control of a kind has somewhat unex-
pectedly issued. A man may, if he chooses to take the consequences, employ an out-
right quack; but as the state has commissioned certain organizations to distinguish
between doctors and quacks, the citizen ought at least to be so far protected that,
whichever he prefers, he may be certain of getting what he pays for. In order, then,
that the public may be in a position to distinguish between properly qualified and
unqualified practitioners of medicine, the General Medical CounciP was established
by statute in 1858. This body, consisting of representatives of the various examining
bodies, of the Crown, and of the profession at large, — in effect, therefore, representative
of the medical profession as constituted at the moment, — was charged with the duty
of registering all properly qualified physicians, and annually printing an authoritative
list thereof. So far the Council possesses no option whatsoever; it is bound to regis-
ter any applicant who presents a medical diploma fi'om a university or a certificate
of admission to membership in any body authorized to license practitioners of medi-
cine and surgery. While the Council thus far enjoys no discretion, it was fortunately
authorized to inspect the examinations of the various organizations above named;
and it was required to protest against examinations that were in its judgment "in-
sufficient,"— in the first instance, to the examining body itself; to the privy council, in
case the body complained of took no action. The privy council might do one of many
things: it might, for instance, close an offending school, or disallow theoffending exami-
nations. The right to inspect and comment upon examinations has been skilfully culti-
vated, until the General Medical Council has now taken thegroundthat it will stamp as
insufficient any examination that does not include a specified list of subjects, by which
interpretation it has practically won the opportunity to dictate the minimum accept-
able curriculum.^ What is more to our present purpose, the same species of tactics
enables it now to hold that no examination is sufficient unless the curriculum in
question presupposes the minimum general education specified above. The examining
bodies in whose hands legal power resides had indeed already started this movement
when the General Medical Council took it up. For years the Council has been sys-
tematically engaged in bringing about an agreement between the various licensing
boards as to a uniform minimum of general education, and it has done much to make
1 For fuller account, see chapter xi on Examinations and chapter xiii on Quacks.
2 See chapter xi. ^
48 MEDICAL EDUCATION
this uniform minimum a reality. An endeavor, however, to gain complete control has
thus far been balked. The Council has therefore never been able to exclude all varia-
tions. It has proposed, for example, that all medical students should be required to
register with the Council before beginning their medical education as well as after
obtaining the qualification. Such centralization would doubtless ultimately result in
wiping out the divergences from the recommendations of the Council that are still
permitted by some of the qualifying bodies. For, be it always remembered, though
now everywhere recognized as reasonable, the minimum basis set forth by the Council
is not legally binding, and no serious objection is made when an alternative or equiva-
lent of substantially the same value is accepted. For instance, the Council specifies
Latin as a subject that should be compulsory; the Conjoint Board of London con-
tinues to leave it optional. The Council was long of the opinion that the preliminary
sciences — physics, chemistry, and biology — should form part of the medical curri-
culum; the Conjoint Board meanwhile qualified candidates who presented certificates
in all or part of those subjects from cei'tain secondary schools. The Council sets its
face strongly against entrance examinations conducted by the qualifying professional
corporations ; its opposition is soundly based on the obvious unfitness of medical bodies
to conduct examinations in, or to pass upon questions pertaining to, general educa-
tion. Tlie laxity of their action in this matter is sufficiently clear from the fact that,
whereas at the College of Preceptors 677-i candidates examined between 1887 and
1891 show 66.5 per cent of failures, 3616 candidates examined at the same period by
the Apothecaries' Society of London show only 23 per cent of failures.^ In response
to the pressure of opinion, all the licensing bodies, except the Conjoint Board of
the Royal Colleges at Dublin, have now abandoned their examinations in general
education. But apparently not beyond all possibility of resumption.^
As the matter now stands, a minimum preliminary standard gradually acquiring
the force of law has been set up in indirect fashion. The right to issue the requisite
certificate of proficiency has practically passed from licensing bodies to the universities,
and to various boards and corporations established for the sole pui'pose of holding
examinations and certifying to their results. No medical school conducts an examina-
tion in general education, or even passes upon the adequacy of such education.'
1 Report of the Educational Committee of the General Medical Council, November, 1892, pp. 14, 15.
*A recent address. May 25, 1909, of the president contains the following significant paragraph:
"The Board of the Apothecaries' Hall of Dublin have informed the Registrar that they nave deter-
mined to postpone until July 1 the resumption of their 'Preliminary Examination in Education,' con-
cerning which the Council, on the recommendation of the Education Committee, expressed a strongly
adverse opinion at its last meeting. The Executive Committee will report on the reply to this intima-
tion which they deemed it their duty to forward to the Board. At a time when two newly constituted
teaching Universities, each with its own Preliminary Examinations, are in process of organization
in Ireland, it is difficult to perceive that any advantage to medical culture can arise from the proposed
incursion of the Apothecaries' Hall into the sphere of general secondary education and examination."
3 The situation in Scotland is distinctly more orderly. Since the early nineties, the four Scotch universi-
ties have maintained a joint board in charge of their preliminary examinations. .\rts and Sciences pre-
liminaries constituting one group. Medical preliminaries constituting another. Moreover, the Scottish
Education Department has latterly instituted leaving-exarainations of uniform character throughout
BASIS OF MEDICAL EDUCATION 49
Quite aside from the question as to whether the standard is high or low, its deter-
mination by external examination is a point well worth dwelling upon. In Germany,
we observed that the existence of an organized educational system enabled the uni-
versity to accept students on the basis of a completed secondary education, of which
the secondary teachers were themselves sole judges. Chaotic secondary conditions in
England compel the universities to sift applications by means of written examina-
tions which they themselves conduct; and as some measure and evidence of educational
achievement are convenient for other purposes than entering the universities, ad-
ditional agencies have been set up for the sole purpose of examining candidates and
conferring appropriate certificates. An unhappy divorce has thus been effected between
examining and teaching. Examining agencies such as the University of London, the
College of Preceptors, the Educational Institute of Scotland, do not concern them-
selves as to how the student has procured the preparation, on the adequacy of which
they deem themselves competent to pass. Of the teaching that has preceded the exami-
nation they know nothing. The examining bodies do not deal with institutions, with
schools as organized establishments of certain types: they deal only with individuals,
whose positive acquisitions they undertake to gauge. To examinations of this external
type the English are generally addicted. Examination is a national industry, getting
examined a national habit. Nor does it stop with secondary education. With rather
more rigid logic than is usually characteristic of the nation, a further step has been
taken : if, quite regardless of how the secondary work was covered, an external examina-
tion is capable of determining its adequacy, why cannot a still higher examination
award academic degrees in the same fashion ? If coaching and tutors can dispense with
the secondary school, w^hy not with the college and the university ? The University of
London, an examining body competent to award all degrees, is thus the logical out-
come of the national predilection for examining and being examined. So much is to
be said for this trait: it gives unusual individuals a chance to work out their destiny
in their own way. But the fallacy lies here : because an extraordinary person will some-
how find himself, it does not follow that eff'ective drilling and cramming on a large
scale according to the letter of stipulated requirements is a fair substitute for the
life and integrity of educational institutions. The examination may indeed disclose
whether or not an individual knows this or that, whether he can reproduce this or that;
but taken alone, it cannot interpret to outsiders how well he has been educated.
Unspeakable mischief has thus been ^\Tought, for the English teacher, constrained
by the written external examination, dare not, to quote Sir William Ramsay, train
his boys "to do something instead of to know something."^
Scotland. These examinations are so designed as to avoid interference with the liberty of the teacher,
while at the same time acting as a control. The so-called intermediate certificate corresponds closely
in value to the preliminary medical examination of the universities ; the leaving-certificate proper cor-
responds to the Arts and Science preliminary examination of the universities. See J. Kerr: Scottish
Education (Cambridge University Press, 1910), and Report on Secondary Education, Scotland, 1910,
by Sir John Struthers (London, 1910).
1 Appendix to First Report, Royal Commission on University Education inLondon, p. 166(London, 1910).
60 MEDICAL EDUCATION
The General Medical Council and the various qualifying bodies publish lists of
acceptable examinations. They include the arts or science degrees of all universi-
ties; junior, senior, and higher local examinations of Oxford and Cambridge; the
matriculation examinations of all universities; leaving and intermediate certificates
issued by the Scotch Education Department, and credentials issued by the College
of Preceptors,^ London, the Educational Institute of Scotland, and some twenty-five
other examinations held outside the United Kingdom. The range is decidedly exten-
sive: the student may begin the study of medicine from the vantage-ground of the arts
or science degree, or at the level of university matriculation, or at a level distinctly
below that at which a university would admit him as candidate for its arts diploma;
and, as we shall see, students of all these discrepant levels are found side by side in
all medical schools.
On the principle that, given several alternatives, the permissive minimum is the
actual standard, the basis of English medical education, while definite, is indisput-
ably low. It comprises four subjects, all of elementary grade, three of them languages.
The passing mark is less than 40 per cent. This scholastic requirement can be readily
met by a fairly well-taught boy of average intelligence at fifteen years of age. On
these entrance terms, the qualification to practise is obtainable through any of the
several professional corporations, — the Royal Colleges or the Apothecaries"* Halls.
Moreover, it is difficult to determine how uniform in value even this low minimum
is. The special medical student certificates issued by the College of Preceptors and
the Educational Institute of Scotland have been regarded with suspicion for some
time. Students presenting them are required to have taken all four subjects at one
sitting; when a recent recommendation of the Education Committee of the General
Medical Council becomes effective, the five weakest of the accepted examinations will
be stricken from the list.^ That the standard, low though it be, may even then be to
some extent nominal has not escaped those concerned. " In the case of independent
examining bodies holding examinations designed for the special purpose of a medical
preliminary, it may be difficult to obtain a guarantee without an inspection of marked
papers from year to year. In such examinations, where the responsibility of marking
answers rests on one examiner, who may be changed from time to time, the variation
of standard may be considerable.'"^ Meanwhile, there are qualifications resting upon
1 This body may be cited in explanation of the characteristically English situation just described. The
College of Preceptors is a body originally composed of private teachers, who procured a charter per-
mitting them to conduct examinations and issue certificates therefor. The College holds written ex-
aminations at regular intervals in education, English, history, geography, mathematics and natural
philosophy, bookkeeping, P'rench and other modern languages, physics, chemistry, political economy,
etc. On the basis of these written examinations, they issue diplomas for teachers, college certificates
accepted by the London County Council, the various medical examining boards, etc. Examining
organizations of this kind are, on the whole, obstacles to educational development; for they encour-
age and reward the things from which English education is struggling to free itself.
2 "On and after the close of the year 1913."
3 Further Report by Ediicational Committee to General Medical Council, May 30, 1900, p. 340.
BASIS OF MEDICAL EDUCATION 51
a somewhat higher preliminary basis. The M.B. conferred after examination^ by the
University of London presupposes matriculation in six subjects, English, English his-
tory, mathematics (including arithmetic, algebra, and elementary geometry), a foreign
language, and two additional branches, — one probably a science. At Cambridge, the
candidate must matriculate in Latin, Greek, arithmetic, algebra, geometry, and in
one of the following three, — theology, logic, or science. Almost all the Cambridge
and Oxford students first obtain a degree in arts; but this is required only at Dublin
University. Of all students throughout the kingdom, 28 per cent are said to register
on the minimum basis.
Educationally, the situation is less clear than the above characterization would sug-
gest. I have said that the universities have an entrance standard above the mini-
mum ; but, as I have already intimated, the university student may comply with either
standard, as he pleases. The higher standards affect only those who are candidates
for the university medical degree; the authorities are quite willing to teach in the
same classes others who have no intention of proceeding to it. Notwithstanding the
diversity of bases on which the license to practise may be obtained, the schools can-
not be distinguished from one another in respect to entrance standard. If, for exam-
ple, the universities trained only students who, being candidates for their degrees,
had matriculated wdth that end in view, English medical schools could be thus
classified: one group, resting on the minimum basis in the matter of preliminary
education, would prepare candidates for examination by the professional cox-pora-
tions; another gi'oup would comprise the universities training students for their own
degree examinations and requiring as preliminary thereto university matriculation ;
Cambridge and Oxford might perhaps form a third and higher level, requiring the
bachelor's degree, now already quite generally offered by their students. As a matter
of fact, however, the provincial and Scotch universities, while requiring university
matriculation^ of students who expect to proceed to the university M.B. degree,
are quite mlling to accept and to teach students who, expecting to qualify through
one of the professional corporations, submit only the inferior preparation. For in-
stance, in 1903, out of a total medical entry of 23 at the University of Liverpool,
only 9 were candidates for the university degree, 14 might have complied only
with the lower requirement of the Conjoint Board and other corporations; that is to
say, over 60 per cent of the entering class might have been below the presumable
level of the insti'uction, if instnaction is assumed to be calculated in reference to
the entrance standards of the institution. The next year, out of 20, there were only
5 deoi-ee* students. Since then, the relative increase of the degree contingent would
^ The candidate studies medicine at any medical school in the United Kingdom, or at a colonial or
Indian medical college; as to that, the University of London is indiflFerent: it merely examines.
2 The term "matriculation" does not in'Scotland technically signify the entrance examination, — the
sense in which it is here employed, — but the registration of the student with the payment of cer-
tain fees. It should also be noted that the entrance basis in the medical faculty in Scotland is dis-
tinctly lower than that in Arts and Science.
52 MEDICAL EDUCATION
appear to indicate that the tendency within the univei-sity is toward homogeneity:
out of an entry of 35 in 1907, 19 were degree students; out of 30 in 1908, 15. Dur-
ing the five years, 1906-1910, 345 students entered St. Bartholomew's, of whom 95
aimed at the London degree, 153 at Cambridge, Oxford, or provincial degrees, and
97 at the diploma of the Conjoint Board. At Edinburgh, "students who do not in-
tend to graduate in medicine in this University may attend any of the classes in the
faculty on payment of matriculation and class fees."^The instruction cannot fairly be
pitched at a definite level until the admission standard is uncompromisingly identical
with the degree standard. Until that happens, the standard is the student's, not the
university's. Nor is the student's standard necessarily a medical student's; for dental
and veterinary students enter common classes wherever those departments are found.
These discrepancies indicate a situation in which differentiation along modern lines
has begun to take place but recently and is very imperfectly carried through.
The same confusion of students at different levels with different goals has created
a very perplexing situation in London. Strictly speaking, the University of London
is, as I have already pointed out, merely an examining body: an individual, having
studied where and how he pleases, appears before the University to be examined, first
for matriculation, later for graduation. Where he has studied before matriculation,
or between matriculation and appearance for graduation, is immaterial to the Univer-
sity. The London medical schools are nominally parts of the University of London;
that is, some of the recognized teachers in these schools have seats on the senate or
governing body of this non-teaching university. The senate can make rules and set
up conditions regulating university examinations; but its arm does not reach into
the internal affairs of any of the so-called constituent colleges or schools in medi-
cine. For all practical purposes, the University of London has no more genuine rela-
tion to the medical schools of Guy's or St. Bartholomew's than to that of the Uni-
versity College of Dundee; it will examine a candidate who has studied at either,
provided only he has previously passed its matriculation examination, — an examina-
tion somewhat more difficult than the minimum above set forth mainly because all
parts of it must be passed at one sitting. Meanwhile, the London schools, part of the
University of London though they be, receive as students not only those who have
matriculated in the University of London, but those who, without designs on the
M.B. degree, expect to qualify at Apothecaries' Hall, the Conjoint Board of London,
the Triple Board of Scotland, or one of the Irish corporations, all admitting on the
minimum requirement laid down by the General Medical Council. Let us suppose
two students at St. Thomas's, for instance: one presents for admission a certificate
from the College of Preceptors; the other has matriculated at the University of Lon-
don. After substantially the same course of professional training,'^ the former must
be content with the qualification of a professional corporation, the latter can append
1 Calendar, University of Edinburgh, 1910-1911, p. 478.
2 The latter is six months longer.
BASIS OF MEDICAL EDUCATION 53
the magic "M.B. London" to his name. Now it happens that the degree of M.B. is
obtainable at Edinburgh after passing a set of matriculation examinations hardly,
if at all, more difficult than the examinations in general education required bv the
London Conjoint Board. Hence, what is denominated the hardship inflicted on Lon-
don students. Entering a London hospital school on the minimum basis, they forfeit
the degree that on the same basis they could obtain at Edinburgh; to gain the degree
in London, they must satisfy the higher matriculation requirement of London L^ni-
versity and study half a year longer. ^Meanwhile, for our present purposes, the point
to note is the impossibility of working out a curriculum in a London medical school
from a fixed starting-point, for none such exists. There, as in the provincial and Scot-
tish universities, matriculation does not mean compliance with a standard on the basis
of which the university conducts its instruction, but merely the amount of attain-
ment from which the university reckons its degree. A student at King's goes in for
the London M.B. degree. He fails : but instead of dropping out, he remains in attend-
ance, taking precisely the classes he would have taken had he passed. He cannot
get the London University degree — that is all. The matriculates who fail and the
matriculates who pass do practically the same work. Just what matriculation means
in reference to the quality of university instruction under such circumstances, it is not
easy to say. Meanwhile, the so-called grievance of the London medical student is more
important to him than to anv one else. The real difficulty is not that matriculation
for the London degree is harder than the entrance basis adhered to by the corpora-
tions, but that neither basis represents a sound secondary schooling from the stand-
point of medical education. In neither case is the training required to pass perti-
nent to the object for which a specific entrance basis is maintained. Both now tempt
the student to break rank and leave school in order to be specially coached. The Ger-
man policy necessarily recurs to mind : there, professional education frankly connects
with secondary education. Its basis coincides with the leaving standard of the gym-
nasium. The complete reliance of the university upon the secondary school has been
a powerful force in making the secondary school strong, and in giving it variety of
form in keeping with the different vocations and professions to which it leads.^
The Cambridge and Oxford standard, while less accommodating in that the terms
of admission are not at the student's discretion, does not actually fix the level of in-
struction throufj-hout the curriculum. The fundamental sciences alone are taught at
the two universities ; for clinical teaching, the students repair to London or provin-
cial hospital schools. A Cambridge M.B. has therefrom received scientific training
adjusted to university matriculation and clinical training designed in the first place
for the much larger body of London hospital school students, whose preliminary
education falls considerably short of university matriculation.
1 A Roval Commission on the University of London is now sitting. For complete information as to
the entire problem of higher education in London, the reader is referred to the admirable account by
the late Sir William H. AUchin, entitled : Reconstruction of the University of London, 3 vols. (London,
Eyre & Spottiswoode).
64 MEDICAL EDUCATION
That the requirement as to preliminary education is adequate when viewed from
the standpoint of modern medicine, few now contend. It can be satisfied by a can-
didate who has no knowledge of any modern language but his own, who has had
no training in science whatsoever, and whose acquaintance with mathematics is too
limited to support a proper study of physics or chemistry in future. Of ominous im-
portance is the well-nigh universal ignorance of German. Few indeed of the leading
British practitioners read that language : they are thus reduced to slow and indirect
methods of communication with the main source of progi-essive ideas in medicine dur-
ing the last half century. Ideas must have become current in English publications
before they are accessible; a considerably larger proportion would encounter them
in French ; in either case, anything like thorough acquaintance with the literature
of a topic at the time of its fullest and most stimulating discussion is out of the
question. Not only is a knowledge of German not required — its necessity is not even
keenly felt. The report of the Board of Education above quoted states that " it is
a matter for regret that there has been some diminution in the study of German." ^
The p>ercentage of the students who offer German in the examinations most in vogue
is actually declining. Of candidates appearing before the Joint Board in 1896, 15.25
per cent offered German; in 1907, only 12.7 per cent. The Oxford Senior Local Exami-
nation in 1895 was tried by l-il-i candidates, of whom 24.2 per cent entered for Ger-
man; in 1907, by 6370 candidates, of w^hom 5.6 per cent offered German; in 1910,
by 10,437 candidates, of whom 4.7 per cent offered German. Even the more mod-
em pro\'incial universities, where the pressure of industrial and commercial need
is acutely felt, show no better results: at the joint matriculation examination of the
universities of Manchester, Liverpool, Leeds, and Sheffield in 1907, 188 candidates
out of 2012 (about 9 per cent) came up for Geniian; in the preliminary examination
of the Scottish universities in 1909, 46 out of 920 (5 per cent) took German.^ Some
of the others may have had a smattering, but not enough to pass a quite elementary
test.'
It is of course true that a considerable portion of the student body have had more
education than is indicated by the stipulations to which they confoi-m; but there is
no reason to suppose that it is adequate to the load it must carry. This is fairly to be
judged from two sets of statistics. In the first place, the general percentage of rejec-
tions among all pupils who go up for examination at the stage of supposed fitness
for the medical school: 36.5 percent in the Oxford senior locals, 33.6 per cent in the
corresponding test at Cambridge, 56.4 per cent in the matriculation examination at
Durham, 68.1 per cent in the medical preliminary at Edinburgh, 60 per cent at Aber-
deen, 65.4 per cent at Glasgow, 76.1 per cent in medical preliminary of the College
1 Page +3.
2 Figures taken from supplement to London TimeSy September 6, 1910, p. 510.
3 Sir John Struthers, in the report above mentioned, says of Scotland : "From more than one quarter
comes the welcome intimation that there are unmistakable signs of a revival of interest in German"
(p. 30).
BASIS OF MEDICAL EDUCATION 55
of Preceptors, 60.4 per cent in the Educational Institute of Scotland.^ Equally sig-
nificant of the inadequacy of basis is the mortality in the early professional exami-
nations: between 1905 and 1909, 39 per cent of its candidates were rejected by the
Conjoint Board in Chemistry: 38 percent in physics, 37 per cent in elementary biology.
The defect is patent : the requirement sets up none too strenuous a performance for
a boy of fifteen. The average age of entrance upon medical study is over 19.^ In 1908,
over 33 per cent of English students registered as beginners by the General Medical
Council offered the easiest acceptable certificate; in Scotland, 12 per cent; in 1909,
35 per cent in England, 15 per cent in Scotland. But the more difficult examina-
tions— the so-called junior and senior — represent a wholly inadequate performance
for a student in his twentieth year.^ The discrepancy between what is asked and what
the student might have performed betrays the undeveloped condition of secondary
education in Great Britain; but the tender considerateness of medical educators
is not calculated greatly to accelerate its progress. The proprietary interest consti-
tutes a most formidable obstacle; nowhere has it been solicitous to hasten general
educational progress to its o^vn hurt. For present conditions the medical schools are
not originally to blame; unfortunately, however, they are hardly yet to be reckoned
among the more active forces making for better things: the General Medical Council
has not yet ventured prospectively to add a science to its preliminary requirement,
despite the improved promise of the secondaiy schools. In consequence, those educa-
tors struggling for the development of scientific training fight without the assistance
that such future compulsion would afford them. "From the first," say the science
teachers of the public schools, " the advocates of science have had to struggle against
the firmly established position of the classics as instruments of education." * Nor has
medicine ever yet been educationally so far independent of proprietary and corpo-
rate interests as to give the aid involved in the announcement of a scientific require-
ment, to take effect, say, even five years hence. Favoring the elimination of the so-
called junior examinations, the General Medical Council finds itself unable to drop
them because that step would either diminish the number of candidates entering
an already too crowded profession, or, by way of avoiding a result so disastrous
to proprietary schools, lead examiners to mai-k more leniently, thus depreciating the
higher examinations to the lower level.
The baneful consequences of proprietary organization thus turn up at every move.
1 Minutes, May 26, 1908, General Medical Council, pp. 22-24.
2 The Education Committee of the General Medical Council has made most interesting studies on this
point: see the Interim Report by Education Committee, i\Iay, 1907.
3 " Under satisfactory educational conditions the senior level should be attained by youths leaving
school between 17 and 18 years of age, that of the junior at 16." Advanced sheets of Appendix l\.
Report of Echication Committee, ■p. 7. "Under satisfactory educational conditions, the level of the
senior examination ought to be attainable by youths from 17 to 18 years of age ; in the present cir-
cumstances only 25 per cent of the entrants pass the preliminary examination by the age of 18."
Interim Report by Education Committee, May, 1907, p. 12.
^ Report on Science Teaching in Public Schools, Education Pamphlet 17, Board of Education (London,
1909). ^
56 MEDICAL EDUCATION
English secondarv education requires stimulusand direction from every possible source.
A learned profession might exercise a powerful leverage. Medicine cannot. It is con-
tent tiirdily to participate in the consecjuences of educational progress after the event.
Though the profession is overcrowded, it does little to compel educational progress.
The reason is not far to seek : replying to an inquiry by the General Medical Coun-
cil as to the practicability of higher entrance requirements in 1899, the then dean
of the Manchester Sciiool replies negatively as follows: "As a collateral issue I may
further be allowed to point out that any marked diminution in the number of stu-
dents entering at the several medical schools must necessarily affect the material well-
being and efficiency of these institutions." ^ 'i'he proprietary school always reckons
on the assumption of its ow^n survival. At the moment, the present requirement may
be on the whole the best obtainable ; but the phrase "on the whole" includes as fac-
tors the proprietary school and a profession governing itself on that assumption.
As opposed to centralization of all power and responsibility in a governmental
bureau, — the situation in Germany, — the vesting of such responsibility largely in
a learned pz'ofession itself is highly attractive. How far it can be carried depends
altogether on the sensitiveness of this guild-like body to the public interest. Now
a guild-like organization is admirably calculated to protect honor and dignity, to
conserve ceremony, and to transmit tradition. But the relative importance of these
things to the members greatly transcends their absolute importance to the public.
It does not follow that one is wholly insensible to the picturesqueness of professional
tradition because one suggests that bodies conserving a tradition have to prove
their fitness under modern conditions to legislate on such subjects as professional
education. The Royal Colleges, the various Halls, are historically impressive ; but as
vested interests they may obstruct the determination of an issue on its merits. The
interest of a guild lies largely, although, of course, by no means wholly, in the past,
or perhaps better, in the past idealized; how far it is permeated by modern ideas
depends upon the degree to which its members as individuals are exposed to influ-
ences that compel readjustment. In the case of physicians, this is doubtless consid-
erable; hence the profession has not stagnated. But, on the other hand, it has not
been educationally aggressive. Representative councils, committees, and corporations
composed exclusively of medical men, most of them at or beyond middle life, are
apt to be needlessly conservative. As a matter of fact, England and Germany com-
bine to show, positively as well as negatively, that medical education is not so much
a medical as an educational problem. Jurisdiction must lie with educators as well as
with physicians. When the educational motive is properly emphasized, one ceases to
look at a proposed reconstruction from the standpoint of its effect first of all upon
proprietary interest or corporate privilege. The educator represents the public inter-
est; he views the educational facilities of the nation in reference to one another, aim-
ing to develop them in harmonious interaction. On the day that his voice is heard,
1 Interim Report hy Education Committee, June 5. 1899, p. 20.
BASIS OF MEDICAL EDUCATION 57
a new point of view is established : unnecessary schools, for whose benefit low stan-
dards are continued, are suffered to expire ; the survivors cooperate with universities
and other permanent educational institutions to force the development of secondary
education on the modern side. With fair warning, they will furnish intending stu-
dents with the best of reasons for participating in this movement by denying them
entrance to the profession on any other terms.
The situation in France — definite like that in Germany — need not detain us long.
The medical student must have achieved the baccalaureate that marks the termination
of the lycee — a secondary school of gymnasial stature; in addition, he is required to
pass a year in the study of the preliminary sciences, which in Germany and Great Brit-
ain still cumber the medical curriculum. A baccalaureate course of secondary instruc-
tion plus a certificate covering the study of physics, chemistry, and biology, issued by
the faculty of science, constitutes the basis of medical education throughout France.
The baccalaureate course takes any one of several forms, all leading to the same
degree. Since the far-reaching secondary school reforms of 1902,^ complete parity has
prevailed as respects the classics, the sciences, modern languages, and mathematics. A
four year primary course constitutes the uniform basis; seven years of secondary in-
struction follow, divided into two parts, four and three years in length respectively.
In the first part, the student elects between the classics, with or without Greek, as he
desires, and a modern course largely scientific in content; in the second, he chooses
one of four groups — the classic languages, Latin and modern languages, Latin and
science, modern languages and science. History, geography, and mathematics are, of
course, present in all. The lycees of the great cities are large and flexible enough to
contain all the alternatives ; at smaller places, the authorities select with regard, as
far as possible, to local conditions.^
The examinations at the close of the course are conducted under the direct super-
vision of the national Minister of Education. They are both written and oral, the
former two to four hours in length, the latter forty-five minutes. The control of the
Minister may extend to the choice of texts and subjects for the written examination;
but more commonly, the examination, like the leaving-examination of the German
Gymnasium, is in the hands of the school faculty.
The French boy, like the German, is thus systematically trained with clear view to a
possible professional superstructure. The baccalaureate standard bears everywhere the
same value. The teachers, who are shortly to begin training men to law, medicine,
or what not, know exactly on what they build. It is true that, consistently with the
Napoleonic origin of the system, the spirit of the lycee is less individual than the range
of selection that it allows, a survival from the former regime under which all were
1 Based on the Enquete sur V enseignement secondaire, 1899, 6 vols.
2 For details see Plan d'itudes et programmes d" enseufnement datis les lycies et colleges (Faris, Delalain
Freres). An excellent account in English is accessible in F. E. Farrington's French Secondarg Schools,
chapter vii (London and New York, 1910), which has been utilized in the preparation of the text.
58 MEDICAL EDUCATION
put through the same grind. However, where option takes place, individuality will
in course of time make itself respected. Meanwhile, France has gone further than any
other country in stipulating that medical education shall rest on a basis not only
high and uniform, but determined or supplemented by the specific requirements of
modern medicine.
CHAPTER IV
THE PRELIMINARY SCIENCES: PHYSICS, CHEMISTRY, AND BIOLOGY
The subjects composing the medical curriculum may be conveniently considered in
three groups: the first including the basic or preliminary sciences, physics, chemistry,
and biology; the second including the underlying medical sciences, anatomy, physi-
ology, pharmacology,^ and pathology; the third made up of the clinical branches,
medicine, surgery, and obstetrics. The second and third divisions form the medical
curriculum taken narrowly. The basic sciences, now to be discussed, are introductory
only. Why need they be taught at all?
The medical sciences — anatomy, physiology, and pathology — begin at what may
be designated as the second level. They may be regarded either as specialized branches
of one of the basic sciences, or as involved and complex products of several of them.
Anatomy and pathology are thus subdivisions of biology, broadly viewed ; physio-
logy is a biological science in which both chemistry and physics are also inextricably
involved. To an intelligent comprehension of the outright medical sciences, a work-
ing knowledge of the basic sciences, physics, chemistry, and biology, is indispensable.
In the first place, the medical sciences employ as their language terms and concepts
that they themselves did not originate and cannot stop to explain; such as induction,
refraction, cell, reaction. The shortest way, perhaps the only sure way, to gain pos-
session of these concepts is by acquiring them in the sciences in which they are first and
most simply used. Precisely the same holds of methods and technique; the student
who comes to the study of anatomy without training in the use of the microscope, to
the study of physiology without ability to handle an electric battery or to cany out
a qualitative analysis, is sadly handicapped. For the medical sciences are experimen-
tal, not merely descriptive; and while even in their descriptive form they cannot be
understood without a knowledge of the basic sciences, intelligent experimental study
is out of the question to a student who lacks practical skill, brought over from the
basic sciences.
Nor does the need of such practical skill cease when the student escapes from the
laboratories to enter the clinic. For here again he is referred back to a previously
acquired knowledge of physical and chemical principles and a previously attained
skill in the practical methods of physics and chemistry. Diagnosis leans heavily now-
adays on the basic sciences: percussion and auscultation are physical methods; the
ophthalmoscope, the laryngoscope, the Roentgen ray, the sphygmograph, are bedside
appliances not to be intelligently employed except by those who understand the
physics of each; in the clinical laboratory, equally important diagnostic factors are
disclosed when chemical methods are employed in the analysis of the waste products,
the secretions, and the fluids of the body. Finally, the conflicting claims of therapeu-
1 In Germany, pharmacology would be included in the third division.
60 MEDICAL EDUCATION
tists, and still worse, of the pharmaceutist pushing his wares, can be judged only by
physicians who firmly grasp chemical theory.
The material provision for all scientific study in the German^ universities is generally
and uniformly excellent. The several sciences usually occupy separate buildings or "in-
stitutes," as they are commonly called. However different in size and splendor, they
are essentially alike in point of structure, equipment, and organization. Each contains
properly furnished lecture rooms, with every facility for effective demonstration : black-
board, projection-screen, lantern, running water, etc. Adjoining the auditorium are
preparation rooms, containing all the apparatus and instruments required for the
setting up of demonstrative experiments. Every department has its own library for
cuiTent use, its o\vn photogi-aphic outfit, its own museum and collection. The chief
possesses an adequate suite, in which he carries out his own researches. Separate rooms
are usually provided for each assistant and each of a few advanced workers, — for
advanced workers are nowhere plentiful. Larger rooms are reserved for the practical
courses arranged for undergraduate students.
The staff" organization consists of the professor, his assistants, advanced workers,
and the necessary helpers. The professor delivers the general lecture course, supervises
the laboratory courses designed for undergraduates, and directs the research of his
advanced students. It is not uncommonly believed that, as his heart is in research,
his more elementary teaching is perfunctorily given. Such is by no means generally
the case. Not infrequently the German professor spends himself so freely in teaching
and what goes with it that he himself ceases to be largely productive. He produces
in such instances mainly through the picked individuals who are admitted to the
larger opportunities open to those who, as assistants or special workers, enjoy inti-
mate intercourse with him. A characteristic and highly important factor in labora-
tory efficiency is the skilled helper,^ who, originally only a servant, has by long experi-
ence acquired so thorough a knowledge of the running requirements of the institute
that he is absolutely indispensable. He is, as a rule, thoroughly familiar with appara-
tus, can mend, adjust, or replace it; he can set up demonstrations, relieving professor,
assistants, and advanced workers of all the drudgery of preparation ; he is respon-
sible for cleanliness and orderliness, and he is usually equal to the responsibility.
If mechanically gifted, he is at times paid more than an assistant.' His loyal and
devoted services are appreciated bv those who benefit from them, for he shares in the
dignity of his institute; regarded and tretited as an official, he is not uncommonly
pensionable; his name and function are recited in the catalogue, in close proximity
to that of the chief and his associates. Like them, too, he is decorated for long and
1 From this point, the words German and Germany include the German Empire and German-speak-
ing Austria, where the conditions, generally speaking, resemble each other. When differentiation is
necessary, I shall speak of the German Empire and Austria, respectively.
p.ner.
3 An assistant in physiology' at Giessen gets 1200 marks a year; the helper, 1400 marks. The Diener
often gets Wohnung (residence-quarters) in the institute for himself and family besides.
PHYSICS, CHEMISTRY, AND BIOLOGY 61
honorable service, albeit in an inferior position. Tlie assistant helper in the bacteri-
ological division of the physiological laboratory at Berlin wears the badge known
as the general order of merit ;^ so also does the mechanician in the main institute
and the preparator in the laboratory of anatomy. The chronicle of the University
of Breslau^ records in one sentence the facts that in the annual conferring of dis-
tinctions, the professor of anatomy received the second class of the order of the Red
Eagle, and the first helper in the laboratory received the cross of the general order
of merit.^ These instances are in no wise exceptional.
The departments of physics, chemistry, and biology belong, as a rule, to the philo-
sophical faculty, although in Austria the medical faculty contains an independent
chair of chemistry applied to medicine. The student pursues his studies in these three
sciences in connection with the required medical sciences during the first two or three
semesters. The departments themselves offer every opportunity for both theoretical
and practical work. But as the student has already begun his medical studies and
time presses, his work is usually restricted as nearly as may be to the simplest forms
of instruction offered.
The backbone of university instmction in science is the demonstrative lecture. In
the course of one or two semesters, the professor in charge of the department reviews
the main facts and the leading principles of his domain, illustrating his exposition, as
he proceeds, with simple experiments, for which all necessary preparations have been
made by assistants and helpers in advance. A student assembly ranging from fifty to
three hundi-ed or more listens to an excellent account of the topic in hand and wit-
nesses the final stages of an illustrative experiment ready to be touched off before
they take their seats. Usually, in the following semester, a practical course of selected
experiments is offered in which the student may be can'ied over the same field that
he has demonstratively traversed.
The minimum requirements in the basic sciences following the usual recommenda-
tion are as follows: physics, lecture courses covering one or two semesters; botany,
lectures during one or two semesters; zoology, lectures during one semester; chem-
istry, lectures during two semesters, laboratory exercises during one semester. The
student's basis in science, obtained incidentally in the course of his first three semes-
ters, thus consists of six or seven courses of demonstrative lectures in four different
subjects and a course of laboratory exercises in one of them. In physics, zoology, and
botany he need do no practical work at all; in chemistry alone is a practical course
compulsory. The requirement in question applies to all students, no exception or
allowance being made in favor of the Higher Realschnle graduates, who have already
traversed the ground more thoroughly than it is covered in the univei-sity. They can-
1 OA, "Allgemeines Ehrenzeichen." « Chronik, 1908-1909. p. 76.
3 Research workers, requiring even more intelligent aid, frequentlj'^ employ women helpers, who are
paid sometimes by the investigators themselves, sometimes by means of grants or donations. It is
now urged that some systematic provision should be made for the proper training of laboratory helpers.
62 MEDICAL EDUCATION
not abbreviate their term of residence at the university by obtaining credit for work
already performed. They enroll in the recjuired chemical laboratory course, from which
they then absent themselves ; a minority of unusually eager students devote them-
selves to advanced work.
The important points in the German arrangements, then, are these : the basic sci-
ences are deferred to the university; they are not taught with special reference to
medicine; they are scattered through three semesters, during which anatomy and
physiology are simultaneously pursued; finally, instruction in them is largely demon-
strative in character. Let us consider these characteristics from the standpoint of
educational efficiency.
It is obvious that the basic sciences must be included at least optionally in the
medical curriculum as long as most medical students prefer the humanistic gymna-
sium. Now, while the scientific schools were at first well content to share on even
terms the gymnasial privileges with reference to the university, it does not follow
that the medical faculty can peraianently concede their entire equality. Even before
the Realgymnasium became a permissive alternative, Pagel urged that it must be made
universally obhgatory upon those entering on the study of medicine.^ The same end
would be accomplished by requiring graduates of classical Gymnasia to find phys-
ics, chemistry, and biology, precisely as graduates of the Higher Realschule are now
compelled to find Latin. The question turns on the comparative advantages and dis-
advantages of the practice of postponing. In discussing this, we must in a measure
cover again ground passed over in the preceding chapter.
In behalf of postponement, as now generally in vogue in both Germany and Great
Britain, it is argued that science studies undertaken in connection with the object on
which they bear gain in seriousness. The student is sufficiently mature to realize the
importance of a task not itself immediately professional in character. His teachers
can select material adapted to his vocation and drive it home by means of pointed
references to medical needs and uses. It is urged that he will probably apply himself
with greater vigor and greater intelligence than during the vaguer and less purpose-
ful stages of his secondary schooling.
The objections are, however, very weighty. It is questionable whether the first years
of professional study are really more earnest than the last years in the secondary
school. Such is clearly not the case in Germany, where the first semesters at the uni-
versity are more or less generally abandoned to the pleasure-seeking characteristic of
student life. Elsewhere, too, a change of residence that cames a boy into a larger city
may not furnish the conditions best calculated to promote close application. At best,
whatever the recommendations, they do not compensate for the overloading of the
curriculum and the rising age of the medical student at graduation. The probabiH-
ties are that more things will have to be put into the curriculum; something may be
excised, but probably less than must or will be added. Is the increased time always
1 J. Pagel : Einfiihrung in dot Siudium der Medicin, p. 56 (Berlin and Wien, 1899).
PHYSICS, CHEMISTRY, AND BIOLOGY 63
to be procured by lengthening the cui-riculum ? Certainly not, unless the most effec-
tive and economical use has already been made of the years just preceding medical
study. Has this been done? Is it possible to hold that the best use has been made of
the years from sixteen to nineteen, when a boy expecting to study medicine can reach
the age of nineteen without a thorough grounding in physics, chemistry, and biology,
and the mathematics necessary to the first two ? Further lengthening of the medical
curriculum must, therefore, as a prudential measure, be obviated by more effective
use of the three preceding years. Even if no such danger threatens, it would be no
misfortune if the present average length of the cuiTiculum could be reduced by the
same policy. For a waste of time can in no case be either a moral, an economic, or an
educational gain.
A second objection, already noticed in the previous chapter, cannot be over-em-
phasized: to defer thorough scientific study until professional education begins, as the
Germans do, means that the student cannot acquire strict scientific spirit and method
until he is already full grown. To that degree the secondary and intermediate schools
are emptied of positive content of form.ative and stimulative character ; they tend to
become schools devoted to purely formal discipline. Now it is undoubtedly possible
to begin rigorous scientific work too early : to teach children physics in the shape of
abstract formulae and chemistry by symbolic equations is obviously premature; it
does not establish scientific thinking, it does not cultivate observational power or
interest. It may prematurely injure both. But because a thing may be done too early
is a poor reason for actually doing it too late. Beyond question, to let a boy get well-
nigh to manhood without practical training in such physical or chemical experi-
mentation and calculation as compels him to analyze phenomena and to apprehend
laws is unpardonable. This is, however, what happens when the systematic study of
the basic sciences is deferred to the university. Nor, as already shown, are the neces-
sary conditions satisfied by unsystematic and superficial scientific instruction in the
secondary schools, that serves mainly to break the monotony of the formal occupa-
tions to which the curriculum is otherwise largely abandoned. Nature study in un-
systematic form has indeed an important function in the child's training; for it pro-
vides him with raw material, in the procuring of which his senses are sharpened, while
his zest in their exercise is continuously heightened. But the scientific basis of medical
study must be something more critical. It is no longer enough for the student to be
aware of nature's fascinations; he must endeavor to conceive phenomena in terms of
law. Rigorous experimentation must be added to delighted observation; symbolic
formulae must succeed animated description. The latter yeai's of youth furnish the
most favorable opportunity for converting the random play of curiosity into sober,
rigorous, and reflective pursuit of the several sciences into which the phenomena of
the external world are resolved. The medical curriculum consciously or unconsciously
assumes from its start that the student possesses power of this type. That is assuredly
not the least cogent argument in favor of his previously obtaining it.
64 MEDICAL EDUCATION
Postponement radically alters the character of the instruction and its amount by
abbreviating the time available for it. The point of departure in science teaching is
the experiment. Now the experiment may be employed in either of two ways: demon-
stratively or actively. The student may witness an expository presentation skilfully
and freely illustrated by experiments conducted by the professor; or he may himself
carry out an experiment, though, of course, with much less artistic neatness and
smoothness. With the exception of one semester's practical course in chemistry, the
German gymnasiast's study of the basic sciences is, as I have pointed out, demonstra-
tive only. For his subsequent need this is clearly inadequate. A demonstration will
undoubtedly convey a fact or a principle; but it has no power to transfer manual
expertness. In so far as physiology, for example, applies physics and biology, the
student is but slightly assisted by a bookish knowledge of particular facts; he must
be able to use physical and biological implements and methods. No passive witnessing
of experiments smoothly executed by an expert who touches off a series neatly ar-
ranged by the Diener and assistants in advance, no merely intellectual grasp or know-
ledge of law thus expounded and illustrated, can take the place of actual participation
by the student on his own responsibility. Demonstration, text-book, and lecture may
all be useful; but the quality of the training is once for all determined by the extent
of the practical features that fall to the student himself. Nor is such participation
valuable solely because it cultivates dexterity; it is enormously stimulating. When
the professor lectures and illustrates, the pupil follows in his wake. He has done his
duty if he understands. To the experimenter, be he professor or student, difficulties
and alternatives appear. In the act of experimenting, even the student does more than
follow : he distinguishes, selects, tries out; his very blunders make a beneficial exercise
in the practical logic of experimental science. Instruction of this type is, however,
costly in respect of time. The opportunity is not obtainable, when the medical sciences
proper and the clinics are clamoring for every available moment. Postponement is
thus synonymous with hasty, superficial, mainly demonstrative teaching.
Finally, the dispersion of the basic sciences through the early semesters does not
conduce to their practical application in the other sciences. As a matter of fact, they
are not introductory. In consequence of the freedom of the student in arranging his
course of study, the instructor in the medical sciences has no way of knowing which
of the basic sciences his students have pursued. Lack of homogeneity compels him to
eliminate them from his calculations. If some members of a class have had chemistry
and others not, the instructor inclines to take the negative view in presenting his own
subject. In consequence, the basic sciences do not furnish the medical sciences with
their point of departure; nor are they worked up into the very tissue of medical in-
struction. The teachers of physiology and pathology, instead of freely using chemi-
cal and physical methods, tend to do just the reverse: each science is presented for
itself. Where they touch, the most elementary illustrations, if employed, have to be
explained. We shall subsequently see that the examination requii'ements are so slight
PHYSICS, CHEMISTRY, AND BIOLOGY 65
that a successful outcome constitutes no convincing presumption of serious study.
"The medical student has paid for his course in chemistry," remarked a professor of
hygiene to me, "but that doesn't mean that he has worked at it." The modicum of
information, which for the foregoing reasons is all the examination expects, is too
frequently procured from drill-masters who employ quiz-compends or other handy
manuals prepared for the purpose.^
The damage done to most students by the present German arrangement is irrep-
arable. From the first, the curriculum is hopelessly overloaded, — clogged with more
subjects than it can possibly cany, — and embarrassment due to this cause threatens
to increase rather than to diminish. However time may be economized by better
teaching, the only part of the cargo that can be unloaded is the work in the sciences
here in question. K tliis is not done, biology may perhaps be recovered in course of
studying anatomy and embryology; but physics and chemistry can hardly be re-
trieved. Leipzig offers short cuts to the requisite proficiency in the shape of special
courses, — three laboratory courses are offered in medical chemistry, and as many in
medical and pharmaceutical physics; the attendance is fair, — 247 in the summer
semester, 1911, as compared with 401 in the anatomical dissecting courses. But the
conception is open to serious question: what is medical chemistry.'' If it means an im-
mediate attempt to deal with the properties and abnormalities of bodily fluids and
secretions, it involves an unintelligent procedure, certain to break down. If it con-
fines itself to the chemistry involved in medicine to-day, it may be partly antiquated
to-morrow. Only fundamental and practical training in general chemical and physi-
cal principles received during the period when time is relatively plentiful and incli-
nation favorable will certainly stand the student in good stead during a sufficiently
protracted period.
In Great Britain, the basic sciences usually make a group occupying the entire
first year in the medical school, an arrangement distinctly preferable to the dispersed
treatment practised in Germany. For the time being, this is also probably the best
that can be done; the rudimentary state of secondary education in England leaves
no other course open. It will be remembered, however, that, subject to the criticism
of the General Medical Council, any university conferring the degree of ]M.B., or any
professional corporation authorized to hold qualifying examinations, is free to arrange
otherwise, if it please. Thus, despite the disapproval of the Council, the Conjoint
Board in London accepted as evidence of satisfactory preparation for examination
in these subjects, certificates representing science work in secondary schools.^ Tlie
1 The Germans call these booklets "Eselsbriicke."
2 The student can thus gain subject credit in three sciences ; but time credit is limited to six months ;
that is, he must spend at least four and a half years in a recognized medical school even if his basic
sciences have been previously discharged. The General Medical Council long disapproved the action
of the Conjoint Board in this matter; and the difference of opinion has not been without unfortunate
consequences. I have stated that, by way of unifying control, the General Medical Council has favored
the compulsory registration of medical students at the beginning of their medical studies, by which
regulation actual control of the preliminary education requirement would be transferred to the Coun-
06 MEDICAL EDUCATION
Council has now conceded the point. The theory involved in this policy is, as I have
repeatedly urged, sound ; its influence on the secondary school is wholesome; whether
it has been or can now be carried out without disregard of standard appears, however,
questionable. The Conjoint Board accepts at face value certificates covering all or
part of the teaching recjuirement in the preliminary sciences from sixty odd secondary
and other schools. A detailed inquiry, made in 1903,^ into the conditions under which
this instruction was given appears to indicate that the Board then lacked intimate
and reliable knowledge of its extent and quality.
The provision for the three sciences under discussion in the way of equipment and
teaching force in Great Britain is very uneven. The universities — those of the pro-
vincial towns, Oxford, Cambridge, Glasgow, Edinburgh, King's College and Univer-
sity College, London — possess modem laboratories in charge of strong productive
scientists, though externals vary greatly. Sir ^Villiam Ramsay's quarters at University
College are cramped and dingy : but clean-cut scientific ideals procure at once vigorous
teaching and brilliant productivity. The laboratory plants at Liverpool, Manches-
ter, and Cambridge, on the other hand, leave little or nothing to be desired ; they are
quite up to the best continental standards. Indeed, the condition of the preliminary
sciences^ in the British universities makes them the most powerful influence for good
in British education to-day. Largely the outcome of private endowment, they furnish
concrete examples of what a proper provision for science teaching means, and what
its outcome — practical and theoretical — may be expected to be.
Very different is the situation in the London hospital schools and the Extra-Mural
School of Edinburgh, Not only is the equipment meagre; scientific ideals and spirit
are conspicuously lacking. As a rule, a single room is provided for each of the three
subjects; it contains what is absolutely needed for the purpose in hand, and rarely
anything further. In London, part-time teachers are sometimes employed: the same
individual conducts perfunctory coui"ses at several schools, or an individual other-
wise engaged, as analyst, for example, is employed to teach science in a hospital school
for a stipulated number of hours weekly. Poverty has led three of the London schools
— St. George's, Westminster, and Charing Cross — to discontinue the teaching of the
scientific branches; their students now resort to the laboratories of King's or Univer-
sity College. The London schools can at best afford only such science teaching as the
fees of the students pay for, and as the number of such students is in no school large,
and in several absurdly small, it follows that instruction is bound to be inadequate.
It has been proposed to consolidate the teaching of the sciences in three institutes serv-
ing all the existing hospital schools. The proposition, however, has fallen through.
cil. Between IftftO and 1900, the Royal Collef^e of Surpeons accepted registration by the General Medi-
cal Council as evidence of proper preliminary education ; in the latter year, the Royal Colleges of Phy-
sicians and Surgeons withdrew from the arrangement.
^ Report by Education Committee on Returns from Teaching Institutions, furnished by Conjoint
Board in England, May, 1903.
2 To which physiology must also be added. See chapter vi.
PHYSICS, CHEMISTRY, AND BIOLOGY 67
There is, in truth, an irrepressible conflict between proprietary interests and scientific
ideals. Proprietary interest seeks to keep alive every existing school. On the other
hand, good scientific teaching once installed in the earlier years will not stop short of
thoroughgoing reconstruction of clinical teaching. To create three satisfactory centres
of science teaching and to preserve the chnical schools as they are, is a vain attempt
to yoke together a tradition and an ideal.
As to method, English tradition and instruction are highly favorable. The Eng-
lishman has little patience with theory. He wants to do things, and to do them for
himself. Sport has developed manual readiness and dexterity. Science teachers accept
this predilection and make a method of it. The practical course furaishes the back-
bone of the instruction. Teachers and text-books may expound and amplify, but they
never supplant. The English student of physics, chemistry, and biology is in theory
expected to learn by doing, not by merely hearing or beholding.
Results, however, appear to indicate that a single year cannot be made to suffice for
practical instruction in the three sciences, certainly not with the English medical stu-
dent of to-day. The actual content capable of mastery is reduced to narrow limits.
At Cambridge, for example, where the scientific spirit is strong, the instruction in
biology aims at most to bring the student into contact with a series of forms, in order
that he may grasp the significance of the whole. The student performs a limited num-
ber of experiments; his teacher interprets them on broad lines. At Liverpool, the
years chemistry is so mapped out that one term is devoted to inorganic chemistry,
mostly the non-metals; in the second, a short course is given in elementary physical
chemistry; about one month is left for organic chemistry. At Manchester, the prac-
tical course in physics includes about twenty individual experiments. But it is found
that the student knows little mathematics; unfortunately, there is now no time to
leani more. He cannot derive the formulae which he employs : at best, he can verify or
apply them. The presence of usually inferior pharmaceutical and dental students in
the same classes complicates an already difficult situation still further. None the less,
it is not to be forgotten that the universities possess spirit and ideals. The bov who
studies chemistry or physics in an atmosphere rendered alive and bracing by the pre-
sence of a Ramsay,aRoscoe,oraThomson gets something that does not show in the syl-
labus. Instruction may perforce be limited in range ; it cannot be mechanical or dead.
In the proprietary schools, the instruction is more meagre and the spirit dull. The
work is nothing more than a drill conducted according to syllabi furnished by the
examining boards. The qualifying examinations will not wander from the syllabus;
neither, then, need the drill-master. The prominence of the science syllabus is due to
lack of time, to the defective preliminary training of the student, and to the exag-
gerated importance attached to the details of the examinations, about which we have
still to leaiTi.^ In any event, the science syllabus is the law in Great Britain. The ambu-
latory instructor has a syllabus for every emergency: if the student has to satisfy the
1 See chapter xi. n
68 iVIEDICAL EDUCATION
Apothecaries or the Triple Board, this syllabus suffices; if the Conjoint Board or Lon-
don University, that. Two laboratory exercises a week in chemistry form the prescrip-
tion for the "First Conjoint;" four half days a week with special tutorial classes
are required for London University ; every school provides both. The student makes
his choice; the instructor has "to put him through." The universities, privileged to
examine their own pupils for the degree which carries the license to practise, are in
theory much more independent of the syllabus than the hospital schools that can
themselves neither grant a degree nor examine for license: but at present, in theory
only. For as the universities prepare students simultaneously for their own exami-
nations and for those of the professional corporations, their curricula must pay due
homage to the cut-and-dried syllabi.
Perhaps the most undisguised drill of commercial character is to be found at the
Extra- ]\Iural School in Edinburgh. The equipment is of the simplest; the end is the
successful passing of the Triple Board examination. The prosperitv of the teacher de-
pends wholly on the success of his students so measured. The extra-mural teacher of
chemistry has rooms in which he conducts classes in organic and inorganic chemistry
and does commercial work besides. He lectures to women students daily from ten to
eleven, to men from twelve to one ; holds one practical class three days weekly in the
afternoon for men, and another three davs weeklv for women; does analytical work
and gives a six months' course for the public health diploma. He lives up to a syllabus
regulated by the examinations, pavs rent for his quarters, and retains his profits.
The vigor with which successive groups of students are drilled in the letter is so far
from being commendable that it is almost necessarily fatal to the most precious ob-
jects of science teaching. It sets up false standards of success, and subjects university
teaching to a comparison that may seriously interfere with its adherence to purer
and sounder methods. ^\Tiat is even worse, the university accepts this teaching in
lieu of its own; a vicious pri\'ilege, even if, as is claimed, it means only that uni-
versity students resort to the extra-mural drill-master to be coached for university
examinations. Such official recognition of cram classes cannot be educationally jus-
tified. It is not to be supposed that empirical medicine is to be transformed into sci-
entific medicine by students, every detail of whose scientific training has been thus
cut to pattern in the most economical fashion consistent with personal safety.
As is always the case with teaching that endeavors to do just enough, science
teaching by syllabi accomplishes too little. Of some 250 candidates examined by
the Conjoint Board in 1907, 85 were rejected in chemistry, 82 in physics, and 103
in biology; of about 100 examined in the same year by the Triple Board of Scot-
land, 44' failed in chemistry, 64 in physics, and 35 in biology;^ at the University of
London, 143 passed and 105 failed in physics and in biology.^ At Liverpool, on the
1 Minutes May 26, 1908, General Medical Council, p. 10. The Board had accepted as evidence of satis-
factory study more than "0 certificates issued by secondary and other schools.
» Jbid., p. U.
PHYSICS, CHEMISTRY, AND BIOLOGY 69
other hand, at the close of the chemical course above outlined, there were but 2 fail-
ures out of 35.
Reports of the inspections of examinations by representatives of the General Medi-
cal Council deepen the impression made by the foregoing considerations. Refemng
to biology, the Inspectors, while praising the arrangements made for holding the
examinations, state : " The Examiners were content with a very modest standard of
knowledge, but they were justified by the state of ignorance in which most candidates
present themselves. Scarcely a single candidate could be said to have exhibited real
grasp of elementary principles. When it was a question of naming the bones in the
skull of the frog, easily to be crammed up, answers often came glibly enough; but in
other matters of a simple nature, it was extraordinary to see the ignorance of can-
didates. The names and uses of the different parts of the microscope seemed wholly
unknown to many." As to physics and chemistry: "The standard is low; the candi-
dates so badly prepared that a higher standard would have rejected the majority.
Most of them showed absolute ignorance and were referred [failed]. Their teachers
must have known that they were ignorant and unfit to commence the study of physi-
ology and professional subjects, although they may have put in the number of formal
attendances required by regulations."^ Inspecting examinations in the same subjects
held at Apothecaries'* Hall, the visitors note the passing of a youth who was ignorant
"of the differences between animals and plants and very hazy as to the distinction
between vertebrates and invertebrates." Of the training in chemistry and physics, they
opine that "if well carried out, it is of no more value than a parlour game or the mem-
orising of a price list."^ Finally, of the examination in chemistry held by the Triple
Board in Edinburgh: "The practical examination in chemistry is hardly worthy the
name; it is of extremely little value as training the student's intellectual powers, or
as preliminary to the study of physiology, or as giving him something that will be
useful in his future career."^
Beyond all question, the ultimate remedy in Great Britain, as in Germany, — a
remedy which, it may be added, will simultaneously solve other difficulties that we
shall encounter as we proceed, — must lie in more thorough and pui-poseful secondary
education. Biology, chemistry, and physics can be systematically and thoroughly
taught to boys between sixteen and nineteen years of age; and time will still remain
for such other studies as may for one reason or another be held desirable. Clearly,
this suggestion remands the basic sciences to the pre-medical period; it takes them
out of the medical cun-iculum. In neither Germany nor Great Britain can the teach-
ing of these sciences as parts of the medical curriculum be held to succeed ; yet the
effort represents perhaps all possible variety. Germany and the English universities
^Report of Primary Examinations, Conjoint Board, May, 1903 (passim, abridged).
2 Report of Examination Committee, May, 1903 (passim, abridged).
^Report of Examination Committee, March, 1903, p. 17 (abridged). A general resume is published in
an undated Report, transmitted by the visitors to the Council, October 1, 1903.
70 MEDICAL EDUCATION
teach them in adequate scientific laboratories, the former, dispersed, the latter, con-
centrated. Neither is satisfactory. The hospital schools teach them with close refer-
ence to the professional end ; their meagre and spiritless drill likewise fails. But one
solution will avail : the fundamental sciences belong to the secondary, not to the
professional period. Concentration on the pi'ofessional object may then begin at once
with the study of the explicitly medical sciences next to be considered.
A distinctly successful aiTangement of this type may be pointed to in France. After
receiving the baccalaureate on lekving the lycce, and before enrolment in the med-
ical faculty, the French student spends a year in pursuing a course made up of physics,
chemistrv, and natural history, currently known as the P. C. N. Two points are to
be especially noted : the course is given in the university faculty of science, not in
the faculty of medicine; in point of quality, it is of secondary rather than university
grade. The instructors are, indeed, men holding high academic posts, — some, like
the late Professor Curie, at Paris, men of great distinction ; the teaching laboratories
devoted to the work adjoin the research laboratories, provided for every professor and
every assistant. Nevertheless, the particularity with which the topics to be treated are
described beforehand, the close control under which the insti-uction is canned on, and
its limitation to a single year from which all other subjects are excluded, stamp the
P. C. N. course as preliminary in spirit and content.
Inclusion in the scientific rather than in the medical faculty has the same effect.
It is no accident that the student is trained in the basic sciences by physicists and
chemists, rather than by medical men who understand physics and chemistry. The
subjects are presented on broad lines and in a scientific spirit, not merely in their
immediate instrumental relation to medicine. Despite the brevity due to extreme con-
centration, an effort is deliberately made, not simply to provide the student with such
information and skill as his prospective medical studies require, but to discipline his
powers of observation and to familiarize him with the process of scientific thinking.
Differences exist as to the wisdom of the undertaking. The medical faculty commonly
deplore what they characterize as the too general character of the P. C. N. work ; they
urge that the instruction ought to be confided to medical men who know what the
student will subsequently need. This is precisely the criticism that one would expect,
as medical education is organized in France to-day. It is not so much an unanswer-
able objection to the constitution of the P. C. N. courses, as an indication of the limi-
tations that we shall shortly observe in the outlook alike of the medical sciences and
of clinical medicine itself.
The arrangements made for the courses in question are at both Paris and Lyons
excellent. At Paris, lack of space at the Sorbonne has led to the erection of an en-
tirely new set of laboratories in the rue Cuvier. The buildings are unpretentious, but
well designed on something resembling a unit system. The different subjects follow
essentially similar lines. Each is demonstratively presented in the morning lectures
of the professor. Five afternoons weekly, from 1.30 to 4.30, are spent in practical
PHYSICS, CHEMISTRY, AND BIOLOGY 71
laboratory work : one devoted to physics, one to zoology, one to botany, and two to
chemistry. The class contains some 550 students, divided into groups containing 16
students each; the groups are combined for the amphitheatre demonstrations, while
they are distributed for the laboratory work, in such wise that class-rooms, each ac-
commodating some 30 to 40 students, are in charge of separate instructors in every
subject. Thus every afternoon, all the subjects are under way, the groups rotating
from one to another, day by day. The laboratory work begins with an introductory
statement by the assistant, lasting half an hour; after which the students repair to
their assigned places for practical work. Individual outfits are provided in botany
and zoology; in chemistry and physics, students operate in pairs. In the last men-
tioned subject several different experiments go on simultaneously; but in the end
each student must have satisfactorily executed the entire set. In all subjects alike,
full notes, drawings, and, where possible, curves are required; the results must be
exhibited to and are graded by the instructor before the student leaves the building.
Two examinations yearly are held ; the final record combines the examination marks
and the class-room grades. A general average of 50 per cent constitutes the passing
mark ; but if the general average falls below this minimum, the entire course must be
repeated, for single subjects may not be counted separately. Except that the numbers
are smaller, and that the laboratory work takes place in the morning, the lectures
in the afternoon, the P.C.N, courses at Lyons duplicate those in Paris. The assign-
ment of the courses to the scientific rather than to the medical faculty is perhaps
even more significant than at Paris, for at Lyons, — excepting only the hospitals, — the
entire university is concentrated on a single site. The medical laboratoi'ies of chem-
istry and physics — for every medical faculty in France contains both — are immedi-
ately at hand, sufficiently commodious, too, to accommodate the P. C. N. students.
The location of the course involves, therefore, an unmistakable judgment as to its
preliminary, rather than its professional, character, and in that spirit the instruction
is imparted.
Unmistakable advantages acci-ue from this disposition of the problem. It avoids
overcrowding of the medical curriculum, it insures painstaking fundamental disci-
pline, it favors the awakening of a general scientific interest by which the students
outlook may be broadened. The objections to which it is liable come from another
quarter. Where three laboratory subjects are postponed to a late stage, and there
concentrated in a single year, it is doubtful whether students whose previous educa-
tion has been largely non-scientific really assimilate what they leani so rapidly, and
whether the knowledge acquired fundamentally affects their mental attitude. But to
these questions it will not be fair to give an answer until medical education proper
has been reorganized in France; then only will one be in position to say whether
the P. C. N. course can stand the strain to which it will be subjected by a scientific
education in medicine.
Before leaving the topic, let me revert to a statement already made. I have said that
72 MEDICAL EDUCATION
for centuries medical education lagged far behind medical thought and practice. Can
it have caught up now? Medical thinking and medical progress involve chemistry,
phvsics, biology, and mathematics at every stage. The teachers of medicine, who are
also creators, are well-trained chemists and physicists. Can they teach at the level at
which they work.'' Not unless their students have been betimes thoroughly trained in
the sciences from which medicine has latterly derived so much of its impetus. The
defects pointed out in the basis of medical education still keep it from overtaking
medical science. Education can in no event include the whole of medical science; but
it may well be of the same piece, provided the student of medicine knows chemistry,
physics, and biology.
CHAPTER V
THE MEDICAL SCIENCES:^ GERMANY
Anatomy
Anatomy is the instrumental basis of medicine and surgery. As the general must
know the country in which he manoeuvres, so the physician must know the site and
outlines of the organs he palpates, and the surgeon the topography of the region
within which he operates. The subject may be taught directly and narrowly with
a view to just such practical application, and countries will be named in which this
happens. Germany, however, is not one of them. There it is universally recognized
that the effort to teach the student exactly the anatomy that, as physician or sur-
geon, it most concerns him to know, results invariably in teaching him less than he
needs to know and in ways that fail to promote the scientific habit, the development
of which is, in the long run, more important than any particular positive possession
ii^ the shape of knowledge. For anatomy is not merely a thing to be learned memo-
riter or to be mechanically mastered by dissection. It is not a closed book or a dead
science. Comparative anatomy and embryology have outlawed the notion that ana-
tomy is merely a descriptive science, whose ambitions are satisfied when a painstak-
ing dissector has completed a minute description of what he finds in the course
of taking the adult body to pieces. The study must indeed furnish the student with
the detailed knowledge of the body which as clinician he requires ; but it must also
bear a part in his scientific training, — in cultivating his powers of observation,
unaided as well as aided, and in training him in the art of inductive inference. Its
position in the curriculum makes it of decisive significance in determining the char-
acter of medical education. The basic sciences have been only indifferently acquired;
anatomy is the one science which all students pursue practically, and which all pur-
sue with considerable elaborateness. A scientific rather than a mere mechanical ground-
ing in it is therefore of crucial importance.
Does the scientific teaching of anatomy sacrifice practical mastery, from the utili-
tarian standpoint.? Assuredly not. It is indeed the humdrum teaching of bones,
muscles, and nerves that is at once most limited and least stimulating. The eye too
closely intent upon its immediate objects may miss their larger and more important
aspects. Indubitably, the student learns anatomy first of all because of its instrumen-
tal value; but it does not follow that he needs to be incessantly conscious of this pur-
pose. The tendency nowadays is to break away from the strictly morphological treat-
ment in the training of medical students as well as in the prosecution of research.
Morphology is found to be more firmly and more fruitfully grasped when the genetic
and functional relations of parts are taken into consideration. Nor does the modern
1 Anatomy, ph3'siology, pharmacologj% pathology, hygiene, legal medicine. I visited the universities
at Berlin, Munich, Leipzig, Breslau, Strassburg, Greifswald, Wiirzburg, Marburg, Giessen, Vienna,
and Graz; and the so-called "Akadamien" at Diisseldorf and Koln.
74 MEDICAL EDUCATION
anatomist hesitate to point out pathological changes by way of arousing an interest
that may subsequently remind the student in the clinic of a previous experience in
the laboratory.^
Thus presented, anatomy loses the artificiality characteristic of the rigidly and
consistently sustained morphological point of view. For this procedure there is pro-
found justification in the principles underlying the organization of all the sciences.
We shall have repeated occasion to point out that the divisions into which the medi-
cal sciences fall are not absolute. As knowledge advances, redistribution constantly
takes place; for the investigator batters down or displaces the bamers which pro-
visionally separate various domains. Anatomy, physiology, and pathology are not
therefore at bottom necessarily exclusive of one another. Such exclusiveness as super-
ficially appears is a matter partly of convenience, partly of individual preference, partly
of financial economy. Overlapping and repetition ought to and must occur. Mall has
pointed out that embryology was bom simultaneously in three departments, — ana-
tomy, physiology, and zoology; histology appeared contemporaneously in anatomy,
phvsiologv, and pathology; bacteriology flourishes equally in botany, hygiene, and
pathology.^ From the standpoint of teaching, on the other hand, dividing lines are
apt to be too sacredly and too long respected, — one of the reasons why teaching finds
it difficult to overtake research. Meanwhile, a certain amount of duplication vastly
increases the effectiveness of instruction, by making one subject the apperceptive
basis of another. Different subjects thus reinforce one another; the several strands of
knowledge are woven into a single tissue. The student's grip is more secure; his field
of vision more extended, and subsequent experience recalls more varied associations.
For this reason, sharp differentiation is not attempted in Germany even where two
chairs of anatomy exist side by side. At Berlin, there are two institutes, one knowTi
as the Anatomical Institute, the other as the Anatomical-Biological Institute. Com-
parative anatomy, embryology, and histology are cultivated in both, as they may also
be in the institutes of physiology and zoology, if workers find their problems for-
warded thereby. Waldeyer urges with great force that in any event histology must
be vigorously represented in the department of anatomy, no matter where else it be
prosecuted. When the unaided eye and the scalpel have reached the limit of their
capacity, the microtome and the microscope must be invoked; for if the anatomist is
concerned to understand the structure of the body, it is absurd to confine him arbi-
trarily to such observation as he can make with the naked eye. The use of the micro-
scope does not alter the nature of his inquiry. It simply enables him to go further,
precisely as the scalpel is an improvement upon his fingers.
Anatomy cannot stand still where such a view of its scientific character and rela-
tionship prevails. The German anatomical institutes are therefore devoted with equal
^ See, for example, Tandler's Antrittsrede, "Anatomic und Klinik," Wiener Klin. Wochemchrift,
vol. xxiii. No. 44.
2 Philadelphia Med. Jour., April 1, 1899.
MEDICAL SCIENCES: GERMANY 75
emphasis to teaching and research; they begin with the cell, taking in the complete
human frame, and often comparative anatomy as well. Is indifference to teaching, even
to elementai-y teaching, the result? An investigator may of course be a poor teacher.
So may he be who is utterly devoid of the research spirit. In general, however, the
German anatomists are excellent teachers. Devoted investigators though they are,
they do not lose sight of the primary purpose for which the medical student acquires
anatomy. One of the most distinguished of them writes : "In the fii-st instance, one
cannot overemphasize the fact that we professors are as a body appointed bv the
state to train doctors. We should indeed do our duty but indifferently if we were
not profoundly concerned with the advance of science. We are therefore rightly ex-
pected to be investigators. But we may not forget that, whatever our responsibility
for scientific progress, we are for our young auditors elementary teachers, — we anato-
mists, above all. Hence, the fii-st duty of the anatomist — to introduce the beginner
to the elements of his profession. If the student is overwhelmed with details or with
matters of controversy, the important foundations are neglected or appear to him
inconsequential. The danger is perhaps increased by the natural tendency of the aca-
demic instructor to dwell on points that especially interest him. Of course, he ought
not to conceal his own preferences, his own lines of interest; he ought, rather, ft-eely
to exhibit them ; otherwise he will not inspire his students. But this must never in-
terfere with laying a sound, broad, elementary foundation, theoretical and practical.
Thus far, indeed, one might almost say that anatomy is an art before it is a science.
Here the student's training proceeds in simple, concrete fashion; here we are elemen-
tary teachers in the strict sense. It is not for the moment a question of standpoint
at all, — whether genetic, physiological, or comparative. The young student wants
to get hold of the naked fact. That is the way, too, in which the seasoned investiga-
tor takes hold of a new problem, — in the simplest and most objective fashion."^
"WTiile the institutes differ in style and splendor, they have practically all been either
built or rebuilt in quite recent times. Without exception, they possess capacious lec-
ture rooms provided with modern projection apparatus; dissecting-rooms invaria-
bly clean, attractive, and with the requisite adjuncts; class-rooms for microscopical
com-ses; museum, library, and research quarters for the chief, his staff, and advanced
workers. The auditorium varies in size from that of Rostock, seating 40 students, to
that of Berlin, seating 400, or the new hall at Munich, seating 590. The departmen-
tal libraries contain at least current periodicals, important works of reference, atlases,
etc. Twenty years ago, when Waldeyer prepared a detailed account for the book on
the German Universities, published by the German government for the Chicago
exposition, the departmental library at Strassburg contained 1000 titles; that of
Konigsberg, 2100; that of Berlin, 3000. The Anatomical Museum at Berlin then
contained over 8000 specimens; that of Giessen, 1200; that of Leipzig, 3200; there
were 10,000 histological preparations at Bonn, over a thousand skulls and skeletons
1 Waldeyer : Wie soil man Anatomie Uhren und lemen ? (pp. 5-7 abridged). Berlin, 1884..
76 MEDICAL EDUCATION
at Halle. Models and special dissections, cross-sections, corrosion preparations, charts,
are always found, and usually in great abundance. At Vienna, the series of prepara-
tions on which special studies were made by Hyrtl, Zuckerkandl, and others are pre-
served with pious care. Every institute has its own photographic outfit, and shop, and
several possess an aquarium.
The most recent of these laboratories — that at Munich — is also the most elabo-
rate. It covers an area of 200 by 300 feet, and is four stories in height. Last year
it accommodated 2000 students, of whom 900 were engaged in dissecting; 600 at-
tended lectures in gross anatomy, 600 attended lectures in art anatomy, 500 those
in embryology and histology; 300 were enrolled in practical classes in histology, 200
in classes for histological technique. Equipment is at hand for the preparation of all
kinds of anatomical specimens, sections, skeletons, charts, photographs, including
X-rays. The building is surmounted by a huge dome, in which the classes in his-
tology are held.^
Considering its scope and activities, the staff of the Anatomical Institute is sur-
prisingly small. There are two chairs at Vienna, Munich, and Berlin ; elsewhere only
one. The staff of the first Anatomical Institute at Berlin consists of professor, two
prosectors, seven assistants (one a volunteer), and the important inferior help, a house-
inspector, a preparator, three helpers, and a mechanic, — making a total of sixteen
persons ; that of the second, the Anatomical-Biological Institute, consists of four in-
structors, with four helpers. The Leipzig institute, in which 400 students dissect, has
a staff of five, with six helpers of different kinds; 250 students work in the subject
at Marburg in an institute conducted by a professor, with two prosectors, two assist-
ants, and two student assistants; 150 at Erlangen, under a professor, a prosector, and
two assistants; about 100 at Rostock, in an institute whose staff includes professor,
prosector, a student assistant, a technical assistant, and two helpers.
The teaching force is undoubtedly hard pressed, and an impression of overwork is
generally prevalent. But in any event, a relatively small staff suffices, — in the first
place, because of the wide employment of the lecture method; in the second, because
in actual dissecting as well as in private study the student is expected to help him-
self. As to this, he is in practically the same position as the advanced student —
no control of his movements, attendance, industry, is anywhere attempted. Only in
one or two subjects — dissecting and the practical work in physiology — is his work
checked up at all ; even then, the supervision is far from exacting. The German theory
holds that the disciplinary period ends with the Gymnasium; that, a profession once
chosen, responsibility must rest squarely on the individual. "No pedantic methods
can be utilized,"" says Klickert, in speaking of the immense Munich establishment;
"a spiritless drill would conflict with the principles of academic teaching by depriv-
ing workers of their self-reliance. Rather, time and stimulus must be given them to
^ The institute is described fully in Die neue Anatomische Atialalt in Miinchen, by Dr. J. Ruckert
(Wiesbaden, 1910).
MEDICAL SCIENCES: GERMANY 77
follow out topics in the literature, atlases, etc., or to put questions to the instruc-
tor.""^ Teaching on these lines is both feasible and effective in the smaller institutions,
where a professor, who knows his students, can casually afford them the requisite
direction and stimulus without making of himself a teaching drudge ; in the large uni-
versities, as the courses are now given, the outcome is more dubious. We shall see that
in them the wholesome German theory is in danger of being defeated by mechaniza-
tion, lack of guidance, or by the passivity of the student, inured to excessive lecturing.
In the subjects included in the scope of the German Anatomical Institute, human
anatomy, comparative anatomy, embryology, histology, elementary courses, and
advanced opportunities are all offered. Before admission to examination, the stu-
dent is required to earn certificates showing attendance on general lectures for one
semester, dissection for two semesters, and practical histology for one semester. As
a matter of fact, few students adhere to the minimum, especially in the matter
of lecture courses. An important subject, like general or special anatomy, is taken
twice, sometimes oftener. Over and above these required courses and exercises, elec-
tive courses are offered in comparative vertebrate anatomy, anatomy for non-medical
students, comparative and experimental embryology, neurology, anatomical tech-
nique, anatomy of the sense organs, anthropology, etc. The great variety of courses
thus offered provides every desirable kind of opportunity. Having once procured the
indispensable common basis, the student may then strengthen himself wherever he is
weak, or develop himself further where he is interested. The offerings at the smaller
universities are less rich, but the principle is the same. For example, Greifswald
offered in the winter semester, 1910-1911, lectures in systematic anatomy, dissections,
topographical anatomy, special dissections for dental students, embryology, special
research courses for advanced students, Darwinism, osteology, histology, and anatomy
of the nervous system. The lectures, dissecting classes, and histological courses are
largely attended : the amphitheatres at Berlin, Munich, and Leipzig are filled to over-
flowing; at Marburg, the lectures on systematic anatomy are heard by 100 to 150
students, at Erlangen by 75; histological classes enroll 300 at Berlin, 80 at Erlangen,
120 at Marburg. But the elective classes are very small; there contact between teacher
and students is close, — and that, too, in the great centres as well as at the small
institutions.
The situation in regard to the supply of anatomical material has in recent years
been decreasingly satisfactory. The laboratories receive the unclaimed dead from
hospitals and prisons, — the former, however, only after post-mortem. The number
of complete bodies is altogether inadequate ; even with the addition of the autop-
sied cadavers, it barely suffices. Time was when the supply was so abundant at Vienna,
for example, that students could work with fresh material, and every individual
might twice dissect the entire body. Nowadays, the student is fortunate who dissects
an entire preserved cadaver once. The law in Saxony gives the Anatomical Insti-
^Neue Anatomische Anstalt in Miinchen, p. 48.
78 MEDICAL EDUCATION
tute at Leipzig the bodies of suicides and unclaimed dead in all Saxony. An allowance
of one body to each student would be held satisfactory, but the supply falls short
of this by almost 50 per cent. The scarcity afflicts all universities, large and small
alike. Only thirty cadavers are available at Erlangen, though twenty more are turned
over later by the demonstrator of operative surgery, for dissecting classes aggregat-
ing 140 students; at Rostock, forty adult and ten infant bodies must suffice for 110
workers; at Marburg, fifty to sixty bodies for 220 dissectors. Democratic sentiment
and clerical influence appear to be mainly responsible for the shortage. Among the
humblest workers, burial societies have been organized which, in consideration of
trifling monthly dues, promise the friendless laborer a funeral quite out of propor-
tion to anything he has had in life. The prospect of having a " handsome funeral"^
has become the ambition of even the abjectly poor.
The teaching methods employed are the demonstrative lecture and the practical
exercise; of didactic lecturing and text-book recitation or drill, the German univer-
sity instinictor knows nothing. The general lecture course conducted daily through-
out the semester by the professor traverses the entire fleld. Charts, lantern projec-
tions, museum specimens, are employed illustratively. Despite the argument already
quoted in behalf of observation and participation by the student himself, the lec-
ture is beyond question everywhere overdone in Germany. It does indeed throw the
responsibility of learning on the student ; but it gives him no effective assistance
toward achieving his pui-pose, namely, the practical mastery of anatomy. Of the
futility of lecturing there is surprisingly little suspicion. Lectures attract the stu-
dent like a mirage. His first course in anatomy disappoints him. He takes a second,
not infrequently a third; but the goal is not thus to be attained, no matter what in-
genuity is employed in illustrating. At Munich, as the professor lectures, an assistant
dissects beneath a reflectoscope which throws upon a huge screen an enlarged image
in perspective: the student thus sees in normal position and relation every structure
described or discussed. At the close of the hour he has a chance to examine for him-
self illustrative models, cross-sections, and drawings, in a students' collection always
accessible. But the net result to him of this demonstrative instruction is nevertheless
slight ; the waste of time, very great. As a matter of fact, a knowledge of the bodily
parts, viewed separately, together, and topographically, can be built up only by dis-
section, reconsti*uction, close study of models, etc. There is perhaps no subject in
which mere elucidation will accomplish so little.
In Germany, dissecting takes place in the winter semesters, histology occupies the
summer. The professor is himself chief of the dissecting-room, which is open and in
active use daily from nine o'clock until five. No matter how large the class, he glides
freely fi'om table to table in the endeavor to keep in touch with students and assist-
ants. Waldeyer at Berlin, Hochstetter and Tandler at Vienna, themselves direct and
take part in this fundamental work; of course, the professor at Marburg, Graz, or
^ " Eine schone Leiche."
MEDICAL SCIENCES: GERMANY 79
Rostock is his own chief of the dissecting-room. Advanced workers are not numerous,
six or eight at any one time in so important a centre as Berlin. They may be physi-
cians working at problems appropriate to a special interest, or investigators pursuing
a purely scientific quest. Noticeable are the cordial welcome extended to the compe-
tent student, the rigid barrier that shuts out the incompetent, and the utter indiffer-
ence of the professor to their numbers. The large responsibility in the selection and
working out of problems that falls to the student himself effectually deters those
incapable of "paddling their own canoe." Thoroughly characteristic is Mall's ac-
count of His : " His was never anxious to have pupils. When I knocked at his door at
first, I was turned away, but after appearing a number of times, was finally accepted.
When he set a problem it was concisely stated; he outlined the general plan by which
it was to be solved. All the details were left to the pupil, and it annoyed him to be
consulted regarding them. He desired that the pupil should have full freedom to
work out his own solution and aided him mainly through severe criticism."^
In this respect, small and large universities do not differ. In both, the professor
and his assistants are accessible; in neither is the student policed. He is of mature
years, and has been severely trained with a view to a university career. His fate is
in his own hands. Subject to the protection of the public by a sufficiently rigorous
examination,^ the argument in favor of such methods at the university is irrefuta-
ble. The difference between small and large universities is therefore not fundamen-
tal. The student at Rostock is not held down by his teacher; the student at Vienna
cannot be.
Practically, however, there is a marked difference in favor of the smaller institution.
Although the theory is in both cases the same, it is inoperable in the larger schools.
The student is expected to do his own work ; and occasional contact with an inspiring
teacher is supposed to constitute the only necessary directive force. This is not want-
ing at Marburg, Giessen, or Wiirzburg; it is highly precarious at Berlin, Munich, and
Vienna. While undoubtedly really vigorous students get abundant opportunity every-
where in Germany, it is questionable whether any of the large universities are in
position to do justice to the ordinary individual. If the production of a small num-
ber of highly trained anatomists were the sole or the main object, one could urge no
objection. For even in the most crowded centres a capable individual readily demon-
strates his presence. According to Ostwald's criterion, the able man is he who does
more than is demanded of him. In Berlin or Vienna, while doing his required modicum
with several hundred others, he will perhaps have no way of disentangling himself from
the mass. But at the point where the ordinary student stops, he goes ahead. One of
several hundred students before, he is now one of half a dozen in an elective or advanced
course, or as volunteer assistant.' Thenceforth, no matter how large the university, it is
small for him. He comes into close contact with his teacher precisely when such contact
^American Journal of Anatomy, vol. iv. No. 2, pp. 150, 151.
2 See chapter x. ' So-called " famulus."
80 MEDICAL EDUCATION
is of the utmost moment in his development. The necessity, however, of training doc-
tors in considerable numbers makes it important to provide in anatomy conditions
favorable even to the effective training of mediocrity in the elements of the subject.
The three great schools — Berlin, Munich, and Vienna — solve this problem differ-
ently. At Munich 500 students dissect at once, in the clover-leaf hall, one hundred in
each alcove. Three students work at each table, ^^^lat with scantiness of material and
the small size of the staff, the professor's demonstrations are forced to play an inor-
dinately important role. As already described, the part under dissection is projected
on a screen and further dissection is carried on by an assistant, who thus keeps pace
with the lecturer's discussion. Everything is told to the student; nothing is left to the
imagination. In histology, 150 students attend a so-called practical course. They sit in
concentric half-circles in the splendid dome, the professor in the centre. Every indi-
vidual, including the instructor, receives the same slide. The professor expounds, the
students follow. When the exposition is concluded, the students make sketches, after-
wards hastily inspected by the professor. A student who has failed receives additional
explanation. Without rising from his seat, the lecturer can press a button and darken
the hall in order that an enlargement of the section under consideration mav be pro-
jected on a screen. Of course no one need be satisfied with the mechanical instruction
thus received; for a willing student may do as much more as he pleases. The fact re-
mains that most students are satisfied, and get nothing else. Munich thus copes with
numbers in anatomy by means of mechanical methods applied to large masses. Vienna,
on the other hand, is frankly overwhelmed by them. Its two chairs divide over 1000
students, of whom last session 460 were in their first semester. With a staff of three
assistants and seven demonstrators, four of them unpaid, and two dissecting-rooms
each capable of containing about 125 students, a professor is supposed to train over
500 students, most of them beginners and practically all without previous scientific
experience. It is an impossible feat. "Vienna is a monster," remarked one of the pro-
fessors engaged in it. The professor continues to circulate through the room, but at
best he glances and passes on. Only when he encounters an anomaly, does he pause
long enough to afford the assistance required.
In Berlin, the physical accommodations are more nearly adequate. The students
in practical anatomy work in four capacious rooms, each containing 50 students in
charge of an instructor. Dissecting is organized as follows: twice weeklv, parts are dis-
tributed to students whose names have been posted. All those who receive the same
part betake themselves to the assigned dissecting-rooms, where an instructor gives
a general explanation and sets them to work. From time to time the students exhibit
their results, are orally quizzed, and are credited by the instructor in the little account-
book kept by each individual for the purpose.^ For histology, the class is arranged in
1 For detailed account, see Waldcyer : " Der Unterricht in den anatoraischen Wissenschaften an der
Universitat Berlin," etc., Berliner Medizinische Wochenschrift, October 10, 1910.
MEDICAL SCIENCES: GERMANY 81
three divisions, each of which is subdivided into gi-oups of ten, with its own demon-
strator. The necessary explanations are made to these small groups; once weekly
a resume is given to the entire class. At each practical exercise at least one complete
preparation is made by each student. The course rooms are open for voluntary appli-
cation daily from 9 till 5 o'clock, and it is stated that perhaps one-third of the
students make diligent use of this opportunity.
Whether medical education is possible on the grand scale without sacrifice of its
scientific character remains yet to be demonstrated. It may be that it is partly a
question of organization, partly a question of adequate provision. Given subdivisions
enough, each fully officered, 1000 students can perhaps be trained as readily as 250.
Even so, the increase of administrative detail may exhaust the strength of depart-
mental heads. We have already learned that students will throng in large numbers
to great cities. If multiplication of departments prove ineffective, duplication of
institutions remains as a possible solution. Such duplication on anything else than
a university basis leads at once to highly objectionable competition; but where uni-
versity ideals and conditions are firmly established, it may prove the only means of
avoiding university monstrosities.-^ Thus far, in any event, the equipment and organ-
ization of the larger institutions have not kept pace with their increase in enrolment.
The equipment and organization calculated to handle the smaller, have been forced
to suffice for the much greater, number. On these terms, large schools go far to belie
the fundamental principles of scientific training. For, while the student can thus be
brought to acquire information, he gains nothing in reflective power. His education
is acquisitive and imitative. The elimination of effiDrt and error reduces his processes
to the level of automatism or mechanism. "It is eternally true," remarks Waldeyer,
"that we really know and hold as an inalienable intellectual possession only what
we have gained by our own effi^rt with a certain degree of actual exertion."^ I have
pointed out that the scientific teaching of anatomy is necessary partly because the
student has previously had no scientific training. To the anatomist, then, falls fii-st
the responsibility of training him to observe, to reason, to act. Hence the importance
of teaching the medical student anatomy in scientific anatomical institutes, which
the Germans clearly recognize. But what becomes of this argument if the instruction
deteriorates into mass instruction in which the student earns the requisite certificate
by following the motions of his leader? Scientific medicine imposes an increasing
strain on the student's initiative. Meanwhile, the preliminary education of the medi-
cal student remains in most cases what it was. Mechanization in anatomical teach-
ing amounts, therefore, to stultification. Nor is this situation wholly met by the in-
disputable fact that a capable and enthusiastic student can achieve as much more as
he pleases.
1 See chapter viii. ^ Berliner Medhinische Wochenschrift, October 10, 1910, p. 17.
82 MEDICAL EDUCATION
Physiology
Not until comparatively recent times has physiology won its independence of ana-
tomy.^ At Leipzig, to take a characteristic example, the two chairs were separated
only when, in 1865, Ludwig began his remarkable career there. Weber, his immediate
predecessor, had carried out his important researches in experimental physiology in
a few small rooms belonging to the Anatomical Institute, of which he was the head.
In the provisional quarters first placed at his disposal, Ludwig had a single assistant,
representing histology. With the erection of a new laboratory, he created physical
and chemical divisions, out of the latter of which a practically independent depart-
ment of physiological or bio-chemistry has developed in many universities;^ histology,
on the teaching side at least, now usually falls to anatomy.
In Germany, the physiological institute is the counterpart of the anatomical in-
stitute : it contains a large lecture hall, conveniently equipped for demonstration with
gas, water, and electrical attachments, blackboard, projection apparatus, etc. The in-
evitable preparation room adjoins, its cupboards full of physical and chemical appa-
ratus, models, charts, etc. In close proximity are the large demonstration rooms, in
which practical undergraduate courses are held, and the smaller demonstration rooms,
to which students repair in small groups: one for electro-physiology, another — with
dark room adjoining — for sense physiology, etc. A workshop in charge of an expert
mechanic is always a striking feature. The rest of the building — something more than
one-half of it — is dedicated to investigation. A complete laboratory would be sym-
metrically developed on several sides, physical, chemical, and operative. But, as a
rule, the laboratories are uneven, emphasizing the approach to physiological problems
which most strongly appeals to the chief at the moment. The Berlin institute is organ-
ized in five divisions, — operative, chemical, metabolic, bacteriological, and physical.
Each division has its separate staff, — a head, perhaps an assistant, and always a skilled
helper. The professor is director; to him secretary and mechanic are responsible. The
entire personnel includes nineteen individuals. At other universities, the organiza-
tion is less elaborate: the Munich and Heidelberg institutes have each a teaching staff
of four, with three helpers; Greifswald, a staff of two, with one helper. But the ab-
sence of a chemical division here, an operative division there, involves in the end
no loss to either science or education ; for the German student, gi'aduate or under-
graduate, migrates freely to the university where those lines of work are cultivated of
which he is in search.
Physiology as it is embodied in the university institute just sketched is not lim-
ited to human physiology. Though the subject belongs to the medical division, it is
there cultivated in its wider bearings. Human physiology is only a special aspect. The
* The two chairs had been separate at Breslau from the founding of the university in 1811. They be-
came separate at Marburg in 1848; Tubingen, 1853; Heidelberg, 1837; Berlin, 1858; Munich, 1863;
Greifswald, 1872; Giessen, 1891.
2 At Strassburg and Tubingen, physiological chemistry has its independent chair.
MEDICAL SCIENCES: GERMANY 88
student of medicine is of course concerned mainly with human physiology, as defi-
nitely related to his professional object. His instruction, however, takes up the higher
mammalian physiology in general, with especial reference to man. Ever and anon the
discussion is brought to bear more naiTowly on medical matters; but no German ever
views his topic in instrumental isolation. To the physiologist, physiology is always
a particular aspect of biology, — and of the biological fringe he is always more or
less conscious. He presents a picture of function sufficiently circumscribed to be of use
to the medical student, but in terms that involve general biological facts and prin-
ciples. The activities of the least pretentious institute thus range in the form of ad-
vanced coui*ses and individual research far beyond the common requirements. At
Leipzig, in addition to the general lectures and laboratory exercises, special courses
deal with the physiology of the circulation and the theory of life; at Munich, advanced
courses are given in metabolism and physical chemistry applied to biology; at Wurz-
burg, in the physiology of nutrition; at Strassburg, in the mechanism of speech and
muscle physiology ; everywhere, too, special research topics are selected by students
after conference with the professor.
The teaching of physiology as part of the medical curriculum takes two forms, — the
lecture and the practical exercise. The lectures endeavor to portray the present status
of the science by presenting and inductively developing its more important aspects.
The presentation is neither merely descriptive nor merely concrete. It is philosophical
in the sense that the student is carried through the systematic steps by means of which
conclusions have been reached and supported. The German lecturer does not simply
purvey facts and laws which his students are to accept on his authority; nor does he
endeavor by elucidation and simplification to bring a given subject-matter within
the comprehension of immature auditors. Be the topic easy or difficult, elementary
or advanced, his exposition is orderly, historical, logical, making a positive demand
on the trained intelligence of the student body, a demand which the exacting disci-
pline of the gymnasium has made them ready to meet. The centre of gravity of the
instruction falls within this lecture course, not within the practical course, which is
distinctly subsidiary. It is urged in defense of this procedure that the foundation thus
furnished is really based on experience; the student has observed the fundamental
phenomena, and has been taught to draw conclusions from them. What matter if he
does not perform the experiments himself? " It does not contribute in the least to my
persuasion that two weights are equal if I myself put them in the scales ; all that is
needed is that I should see their equilibrium."^
Of the quality of teaching, what has been said of anatomy may be repeated. The
exposition is admirable ; it affiDrds a clear, comprehensive, and thoroughly scientific
introduction, philosophic in conception and as concrete as convenient illustration can
make it. The necessary previous an-angements have been made most carefully ; at the
proper moment, an effectively prepared illustration clinches the point that has been
1 J. Rosenthal: Ber physiologische Unterricht, p. 19 (Leipzig, 1904).
84 MEDICAL EDUCATION
developed. So subordinate, however, is the place occupied by the practical course that
a semester or more frequently elapses between the lectures and the laboratory work.
There are two points of view from which the Grerman disposition of the subject
must be regarded, — that of pedagogical theory, and that of practical expediency
under existing conditions.
Pedagogically considered, the German practice is surely mistaken. Ahke in content
and purpose, modem phvsiology is an experimental science. Exposition neither con-
vevs its content nor answers its purpose. In endeavoring to possess himself of such a
science in however elementarv a fashion, it is precisely the beginner who must needs
acquire essential concepts through his own experience : only after terms have obtained
vital meaning from experimentation do they become for the first time significant sym-
bols which enable him subsequently to actualize what he has not himself done, to reason
with factors that he himself has not disengaged, — in a word, to reap where he has not
himself sown. The most brilliant demonstration is in this sense less educative than a
more or less bungled experiment executed by the student with his o^vTl hands.^ In a
sense, a demonstration deceives: the student who watches its smooth progress from
his seat forms no conception of the difficulties involved in the preadjustments. More-
over, follow though he may in thought, he after all sees and thinks only what he is
told to see and think. Not only does he acquire no manual dexterity, the acquisition
of which is so important; he does not even think independently, — the very capacity
on which scientific medicine presumes. The teacher observes and thinks, — the student
is passively and unresistingly led.^ Especially, therefore, at the start, the exhibition
of a tracing is a wretched substitute for the experience of making it, even though
in the former case the tracing is perfect, and in the latter well-nigh unrecognizable ;
the more so where, as on an occasion at Berlin, a pulse tracing made by an assist-
ant before the class met was held up to the view of over one hundred auditors, few of
them close enough to see it. Indeed, the exhibition in the lecture goes far to deprive the
act of making it two semesters hence of educative stimulus and value, by so largely
diminishing the element of surprise.
Whether, however, the introduction of the experimental method on a scale suf-
ficiently elaborate to make it the central point of phvsiological instruction is now
feasible in Germany is another matter. Physiological experimentation implies good
previous practical training in physics, chemistry,and biology. Anatomy may — though
not without deplorable limitations — be a first science; a boy can learn to dissect,
even if he has had no antecedent scientific training. But to teach experimental physio-
logy to boys who have never worked in scientific laboratories is a task that wastes the
1 " It is quite clear that through the student's own experimental activity with all its slips and imperfec-
tions, a better and more enduring picture of physiological phenomena is gained than is possible where the
student hears about experiments in the course of a lecture or sees a curve on the blackboard." Fried-
rich von Miiller : " Amerikanische Eindriicke," Munch. Med. Wochen., 1907, No. 49. Sonderdruck, p. 7.
^ " Dabei verhalten sich die Zuhorer passiv, der Lehrer ist es der beobachtet und denkt." J. Orth : Die
Stellung der path. Anat., p. 30 (Berlin, 1904.).
MEDICAL SCIENCES: GERMANY 85
teacher wathout greatly profiting the student. The Germans are therefore doubtless
right not to attempt it; but they are just as surely wrong not to prescribe a prelim-
inary training that would wan-ant the attempt.
Here again science and education still diverge. Clinical medicine is penneated by
the spirit of physiology, and physiology is an experimental science. A standpoint es-
tablished in anatomical investigation can be brought over into anatomical teaching;
but the standpoint estabhshed in physiological inquiry cannot be made active and
actual in physiological instruction. The student knows too little and can do too little
to permit it. To some extent, medical education continues to suffer throughout from
the consequences of this defect, as we shall observe later in dealing with pharma-
cology and in clinical medicine. In these, as in physiology, the traditional descrip-
tive presentation by lectures still holds the stage, educationally speaking; albeit the
most rigorous procedure has been worked out in them on the side of research. From
the investigative standpoint, physiology is as highly experimental a science as chem-
istry. On the teaching side, however, it continues preeminently, even if illustrativelv,
descriptive, just as though it had not broken away from anatomy in order to de-
velop on expeiimental lines. The student may see or perform a few experiments upon
frogs, — the substance of his physiological knowledge is not altered thereby: his con-
ception of such important functions as respiration, circulation, and metabolism is
verbal, not functional, for it comes to him as description and descriptive it remains.
TTie practical course, therefore, in Germany is a thing by itself, and as a rule is
still unsatisfactorily carried on. Quite independent of the lecture course, it is often con-
ducted by another instructor and almost invariably taken in a subsequent semester.
It does not and cannot furnish the lecturer either basis or point of reference. Con-
sisting as it does of certain exercises specified and minutely described in a syllabus,
the practical course tends to be an isolated series of experiments mechanically exe-
cuted rather than a stimulating and successful application of scientific method to
physiological problems. Neither in small nor in large universities is the equipment
usually suflScient for any other treatment of the matter. At Greifswald, there were
only thirty students in the practical course. But as there are only two or three sets of
muscle and nerve apparatus, which students must use in succession if at all, the practical
course deteriorates into an informal demonstration, in which the professor or his one
assistant does the work, while the students crowd around to look on. The course is
practically a demonstration course at short range. When the class becomes twice as
large, diificulties arise. The number is too great for the intimate and informal demon-
stration just described. Equipment, space, and staff are insufficient to allow the entire
body, di\'ided into small groups, to be occupied simultaneously with the same experi-
ment. The difficulties arising from the lack of previous experimental training are thus
apt to be increased. "\Miere fifteen groups composed of four inexpert students, each in
cramped quarters and with an inadequate staff, are engaged in performing a varietv of
experiments concuiTently, the assistants or the more skilful students do a dispropor-
86 MEDICAL EDUCATION
tionate share of the work. As the classes grow in size, these unhappy conditions are
further aggravated. At Vienna, there are some four hundred students, divided into
three divisions of over one hun(h"ed each. Each division has one laboratory exercise
weekly. On account of the entirely insufficient equipment, the divisions break up into
some twenty groups containing five or six students apiece; and these half dozen are
supposed to carry out one of the experimejits described in the syllabus. The inexpert-
ness of the students, partly due to the absence of pro{)er training in chemistry and
physics, and the variety of experiments simultaneously in progress, owing to lack of
equipment for any one, tend to convert the exercise into a disorderly and confused
demonstration by the professor and his assistants, who go from table to table setting
things right and themselves doing the work. At one table a blood count was under
way. Twenty students sun-ounded the table. An assistant started the process; strain-
ing to the uttermost, I was not able even to see what he did. Experiments in blood
pressure and respiration were in progress at other tables under precisely the same
conditions.
At Munich, to escape confusion, the course is highly mechanized. The student enters
the laboratory, in which practically the entire series of experiments is already set up,
each experiment in triplicate, and, indeed, so set up that the various adjustments
are immovably fixed. Experience has taught that it does not pay to leave students
the chance to tamper with the instrument. Nut, bolt, and screw have therefore been
either riveted or dispensed with. The student has only to "touch" the thing off and
the instrument does the rest, M'hereupon he passes on to the next experiment. What
a mechanical toy of this nature really adds to a demonstrative lecture course, it is
not easy to say.
At Berlin, the laboratory exercise is preceded by a lecture which takes off its edge.
The practicum is announced for the hour from twelve to one; but the demonstra-
tive lecture occupies the former half of the period. ^\Tiat the professor does first, the
student subsequently imitates. On the chemical side, the equipment is good; on the
physiological side, woefully inadequate. At Marburg, however, conditions are better:
there are twelve sets of apparatus, at which the students work in groups of four, so
that all members of the class are similarly occupied. The gain in order and coher-
ency is enormous. The exercise can reallv be led as it cannot be when three or four
instructors are overseeing six or eight different experiments at once.
The fact is, that undergraduate physiological teaching occupies now substantially
the standpoint of forty years ago. At that time, Billroth wrote somewhat naively, in
reference to physiology, that "it is of great importance to the entire scientific life
of the physician not to be content with merely gazing at the experiments and de-
monstrations prepared for the lecture; the student must now and then go behind the
curtain to see how things are done, occasionally even himself try."^
Essentially, this is what the student still does: he now and then goes behind the
1 Lehren und Lemen, p. 84.
MEDICAL SCIENCES: GERMANY 87
scenes to see how things are done; occasionally he himself tries. He does not, however,
rough it; and not otherwise can he be hardened. To grasp modem science, the student
must be trained to think concretely and experimentally. He must be bred to disti-ust
description. Description as such is indeed a draft on his faith that he must be taught
not as yet to honor, if he is going to apprehend function dynamically, as scientific
medicine requires. But if, on the other hand, he is to acquire fundamental concepts
experimentally, he must face the risks and alternatives that experiment involves. He
must not be spared the exercise of intelligence ; for where intelligence goes out at the
window, mechanism enters at the door. Whether the end be intelligent apprehension
or intelligent use, mechanical methods of training are unavailing. If, then, physiology
is to be taught as an experimental science, as a science of function, the student must
be allowed to run risks, to calculate, to observe, to vei-ify, to conclude. Eliminate risk
and the experiment becomes a mechanical toy: it may amuse, it does not discipline.
Scientific education is an effort to habituate the student to employ a certain method
in obtaining facts. If pulling a string solves the problem, how has he learned to handle
himself when a genuine emergency presents itself.''
For such physiological instruction as we have in mind, the students must as a body
be purposefully prepared; the institutes must be adequately equipped and manned.
Only for the small minority who elect to continue their physiological studies are
these conditions already fulfilled in Germany. No one of these who wants to perfect
himself in experimental phvsiologv lacks the chance; competent students find every-
where hospitable quarters and stimulating direction. They are nowhere numerous,
two or three perhaps in the smaller institutes, six or eight in the largest; for these,
the professor, and his assistants, every possible provision within the limits of the
budget is made. It would not be fair to represent the institute as generally resentful
of the necessity for providing elementary instruction ; for whatever it undertakes, it
does conscientiously. But in this capable minority it obviously flowers. Nor do these
necessarily remain physiologists. In the last half century, clinical medicine has ob-
tained its most important recruits from the advanced students and the assistants of
the physiological institutes.
Pharmacology^
The development of physiology and chemistry as interlocking sciences was bound to
result in an inquiring therapeutic mood. For chemistry extricated the active princi-
ples of the crude drugs traditionally employed, and experimental physiology created
the conditions for accurate observation of their effects. Conflict of therapeutic opinion
was general and acrid enough to suggest a test as soon as it became feasible to cor-
relate cause and effect. Tradition ascribed a certain efficacy to, let us say, camphor
or sarsaparilla. The "experience" of one man vindicated tradition ; the "experience"
1 Discussed here ^vith the sciences, though by the German examination ordinance included with the
clinical branches.
88 MEDICAL EDUCATION
of another went directly against it. Where does truth lie ? Organic chemistry and
experimental physiology put the pharmacologist in position to determine.
The juncture was also otherwise auspicious: while miscellaneous dosing was still
generally prevalent, intelligent practitioners had been infected with nihilistic doubts
from two highly divergent sources: the disclosures of the autopsy table brought an
overwhelming conviction of the futility of elixirs and extracts to combat, to terminate,
or to repair organic changes so profound and destructive; homeopathy, by appearing
to demonstrate that minimal are as efficacious as larger doses, hinted at the perhaps
frequent impotency of both. The immediate outcome of the nihilistic mood was a
wholesome emphasis of physiological therapy. We are, apparently, — so the argument
ran, — powerless to cure; but a rational mode of living, in the first place, prevents
disease, and, in the second, assists the body struggling for survival to regain its nor-
mal course. The new science of pharmacology represented from the start a distinctly
more hopeful therapeutic attitude: instead of discarding, it undertook to probe;
not content with testing traditional and empirical claims, it ventured the effort to
ascertain the physiological effect of drugs hitherto unemployed. Finally, proposing
to itself definite clinical and theoretic problems, it sought to create agents capable of
coping with them. Its most recent outcome, Ehrlich's salvarsan, is a deliberate effort
in constructive therapy.
The critical and constructive science of pharmacology thus succeeded the descrip-
tive science of materia medica in the medical curriculum. A curious reversal of rela-
tionship has resulted. The teacher of materia medica described the origin and ap-
pearance of roots and herbs, as his own senses infonned him; for their therapeutic
efficacy he took the word of the physician; he recited what the doctors told him.
The pharmacologist has, however, brought the doctors to book. He began by ex-
posing medical error and superstition. He has now become the expert to whom the
clinician does or should appeal. Whatever qualifying factors the clinician may need
to introduce, — and clearly one cannot leap in judgment directly from the guinea
pig in the pharmacological laboratory to the sick man in the hospital ward, — the
accurate experiment of the pharmacologist furnishes a definite point of departure.
AVhat is perhaps equally important, experimental pharmacology has rescued the phy-
sician from therapeutic credulity without plunging him into therapeutic despair. For
the undiscriminating confidence of the empiric, on the one hand, and the unjustified
negations of the nihilist, on the other, experimental pharmacology has substituted
a reasoned and regulated faith that knows where to be confident, where to be only
hopeful, and where — for the present at least — to throw up its hands. Science recog-
nizes limits: and while stubborn and unwaveringly assertive here, it confesses itself
incapable there. It knows and loves both attitudes, each at the appropiiate time.
We are in position now to understand the comparative recency of the pharmaco-
logical institute and the limited extent to which the subject figures in required
medical instruction. The science itself has been cultivated for a century. In the
MEDICAL SCIENCES: GERMANY 89
year following Waterloo, Sertlirner, having previously discovered morphine and
manufactured it in pure form, at length ascertained its physiological properties ;
strychnine, codeine, atropine, cocaine, digitalis, were all pharmacologically worked
out — the last by the clinician Traube— before the first separate institute for ex-
perimental pharmacology in a German university was established at Marburg, in
1867, following the lines of Rudolf Buchheim's laboratory at Dorpat, dating from
1849.^ A proper building was provided in Berlin for the first time only in 1883. Pre-
viously, Liebreich had carried on his researches in a small rented house, lecturing at
the university and using as his preparation room quarters serving simultaneously
as the seminary for Romance languages. More suggestive still of novelty is the fact
that one of the main creators of the science, Schmiedeberg, still occupies at Strass-
burg the chair to which he was called in 1872. In his laboratory the men were trained
who fill the professorship of pharmacology at Giittingen, Halle, Heidelberg, Rostock,
Tubingen, and Wlirzburg.
One is not surprised, therefore, to find that a well-equipped lecture hall, its neces-
sary preparation room, and a collection of crude and refined preparations consti-
tute the sole provision made for regular teaching in pharmacology. The individual
experiment, ill developed in physiology, has not yet been attempted in pharmacolo-
gical instruction anywhere in Germany. An official account of the Leipzig Institute
states: "In arranging rooms for practical work, it was assumed that in the chemical
and operative laboratories, scientific experiments would be mainly carried on by
those who had already attained an advanced stage of progi'ess. These laboratories
therefore contain no extensive halls for practical courses, excepting only the hall
used in pharmaceutical instruction."" ^ The pharmacological institute is thus mainly a
research institute. On the chemical and operative sides it is usually well equipped.
Occasionally, as at Berlin, an immunity division exists also. At Greifswald, the in-
stitute lies in a charming garden in which are grown many of the plants needed for
demonstration in materia medica. The staff at Wurzburg, fairly representative of
conditions at a university of medium size, consists of the professor, two assistants, a
mechanic, and helper ; it is but slightly larger at Berlin and httle smaller at Rostock,
for in the absence of practical courses, the size and demands of the institute do not
vary greatly. It is no more difficult to set up a lecture to be heard by three hundred
students than one to be heard by thirty, and the number of advanced workers is in
any case small, varying within narrow limits with the eminence of the professor.
A simple course of lectures disposes of the undergraduate work; it comprises ex-
perimental demonstrations in pharmacology and toxicology, what is of practical im-
portance in materia medica, and exercises in prescription writing. Optional practical
courses are given : atBerlin,in toxicology, in recent remedies, in advanced experimental
pharmacology; at Vienna, in the pharmacology of the nervous system ; at Greifswald,
1 In 1869, Buchheira, having been called to Giessen, established a laboratory there.
2 Festschrift zur Feier des 500jdhr. Bestehens der Univ. Leipzig, pp. 90, 91 (Leipzig, 1909).
90 MEDICAL EDUCATION
in German poisonous plants, etc. These definitely announced courses do not include
special researches, the subjects of which are privately agi'eed on in conference between
the director (as a professor is usually called) and the individual concerned. The optional
courses even in the largest institutions attract but a very small part of the student
body : on the occasion of a visit to an elective practical course for beginners at Berlin,
I found five students in attendance.*
With this situation the instructors are not satisfied. They perceive that experi-
mental science teaching demands the practical course. A new danger nowadays in-
creases its urgency in pharmacology. The critical pharmacologist has discredited the
old wives' tales that kept up the traditional pharmacopoeia. Meanwhile, the enter-
prising manufacturer is spinning a new superstition: the chemical industry of Ger-
many is aggressively and intelligently directed. It has won admiration and confidence.
It has, however, a highly developed commercial side. Only a critical pharmacological
sense can enable the practising physician to know when to doubt and how far to be-
lieve the sanguine and assertive claims made upon him by the manufacturing chemist.
Meanwhile, as the medical sciences increase in number and importance, it becomes
clear that the undergraduate student of medicine cannot do everything. One can con-
cede that the Germans waste time in lecturing and still maintain that in no event
can the ordinary medical curriculum be completely representative of all the elements
that constitute scientific medicine. The very hopelessness of thorough mastery brings
out in clear relief the fact that medicine is scientific, not because of this or that posi-
tive possession in the shape of knowledge, but by reason of its adherence to and ex-
emplification of a certain method. It matters little what particular facts the student
knows at gi'aduation, for he can in any case know comparatively few, provided in-
tensive training in a few branches has fixed a keen and sound mental disposition. If
he has contracted the inquiring habit, if he can detect logical error, if he can use his
senses and his fingers, he has been well educated in essentials. He gets such an edu-
cation by doing a few subjects thoroughly rather than by doing many superficially.
By all means let there be a student's experimental course in pharmacology, but it
need not be universally required, if at the same time the corresponding course in
physiology is properly elaborated. An intensive course in one or the other, as the stu-
dent may choose, is better than a brief course in both, and such an option is decidedly
in keeping with German tendencies. Moreover, the medical curriculum is not a mosaic
of separate pieces. Its different constituents are not permanently marked off from
one another by sharp unbending lines. Anatomy is supplemented and to some extent
retaught in pathology and surgery; pharmacology may be touched again in thera-
peutics^ and the clinic. Excellent pharmacological studies come nowadays from the
1 The classes vary considerably in size according as the semester is just beginning or is drawing to its
close.
2 We shall see (chapter vii) that this subject is undeveloped in Germany, except in special optional
lecture courses dealing with particular forms of therapy. See page 186.
MEDICAL SCIENCES: GERMANY 91
clinic; inevitably, where the clinician is so often first a physiologist. The opportunity
to acquire the pharmacological point of view does not then terminate with the lecture
course which the student is required to hear.
Fortunately, the compactness of laboratory and clinical plant has tended to promote
the interaction of clinic and laboratory in Germany. Pharmacology is indeed capable
of a pure development; that is, given drugs and animals, an indefinite investigative
evolution is possible. In its course practical results will undoubtedly emerge, the more
surely, perhaps, if they are not too eagerly desired or too nan-owly pursued. Meanwhile,
the science would cut itself off from a fertile source of suggestion if it lost touch with
the clinic. It is one of the most striking results of Gennan conditions that this does not
occur. Physiologist, pharmacologist, and clinician understand and employ one tech-
nique. Occasionally, they make a team for the elucidation of a particular problem from
every aspect.^ Oftener, their research products show the clinician making an inroad
into pure scientific investigation, the pharmacologist taking hold of a concrete clinical
difficulty.^
This, finally, is to be remarked in concluding: the essence of scientific training is,
I have said, the practice of method. We have found that in physics, in chemistry,
in physiology, in pharmacology, the German student practises that method too little;
undoubtedly he must practise it more in those lines in which he practises it at all.
Meanwhile, let it not be forgotten that he lives in an atmosphere created by that
method in its most rigorous and active form. He is taught by men who think and
act in no other way. Medical education indeed lags behind medical research. Yet the
actual education that the student gets is always better than the education that on
inspection he appears to be getting : it is better because of the quality and activities
of the men from whom he gets it.
Pathology
I have already had occasion to point out the provisional nature of the various
subdivisions of medical study : anatomy, physiology, pharmacology, bio-chemistry,
tend under vital handling continually to overlap. The lines between them are con-
ventional, not absolute, and ought on occasion to be entirely ignored. This does
not mean that scientists are once more to revert to the encyclopaedic type, that
instead of anatomists, physiologists, and pharmacologists, we are to desire a race
of cosmopolitan Boerhaaves, — citizens at once of the entire medical world; it does
mean that, however necessary minute subdivision of labor may be for puiposes of
research, and whatever divisions may be adopted out of wholesome respect for human
finitude, teaching and practice require that from time to time those things should
join which science has, for its immediate puiposes, chosen to put asunder.
1 See O. Loewi, " Pharmakologie und Klinik," Wiener Klinische Wochenschrift, vol. xxiii. No. 8.
2 An inspection of the contents of the German scientific journals shows the extent to which clinicians
are contributors to pure physiology and pharmacology.
92 MEDICAL EDUCATIOxN
As we approach the clinic, the perplexities attending delimitation thicken. How
is a definite province to be marked out for pathology ? The abnormal like the normal
has its two sides, — structural and functional, — intertwined with each other and
with the successive pictures of the patienfs condition reflected in the clinical recoz'd.
No single part of this complicated situation can be comprehended, if taken by it-
self. Morphological, physiological, and clinical elements require to be considei'ed to-
gether. In working out a field for pathology, we are therefore warned not to repeat the
error made on the normal side when a hard-and-fast line was drauii between anatomy
and physiology; for morbid anatomy is unintelligible without frequent incursions into
etiology, without constant cross-reference to clinical history and repeated experimental
inquiry. Pathology seems, then, to span well-nigh the entire medical cun'iculum. To
understand it, one must have grasped not only the fundamental branches, but the
clinical as well. Evidently, the student's pathological training involves in a peculiar
way his fundamental training, a certain measure of independent training, and con-
stant thought and cross-reference throughout his subsequent clinical career.
The founder of cellular pathology was acutely conscious of this complicated rela-
tionship. Virchow conceived the science as involving both anatomical and physio-
logical aspects, as, indeed, Rokitansky, in general less thoroughgoing and incisive a
thinker, had done before him. Virchow's especial emphasis at the moment upon ana-
tomical thinking betokened no narrowness of conception; it was due simply to the press-
ing necessity just then of getting rid of metaphysical and constitutional notions as to
the origin and nature of disease. As long as those vague generalities were entertained,
research lacked a foothold. The anatomical postulate facilitated investigation because
it asserted that an agent must be discoverable and a particular point of entry ascer-
tainable. Disease has, Virchow urged, a local habitation; not in a region, nay, not
even originally in an organ, but in a cell. From a focal cell the disastrous process
spreads. The purpose of the autopsy is not only to reveal its ravages in this organ or
that, but to locate its starting-point and to follow out its course. Every autopsy must
therefore be a complete autopsy, to the end that the next clinical experience of like
character may revive the picture of the pathological substratum just uncovered.
Virchow's insistence upon definite anatomical thinking looked, however, to ulti-
mate interpretation of functional disturbance. The morphology, histology, and
chemistry of diseased organ and tissue were to him only means toward the compre-
hension of the causation and course of disease. At the very outset of his career he
declared: "The reform of clinical medicine will assuredly be introduced by patho-
logical anatomy, but pathological anatomy cannot possibly complete it, for the dead
alone warrants no inference as to the living. If the pathological anatomist refuses to be
satisfied with isolated dead material, if he wants to see connections between the disjecta
membra, he is bound to be simultaneously pathological physiologist."^ The master-
1 Quoted by Orth: Die Stellung der path. Anat., p. 10 (Berlin, 1904).
MEDICAL SCIENCES: GERMANY 93
intellect thus always loves to gather together the relevant threads which smaller minds
incline to separate. From the first, Virchow conceived his journal as the "Archives"
for pathological anatomy and physiology and clinical medicine. Rokitansky had already
enunciated a similar view. "Pathological anatomy," he had declared, "applying its
methods of observation and investigation to the living body, requires an experimen-
tal pathology for the purpose of establishing the conditions sun-ounding the origin,
existence, and involution of the anatomical disturbances it discovers."^
In point of historical development, the intention of neitlier thinker has been wholly
realized. For reasons that will be mentioned, the strong emphasis which the anato-
mical side originally required, determined the channel to which pathology has since
then been largely confined. Physiological interest has not been generally active in the
pathological laboratories of Germany ; with some notable exceptions, the pathology
of function has been studied in laboratories of bio-chemistry, pharmacology, bac-
teriology, and in medical and surgical clinics, rather than in pathological institutes.
In Austria, a somewhat diflferent line has been taken: experimental pathology has
there so far established its importance as to win a dangerous degi-ee of independence.
Despite the absence of the experimental or physiological side, the pathological
laboratory in both countries fully conforms to the scientific conception that converted
a hospital dead-house into a university institute. In the first place, it is impoi*tant to
note that in becoming a university institute, the pathological department did not in
the slightest degree disturb its relation to the hospital. The professor of pathology
holds a university chair, which includes the post of pathologist to the hospital in
which the university clinics are conducted. The professor of pathology and the hos-
pital pathologist are in Germany one individual, — never two, — and he has one work
place, — never two. To the German mind, division of this function into two parts,
centred in different individuals, or located in two places,^ is simply unthinkable. We
shall soon learn that the hospital may be variously related to the university:^ like
the university, it may be the property of the state; or it may be the property of the
city leased for educational purposes to the state; or it may even be in part or whole
private property. But whatever be the legal relationship of hospital and univei-sity, a
pathological laboratory is planted on the hospital grounds and the professor of patho-
logy in the university is ex-oflScio its chief, with as complete freedom of action in
his domain as the professor of Greek enjoys in his seminary room. At Munich, for ex-
ample, much of the clinical teaching of the university is conducted in a municipal
hospital. The pathological laboratory, however, was erected by the state, its head,
the university professor of pathology, being ex-officio pathologist to the municipal
institutions on the left bank of the Isar; as a matter of course, he is in the same
relation to the clinics that are the property of the university, all autopsies being per-
1 Quoted by Paltauf : " Die allgemeine und experimeatelle Path.," Wiener Medizinische Wochenschri/t,
1900, No. 51.
2 See chapter vi. ' See chapter vii.
94 MEDICAL EDUCATION
formed by him in the pathological institute. Equally enlightened cooperation be-
tween a hospital that belongs to a municipality and a university that does not takes
place at Leipzig. The city furnished the land; the university erected the building
and appoints the professor. The pathological institute of the university agrees to j)er-
form for the municipal hospital, on whose grounds it is placed, all the functions that
properly belong to a laboratory of this character.^ A compact defines the further re-
lations of the parties in interest down to minute details. The members of the munici-
pal hospital board, the administrative head, and the official inspector are privileged
to enter the rooms of the institute only when no work or teaching is in progress; the
university has to pay the municipality at full tariff prices for gas and water consumed.
Every provision of the agreement frankly aims to promote complete scientific and ed-
ucational freedom and responsibility. It is interesting to be told that these ideal con-
ditions have not always prevailed. The city and the university have both had to learn
how to administer the joint institution: they have long since mastered the problem.
Under these circumstances, the precise legal status of the pathological institute is
now a matter of no educational importance. There is no occasion to remember that
the hospital is a municipal institution in which the state enjoys teaching privileges,
while the pathological institute is a university affair on municipal ten-itory. The
pathologist has full and free scope to do what and as he pleases. Autopsies he per-
forms as a matter of course ; experimental studies he caiTies on as far as equipment
and budget allow ; and he has the fullest access to the clinical records of the hospital,
so that he is as secure against detachment as he is against poverty.
The close connection of institute and hospital, which is indispensably necessary in
the case of pathology, the Germans have correctly perceived to be of fundamental
importance in other subjects as well. The medical faculty is an organic whole. Ana-
tomy cannot be completely severed from physiology, physiology from pharmacology,
pharmacology from pathology. At any time, of course, anatomist, pharmacologist,
or pathologist may for specific purposes cut all his communications; he may abstract
from all other phenomena. But what research divides, teaching and practice unite;
the subject that is for a special purpose detached at one point touches or interlaces
at a dozen others. There are in Germany, therefore, no half schools, teaching anatomy,
physiology, and pathology only;* no divided schools, teaching the subjects just men-
tioned in one city, while the hospital is located in another; no scattered plants,^ the
width of the town dividing the pathologist from his source of supplies or his proper
field of action. In the heart of the great city of Berlin, spacious grounds have been
procured for the Charite and the medical laboratories. Physically and geographically,
the medical plant is a unit, pathology at its very centre. The huge Vienna school is
* As at Munich some of the clinics belong to the university; their autopsies go to the Pathological
Institute excepting only those of the chilaren's clinic.
' Chairs of physiology and anatomy exist at Miinster, which has no medical faculty.
' Such as Paris, for example. See chapter ix.
MEDICAL SCIENCES: GERMANY 95
amazingly compact. Space for laboratories not dreamed of when Joseph II laid out
his great Krankenhaus has been procured in its vicinity for anatomy, physiology, and
pharmacology as they developed : pathology guards the exit. The influence of geo-
graphical integi'ity is incalculable: suggestive intercourse of a most stimulating kind
results under conditions in which, as I can testify, the professor of pharmacology
leaves his laboratory to attend the opening address of the newly called professor of
ophthalmology, and afterwards detaches himself from a guest in order to canvass a sci-
entific proposition with a group of physicians and surgeons. In the effort to preserve
unity of plant, great outlay has at times been necessary. The smaller universities, busy
for the last two decades in gradual reconstruction, have profited by experience, acquir-
ing large tracts on which, one at a time, institutes and clinics are being gradually re-
built. Decided impatience is manifest where, as at Giessen and Marburg, reconstruc-
tion is not vet complete. AVhere the perfected plan still leaves five or ten minutes'
walk, as at Vienna, between the hospital and the laboratory of experimental patho-
logy, the break is lamented as an organic defect.^ At Graz, something like dismay
prevails, for new hospital plans have been drawn, and nothing has been said as yet of
new institutes on the same plot : except, of course, pathology, — unthinkable otherwise
than as part of the hospital plant.
A pathological department requires, first of all, a sufficient supply of autopsies.
Fortunately, the attitude of the authorities and of the public toward the post-mor-
tem is highly enlightened. Managers of non-university hospitals connected with uni-
versities realize that the interests of science and the interests of the public are in
the long run identical. The autopsy satisfies the interest of the pathologist; at the
same time it assists the clinician to understand and to cure disease. This holds equally
of teaching and non-teaching hospitals. Every possible precaution is therefore taken
by way of obviating objection on the part of the family to the post-mortem : the
relatives are tactfully handled, the body is neatly prepared for burial. The institute
invariably contains a chapel in vhich the rites are conducted with scrupulous defer-
ence to the feelings of those concerned. Very rarely indeed is offense given or taken.
Where conditions are so generally favorable, it is difficult to discriminate; but Vi-
enna probably deserves the palm, for there, with singular intelligence, it was pro-
vided, on the building of the Allgemeines Krankenhaus late in the eighteenth cen-
tury, that as a matter of right and duty every death must be autopsied; the depai-t-
ment has legal right to retain organs for subsequent study. Every person dying in the
wards comes as a matter of course to the pathological institute.^ The rare objections
are easily pacified. In the German Empire, the consent of the nearest relatives is usu-
ally required, and almost as usually obtained. The Leipzig compact above mentioned
stipulates that immediately after verification of death by the physician in charge, the
body must be carried to the pathological institute: if death has taken place between
1 The clinic furnishes "Anregrung und Anwendung," said Professor Paltauf.
2 Guy's Hospital, I^ondon, has always made this stipulation, too. See page 128.
96 MEDICAL EDUCATION
midnight and four p.m., the body cannot be autopsied till the morning of the next day ;
if death took place between four p.m. and midnight, autopsy cannot be performed till
the afternoon of the following day. But this delay may be waived with the consent
of the nearest relatives, in their absence beyond range of communication, or in the
public interest. In general, autopsy is carried out unless the hospital administrator,
at the instigation of relatives, forbids in writing. At Munich, substantially a similar
routine is followed: autopsy takes place as a matter of course unless the contrary is
definitely requested. Silence on the part of the relatives gives consent.
The amount of material that thus comes to post-mortem in large cities is enor-
mous, and even in the smaller, quite adequate. The Allgemeines Krankenhaus at
Vienna furnishes the university more than 2000 post-mortems a year. The supply
being thus ample, the right of autopsy is occasionally waived; in such cases, no rela-
tives appearing, the body may be sent to the anatomical institute or used for instruc-
tion or examination in operative surgery. At Berlin, from 1300 to 1400 post-mortems
are annually available at the Charite,^ of which perhaps 100 unclaimed bodies are
subsequently sent to the anatomists. At Munich, 1200 post-mortems a year are made
in the institute; five were made on the day of my visit. Perhaps 30 are annually
refused, but this number is counterbalanced by private autopsies made at the request
of relatives or physicians. Leipzig furnishes an admirable illustration of successful
education of the public. In an interesting historical account of the evolution of his
laboratory,^ Marchand notes that in the twenties, some 12 to 15 post-mortems were
made yearly; in 1879, there were 657; from 1900 to 1907, the figures rose steadily
as follows: 1018, 1139, 1160, 1213, 1258, 1352, 1383, 1531. Refusals, though in-
creasing somewhat in absolute number, have never been considerable. During the
same years they ran as follows: 64, 85, 86, 112, 127, 164, 179, 188.^ In Breslau, the
university has two sources of supply: its own hospital, of recent origin, to which
the university professor is pathologist as matter of course; and an additional insti-
tution, to which an assistant to the professor of medicine is now prosector. The fol-
lowing table shows the amount of material available:
Year
1901-1902
1902-1903
1903-1904
1904^1905
1905-1906
1906-1907
1907-1908
1908-1909
1 This is by no means the full supply of material at Berlin. See below, page 100, note.
2 Das patholoffische Institut der Universitdt Leipzig, pp. .5, 9 (Leipzig, 1906).
3 Festschrift der Universitdt Leipzig, pp. 60, 61 (Leipzig, 1909). As the children's clinic makes its own
autopsies, these are not included.
University Ilospi
tal
Allerheiligen Hospital
373
807
424
812
419
719
462
602
487
715
447
871
634
1038
570
1077
MEDICAL SCIENCES: GERMANY 97
The percentage of refusals at Breslau is decreasing : 9.3 per cent, 8.01 per cent, 6.6
per cent in three successive years in the University Hospital ; 29.5 per cent, 12.4 per
cent, 10.2 per cent in the years 1905, 1907, 1908, respectively, at the Allerheiligen
Hospital. At Wiirzburg, about 270 autopsies are made annually in the University
Institute; fresh material from as many more made outside by an assistant of the pro-
fessor is available. At Strassburg, the weekly average is 25 autopsies. At Greifswald (a
town of about 24,000 inhabitants, where there are 218 students in the entire medical
course), there were 307 post-mortems in 1908-1909, 263 in 1909-1910; 954 speci-
mens, surgical or other, were contributed to the institute in the former year, 838 in
the latter. At Gottingen (34,081 inhabitants, 280 students of medicine), 295 post-mor-
tems were done in 1909, 1272 specimens were sent in. At Marburg (20,136 inhabit-
ants, 396 medical students), 187 autopsies were made in 1909, 960 specimens sent in,
and fresh material came from Frankfort, Cassel, and Gross Lichterfelde. At Giessen
(28,769 inhabitants, 148 students), there are 350 autopsies annually.
Nor does the wealth of the pathologist excite the envy of the anatomist or the
professor of legal medicine; for it is recognized that their supplies have definite and
different sources. The autopsy isthenecessary final step in the elucidation of a clinical
problem. It satisfies a legitimate purpose, at once scientific and practical. As a rule,
the body that comes to autopsy could in no event reach the anatomical institute.
In the cases in which this might be its destination, the pathologist may, as at Vienna,
send it there unopened; he certainly will, after the post-mortem.
The pathological institute usually occupies a building all its own, but at Strass-
burg a huge structure serves for both anatomy and pathology, and at Leipzig a wing
of the pathological laboratory is devoted to legal medicine. In content and arrange-
ment there is no essential variation. Separate rooms are provided for the reception
of bodies, for their proper preparation for burial, for their inspection by relatives, and
for funeral services. The consideration for the sensibilities of those involved indicated
by these arrangements doubtless has had much to do with the almost total disap-
pearance of prejudice against the post-mortem.
The autopsy room itself is invariably large, well lighted, and admirably ventilated;
it contains revolving tables, usually of marble, varying in number according to need,
there being six at Leipzig, for example. Long tables for the exposure of fresh material
to examination by students are ranged along the walls. Adjoining rooms serve for
quick histological work, for photography, etc. In easy reach are the various lecture
and course rooms, each with its proper equipment, the former invariably containing
projection apparatus; the preparation room adjoins, with such apparatus, charts, etc.,
as are required for the regular lecture course. Space is provided for investigation
in one or more of several directions, anatomical, bacteriological, chemical, and opera-
tive. A working library is of course at hand;^ and a steadily growing collection, gross
1 Its appropriation is small, only 300 marks a year at Berlin, but it is supplemented by the journals
received by the members of the staff.
98 iVIEDICAL EDUCATION
and microscopical, beautifully mounted, — often in the natural colors, — indexed, and
labeled so as to refer readily to both clinical records and autopsy protocols, forms an
epitome of the activity of the institute from its founding to the present day. Virchow
rightly denominated the collection the "Archives" of the pathological laboratory.
Many of these, representing a special interest of the director, are, like Von Reck-
linghausen's collection of bone-disease at Strassburg, impossible of duplication and
of priceless value in consequence. To prevent needless expansion, renovation of the
museum is continuously in progress; older specimens are discarded to make way for
superior exemplars more perfectly preserved. None the less, a precious nucleus of rari-
ties goes back to the beginning of the collection. On the rebuilding of the institute
at Leipzig, 2532 of the older preparations were retained; since 1900, 3628 new spe-
cimens have been added. The collection at Marburg numbei's fully 6000 specimens.
Intelligent hospital routine, teaching, and research are thus all promoted by practi-
cally the same features of institute construction and equipment.
The organization of the staff once more bears all three in mind. An institute of
such scope is a complex affair, requiring division of labor. To teach and to conduct
frequent autopsies already taxes the strength of one man. The working-up of material
from several points of view, and the experimental determination of doubtful points,
demand relatively large staffs, with considerable differentiation. The Berlin institute
comes perhaps nearest to ideal completeness in its internal arrangements; there sepa-
rate divisions, each with its own head immediately responsible to the director, ex-
ist for anatomy, histology, chemistry, bacteriology, experimental pathology, and the
museum. Each division chief has his own helper, and, the budget allowing, a paid
assistant, — not very well paid, however. There are, besides, volunteers and advanced
students, the former helping in all the routine of the laboratory, in teaching, and
in research. They vary in number from one to four or five. A chief and six assistants
would thus man a complete pathological institute on an elaborate scale. Needless
to say, few institutions are so completely equipped. As a rule, the staff is about half
as large :^ it consists at Munich of a professor and three assistants; at Leipzig, of
professor and four; at Wiirzburg, of professor and three; at Erlangen, of professor
and two; at Marburg, of professor and one. The great number of autopsies neces-
sarily restricts most of these laboratories to pathological anatomy and histology, to
careful work in which subjects, teaching and research are mainly limited. Current
conditions in Germany, as I have already pointed out, thus emphasize the anatomi-
cal aspect, to the disadvantage of the physiological and the experimental. At Berlin
alone is the operative side represented. Elsewhere, the burdens that might in part be
borne by experimental pathology fall to physiology, pharmacology, bacteriology, and
experimental medicine and surgery. Medicine as a whole need not necessarily suffer,
but pathology indubitably does.
The difficulty involved in the complete or symmetrical organization and diffcren-
1 It is to be understood that helpers and mechanic never fail.
MEDICAL SCIENCES: GERMANY 99
tiation of a department is one that goes deep into the constitution of modem science.
A certain field must be subdivided. Time was when it could be roughly partitioned be-
tween several non-competing, mutually exclusive jurisdictions. The several jurisdic-
tions now encroach on one another; and what is more, superior jurisdictions have been
erected laying hold for this purpose or for that of previously independent estates.
The complications of federal political organization are trifles compared with the
complexities of scientific organization and differentiation that come about. It results
that the scientist must perforce abate his pretensions to completeness, and realize the
strictly provisional import of such differentiation of subjects as is at a given mo-
ment in vogue. If "chairs" in the university are taken to represent relativelv stable
lines of approach, then anatomy, physiology, pharmacology, and pathology are far
enough apart in interest and point of view to be perhaps permanently differentiated.
Other points of view may get full recognition within these subdivisions, or by cutting
across several of them, without attaining absolute independence. The tendencv to
erect independent departments involves serious dangers, since there is no knowing in
advance when a point of view, fertile for the moment, should be discarded for another
still more so. It is, however, favored by the inclination of the less capacious minds to
domesticate themselves snugly in their own compartment. Unhindered, they would,
like the mediaeval state builders, carve small bits from each of several dukedoms, to
make principalities for themselves. Fortunately, the poHcy of subdivision breaks down
of its own weight, because there is no end to the length to which it might be carried.
Experimental and physiological pathology looks like a subject of this sort. It
supplies a link between pathological anatomy and the clinic. The pathologist sees
on the autopsy table the final results of disease; the clinician sees reflected in symp-
toms the progressive steps of structural change which he cannot himself observe. By
experimentally reproducing disease in animals, sti-uctural and functional alterations
can be compared at every successive step. The pathological department that lacks
an experimental division remains on a descriptive basis. But, on the other hand, the
clinic that foregoes animal experimentation is confined to empirical procedure.
Physiological pathology will therefore necessarily be cultivated in several places, —
in pathology, phannacology, bacteriology, medicine, and surgery. It cannot get a sep-
arate establishment along lines comparable in respect to clearness with those on which
anatomy and physiology have been built up. No definition of experimental pathology
that rightly characterizes Strieker would wholly exclude Traube, clinician, Billroth,
surgeon, or Cohnheim, pathologist. The obvious inference is that while experimental
pathology is a necessary part of a pathological institute, it is not only that ; for it
represents the application of physiological or other methods to problems that may
turn up indifferently in any one of several places. If, then, it reaches the status of a
chair, its connections with the anatomical-pathological institute on the one hand, with
the clinic on the other, must be maintained unimpaired. It may under such circum-
stances become practically a chair of experimental medicine, — a chair, not the chair,
100 MEDICAL EDUCATION
for under existing conditions every teaching post of medicine or surgery must be
more or less so. This is precisely what hcos happened at Prag, where a lucky histori-
cal accident gave the incumbent control of a small number of beds.^ Elsewhere, par-
ticularly at Vienna, independence of pathological institute and hospital alike is re-
garded as a serious limitation.^ When the subject gets the comparative isolation of
an entity or "chair," it suffers from it. AVhen, on the other hand, it gets the facili-
ties it needs, it ceases to constitute a single logical division, for the same facilities,
directed to different problems, reappear in each of several places.
Pathological-anatomical institutes of the type described exist generally throughout
Germany, not only in connection with teaching hospitals, but as part of a complete
general or special hospital. The non-academic hospitals of Hamburg, Frankfort,
Diisseldorf, Koln, and Berlin are in this respect no whit inferior to the univei"sity
hospitals above mentioned. Their modernity of constiTiction, elaborateness of equip-
ment, and productive output have to be reckoned with in the effort to understand
the vigor with which the subject has been prosecuted in Germany. These institutions
are often used for teaching purposes. Frequently, too, if situate in university towns,
the prosector of the municipal hospital is docent or professor extraordinary in the
university. Though distance forbids the formation of regular undergraduate classes,
the rich material is not wasted, for groups of advanced students and physicians fairly
live in the dead-houses of the new Berlin hospitals. At Friedi-ichshain and the Vir-
chow'sche Krankenhaus (Berlin), routine and research are equally safeguarded: an
intelligent municipality places pathologists of distinction in control, — in both cases
the present incumbents are titulary university professors and docents, — and gives
them every facility for observational and experimental study, including animal-houses,
thus making the pathological laboratory of a city hospital a scientific establishment
in which teaching and research are systematically prosecuted. V'on Hanseman''s labora-
tory at the Virchow'sche Krankenhaus and Pick's at Friedrichshain have three divi-
sions, anatomical, chemical, and bacteriological, each with a permanent head busy
in investigation, assisted by capable volunteers. Something like 1500 autopsies are
annually made at each,^ On the day of my visit at the Virchow, nine were made, five
going on simultaneously; by way of service there are four corpse-servitors, one "prepa-
rator," one helper each in the anatomical and chemical divisions, two in the bacteriolo-
gical, and five for other purposes. A superb collection of 3000 specimens exists there.
Nothing but time and energy limit the amount of work that a student may get
1 At St. Mary's, London, Sir Almroth Wright enjoys the same advantage.
2 This important topic is discussed in tlie following articles :
J. Orth : Arheitennns dem Patholofjiirhfin Institut zti Berlin, p. 33 (Berlin, 1!)06).
A. Bickel : Ueher die Entwickeluntf der path. Physialorfie (containing bibliography) (Stuttgart, 1904).
R. Paltauf : "Die allgemeine und experimentelle Path.," Wiener Klin. Wochen., 1900, No. .51.
R. Paltauf: "Ausprache bei Eroffnung des Instituts fur allg. und exper. Path.," Wiener Klinische
Wochenschrift, 1908, No. 4-4.
' About fiOOO post-mortems are made annually in the pathological institutes of tlje municipal hospitals
and the Charity, Berlin.
MEDICAL SCIENCES: GERMANY 101
in general and special pathology. In order, however, to understand accurately the sit-
uation of the undergraduate, a subsequent chapter dealing with the curriculum must
be to a slight extent anticipated. In discussing anatomy, physiology, and pharmaco-
logy, I spoke of required courses: the student is not admitted to examination unless
he furnishes properly authenticated evidence that he has absolved them. No such
stipulation apphes to pathology : the student is examined in the subject on applica-
tion. He is required to furnish no written evidence of attendance on any particular
course of lectures, demonstrations, or practical exercises. He may prepare for his ex-
amination at his own peril as he pleases. Instruction is nevertheless offered on the sup-
position that the student needs, and will usually avail himself of, systematic training
by way of acquiring the requisite basis. Doubtless most do, though some at least take
large risks, relying more or less on the energy of an expert drill-master invoked prior
to examination, or on a brief experience a,?, famulus^ or undergraduate volunteer.
Instruction opens with a coarse of lectures in general and special pathology, occu-
pying as a rule two semesters : the former dealing with the concept of disease and its
ultimate material basis in the cells, fluids, and tissues of the body; the latter with the
changes that take place in the different organs, in consequence of specific processes.
Clinical reference crops up continually. " I never lose sight of the fact that I am
training doctors, not pathological anatomists," writes Orth.^ Here, as everywhere
else, the oral presentation is abundantly illustrated. In the larger universities the
projectoscope is used with microscopic slides as the lecture pi'oceeds; fresh and pre-
served gross specimens are in some places passed ai'ound the class, in others are de-
monstrated to groups of students by assistants and volunteers at the close of the hour.
Orth, an excellent and vigorous teacher, regards the latter method as preferable.^ He
urges with force that, in a large class, before the specimen has traveled far, the lec-
turer has taken up another point: those who receive it thereafter can never be sure as
to just what point it was designed to illustrate. Moreover, those who listen carefully
cannot pause long enough to observe well ; vice versa, those who study the specimens
lose the lecture. The demonstration following the lecture is pointed and controlled,
— benefited rather than otherwise by the fact that only those stay who care.
No difficulty whatever arises in smaller institutions. Though the lantern is em-
ployed for enlargement of histological sections, the microscope is likewise used, and the
lecture may be interrupted long enough to permit each member of half a dozen small
groups to verify what has been thrown on the screen. Gross specimens can be sent
around the class without danger of being excessively belated.
A histological course is also offered, usually in the summer semester: the extent of
participation by the student himself varies. But in any case, he prepares some fresh
1 See below, page 103. 2 Orth: JXe Stellung der path. Anat., p. 28 (Berlin, 1904).
3 Orth has described his method in great detail in the pamphlet just mentioned above, and in "Die Ent-
wickelung des Unterrichts in der path. Anat. und allgem. Path, an der Berliner Universitat," B^»^
liner Klinische Wochenschrift, October 10, 1910.
102 MEDICAL EDUCATION
material, the supply of which never fails, and uses the simpler stainijig methods. Not
infrequently, the clinical significance of the phenomena observed is dwelt on.
The instruction thus far described aims at a definite goal. The German pathologist
looks toward the autopsy from the first. Teaching of pathology that did not expect
to be thus rounded out would be regarded as almost absurd. General and special
pathologvand histology constitute, then, only the necessarv basis for the post-mortem.
An autopsy demonstration course in which the professor systematically demonstrates
organs and regions in succession exhibits methods and explains principles. It is fol-
lowed bv autopsy courses, conducted by professor and assistants with small groups,
in which courses the student himself does the autopsy, writes the protocol, and works
up the material. Even so, the instruction has not reached its logical terminus; that
comes only in the clinical years, w'hen a case clinically demonstrated by the professor
in the wards having terminated fatallv, the next lecture hour belonjjing to the clini-
cian is occupied by the pathologist, who conducts the post-mortem in the presence of
professor and class : as wholesome a confrontation for the clinician as for his students.
We shall have occasion hereafter to inquire how generally students profit by thor-
ough and timely use of the ample opportunity thus offered for grounding in the
science of pathology, widely interpreted. Meanwhile, of the opportunity itself there
can be no question. At Berlin and Munich, every member of an autopsy course may
himself perform at least two complete autopsies in the semester; at Strassburg, daily
autopsies gather material for the fresh demonstration course held thrice weekly
and remarkable for its wealth and variety of content; striking and highly stimulat-
ing, too, is the frequent astonishment of these widely traveled pathologists at the
novelties they themselves encounter as they demonstrate or expound. The museum
is needed only for comparison and additional illustration: fresh material forms the
basis of the training. The new incumbent at Wlirzburg goes so far as to discard
the usual order of lecture topics; after a brief introduction, he teaches general and
special pathology in such order as his fresh material determines. The fresh material
at the moment available, not the order followed in a treatise, makes his text. This
is in line with the practice followed in the clinic, where no effort is made to present
disease in a fixed order of topics. The student is already familiar Avith normal ana-
tomy and physiology: he ought to l^e indifferent as to the succession in which abnor-
malities are presented. The method is therefore pedagogically sound. The post-mor-
tem gi'oups are usually small, — twelve at Vienna, where four bodies are autopsied at
each of three weekly meetings. Naturally enough, the small university towns are less
fortunately placed. But the number of students is correspondingly reduced, and easy
emigration enables the student at some time in his career to enjoy in Berlin what
may have been relatively scant at Erlangcn. "^Tlie difference is, at the worst, one of
degree, not of kind; quantitative, not qualitative.
In the matter of the clinical autopsy, the smaller universities show the greater con-
scientiousness. It is the essence of the clinical autopsy that, a patient used for teaching
MEDICAL SCIENCES: GERMANY 103
having died, the entire student body with teacher and assistants should repair to the
autopsy room, where the professor of pathological anatomy or his prosector performs
a post-mortem and discusses the findings. At Berlin, one is told that the clinical chiefs,
hard pressed for time by the combination of university work and consultative practice,
rarely witness autopsies with their students. Correlation is far better in some other
institutions, as, for example, at Breslau, where Minkowski adjourns his clinical lecture
to the dead-house, and with the students to whom he has exhibited the case regularly
witnesses the autopsy on it; at Leipzig, the clinicians are, once more, irregular; the
" good old custom,"^ as Marchand calls it, is somewhat in abeyance; at Vienna, strong
tradition requires the attendance of the clinician or his first assistant at the autopsy of
cases not used in teaching ; and of the teacher himself and his class when the pathologist
occupies the usual clinical hour with a clinical autopsy. Whether or not the ordinary
student always gets the minimum with which we have thus far dealt, there is no ques-
tion but that in pathology, as in other subjects, the zealous student can get as much
more as time and inclination allow. In the first place, there are research opportunities
everywhere; next, additional courses, more commonly at large universities, — dealing
with special topics : chemical pathology, experimental pathology, pathological ana-
tomy of the sexual organs, neuro- pathology, pathological-anatomical diagnostic, di-
agnostic course with fresh material, are a fair sample of what Berlin offers in a single
semester ; experimental pathology of circulation and respiration, pathological anatomy
of infectious diseases, are offered at Vienna. Even more characteristic, however, are the
opportunities of the student a.s famulus, of the graduate as volunteer, to make them-
selves part of the laboratory routine. For periods varying from six weeks to three
months or more, sometimes during the semester, more often in vacation, the student
attaches himself to the laboratory of his choice, in or outside the university. He be-
comes an under assistant, with unrestricted opportunity, once the professor or division
chief has finished, to utilize any material that he selects. The graduate volunteer is at
times hardly distinguishable from an assistant except by absence of salary : he helps
with teaching and demonstration, and takes his place among the paid assistants during
the professor's lecture. It is impossible to exaggerate the importance of these practices,
whose vogue so fully justifies Ostwald's characterization of the unusual man whom the
German system wisely aims to save from an enforced mediocrity. In each of the moi-e
active divisions of the Berlin laboratory, from one to four volunteers may always be
found; in the pathological institute of the great hospital at Vienna, there are usually,
all told, some twenty-five, pledged to remain an entire semester at least. They take
part in histological and bacteriological investigations, occasionally do a post-mortem,
and, besides, are busied with a research theme, sanctioned, if not assigned, by the direc-
tor. Rare, indeed, is the laboratoiy in which no students are to be found as famuli}
1 "DiegutealteSitte."
2 The famulus is admitted just as freely to all other laboratories, — those of gross anatomy, histology,
etc.
104 MEDICAL EDUCATION
Von Hanseman had one hundred and thirty-seven during nine years' incumbency at
Friedrichshain ; Pick, who now holds the post, has always four or five, taken for not less
than three months' service ; during the long holidays, Greifswald has invariably four to
six practising the finer histological and anatomical methods. The Marburg "Chronik"
for 1909 names three. Noticeable everywhere is the absence of formality and fussiness.
This people, supposedly addicted to red-tape, keep their laboratory doors wide open;
the laboratory is meant for work : let its opportunity and material not go to waste.
It will have been noticed that experimental pathology and physiological patho-
logy play no part in the regular training of the undergraduate student. Their im-
portance is theoretically conceded ; but no effort has yet been made to organize them
as parts of the usual curriculum. Now it is — or ought to be — a fundamental prin-
ciple of science teaching that observation is enormously and legitimately assisted by
reference to sf problem or a process. The student's powers of observation in pathological
anatomy will be strengthened by being brought into contact with the functional dis-
order in reference to which alone pathological morphology has for him actual signifi-
cance. He will take a new interest in structural changes, if he has followed their devel-
opment or watched their effects on the general condition of an animal.
The backwai'dness of the Germans in introducing physiological pathology into
the curriculum of the average student is due to considerations previously mentioned.
Virchow's successors as a rule lacked his scope. They found themselves fully occupied
in the autopsy room. Appropriations were insufficient to employ a staff or equip a
department for experimental work. Meanwhile, the work itself was not neglected; in
recent years it has thriven everywhere except in pathological -anatomical institutes. As
for teaching, there is nowadays little disposition to increase the complexities of the edu-
cational situation by adding new subjects to a curriculum already fairly unmanageable.
Such instruction as is offered — in Berlin and Vienna, for example, whether in a special
division of the pathological-anatomical laboratory or in a special institute of experi-
mental pathology or serology — is of an advanced and research character altogether. Un-
questionably, it need not be so. Undergraduate courses in experimental pathology have
elsewhere proved feasible. But before they can be introduced in Germany, the facilities,
appropriations, and staffs of the schools must be bettered, and a somewhat higher
degree of correlation must be established between the several institutes and clinics.
Hygiene
The most recent in origin of the institutes invariably found in the medical facul-
ties of Germany is that devoted to hygiene. The movement which in our own time
has culminated in this department began in England as an outcome of the problems
arising from the rapid growth of cities and the spread of the factory system. \'en-
tilation, water-supply, nutntion, clothing, and contagion remained, however, topics
amenable to merely empirical handling by teachers of medicine, physiology, or patho-
logy, until Von Pettcnkofer, docent in dietetic chemistry at Munich, enunciated in
MEDICAL SCIENCES: GERMANY 105
1853 his conception of hygiene as an inductive and experimental science whose sub-
ject-matter is the influence of natural or artificially modified environment on the
health of the individual. Successful studies of ventilation, soil, and water-supply pro-
cured for Von Pettenkofer a full professorship in 1865, and the first of hygienic labo-
ratories in 1878. His failure, however, to reach rock-bottom in the matter of plague
left the soundness of his conception somewhat in doubt. Except at Leipzig, his in-
stitute provoked no imitation until new vistas were opened by the brilliant rapid-fire
discoveries of Koch and his pupils in the early eighties. In bacteriology, hygiene,
already preoccupied with contagious disease, found precisely what it needed to justify
its separate existence. Bacteriology transformed hygiene from an empirical art into
an experimental science. Within twenty years thereafter, every university in Germany
had obtained its hygienic institute. Its function is at once educational, scientific, and
practical. There students are taught, health officers trained, theoretic problems in-
vestigated, preventive and curative sera produced, vaccination practised, examinations
made, and the sanitary difficulties of the community solved. Meanwhile, independent
institutes, serving in some respects the same ultimate purposes, have also been estab-
lished; witness the Imperial Health Office at Berlin and Gross Lichterfelde, the In-
stitute for Infectious Diseases, founded as a working-place for Koch at Berlin, the
Royal Institute for Experimental Therapy at Frankfort; at each of which practical
activity and scientific research are in simultaneous and mutually helpful progress.^ In
addition, bacteriological divisions are found occasionally in laboratories of pathology
and almost universally in those of the medical clinic. Bacteriology furnishes thus an-
other illustration of the complicated nature of scientific relationships at a high level.
There is no one way, as there is no one place, in which it must be prosecuted. It is
equally at home in hvgiene and in medicine. Its possibilities will not be exhausted in
either: hence, endless diversity of organization is possible; uniformity is not a thing
to be artificially aimed at ; completeness is unattainable.
The central feature of the hygienic institute is its bacteriological equipment : lec-
ture halls, course rooms, research rooms, and animal quarters are provided. Every pos-
sible provision is made for the culture, isolation, and microscopic and experimental
study of bacteria. Subdivisions are found in the more extensive institutes for the
chemical, physical, and climatological aspects of hygienic investigation.^
The required instruction is limited to demonstrative lectures. A practical course
in bacteriology, in which the student observes the important organisms, is everywhere
offered; how large a proportion of students take it cannot be positively stated, — per-
haps 50 percent or more; but the arrangements for thorough individual work are not
usually adequate. At Vienna, three practical elementary courses are annually offered in
bacteriology : their combined attendance is less than one hundred, — something like
^ See Medizinische Anstalten auf dem Gehiete der Volksgesundlieitspflege in Preiissen (Jena, 1907).
- For a detailed description of such an institute with illustrations, see R. PfeiiFer, " Das hygienische
Institut der Universitat Konigsberj; i. Pr.," Klinisches Jahrbuch, 1903, p. 639.
106 MEDICAL EDUCATION
one-fifth of an entering class. The only practical exercise everywhere required is that
in the art of vaccination : the student must take charge of at least two cases. The
pedagogical principle involved need hardly be restated. Bacteriology is included in the
medical curriculum because without it infection, immunity, and certain novel thera-
peutic measures cannot be intelligently grasped; a descriptive or illustrative presen-
tation of the subject is only a little better than the didactic lectures characteristic
of the pre-scientific era. Strictly scientific pedagogy requires that the student, start-
ing with micro-organisms obtained from the clinic, cultivate the pure bacteria, repro-
duce in animals the characteristic lesions, and thence procure once more the pure
culture; he can work out simple but fundamental problems in immunity and asepsis
at the same time. A practical course of this nature would involve no insuperable
difficulty if attempted with students who had entered the medical school with some
positive training in biology. Here, as in dealing with physiology and pharmacology,
we stumble on the defects due to a predominantly linguistic secondary education.
Let me repeat that it is not necessary that every student be required to take inten-
sive practical courses in every subject. "To know and do one thing properly," said
Goethe, "is more truly educative than halfway performance in a hundred branches."
Training, point of view, proper kind of interest and attitude, may be better derived
from prolonged work in one or two subjects than from superficial work in half a
dozen. The German arrangements lend themselves readily to this view. As practical
courses — elementary and advanced — are offered in all subjects, students could easily
divide up among them, so that every individual would be thoroughly trained in at
least one of the fundamental subjects in addition to anatomy. That any such out-
come actually results is highly unlikely. The material from which the facts could be
ascertained lies in the archives of the Examination Commissions of the several uni-
versities, but it has never been critically studied. What happens is probably this:
extremely zealous students enter practical courses not only in one subject, but in sev-
eral subjects; less enthusiastic students — a very numerous body — do as little as they
safely may. Meanwhile, the opportunities open in hygiene as elsewhere to afamulusy
an advanced worker, or a practising physician, are practically unlimited. In addition
to the regular undergraduate courses, Berlin offers work in military sanitation, occu-
pational hygiene, public health, school and social hygiene, etc.; Marburg, in animal
parasites; Graz, in the sanitary and economic aspects of the use of alcohol, sexual
hygiene, etc. Everywhere research is promoted on any topic approved by the director.
As evidence of the practical usefulness of these laboratories, it may be mentioned
that in 1909, 2750 examinations were carried out in the institute at Marburg, 731
at Greifswald, 2196 at Breslau, 5889 at Gottingen, the last mentioned divided as
follows: tuberculosis, 1614; diphtheria, 1743; typhoid fever, 2081; scattered, 451.
The student who serves as famxilu.'i is privileged to assist in this work to the extent
of his competency.
The more recent developments in immunity, serology, etc., occupy no uniform aca-
MEDICAL SCIENCES: GERMANY 107
demic position in Germany. The problems involved are obviously accessible from bac-
teriology, pharmacology, or experimental therapy. The elasticity of the university or-
ganization is favorable to their study in all or any of several laboratories, — wherever,
indeed, a capable individual finds an appropriate leverage. Intersection, wholesome
in the underlying sciences, has at this stage become constant and puzzling; strict dif-
ferentiation would be artificial and depressing. In Berlin, immunity and experimen-
tal therapy are presented as a subdivision of pharmacology ; immunity and experimen-
tal chemo-therapy of infectious diseases as a subdivision of pathology; and similar
courses are given in their laboratories by the university docents holding positions in
the Koch Institute. At Marburg, experimental therapy is yoked with hygiene, an in-
dependent division having been there created for Von Behring ; at Vienna, bacteriology,
serology, and experimental pathology and hygiene occupy a new building, in which
they are all on an intimate footing, despite their administrative independence of one
another. The instruction offered in these laboratories is of an advanced character.
Even where so-called "beginners' courses" are offered, the participants are usually phy-
sicians of some years' standing returning to the university to get in touch with recent
ideas. IVIeanwhile, the instructors are themselves invariably productive workers, char-
acterized as a class by their immense devotion and the wretchedly inadequate pay that
seems in no wise to abate their zeal.
Legal Medicine
It remains to mention only the Institute for Legal Medicine, which, having attained
independence and a full professorship in Austria, seems not unlikely to achieve the dig-
nity of a separate establishment in Germany, too. The theory on which the institute for
legal medicine is based may be formulated in a sentence. A doctor is one thing; a med-
ico-legal expert something more. To avoid scandal, the courts require reliable sources
of accurate and disinterested scientific counsel. They get it at Vienna, Prag, Graz, and
Innsbruck by constituting the university professor of legal medicine their official
adviser in all matters requiring the services of a medical expert. The chair was estab-
lished at Vienna a century ago. It is a full professoi-ship, of equal dignity with chem-
istry or anatomy. In his institute the professor performs all autopsies required for
judicial processes, — 300 to 400 yearly; thither are also brought all coroner's cases,
sudden deaths which no physician's certificate covers, administrative cases, as, for ex-
ample, death due to suspected cholera, still-born infants from the gynecological clinic,
— these various sources contributing fully 1000 autopsies more annually; and here, too,
blood-spots, stomach contents, hair, clothing, etc., are subjected to analysis as clues
for the unraveling of criminal mysteries. For the carrying out of all such examina-
tions the institute is equipped with post-mortem room, photographic outfit, chemi-
cal and physical apparatus, and a highly fascinating museum. In criminal trials, two
experts, and no more, invariably appear: one is, as already mentioned, the university
professor; the other, an outsider, a trained expert, also, designated by the court.
108 MEDICAL EDUCATION
The development in the German Empire is less complete. The subject was long
taught quite incidentally; it is still represented only by an associate professorehip.^
Institutes are found at Berlin dating back to 1886; in Leipzig, established in 1905.^
Kcinigsberg, Breslau, Kiel, and Munich have procured facilities only within the last
year or two. Elsewhere they are still, as a rule, non-existent. The staff at Berlin con-
sists of the professor and two assistants; in other universities, of the professor and
one assistant; at Heidelberg, both posts were vacant in 1910. The intimate relation be-
tween courts and university that has been pointed out in Austria has not as yet been
generally or securely established in Germany. In 1901, the instructors at five Prussian
universities, including Berlin, were made ex-officio medico-legal experts; at Marburg,
Greifswald, and Gottingen, by reversing the process, the district physician was desig-
nated associate professor in charge of legal medicine at the university.* But the lines
are less tightly and clearly drawn than in Austria; in consequence of which, material
is not regularly diverted to the medico-legal institute. The need of the anatomist
makes him a hungry competitor for bodies, while chemical and other investigations
are apt to be sent to the appropriate specialist.
Instruction in legal medicine* is by means of a demonstrative lecture course, nomi-
nally required in both Germany and Austria. But as the German student is not ex-
amined in the subject, he pays his fees and usually remains away. Students of law are
more assiduous in attendance than those of medicine: even so, on the day of my visit to
the lecture room at Berlin, there were hardly twenty-five present. Photographs and
museum specimens, wherever they exist, are employed for illustration. As yet the sup-
ply is necessarily meagre in most places. In Munich, a collection has just been started;
at Wurzburg, a beginning has not yet been made. Progress will be slow in Germany
under the present statutes. In Austria, criminal autopsies are performed in the pre-
sence of the class; not so in Prussia, where they must be privately carried out. If
an autopsy is made under these conditions, it does not profit the students; if a crim-
inal autopsy is not required, the hard-pressed anatomist lies in wait for the body.
The study, therefore, cannot be said to be seriously pursued by German students; on
the other hand, courses conducted for medical officers, who attend under orders or
for the purpose of qualifying for governmental posts, are seriously regarded.
Conclusion
Now that I have completed a detailed account of the German laboratories, let me
briefly sum up. Aside from the question of curriculum, the strength of the German
^ An extraordinarius.
* The extraordinary professorship at Leipzig was created in 1897.
3 See " Die Entwickelung der gerichtlichen Medizin," etc. Strassman, in Das Preussisrhe MedkinaUu.
Gesundheitswesen (Berlin, 1908).
* For details, see Strassman, as above; also Fraenckel, "Die praktische Unterrichts-Anstalt fiir
Staatsarzneikunde," Berliner Akademische Wochenschrlft, 1907, No. 11.
MEDICAL SCIENCES: GERMANY 109
situation lies in the integrity of the separate laboratories, their internal completeness,
their uniformity of type, their proximity to each other and to the clinics ; the organi-
zation which relieves professor and assistants of menial drudgery ; and the large scope
opened to ability by means of advanced courses and research work for graduates,
by means of Jamidieren and optional courses for undergraduates. Every one of these
points would bear further emphasis if space permitted. Geographical compactness
makes the entire medical department, externally viewed, a unified plant. It is not re-
garded as important that the medical institutes should adjoin the rest of the university.
They are rarely situated on the same plot with the libraries and seminary rooms be-
longing to philosophy, law, and theology. At Vienna, Berlin, Breslau, Marburg, and
Strassburg, — to mention no others, — a student of medicine need not see the other
academic buildings. But lack of local contiguity does not shatter the ideal unity of
the university. The four faculties are animated by the same purpose, too finnly held to
be endangered by a certain amount of local separateness. Meanwhile, the constituent
parts of each faculty are kept as compact as possible. The institutes and the clinics
that form the medical department are therefore treated as a unit. The student loses no
time in going from one laboratory to another, or from the institutes to the clinics ; their
proximity suggests their interdependence.^ Scientist and clinician not only occupy
the same university status, but they are in easy and natural communication. The same
ideals inspire them ; different aspects of the same problems engage them. Yet, though
stimulating and assisting one another, every institute leads its own independent life.
A worker has at hand what equipment he is sure to need. He does not borrow, he
does not interfere by using rooms or implements belonging to others. Wiirzburg is
typical; the institutes of physiology, pharmacology, anatomy, and pathology adjoin
one another, the last two communicating. Yet physiology and pharmacology have
each its o^\^l shop in charge of its own skilled mechanic, while physiology, anatomy,
and pathology have each its o\mi photographic outfit.
These conditions are highly favorable to the development of the several sciences.
Research is favored by independence and privacy, by naiTOwing down of one's prob-
lem, even though from time to time the investigator is compelled to reach over
into other domains for means and methods. From this point of view the German ar-
rangement is ideal: the worker has his privacy as long as he wants it; help is next
door whenever it profits him to seek it. Teaching, however, requires interrelation,
cross-reference, "team-work." Now it is clear that in dealing with so intricate and
extensive a subject-matter as medicine, any attempt to devise too highly organized
a system of cross-relationships would give to instruction a conventional, cut-and-dried
aspect that would be in the last degree unfortunate. A certain amount of looseness,
unevenness, variety, leaving some interrelations to be worked out by the student, even
at the risk of being missed by him, is more wholesome for both teacher and taught.
It is questionable whether the several German laboratories sufficiently take ac-
1 Some of the buildings recently erected at Berlin depart from this sound principle.
110 MEDICAL EDUCATION
(.ount of one another as they proceed in their teaching. In my judgment, this defect
is not solely or mainly due to the emphasis placed upon research, and is remediable
without interference with the conditions in which research has flourished. The vari-
ous parts of the medical cumculum pursued by the German student fail to play upon
one another because the course of study is almost chaotic: the instructor has no way
of knowing precisely what previous training his students have had; and not knowing
what other branches they may have pursued, he simplifies the situation by presum-
ing upon the least possible.
An equally serious defect is unquestionably the priority and the predominance of
the lecture, by which sound pedagogical relationship is practically inverted. Science
is method, — a method of doing; it is primarily practical, rather than speculative
or theoretical. Training that expects to instigate action must rely on action; it must
stress experience, not forestall experience. Merely communicated knowledge is pale,
tenuous, flat, lacking in color, stereoscopic quality, and stimulative effect. This sound
and obvious psychological principle, the lecture, which is the backbone and substance
of the required teaching, largely ignores. On the other hand, I do not mean to imply
that the student can be trained by direct and concrete methods alone ; for this, the
field to be covered is much too extensive. Fortunately, a somewhat limited actual
experience will, if genuine and intelligent, invigorate and actualize a vast mass of
vicarious experience. Soundly trained at bottom, a man may read far and listen freely
without losing his sense of reality. The Germans apply this principle in dealing with
research; but they have thus far failed to realize that it holds equally in respect to
elementary training. Yet training in a practical sense is equally with research the
business of the university, — the training of physicians, among others. Even where the
practical course is provided, as in anatomy and physiology, the pedagogical arrange-
ment is not thoroughly sound: in the former, a needless amount of lecturing survives ;
in the latter, lecture and practical exercise are not organically related.
The peculiar contribution of the scientific institute of Germany to pedagogical the-
ory is in its combination of teaching with research. Therein the gymnasium and the
university are distinguished from each other. In the former, the youth is subjected
to a formative discipline; in the latter, his disciplined powers are applied to the mas-
tering and improvement of progressive sciences. The gymnasial teacher is a school-
master; independent scientific and philosophical activity, however common, is not
indispensable to the conscientious discharge of his primary duty. Production is inci-
dental, not essential, to effectiveness as a secondary school teacher.
The university professor regards teaching and investigation as necessarily and
indispensably involved in each other. The univei-sity student of medicine or philology
is mastering not a given content, but a progressively advancing science or art. The
Germans hold, and with justice, that only in a generally productive environment can
the right mental attitude be inculcated. It is of course true that the exigencies of
teaching limit the problems which an institute may take up. Heavy demands on
MEDICAL SCIENCES: GERMANY 111
the time and strength of a university faculty are made by administration, by exam-
inations, as well as by actual instruction. Not even universities can be carried on with-
out drudgery, — important as it is to keep routine within bounds. That granted, most
university teachers are wisely and nobly used, even though teaching restricts their
work in research. They are not mostly men of original genius. While still actively
engaged in increasing knowledge, what better can they do than to train the oncoming
generation for more effective social service, and to sift out the rare individuals who
are so fertile, so fundamental, so intense, that they deserve to be segregated ? In order
that precisely these latter may be most favorably situated for uninterrupted devotion
to fundamental problems, the foundation of research institutes has been suggested.
A few have already been established; more are in prospect. There is no question that
the intricacy and importance of fundamental scientific investigation suggest just such
concentration of effort and of resources as the research institute offers. Whether these
institutions should be entirely separate, or, as Kraepelin has urged,^ be affiliated with
the universities, it is not easy to say. Certain limitations as respects feasible appoint-
ments, organization, responsibility, have hitherto tended to attach to all university
institutes ; from these limitations, the research institutes ought undoubtedly to be
£ree. Will simplicity, elasticity, and singleness of aim be promoted by independence
or affiliation? The answer to that question must decide the point at issue. Meanwhile,
however it be answered, there could be no greater en-or than to suppose that the univer-
sity is likely to be thus deprived of one of the two functions which it has hitherto
discharged, or that its impoi-tance in investigation is likely even to be diminished.
Vitality of advanced teaching requires the proximity of investigation; and the fields
open to investigation are too rich and too extensive to be completely occupied
by institutions of a single type. Occasional geniuses of peculiar intensity may be set
aside in research establishments solely for productive work ; the more common but
not less useful type of scientist may find iniintenaipted application to either teaching
or research insupportable. A modicum of routine in the shape of teaching may then
assist research, just as research will help to illuminate one's teaching. The same holds
also of industrial or other practical activities. Factories, health offices, and other es-
tablishments of similar character have their own routine; but routine itself is most
intelligent if those ultimately responsible for its direction promote fundamental
study of the problems which it involves or suggests. There are better ways to do what
is being done; there are better things to do. Hence a really effective organization will
never limit itself to routine. The marvelous progress of German industry, German
sanitation, German hospitals, is due in no small measure to the fact that industry,
sanitation, and medical care have, like university teaching, cultivated research in all
relevant directions. Institutes for pure research will, then, to some extent be estab-
lished and liberally sustained. But research will still continue to animate university
laboratories, municipal hospitals, industrial establishments, and sanitary institutes.
1 In Silddeutsche Monatsschrift, Mcy, 1911.
1V2 MEDICAL EDUCATION
The very fact that the conditions required by investigation cannot be simplv and
rigidly formulated makes it possible and necessary to work creatively under an immense
variety of circumstances. From this, research benefits: for it thus gets the advantage
of all the suggestions made by practical experience, all the questions propounded by
practical difficulties, whether in the class-room, the factory, or public life. That any
single source of helpfulness or suggestiveness — the university, above all — should be
even partially closed may well be deemed preposterous.
That vigorous teaching and unwearying research have flourished together in the
German university must in the end be largely ascribed to the elasticity characteris-
tic of the organization. No obstacle obstructs the search of a mature student for a
stimulating and congenial teacher; and a teacher with ideas can always gain a hearing
for them. It is true that men whose productivity has ceased occupy important chairs in
some universities ; but in the same institutions, docents with more modem views ex-
pound the newer faith, which has perhaps already invaded a professorship somewhere
else. While organized faculties tend to relapse into conservatism by favoring their
own contemporaries, the press\ire of the student body, the legitimate competition
of universities with each other on a scientific plane, force the filling of vacant posts
with men who represent progressive tendencies. Around such individuals, students of
quick susceptibility soon gather; a school forms. The speed with which thereupon a
novel standpoint travels over Germany is one of the amazing features of its univer-
sity life. And this quick apprehension and incorporation of demonstrated truth is re-
sponsible for what I have repeatedly pointed out, — the uniformity of the scientific
institutes in respect to type, organization, and ideal.
CHAPTER VI
THE MEDICAL SCIENCES: GREAT BRITAIN AND FRANCE »
Anatomy
The medical sciences are cultivated in Germany for their own sake. "VMiile this stand-
point leaves some unsolved problems in connection with medical education, it has
resulted in the splendid scientific development described in the preceding chapter.
Whatever defects exist, they are not at any rate defects of material ; for every ele-
ment needed for the arrangement of a sound and properly motived medical curricu-
lum is to be found in the rich and vigorous institutes of the German university. With
the single exception of British physiology, the medical sciences in Great Britain and
France, on the other hand, have remained in an instmmental relation to medicine
and surgery. They have never whoUy succeeded in establishing the fact that they
have reached their majority, that they have a right to their own independent careers.
It is still feared that if they asserted their own intrinsic interest and possibilities of
development, they would lose sight of their obligations to the other members of the
medical family.
For this reason, homogeneity and uniformity at a high level stop abruptly when
we leave German for English, Scotch, or French soil. Of the medical sciences, ana-
tomy henceforth signifies for the most part dissecting; experimental pharmacology
is all but unknown in medical schools; the pathological laboratory as a rule shrinks
to a dead-house ; physiology alone can be said to flourish in British medical schools as
a whole, — not even that in the French schools.^ Important contributions to progress
in every one of these branches have indeed been made in all three countries, but in
general they emanate from individuals, not from institutions; from individuals, too,
who, even if teaching in medical schools, have, as the whist phrase runs, had to "play
their own hands." Hence their occasional, even if brilliant character, and their fail-
ure to determine a line of scientific development. The specialist has been slow to
develop. The medical sciences have been cultivated by young men awaiting practice;
a brilliant scientific achievement has brought them patients, not pupils and further
scientific opportunity. It happens in consequence that the fundamental sciences, as
far as they go, have been worked up in the tissue of practical medicine and surgery,
— a fortunate circumstance; but, also, that they are generally held to be worth while
only in so far as they aid the physician directly and unmistakably to diagnose, cut, or
1 It should perhaps be explained that Great Britain and France are combined here and elsewhere
because educational conditions in the two countries are, in respect to medicine, more or less similar.
In neither has the differentiation between medical education and the medical profession been strictly
or completely carried out. Moreover, both countries possess on the clinical side the excellent bedside
method of instruction. As I have dealt with England in considerable detail, those resemblances make
it unnecessary to describe French conditions at the same length, though they are in themselves perhaps
equally interesting.
2 I visited the following places : London, — all schools, —Liverpool, Manchester, Sheffield, Edinburgh,
Glasgow, Paris, Lyons, and Lille.
114 MEDICAL EDUCATION
prescribe. I mean by this that they enjoy only instrumental significance. Poverty and
dependence have resulted, but dependence has been more damaging than poverty.
For though the absence of resources and facilities is indeed sharpiv felt, the location
of controlling educational influence in the wrong place is much more unfortunate.
The medical scientist, reluctantly recognized in Great Britain and I'rance, is still
misconceived. In both countries, the floor is held by the clinician of a generation just
passing, who persists in regarding the laboratory man as an inferior.^
Nevertheless, progress has been made. Half a century ago, Oxford and Cambridge —
still mediaeval — embodied the English conception of a university. To-day, the pro-
vincial universities exemplify not unworthily the modern conception of a higher in-
stitution of learning, and the ancient foundations have awakened to the importance
of scientific method and research. Strangely enough, the priceless good fortune which
in both England and France intimately associated medical training with easy access
to the sick has been among the factors that have in both countries retarded the de-
velopment of the underlving sciences. As the old proverb has it, "The good is ever
wont to be an enemy to the best." The physiologists leading, the medical scientist is,
however, now in a fair way to establish, in Great Britain at least, his independence
of the clinician, even though he has not yet conquered his condescension.
British anatomy developed under the influence of the Edinburgh school, whose tra-
dition was formed and consolidated by the long reign of the three Monros.^ Their
method and point of view may be easily characterized. In the fii"st place, they were
physicians and surgeons,' as well as anatomists. They had prosperous practices, huge
classes,* and little anatomical material. To these conditions they adapted themselves.
In their anatomical instruction, they employed the expository method, describing with
rare eloquence, and exhibiting drawings and engi'avings by way of illustration. The
elegant descriptive lecture was thus established as the original Edinburgh method.
From this procedure John Bell revolted toward the close of the eighteenth century.
"He saw" — so runs Struthers'^s account — "that it was not merely demonstration, but
the practice of dissection which was wanted." In his own words: " 'In Dr. Monro's class,
unless there be a fortunate succession of bloody murders, not three subjects are dis-
sected in the year. On the i*emains of a subject fished up from the bottom of a tub
of spirits are demonstrated those delicate nerves which are to be avoided or divided in
our operations ; and these are demonstrated once at a distance of one hundred feet!
Nerves and arteries which the surgeon has to dissect at the peril of his patient's
* Sciences are taught "by teachers who are rather looked down upon and who are not in close touch
with the higher teaching of their subject." Principal Headlam of King's College, London: Appendix
to First lleporl of Royal Commission on University Education in London, p. 104 (London, 1910).
2 One hundred and twenty-six years : Alexander Monro, primus, thirty-eight years, succeeded by his
son, Alexander Monro, secundus, fifty years, succeeded by his son, Alexander Monro, tertius, thirty-
eight years.
2 The professorship of surgery was apparently implied in the appointment to the chair of anatomy.
On the petition of the second Monro, the fact was made explicit by a new commission in 1777.
* Struthers gives statistics, p. 29.
MEDICAL SCIENCES: GREAT BRITAIN AND FRANCE 115
life.' "^ It was still, of course, too early to look upon anatomy as anything but the hand-
maid of sui-gery ; even so, forty years passed before what Bell called "the windy and
wordy schooP' of Edinburgh explicitly adopted his position. As late as 1825, out of a
class of 200, not above 30 engaged in dissecting.^ Even when, a year later, a practical
course of three months' duration was made compulsory of candidates for the diploma
of the College of Surgeons, the lecture was neither supplanted nor curbed. It struck
no one at the time, and it has struck few since, that the practical exercise and the
descriptive lecture are non-compatibles. The practical exercise was simply annexed,
and the union of lecture and dissection from the surgical standpoint became thence-
forth the recognized method of the nineteenth century. "To have the science of
anatomy and its application expounded by the anatomist in the lecture room is of
unquestionable importance; but this must be accompanied by careful instruction of
individuals in the practical rooms. It is the combination of the two which constitutes a
good school of anatomy."* The lecturer tells the student what to look for; on the dis-
secting-table he finds it. The process of learning is a process of identification and re-
tention. The science is a closed book. Even if the volume be occasionally opened for
emendation, the adult body is after all what it is. The conventional anatomist is exceed-
ingly expert in taking it to pieces, precisely as it has been taken to pieces before. He
has a name for every distinguishable feature and a mark for every one of its distin-
guishable parts. His patience and vigor in explanation and inculcation are beyond
all praise. Didactic description, dissection, drill, — these are English and Scotch ana-
tomy; a conscientious, prolonged, painstaking, but uninspiring routine that usually
accomplishes what it deliberately sets out to do. Its merits and its limitations are
thus at once characterized.
The British or French anatomist requires little at best. Arrangements for preserving
cadavers; clean, well-lighted, odorless dissecting-rooms; a lecture hall with a black-
board, freely and very helpfully utilized; a museum containing a varying number of
charts and special and mounted dissections so labeled as to facilitate the identification
of parts; an ample supply of bones, — all these the most fortunate anatomists have,
and in most instances this is all they have. The Edinburgh department has now a pro-
jectoscope and a photographic outfit, — the latter a very rare detail. Occasionally, the
lecture room contains a projectoscope, as at Glasgow, Liverpool, Manchester, St. Bar-
tholomew's, and Guy's (London), and a small supply of embryological models. At most
of the London hospital schools, and at Univei-sity College, London, the departments
are scantily equipped, on the simple lines just indicated. This statement applies also
to the Extra-Mural School of Edinburgh,, whose outfit consists mainly of blackboard,
books, and bones. At Paris, the teaching equipment includes dissecting-rooms and
lecture hall, the latter too small to accommodate the hearers; the student collection
is of little value for its ostensible purpose, A large, well-hghted hall, supplied with
dissecting-tables, at each of which five or six students work together, constitutes the
I Struthers, p. 38. '^ Ibid., p 64, note. ^ Ibid., p. 94.
116 MEDICAL EDUCATION
equipment, and suggests the character, of the instruction at Lyons. Microscopes and
reflectoscopes must be rare indeed in the smaller provincial universities of France, if
Lille may be taken as a fair example. Nevertheless, even the weakest schools avoid
scandal. They are merely backward. Everywhere the student can learn and can dissect
the parts of the human body. At one or two of the smaller English institutions,
Oxford and Sheffield, for example, really charming apartments are devoted to the
subject.
The break with this traditional method of presenting the subject comes with re-
cognition of the genetic view. To understand the topography of the adult body, one
must understand its genesis. Histology and embryology are thus introduced. There-
with anatomical research becomes one of the legitimate concerns of the anatomical
department. The systematic lecture tends to fall into the background; dissecting
becomes an exercise in inductive thinking as well as in manual dexterity. Ceasing
to be an incidental occupation for a physician or surgeon, the subject requires the
constant presence of a specialist devoted to teaching and investigation. Development
along these lines is apparent at Glasgow, Manchester, and King''s College, London,
at all of which the departments are distinctly more than the dissecting and lecture
rooms elsewhere devoted to the patient inculcation of facts. At Manchester, indeed, —
and thus far there alone as yet, I believe, — the systematic lecture has been discarded.
There the professor no longer describes the bones, blood vessels, muscles, and nerves; he
employs the lecture to present comprehensively and organically what dissection takes
apart, — the lymphatic system, for example. Even where the broad scientific conception
of the subject has not established itself, modern conditions have been recognized to the
extent of employing as heads of anatomical divisions men who no longer carry on medi-
cal and surgical practice. There is now little disposition either in France or Great
Britain to question the wisdom of placing specialists in charge of the department: at
the Scotch univei-sitieSjmost of the English universities, in most of the London schools,
and in Paris, the modem order thus far prevails. Tliese men being teachers may, like aca-
demic teachers in other branches, migrate freely from place to place. Curiously enough,
in Great Britain the current flows from, not towards, London. The poverty and com-
mercial aspect of medical education in the hospital schools render the posts there de-
cidedly unattractive : a capable teacher, turning up in one of them, will shortly be called
to the greater comfort, dignity, and remuneration of a provincial or Scotch univei'sity.
Exceptions to the full-time specialist can, however, yet be noted; the departmen-
tal head at Liverpool is consulting surgeon to the local Hospital for Diseases of the
Throat and Chest; the head at St. Mary's (London) is chief surgeon to the out-patient
department. Of a teaching staff of subordinates, relatively permanent in composition,
devoted to the academic career and to scientific ideals, there is as yet little trace.
Professor Elliot Smith has instituted one at Manchester; but elsewhere in Eng-
land, the demonstrator of anatomy is still usually a young surgeon, teaching anatomy
because the demands for his surgical services are not yet pressing. Of three demon-
MEDICAL SCIENCES: GREAT BRITAIN AND FRANCE 117
strators at the London Hospital school, two are simultaneously assistant surgeons;
the senior demonstrator at Charing Cross (London) is an assistant surgeon ; and one
of the juniors, the orthopaedic surgeon; at St. Mary's (London), the senior demon-
strator is assistant surgeon in the department of ear, nose, and throat. The head
demonstrator at Guy's (London) is surgeon in charge of the genito-urinary work;
another demonstrator is anaesthetist; one of the demonstrators at St. Bartholomew's
(London) is assistant in out-patient surgery. Junior assistants, often in practical
charge of the dissecting-rooms, are well-nigh invariably young surgeons. They pass
through the anatomical purgatory on their way to the hospital staff ladder. The in-
sti'umental character of the subject — and in narrow reference to surgery, at that —
could hardly be more unmistakably emphasized. Nor is its independent dignity en-
hanced when, as at St. Thomas's (London), the head of the department supplements
his income by serving as Secretary of the Students' Club, as well as lecturer in the
London School of jNIedicine for Women.
The activity of the departments still expends itself almost wholly in routine
teaching, thus defeating one of the main purposes that the academic basis is de-
signed to fulfil. For the whole-time teacher is not wanted only in order that he may
drill successive classes during as many working hours as he can contrive to keep awake.
Not only the student, but the subject, demands his devotion; by devotion to the sub-
ject in a creative, not sacrificial, sense, he must assist in maintaining conditions con-
genial to the existence of a spirit of inquiry. Between the full-time extra-mural drill-
master at Edinburgh and the busy surgeon at London, there is small ground for pre-
ference, scientifically speaking. At his worst, however, the full-time teacher has one
great advantage : he is not a stranger to his own dissecting-room. Lender the surgeon
anatomist there was — and where he survives still is — little or no commerce between
the dissecting-room and the lecture hall. The effort to establish communications be-
tween them was actually resisted at Paris; nor has resistance been yet overcome,
although Nicolas, the present incumbent, declined to accept a call thither from Nancy,
unless control of the practical work went with the professorship. The surgeon as-
sistants and prosectors resent a policy of departmental organization; and the stu-
dents have taken advantage of the tension actually to rebel. They are so far from
recognizing or even conceding the wisdom of importation on the basis of merit that,
having come to Paris to study, they insist on being taught by a Parisian, not a pro-
vincial, anatomist. Disorder resulting from the inopportune and violent expression
of this sentiment, whenever the professor entered the hall, has just led the govern-
ment (December, 1911) to close the medical school to all students of the first and
second years.
The ruthless expenditure of the teacher upon routine is, however, common. The
French or British student wants to pass. What he does, and the way in which he
does it, are carefully and narrowly calculated with this end in view. The schools know
this and trade upon it. I have already pointed out that British medical schools, strictly
118 ^MEDICAL EDUCATION
speaking, liave no entrance standards in medicine. The student selects the qualifica-
tion he prefers and complies M'ith the general educiitional recjuirement that it carries;
all schools train simultaneously students seeking different qualifications. Essentially
the same situation exists in the professional instruction offered by the medical
school. The school conducts a variety of courses in each subject. Each course has a
particular qualifying examination in view. No course offers much margin; it includes
what is believed to insure a safe passage of the barrier, — no more, no less.* To the end
that a student contemplating one qualification may be efficiently protected against
doing the extra bit involved in another or higher quahfication, special officers — so-
called tutoi*s — are appointed to shepherd the respective flocks. The Conjoint men form
one group; the Oxford men, another; the Cambridge men, a third; the London Uni-
versity degree men, a fourth; the fellowship men, a fifth. Competition for students
turns very largely on the efficiency of the tutorial work thus organized; and the time
and energy of the full-time teacher and his part-time assistants are utterly consumed
in an endless succession of drill classes. The prosperity of the school depends primarily
on its percentage of successes, and, be it added in passing, on its athletic facilities;
for, though forced to forego laboratories, apparatus, and teaching staff by reason of
poverty, almost every London school supports an athletic field.
Let us examine the anatomical instruction at St. Bartholomew's, by way of ex-
ample. Students expecting to qualify before the Conjoint Board hear four lectures
weekly from October to March and two lectures weekly in the summer session. Spe-
cial and different additional provisions have got to be made for each of the follow-
ing groups: (1) the Intermediate M.B. Oxford men; (2) the Intermediate M.B. Cam-
bridge men; (3) the Intermediate M.B. London University men; (4) those going in
for the Primary Fellowship of the Royal College of Surgeons, etc. Now, the fellowship
examinations recur twice annually, in November and May. It would never do for a stu-
dent who goes up in May to do his work in October: the course must therefore be
given twice. The Cambridge M.B. comes in December and June; two groups must then
be formed with a view to its requirements, etc. These different examinations corre-
spond to no genuine distinction in individual capacity,individual function, or scientific
interest. The Conjoint men, the London degree men, the Oxford men, are, after all,
only ordinary doctors. The different appellations have merely a social, professional,
and business value, and the student strives for the one which satisfies his personal
ambition. The schools assist him so to strive that the entire burden of effort, beyond
mere absorption, is successfullv shifted from him to the tutors and demonstrators who
are sterilized in order that he may write one set of letters rather than another after
his name.
* The objection to this is neatly put in the following verses :
" Willst du dein Brotfach recht verstehen
Musst audi in Ncbcnfacher sehen ;
Wer nicht mehr lemtc als er musst
Hat, was er musste, nie gewusst"
MEDICAL SCIENCES: GREAT BRITAIN AND FRANCE 119
A heavy price, this, to pay for doubtful success in a futile cause. With the schools
straining every fibre toward passing their students, the Conjoint Board rejected 42
per cent of its candidates in anatomy and physiology between 1905 and 1909.^ But
a higher percentage would still be an insufficient apology. Suppose the students did
learn the facts that their tutors realize in advance they must know, and thereupon all
come to a dead halt — students and teacher alike? Can a structure like clinical science
be erected on so limited, inert, and inelastic a foundation? The point we have already
discussed recurs: science is method, not information. The French and English stu-
dents have been drilled in details, but they have failed to acquire scientific method.
Their routine has entirely lacked stimulating quality; the best proof is that their
schools make no allowance for unforced individual initiative in anatomy. The student
may indeed make an additional effort, but its tangible reward must first be dangled
before his eyes in advance. He will put in some extra blows for a diploma or a fellow-
ship, but openings are not created for disinterested scientific zeal. There is forcing
from without rather than impulse from within. There are no Jarnidl in England; no
optional courses to satisfy the mere love of work; and in most lines no institutional
research.
The drill-master is a fairly universal institution: he can be found wherever there
are students who shirk and examinations that threaten. As the "Einpauker'' he
exists in Germany; obviously, the abundance of lecture courses — to the contents
of which certain tests are restricted — gives him there an opportunity that he is not
likely to neglect. But after all, the German "crammer" operates shamefacedly. He is
no part of the educational system. He knows in his heart that he defies its spirit and
intent. In Great Britain, cramming is of the essence of the system itself. It is aided,
abetted, and required by the schools,^ — at Edinburgh, even by the university. For the
extra-mural teacher of anatomy serves as drill-master to the university students : the
Extra-Mural School has even asked a subvention from the government on the repre-
sentation that it "teaches" the university students.^ And how? There is a daily lec-
ture on bones : every man gets a specimen ; three weeks may be spent in hard teach-
ing of the temporal bone; and the teacher does everything, — emphasis, repetition,
quizzing, being his tools. The duller student sets the pace. In winter, three separate
demonstrations are given daily; the men going up for examination take all three.
How can they escape ignorant? — in the course of three months the entire body has
been covered! In general, conditions are less satisfactory in France than in Great
Britain. At Lille, equipment and facilities ai-e inferior to even the poorer London
hospital schools. The narrowly instrumental point of view is still further accentuated
by the only too obvious subordination of all the underlying sciences to the chnic. For
1 Figures for the other subjects are given in chapter xi.
2 Cooke's School at London, and Anderson's College, Glasgow, like the Extra-Mural School at Edin-
burgh, make a business of cramming for examinations.
3 Minutes of Evidence taken before the Committee on Scottish Universities, p. 62 (London, 1910).
120 MEDICAL EDLXATION
the French student puts in — or is supposed to put in — his mornings at the hospi-
tal; he dissects and attends lectures in the afternoon. During his first year, hospital
attendance is optional ; instead of devoting the flower of the day to anatomy, he is
privileged to waste it. At Paris, dissecting is crudely done. One hundred students
occupy each of eight halls; tables and a blackboard constitute the equipment, a single
demonstrator with three assistants constitutes the staff. At Lyons, smaller numbers
are perhaps more efficiently handled. But the absence of embryology and the treatment
of histology as a separate entity, apart from both physiology and anatomy, confines
the subject to narrow limits.
The supply of material in both countries is unsatisfactory. In Paris, it is steadily
decreasing. There, unclaimed bodies are held for seventy-two hours before delivery
to the anatomist. As the hospitals lack satisfactory cold chambers, the condition of
the material leaves something to be desired. Material is more abundant at Lyons,
where in the winter of 1911, 200 cadavers — most of them already autopsied — were
furnished by the hospitals for a dissecting class somewhat less than 300 in number.
In England, the unclaimed dead from hospitals and infirmaries constitute the ana-
tomical supply. But what with the increase of sentimentalism and democracy and the
institution of old-age pensions, conventional burial awaits many a corpse that would
formerly have been dedicated to education. In consequence, from ten to twenty men
take part in the dissection of each cadaver. In London, the struggles of the schools
confuse the situation. Bodies are pooled and divided, but, it is charged, "some schools
don't run straight," — an incidental result of proprietary competition.
Physiology
British physiology contrasts strongly with British anatomy. It was in the first place
earlier successful in procuring the academic environment which guarantees protection,
continuity, and congenial company. I have already pointed out that the medical sci-
ences in Great Britain have lived on the chance that brilliant men could devote to
them a decade marked by youthful enthusiasm, prior to more or less complete im-
mersion in practice; that almost inevitable absorption in practice, following scientific
achievement, interrupted the development of science by making it impossible for a
teacher to train his successors. Physiology proved a fortunate exception to this general
rule. William Sharpey, appointed professor of anatomy and physiology at University
College, London, in the thirties, was a pioneer in developing the latter subject in an
independent fashion. He gave their start to !Michael Foster and Burdon-Sanderson,
whose studies took a modern turn under the influence of Ludwigand Claude Bernard.
Full academic recognition and protection were procured for physiology in 1883, when
Foster became professor at Cambridge, and Burdon-Sanderson professor at Oxford.
The importance of academic status could not be more impressively established. Physi-
ology thenceforth enlisted the total devotion of men interested in it for its own sake;
it furnished a legitimate and satisfactorv career, to which a succession of able men
MEDICAL SCIENCES: GREAT BRITAIN AND FRANCE 121
have been attracted. The subject has thus advanced with unbroken continuity, until
it is now the most highly developed of all the medical sciences in England, with inter-
national recognition. Nor is this fact of importance merely from the standpoint of
research; for physiology is hkewise the most efficiently taught and most stimulating
subject in the medical cun-iculum. The history of British physiology proves conclu-
sively that what is best for a subject is best for all the varied purposes which, directly
or indirectly, it subserves.
Up to the time when Foster began his career, physiology had been taught — as Fos-
ter himself says — by "men whose intellectual loins were girded for other purposes, and
who used the posts as stepping-stones*"^ to other ends. The instiniction had consisted of
lectures, illustrated by occasional experiments, a simple course in histology, and per-
haps a few chemical exercises. To Foster himself is largely due the initiation of the
practical course in training undergraduates. He held that the "teacher must have the
means of leading his students along the only path by which the science can be entered
upon — that by which each learner repeats for himself the fundamental observations
on which the science is based" in a laboratory where "each post for teaching is no less
a post for learning." Huxley had previously successfully applied the same principles in
arranging his courses for teachei*s, at South Kensington, where an introductory talk
of an hour was followed by four hours' laboratory work, in which with naive astonish-
ment and delight those who had been teaching natural history from books now for the
first time came to know the objects themselves.^
Despite its flourishing condition, special institutes of physiology are still rare in
Great Britain, though they exist at University College (London), and at Glasgow,
for example. In general, all the medical laboratories are housed together, under which
circumstances physiology gets a suite of rooms varying in number and extent. By
all odds the most modem establishment is the Institute at University College, Lon-
don, It forms a rectangular edifice occupying a site of 44 feet by 144 feet. The
ground floor is devoted to laboratories for research in physiological chemistry, con-
sisting— if we follow them in order — of a balance room, the private quarters of the
assistant professor in charge of the department, a general research laboratory, ac-
commodatino- eight workers, a combustion room, a distillation room. The floor above
is devoted to experimental physiology on one side of the staircase; on the other
side to the lecturing theatre, seating two hundred students, and equipped with two
lanterns. A departmental library of some four thousand volumes, the professor's pri-
vate laboratorv, a general research laboratory, and two rooms for the physical in-
vestio-ations occupy the rest of the story. The second floor is given to histology,
neurology, and aseptic work. The students' class-room for histology and experimen-
tal physiology is 63 feet by 42 feet. It is filled with working-benches accommodating
1 "Address before British Association for the Advancement of Science," printed in British Medical
Journal, 1897, vol. u, pp. 445, 446.
2 Life and Letters of T. H. Hiuehy, by his son, vol. i, pp. 405-410 (New York, 1901).
122 MEDICAL EDUCATION
seventy workers; each student is provided with locker and drawer, with water, gas,
and electric light. Five long tables are equipped with shafting for experimental work.
The floor includes further: a demonstration theatre, accommodating forty students,
and equipped with kymograph, artificial respiration apparatus, time-marker, with
water and electric power; a suite of rooms devoted to the physiology of the nervous
system ; and the aseptic department, consisting of sterilization room, operating-room,
animal bath, and animal hospital. Close by are satisfactory quarters for animals. The
Glasgow laboratory, though less well planned, is likewise a complete institute of mod-
em character. At jNIanchester, the physiological rooms are quite extensive; a well-
equipped and ])roductive department occupies somewhat rambling quarters at King's
College (London); at Edinburgh University, the provision is crowded and inadequate,
though a highly active incumbent has succeeded in triumphing over limitations of
space and inadequacies of equipment. The extra-mural department there is meagre
in the extreme. Of the London hospital schools, Guy's and the London are perhaps
most satisfactorily fitted out. At St. Bartholomew's, the subject commands only two
large rooms, one for chemical work, one for experimental work, and a smaller room
for the instructor. At most of the hospital schools, narrow resources leave little time
or energy for scientific activity. In general, however, the facilities for routine practical
work by each student on both chemical and experimental sides are everywhere good,
— far exceeding anything to be found in the German Empire, Austria, or France.
In France, indeed, the subject is for the great mass of students only demonstra-
tively and descriptively presented. At Paris, lectures to medical students are given in
the large amphitheatre of the Faculte de Medecine in the Ecole Pratique. The demon-
strations are hampered by reason of the fact that the same amphitheatre is used by
professors in different subjects. The general lectures are supplemented by smaller
courses — likewise of demonstrative character — in which the classical experiments are
exhibited. Little provision for practical experimental w-ork by the student exists. The
teaching of all the sciences has been severely criticized on this account. A recent critic
urges with great force that science teaching is properly teaching by collaboration,
not by affirmation. "It is necessary that master and student be associated in a com-
mon task. The student is not a mere pupil who listens or takes notes; he is an appren-
tice who is exercised in observation and experimentation in contact with a master."^
On the other hand, there are some opportunities for research, as Richet's publications
prove. Unfortunately, however, the research laboratory of the professor is situated not
in the Ecole Pratique, but in a separate building, several miles distant: so weak is the
bond between medical teaching and research in France. The lal)oratory at the Ecole
has been turned over to the agregc. At Lille, there are found a few sets of apparatus
of recent make, but the general appearance of the department is decidedly forlorn.
In England, physiology is now invariably taught })y specialists; the departmental
staff, however, is not as yet satisfactorily developed. Assistants who expect to make
* " L'Ecole de Medecine Technique," by M. le Dr. Le Rcdde, Trifiune MMicale, October 8, 1910.
MEDICAL SCIENCES: GREAT BRITAIN AND FRANCE 123
their careers in the subject are indeed found in Liverpool, Glasgow, Edinburgh, and
occasionally in London; but more frequently — largely on account of lack of funds
— the junior assistants are young physicians, waiting for an opening in medicine or
surgery. The same condition accounts, too, for the exhaustion of the specialist in
routine work at more than one institution : the lecturer at St. Bartholomew's is, for
example, simultaneously instructor in the same subject at the Bedford College for
Women.
To the English belongs the credit of devising a sound method of undergraduate
scientific instruction, just as we shall shortly perceive that they have applied the
coiTect principle in clinical instruction. The national instinct must be fundamentally
sound; for the head of Dotheboys Hall was already on the right track. "We go
upon the practical mode of teaching," explained Mr. Squeers to Nicholas Nickleby.
"C-1-e-a-n, clean, verb active, to make bright, to scour; W-i-n-d-e-r, winder, a case-
ment. A\nien the boy knows this out of book, he goes and does it.""
The essential features of undergraduate instruction are these: the demonstrative
lecture and the practical work run side by side. When Foster lectured on digestion, his
practical course dealt with the chemistry of the process. Each student has an assigned
desk with complete individual equipment; he sets up and carries out his own experi-
ment. The examination requirements tend undoubtedly to overemphasize lecture and
text-book work, but the instinct and preference of the better teachers refuse to be
bound down. Obscurantist anti-vivisection legislation, however, constitutes a serious
handicap; for on the operative side the laws endeavor to cui-tail such leeway as the
examinations leave ^ by restricting the experimental work of the student to pithed
froo-s. Shen-ington has, however, devised an operative course with mammals which,
without infrino-ing the law, involves the use of decapitated cats under artificial respi-
ration.^ He thus procures reactions more nearly resembling those of the human subject ;
and experiments can be worked out which bear more closely on medical problems.
Undoubtedly the labor of conducting such courses is heavy. Nowhere, I believe, is the
staff what it should be in point of size; but the vitality of the subject is evidenced
bv the enthusiasm of this instruction despite the handicaps, and the not uncommon
concurrent productivity of the instructors.
It is important to note that the method just now characterized is never defeated by
numbers. The English do not resort to mass or demonstrative teaching in physiology;
by skilful adjustment they avoid the necessity. The Liverpool classes are of course
small; but the method would not be abandoned were they much larger. At Guy's, a
class of 60 is handled by two men ; at Cambridge, 100 are managed by subdivision
into three groups, each group spending one day a week at each of the three parts into
1 See appendix to Fmirth Rpport of Royal Commission on Vivisection, testimony of Professor Gotch,
pp. 34-49, and that of Sir Victor Horsley. pp. llS-149.
2 He described his method in Journal of Physiology, vol. xxxviii, p. 375, and Quarterly Journal of
Physiology, vol. iii, p. 209.
124 MEDICAL EDUCATION
which the course is divided — chemistry, histology, operative work; and in histology
— at Cambridge as at Edinburgh — the student prepares his own slides; most signifi-
cant of all, however, is Edinburgh, where i240 students attend the practical course at
the University. Only lack of space and proper number of assistants restrict the physio-
logical work to the nerves and muscles. I witnessed one of these exercises : nothing
could have been more orderly or effective. Every student competently handled his own
apparatus, made his tracing, pasted it in a book, and wrote up the recjuisite notes: he
was "signed up'' only if his results were satisfactory. The practicum lasts two hours;
but the laboratory is open all day, and students are free to come and go as they
please.
The skill with which the practical work is handled effectually disposes of the con-
tention that it is feasible only with small classes. There remains the objection based
on the quality of the student's work: a German would urge that the boy fumbles,
blunders, wastes time, achieves a result inferior in finish to the professorial demon-
stration. The fact is in general indisputable, but it quite misses the pedagogical
point. We are not primarily interested in the product. Market considerations do not
decide the value of the practical exercise. We are concerned to establish within the
student's intellectual habit the priority of observation over authority. He is, for ex-
ample, required to draw, not that he may produce artistic illustrations, but that he
may be forced and trained to see. The student's own blunders and bruises can alone
finally set him on his feet; to save him from error, to keep him whole, means only
ultimate helplessness. Fortunately, men are so constituted that a necessary lesson
can be learned even while the actual exercise is far from expertly done; nay, more, even
though the entire field be but fractionally covered. A student who has experimen-
tally grasped the actual import of metabolism, respiration, secretion, circulation, can
read far and freely without losing touch of reality.
In the long nin, the entire complexion of one's thought may depend on whether
one starts with description or experience. To begin with, description tends to reduce
experience to mere illustration. In that case, the student starts with a notion, and the
experiment only bears it out. A practical course of this sort confirms him in a kind
of unquestioning passivity. Premature communication from an authoritative source
may thus in advance destroy that virgin freshness of curiosity which is so powerful
an incentive to inquiry and effort. Professor Paton, at Glasgow, has worked out a
practical course for students on the opposite principle: "The problems to be inves-
tigated and the method of investigation are indicated, but the results to be obtained^
and the concbmons to be druicn, are left to the stmlent, who must before all be taught
to observe and to experiment without preconceived ideas, and without any anticipa-
tion of a particular result, but with a mind open to accept whatever result may be
obtained, and from that result to attempt the solution of the problem under inves-
tigation. The course should be taken along with a course of lectures and demon-
strations, and it should be arranged that in each part the practical work jirecedes the
MEDICAL SCIENCES: GREAT BRITAIN AND FRANCE 125
lectures.""^ Professor Paton does not deny that it is hard teaching: "The students feel
hopeless at first; but let them fumble and come to grief. They soon take hold; thence-
forth the practical exercise informs and vitalizes the lectures."^ The concrete method
is not everywhere so strenuous as this; nor, perhaps, need it be. Lectures and prac-
tice may run parallel with satisfactory results and not too gi-eat expenditure of time.
On the other hand, practical instruction may be rendered as safe and simple as at
Munich; as it is, in some ways, at Manchester, where physiology is concretely taught
in a way that effectually avoids imposing any strain on either imagination or reason-
ing powers. Every conception is \nsuahzed not by, but for, the student : this bottle
shows the actual volume of lime in the body; that, the actual amount of carbon
breathed out in one hour. Printed slips distributed as the class meets give in concen-
trated form the contents of the forthcoming lesson. ITius may the practical defeat
itself by denying to the student all responsibility and opportunity for the exercise of
power. There is no error; but then there is no effort.
The minimum requirement in the subject comprises two lecture courses occupying
a summer and a winter session, and practical courses of the same length, in the same
sessions. The practical courses are devoted to physiological chemistry, experimental
physiology, and histology.^ The last-named is at times treated in a somewhat step-
motherly fashion, and would undoubtedly fare better if assigned to anatomy, which
would, in its turn, be enriched by the transfer. Additional courses — lectures and prac-
tical— are supplied for candidates going up for the more difficult examinations.
With this word the obverse side of the picture comes into view. The instruction
suffers from the limitations imposed by the low entrance requirements; for practical
physiology can hardly be properly developed with students whose physics and chem-
istry are as meagre as we have found them to be. The cut-and-dried science teaching
of the first year thus hampers the physiologist at every step. He is still fuilher ham-
pered by the tutorial treadmill. What I have said of the variety of examinations for
which special preparation must be made in anatomy holds equally true in physio-
logy; with increased bitterness resulting, for the physiologist has other ideals. There
is, however, no escape : in London, at least, he could not make ends meet without the
income derived from tutorial classes. He practically takes upon himself full responsi-
bility for the fate of his pupils; the catalogues of the competing London schools vie
with one another in describing their endeavors to make their patrons secure. "Special
1 A Practical Course of General Physiology for Medical Students, by D. Noel Paton and G. H. Clark,
preface (Glasgow, 1908).
2 There are 600 students of medicine at Glasgow, so that the classes in physiology are not small.
3 I have been told that the combination of histology with physiology follows an Edinburgh precedent,
which originated in business, not scientific policy. The subject was first taught there by Bennett, pro-
fessor of physiology, to whom it was assigned in order that the fees might supplement his small salary ;
the anatomist was already prosperous enough. In France, as I have already remarked, histology* forms
by itself a separate department, — a very undesirable arrangement. The instruction is altogether imi-
tative— the student looks at slides already prepared and sees what he is told to observe. But the ana-
tomical or physiological implications remain unilluminated.
126 MEDICAL EDUCATION
classes and examinations are conducted throughout each session," reads the catalogue
of the London Hospital School; "tutorial revision classes are held by the demonstrator
every three months," The student going up for the first time may attend or not as he
pleases; but "attendance is compulsory for those who have been referred."^
I alluded to the contrast between anatomy and physiology in medical schools.
Anatomy, we found, had not yet modernized in Great Britain ; it has never shaken
loose from the domination of the original Edinburgh idea. To this day it remains only
an instrument, necessary to medicine and surgery, with very occasional interest be-
yond. The instruction offered is practically unvarying from school to school: sys-
tematic anatomy for all comers, advanced anatomy nicely adjusted to the somewhat
more difficult examinations, practical anatomy, — these, with a uniformity that could
belong only to a dead science, recur everywhere. The provincial universities, Oxford,
Cambridge, the London Hospital Schools, all are practically alike. Physiology, on
the other hand, presents the variety belonging to a living science. The requisite
minimum and the higher courses necessary to the more advanced examinations are
given in every school. But the departments do not stop there; optional courses are
everywhere offered. At Liverpool and Edinburgh, for instance, three or four students
annually interiiipt their progress along the beaten path to the medical examinations
in order to earn a B.Sc. degree by advanced work or research in the laboratories of
physiology or bio-chemistry; at Glasgow, the same degree is offered under similar con-
ditions. The student can pursue advanced work in any one of five branches: (1) meta-
bolism and digestion, (2) circulation and respiration, (3) muscle and nerve, (4) special
senses, (5) physiological chemistry; and in the division that he elects he is required
to work out a minor problem adapted to his powers. At Cambridge and Oxford, the
"honor degree" attains the same end. This active spirit crops out also in the London
Hospital Schools. At Guy's, for example, brief electives cover the physiology of the
skin, the secretion by the kidney, the variations in the chief constituents of urine;
St. Thomas's offers an optional in coagulation of the blood, muscle, and milk; Lon-
don Hospital, one in the physiology of the senses. The research journals bear constant
testimony to the activity of Starling"'s laboratory at Univei*sity College, Halliburton's
at King's, Hill's at London Hospital, Sherrington's at Liverpool, Schjifer's at Edin-
burgh,— to pick out only the best known. The conditions are not always favorable,
for the routine load is heavy; but where ideals burn brightly, conditions do not have
to be propitious: difficulties are surmounted somehow. This is perhaps the more
remarkable because physiology in England foregoes the incentive that in Germany
is furnished by the clinic. We have learned that German medicine has taken up the
physiological point of view. The German clinician is a trained, often a productive,
physiologist. English phvsiology has not yet conquered English medicine. With a few
brilliant exceptions,' — such as Sir Victor Horsley, for example, — the English surgeon
and clinician have done little to apply physiological method and technitiue to clinical
^ " Referred " = failed in examination before the qualifying body.
MEDICAL SCIENCES: GREAT BRITAIN AND FRANCE 127
or surgical problems. In consequence, unlike Germany, the productive literature of
physiology in recent times must in Great Britain be credited almost entirely to physi-
ologists alone.
Pharmacology
In dealing with anatomy and physiology I have already intimated that the medical
schools are not entirely representative. This is even more emphatically true of British
pharmacology.^ Excellent pharmacological studies have been made by physiologists
as well as by clinicians : witness Langley ""s work with nicotine. Ringer's on the inor-
ganic salts, Brunton's with the nitrites. Eraser's with strophanthin. Moreover, some
firms of manufacturing pharmacists in England maintain excellent research labora-
tories of pharmacology. Our account is, however, concerned with pharmacology as
an integi'ated department of a medical school. For only where pharmacology attains
the status of a university department do productive workers follow one achievement
with another, and only under such circumstances does the subject become a definite
element in the medical curriculum.
In but one British institution. University College, London, has pharmacology as yet
reached the dignity of a full-time professorship. Cushny's laboratory there, with chem-
ical and physiological divisions, is the only establishment of its kind in Great Britain.
King's College, London, indeed claims a professorship, but the incumbent is on duty
only during the summer session; during the winter he serves as lecturer in the same
subject at Cambridge, JModest experimental laboratories are found at Glasgow and
Liverpool ; but the professor at Glasgow is a practitioner, while Liverpool devotes only
a lectureship to the subject.^
Despite the proximity of physiology, there exist two serious obstacles to the ex-
perimental development of the subject in the medical school : anti-vivisection legis-
lation, on the one hand, and the strongly empirical leanings of the profession, on
the other. Practical classes in pharmacology cannot be conducted with frogs; and the
present state of public opinion, as evidenced by existing statutes, permits nothing
else. The medical profession has not yet discerned that what it calls the "precise ob-
servation of disease at the bedside"^ is, as a matter of fact, vague and inconclusive:
the critical study and teaching of therapeutics involve the acceptance of a radically
different point of view, Cushny finds, for instance, two distinct clinical views as to the
efficiency of ergot in childbirth. "When I began to look into the question,"" he
says,* "I expected to find that each side would have a series of observations, but
that these conflicted with each other. But I could find in the whole literature no evi-
dence that any one had ever contemplated such an investigation. Here was a drug,
1 In its modern form, the subject plays practically no part in French medical education. The instruc-
tion in therapeutics is limited to lecture courses conducted by practising physicians.
2 There is a summer lectureship in experimental pharmacology at Edinburgh also.
3 Norman Moore: Medicine in the British Isles, p. 157 (Oxford, 1908).
* A. R. Cushny, "A Plea for the Study of Therapeutics," Proceedings of the Royal Society of Medicine,
November, 1910, Pharmacological Section, p. 4.
128 MEDICAL EDUCATION
given in thousands of cases each year, the action of which could be investigated with
apparatus no more complicated than an ordinary watch, and the action and useful-
ness of which were in doubt, yet no such investigation stands recorded, the nearest
approach to it being the observation that 'the pains were stronger and more frequent.'"
The inertia of a self-governing profession thus constitutes the second obstacle to the
proper development of experimental pharmacology in medical schools.
In the absence of a modern development within the schools, the teaching of the
subject is generally restricted to pharmacy, prescription-wnting, and the old-fashioned
materia medica, of which Huxley said as far back as 1870, "I must confess that, if I
had my way, I should abolish it altogether." The equipment consists of not much more
than a collection of drugs, a blackboard, and some simple pharmaceutical utensils.
As late as 1906, the quartei's at Oxford were described^ as "little better than a shed."
The lecturers only assistant was a boy who swept out the rooms. All the mechanical
work was done by the lecturer. A great part of the apparatus belonged to him, and
there was no convenient place to lodge it in safety where his lectures were given. In
most schools the instruction is assigned to physicians not otherwise engaged. At Guy's,
an assistant physician lectures; the demonstrative classes are held by a teacher who
also does duty in two other departments, — physiology and forensic medicine; at the
London, there are two lecturers, a physician and his assistant physician, the latter
conducting the demonstration and quiz classes; at Charing Cross, an assistant phy-
sician gives all instruction in materia medica, pharmacology, and therapeutics; at the
Middlesex, the same function falls to the physician to the out-patient department;
at Sheffield, where I was informed that "small schools cannot afford pharmacology,"
one of the physicians to the Royal Infirmary is also medical officer to its skin depart-
ment, and professor of all three branches under discussion. A different attitude on
the part of the profession is not likely to be produced by teaching of the character
described. Some way must be devised to break the vicious circle which tends to keep
British therapeutics from closer intercourse with physiology and chemistry. ^Vhat
that way is will become clear when we come to consider clinical teaching in Great
Britain.
Pathologv
In certain important respects the historical situation of British pathology has been
excellent. The medical school grew up within the hospital, whose dead-house neces-
sarily became its pathological department. School and hospital were so interwoven
as to be indistinguishable; compactness of arrangement facilitated communication
between the wards, the post-mortem room, and the museum, to all which the student
enjoyed unhampered access. Furthermore, an excellent tradition had been widely
established in reference to autopsy. Guv's at London, like the Allgcmcines Kranken-
haus of Vienna, practically assumed that every case ending fatally would be autop-
1 In the British Medical Journal. June 23, lOOfi.
MEDICAL SCIENCES: GREAT BRITAIN AND FRANCE 129
sied, and the death-roll now numbers some 700 cases annually. At the London Hos-
pital, 1288 post-mortems were made in 1909 ; 600 take place yearly at St. Bartholo-
mew's; 500 at the Middlesex; 350 at St. George's; 250 at St. Mary's; 200 apiece
at Charing Cross and Westminster. In general, between 80 and 95 per cent of the cases
ending fatally in London are autopsied. In Scotland and the provinces, sentiment in
reference to the post-mortem is less favorable. Consent must first be obtained. At
the Royal Infirmary, Manchester, the annual average now borders on 200 ; at Liver-
pool, 150 autopsies — about 50 per cent of the deaths — were made last year; at New-
castle, over 300; at Glasgow, about 250; at the Royal Infirmary, Edinburgh, 470, —
55 per cent of the deaths, — from which, however, as we shall shortly see, the Univer-
sity derived little benefit. As the medical schools are, with the exception of Edin-
burgh and Glasgow, all small, post-mortem material is relatively more abundant
than is usually the case on the Continent. It is, moreover, supplemented by material
from the wards and operating-rooms, for the clinical laboratory is in England usually
a part of the pathological department, or the department of bacteriology closely
associated with it.
In this generally admirable situation a rift appears in the light of recent scientific
developments and requirements. The hospital pathologists were originally junior
physicians or surgeons, whose work in the post-mortem room went no further than
morphological or histological examination. From time to time, brilliant observers like
Bright, Addison, and Hodgkin utilized to the full their opportunities in this direc-
tion by making complete studies in which the phenomena that as physicians they
observed at the bedside were con-elated with the pathological conditions that they
laid bare on the autopsy table. Three notable achievements of this character stand
to the credit of these three men; other similar perfoi-mances might be cited. Unfortu-
nately, glory thus obtained was dangerous ; it was apt to result in more practice rather
than in more science. What happened to Matthew Baillie at the close of the eighteenth
century has from time to time been repeated in the careers of Todd, Bowman, and
others since. British pathology lacking definite differentiation has therefore been
marked by the maintenance of a close relation with medicine and surgery, and by
discontinuous meteoric performance in which the dead-house and the bedside both
figure.
Like anatomy and physiology, modem pathology now requires to be constituted as
an independent department carried on for its own sake. It is hardly necessary to repeat
that such independence does not involve isolation. On the contrary, pathology, like
physiology, gains in instrumental significance with every advance made in its own
internal development. To this internal development, however, certain elements in the
English situation now interpose serious obstacles. English hospitals are maintained by
subscription. Praise can hardly exaggerate the devotion with which men and women
laboriously procure year by year the huge sums required for their maintenance. Nor
is their duty done when the^ funds are raised; for the hospitals are managed by their
130 MEDICAL EDUCATION
patrons, who emulate one another in making them home-like and attractive. Food,
nursing, and appointments are therefore all excellent; probably nowhere else in the
world is the level of hospital comfort so uniformly high as in Great Britain. "WTiat has
this to do with pathology.? Unfortunately, a great deal. The pathological department
— even in the school hospitals — is largely supported by the hospitals; its conduct
must therefore take scrupulous account of British prejudice.* England happens to
be a country where laws governing scientific progress are written, more or less, by
those who do not believe in it. Money is even accepted for research on conditions made
bv ignorant or prejudiced donoi*s that particular methods of investigating will not be
resorted to. Nothing can be countenanced by the hospital that is likely to alienate
subscriptions; and just at this moment a considerable proportion of the British pub-
lic are more sensitive about the lives of dogs and guinea pigs than about the lives of
men, women, and children. At a time when the pathologist advances beyond morpho-
logical and histological work by means of animal experimentation, the pathological
department must for the most part forego animal experimentation, and ^nth it all
chances of active development along something more fruitful than morphological lines.
In consequence, pathology now occupies in England a somewhat confused posi-
tion. On its merits it ought to follow physiology in obtaining its own institute, but
unlike physiology, it dare not leave the hospital from which it derives inspiration and
procures material. Under these circumstances, a medical school must either make a
sacrifice or employ a makeshift. Most of the London schools choose the former alter-
native. They relinquish all endeavor to participate in the modern experimental move-
ment. Their pathological department is a dead-house, in which young physicians and
surgeons perform autopsies. Where the amount of material is unmanageably large,
specialists are appointed to devote their entire time to morphological and histologi-
cal work without animal experimentation. The pathologist to the hospital is on this
basis usually one of the teachers of pathology in the medical school, and frequently
head of the clinical laboratory. His diagnostic aid and post-mortem work keep medi-
cine and surgery in close contact with his department — a thoroughly wholesome
1 In consequence of the charge that funds subscribed to the hospital were being diverted to medical
education, a commission of inquiry was appointed in 1905 by King Edward's Hospital Fund for London.
It is clear from the testimony that the outcry originated only in a desire to hamper vivisection still
further. The testimony having conclusively established the advantage to the hospital of attachment
to a medical school, an anti-viviscctionist witness was asked whether there was any objection to
"legitimate expenditure by a hospital upon services rendered by the school in the way of bacteriologi-
cal and other inquiry." The witness replied in the negative, "provided that those services do not in-
clude practices repugnant toa large numberof very good people,[andlalways provided that itisaservice
actually for the relief of an actual patient, not an experiment ; and provided that it does not involve
vivisection, because I do not think that hospital funds ought ever to be used in the pursuit of a prac-
tice which a large number of people — the most humane people in the Kingdom — regard with abhor-
rence." Report of Committee, pp. 118, 119 (London, 190.5). The entire report is worth reading for the
light it unintentionally throws on the undeveloped condition of some members of the intelligent portion
of the British public in respect to scientific matters. Sir Cooper Perry, superintendent of Guy's, was
asked by a member of the commission (page 36): "Would you say that, even if a hospital had no med-
ical school attached to it, in order to be efficient it would be bound to have some sort of pathological
laboratory, if f>ossible, attached to it?" Educational reform suffers seriously from the existence of such
innocence in high places.
MEDICAL SCIENCES: GREAT BRITAIN AND FRANCE 131
relation. At Guy's, a separate endowment supports on an academic basis the school
lecturer in pathology, as a result of which he may carry on animal experimentation
in his school laboratory, while the morbid anatomists in the dead-house do not. In
the provincial and Scottish universities, a makeshift arrangement more in harmony
with modern tendencies is working out. These institutions have completely taken
over the underlying scientific branches; but clinical teaching still remains a perqui-
site of the hospital staff, in whose appointment the universities have as yet little
voice. Pathology, facing both ways, occupies an ambiguous position. As laboratory
science, it belongs to the university; as clinical adjunct, it must remain in the hos-
pital. Between the two it hovers dubiously. The hospitals educationally linked to
the universities have come to recognize the importance of placing a specialist — not
a physician or surgeon, resident or otherwise — in charge of the pathological depart-
ment; as they themselves are rarely in position to afford the expense, a working
arrangement has been made according to which the university appoints and pays
a professor of pathology, who becomes ex-officio pathologist to the hospital in
which the clinical teaching of the university is done. A single individual thereupon
administers a bifurcated department: he has his experimental laboratory at the uni-
versity; he does his autopsies at the hospital. This arrangement is in force at j\Ian-
chester^ and Sheffield. At Liverpool, a similar plan is followed, but, as it appears,
on a somewhat informal basis, for the hospital has not yet surrendered to the uni-
versity priority in appointment; nevertheless, the governors made the present uni-
versity professor pathologist to the hospital, and as the two institutions are close
neighbors on an increasingly intimate footing, there is no likelihood that a com-
bination reciprocally beneficial will be disturbed. The other hospitals in which the
University of Liverpool also recognizes clinical teaching have, however, their own
pathologists — practitioners, I believe, in all instances. Much the most satisfactory
solution has been reached at Glasgow, where the entire pathological department
of the university, uniting dead-house and experimental laboratories, is situated on
the Western Infirmary lot; the building is a recent structure, admirably adapted to
the needs of teaching, research, and hospital routine. The incumbent of the chair is
named by a joint committee, of which four members are designated by the univei-sity
and three by the governors of the infirmary. Perhaps the least satisfactory disposi-
tion to be found anywhere exists at Edinburgh, where the pathologist to the hos-
pital and the professor of pathology are two different individuals, having no relations
whatsoever with each other.
Despite the fact, then, that Virchow designates John Hunter as the father of
experimental pathology,^ pathological experimentation does not yet flourish in Eng-
land, except in the department of physiology. The compensatory development noted
1 The present incumbent is also consultinf? or honorary pathologist to certain special hospitals also
used in the clinical teaching, each of which, however, has its own active pathologist.
2 Lexis : Die Deutschen Universitaten, vol. ii, p. 258 (Berlin, 1893).
132 MEDICAL EDUCATION
in Germany, where pathological physiology is cultivated in institutes of physiology,
pharmacology, bacteriology, and in the clinic, has not yet attained any considera-
ble proportions in Great Britain. It is found at Liverpool in the department of bio-
chemistry; at Manchester, in the university laboratory of pathology; at University
College, London, and at Guy"'s, in research departments detached from the hospital
dead-house; at Glasgow alone, as far as I observed, is an entire pathological depart-
ment located on hospital grounds.^
Lender these conditions, we are prepared to find that differentiation and organiza-
tion have not proceeded far. The pathologist has not, as yet, everywhere established
himself as specialist. The lecturer on pathology^ in the school is not alwavs the
pathologist to the hospital ; the differentiated subordinate staff is almost unknown.
At Charing Cross and Westminster, the lecturers on pathology are visiting physicians;
two assistant physicians are pathologists to the hospital. At University, Middlesex,
and the Royal Free, an assistant physician is lecturer in pathology; at the fii"st two,
the curator of the niuseum is pathologist to the hospital. The lecturer on pathology
at the London is bacteriologist to the hospital; the pathologist to the hospital has
as his assistants several physicians and assistant physicians. The subordinates in the
department are mostly doing simultaneous duty elsewhere, — heavy routine duty at
that. At Guy's, where the lecturer is a specialist, assistant physicians or surgeons not
really belonging to the department of pathology fill the subordinate posts; at St. Bar-
tholomew"'s, the teacher in charge of chemical pathology was out-patient physician,
and physician in charge of diseases of children; the morbid anatomists are medical or
surgical registrars, and one of them, chief assistant in orthopaedic surgery, besides. At
St. Mary's, the pathological chemist carries an amazing bui'den; he is out-patient
physician, medical tutor, and lecturer on medical jurisprudence, toxicology, hygiene,
and public health! At Charing Cross, the demonstrators are assistant physicians. At
the London, general and surgical pathology and pathological histology fall to the
lecturer in bacteriology; morbid anatomy and special pathology to the head of the
pathological institute, but the two parts are apparently in no definite relation to each
other. Even in the provinces, where the head appears always to be a professional
pathologist, departmental integration is imperfectly achieved : the curator at Sheffield
is a physician, the demonstrator a surgeon; the assistant lecturer at Liverpool is
physician to one of the hospitals recognized by the university as part of its clinical
school. Instead of a compact central department from which lines of communica-
tion radiate to every division of the hospital, absence of a comprehensive, clean-
cut conception and organization tends to splinter the subject into disjointed frag-
ments. The junior staff members are less closely related to the departmental head in
1 Since my visit to Glasgow, it is ref)orted that an exactly similar arrangement has been made (1!>11)
with the Glasgow Royal Infirmary, where a second university professor of pathology is ex-officio
pathologist to the hospital and director of the pathological institute there.
- The lecturer, as he is called in the London hospital schools, is equivalent to the professor in the
colleges and universities.
MEDICAL SCIENCES: GREAT BRITAIN AND FRANCE 133
pathology than to the other departments to which they are simultaneously attached,
and to which they are really looking for promotion and a career. Temporarily, they
are assigned to the pathological aspect of medicine or surgery, as the case may be,
but they are not members of the pathological team.
Nor under these circumstances does even the autopsy form the nucleus of a defi-
nitely integrated department. Indeed, no uniform practice as to the making of post-
mortems prevails. Here, it falls to the hospital pathologist, who is simultaneously
curator of the museum;^ there, to recently graduated medical and surgical registrars;
again, to assistant physicians,^ — conditions that do not even favor morbid anatomy
of a generally high grade. Unmistakable is the divorce of morbid anatomy from experi-
mental pathology in the few places where the latter is prosecuted. The lecturer in
pathology at the University Hospital School bears the additional title of research
director, but he is not pathologist to the University College Hospital ; the research
that he directs occupies quarters in the school building across the street. The lecturer
at Guy's is an experimenter : three assistant physicians are morbid anatomists at the
hospital ; the professor at Manchester is also of an investigative turn, with a labora-
tory at the university ; the autopsies are performed in the dead-house of the Royal
Infirmary by a pathological registrar. In its integi-ated department, presided over
by a professor with two full-time assistants, Glasgow alone possesses an institute in
which autopsies, teaching, and research go on harmoniously, under the direction of
the chief.^ It is the onlv complete organization of the kind that I saw in Great Britain.
Research has, however, also other difficulties to surmount. Funds are extremely
scarce. A recent endowment will still further stimulate investigation at Guy's. Else-
where, lack of resources is seriously restrictive, even where facilities and ideals exist.
The research director at University College will inevitably, unless his research post
is better supported, be forced out of research into practice ; his co-workei-s are Beit
scholars or cancer workers belonging to Fulham Hospital. A single investigator was
noted at St. Bartholomew's; five workers were engaged in research at Glasgow, all
supported by outside grants; should these grants be withdrawn, their work would
cease. At Middlesex, a special endowment maintains cancer research. In general, how-
ever, it is fair to say that pathological research in Great Britain is precarious and
personal. The conditions do not make for it. A keen man who can snatch an hour
here and there may, if persistent, turn out a piece of work ; a student, too, if he has
resources of his own, or obtains — and retains — a scholarship or grant. But the teacher
has o-ot to contend against diverse employments and a deadly teaching routine ; the
student ao-ainst insecurity of support, lack of facilities, and weakness of ideals. Under
no such conditions will the severed members of British pathology be reunited and
inspired with the breath of life.
1 As, for example, at University College Hospital.
2 As, for example, at Guy's.
3 The same may now be said of the second pathological institute. See note 1, preceding page.
134 MEDICAL EDUCATION
The provision for pathology consists essentially of the post-mortem room, with
adjoining space for microscopical work, and a museum. At St, Bartholomew's, a
pathological building has recently been erected, in which four Hoors are devoted re-
spectively to clinical pathology, morbid histology, and bacteriology, chemical patho-
loo-y and the library, and autopsy work. In the handsome school building erected by
Sir Donald Currie for University College, London, attractive and somewhat exten-
sive provision is made for investigation in physiological pathology. The modern
establishment at Glasgow already mentioned has been further supplemented with a
separate attractive and convenient laboratory for clinical pathology under a director
appointed by the univei*sity. With these and perhaps a few other exceptions, the
pathological department of the hospital is practically a dead-house. Everywhere,
however, the abundant material has been conscientiously and skilfully utilized in the
formation of a museum. The impetus toward the upbuilding of collections came from
John Hunter, whose valuable collection forms the nucleus of the superb museum of
the Roval College of Surgeons in Lincoln's Inn Fields. Guy's has assembled some
8000 specimens, beautifully mounted and carefully catalogued ; St. Bartholomew's has
some 7000; Middlesex, 5000, among them some of the handiwork of Sir Charles Bell ;
St. Thomas's has 3000, among others, the specimens used by Sir Astley Cooper in his
work on dislocation, fractures, and hernia; St. Mary's has 3000; Charing Cross, 2800;
and King's College Hospital, 1900. These collections play a great — unfortunately
not in all respects a wholesome — role in the pathological instruction.
The character and content of the teaching are determined by the considerations
so far brought forward. Pathology is regarded as an incident to medical and surgi-
cal practice, — a way of elucidating certain structural factors that physicians and sur-
geons must regard. Though denominated a separate subject, it is in England largely
taught by men to whom it has not even provisionally a separate existence. Except
at Oxford and Cambridge, it does not constitute a subject for examination, figur-
ing only incidentally in the medical and surgical examinations conducted by physi-
cians and surgeons, — an excellent thing in so far as the subject is brought to bear
on clinical problems, and the curriculum is held together, rather than dispersed into
non-intei-acting separate units ; but damaging in England because at no period in
its studv, as in no moment of its cultivation, does a freer breath blow upon it.
Pathology being for the most part dead-house and museum pathology, rather than
a physiological study of pathological process, its teaching is mainly concerned with
explaining the dead signs of something that has taken place. Lecture and demon-
stration courses dealing with general and special pathology and histology are every-
where given. But the brunt of the teaching falls on the museum and revision teachers.
The collections are arranged along uniform lines; typical sets of specimens illustrate
medical, surgical, and gynecological pathology; they are classified in separate divi-
sions, labeled, and descriptively catalogued. The student purchases a catalogue and
verifies its description by repeated inspection of each set. His tutor laboriously drills
MEDICAL SCIENCES: GREAT BRITAIN AND FRANCE 135
him in this purely imitative observation, until he acquires a high degree of mechani-
cal expertness in recognizing ordinary lesions in a pickled or preserved condition.
How much he is thereby assisted in dealing with fresh material is a question, the
value of the instruction depending very largely upon just that. For sound training in
abnormal anatomy aims at the interpretation of fresh material. The proper use of a
museum is incidental and supplementary : it is a reservoir from which additional or
analogous specimens may be drawn by way of exhibiting conditions similar to, or
likely to be confused with, the particular lesions disclosed by autopsy.^ The juxta-
position of fresh and preserved specimen lends emphasis or compels comparison,
distinction, interpretation. The museum specimen alone, as thing-in-itself, is at
once fragmentary and misleading. It may be made a means of communicating a cer-
tain amount of information; but how far are the student's active powers stimulated
and directed by the English usage? Consider for one moment: A collection has been
made that covers the ground. A student who "knows" it will be familiar with the spe-
cimens submitted to him at the examination. It is none the less mechanical and rou-
tine teaching because it deals with objects. Objects as such no more connote thought
than do words as such. Objects have an advantage over words only because they are
usually associated with practical difficulties that coerce thinking. But information
procured by merely verifying on objects the contents of a card index stimulate the
thinking-process little more than definitions learned from an illustrated text-book.
In such circumstances, the museum is only a text-book to be learned. The energy
that goes into this museum teaching is assuredly to no slight extent misapplied.
Much the most valuable part of the student's training he gets through the post-
mortem clerkship. For periods varying from one to three months, he is privileged
to spend half the day in the dead-house, where he witnesses the autopsies, writes
up the protocol, examines specimens, and generally assists in the work. Systematic
autopsy records are everywhere kept, closely articulated with the clinical records of
the hospital. The student thus handles fresh material under conditions that point
many a medical and surgical moral. This most valuable experience he still further in-
creases when, as clinical clerk or surgical di'esser,^ he follows to autopsy such of his
cases as have terminated fatally.
Of the rest of the teaching, there is little to be said. Medical pathology, surgical
pathology, etc., are laboriously inculcated with the aid of museum specimens, and fresh
material is demonstrated weekly or oftener. Between service in the out-patient depart-
ment, in the clinical laboratory, at the autopsy table, in the museum, and their tutorial
classes, the junior teachers are fairly exhausted day after day. Meanwhile, the stu-
dents pursue all alike the same course. Even at Manchester or Liverpool, pathology
holds out no inducement like physiology to pause long enough to do something aside
1 Rare conditions, not regularly encountered in the dead-house, may have to be presented in the form
of preserved specimens. But this is a distinctly unsatisfactory, even though unavoidable, substitute.
2 See chapter viii. ^
136 MEDICAL EDUCATION
from the beaten path. Pathology is not a B.Sc. subject. Little more opportunity is
usually offered than all are practically required to take.
None the less, I am far from wishing to convey a merely unfavorable impression
of the facts and possibilities of English pathology. The materials lie close at hand for
an easy reconstruction. Where clinic and post-mortem are together easily accessible
to both instructor and student, where collections exist and physiological science is
highly developed, a few bold strokes would at once transform a more or less unsatis-
factory into a highly satisfactory situation.
I have so far left Edinburgh out of account : there, conditions are so much worse
than anywhere else that it requires a paragraph to itself. The medical faculty of the
university teaches medicine and surgery in the wards of the Royal Infirmary ; but
with the pathological department of the Royal Infirmary the university has no con-
nection. The professor of pathology in the university is a visiting physician to the
infirmary; the pathologist of the infirmary is teacher of pathology in the Extra-Mural
School. The pathological department of the university cannot even call its patho-
logical collection its own : for it is housed in the anatomical museum, to which the
pathologist does not even carry a key! In the catalogue account of the courses in
pathology at the University of Edinburgh, the words "autopsy" and "post-mortem"
do not once occur.^ University students are forced to resort to the extra-mural teachers
for their post-mortem work. But the abundant material of the infirmary so fully occu-
pies its inadequate staff with routine that they have absolutely no time for research;
the teaching is altogether of stereotyped character. Post-mortems are largely the work
of the house pathologists. Of the disadvantages of local competition in medical edu-
cation measured by scientific standards there could hardly be a more striking instance.
The only really active laboratory in Edinburgh is the independent research labora-
tory of Professor Ritchie, not a part of either school. This institution subsists on
the income derived from routine analyses done for the profession, and on subsidies
devoted to research in neuro-pathology and parasitology; it lacks clinical connec-
tions. Obviously, a modern pathological institute will not exist in Edinburgh until
these three disconnected fragments are welded together in the university.
Somewhat singularly, the most prosperous of British Medical Schools in recent years
has been the school at Cambridge. The Cambridge and Oxford schools give only half
the course, viz., the basic and the medical sciences, — physics, chemistry, biology, ana-
tomy, physiology, pharmacology, and introductory pathology, students proceeding to
London for the rest; but both universities possess complete facilities, not only lab-
oratory, but clinical. At Oxford, RadclifFe Infirmary with 180 beds is closely affiliated
with the university; at Cambridge, Addenbrooke's Hospital with 150 beds. This is
highly interesting as embodying the only terms on which a partial school can be satis-
factorily conducted. The preliminary sciences, — physics, chemistry, and biology, —
if the view previously expressed is correct, belong properly to the studenfs general
1 Catalogue, 1910-1911, pp. 498, 499.
MEDICAL SCIENCES: GREAT BRITAIN AND FRANCE 137
education. Anatomy and physiology may perhaps be taught without clinical associa-
tion, though probably not even then without a certain loss; but pathology is entirely
impossible away from the dead-house of a hospital. Fresh material is required from
the first; and fresh material is not otheruase procurable. The plan of instruction
followed at Cambridge is capable and worthy of imitation : experience has indicated
that a knowledge of pathological and bacteriological principles is of great use to stu-
dents if acquired previous to clinical work in the wards. From the hospital at hand
they procure the requisite material, and at the same time are introduced to elementarv
methods of physical diagnosis. Pathology binds together the two parts of the medical
cuiTiculum, — hence neither part can exist without it, or without the sources whence
its fresh supplies are drawn. This dual relationship is further recognized in the Cam-
bridge examinations, as we shall hereafter see:^ a separate examination in general
pathology must be passed before the clinical years, while medical and surgical patho-
logy constitute parts of the final examinations in medicine and surgery respectively.
Conditions in France leave much to be desired. Pathology and the hospital we have
found to be inseparable. But in France, the organization of the medical school rules
out the requisite interlacing. The hospitals are not organic parts of the medical school.
At Paris, in each of a dozen institutions, managed by the Assistance Publique, wards
are assigned to certain professors in the medical faculty. At Lyons and Lille, the same
arrangement exists on a smaller scale. The autopsy work in each hospital falls to
internes who have no relation to the professor of pathology, who gives his lectures at
the distant l^cole de Medecine. The threads thus fall apart. Instead of a pathological
institute belonging to the university, there are hospital dead-houses, scattered through
the city and disconnected from the university and from each other; in these dead-
houses, the hospital internes enjoy unrivaled opportunities to study morbid anatomy,
— opportunities of which the best of them take full advantage. Meanwhile, the univer-
sity chairs of pathological anatomy, experimental and comparative pathology, gen-
eral pathology and therapeutics, surgical and medical pathology, are all occupied by
men in active practice, who simply lecture at the school. To each professor is attached
a helper, who arranges his lecture demonstrations with preserved material, and a labo-
ratory chief, with assistant and helper, who has charge of the research laboratory
assigned to the chair. The instraction is mainly by demonstrative lectures, though
brief practical courses are offered from time to time. For example, a practical course in
histoloo-ical technique is offered by an agrege and preparateur, open to physicians and
matriculated students, for 50 francs per trimester; similarly, a three months' course in
pathological histology, " the number of places limited;" a third consists of ten exer-
cises in histo-bacteriology, costing 60 francs. Under these conditions, undergraduates
will not laro-elv participate, nor are the material facilities at all adequate to general
participation. The defects of these arrangements have long been deplored as anachro-
nisms survivino- from a time when pathology had not yet attained its majority. As far
1 See chapter xi. >.
138 MEDICAL EDUCATION
back as 1880, a committee, one of whose members was Charcot, worked out a scheme
for an Institute of Pathological Anatomy ; it was designed to be the clearing-house to
which the hospitals should contribute their material, and in which medical students
should be trained in pathological anatomy, histology, and chemistry. With the ap-
proval of the faculty, the project was formally submitted to the ministry by the dean,
but, as Prevost mournfully remarks, "the institute of pathological anatomy remains
in the stage of project."^
Bacteuiology, Hygiene, and Legal Medicine
The remaining topics do not require extensive comment. The position of bacteri-
ology is not easily defined on account of its intimate yet various association with
pathology and the clinical laboratory. At St. Bartholomew's, St. Mary's, St. Thomas's,
Westminster, and at Sheffield, the subject is closely attached to pathology; at Guy's,
University, Middlesex, and Charing Cross, rather with the clinical laboiatory. At
London Hospital, it approaches more nearly the status of independence, though the
departmental head is school lecturer in general pathology, also ; the variations are,
however, of no great importance because, with rare exceptions, the departments de-
vote themselves to school and hospital routine. Their scope is narrow; the subject is
not viewed as the nucleus of a hygienic institute, but rather as a diagnostic resource.
The staff* is small; the burden of clinical examinations for the hospital, and occasion-
ally, as at Middlesex, for the outside profession besides, onerous; and the teaching,
though limited to brief courses, incessant. Funds applicable to research are scarce.
Most favorably situated is the Lister Institute, with an endowment of £250,000, the
income from which fund is supplemented by fees received for services rendered to
municipal and state health authorities and by the profits derived from the manufacture
of sera. Its surplus of time and money is devoted to research; four or five workers are
also maintained by special grants. Neither hospitals nor medical schools are, however,
financially strong enough to patronize research, or to protect the time of the labora-
tory chief. Grants and scholarships in small number must be mainly relied on. The
equipment, as a rule, is adequate to its purposes: at the London Hospital, more than
adequate; at Charing Cross, rather less. At King's College, which boasts the first
English laboratorv devoted to bacteriology, and at Cambridge, the provision is
especially satisfactory; in both places there is an eye to research.
Instruction proceeds by means of lectures and parallel practical exercises, in the
course of which the student cultivates the commoner organisms in media and examines
films and sections. The teacher is grievously hampered by the prejudices of hospital
subscribers and by the anti-vivisection laws. The statutes require that both persons
engaging in, and places used for, animal experimentation must be licensed. As hospital
governors are usually hostile or unsympathetic, neither experimental nor demonstra-
1 "L'institut anatomo-pathologique est demeur^ k I'^tat de projet." Provost : La Faculty de Nidecine
de Paru, p. 54 (Paris, 1900).
MEDICAL SCIENCES: GREAT BRITAIN AND FRANCE 139
tive work can be performed on hospital premises, though a rabbit inoculated elsewhere
may be procured and subsequently exhibited. How much teaching a particular student
gets depends altogether on the body before which he expects to qualify : the average
London student attends a three months' course, sometimes in conjunction with clini-
cal microscopy; Cambi'idge and Oxford men get three months more.
I have repeatedly pointed out the inestimable advantage of closely interlacing
medical school and hospital. \\Tiere, however, funds are short and ideals undeveloped,
this intimacy is apt to lead to highly undesirable makeshifts. Time and energy which
perchance escape from hospital routine are at once pounced upon by school routine :
the young surgeon is drafted by the departments of anatomy and pathology; the
young physician by the school physiologist; the bacteriologist by the clinical labo-
ratory or the Department of Public Health. What with hospital and school routine
and the differing demands of the examinations, it is small wonder that English
medical schools are as a whole unproductive.
To this generalization, two exceptions at once suggest themselves, both tending
to confirm the point previously made, viz., that the development of a scientific branch
depends in the first instance on the momentum contributed at a favorable juncture
by an individual with ideas. Two such contributions have recently been made in Eng-
land, and both have proved decidedly stimulating, — Sir Patrick Manson's in the realm
of parasitology, Sir Almroth Wright's in the direction of therapeutic inoculation.
Lectureships in Tropical Medicine have been widely established in British medical
schools. Sir Patrick ]Manson himself lectured at St. George's, Charing Cross, the Royal
Free, as well as the London School of Tropical Medicine. The last named, located
at the docks, adjoining a branch hospital of the Seamen's Hospital Society, with fifty
beds, is occupied in training men for tropical residence and service as well as with
tropical research. Bacteriology and animal parasitology are systematically taught;
the hospital furnishes material, clinical experience, and autopsies. The Liverpool
School, affiliated with the University, discharges the same functions, and in addition
has made a feature of expeditions to tropical countries. Its laboratories and an ex-
cellent museum are admirably placed beside the university laboratories of bacteri-
ology, hygiene, pathology, and bio-chemistry, and it controls a ward of twelve beds
in the Royal Southern Hospital, close to the docks ; research is supported by special
gifts, its own funds, and governmental subsidy. The school has sent out more than
twenty expeditions for the study of malaria, trypanosomiasis, yellow fever, etc., as
well as to caiTV out prophylactic measures in the colonies. It publishes two important
series of memoirs and annals.
At Liverpool, Manchester, and Edinburgh, bacteriology forms, as in Gennany, the
nucleus of a hygienic institute. The Manchester institute, the most extensive of the
three, supports itself by working for municipalities, practitioners, etc. In 1908-1909,
5477 examinations were made in the laboratory for diphtheria, 202-1 for typhoid,
2417 for human tuberculosis, 787 for bovine tuberculosis. Its income from work of
UO MEDICAL EDUCATION
this nature, something like £3000, goes to keep up the institute and to promote in-
vestigation in the Hue of municipal and house sanitation. Elsewhere in British medical
schools the stimulating association of bacteriology and hygiene in a single institute
has not yet taken place. The medical schools furnish instruction in public health, con-
tributed by a visiting lecturer and consisting of discourses on such topics as housing,
sewerage, water-supply, epidemics, vital statistics, etc. Candidates for the special
Public Health Diploma, required of sanitary officials, must take additional courses
in chemistry and bacteriology; but these future guardians of public health cannot,
during their training, inoculate a rat or a guinea pig without encountering the
penalties of the anti-vivisection laws!
In France, the practical teaching of bacteriology appears to be left by the univer-
sities to the Pasteur Institutes, where such exist in university towns, as is the case at
Paris and Lille. At the latter, Calmette, director of the Pasteur Institute, also occu-
pies a professorship in the university; in consequence, the university instruction in
hygiene and bacteriology is transferred to the Pasteur Institute, where the facilities
are thoroughly admirable: fourth-year students receive there excellent practical in-
struction amidst an active scientific environment. At Paris, no official connection be-
tween the Pasteur Institute and the university has been brought about. The university
provides instruction in parasitology; latterly, too, an Institute of Colonial Medicine
has been established along the lines of the English Tropical School : in the university,
laboratories of pathology, parasitology, and hvgiene, and in the hospital of Auteuil,
appropriate courses are given to graduates and final-year students in bacteriology,
hematology, tropical pathology, epidemiology, etc. But the active centre of bacte-
riological teaching and research at Paris is the Pasteur Institute, not the university:
spacious class-rooms are there provided, with individual equipment, animal-houses,
distinguished investigators, and a stimulating atmosphere. A large class — mostly
mature workers — annually attend the winter courses given by Roux, MetchnikofF,
Besredka, Laveran, and others in cooperation, Lyons alone is now developing within
the university a modern department of hygiene, though it is not yet in position to
command the entire time of the professor. On the other hand, parasitology is in
France a separate department; in some universities, Paris, for example, extremely
active, though with meagre support. While mainly concerned with research, the
department offers a brief practical undergraduate course which is compulsory.
Institutes for legal medicine in something like the Austrian sense exist only at
Edinburgh and Paris. At Edinburgh, the chair is incorporated in two faculties, law
and medicine. Tlie present incumbent, like his predecessor, holds the office of police
surgeon to the municipality, a connection which insures the university a steady stream
of material for the purposes of instruction and investigation. As police surgeon he
sees — and as professor exhibits to his students — cases of assault, alcoholic excess, drug
habit, incipient insanity, violent death, etc. The course, required of all students, does
not aim to make medico-legal experts; but it enables physicians to discharge cred-
MEDICAL SCIENCES: GREAT BRITAIN AND FRANCE 141
itably their public duties as medical men in relation to the law of the land. It is held
to be important that they should be able to deal intelligently with problems which
may face any medical man. They must, for example, "know how to observe the es-
sential details in case of death from violence, to investigate a case of alleged rape, to
determine the presence of blood on clothing, to give an opinion as to whether a newly
bom infant has lived, to perform post-mortem examinations."^ The lecture room,
the museum, and the public mortuary afford the requisite facilities for such instruc-
tion.
In the absence elsewhere in Great Britain of a working connection between the
university and the police authorities, legal medicine amounts usually to little more
than a perfunctory lecture course of didactic nature by a teacher with or without par-
ticular interest in the topic. At Liverpool, the course falls to a clinician ; at Glasgow,
it is merged into Public Health ; in London, one encounters a highly picturesque va-
riety, due to the economic necessity of devoting to a new routine scraps of time saved
from previous occupation of the same quality; at the London, the instruction in legal
medicine is shared by two men, one otherwise attached to teaching and outside work
in Public Health, the other, a physician, lecturer in clinical medicine and visiting
pathologist ; at Guy's, of the two instructors, one is also pharmacologist and assist-
ant physiologist, the other assistant physician and morbid anatomist; staff physicians
teach legal medicine at University College and St. Bartholomew's, out-patient physi-
cians at St. Thomas's and Middlesex, the pathologist at St. George's ; at St. Maiy's,
the subject falls to the obliging instructor, who gathers up the remnants of pathology
and hygiene while carrying on tutorial classes in medicine and doing duty in the
out-patient department!
In Paris, the chair of legal medicine, created in 1823, has, since 1877, been attached
to the somewhat remote morgue, where the prefect of police, by aiTangement with
the faculty, has provided facilities for instruction. The material is enormous in quan-
tity and variety, — 1422 dead bodies were carried thither in 1911. The topic for the
day's lecture is determined altogether by the contents of the mortuary : now a case
of infanticide, again a case of poisoning or inj ury, will furnish the text. A laboratory
of toxicology, situated at the prefecture of police, also belongs to the department.*
At Lyons, an excellent establishment of the same character has been recently erected
in close proximity to the other laboratories of the university.
Conclusion
Discussion of the organization of medical education in Great Bi-itain and France
cannot be complete until we have examined the clinical conditions. But the reader will
already have remarked the unevenness of the laboratory development as compared
1 Private letter from Professor Harvey Littlejohn.
2 The details of the arrangements between the medical faculty and the morgue are given by Prevost,
pp. 37-39. ^
142 MEDICAL EDUCATION
with Geniianv. Now, in Germany, it is found that relative homogeneity of ideals
and facilities is entirely consistent with great disparity of scientific eminence and
pedagogical skill: though the student will hardly have to endure radical defects any-
where, he is not only free, but encouraged, to seek larger or more congenial oppor-
tunity bv moving at intervals from place to place. In France and Great Britain, on
the other hand, where a modern medical school can be conceptually created only by
piecing together features from several schools, the student permanently suffei-s the
deficiencies of the institution to which he commits himself at the outset. Assuredly
it is business, not education, when the English medical school appeals to the loyalty
of the student, skilfully played upon by social and athletic inducements, rather than
stimulates him to seek his own advantage and the advantage of medical science by
attaching exclusive value to scientific opportunity and achievement.^ ^Vhatever the
reason, an English boy begins his medical course at Manchester, let us say, where
the preliminary sciences and anatomy are thoroughly satisfactoiy ; ^vhy should he
not emigrate to University College for physiology and pharmacology, — the latter
accessible almost nowhere else.? Such an adventure never enters his head, ^^'hat hap-
pens, then, is this: a good part of his instruction is provided for in every school by
makeshifts of a decidedly depressing sort. He gets excellent instruction in this branch
or that; in half a dozen others, he is taught by men whose heart and hopes lie else-
where. Student and instructor are alike wrecked. The teaching is second-hand, prob-
ably shop-worn, lacking conviction and range. The student is habituated to "re-
quirements." What incentive has he to reach out, when his incidental and accidental
teachers cannot and do not.'* Good teaching is infectious; but to communicate infec-
tion, the teacher must himself first be stung. Circulation of students in search of op-
portunity would put upon the British medical schools a pressure that they could not
resist: for they must either meet scientific competition or collapse. As long, however,
as school lovaltv is a cohesive force powerful enough to maintain intact an enrolment
once procured, medical schools, appealing to immature youths, may compete by means
of club-rooms and athletic fields more effectually than with laboratories, and less
expensively.
This is, of course, only to say that in order fully to become educational, the med-
ical school must first wholly cease to be commercial. Personal pecuniary and profes-
sional interest keeps alive eleven medical schools in London, and struggling, poorly
attended schools in each of the provincial universities. And within the London med-
ical schools, the move to concentrate scientific instruction is resisted in part by the
teachers whom consolidation will dispossess of laboratory headship. That medical
education in the metropolis can be modernized by the halfway measures which leave
clinical instruction as and where it is, while bringing together the laboratory branches
in three centres as has been proposed, I do not for one moment Ixjlieve. Concentra-
* Oxford and Cambridge are exceptions, for they frankly recommend in respect to clinical instruction
the superior facilities to be enjoyed elsewhere.
MEDICAL SCIENCES: GREAT BRITAIN AND FRANCE 143
tion would undoubtedly improve matters by pooling fees for the maintenance of fewer
laboratories, thereby sustaining several fairly complete staffs instead of nine fractional
organizations. But it is a mistake to suppose that in any case modern laboratories
of anatomy, physiology, or pharmacology can be supported out of student fees. The
concentrated medical institutes relying upon them would still be routine affairs, with
overworked chiefs and assistants drafted for short periods fi'om out-patient clinics.
Moreover, if, to play fair, the central institutes were equally remote from all the
teaching hospitals, the scheme would involve sacrificing the integrity of the medical
school as an organic whole. Anatomy and pharmacology are doubtless worth culti-
vating in isolation rather than not at all; but a solution conditioned upon their iso-
lation denies to them the stimulus of the clinic, and deprives the clinic of immediate
interaction with the influences from which its reorganization and regeneration must
eventually proceed. Centralized teaching laboratories of the medical sciences would
resemble a bridge minus its farther approach: a structure ending in mid-air, instead
of a pathway over which the student would be inducted into the hospital wards, —
a broad avenue by means of which laboratory scientists and scientific physicians might
secure unimpeded communication with one another. It would have been fortunate had
the concentration plan failed on account of attempting too little. As a matter of fact,
the project failed, not because it was not sufficiently comprehensive or because it was
conceptually defective, but because it appeared likely in the end to assist certain clin-
ical schools rather than others, and because in some instances it involved reduction
of rank, perhaps even cashiering. The hope of English medicine lies at this moment
in the laboratories ; and, in general, the laboratory men have sound ideals. But even
they will fail to modernize English medicine unless in destroying the commercial,
they also sink the personal, point of view.
In France, two serious obstacles exist, — the preponderance of clinical teaching and
the preponderance of Paris. Let us devote a word to each.
The overwhelmingly clinical character of French medical teachers goes far to sup-
press the laboratory branches in any active sense. In practically all theoretic branches
outside of Paris, and in most of them in Paris, chairs are held by prominent practi-
tioners who are also teachers of clinical medicine; an eminent pediatrist is at Paris
professor of pharmacology; a famous neurologist is professor of pathology; the chair
of history of medicine has just been filled with a pathological anatomist. Specialists
cannot be developed as long as the agrege system maintains its present form. The
agrege is appointed for nine years, at the termination of which period he drops out,
unless, perchance, he receives a professorship. He dare not, as a rule, risk his future
by devoting himself wholly to physiology or pathology; he must build up a practice
against the day when he is automatically dropped from his academic post. This inci-
dental treatment of the medical sciences is paralleled by the treatment which they
receive in the student's time-card. At no period of the student's career has a labora-
tory a first lien on his attention. Even in his first year, dissection is placed in the
1^4 MEDICAL EDUCATION
afternoon, in order that he may be free to follow the clinics in the morning, if he will.
These conditions do not make for research; and where active research has not estab-
lished the inherent worth of a given branch, teaching recognizes it only in step-
motherly fashion. "The student need not worry about methods; he need only learn
results," remarked a Paris professor. The teaching of physiology, pharmacology,
and other underlying sciences is mainly expository; between the laboratories and the
clinics there is little stimulating intercourse. To all intents and purposes, the French
schools are thus still clinical schools.
The domination of Paris is perhaps to no small extent responsible for the persist-
ence of this point of view. Where Berlin and Vienna find themselves hard driven to
provide practical laboratory training for their students, Paris may well confess itself
overwhelmed. If modern medical education be interpreted as involving practical labo-
ratory training in a liberal spirit organically related to clinical training of the same
type, the problem of Paris is perhaps soluble only through decentralization, — a solu-
tion for which an instrument is at hand in the provincial universities. Their small
size gives them a great advantage over Paris, for they are not too clumsy to introduce
reforms, — provided, of course, the consent of the government can be obtained. In
the provincial schools the "block" system, on which the laboratory branches engage
the student's entire time and attention for two years at least, is at once feasible
without complete aloofness from the clinical side. An experiment along these lines
would require that the earlier teaching be confided to specialists. Revision of clinical
instruction would in course of time result, for more fundamental scientific training
forces ultimately a corresponding readjustment in clinical instruction. That, we shall
now see, has taken place in Germany, where clinical education promptly adopted the
ideals and availed itself of the resources that the laboratories had worked out; and
that in all probability will take place in Great Britain and France when once Eng-
lish and French laboratories gain their appropriate recognition and development.
CHAPTER VII
CLINICAL INSTRUCTION: GERMANY
The profession of teaching, like the profession of law or the profession of engineer-
ing, is in general supposed to be important and exacting enough to occupy fully a
man's time, energy, and capacity; otherwise, teaching would not be a profession at
all. The present chapter regards clinical teaching from this point of view. It assumes
that in a soundly organized university the medical faculty is in the position of any
other faculty, — that of arts, of philosophy, or of science; that within the medical
faculty thei-e is no distinction in kind between the professors of the fundamental or
theoretical branches — anatomy and pathology, for example — and the professors of
the clinical or practical branches — medicine, surgery, and obstetrics. The professor of
medicine or of surgery is indeed a physician; but from the standpoint of educational
ideals and activities, this is of secondary importance. He is first of all a university
professor; that title indicates his dominant and consuming interest.
If, now, the teacher of medicine is a teacher in precisely the same sense in which
the chemist or the mathematician is a teacher, then his workshop, the hospital, is
only another sort of laboratory. Set down the conditions which the chemist requires
in his laboratory in order to teach and to investigate : the same conditions, and only
the same conditions, will enable the clinical professor to produce corresponding re-
sults. I am speaking of course of essentials. It matters not whether the chemical labo-
ratory occupies a rented or an owned building ; whether it is of boards or of marble.
It matters profoundly, however, who selects the chemist and for what reasons, and
whether any outside authority, unsympathetic with his main purpose, sets limits to
his freedom, interferes in his choice of associates, or whether the chemist himself is
only incidentally engaged in teaching. It is, by the same token, immaterial where the
legal ownership of the university hospital be lodged, whether in the state, a munici-
pality, an association, or in the university; but it is highly important that, whatever
the nature of its legal relationship to the university, the professor of medicine should
be selected on the same basis as the professor of chemistry, that he should occupy
precisely the same attitude toward teaching as a profession, and that he should work
in the hospital under no other limitations than attach to the chemist in his laboratory.
Now, as in the Middle Ages, the German professor is essentially a wanderer. A stu-
dent here, an assistant there, a decent elsewhere, finally a professor somewhere else,
his commonwealth is an ideal one, his abode there, where his fellows are gathered
together. All German-speaking lands form in this respect a Zoll- Vetrin within which
academic free trade obtains. The German clinician is in this highly characteristic
sense thoroughly a teacher; he roves as rove his philological and philosophical col-
leagues. He is not nominally or incidentally, but actually, a professor. Long since he
took with open eyes the risks of the academic career; for many yeai-s he endured its
U6 MEDICAL EDUCATION
hardships. It is indeed difficult to find a professor of medicine, surgery, or any other
clinical branch who is deeply rooted in the soil in which he is now found. They have
as a class been called to their present posts from less important positions, in which
they have previously demonstrated their worth. ^ Recognition is the powerful and
uninterrupted stimulus which the Geniian system applies. The Gennan produces,
and continues to produce, because performance alone obtains results: without it, no
fortuitous advantage avails; with it, fortuitous advantage is superfluous. A charac-
teristic career will thus be associated with half a dozen universities, successively at-
tracting an able man by superior opportunities and inducements. Friedrich Midler,
after studying at Munich, Tubingen, and A\ urzburg, has taught at Wiirzburg, Ber-
lin, Bonn, Breslau, Marbui'g, Basel, and Munich, besides declining calls to Greifs-
wald, Berlin, and Vienna. Vacancies in the clinical faculty ai'e filled as vacancies in
other faculties ai'e filled — \vith men who add lustre to the university. The prizes seek
out the competent.^ The professor of surgery at Leipzig lives at Leipzig because
he is a professor of the university there; he is not a professor of the university
because, first of all, he happened to be practising his profession in Leipzig. The 3G00
physicians of Berlin, among them doubtless many very able men, lay as such no
claim to the high places in the medical faculty of the university there; of the present
holders of full professorships, every one was called from outside, — from Gottingen,
from Graz, from Heidelberg, from Greifswald, — posts which had themselves been
reached only after a long and arduous upward progress. Inbreeding is utterly un-
known.
This unhampered circulation of the professor has been a highly important factor
in the rapid and general renovation of clinical teaching in Germany. Uniformity of
law, which permits only a single type of school, is consistent with considerable diver-
sity in respect to plant, equipment, and endeavor. The "calP forces everywhere sub-
stantially the same level. A first assistant at Berlin is invited to fill a vacant chair at
Greifswald. The promotion is itself an important one; but already the rising scientist
looks further, — to Breslau, perhaps, to Heidelberg, or Munich. His career, however,
will stop short at Greifswald unless he there win distinction commensurate with the
previous performances that have carried him thus far. His acceptance is therefore
conditional upon improvements, extensions, and support, that will pro\nde him as
good facilities as he possesses in his inferior post. The medical clinic at Marburg — the
1 A single exception came to ray notice. Poppert, professor of surgery at Giessen, has passed his en-
tire career there: obtained his degree in 1886; assistant until 1894; decent, 18S9; extraordinary' pro-
fessor, 189-2 ; professor and director of clinic, 1900. A few others may be cited, but they are in any case
very rare.
* Politics and religion do, however, count. Hebrews and social democrats are not called to full pro-
fessorships ; in some states chances favor a Catholic, in others a Protestant. See Eulenburg : D^r nka-
cUmUrfu? Xachitwfu, p. 54. Faculty vacancies are filled in this wise : the faculty nominates three per-
sons to the ministry; the minister may appoint one of the three or go outside the list. He usually takes
the first nominee. While this method may lend itself to cliqueishnes^!, the appointments are generally
made on the basis of merit alone, subject to the political or religious bias above mentioned.
CLINICAL INSTRUCTION: GERMANY 147
first of a series of new clinics, begun twenty years ago and now just approaching com-
pletion— is at this moment vacant; rebuilding on thoroughly modern lines is the
condition on which alone it can be acceptably filled. A Wiirzburg professor has re-
cently been called to Gottingen; the Bavarian government retains his services at the
price of facilities at least equal to those which Prussia offered. A more thoroughly
wholesome competition cannot bedevised. Assuredly, it has been oneof the main agents
in bringing about the complete modernization of its hospitals which is one of the
most striking features of modern Germany. Remarkable industrial prosperity has had
to provide the means ; efiicient rulers have had to conceive and put through the pro-
jects. But the quick diffusion of sound ideas must, in the first instance, be ascribed
to the migratory character of the German medical teacher and hospital director.^
Nor do university hospitals form a class by themselves in this respect. Municipal in-
stitutions in both university and non-university towns participate in scientific com-
petition. In equipment and organization, they follow the lines of the university clinics.
Their clinical directors are salaried officials, not infrequently called from other towns
or from universities; continuous service, excellent laboratories, and abundant material
enable them to win in a city hospital such scientific distinction as often leads directly
from municipal service to high university posts: Von Noorden, first assistant in the
medical clinic at the University of Berlin, was called to Frankfort to be physician-in-
chief to the municipal hospital; his achievements there in the pathology and therapy
of metabolism resulted in 1906 in a call to the chair of medicine in Vienna. His, now
head of one of the medical clinics at Berlin, was chief physician to the city hospital
of Dresden, before becoming in 1902 professor in the University of Basel ; Koenig was
lately summoned fi'om the municipal hospital of Altona to the chair of surgery at
Greifswald ; Minkowski went from a similar medical position at Koln to the same uni-
versity, a few years later accepting his present post at Breslau. Brauer, on the other
hand, has just retired from the professorship of medicine at Marburg to become
director of the medical division of the city hospital of Hamburg.
From the explicitly professorial character of the German clinical teacher all else fol-
lows. He is a state official, hedged about with the dignity of high office. Inferiors and
subordinates treat him with conspicuous deference. He is "Herr Professor" outside as
well as inside the university, not "Herr Doctor." His devotion to science and teaching
has thus far, as a rule, sustained the professorial role. In general he has spent as many
hours in his hospital as the scientist in his laboratory; he has taught as hard and
produced as much. Daily lectures at eight o'clock or earlier are not uncommon, after
1 One offset ought perhaps to be mentioned. Sometimes a professor is called so quickly from one post
to another that he leaves before making himself felt. Thus a certain instability now and then results.
For example, at Greifswald, since 1900, four professors have in rapid succession filled the chair of
internal medicine: Krehl, 1900, called to Heidelberg, 190^; ]\Ioritz, 1902; Minkowski, 1905, called to
Breslau, 1909; Steyrer, 1909. Practically the same is true of surgery: since 1899, the chair has been
occupied by Bier, called to Berlin ; Friedrich, called to Marburg ; Payr, called to Konigsberg, and now
by Koenig ; after a year at Konigsberg, Payr has been called to Leipzig. But this occasional insta-
bility weighs little against the enormous advantages of the custom.
148 MEDICAL EDUCATION
which ward rounds are made and laboratory conferences held. One o'clock may find
the clinician or surgeon still at work in his clinic; not infrequently he returns in the
afternoon. The best type of German clinician thus applies himself without stint to
the care of his patients, to teaching, and to research. His pride is to be known as
teiicher; his fame as teacher satisfies his ambition and fills his purse — as far as it is
ever filled at all. A ])rominent professor disclosed to me the sources of his income:
S300 as hospital physician, paid by the citv; §2000 as professor, paid by the state;
SoOOO in student fees. He also does some consultation practice in the afternoon.
There is, however, a growing suspicion that the idealism of the clinical professor is
yielding to the temptation, perhaps the need, of increased income. Assistants are
scarcer than formerly when the deprivations attendant on the scientific career were
less deteiTent than they now appear to be. The scale of living has been altered by in-
dustrial prosperity ; new ideals, material in character, are creeping in. Socially speak-
ing, professorial station and a large income make together a formidable combination.
The physiologist or the mathematician has no temptation to resist. His income as
teacher cannot be amplified, except through success as an investigator. The material
motive, if existent at all, drives him back to his students and his laboratory. Not so
the clinician. Having once attained distinguished position, an extensive and lucrative
practice can be built up on the basis of scientific achievement in the past. The in-
come from this source and the social position that goes with it tend to withdraw him
from personal activity in the wards and laboratory, and from close personal contact
with his students. In the laboratory he supervises; to the students he lectures. In
these circumstances, the assistants do the detailed ward w-ork, conduct research, and
give the students whatever individual training they get. Instances of such demorali-
zation are still exceptional; in the main, the clinical professor is loyal to the academic
tradition. It is worth asking, however, whether, especially in great cities, the tendency
to exploit university clinical positions may not require to be checked by concentrat-
ing the professor's activities in his clinic, exactly as the physicist's are concentrated
in his laboratory; what with examining, teaching, administering, and looking after
the wards, his burden would still be heavy enough. The proposition is not a new one;
Ludwig is reported to have broached it years ago. Hardly feasible then, because the
hospitals possessed in the abject poor too limited a clientele, the arrangement could
now be operated without seriously abridging the experience of the clinician. Hospitals
are so freely utilized, even in Germany, that a university professor in a large city can
there procure whatever material he requires, and can there perhaps to best advantage
discharge his full duty to science, education, and humanity. The alternative, that
two chairs be constituted, one devoted to research, the other a willing sacrifice to
practice and routine, may be dismissed as inconsistent with the fundamental concep-
tion which gives to the German university its unique significance and power.
Fundamentally characteristic of the German professor is his freedom to teach what,
and as, he pleases. Obviously, as the clinical teacher is thoroughly a teacher, his free-
CLINICAL INSTRUCTION: GERMANY 149
dom in teaching implies that he is the complete master of his clinic on both medical
and educational sides. So he is. The technical relationship of hospital to university
is indeed decidedly various. But no matter what the legal form, general practitioners
and hospital managers stand upon the same platform with the university authorities.
All alike reverence science; all are alike zealous to maintain the conditions essential
to medical progress. The freedom of the professor in his wards is therefore never
imperiled or impaired. He makes such use of his chnical material as his judgment
approves; he chooses his own staff; he spends his appropriation on such work as he
himself prefers to carry on. The practising profession, so far from seeking to divide
or to abridge his power, would strongly resent any effort in either direction, — a con-
dition of affairs that is possible only where local considerations have been eliminated
by the selection of a teaching faculty on the basis of scientific eminence alone.
The simplest form of university and hospital relationship exists in Prussia,^ where
both belong to the state.^The hospitals are therefore university hospitals, maintained
by the state primarily for the purpose of serving the medical faculty of the univer-
sity. If, for instance, the medical faculty were discontinued, the state would discon-
tinue the hospital, leaving the municipality to deal with the situation as it is dealt
with in towns where the state does not support a university. Even in Prussia, how-
ever, variation exists : for while the Chai'ite, the main clinical reliance of the L'niver-
sity of Berlin, itself stands in a unique relationship to the two departments of war
and education,^ side by side with it exist certain clinics and policlinics which are out-
and-out university institutions. Elsewhere in Germany the relationship of the uni-
versity to its clinical facilities is highly diverse and involved, though, as we shall see,
the conditions essential to effective teaching and research are never infringed upon.
Not only are non-university hospitals used by the universities, but at times different
portions of the hospital, taken as a whole, belong to different organizations. Intelli-
gence and good will enable the several parts to function as one; a single pathological
institution serves for all. At Leipzig, for instance, the medical and surgical clinics of
the university employ by contract the corresponding wards of a municipal hospital;
but the medical and surgical policlinics belong to the university. The women's clinic
and the psychiatric clinic belong to the university outright, the pediatric clinic to
1 The same is true of the single Wiirttemberg university at Tiibingen.
2 It is important to bear in mind that on the Continent all universities are state institutions. In the Ger-
man Empire the universities belong, however, not to the empire, but to the several constituent states,
Prussia, Saxony, Bavaria, Hesse, Baden, etc. Where the state — for example, Prussia — maintains
both the university and the hospital, the latter is practically a university hospital; but if, while the
state maintains the university, a city or an endowment supports the hospital, some form of contract
is employed to define the relations between them.
3 Originally, the Charite was designed for the special training of military surgeons, though in conse-
quence of its subsequent connection with the university, its students are now mainly cixnlians. The
military still retains an advantage, since all the house appointments are reserved for them and one of
the two administrators is a military surgeon. A complete account of the growth of the Charite. its
teaching development and administration, is to be found in ChariU'-Annalen, vol. xxxiv; a briefer
account in Medizinische Anstalten auf dem Gehiete dsr Volksgesundheitspflege in Preussen, pp. 318-373
(Jena, 1907).
150 MEDICAL EDUCATION
an association; the eye clinic rests on an endowment administered by the university.
Munich is almost as diverse as Leipzig: the city has turned over to the university
certain wards in the municipal hospital for the teaching of internal medicine and
surgery; the psvchiatric and the women's clinics belong to the university; the chil-
dren's clinic belongs to an association aided by the state; all the policlinics are com-
bined in the new and handsome Reisingerianum, which began with an endowment
but has now been taken over by the state. Yet, educationally, these diverse units pull
together and phvsically form one plant compactly placed, with the scientific institutes
adjoining. At Wurzburg, an extremely delicate situation has been handled for acentury
without sacrifice of educational principle. The hospital and the university were founded
by Bishop Julius Echter of Mespelbrunn in the sixteenth century. They remained
tocrether under clerical control until the university was secularized in Napoleon's time.
Since then, the cleavage in Bavarian politics and society has taken place on religious
lines; but the universities have been the stronghold of the anti-clerical liberals. The
two parties do not like each other. But general incompatibility has led to no viola-
tion of essential educational conditions as between the clerical hospital and a medical
faculty anti-clerical in its views. The necessity for more space and more modern equip-
ment, however, has led the state to erect separate university clinics for gynecology and
obstetrics, and psychiatry; but medicine, surgery, and dermatology are still taught
in the Juliusspital. The university designates its professors in these branches, who
become in virtue of that appointment heads of the respective clinics. The staff salaried
by the university has unconditioned control of the wards; the endowment meets all
ordinary hospital expenses. As the hospital, while still capable of serving a philan-
thropic purpose, has long been educationally inadequate, the state purposes shortly
to build its own clinics for medicine and surgery. But cooperation would probably
have continued indefinitely had the ancient cloister lent itself to modern needs.
The German Empire may furnish us one more example of a complicated hospital
relationship smoothly serving university needs. The medical faculty of the Univer-
sity of Elsass-Lothringen at Strassburg was, on its reorganization following the
Franco-Prussian \Var, domiciled in the mediaeval Bvirgerspital, a richly endowed
institution administered by the municipality.^ In consequence of rebuilding, made
necessary by the antiquated character of the old hospital, a highly involved situation
has come about : a superb new children's clinic has been built by the endowment,
but is conducted by the universitv; other new clinics and the policlinics have been
built by the university on ground belonging in part to the hospital; finally, in the
endowed hospital itself certain clinics have been unreservedly turned over to the uni-
versity, the others being conducted by the municipality. Wherever the university
is interested, it has both medically and educationally independent and complete
power. Nevertheless, in everything that pertains to the executive and business man-
agement, all the clinics melt into one, just as, geographically, they and the labora-
* The Verwaltungsrat is chosen by the Gemeinderat.
CLINICAL INSTRUCTION: GERMANY 151
tories are one. In this technically intricate situation the simplest rules suffice to avoid
friction and to promote effectual cooperation. They run as follows: "The service falls
into two definitely separate divisions: 1. The university clinics; 2. The non-university
clinics. The university clinics are conducted by the professors^ of the faculty of medi-
cine; the physicians to the non-university divisions are selected by the administrative
board. In the university clinics the university authorities select the assistants; the
administrative board selects the assistants in the non-university divisions."^
Conditions in ^'ienna are strikingly similar to those in Strassburg. The great All-
gemeines Krankenhaus is supported by a consolidated endowment fund administered
and supplemented by the state.^ Like the Bvirgerspital of Strassburg, it contains
both university and non-university divisions: of the seven medical services, three are
assigned to the university; the other four are retained by the hospital administra-
tors. The local profession not only gladly permits the university to enjoy its allotted
divisions, filling the posts in them in its own way, but makes no objection when
imported university professors are simultaneously made tlie heads of non-university
divisions. Vienna practitioners, in other words, make no effort to capture what might
be regarded as their remainder. Thus, the university professors of dermatology and
psychiatry occupy assigned services in virtue of their professorships; but the hospital
administration has turned over to them also non-university wards. As they are equally
supreme in both, they can, of course, use both for teaching. The main difference lies
here: in the university wards, the professor designates his own assistants and gets a
subvention from the state for laboratories; in the non-university wards, the assistants
are designated by the administration and the head gets a smaller appropriation from
the administration for laboratory work. Moreover, there is so general a disposition
to increase the teaching facilities of the university that in appointing physicians and
surgeons for non-university divisions, the authorities usually select university docents
or extraordinary professors, who thereupon at once offer instiniction which the uni-
versity of course recognizes. Thus, practically the entire hospital is the scene of uni-
versity teaching, though of strict right the facilities of the university are limited to
a few specified services.
One more Austrian example will suffice to show how a hospital situation far from
simple in form is made to answer academic ends. Let us take Graz, where the uni-
versity is a state, the hospital a provincial, institution. The province of Styria lets
its provincial hospital at Graz to the Austrian state for the clinical teaching of the
1 This title means always full professor, the so-called Ordinarius. It happens both here and at Vienna
that not infrequently the non-university divisions are headed by physicians who hold subordinate
university posts, for example, Extraor dinar itis (associate professor) or Docent. Such appointments
are made by the administration and do not in any sense belong to the university; but the appointee
is free to give clinical instruction in the wards. Thus a university instructor holding simultaneously
a non-university hospital appointment gives by means of it recognized university courses.
2 Satzungen fur das Biirgerspital, vol. ii, pp. 15, 17, 18 (Strassburg, 1904).
3 A recent proposition to turn the administration of the fund over to the provincial authorities has
been successfully resisted by the university.
152 MEDICAL EDUCATION
university medical faculty. In this hospital, the services are once more divided into
university and non-university divisions. In internal medicine, twenty beds form the
university, eighty beds the non-university, division. The university designates the
chief of the university division, bringing him in from wherever it pleases. One would
expect the province to appoint a chief of the non-university division from the local
medical profession. Not so. Without the least objection from the local profession,
the province regularly confers the non-university division upon the professor selected
by the state for the university division. The entire service of one hundred beds is
therefore available for university teaching and research. As at Vienna, and even more
commonly than at Vienna, the Graz professor, as the appointee of both state and
province, finds himself between two masters, both of whom let him entirely alone.
Indubitably, the Prussian system is the simplest. Other things being equal, both
parties prefer it. But its superiority is not so pronounced as to constitute any seri-
ous objection to cooperation between the state and other agencies. The financial
burden involved in the Prussian plan is resented by the educational department,
which has different — purely educational — uses for all available funds. On the other
hand, hospital support is fairly to be reckoned a municipal responsibility, as much
so as repairing the streets. To let each city bear the burden resulting from unavoid-
able wear and tear, human and other, seems at once the most economical and the
most equitable way of meeting such obligations. So far, there is therefore no sound
reason why the Prussian state should assist in caring for the sick poor of Breslau
and not the sick poor of Cassel. Does the use of a hospital for teaching purposes
import into the situation complications enough to invalidate this position? Certainly
not. In the conglomerate hospitals of Munich and Leipzig, either party might indeed
make the arrangement intolerable; neither party has ever done so. Trifling irrita-
tion does indeed occasionally arise : the municipality is inclined to stint appropriations
for laboratory work, for a more varied diet, for more abundant supplies, for building
alterations. The university makes subventions designed to cover precisely these items;
for where teaching and research go on, laboratories are more expensive, diet more
elaborate, bandages more freely consumed, and building additions more often required.
The question arises as to just where teaching and research begin to raise normal cost.
The university pays, of course; but the municipal administrator thinks it pays too
little, the minister of education thinks it pays too much. As a matter of fact, both
parties gain : the city obtains for the hospital superior medical care without much ex-
pense; the state obtains chnical facilities for the university very cheaply. Occasionally,
friction has arisen on questions of dignity: the German professor bears himself in a
lordly fashion ; the city official may at times regret the power he has parted with, as,
for example, at Munich, where the city pays the salaries of certain assistants, while
the university professor chooses them. At Leipzig, it is recalled that a professor once
arranged to take four assistants with him on a four days' scientific excursion. The local
magistracy objected on the ground that the working capacity of the hospital would
CLINICAL INSTRUCTION: GERMANY 153
be impaired. By way of compromise, three assistants went for three days. Friction at
least as serious might arise in a hospital owned and controlled by the university. The
relations between the department of pathology and the medical or surgical clinic, even
if both were university departments, might any day be equally strained. We are too
apt to impute blame to external conditions when human nature itself is really respon-
sible. Friction arises indeed; but it arises anyway. No human relation involving two
or more persons is wholly immune. Where the university professor teaches in a muni-
cipal hospital, he encounters an occasional lack of intelligence in city officials; where
he teaches in a state hospital, he encounters a similar lack in somebody else; not im-
possibly some one might even encounter it in him. In neither case is the situation
inherently unworkable. The slight adjustments made necessary by the complicated
relationships here set forth are a small price to pay for the advantages both parties
enjoy. It is simply a question of good sense. On the whole, all these various arrange-
ments work in Germany because all parties show good sense; and where in other coun-
tries similar arrangements are held to be inoperable, it is for lack of good sense. I am
not exaggerating the sound judgment that the Germans show in this whole matter.
Nowhere has there ever been manifested the slightest danger of interference with the
conditions necessary to effective teaching and research, namely, with the appointment
of professors by the university and with the professor*'s organization and management
of his clinic; nor have professors accepted calls just to get out of a municipal clinic
into an out-and-out university clinic. Miiller refuses to abandon Munich for Berlin,
though he would thus exchange a city for a state hospital; Striimpell leaves Breslau —
a university hospital — to go to Vienna, where his clinic was only an assigned divi-
sion in an institution supported by endowment managed by the state, and a year
later accepts a call to Leipzig, where he will be domiciled in a municipal hospital :
in three successive posts, in three hospitals of different character, he experiences, as
far as his professorial privileges and functions go, no essential alteration of environ-
ment.
The truth is, that the diversity above described is superficial only. Below the sur-
face, all these hospitals are identical in principle. Administrative responsibility and
medical responsibility are absolutely sundered. What difference can it make whether
the hospital belongs to the state, or to the municipality, or to an association, if in
all alike a sharp line is drawn between executive and professional function? If the
university (state) hospital confused these two essentially distinct functions, the uni-
versity professor would find his lot intolerable ; on the other hand, the moment the
line is drawn in a hospital merely affiliated with the university, it becomes readily
and effectually available for educational purposes.
Functional organization is thus the secret of German success in this matter. The
German hospital has no medical superintendent. It chances that at Vienna the ad-
ministrator is a physician ; but his business is purely administrative, none the less.
His medical training may eucible him the better to understand certain problems, but
154 MEDICAL EDUCATION
he scrupulously avoids presuming upon it to interfere with the medical or surgical
management of the wards,^ At the Charite (Berlin), the "medical director"^ appears
to be found, but the title is a misnomer. There, as elsewhere, medical and adminis-
trative sides are totally distinct, and neither party would have it otherwise. So con-
sistently is this division held to, that a suit for malpractice would lie against the
physician in charge personally; the hospital as such could not be involved. Two co-
ordinate administrators keep house. They look after buildings, kitchen, repairs; they
engage the help and distribute the nurses. Control is exercised through a number of
inspectors, who, without any very specific instructions, are expected to see to it that
the housekeeping is "ship-shape." Daily they meet in the offices of the "Direktion"
to report on the physical state of the vast institution.
Similarly supreme in all that concerns medical and laboratory conduct is the chief
of the clinic. He is absolute master in so far as concerns the selection of assistants, the
admission of volunteers and students, the management of the laboratory, the carry-
ing out of treatment. He receives, for example, a laboratory appropriation : he spends
it as he pleases. Neither side — administrative or medical — reports to the other; both
are subordinate to the central authority. As every possible duty belongs to either one
or the other, nothing drops between them. Each is happily free of the other's busi-
ness. This principle holds universally. The clerical administrators at Wurzburg, the
provincial administrators at Graz, hamper the clinical professor who is a guest in their
wards as little as the civil administrator at Breslau hampers the professor who enters
the hospital of legal right. The main difference lies here : the professor who works in
a university hospital gets his whole budget from a single source; the professor who
utilizes a municipal clinic derives his budget from two sources, pooling both sums
when once he obtains them. But negotiation Mith two contributing parties is somewhat
tedious. Is a desired piece of apparatus properly a charge upon the town or upon the
university? If upon both, in what proportions? Are both able at the moment to pay
their respective shares? If not, shall the impecuniosity of the one wholly excuse or
more heavily burden the other? Is expenditure on a proposed piece of work chargeable
to education or to hospital routine? One must not close one's eves to such perplexities.
Nor, on the other hand, must they be allowed to loom too large; for the professor who
has to deal with only one party also encounters delay and compromise in consequence
of the ministerial obligation to reconcile conflicting claims upon resources that can in
no event be adequate to satisfy all.
The exact form which hospital administration takes is therefore relatively unim-
portant. When professors attend to their duties, and when the distinction between ex-
ecutive and medical control is observed, administration may take what form it will
without detriment to educational interest. Huge hospitals like the Charite at Berlin,
the Allgemeines Krankenhaus at Vienna, the Blirgerspital at Strassburg, possess a
^ The same thing happens at Guy's (London), see page 199.
2 Der aerztliche Direktor.
CLINICAL INSTRUCTION: GERMANY 155
highly centrahzed administration : one or two officials wield supreme executive con-
trol. The much smaller clinics at Marburg are, administratively considered, separate
entities. The professor is there nominally the administrator, the executive duties being
turned over by him to a business representative. At Greifswald, some clinics are con-
ducted on the Marburg plan; in other cases, two or more clinics are combined under
one administrator. Breslau has one kitchen for the entire institution, except psychia-
try, Marburg a separate kitchen for each clinic. It all comes to the same thing in the
end. Discuss as we will the respective advantages of one form of administration over
another in reference to economy or simplicity, the conclusion is educationally of no
material consequence, if a fundamentally sound differentiation has left educational
and scientific management where, from the start, it properly belongs.
Successful operation of the arrangement described is conditioned simply on atten-
tion to duty. The hospital administrator, whatever he be called, is forced and habit-
uated to intervene if hospital physicians are irregular or otherwise neglectful in
attendance; nurses assume enlarged responsibilities where the resident staff is com-
posed of inexperienced transients. We shall see this again in England, where the same
theory as to management prevails as in Germany. The executive end is at times
over-heavily burdened because some members of the unpaid visiting staff sacrifice
hospital duties to practice engagements; unquestionably, too, English nursing, far
superior to anything to be found on the Continent, is tempted to transcend its
proper sphere because of the absence of a seasoned resident medical staff, analo-
gous to the German assistants. The payment of the German hospital physician, —
university or other, — the existence of the stable, salaried staff, render the theory
on which duties are differentiated as between executives and physicians a readily
workable one.
With complete medical control within the wards goes control over the admission
of material. Having decided that universities properly supported by the state and
possessing traditions and ideals deserve opportunities to teach and to investigate, the
authorities go one step further: they give them the pick of the material in order
that nothing valuable may be lost to them. At Strassburg, for example, there are two
medical divisions, one a university, one a non-university, service; the same is true of
surgery. The admitting office is in charge of two physicians; but in order that edu-
cation may get the preference, these admitting officers are designated by the univer-
sity, and have the right to send into the teaching wards all the interesting and valua-
ble cases.^ At Vienna, an equally intelligent policy prevails. Two receiving officers are
on duty day and night : one represents the university divisions, the other the non-
university divisions. The university representative has first choice. If he rejects the
case, the non-university representative must accept it if there is space.
Finally, one more concession, already touched on: the wards given to the university
1 The sole possible exception is in case of a patient sent to the hospital by a physician outside with
an express request that he be turned over to a particular service.
156 MEDICAL EDUCATION
become the teaching home of the full professor, or ord'marius. Meanwhile, the uni-
versity appoints associate professors {cxtraurdinarii) and docents with leave to teach,
though facilities do not, as a rule, go with the appointments. They offer such lectures
and courses as they please, fixing and retaining the fees. In clinical subjects these in-
structoi-s can do little unless they get access to material. They procure it in various
wavs; at times by becoming assistants to the full professor and using his material
by courtesy, — an easy matter when a professor has a clinic of several hundred beds and
a policlinic besides; occasionally, they start private clinics and policlinics. But very
frecjuentlv, the ea'traordinarius or the docent is appointed by the city to be chief
of a non-university division; and though the city designates and pays his assistants,
it makes no objection to his using the material for teaching. Hence the non-univer-
sity wards of the great public or endowed hospitals of Vienna and Strassburg are
virtually parts of the educational resources of the university.^
In respect to location, the clinics used by a medical school, while possessing their
own special laboratories, belong in close proximity to the general laboratories. This
point has already been developed in our discussion of the laboratory branches. The
medical school is a single plant, characterized by the mutual suggestiveness and help-
fulness of its various parts. The orderly progress of medicine is in the first place con-
ditioned upon the formulation of problems, originating indifferently on the clinical
or the laboratory side. A problem may spring from a case, a group of cases, a theo-
retical observation of chemical or biological character, from the suspected therapeutic
efficacy of some agent contrived in the laboratories, or in any one of a dozen other
wavs. Knowledge of a clinical condition is complete only when it embraces functional,
chemical, physical, and morphological sides. Thoroughly to understand the pheno-
mena of disease, then, transit to and fro between the bedside and the fundamental
laboratories must be unobstructed. Distance is hardly less formidable an obstruc-
tion than absence of interest or of sympathy. For it not only stops the give-and-
take, but it forbids that casual intercourse between men working at different points,
but with common ultimate objects, which is so effective a stimulus. A word, a hazarded
guess, may in just such informal intercourse prove the seed dropped on receptive soil.
The immediate proximity of the rest of the university is a matter of less importance.
For the unity of the whole is ideal, rather than practical. Ideals unite the department
of medicine with those of letters and science, once the department of medicine is
itself an organic whole.
The German universities have not thus far deviated from sound principle in this
matter, except as mere size of plant and number of students have tended to make
intercommunication difficult. Otherwise, hospitals and laboratories form a compact
geographical whole. The kernel of the clinical end of the university at Berlin is the
^ At Graz, only one division is at present not headed by a university teacher. It happens, too, at the
moment that the director of the Hospital is a university docent; his predecessor was not. He is, of
course, as director, responsible to the province of Styria. His university docentship is an entirely in-
dependent affair.
CLINICAL INSTRUCTIOx\: GERMANY 157
Charite ; the laboratories of anatomy, physiology, pharmacology, and chemistry are in
the immediate vicinity, — as close as the exigencies of university building in the heart
of a great city permit. The more recently added subsidiary clinics are unfortunately
somewhat removed, — a disadvantage that is greatly deplored. At Vienna, the AUge-
meines Krankenhaus forms the core; the laboratories are all within a few minutes'
walk. That of experimental pathology and sero-therapy is hardly more than five
minutes' distance: yet already it suffers from detachment. Workers there miss the
stimulus of the sick-bed to which experimental pathologists more fortunately situated
have easy recourse, — Hering at Prague, and Sir Almroth Wright at St. Mary's (Lon-
don), for example. The very minuteness to which our intense specialization tends re-
quires indeed to be combated by geographical integration of the school plant. How-
ever profitable it may be to carry on pure researches in experimental pathology or
pharmacology, the clinic is needed, ever and anon, to bring results to bear. The inter-
action between pure science and practical application, whether casual or intentional,
produces a situation in which problems spring up readily and sane standards of
value prevail.
In the smaller universities there is less danger on this score. Space is more easily
procured; and departments are both fewer and less extensive. The reconstruction of
the antiquated plants of these schools has, as a rule, proceeded with the express de-
sign of bringing everything together finally on a new site. For instance, the rebuilding
of the medical clinics and laboratories of Giessen began in 1889, and has gone ahead
since as the little state of Hessen has been able to contrive the means. The clinics
have now all been rebuilt ; of the laboratories, pathology and hygiene have been pro-
vided, anatomy is close by, pharmacology is under way; only physiology remains to
be transferred.
An exception threatens. The hospital at Graz and the laboratory institutes have
been heretofore in easy reach of one another. But a site some twenty minutes distant
has recently been acquired, on which it is proposed to construct a modem hospital. The
laboratory men view the step with dismay. In the past it has happened that two men
— a pharmacologist and a clinician — have together attacked a problem. L'nless the
laboratories — unfortunately themselves too good to throw away — are removed, such
scientific connection will be snapped.
The natural home of a medical school is obviously a large city; there abundant
and varied clinical material exists at hand; thither rare and obscure cases mav be
easily transported. The German universities, however, grew up in days when the
teaching of medicine consisted of theoretical exposition rather than actual confronta-
tion. It was as easy to expound Hippocrates in a village as in a metropolis. But things
have changed, and meanwhile the surviving universities remain, with one exception,^
where they were. To some extent, the rapid growth of towns has cured the difficulty.
1 The Ludwig Maximilians Universitat was transferred from Ingolstadt to Landshut, thence to Munich
in 1826. ^
158 MEDICAL EDUCATION
Between 1871 and 1905, Heidelberg increased in population from 19,983 to 49,527;
Bonn, from 26,030 to 81,996; Kiel, from 31,764 to 163,772; Freiburg, from 26,440 to
74,098. But towns like Greifswald (population 23,767 in 1905), Gottingen (34,081),
Marburg (20,136), Giessen (28,769), Tubingen (16,809), are obviously incapable of
furnishing sick people enough. The details of the mechanism by which this natural
defect has been remedied by a financial device that adds the resources of the province
to those of the town will be more fully explained when we come to deal with the
financial aspect of medical education.^ Suffice it here to say that the fame of the pro-
fessor, the forethought and liberality of the state, have been the important factors in
building up clinics aggregating 881 beds at Tubingen, 458 beds at Gottingen, 478 at
Greifswald, 664 at Marburg, — and this despite the proximity of the universities named
to each other and to large towns like Frankfort a. M. or Berlin; for Marburg is less
than twenty miles from Giessen, and Giessen just forty miles from Frankfort.
Greifswald may serve as typical of the small town university clinic. Its situation
appears highly unfavorable, for it lies in a thinly settled agricultural region. There
are no factories in or near the town; immigration has consistently avoided it. Stral-
sund, Stettin, and Berlin itself, all with excellent municipal hospitals, are in the
vicinity. The sick poor nevertheless go in sufficient numbers to Greifswald because,
in the first place, as we shall later see, it actually pays to do so, and because, in the
second, the fame of the professor is a powerful magnet. The peasant does not know
the details; he does not know that the Greifswald surgeon has just refused a call to
Tubingen, or that the chief of the medical clinic has just come from Berlin, where for
years he has been first assistant to Kraus; but the dullest rustic has long since grasped
the fact that the professor is chosen for his skill and learning. The size of the town
and the size of the university do not therefore affect the type of institution at all.
The clinics of Greifswald are in form, organization, content, and conduct essentially
the same as those of Leipzig and Berlin, even though internal differentiation may
not be carried quite so far.
The clinic is everywhere fed and supplemented by the policlinic — or out-patient
department — attached to it. The professor is in simultaneous charge of both; even
though in large towns the actual care of the policlinics is delegated to his assist-
ants, his beds are replenished from the ambulant cases, which are also utilized for his
lectures. In Berlin, Munich, and Leipzig, the amount of material available is thus
enormously increased. Surprising is the showing made by the smaller towns. At
Tubingen, the smallest of all, 7000 patients annually attend the medical policlinic;
some 3000 more are looked after at their homes bv assistants and students. An ex-
cellent relation has been established with the physicians of the neighborhood, who
frequently refer cases to the university professors.
It is clear, then, that no medical school in Germany exists without a sufficient —
' Chapter xii.
CLLMCAL INSTRUCTION: GERMANY 159
we should say, an abundant — supply of clinical material.^ Where the small towns
do not lack, the great cities will surely not suffer. Nor do they. Berlin possesses 1462
beds at the Charite, and 485 in supplementary university clinics, a total of 1947 beds
under absolutely complete control;^ Leipzig, — in point of material relatively the
richest of German clinics, — 2123;^ Munich and Vienna are both well provided.
The importance of mere abundance can hardly be overestimated. The undergrad-
uate student, of course, needs in the first place to study typical cases well. He does
not at this stage require numbers; but once he has learned types, variety of illus-
tration is necessary in order to drive home the lesson he has just learned, and to
differentiate the type he has just mastered from others more or less closely resem-
bling it. To the teacher, mass of material is even more important. For the clinical
teacher — being, according to our hypothesis, also a clinical investigator — occupies
himself with a specific problem. He needs all the material bearing on it that he can
get; and his chances of obtaining it are best where the absolute capacity of the hospital
is greatest. A hospital of 250 beds may indeed contain what is immediately necessary
^ Abundance is not only absolute, but relative ; that is, the amount of material is large relative to the
number of students. The following table gives the amount of material available in each of three impor-
tant clinics and the number of students attending at Breslau in each of several years :
Internal Medicine
Women's Clinic
Pediatrics
Tears Cases
Students
Cases
Stxidents
Cases Students
1901-1902 1805
70
1577
71
210
41
1902-1903 1716
68
1577
43
262
25
1903-1904 1708
61
1647
60
246
26
1904-1906 1801
42
1539
47
248
20
1906-1906 1696
38
1605
27
«65>
19
190&-1907 1760
46
1638
44
280
24
1907-1908 1688
46
1824
344
32
1908-1909 1523
44
1846
340
29
wing table I have coupled
1 the total number of beds and total
average £
ittendi
d winter semesters of 1905-1906 :
Place
Beds
StvAents
Berlin
1947
991
Bonn
1217
(640 in
Insane Asylum)
196
GSttingen
458
171
Halle
613
144
Kiel
582
236
Konigsberg
484
176
Tubingen
881
163
Giessen
608
148
Heidelberg
856
260
The number of patients who object to being used for teaching is not seriously large : out of 2750 medi-
cal cases at Tiibingen (1910), 2400 were usable. Professor Friedrich von Miiller, testifying before the
Royal Commission on University Education in London, estimates one-tenth as not usable. {Appendix
to Tliird Report of the Commission, p. 319, London, 1911.)
2 This does not include private chnics and policlinics belonging to instructors and used in teaching.
3 The details are interesting.
Internal medicine 800 beds
Surgery 411 beds
Women's clinic 156 beds
Psychiatry 160 beds
Eye 100 beds
Children 264 beds
Dermatology 208 beds
Ear, Nose, and Throat _35 beds
Total 2123 beds
160 MEDICAL EDUCATION
for the fundamental instruction of a small undergraduate class: it is less likely to con-
tain much material germane to the obscure problems selected for study by clinician or
surgeon. According to the doctrine of probabilities, a hospital of 1000 beds, freely
open to all comere, is far more likely to furnish what is interesting or rare, and in
the necessary abundance.
As respects amount of available material, the German university is even stronger
than the foregoing statements indicate. For the clinical resources of all are practically
pooled for the benefit of the entire student body. The German student migrates
freely. A local defect need, therefore, cost him nothing. What of it, if Giessen has
no children's clinic at this moment? The student will spend a semester at some uni-
versity that has. What of it, if internist or surgeon be slightly antiquated? Pending
a change in the chair, students get medicine and surgery somewhere else. Doubtful as
to whether a large or a small school is better, the student escapes the dilemma by
attending both. Every German student can thus piece together for himself a clinical
experience in which, so far as quantity of material or quality of teaching is concerned,
there is absolutely no defect whatsoever.
I have said that the German hospital is a functional organization, the ultimate
units of which are the several clinics and the pathological laboratory common to them.
Of these separate clinics there are always at least five, each usually with its own pa-
vilion: internal medicine, surgery, psychiatry, obstetrics and gynecology (combined
as the "women's clinic"), and ophthalmology. This is what one finds at Gottingen,
Konigsberg, and Marburg. A distinct tendency is observable in the direction of pro-
viding separate clinics for dermatology, pediatrics, and even other branches. They
already exist in large centres like Berlin, Vienna, Munich, Strassburg, and Breslau;
and are found here and there in smaller places. Bonn has, for example, its separate
dermatological clinic of 90 beds, Greifswald its children's clinic of 30, Ilalle an ear
clinic of 25, Tiibingen an ear clinic of 10, In general, there is only one clinic in each
department; but in large cities, medicine, surgery, and occasionally the women's clinic
are divided : at the Charite, for instance, there are two services in internal medicine,
two also at Munich, three at Vienna.-^ Even so, the number of beds is not infrequently
excessively great. In case a second clinic is established, the entire organization and
equipment are repeated. The two share nothing: each clinic has its own staff, its own
laboratories, its own policlinic. Each is as complete as if there were no other.
The scope of the several clinics is for the most part self-evident. Worthy of special
comment only are the women's and the psychiatric clinics. The women's clinic cojn-
bines obstetrical and gynecological wards. Separation into two specialties tends to
make a midwife of the obstetrician and an abdominal surgeon of the gynecologist,
to the neglect of the fundamental pathological and physiological problems in both
cases. Consolidation avoids the necessity of drawing arbitrary lines by way of mak-
ing two specialties where nature has made but one: for obstetrics and gynecology
' Not counting the non-university divisions.
CLINICAL INSTRUCTION: GERMANY 161
have a single physiological and anatomical point of departure, — namely, the child-
bearing function.
The psychiatric clinic has been differentiated out of the insane asylum, previously
utilized for such instruction in mental diseases as was in vogue. The insane asylum
makes a poor clinic : thither come, only after delays due to legal formalities or do-
mestic sensitiveness, chronic cases that have already passed through many phases. The
psychiatric clinic, on the other hand, in conduct, appearance, and location simply
one clinic among many, now receives these patients at a time when they may still be
medically helped and while they are educationally and scientifically most suggestive.
There is, besides, a large class of patients — hysterics, alcoholics, etc. — for whom no
proper hospital facilities existed prior to the creation of the psychiatric clinic. In
general, psychiatric patients need to be retained for relatively short periods. A clinic
of 100 beds may therefore accommodate something like 2000 cases in the course of
a year.
The objects which the German clinic is designed to subserve are three: healing,
teaching, and research. Its equipment, organization, and conduct are throughout
mindful of its threefold purpose. In general, each clinic has its own building, con-
taining wards, lecture hall, examining, demonstration, and preparation rooms, mu-
seum, laboratories appropriate to its function, — all under a chief, who has a staff
made up of paid assistants not engaging in practice, part-time assistants, volunteers,
nurses, and helpers. By way of illustration, let us describe one of the new medical
clinics of the Charite (Berlin).
The clinic as a whole comprises six precisely similar "stations," each "station"
with 28 beds, made up as follows: a central ward containing 18 beds; small rooms
adjoining containing together 10 beds; a convalescing room; an examination room,
bath, diet kitchen, quarters for nurses, etc., and finally a clinical laboratory fully
equipped for routine examination of blood, urine, sputum, etc. The immaculate ap-
pearance of these little laboratories is ascribable not to lack of work, — an immense
amount of material is daily handled in them, — but to a system of fines for offenses
against good housekeeping: a penalty of two cents is imposed if a gas-jet is left
burning, one of ten cents if a lens is left lying about. In consequence, no worker loses
any time disposing of litter left by another.
To each clinic as a whole belongs a set of research laboratories, varying with the
character of the clinic and the particular problems in which the staff is at the mo-
ment interested. Appropriate to the medical clinic are laboratories in which chemical
and biological methods may be applied to clinical problems, — thus supplementing
observation of symptoms and statistical study by direct experiment. Surgery has its
laboratories of pathology and experimental physiology. Animals for experimental pur-
poses are always provided; for with his sure scientific instinct, the German has real-
ized that one must experiment in any event, and that one avoids experimenting with
man in precisely the measure that one can experiment with animals. The women's
WZ MEDICAL EDUCATION
clinic is equipped with laboratories of pathology, embryology, and chemistry. Psy-
chiatry is fitted out for psychological, anatomical, and histological studies. Kraepe-
lin"s new clinic at Munich contains appliances for measuring perception, reten-
tion, reaction time, and the ability to perform mental work; apparatus for recording
involuntai'v and reflex movements, for the investigation of the influence of mental
processes on the pupil, respiration, heart- beat, blood pressure; a sound-proof room,
where extraneous sensory stimuli may be excluded; a sleeping-room, where the depth
of sleep may be studied in the effort to understand the physiology, pathology, and
hygiene of sleep. Photographic rooms, Roentgen ray apparatus, and a collection of
pathological specimens are practically invariable features of each clinic. Hydrothera-
peutic apparatus, electric, colored-light, and other baths, douches, a pneumatic cham-
ber, Swedish movement gymnasium, and similar equipment are commonly found.
The above description applies generally to the equipment of all German clinics,
be they in small places or in large. The medical clinic at Greifswald, to take a small
university, contains a lecture room equipped with epidiascope for the projection of
cuts, slides, and illustrations, an apparatus for displaying Roentgen photographs, a set
of reagents for making essential clinical determinations on the spot, a long table for
microscopes, on which at the close of the lecture students may examine the slides pre-
pared or demonstrated; research laboratories of chemistry and bacteriology are pro-
vided for assistants, who are selected because of their fitness to work in one or the
other direction; a gymnasium, an electric bath, an excellent librarv in receipt of all
important journals, a room for undergraduate instruction in clinical microscopy, —
these are all features of the medical clinic in a remote Pomeranian village. Even
where, as at Munich, Vienna, Graz, or Wurzburg, antiquated buildings still house the
clinic, space has somewhere and somehow been contrived for laboratories. At Vienna,
for instance, they have been squeezed into the old clinical building; space has also been
won for laboratories in the wooden sheds erected in the hospital courts for ambu-
lant patients. At Wiirzburg and Graz, the necessary rooms have been made in out-
of-the-way comers in the ancient cloisters utilized as hospitals. Meanwhile, thanks to
the vitalizing influence of science, new clinics, which will concentrate and economize
effort, are in almost all these universities either in process of erection or planned for
the near future; for, though scientific work can indeed be done in a hovel or a cellar,
comfortable quarters and adequate equipment effect immense economies.
The staff" of the clinic consists of the professor, assistants, and volunteers. At Ber-
lin, there are eight assistants in the second clinic above described, three of whom live
in the house. The assistants divide the "stations" and the laboratories between them;
so that, while the entire body of assistants follows the chief on his rounds, responsi-
bility for the current oversight of the different wards and for special laboratories
always falls to a particular assistant. A designated individual is responsible and all
get benefit. The clinic and the laboratories belonging to it thus form a tight organ-
ization : for the laboratory heads also being assistants are each, as a rule, in charge
CLINICAL INSTRUCTION: GERMANY 163
of a "station."''' The professor himself, while directing the entire clinic, usually acts
as chief of one of the laboratories. Miiller at Munich, for instance, is in immediate
charge of the chemical division, while assistants are, under his supervision, in charge
of bacteriological and other divisions; questions falling outside the laboratories im-
mediately connected with the clinic are referred to the appropriate institute. To the
staff of the clinic one must also reckon "volunteer" assistants, who flock to the more
prominent clinicians, by whom they are hospitably received, being allowed easy ac-
cess to the wards and laboratories.
This type of organization is universal. Mliller's clinic of 400 beds at Munich is
divided into units averaging 50 beds apiece, each in charge of an assistant, aided by
a Praktikant — a non-resident interne of vague status^ — and one or more volun-
teers. The medical clinics at Vienna contain 100 beds each, with four to seven assist-
ants, and the usual number of volunteers; 200 beds form the medical clinic at Tu-
bingen, in handling which the professor is assisted by a staff of seven, not reckoning
volunteers;^ at Heidelberg, a professor and twelve assistants form the medical staff. ^
On the surgical side similar arrangements hold : the professor at Heidelberg has an
organized staff of 13; at Greifswald, one of 6. The smallness of the staff gives its
members remarkable opportunities; but it tends also to require them to spend much
time in doing or overseeing mere routine. What is valuable to the assistants and to
the patients in this abundance of opportunity probably would not be diminished if
the students, while serving their practical year, were made more responsible parts of
the hospital machine. I shall have occasion to point out shortly that the practical year
is well-nigh universally regarded as a disappointment, precisely because no definite
duties have been attached to it. If, now, the Praktikant occupied a definite place in
hospital economy, the educational value of the experience would be greatly increased;
the needs felt in the effort to realize the full value of the experience would react favor-
ably on the conduct of medical education ; the routine care of the patients would
probably be improved; and the assistant, instead of finding his actual opportunities
reduced, would obtain more time for the prosecution of important activities.
On the side of organization, the assistant is the most important link in the chain,
and this chain, at least, is as strong as its strongest link. What the assistant is, the
professor was; what the professor is, the assistant hopes some day to become. The
assistants are the men in training for high clinical posts, and their training shapes
their clinical careers. Dissimilar in details though all these careers be, in principle they
are alike. The German clinician has a point of view that goes back to an intensive
discipline in one or more of the underlying sciences. A generation or two ago, this
discipline was pathological; nowadays, it is more apt to be chemical or biological,
and no perfunctory training in chemistry or physiology at that. The prospective
1 See below, p. 178.
2 The entire force numbers from 55 to 60 persons, of whom 19 are nurses, 2 orderlies.
3 The entire force numbers C% of whom 30 are nurses.
164 MEDICAL EDUCATION
clinician pauses in one of the fundamental branches long enough to achieve some
genuine distinction : he will frequently have turned out a substantial piece of work in
chemistrv, physiology, or pharmacology before, as volunteer or assistant, he attaches
himself to the retinue of a distinguished clinician. Opportunities in one or the other
capacity abound, for the dooi-s of the German clinic swing open readily to any trained
man who wants to work. There is place for him at a table in one of the research labo-
ratories; he obtains readily from the wards such material as he wants. The chief will
talk with him about his problem, perhaps assign to him some aspect of the larger task
upon which the combined forces of the clinic bear. The staff thus works like a team, with
an organization at once loose and sympathetic, allowing every worker his independence,
insuring him at the same time a definite function in a planned organic scheme. The
volunteer is expected to remain a reasonable time — six months, perhaps; he is welcome
to stay longer if he makes good ; if not, he is let alone, and soon moves on, unnoticed. As
a rule, the assistants are recruited out of the ranks of the volunteers. Local considera-
tions have nothing to do with appointments or promotions. It matters not in the least
where one lived, studied, or was graduated. Anybody can get into a clinic anywhere,
just as he can go into a laboratory of physics or a seminar}^ for Greek, the sole question
being competency. The volunteers form, then, a sort of nursery from which the assist-
ants of lower rank are apt to be selected. Thenceforth promotion depends altogether
on performance. The line is continually broken; it zigzags from place to place. The
assistants' posts carry small salaries and the privilege of living in the clinic. The
income may be augmented by fees received for conducting optional courses in clinical
microscopy and physical diagnosis.^ On these terms the assistants serve long periods
with marvelous enthusiasm and devotion, at times following their chief wherever he
is called. Of the Berlin assistants, one has served with his chief seven years, two (one
of them a woman), five; at Breslau, there are surgical assistants who have also seen
seven vears of service ; in one of the medical clinics at Vienna, the longest term is
twelve years, the shortest, six.^ The stable character of the stafFhas many consequences;
in the first place, it makes it possible to open the clinic freely to others. The official
staff is not adequate to look after the number of patients a clinic ordinarily contains;
and thus far it has not been supplemented by resident internes. The well-nigh con-
tinuous presence of four or five assistants in a service of one hundred beds renders
feasible the admission of eight or ten volunteers, without danger to the orderly con-
duct of the laboratories or proper care of the patients.
1 In recent years an unfortunate tendency has developed : more of the assistants hve out of the chnic
and engape in practice.
2 The training of the German assistant is illustrated in the following typical careers :
Munich, second medical clinic. First assistant : two years, assistant pathological anatomy, Zurich ;
one year, voluntary assi.stant, medical clinic, Ba.sel ; clinical assistant at Munich since 1902; scientific
work on pathology of diseases of blood, metabolism, nephritis.
Second assistant : one year assistant in chemistry, Prag; two years assistant in pharmacology, Prag ;
one year voluntarv assistant, medical clinic, Basel ; assistant physiologist, Munich, since 190-2; for the
last three years, director of research laboratories ; scientific work on diseases of metabolism.
CLINICAL INSTRUCTION: GERMANY 165
But of far greater importance is this consideration : the stability of the German
clinic establishes schools which introduce continuity into medical development. The
present race of internists were the pupils of chemists and physiologists, and have them-
selves trained their own successors, who are simultaneously affected by new lines of
investigation. Long association with a chief who has ideas and a point of view creates
a band of workers standing for definite conceptions. Scientific progress is achieved
in no other way. It begins with the teacher, not with the student, — a teacher of
original and inspiring power. It is idle to supply conditions favorable to students
unless efficient measures have been taken first to procure the teacher and to provide
for him the environment essential to continuous activity. The German clinic answers
this description ; hence, workers will surmount every obstacle in order to attach
themselves to it.^
I have said that the German clinic has three functions, healing, research, and teach-
ing. Though our concern is primarily with the last, it is impossible to omit the other
two : in the first place, because the question at once arises as to how unrestricted free-
dom of teaching reacts on the patients; in the second, because the scientific spirit
completely dominates every activity that goes on within a German clinic.
The preference of the German peasant or artisan for the univei-sity hospital refutes
at once the notion that the patients of the professor are to him problems rather than
pei-sons. The peasant is right : nowhere does he receive such intelligent or continuous
attention as in the university clinic. The professor himself makes daily rounds through
the wards, pausing for examination or discussion wherever conditions require. Mean-
while, the assistant, himself a trained and experienced physician, sees every patient in
his division on his regular afternoon rounds. One or two volunteers are also apt to
take a hand. The X-ray room and the clinical laboratory are continuously invoked for
diagnostic aid. There is thus little chance that significant symptoms \rill escape
notice, or that possible therapeutic measures will be neglected. Occasionally it may
happen that an interesting patient is somewhat too conscientiously examined, for
no member of the retinue likes to have a really unique phenomenon escape him.
In general, however, the quantity of material available in the clinics and out-patient
departments is so liberal in comparison with the number of assistants and students
that the patient is not unnecessarily annoyed.^
1 The German arrangement may at times bear hardly on an individual. WTien a professor is called and
brings several assistants with him by way of transplanting his organization and procuring homoge-
neity in the teaching of students and the conduct of the clinic, he necessarily displaces the assistants
left by his predecessor. The latter go into practice, where, of course, their experience proves of price-
less benefit. They may continue to teach, provided they procure the necessary material.
2 In connection with the utilization of Frankfort's hospitals for the proposed new university, the
municipality has investigated this question. The commissioners propose that no patient be used for
teaching purposes against his mil, as is the custom of Strassburg, Munich, and Leipzig. "On inquiry
we ascertain that no difficulty arises on this score, for the patients, even those of the higher classes,
are always ready to be thus utilized." (Bericht des Sonder-Aitssckmses, p. 6.) The suggested arrange-
ment expressly stipulates that "teaching is to be carried on with all possible regard for the welfare
of patients," etc. {Ibid., p. 34..)
ICfi .AIEDICAL EDUCATION
One hears it asserted none the less that the German hospital patient is, to say
the least, unsympatheticallv handled. I feel certain that the charge is due mainly to
misiipprehcnsion. The nursing is indeed inferior, for the trained nurse is just begin-
nin<^ to make her way into Germany; her place is still occupied by a somewhat unin-
telligent and quite unattractive maid, bordering on the ordinary servant type. But
the continental laboring man or woman is not offended by her somewhat uncere-
monious attentions. As for the professor, he is a superior being dealing with social
inferiors. Often enough he handles his patients with charming gentleness and kindly
humor; but even a brusque or impatient bearing on his part implies no real harsh-
ness. The German mistress carries herself thus to her servants ; the German employer
to his clerks; why not the doctor to his hospital patients.-^ Something must be ascribed,
also, to a certain cynicism as respects human life that one encounters in old societies:
the lower classes are habituated to hard conditions; the upper take that for granted.
General social conditions determine the relation of doctor and patient inside the
hospital and out. The supremacy of the professor has nothing to do with it. If the
hospital administrator or hospital board were free to control him as they pleased, this
is one point in reference to which it would in general occur to no one to suggest a
change.
As to research : be a man never so busy with patients, teaching, or what not, no
member of a German clinic can do his full duty by faithful attention to routine.
Research is in the air. I have already pointed out in dealing with pathology that
every medical and surgical clinic is potentially, and almost every one of them actually,
a chair of experimental pathology. While the laboratories connected with the clinics
are in the first place concerned with clinical problems, they do not hesitate to attack
fundamental questions if in the course of an inquiry it develop that the theoretic basis
is lacking. Between the laboratories within and the laboratories outside the clinic,
the relation is one of helpful, informal cooperation.^ A certain amount of duplication
is inevitable; but on closer scrutiny, even duplication is perceived not to be without
specialized differentiation. In any case, the notion that differentiated clinics are
narrow is completely upset. The German inteniist studies and teaches disease not
from one standpoint, but from many: the chemistry, pathology, and bacteriology of
every condition are thoroughly investigated. It is therefore a misconception to allege
that scientifically conducted clinics are narrow, whereas empirically conducted gen-
eral hospitals are broad. It is urged, too, and with greater reason, that some of the
research turned out is of no great value. But it may be asked what percentage of the
suggestions that occur to any individual who has a fertile mind are w^orth toleration
and development? Surely, a very small percentage indeed. In order to get an occasional
1 " But I do not regard it as essential that everything pertainine: to the clinic be carried out in its labo-
ratories. Special problems may well be referred to the university institutes for cooperative solution.
I hope to cultivate intimate relations between the children's clinic and the theoretical institutes."
Inaugural address of Professor v. Pirquet, " Die neue Kinderklinik," November V.i, 1911, Wiener Medi-
zinische Worhenschrift, No. 4T, 1911 (abridged).
CLINICAL INSTRUCTION: GERMANY 167
idea that is sound or valuable, one must sprout a large crop of ideas. Research is in
this way wasteful, irresponsible; it leads continually into blind alleys; its "mines"
turn out to be mere "pockets." But the cost is immaterial, once a "strike" is actually
made.
The clinic, however, is not only a place where the sick are cared for and scientific
research is carried on : there also doctors are trained. The professor of medicine is at
once physician, investigator, and instructor. We have briefly discussed him in the first
two roles. Let us describe him at somewhat greater length as teacher.
Proper methods of teaching medicine must be determined by consideration of the
subject-matter and the object in view. The student's medical education inducts him
into a vocation in which he becomes at once responsible for human life. The medical
school is therefore bound to train physicians. Does this mean men who have at their
fingers' ends an infinite number of recipes, one or another of which come to mind the
moment a given set of symptoms is perceived? Assuredly not. That might conceivably
be the correct way to train physicians, if human ills were all thoroughly understood,
catalogued, and set dowTi each with its appropriate remedy. As a matter of fact, few
abnormal conditions have been as yet worked out to anything like this extent; none
completely so : for even such specifics as the anti-diphtheritic serum, quinine, and mer-
cury, cannot be mechanically or unintelligently employed. Every human body has its
own idiosyncrasies ; no two sets of abnormal conditions are ever precisely the same ; no
two organisms ever respond in precisely the same way. Milk helps one diabetic and
harms the next. It is therefore impossible to develop two types of physician, one to
find things out, the other to apply what has been ascertained. For the same kind of in-
telligence, the same sorts of observation, knowledge, and reasoning power, are needed
for the application, as for the discovery, of effective therapeutic procedure.
Forthis reason, the important point in medical education must be to put the student
in possession of scientific method. Knowledge of so-called fact falls short or becomes
antiquated and useless; scientific technique lasts and improves. Once the physician
knows how to unravel the puzzle that the patient presents, to note and to foUow out
clues, the mastery of the positive resources of therapeutic art is a comparatively simple
matter. "Diagnosis," says Friedrich von Miiller, "is the peculiar art of the physician."
This does not mean that the physician's interest ceases when he has worked out his
problem and given it a name: in a sense, he is then just ready to begin. But correct
diagnosis means intelligent control;^ it means a fight in the open. The ground is firm
beneath the doctor's feet. He has still, indeed, his fight to make, — to win the battle
or postpone defeat. And one battle, at least, he will sooner or later inevitably "lose.
This point we may regard as of the first importance: medical education aims
fundamentally at scientific discipline in the art of diagnosis. How is the student to
acquire such practical skill ? He possesses already the concrete acquaintance with the
structure and operation of the normal body which he brings from his studies in
1 "Qui bene diagnoscit, bene medebitur."
IQS MEDICAL EDUCATION
anatomy and physiology. He has dissected the cadaver and learned the topographi-
cal relation of its various parts ; he knows from experience the size and location of
the intenial organs in health. Physiology has taught him what is normal in respect
to bodilv temperature, the condition of the skin and tongue, the composition of
urine, blood, etc. All this he knows — not merely knows about. It constitutes, then,
his point of departure.
Does not this basis itself suggest how he must acquire his knowledge of the ab-
normal and its significance ? Professor Dewey has very rightly remarked that in edu-
cation " the initiative lies with the learner." With the picture of the normal in mind,
confront him with the abnormal : let him note discrepancies, make his interpretation,
and then ascertain by still closer observation and examination whether his interpre-
tation is sustained. To begin by telling him, by pointing out, by calling his attention,
is to deprive him of that initiative which is so highly educative. Learning is a game
in which the student must move first.
At bottom, then, the "peculiar art of the physician" is the ability to make an
inference on the basis of observed and ascertained fact; and the student acquires
the art, if at all, by doing the work. The unaided eye, ear, and finger first come into
play. The appearance of the skin, the shape and size of members and organs, the
" feel " of a region, — here are certain physical signs that make up one part of the
picture. The patient's view of his own case provides another set of factors ; for every
patient is a doctor observing his own case, to the extent of the experienced dis-
comforts that he rehearses in giving the "history"" of his trouble, A third set of
factors remains to be ascertained through microscopical or other investigation in the
clinical laboratory, X-ray photographs, or pulse tracings. Such are the completed
data on the basis of which the physician ventures his theory or diagnosis ; until he
has assembled them, as far as they are relevant, suspense, not decision, is his proper
state of mind. Notions occur to him, of course, as he goes along. Instead of adopting
one or another, and thus either distorting or bringing to a close the process of impar-
tial objective study, he does precisely the reverse: he entertains a definite sugges-
tion only as a basis for further observation. "If the patient has malaria,"' — this is
one of the suggestions that dart into his mind as he proceeds, — "then," he reflects,
" I ought to find this or that condition : is it there ? "" The entire handling of a case is
but a repetition of essentially this process. Logically viewed, treatment is an exper-
iment, the patient's condition from time to time constituting nature's response to
the physician's effort. Whether the physician perseveres in his line of action, modifies
it, or beats a retreat depends upon the character of this response.
AMiether the student is well or ill trained is determined accordingly (1) by his
ability to extract from the patient by cross-examination a coherent account of himself
and the conditions he complains of; (2) by his skill in observing with aided or unaided
eye, ear, and finger anatomical and physiological abnormalities; (3) by his capacity
to detect iiTegularities in urine, blood, sputum, etc.; (4) by his facility in putting
CLINICAL INSTRUCTION: GERMANY 169
togethei- all these facts and drawing from them a conclusion as to their meaning in
combination. This is diagnosis — "die eigentliche Kunst des Arztes."
Upon this basis he begins next to learn therapeutics, whereupon repeated observa-
tion of the progress of the patient must in the same way by actual experience test
the thoroughness of his observation, the soundness of his inference, and the value
of the expedients employed. In the end, a well man goes out of the hospital door, or
the autopsy illuminates what remained dark and problematical.
The best of medical schools will not, of course, make expert doctors : only long and
varied experience ever does that. But the medical school must start the youth along
right lines; train him to know and to use his tools, give him sound conceptions,
methods, and ideas. For the most part, these acquisitions depend either upon doing,
or upon participation in doing, under competent oversight and control; nor are they
acquired even by doing unless by continuous and thorough doing. To get a history
of one case, to conduct the physical examination of a second, to make clinical labo-
ratory examinations of a third, and probably never to see any one of the three a sec-
ond time, is not a discipline that can be substituted for combination and coiTelation
of all three on patients observed from beginning to end. The things just mentioned
have indeed their uses: a man must be trained to get histories; he must be trained
to observe physical signs; he must have a course in the clinical laboratory. But un-
less these separately acquired skills are finally brought together and continuously
used together, he has not been trained to obtain and to comprehend the necessaxy
factors in their relation to one another.
The backbone of clinical teaching in Germany is the demonstrative lecture ; merely
theoretic or didactic discourses or exercises are entirely unknown.^ Straight from the
study of anatomy and physiology, without previous training in pathology or physical
diagnosis, the student takes his seat in the amphitheatre to listen to non-systematic
clinical lecturing in medicine first and foremost, subsequently in surgery, obstetrics,
etc. A full account of just what he must and of what he does attend will be given
when we come to consider the curriculum ; suffice for the present an account of the
methods of teaching as such. The text of the lecture is a concrete case exhibited in
the arena. In its course two or three cases are shown. The professor reads, first, the
history taken by an assistant; next, the laboratory findings contributed by another.
He himself then proceeds to point out the significant physical indications. The stu-
dent witnesses at long range the process of arriving at a diagnosis. But the German
professor does more than make a diagnosis. He goes on to a luminous and compre-
hensive discussion of the entire topic, dealing exhaustively and scientifically with the
1 There is little doubt that in abandoning the systematic lecture the Germans are right ; the pity is
that it has not been more largely relinquished in anatomy. The theoretic lecture is retained because
it is alleged to "round out" the student's knowledge. As a matter of fact, this appearance is highly
deceptive. The student's knowledge remains fragmentary despite its seeming completeness ; it would
be more wholesome for him to feel its fragmentary character than to be told that he has achieved a
bird's-eye view of the whole, in which vast abysses of ignorance have been skilfully glossed over.
170 MEDICAL EDUCATION
causation, development, and treatment of the disease, incidentally giving due recogni-
tion to those who have contributed to the literature of the topic. Slides representing
pathological conditions in previous cases that have passed through the clinic are pro-
jected upon a screen; gross specimens brought from the museum are demonstrated;
and microscopes with mounted sections are at hand for those who can afterward pause
to look into them. At the close of the hour, the subject has been presented in all its
relations, historic and scientific; guiding principles have been established and incul-
cated; a competent and attentive listener is in position to plunge into the literature
of the subject without danger of getting lost.
One hears poor lectures occasionally; but the general level is extraordinarilv high.
The German professor talks with ease and force. The daily event has been conscien-
tiously prepared for in advance. The professor knows the case and the literature;
supplementary and illustrative material is ready for him when he wants it. There is
indeed the best of reasons for keeping up to the mark: for dull lecturing will soon
empty the auditorium. In the summer semester at Munich, Miiller lectures daily
at 9.15. Shortly after 8.30, the hall begins to fill; by 9 o'clock, every seat is taken;
chairs are brought in until every available inch of space is covered, — there is barely
room for the professor, his patient, and the assistants. The auditorium is a primi-
tive affair in the old municipal hospital; but it possesses all the essentials, — re-
flectoscope, screen, blackboard, running water, table with reagents, microscopes,
etc. A path is opened in order to wheel the patient in. The professor reads the his-
tory; displays on the blackboard the temperature chart ; then in quick, clear fashion
explores the patient, pointing out what he finds, discoursing on its significance,
suggesting alternative explanations, until he settles down on the most probable di-
agnosis. This furnishes the topic for development and further illustration. The etio-
logy, the pathology, the therapeutics, of the condition are set forth with wonderful
vigor and lucidity. My notes abound in accounts of similar discourses. The effort made
to prepare for a complete exposition is everywhere striking. For the last lecture of the
semester a case of progressive paralysis was to be exhibited. A series of charts had been
prepared expressly, exemplifying step by step the progress of the case since it first
came under observation a year or more previously; drawings had been made to show
the range of vision in each eye at regular intervals during that period. Finally, after
thorough exploration of the patient, a reflectoscope demonstration was given of sec-
tions of the spinal cord responsible for analogous degeneration in other patients who
had been under observation in the clinic ; in one of these latter, acute disease resulting
in death had interrupted the developing paralysis; in another, a similarly terminated
degeneration had not yet proceeded far enough to start paralysis, the microscope
indicating the fate that the individual had escaped. It is hard to overrate the conta-
gious and stimulative effect of such discourse — clear, logical, comprehensive, and
at every step concrete. A master mind at work is exhibited daily to two hundred
students or more.
CLINICAL INSTRUCTION: GERMANY 171
These are the two strong points of the clinical lecture : it enables a strong man to
influence a large student body, out of which by selection the really capable are picked
in order to enjoy closer intercourse with him ultimately as volunteers or assistants;
the presentation constitutes an object lesson in scientific method, for the single case is
first studied, then classified, and finally made the basis of a series of generalizations
which relate it in all its aspects alike to what is known and to what is obscure. The
best teachers make for the lecture no other claim. "The chief emphasis of the lecture
does not fall on the examination of patients by students ; in the foreground stand rather
close examination by the teacher and thorough discussion of symptoms and therapy.
This seems to me the main function of the internal clinic, which under existing con-
ditions is only to be attained by slighting practical work by the student at that time."^
On the other hand, it must be confessed that one does not follow a series of such
discourses with much profit unless a considerable personal experience has preceded. The
lecture is concrete to the extent that the patient lies there to be looked at ; test-tubes,
pathological specimens, projections, add a certain sense of reality that a text-book
or a didactic discourse conspicuously lacks. None the less, there is from the standpoint
of the young student a good deal of remoteness about it at bottom. For even though
he handle the preserved specimen and examine the microscopic slide, he does not him-
self study at first hand the patient about whose physical condition the entire perform-
ance turns. As to that, he has only the professor's word. Can this vicarious experience
actually sustain the structure built upon it.f* Only if a rich experience has previously
contributed such a store of sense perceptions that words are now as effective as things.
This is not the case. For the average student, lectures of the type described form the
introduction to clinical study. No solid background of previous experience vitalizes the
terms and symbols which come up to him in quick succession from the arena into which
he gazes. No effort is made even to adapt the lecture by making a distinction between
elementary and advanced instruction. Students in their first clinical semester, students
in the last, and graduated physicians listen to the same lectures. They are bound to
be, for the most part, "words, words, words," lacking the fullness and warmth which
prior experience could alone contribute to them. And not only does nomenclature
convey no precise or realizable meaning : it does not even assist or encourage obser-
vation. It is more apt to prove an obstruction to observation. Familiarity with terms
breeds contempt for experience. Terms are helpful counters with which to facilitate
genuine mental operations only if a kernel of actual experience lies in the heart of
them. Indeed, during the early stages of learning, names ought to be subsequent to ex-
perience; at least, between namesand experience the mind must flyback and forth until
the idea has defined and actualized itself. When a more or less varied fund of ideas has
been thus acquired, discussion may take place to good advantage; for then only can
generalization really embody the student's living sense of what Professor Dewey calls
"the net meaning that emerges from dealing with particular facts." The clinical lec-
1 Private letter from a professor of internal medicine.
172 MEDICAL EDUCATION
ture inverts sound pedagogical order in coming before the experience that it proposes
to expound ; and it errs further in substituting at the start a related or described
or exhibited experience for a personal one. Grant for a moment that the German
theory is sound; that the student can be schooled to scientific thinking by witnessing
a succession of admirable exhibitions of the art. Even then the endeavor must fail,
unless through experience a sound basis in sense perceptions has been acquired pre-
viously.
But the theory is not sound, or perhaps better,not sufficient: the student expects not
only to understand conditions, but to practise an art. Subject only to the requirement
of the hospital year, — to be presently discussed, — the German student of medicine
inay, and usually does, go straight from the university into practice. A long appren-
ticeship converts the philosophically and theoretically trained jurist into a lawyer be-
fore he can practise his profession independently. No such provision insures a guarded
and lengthy experience to the physician before entering upon practice. He goes, I say,
in most cases, almost straight from the university to attend disease, accident, child-
birth, in the home. To him, therefore, the university has got to be a Fach-Schule,
a technical school, though, of course, not merely a FaehSchule in the narrower sense.
But a technique one does not master by looking or listening. It has got to be learned,
if at all, by doing. I pointed that out in discussing the character of modern medicine:
on the side of ideas, mediaeval medicine dealt with abstract principles that could only
be talked about ; modern medicine deals exclusively with sense perceptions, out of which
it derives such principles as it has arrived at. The student can understand scientific
ideas only in so far as he himself shares in a repetition of the experience out of which
they have Ix^en developed. Precisely the same holds of medical or surgical relief. It de-
mands technical skill, — whether in manipulation or inference is immaterial. Let the
student watch another ever so closely, let him even himself learn separately a few tiicks
or devices, his own fingers, eyes, ears, brain, make thus no progress toward effectual
cooperation. That he must do time and again with the assistance, supervision, and
under the control of the teacher; and not after he has learned, but while he is learning
and as the means of learning. The child told never to approach the water until he has
learned to swim is the analogue of the student not carrying a case through until he
has learned to do so. His actual responsibility must not be great, nor must it expect
to make of him a complete doctor; but in form it must reproduce that of his master, if
it is to start him on a line of scientific and practical development. Ostwald has put
his finger on the weak spot: "In place of the lecture, which means mass teaching pay-
ing no regard to the individual, various arrangements for practical instiiiction are
making their way. ITie essential point is that the apprentice under the personal guid-
ance of the master leams what is most important and significant, and what can be
taught, namely, the procedure of investigation. It is no longer enough that a student
appropriate what excellent men have done before. How to work must be taught and
learned, and this is not to be accomplished by means of lectures: one must put the
CLINICAL INSTRUCTION: GERMANY 173
student to work."^ This is no argument for the sacrifice of scientific spirit to "practi-
cal" training; it implies, however, that genuine scientific discipline is an active, not
a passive, process.
There are of course other objections to the lecture besides passivity: it is discontin-
uous. The student sees a patient once ; what happens subsequently he does not see.
How is he to appreciate the course which typical diseases actually take? At best,
he may hear about that from time to time; perhaps ultimately witness an autopsy.
But what is the result of the therapeutic procedure indicated in the lecture, and what
the subsequent development of the processes pointed out, he has no opportunity to
observe. Nor is he forced to think in clear and orderly fashion by being required to
register his observations and thoughts in black and white. Again, lecturing almost
inevitably overtaxes assimilative power. Lecture appointments come at successive
hours. Unlike practical work, they have a set beginning and a definite end. Under
the impression that knowledge is to be accumulated and training obtained in that
way, the student arranges to hear a succession of discourses daily. In the course of
a few hours, his mind is overwhelmed with facts, theories, and ideas delivered to him
far more rapidly than his mental processes operate : they simply stop. In the end, he
is compelled on the advent of the examination to get ideas clear, at least in form,
by conning quiz-compends. The psychology of practical work is just the reverse. Ex-
perience tends to set itself in order; it knits or arranges itself with but the simplest
explanations by the instructor.
So far, I have considered the lecture alone, because it is the customary and tradi-
tional form in which instruction is imparted. The German university is historically
a lecturing institution. Knowledge was thus handed down, principles expounded and
passed on. As science developed in the last century, the critical and investigative
spirit took hold of and adapted the ancient structure. In seminaries and laborato-
ries, small bodies of advanced students came into contact with active investigators
in history, language, chemistry, and biology. But medicine presented a problem of
its own, in the numbers of students to be handled, in the necessity of welding together
portions of many separate sciences into one practical art. This necessity led in the
first place to substitution of the non-systematic clinical lecture for the didactic ex-
pository or philosophic lecture. But even though concrete ideas could be thus more
or less successfully communicated, the student gained no practical skill. It was ob-
viouslv necessary to supplement the lecture Avith certain correctives. We shall soon
see^ that the official curriculum is still almost wholly a matter of lecture courses;
but directly or indirectly, an effort is made to correct and amplify lecture hearing by
actual training. Let us examine the machinery provided for this purpose.
The student has four different chances to correct the defects that inhere in lectur-
ing. The first is provided by the so-called " courses." Diagnosis depends in the first
1 Forderung des Tages, p. 567 (condensed).
2 Chapter x. ^
174 MEDICAL EDUCATION
place on the arts of palpation, auscultation, and percussion; in the second, on the
ability to examine blood, urine, and sputum. Optional introductory courses of both
sorts ai-e offered at small cost by the assistants in the medical clinic;* in the same
way, courses in bandaging and surgical diagnosis are offered by the assistants in the
surgical clinic, manikin courses by those in the women''s clinic. The abundant mate-
rial of clinic and policlinic (out-patient department) is freely at the disposal of these
instructors; the courses are so numerous that the attendance is usually not too
large to enable student and instructor to work together under proper conditions. As
they are the main support of the docents giving them, and students are excellent
judges of effective drill, competition brings about thorough teaching. How far the
lecturing is thus con-ected remains a question : in the first place, if the courses are
really to enlighten the lectures, they ought to precede them. That they rarely do. At
best they begin in the same semester as the lectures ; frequently not even that.^ For
the youth may pick up the necessary technical tricks after he has heard all the lec-
tures he requires. Some students get no systematic courses at all; for they are not
required to take them. A student may, if he chooses, get a little coaching before
examination or acquire the essential elements incidentally by working in the clinic
as Jamidu^. But in any event, "courses" can teach only the use of technical devices.
They give no opportunities for thorough and continuous clinical observation. In one
course the student sounds a chest; in another he examines a specimen of sputum. But
the sputum and the chest do not belong to the same patient, and he cannot safely
interpret them apart from each other and from other data now and subsequently
obtained. Hence, the course itself, while training the student to use certain diag-
nostic methods, does not correct the lecture in so far as the lecture fails to enable the
student to participate in complete and continuous observation of the entire process
of disease.
The other three devices aim to do this very thing: a required clinical lecture course
does not count for the student unless he has served as Praktikant in connection there-
with; he has also the option of attending the clinic informally as famulit,<i or hosjyi-
tant; finally, at the close of his medical studies he must serve a year's intemeship.
First as to the Praktikant. What happens is this: at the beginning of each lecture,
two or more students are called into the arena from the list of those who, having
paid the fee, expect to obtain credit for the course. These are the so-called Prakti-
kanttii. Theoretically, they are supposed to examine and interrogate the patient and
to propound a diagnosis and a line of treatment, which they must then defend against
the professor.
As a matter of fact, the thing is not feasible. To begin with, as the clinical teach-
ing is not graded, the student has not been led up to the part which he is abruptly
* In rare instances the professor himself conducts the course in auscultation and percussion; Miiller
docs this at Munich.
' See below, chapter x.
CLINICAL INSTRUCTION: GERMANY 175
required to play.^ At most he has had a course in physical diagnosis; perhaps not
even that. Moreover, professors tend to present to their class "interesting," that is,
difficult cases ; first, because they care about them, second, because the auditorium
always contains advanced students and graduated doctors, to whom something can
really be communicated. Where and how is the untrained "practitioner" tobegin.'^
It is all very well to urge the old principle: throw a man into the water and tell him
to swim, A sorry line of casualties mark its application to education. Of a totally
strange situation there is simply no way for the average student to take hold.
Moreover, even if he knew a trick or two, the conditions are most unfavorable to
their profitable employment. An audience ranging in size from 50 to 300 is looking
at a necessarily awkward beginner. \Vithout previous sight of the patient,^ he has to
elicit important facts in short order and to venture an explanation. He knows little,
he has had no experience; publicity awes him; time presses. The professor gives him a
cue, watches him fumble, and then, almost without knowing it, takes the ball, as indeed
he must. He has to choose between working with one Praktikant and entertaining his
large audience : no one successfully achieves both. In a few moments the Praktikant
has slunk out of sight. He stands inactive first on one foot, then on the other, during
the remainder of the period. His practical participation has therefore amounted to
nothing: were it very active, indeed, it would not materially affect the character of
instruction unless frequently repeated. As a matter of fact, only two such appearances
are required per semester, and books are generally signed up quite regardless of the
quality of the response. Meanwhile, the professor, once fairly in the midst of his
topic, forgets all about the Prakiikant: what started out to be model practice for him
becomes an exercise witnessed passively by the entire class.
My notes contain many accounts of praktickren. It works better with small classes
than with large; but the amphitheatre so effectually separates arena fi-om audito-
rium that the teacher cannot continuously command both. Few teachers even try.
I recall two characteristic cKcasions, one at a large, the other at a small, university.
In the former instance, two Praktikanten appear, after a dozen names have been
called. The professor sets them to examining the patient. They are completely non-
plussed. He directs their attention to a certain spot: "Can't you feel a cyst.^" They
are not quite sure. With some hesitation one of them ventures a timid "Yes." It is
not quite convincing. "Really?" the professor inquires. There can apparently be no
doubt it is there. "Yes,'' they both reply with emphasis; and that is all. By the time
1 In a few institutions, "propaedeutic" clinics have been established; but they have not met the diflS-
culty. The "propaedeutic" clinic may be just as advanced as any other. Even where, as at Berlin,
simpler material is presented, the method of presentation is the same : the student looks on. I witnessed
such a clinic attended by 70 students at BerUn. A tuberculous child and a woman with a floating
kidney were demonstrated. An assistant led the child around the room to show the Von Pirquet re-
action ; the professor alone examined the other patient, holding up a bandage which was to be relied
on to prevent discomfort. At the end of the hour, the patients sat in the arena, 15 or 20 students crowd-
ing around each ; within five minutes, over half had left.
2 In some clinics, the Praktika.J has an opportunity to examine his patient beforehand.
176 MEDICAL EDUCATION
the second patient is brought in, the professor has wholly forgotten about his student
assistants. He examines, describes, expounds. A third case is brought in, — typhoid,
it proves. The professor does everything. Twice only are the Praktikanten addressed, —
once with a recjuest to look at the roseola, again to feel the spleen. Thenceforth they
retreat ever further into the background, differing from the students in the benches
only in being a little closer, — and much more uncomfortable.
In the other instance alluded to, there are only thirty students in the auditorium.
The professor, three assistants, and one Praktikant occupy the arena. The patient
enters. The professor reads the history, makes the examination, and then gives the
whole thing away before he even becomes conscious of the presence of the Praktikant.
The latter never elicits for himself and reports a single fact; once he listens to the
heart beat after he has been told what he will hear. Whether even then he actually
hears it, there is no telling. A strange discoloration of the patient's mouth being
noticed, the entire class files by in order to see it: so that in a small school the Prak-
tikant gets very little that all cannot get. Everywhere, all students are Praktikanten
to the extent that they are privileged to remain behind after the lecture in order
to examine for themselves the patients demonstrated. But crush and haste combine
to deprive the opportunity of any considerable value. I have some figures that show
what it amounts to: in a Vienna clinic which eighty students attended, five stayed
after the lecture. On another occasion elsewhere, three cases had been shown to about
ninety students; immediately after the lecture, between twenty and thirty students
crowded around each of the patients; in two minutes by the watch, two-thirds of
them were gone; all but five were gone in less than five minutes. Prakticieren, there-
fore, cannot be fairly said either to supplement or to mitigate excessive lecturing. It
is a futile device.
What I have called the second corrective is entirely optional, consistently with the
German notion that it is the business of the university to offer opportunities, allowing
the student to avail himself of them or not at his peril. The student, if he chooses,
may serve as "famulus" or "hospitant" in one or more clinics. In this capacity he is a
helpful guest in the wards and laboratories. He does whatever he can and will, making
himself useful as a "cub" or "fag:" follows the chief on his morning rounds, the as-
sistiuits in the afternoon; examines patients, %\Tites up histories, studies blood, tissues,
urine, in the clinical laboratory to his hearfs content. There is no denying that the
famiilu.s gets an excellent opportunity of precisely the proper kind; indeed, the read-
iness with which the German system provides such optional opportunities for the able
and wilHng is the strongest point in its favor. Let the university proffer opportunities:
students worth saving will utilize them, — a rigoroas discipline, excellent in its way;
in the domains of language, literature, and philosophy, perhaps excellent altogether.
For pure science and pure scholarship know how to protect themselves against im-
jx)stors: the student who misuses or neglects his opportunities in these fields achieves
nothing, — that ends the matter. He indeed suffers; but — so it is argued — there is
CLINICAL INSTRUCTION: GERMANY 177
no helping that. In no event could he have been saved to competent or productive
scholarship. "Boys must be risked that you may get men," said Herbart.
The case of the medical student, however, stands somewhat differently. The pro-
ductive scientist the university can fairly leave to his own devices, — the productive
medical scientist like any other. Research anatomists, research clinical chemists, must
appear before the bar of expert opinion : society is thereby amply protected against
mischievous error as to matter of fact. But the world in which the physician plies
his vocation is absolutely without any adequate protection whatever, once the state
admits him to practice. His hold upon public confidence may be in no small mea-
sure independent of his competency. I abstract for the moment from the protection
afforded by entrance requirements and qualifying examinations: just now, we are con-
cerned only with the guarantee and protection afforded by the training as such. What
Ostwald calls the "antiquated lecture procedure""^ furnishes no adequate guarantee ;
"prakticieren" does not help it. "Famulieren" is in conception far sounder. Let us
see whether it is sufficiently general, varied, and prolonged to save the day.
In the first place, we must reflect that required lecture courses are so numerous that
a student can become a, faimdus during semester only if he freely cuts his lectures:
perhaps one may judge as to the repute in which lectures are held from the fact that
some clinicians accept a,?, famuli only students who are willing to desert the audi-
torium for the time being. The vacation, however, is generally regarded as the proper
season for Jam itlieren. On the face of it, it is improbable that any but the more in-
dustrious will devote their holidays freely, despite their undue length, to this some-
what arduous service. As a matter of fact, despite the general reliance upon famu-
lieren as a supplement to the lecture system, no one has ever undertaken to gather
statistical information as to its operation. One is sometimes told, "Every one be-
comes a 'famulus,'"''^ but I am persuaded that this is far from true. One of the
Berlin internists assured me that comparatively few students serve in this capacity;
a student who had just finished at Berlin, after spending the earlier semesters else-
where, judged that not over 50 per cent of his acquaintances had heeufamidi at all;
a professor extraordinary opined that perhaps one-third of the student body serve in
several different clinics, one-third more for a brief period in one clinic, the remaining
third not at all. In Vienna, an assistant in one medical clinic estimated that on the
average perhaps 30 per cent of the students work as famuli ; a professor in another,
a o-ood deal disgusted with the Austrian student, declared that of 150 enrolled stu-
dents, not over half a dozen became conscientious famuli during either semester or
vacation. At Munich, the custom has fallen off since the institution of the practical
year. The most favorable conditions exist in the medical clinic at Leipzig. There, as
far back as the sixties, Wunderlich introduced the practice of dividing out the daily
incoming patients to the students, who became virtually clinical clerks. The privilege
^ "Das veraltete Verfahren der Vorlesung." Grosse Manner, p. 417.
2 " Jeder famuliert."
178 MEDICAL EDUCATION
still continues. Every student has thus the chance to observe continuously ten to
twelve patients in the course of the semester. Estimates differ as to how regularly
the students take part : one authority ventures "a half," another "a considerable
number," a third, "the industrious."
Faimdkren is therefore by no means universal: is it sufficiently varied? Once
more, despite the importance attached to it, there are no facts at hand. I took occa-
sion at N'ienna to sample the situation. Afamnliis in his last semester of study ascer-
tained for me by personal inquiry how varied had been the experience of 22 fellow
students in their final semester, all having completed Wveiv famiiUeren. All had Ijeen
famuli in internal medicine, averaging a little over five months each; of the 22,
15 had never been Jam^iH anywhere else; of the remaining 7, 4 had heen JamuU in
surgery (on the average less than two months each), and 3 in dermatology (on the
average a little less than three months each). None had heen Jam ulus in obstetrics.
A similar inquiry was made for me of 17 students in their last semesters at Berlin :
10 had heen famuli, 5 in both medicine and surgery, 1 in pathology and surgery,^
4 in medicine.
Finally, what is the service actually worth to the famulus ? It is undoubtedly of
very uneven value. Leipzig has come nearest to organizing it on a definite basis. The
late Professor Curschmann had prepared a printed statement running somewhat as
follows :
"In their own interest I lx?g my students to observe the following:
" Before entering my clinic students must be trained in pathological ana-
tomy, general and special pathology and therapeutics, and, above all, in the arts
of percussion and auscultation.
"All the patients in the medical division will be assigned to the Pralctil-anten
for continuous clinical observation, the more difficult cases to the more experi-
enced.
"In reference to their cases students are expected to prepare a complete his-
tory, with especial attention to the ' anamnese,' the findings on the original ex-
amination, the more important developments in the coui-se of the disease, the
general and special tre^itment. Acute cases ought to be visited daily; chronics
at least twice weekly. The wards are open for the purpose 8-12.30 a.m., 3-6 p.m.
I recommend students in case of difficulty to appeal to the assistant in charge
of the 'station,' who will facilitate their work in every direction. Industrious
attention to the assignetl patients and carefully prepared records are among
the most important features of clinical training. They distinctly influence my
opinion of the capacity of the student.
"For chemical and microscopical study, a room equipped with microscopes
and reagents adjoins the amphitheatre. I recommend its free use and shall l)e
happy if investigations extending Ijeyond immediate need are there undert^ikeii."
This is the famulu.'i eX his best. Definition is in general much looser. One hears it
alleged too often that the famulus is not assigned to the assistant to train so much
* Two of the famuli had served three times each in surgery.
CLINICAL INSTRUCTION: GERMANY 179
as to do chores; the head does not concern himself about the amount of training
that the J^'o mid us derives from his service. In one place he is employed in lieu of
a typewriter;^ elsewhere he is a sort of higher servant. But sometimes he gets al-
most the opportunities of an under-assistant. The value of the arrangement therefore
varies greatly. It depends partly on the student, but partly also on the assistants
into whose hands he falls. This vagueness cuts both ways : it gives an unusually keen
famulus an extraordinary chance; but it may also tend to empty the function of
definite content. For a precise and systematic responsibility cannot be left to a preca-
rious agent without assignable function. Thejajnulus suggests the English "clinical
clerk ;''^ but he is inferior to the English analogue in variety of service, universality
of custom, and definiteness of responsibility.
So far, then, the undergraduate student cannot in general be said to receive actual
training in the wards. His case is not materially bettered by the so-called "clinical
visits " announced at Berlin, Wiirzburg, and elsewhere. In the first place, they occupy
only one hour once a week; in the second place, undergraduates rarely attend, Instnic-
tion described as "at the bedside" in Leipzig means only a course in clinical niicx'o-
scopy, in which the student analyzes blood and urine from patients unknown to
him ; there also I met an assistant who was followed on his rounds by students "every
week or two." Except for famulieren on Curschmann's plan, the wards at Vienna are
probably more freely open to undergraduate students than those anywhere else. But
the defects of their training are disclosed by their reluctance to enter them. In the
already mentioned clinic, in which 150 students are enrolled, not more than ten attend
the regular afternoon rounds of the assistants, and, remarked an assistant, " almost
always the same ten." In another, I was told that I should find something Hke twenty
to thirty students attending between 4.30 and 6. It just happened that on the after-
noon of my visit one undergraduate student appeared between 5 and 5.45; all others
in attendance were assistants and volunteers. The student in question had prepared
a case history, but made no physical examination; in the next ward we heard that
a student had been there and left. The assistant explained: "Of course I compel no
one; nor do I bother about those who either don't come or don"'t take it seriously."
A professor summed up the situation for me as follows: "In general, the participa-
tion of the students in the direct examination and observation of patients at Vienna
is extremely defective, though everywhei'e opportunities abound." He might have
added that the amount of material in clinics and out-patient departments is so rich
that the Leipzig plan could be regularly instituted without difficulty. The obstruc-
tion is historical, as we shall hereafter see.^
Pressure from the practising profession has led in recent years to the insertion
of a hospital year between the univei"sity and professional practice in the German
Empire. Admirable in conception, the device has yielded very disappointing re-
sults. The reason seems clear: it is another case of locking the stable after the hoi-se
1 "Als Schreibmaschine ausgeniitzt." 2 ggg chapter viii. 3 See chapter x.
180 MEDICAL EDUCATION
has straved. Free run of the hospital for a year furnishes experience, not training;
how much the experience will in general profit depends on the sort of training the
interne has had beforehand by way of preparation. If as student he became accus-
tomed to passivity, he Avill as interne tend to be helpless. The practical year could
succeed only with well-trained students capable of being used in the conduct of the
hospital. Its proper use would then be as a bridge between training and practice;
fundamental training it cannot itself supply. In other words, listening and doing
form Ijetween them an active practical habit only if a relatively small quantity of
listening has been thorouglily kneaded into a relatively large quantity of doing.
Three veai-s mainlv of listening followed by one year intended to be wholly of doing
is the wTong proportion in the wTong chronological relationship.
Other difficulties, less fundamental, have arisen. If the Praktikant ^ is to be used,
the hospital must be so reorganized as to give him a responsible function, thus prob-
ablv improving the situation of all parties concerned, — students, assistants, and pa-
tients. Thus far, no such adjustment has taken place, in consequence of which there
is nothing in particular for the Praktikant to do. Recently, a petition has been sent
to the Govermnent begging larger opportunities for the Praktikant in some one divi-
sion, if it is not feasible to give them generally. "Even one-sided training would be
better than the present lack of duty or occupation." The attitude of the assistants
now decides : if that is sympathetic, the Praktikant gets a good deal ; if not, he may
l>e insensibly turned into an amanuensis; or worse still, lacking oversight or responsi-
bility, the fresh graduate may waste the year in reveling.^
Hospital managers have also done something to defeat the purpose of the enact-
ment. The number of hospitals authorized to receive Praktikanten is quite large. It
was intended that Pj-aMikanten should be subordinate to the assistants, who were to
supervise their activities. But the weaker hospitals have used the concession to get
rid of assistants altogether, by way of reducing expenses. They offer free quarters
and small salaries to Praktikanten who are looking for an opening,^ and then use them
in place of assistants who would get higher pay. In addition, the required service
as Praktikant is alleged, curiously enough, to have reduced the number of those
offering for assistantships. Enforced work during one year seems to disincline men to
voluntary effort for two or more. If this is not corrected, the practical year will tend
to break down perhaps the most valuable feature of German clinical organization.
Finally, the hospital year is not always a hospital year: for two-thirds of it may be
spent in laboratory work. One concludes, therefore, that the value of the hospital year
will depend on the previous improvement of the clinical teaching, and on the reor-
^ His proper designation is Medizinal Praktikant, whereby he is distinpruished from the Praktikant
of the Vorletung aljove described. In the present connection the word has reference to the practical
year.
* '* Das ganze Jahr wird jetzt verbummelt," is frequently charged.
' See advertisements in the German medical journals.
CLINICAL INSTRUCTION: GERMANY 181
ganization of the hospital so as to promote a sound relationship between the assist-
ant and his youthful charge.
Those who admit more or less fully the defects which I have pointed out, hold that
they are, or must be, mainly corrected in the policlinic. But, as a matter of fact, they
cannot be. However useful the policlinic, its patients come irregularly, cannot be
sufficiently controlled, and represent only certain types of cases. Undoubtedly, subject
to these limitations, the out-patient department is capable of furnishing a highly
important training. But, except in so far as its material is utilized in giving practical
courses in physical diagnosis, laryngoscopy, etc., it now really contributes as a rule no
novel features to clinical teaching. It serves for the most part as the reservoir which
feeds the clinic and from which the assistants procure material for their coui-ses. Per-
cussion, auscultation, bandaging, ophthalmoscopic, and other practical courses are
largely conducted in the out-patient departments, where an abundant and varied
supply of material is at hand. This material, strictly speaking, belongs to the chief;
assistants employ it by courtesy. Now it happens frequently that the calling of the
chief results in leaving behind a number of docents and extraordinarii who have
been his assistants; the incoming chief, as I have already mentioned, chooses or brings
along his own assistants. Those displaced continue to possess academic titles, but lack
matei'ial with which to teach. ^ This has resulted in the establishment of private poli-
clinics, especially in larger towns.^ A docent, now no longer an assistant in the clinic,
opens a private out-patient department in connection with his office in the vicinity
of the university policlinic, if possible. He thus keeps his name in the university
catalogue, is in position to conduct courses, and profits directly and indirectly. Occa-
sionally, such policlinics are well equipped, and the courses offered are well attended.
Many of them, however, lack both equipment and students : they continue to be an-
nounced from year to year because the nominal university connection has a certain
merchantable value. At Breslau, I tried to visit one of them, suspicious because it pur-
ported to be held across town from the medical department. At the announced hour
1 found neither docent, patients, nor students, and was informed by the Pfortnerin
that the docent had left his office "long ago."^ At Munich, it is proposed to limit the
docentship to a term of years in order to prevent the exploitation of the title. At
Vienna, the dispossessed instructors — that is, men holding academic titles, but ^\^th-
out teaching material — combined in 1872 to establish a policlinic, to which recently
a clinic of 120 beds has been added. A similar establishment on a smaller scale ex-
ists at Leipzig.
In large centres, out-patient teaching is carried on in the clinical amphitheatre;
it differs fi-om teaching with in-patients only in that the patient has his clothes on.
^ This difficulty cannot arise in subjects like languages, economics, mathematics. For the docent gets
easy access to the library and needs only a room in which to meet his class. That the university affords.
2 Private clinics belonging to professors extraordinary are used in the same way.
3 "Schon lang weg."
182 MEDICAL EDUCATION
A policlinic exercise in psychiatry at Berlin was attended by 300 hearers. Each en-
rolled student serves as Praldikant twice a semester under the conditions heretofore
explained. The discourse is admirable: beginning with a concise elucidation of the
essential features in the case displayed, it rises at once from the patient and fairly
sweeps the entire horizon of the topic in hand, always in close touch with actual
phenomena, yet without slavish adherence to the instance just then in the arena. In
one of the medical policlinics of Berlin, attended by some 200 students, I witnessed
a demonstration of a case of obesity, in which five Prald'ikaiiten were simultaneously
supposed to be engaged. Every fact of importance was promptly ascertained from the
assistant who had previously examined the patient and communicated by the pro-
fessor to the entire audience without any activity whatsoever on the part of any of
the Praktikanteji. A heart murmur was announced: only one of the five verified it.
Here as elsewhere the striking features were the passivity of the Praktikanten and
their meagreness of response when addressed, on the one hand, the breadth, vigor,
and richness of the pi'esentation of the professor, on the other : for the air was satu-
rated with ideas, — this simple case of obesity being illuminated with a profound and
incisive discussion into which historical, social, physiological, and geographical con-
siderations entered. It is, I believe, impossible to overestimate the stimulating effect
of such talk ; but it cannot possibly reach the end desired. As a matter of fact, of the
five Praktikanten on this occasion, only two uttered a word and only one touched
the patient.
Substantially the same procedure, on a smaller scale, takes place in smaller univer-
sities. At Greifswald, Wurzburg, etc., an ordinary room is used, the students sitting
around in class form. Patients are introduced, and the students in rotation serve as
Praktikanten. The performance is more intimate and responsible than in the big am-
phitheatre. But it is mass teaching still, despite the abundance of material and the
smallness of the student body. Nothing but the persistent lecture tradition hinders
actual participation by individuals and small groups.
At Munich alone — as far as my experience goes — is an effort in the latter direc-
tion made: even there limited to internal medicine, though fanmli and volunteei*s
take part in other divisions. The out-patient department — the Reisingerianum,^ so
called in memory of the original donor — is perhaps the most commodious and con-
venient in all Europe. The division of internal medicine is presided over by a chief
and four assistants, each in charge of a subdivision. Four graduates doing their prac-
tical year, volunteers, and famuli attend: in addition, the undergraduates who must
earn the requisite Praktikanten certificate or credit. The last named receive the
new patients for independent examination, compile the necessary history, and make
urine tests for alljumen and sugar, prepare and observe blood and sputum slides, study
' 5>ee a clcs<ription by Professor Richard May, Miinrhentr Medizinisrhe Worhenschrift, Nos. 2 and 3,
1911. The rules are printed in a Httlc pamphlet, to be obtained either from the Keisingerianuni or from
the publisher, G. Franz'sche Hofbuchdruckerei, Munchen.
CLINICAL INSTRUCTION: GERMANY 183
X-ray photographs when made, and finally venture a tentative diagnosis. Though
the student is throughout under the control of one of the assistants, his participation
is distinctly active. In the afternoons, he may take pai*t in district visiting.^ This
out-patient apprenticeship requires attendance for one hour twice weekly during
a semester. Some effort is made to encourage regularity by requiring students to
register attendance in the office and to adhere to the room which they originally
select: the rules suggest that thus the Prahtikanten will have the advantage of keep-
ing track of patients who return for treatment.
Unfortunately, required participation of the kind described does not at Munich
extend beyond the medical policlinic. At Vienna, on the other hand, one finds a sort
of dressership in the surgical out-patient department. The class ^ in clinical surgery
is divided into groups of ten to fifteen, each of which groups attends the out-patient
surgery between four and five in the afternoon for a week or two. The members ex-
amine cases and follow the assistants; in their too brief service they can see a good
deal, but do little. On the day of my visit, seven were present and the instructor
congratulated the group on the large attendance.
The foregoing account has as a whole immediate reference to interaaJ medicine,
which receives in Germany its proper stress; but it is generally applicable to all clinical
instruction. Everywhere the demonstrative lecture forms the backbone; and the part
of the Praktihant is only rarely more than nominal.
I heard, for example, the concluding lecture of the semester in psychiatry at Munich.
The exercise lasted two hours ; seven cases were demonstrated. The Praktikanten stood
by while the professor quizzed the patient. When he had elicited all necessary infor-
mation, he turned to the Praktikanten with the question that at that stage really asked
itself, quite regardless of whether one stood near the professor or sat on the benches.
"What sort of clinical picture have we here.? For," he added, "what we now want
is diagnosis, — that is precisely the art of the physician."^ Neither of the two Prak-
tikanten recognized the picture. "I showed you a similar case in a former lecture;
perhaps you were not present." Both thought they were, but neither recalled.
The surgical lecture takes two forms : operations by the wholesale in some places,
diagnosis in others. At Berlin, three operations were simultaneously in progress be-
fore a crowded auditorium ; six Praktikanten were on duty in the arena at once. A
Praktikant ventured a diagnosis of "sarcoma." A brief colloquy took place between
student and professor. Just what the former said was inaudible ; but not so the pro-
fessor's criticism that his "answer was several centuries behind the times." The youth
was mute when required to give the distinction between sarcoma and carcinoma. None
the less, he was "signed up," as was likewise another Praktikant who stood by with-
1 One finds district policlinics, as these are called, elsewhere too, — for example, at Marburg, Tubingen ,
and Leipzig; but at tiie last named I was informed that the "students are too busy to go."
2 The "class" always means those who have paid the fees for the course.
3 "Diagnose, — das ist eben die Kunst des Arztes."
184 MEDICAL EDUCATION
out opening his mouth the entire time. At Munich, the professor began by explain-
iuf a proposed abdominal operation by means of a chart. A dozen assistants stood
around him. I sat a httle to one side of the centre and saw nothing but the patient^s
covered feet and the crowns of the heads of the staff. The staff itself was so numerous
that those in "the outer darkness" had to crane their necks to see anything at all.
At Wiirzburg, I witnessed a surgical clinic given to fifty students. Three Prakti-
kantni were called down : a patient with a growth on the tongue was exhibited; ques-
tioned as to what they would do under certain conditions, not one of them replied.
The lecturer thereupon explained ; the Prakt'ikanten were closer to the patient than the
rest of the audience : other difference there was none. A second case — deformity of the
lower limb — was introduced. The same procedure took place. The professor pointed
out everything, to the Praktikanten as to others, — even the fiict that the two limbs
were of uneven length, — but none of the three was able at once to put his finger on the
head of the femur. The truth is, that prakticieren is, as carried on, an absurd method.
It could avail only if the student, after proper preliminary training, saw his patient in
good time before the lecture hour, studied him carefully, and even read up the topic.
He could then be quizzed to some effect; to expect an untrained boy to observe, to
reflect, and to conclude on the spur of the moment, like an experienced consultant,
is bound to yield disappointing results.
Fayr at Greifswald^ does little operating before the class; Kiittner at Breslau, none
at all. Their instruction is an exercise in surgical diagnosis. The classes being rela-
tively small, each student can be brought into contact with a much larger number
of cases; and a more or less lively participation by the entire class is possible. The
results are immensely better. The Praktikant in the surgical clinic at Breslau exam-
ines the patient first; makes up his mind somewhat deliberately, is compelled to de-
fend his position against the instructor, the class taking part spiritedly. At Vienna
and Leipzig, optional coui"ses of the same character are offered by assistants, the re-
sponse on the part of the students being for the most part unsatisfactory. They appear
to lack both skill and knowledge, somewhat more sadly than one would anticipate.
Optional also are courses in bandaging and in operations on the cadaver. Courses in
operating on animals are not as a rule offered to undergraduate students.
In the women's clinic, work is in general similarly organized. The fundamental
technique is supposed to be cared for in optional courses offered by assistants, who
have free use of the abundant material of the clinic. At Vienna, for example, these
courses include the techni(}ue of delivery, diagnostic technique, pathological histo-
logy, manikin work, gynecological diagnosis and therapy, physiology and pathology
of child-lx;aring, operations on the cadaver, etc. The student body disperses itself at
will among thase classes; and those who cannot, or do not, pay for courses take their
chances of acquiring basis and technique asjcimidi. The lectures of the professor,
meanwhile, follow conventional lines, — demonstration and exposition, with prakti-
1 Now at Leipzif^.
CLINICAL INSTRUCTION: GERIMANY 185
cieren. Greater care is subsequently taken to insure a minimum of practical experience.
In the splendid new women's clinic of Vienna with its 700 beds, excellent quarters
for undergraduate students are provided. In one of the services, every student gets
a period of three weeks'" actual residence : during the first, he examines cases of preg-
nancy and observes delivery; during the second, he attends gynecological operations
as Praktikant; during the third, he follows in similar fashion the Mork of the septic
ward. In Germany, the student does not necessarily reside in the obstetrical clinic
during an appointed period; but actual participation in at least four deliveries is
required.
The most recently developed of chnics is that devoted to pediatrics. The specialty,
first differentiated in Austria, has now been recognized in practically all German
universities. The Munich clinic contains ISO beds; the lectures are attended by 200
students. In the auditorium, scarlet fever, measles, diphtheria, and whooping cough
are demonstrated; a class of 40 divided into two parts also goes into the wards. But
the bedside work is not highly developed — " unfortunately ,'"' as my escort admitted.
As to the range of instruction offered in every clinical branch, what has been said
of each of the underlying sciences may be repeated: evei'y institution provides the
fundamental coui-ses of general importance; beyond that all go, and no two agree.
At every stage, before and after graduation, the eager worker can procure further
opportunity both in training and in research. At Vienna, in the winter semester of
1910-1911, about 120 different lecture and practical courses were announced in
internal medicine, not reckoning individual researches carried on under the guidance
of the directors ; at Berlin, 80 ; the same rich and varied abundance is characteristic
of other branches, each of which is presented on large lines, while within each, in-
tensive and specialized work is offered for the benefit of capable workers. In internal
medicine, surgery, gynecology, pediatrics, and other branches, clinics of broad scope
are held from four to six times weekly; these furnish the backbone of the instruc-
tion, are in general character the same at all institutions, and are attended at one
time or another by all students. Beyond this point, no two institutions agree. A few
examples must suffice to indicate the variety and abundance which enables and en-
courages everv student and every graduate to push beyond the elements at the proper
time. From the Berlin announcement I may cite in medicine : traumatic origin of in-
ternal disease, diseases of digestion, diseases of the lungs, prognosis of internal disease,
diseases of nutrition; at Strassburg, one finds a course in diseases of respiration and
circulation; at IVIarburg, diseases of the spinal cord. In surgery, Vienna offers special
courses in diseases of the urinary tract, orthopaedics, and a-typical operations; Wiirz-
burg in surgery of the brain, Leipzig in surgery of the kidneys and in militarv sui'-
gery. It is needless to extend this account to other departments, for in all the same
conditions obtain.
The average student learns therapy non-systematically in connection with his clini-
cal work, the main emphasis everywhere falling on diagnosis rather than on therapeu-
186 MEDICAL EDUCATION
tics. But for students at an advanced stage and for graduates, large provision is
made in the shape of special courses, Berlin offers instruction in diet and dietetic cures,
hvdrotherapv, general therapy, diet management of internal disease, a therapeutic
course in internal disease, therapy of neuroses, therapy of tuberculosis, therapy of
infections; Munich, in special therapy, therapy of digestive diseases, physical ther-
apy; Gi"az, in therapy of heart disease, of metabolic disturbance, and of the ner-
vous system. Clearly, no student can leave such an atmosphere under the impression
that his work is finished, that he knows his subject. A common misapprehension
must at this point be guarded against. The more advanced courses above mentioned
are specialized in character. There could, however, be no greater error than to sup-
pose that the German clinician or surgeon is naiTOW in his training or interests,
— narrower, for example, than the clinician or surgeon in countries where differen-
tiation and specialization are not carried so far. The revei-se is true: the German
professor has had a superb training in the underlying sciences; and his clinical
activity is deepened accordingly. In the general clinics which all students attend, as
well as in the special courses, the treatment of the topic is exhaustive : pathological,
physiological, and chemical sides are all presented. Topics are indeed specialized; but
the presentation is broad, varied, and suggestive.
The defects in ordinary instruction have no essential connection Avith the merits
of the German system. They mark only the failure of medical education to overtake
medical thinking; they could lie corrected without interfering with the organiza-
tion or spirit of the clinic. I have already urged that a more orderly distribution
of students would avoid repeated attendance on the same lecture courses and the
overcrowding thus entailed. Under such circumstances, ward and out-patient work
could at once be introduced into the smaller universities : at Erlangen, a start has
been made in this direction.^ At the larger univei-sities, with their enormous amounts
of available material, active participation of students in the wards and policlinics
would also become feasible, if the faculties were reorganized and enlarged with this
end in view; the too small hospital staff and the fee system are obstacles that must
be got rid of. An intangible difficulty exists, too, in the fear that more sequence and
arrangement portend the downfall of academic liberty. Though the freedom of the
student has been more and more limited by the requirement of certificates for one
course after another, it is still feared that the introduction of greater sequence
might rob him of something that is precious and characteristic. The danger is indu-
bitably a real one; for measures that converted the university into a secondary school
would cost more than they are worth. The problem is to avoid this, while still retain-
ing for the assistant his present advantages and giving the average student greater
opportunity to participate after proper preliminary discipline.
So much for the methods of clinical teaching employed in Germany. But the
reader needs to be warned not as yet to make up his mind as to its pedagogical
> AerUlirhM VereiruUatt, June 7, 1910: "Zur Erwerbung der Praktikantenscheinc."
CLINICAL INSTRUCTION: GERMANY 187
worth or its practical outcome. As to that, we shall be in no position to form an
opinion until we have ascertained how the various factors, heretofore separately con-
sidered from the standpoint of method as such, are combined into what we should
call the curriculum. But a word of caution is needed here, and will have to be re-
peated. An analysis of method, a description of the required curriculum, may be
both fair and accurate without by any means exhausting the full significance and
secret of German medical education. I have time and again emphasized the fact that
the air of the German clinic is surcharged with ideas : a German professor cannot
describe a physical examination without explicitly or implicitly giving the historic
setting of the various elements disclosed ; he cannot propose a line of treatment
without a sketch, lucid and illuminating, however brief, of the chemical, physiologi-
cal, and pharmacological investigations that have thrown light on the problem in
hand. Be the technical defects of the German student's training what they may, be his
fund of positive knowledge correspondingly meagre, — and I have no disposition to
extenuate, — familiarity with ideas provides him with a principle of progress which
will stay with him, to encourage him to acquire what he lacks in practical tech-
nique, to enable him to apprehend the quick development of scientific medicine. Even
the average man gets this. The able, industrious, and strong have furthermore pro-
cured for themselves a training which, theoretically and practically, far outruns every
limitation as to both quantity and quahty that seems characteristic of the system.
CHAPTER VIII
CLINICAL INSTRUCTION: GREAT BRITAIN
The hospitals and infirmaries^ in which clinical instruction is given in Great Britain
are without exception voluntary institutions, mainly supported by annual subscrip-
tions or gifts and governed by their subscribers through an elective board. The
administrative staff is salaried; a few minor medical and surgical posts are modestly
remunerated. But the important medical and surgical officers are volunteers, and the
insignificant rewards attaching to paid appointments are little more than nominal
when viewed in the light of their heavy burden of routine.
It is impossible within the limits of this chapter — and indeed foreign to its pur-
pose— to do full justice to the efforts of these excellent establishments in coping
with the formidable problems of disease among the too abundant Scotch and Eng-
lish poor. Suffice it to say that, whether wholly adequate or not, in this cooperative,
voluntary endeavor all classes of society loyally and earnestly unite: the nobleman,
the merchant, the artisan, together contribute to the funds and assemble to select
the managers. No more admirable outlet for civic and social service exists in any
modem nation. On the professional side, the spectacle is not less noteworthy : with
one or another of the voluntary hospitals all the great names of British medical his-
tory have been associated as volunteers; and they are venerated with the intimate
pride so charmingly characteristic of British devotion to its past. Harvey was phy-
sician to St. Bartholomew's during four and thirty troubled years: the rules gov-
erning the kinds of cases admitted to the wards drawn up by him at the request of
the governors are followed there to this day. John Hunter, Edward Jenner, and
Thomas Young, the last named the expounder of the undulatory theory of light,
are among the glories of St. George's : in the board room there, one is still shown
the couch on which, prematurely exhausted by his restless labors. Hunter breathed
his last. Sir Charles Bell served on the staff of Middlesex ; Cheselden was surgeon to
St. Thomas's; Sir Astley Cooper to Guy's. On the roll of the Royal Infirmary at Edin-
burgh can be found the names of all the worthies who built up the medical repute of
the university and the extra-mural school, — among others, the Monros, Rutherford,
Cullen, James Simpson, and Charles Bell. Nor has this custom ceased to obtain. Our
best-known medical and surgical contemporaries have attended or still attend the
practice of the voluntar}^ hospitals: Lister at King's, Treves at the London, Horsley
at University, Lauder Brunton at St. Bartholomew's, Eraser and Gibson at tlie Royal
Infirmary, Edinburgh.
^Vhile the voluntary hospital is supported as a charity, it has in its wisdom lent
itself freely to concuiTent educational use. It is as such only that it forms a topic for
' The terms are equivalent, "hospital" being in common use in London, " infirmary" in the provinces
and Scotland.
CLINICAL INSTRUCTION: GREAT BRITAIN 189
discussion in these pages. I propose, abstracting from all else, to survey and to criti-
cize it from the standpoint of modern medical education. I admit in advance a cer-
tain unfairness in this procedure : the voluntary hospital is a charity ; it lacks the re-
sources to be anything else. It may look ungracious to find fault with an institution,
primarily designed to relieve distress, because its organization and conduct no longer
answer certain rapidly changing secondary ends.
To deeper reflection, however, the entire situation assumes a somewhat different
shape, for the problem of the hospital has itself shifted. That problem was, in the
pre-bacteriological days, a diseased individual; now, the problem is disease itself. The
necessity of this enlargement in scope has already been perceived by the more alert
managers of the metropolitan hospitals. "They are not now, as they used to be,
simply resting places for sick people, whereby food and warmth and rest and treat-
ment are provided; their fight is not against disease in a sick person only, but against
the sick person's disease," -writes Mr. E. W. Morris,^ the executive officer of the Lon-
don Hospital. The patient is something more than an individual, — he is a warning,
a problem, a symptom of economic or hygienic ignorance or maladjustment; remedial
measures must be supplemented by prophylactic and investigative effort. In truth,
effective charity of any sort nowadays involves scientific thinking. The relief of indi-
vidual distress by direct ministration is not enough: we must indeed deal with the
present results of untoward conditions, but the hope of society lies in ascertaining
and removing their causes. True of all social endeavor, this is nowhere else so patent
as in dealing with disease; nowhere else is the connection between ministration to the
unfortunate victim and scientific effort to master the causes so obvious. Medical edu-
cation and medical science thus become the province of the hospital in virtue of its
primary charitable duty and purpose. The hospital cannot possibly discharge this ori-
ginal charitable function unless it endeavors to prevent the spread, and to attack the
sources, of disease. But the features that have become essential to the effective doing
of the original and conscious duty are the features to which discussion from the stand-
point of modem educational requirements will call attention : if, therefore, it savors
of unfairness to view the voluntary hospital strictly from the scientific and educational
standpoint, it must be because the hospital has not yet adjusted itself to the requisite
extension of its avowed object.
We have found that the hospital in Germany embodies the conception just stated.
It relieves the individual ; but it is at the same time deliberately occupied also with
research and teaching, — occupied, that is, in social and scientific warfare on disease
in its citadel; for disease is intrenched in ignorance, and can be dislodged only by
knowledge. The professor of medicine in Germany is the leader in this struggle. It
is precisely his function to lead in it. Though to some extent he practises medicine, he
is first and foremost a teacher and investigator. His associations ai-e with his fellow
1 In a personal letter, slightly abridged.
190 INIEDICAL EDUCATION
university teachers. Whatever preeminence he enjoys comes to him primarily in vir-
tue of his academic standing and scientific repute; it is a preeminence among scholars
and scientists. By the standards and ideals of the teaching profession he is judged;
for its rewards and distinctions he strives. The prominence of German medicine thus
springs from the academic constitution and bearing of the medical faculty; from the
fact that academic ideals, established in the university hospital, have thence spread
until they now dominate the hospital system of all Germany: in consequence of which
both men and ideas circulate freely.
Very different is the situation in Great Britain, where an informally constituted
medical school was operated incidentally by the staff of the voluntary hospital out
of which it grew. The voluntary hospital originated as a private charity; such essen-
tially it still remains. Its history is in the main the story of personal devotion and
sacrifice in the relief of indi\ idual misfortune. On this basis, educational activities,
in some respects extraordinarily effective, have been built up ; but the personal basis
persistently limits their scope. The medical friends and connections of the hospi-
tal patrons and managers naturally became its medical attendants. On their ward
rounds they were followed and assisted by students who had paid them for the priv-
ilege of thus working out an apprenticeship. Visiting and teaching functions be-
came inextricably involved with each other under ideal conditions so far as the
use of the hospital material is concerned. But the visiting function always main-
tained priority. The visiting physician or surgeon might teach; but he had to get
his staff appointment first in order to do so. As clinical instruction in Great Britain
is everywhere imparted by visiting physicians and surgeons, its value and character
are determined by the ideals and constitution of the attending staff of the voluntary
hospital.
AVhat are these ideals.'*
The medical profession in Great Britain ripens in the consultant who represents
the prosperous culmination of a successful professional career. The medical graduate
makes at the outset a choice between consultant and general practice, but private prac-
tice of one or the other type is the goal at which he drives. The path to consultation
practice leads through the hospital and medical school; aiming at that, he never em-
barks on miscellaneous outside practice at all. He sticks to the school and hospital,
entering their service, on the conclusion of his studies, in any available subordinate
post, and looking forward even then, at the end of a long but straight vista, to a house
in Harley Street. For this he endures many years of almost unrequited routine. He
learns his art in the hospital wards and in the out-patient department, by faithful
attendance on the superiors into whose shoes he ^\•ill eventually step. Long service
makes of him indisputably a safe and able counselor. Once accepted as such, he reaps
his reward. He Ijecomes a member of the hospital staff, a lecturer in the medical school.
His day now dawns. As a rule, hospital appointments have carried no remuneration;
the school fees — once no insignificant item — are, in the London schools at least,
CLINICAL INSTRUCTION: GREAT BRITAIN 191
almost entirely absorbed by the increased cost of the laboratory instruction.^ But the
indirect profits are, in any event, the important ones: from his colleagues and from
his former students, business makes toward the consultants. Only a genius can build
up a practice any other way, — an experiment almost never made. Teaching is thus
the means to the desired worldly end, — like other means, liable to suffer when it has
accomplished its purpose. The British consultant may or may not love or care to teach;
but he has little choice if he wishes to achieve a typical success. The great lights of
British medicine — John and William Hunter, Sir Benjamin Brodie, William Stokes,
Sir James Simpson — have achieved just such successes. They were prominent person-
ages in their day ; their patients numerous and distinguished, their incomes large, their
expenditure lavish. The standards by which they are judged do not differ essentially
from those by which the successful barrister or financier is measured. They were in-
deed sometimes productive men, — Hunter and Simpson, men of original genius. But
the words of Brodie's biographer are fairly applicable to the British consultant at
large: "Brodie combined, in an unusual degree, success in practice with eminence in
science; but it seems to me inconceivable that he should ever have sacrificed the for-
mer to pursue the latter."^ The end is distinctly non-aca,demic, — personal, not social,
if social is understood to imply primary devotion to education and science.
Thereby it is at once marked off from the ideal of the German clinical and the Eng-
lish laboratory teacher. On this distinction, the entire argument that I shall submit
hinges. The German clinician and the English physiologist desire primarily scientific
repute. Whatever else they crave, they know at heart that they will be rated and graded
by their scientific achievements. If the German clinician wants students and patients,
if the English physiologist wants a call bringing increased salary, — in either case,
success is conditioned on scientific achievement. Aside from the spontaneous scientific
interest, which is, as a matter of fact, almost invariably his controlling motive, even
worldly gratification hangs on unworldly distinction. The English medical man re-
verses the relationship. Intellectual ability occurs and is honored. The English con-
sultants are cultivated, charming, and able men, excellent physicians, occasionally
distinguished contributors to scientific knowledge. But the system does not seek out,
does not reward effort or achievement in a scientific direction. For the consultant,
scientific distinction is a becoming decoration : it is not the breath of his nostrils.
Between the teacher of physiology and the teacher of medicine, the distinction is
thus, in Great Britain, one of kind, not of degree. The clinicians who largely man-
age the hospital schools judge rightly that physiology is an academic pursuit which
must participate in academic renunciations, — renunciations that are not hardships
to be borne so much as bulwarks to be thankful for. The physiologist is, as a mat-
1 In the provinces and in Scotland, however, where the universities supply the fundamental instruc-
tion, clinical teachers still usually receive the fees of their students, and teachers who are also exam-
iners derive a considerable income from the natural partiality of students for such instructors as guard
the portals to the qualification. See chapter xii.
2 Timothy Holmes : Benjamin Brodie, p. 126 (London, 1898).
19i> MEDICAL EDUCATION
ter of fact, rather too well protected ; for simplicity overdone may entail embaiTass-
ment almost as distracting as prosperity. But at bottom the point is well taken: the
cultivation and teaching of the medical sciences make for a quiet, scholarly, devoted
career; on which basis the clinical teachers of the British medical schools are not,
strictly speaking, to be reckoned in the teaching profession at all.
About that there is no false pretense whatsoever. A medical school seeking an ana-
tomist or physiologist goes into the market and procures the best teacher and inves-
tigator it can afford. There is lively competitive bidding, in which all English-speak-
ing nations join. But for physicians and surgeons the hospitals engage in no such
competition : they are obviously seeking to build up not the best staff, nor the most
productive staff", but just a good congenial staff"; a staff" composed of men who have
grown up together in the same tradition, who like one another, who can cooperate in
works of charity, and in professional matters lead up to one another's hand. They
deliberately inbreed.
I have spoken of the unity of the London schools, of the split in the provincial and
Scottish institutions.^ In a deeper sense, the unity of the former is only geographical.
Rightly taken, a medical school, organically one on the scientific plane, is not to be
found as yet in Great Britain. Scientific medicine involves the adoption by the clinic
of the methods and conceptions of physiology and the other sciences. As to this,
it is immaterial whether the situation to be dealt with is wholly known or largely
involved in obscurity. The validity of the scientific attitude does not depend upon
accurate and exhaustive knowledge of the particular case in hand. If it did, modem
medicine would divide into a scientific section, a section partly scientific and partly
empirical, and a section wholly empirical. As a matter of fact, scientific method may
guide the physician, whatsoever complex of factors he is handling, not only in hand-
ling what is mathematically exact. Krehl has recently pointed out that the concept
of diathesis was expelled a generation ago from medicine as excessively vague and
fantastic. The concept is now again discussed, but it is purged of all metaphysical
mystery. Too complicated to be even yet resolved into known factors, it is neverthe-
less treated with the conscious critical severity that constitutes the essence of scien-
tific method. The science that has most profoundly aff'ected clinical thought on the
Continent is, as I have said, physiology. Now, though physiology has had in England
an exceptionally favorable development, it has not transformed medicine or surgery.
The English physician does indeed employ diagnostic and therapeutic devices of
laboratory origin: he uses the microscope, the X-rav, the ultra-violet rays. But these
are the instrumental, not the conceptual, suggestions of the laboratory; except in
isolated instances, the English physician is still of the intelligent empirical type. He
has indeed studied pathology and physiology, and helped to teach them. But they
were so much scaffiolding, for the most part, to }>e kicked away when they have served
their end. Once on the hospital staff", the typical English clinician gives up the labo-
* See chapter i.
CLINICAL INSTRUCTION: GREAT BRITAIN 193
ratory and with it the laboratory state of mind. He contributes no longer to theo-
retical literature ; his world changes. He fraternizes with another social set. Bacteriolo-
gists, pathologists, and other laboratory men are the servants rather than the peers
of the physicians and surgeons. Between them there is little genuine sympathy. The
laboratory instructors have, indeed, proved so serviceable to both institutions that
they have knit hospital and medical school closer than ever : the physiologist, who
came in by the school door, trains the clinical clerks to examine blood and urine; the
bacteriologist, entering by the same portal and becoming head of the clinical labora-
tory, makes diagnostic examinations for the staff; the teacher of pathology is chief
of the hospital dead-house. But these services, rendered by the laboratory heads,
remain on the instrumental basis. Medical and surgical practice has not been re-con-
ceived in the light of conceptions which have emanated from the laboratories. The
hospital schools thus continue to constitute a compact corporation, whose precise edu-
cational character depends at bottom on the terms of appointment to the medical staff.
The present staff member entered the hospital as student, and, rising steadily by
seniority, will retire from his medical or surgical post at sixty or sixty-five on the basis
of age. He has served in succession as house officer, resident, medical or surgical regis-
trar, assistant physician, physician. Within the walls of one hospital he will usually
have passed his entire career. " Preferment goes by old gradation, w here each second
stood heir to the first." ^ There are ten physicians and surgeons at St. Bartholomew's,
every one of whom got his education there ; eight physicians and surgeons at Guy's, of
whom seven were students there; fifteen at the London, of whom two-thirds studied
there; ten at University, of whom seven were students there. Of the five university
chairs at Edinburgh, four are filled by former Edinburgh students. It does not fol-
low that the exceptions — the one at Guy's, the five at the London, the three at Uni-
versity, the one at Edinburgh — were deliberately called to the posts they occupy.
They, too, attained them by promotion, — only the point of departure was higher
up. For the line begins at different points in different institutions. Below it or at
its start, the hospital governors appoint nowadays, usually following the sugges-
tions of the visiting staff.^ Personal considerations weigh heavily.^ But the line once
1 Othello, Act I, sc. i, 1. 36.
2 In some hospitals, an election committee, on which the governors, the staff, and the honorarj' staff
are represented, makes new appointments.
3 Some hospitals, especially in the provinces, have no junior staff: there are only internes (recent grad-
uates) and the visiting staff. This is the case at Sheffield, where, in consequence, the candidates for
visiting posts canvass the governors for their votes. Moore, The Dawn of the Health Age (Edinburgh,
1910), gives the following account of the manner in which posts are filled in such instances:
"In what manner do we usually choose the best physician or surgeon when there is a vacancy on
the staff of our great voluntary hospitals?
" By hard canvassing of the members of a lay committee, who themselves usually know nothing
of the relative professional abilities of the rival candidates, but are swayed by the facts of the social
standing and influence of the candidate or the candidate's friends.
"Fulsome testimonials as to the candidate's abilities are got together and printed by each candidate ;
these are circulated, along with verbal embeUishments, by each candidate's social friends amongst the
electors, who are nobbled to vote one way or another by pressure, cajoling, or beseeching.
" In the city of Liverpool, one large general hospital has a committee of over one thousand mem-
194 MEDICAL EDUCATION
started, filling of vacancies by promotion is a foregone conclusion unless distinct
unfitness has developed. Advertising for applications is a survival, well understood
to be an empty form. Promotion by seniority is surest of all at the last and most
important advance to full staff membership, the step that carries with it a school
lectureship. At University (London), the final step is automatic: the title of assist-
ant phvsician or assistant surgeon lapses after seven years, the individual in question
becoming physician or surgeon as a matter of course.
\\'hat has been the probable course of staff physicians or surgeons who have not
throughout adhered to the hospital to which they attached themselves as students?
Obviously, the more populous medical schools are unable to provide a continuous series
of appointments for all their own graduates who aim at the consultant career, not
even for all the promising ones among them. The smaller schools, on the other hand,
may have too few candidates — or too few satisfactory candidates — to meet their
own needs. A certain amount of migration therefore takes place immediately after
graduation.^ A student, finding no opening in his own hospital, catches at one of the
lower rungs of the ladder somewhere else. He secures a resident appointment in the
hospital or assists in a subordinate capacity in the medical school, — as demonstrator,
or assistant demonstrator, of physiology, anatomy, or pathology. His foot is now on
the ladder of the institution to which he has transferred himself. If faithful, he be-
comes increasingly valuable, and is rewarded for his school service by the position of
medical or surgical registrar of the hospital, in which capacity he becomes responsible
for the case records. His familiarity with cases will probably give him opportunity to
teach on the clinical side. When openings occur, he is not likely to be passed over; his
superiors on the staff, recognizing the claim established by assiduity, recommend him
to the governors, who almost invariably concur. Careers of this type are common
enough in the smaller London and provincial schools. Charing Cross, St. George's,
Westminster, with an annual entry of a dozen or two, more or less, get the overflow
of the big schools.^ All the four St. George surgeons were educated there; but of its
four physicians, one was a student at St, Mary's, one at St. Bartholomew's. None
bers, nearly all laymen, who elect the physicians and surgeons in this way. At a recent election sev-
eral gentlemen who desired the position of surgeon to the hospital had their claims considered by
this huge committee and the committee's friends in the city. Without making any criticisms on what
the actual result of the election happened to be, it might be suggested that a method which would
have worked equally well, and saved enormous trouble and expense, would have been that of putting
all the names of the candidates in a hat and drawing one out. ' (Page 43.)
Physicians and surgeons so chosen become teachers in medical schools in virtue of their hospital
posts. Similar methods of choice originally existed everywhere, but they are passing out. "Down to
very recent times," says Holmes (Life of Brodie, p. 1-20), "the members of the staff were elected at
St. George's by the votes of all the governors." He describes an election in 1843, when 3-21 governors
attended : '* The contest was hardly inferior in heat to that attending political elections. . . . The extent
to which canvassing had been carried is shown by the names of the great personages persuaded to
come down," etc. (Page 121.)
* The Engli.sh would say "qualification" (for practice).
' Of eight physicians at Liverpool, five were London students, two Edinburgh, one Dublin ; of eleven
surgeons, three were Liverpool students. The percentage of men locally trained is likely henceforth
to rise, for the provincial schools are now in more active competition with London and Edinburgh.
CLINICAL INSTRUCTION: GREAT BRITAIN 195
of the six physicians and surgeons of Westminster studied there. As juniors, the
incomers are promptly naturalized in the hospital of their adoption, in which there-
after their rise proceeds according to the principles above explained. The line has
begun later; but once begun, it does not easily break.
Naturalization at the top — outright importation of a member of the visiting staff,
in other words — is so rare that the few instances in which it has occurred are uni-
versally cited as exceptions. In our time, Listers career is unique, for he filled a regius
professorship at both Glasgow and Edinburgh, and was called from the latter to the
professorship of clinical surgery at King's College, London. Recently, the L^niversity
of Manchester, controlling by contract one medical service in the Royal Infirmary, has
ventured to invite the present holder from Newcastle. But the innovation was bitterly
resented by the local men, alive to the danger lurking in such a precedent. The pro-
fession of the metropolis has hardly yet recovered from its astonishment when, a few
months ago, space was made on the staff of the London Hospital for James Mackenzie,
whose important researches on the heart had earned translation into foreign tongues,
but not, up to that time, an opening for their author in any London school of medicine.
Occasionally, hospitals reclaim their own : Sir Thomas Barlow, a student of University
College, served on the stafi' of Charing Cross and the London before being appointed
physician to L^niversity College Hospital; Sir Francis Champneys, a St. Bartholo-
mew's man, won as obstetrician at St. George's the distinction which led to his pres-
ent appointment at his own school. In Scotland, the universities "control" a limited
number of services,^ but their range of choice is local only. The historian of the
University of Edinburgh notes that Laycock (1855-1876) was the first professor not
educated in Scotland;^ one of the present five university professors was educated at
University College Hospital, London, and was subsequently assistant physician at
St. Thomas's:^ otherwise, the university has consistently resorted for its appointees
to the local Extra-Mural School. There can be but one explanation of this phenome-
non : hospital and school positions are points of business vantage which the local men
propose to hold for their own benefit. They contend keenly among themselves for
them until the jealous competition is suspended because danger from without forces
them to join hands to resist invasion. Fortunately, a better spirit exists in the two
ancient English universities, one of which, Oxford, has recently filled its regius pro-
fessorship of medicine by calling Professor, now Sir William, Osier from Baltimore.*
1 In Edinburgh, only by custom.
2 Thomas Laycock, professor of medicine, 1855-1876. Laycock was not only an Englishman by birth,
but had received none of his medical education in Scotland. Born in Yorkshire, he was a graduate
of University College Medical School, London, and subsequently studied in Paris and Gottingen. In
1846, he became lecturer on medicine in the York Medical School, and was nine years later called by
the town council to Edinburgh to succeed Alison in the chair of practical physiology. Grant : Story
of the University of Edinburgh, vol. ii, p. 413.
3 William Smith Greenfield, professor of pathology, also physician to the Royal Infirmary.
* So at Cambridge, the professors of medicine and surgery are outside men brought down by the uni-
versity. They attempt only elementary teaching; the professors use the material in the hospitals for
teaching, but do not themselves conduct the hospitals.
196 MEDICAL EDUCATION
In general, however, it is fair — and necessary — to say that the laboratories and the
clinics represent different and incongruous stages of development. The laboratories are
educational institutions, the heads of which are called for merit; the hospitals are not
as vet educational institutions, because neither in inferior nor superior posts do edu-
cational criteria govern appointment. Nor can medical education rise to a uniform
modern plane until the methods of appointment now in vogue in the laboratories are
applied to the staff of the teaching hospital.
Other defects in construction, equipment, and organization cannot be overlooked.
The voluntarv hospital has taken thought for administration, diet, nursing, phar-
macv, beds, and out-patients. There, for the most part, it stops. Now a medical school
requires laboratories at what may be called three different levels, — the general labora-
tories of physiology, pathology, and chemistry, in w hich the underlying sciences are
taught and theoretical problems are under investigation ; the routine clinical labora-
tories, in which the current ward work is done, — blood, urine, sputum, etc., examined
and students trained in diagnostic routine; the research clinical laboratories, in which,
varving with the inclination of the chief and his staff, obscure clinical questions are
investigated, now from the chemical, now from the physiological, now from the bacte-
riological side. For example, the physiologist studies normal metabolism; the clini-
cian gets thence the basis from which, in the research laboratories of the clinic, he can
study the metabolism of the diabetic. It is, of course, not utterly impossible to carry
on both sorts of investigation in one set of rooms. But the waste of time and energy
where decent accommodations are lacking is, to say the least, a powerful deterrent.
And, as a rule, where no facilities exist, little or no achievement is nowadays recorded.^
How far the British medical school has acquired the fundamental laboratories, we have
already seen." Beyond this, the voluntary hospitals have made no uniform or marked
progress. To each of the several wards of the Royal Infirmary, Edinburgh, clinical
laboratories are attached, equipped for routine examinations and for the training of
students in their technique, some of them possessing incubators and other appliances
for the making of ordinary cultures ; at Manchester, too, each hospital block has its
own clinical laboratory.^ This arrangement, so common on the Continent and so ob-
viously conducive to economy of time and thoroughness of study, does not, however,
generally obtain in Great Britain. A class-room is usually — not invariably — provided,
where a junior physician conducts a course in clinical microscopy and pathology. The
students serving clinical clerkships sometimes work there, sometimes on tables in the
wards, sometimes in a small room elsewhere, — rarely, as at St. George's, in adequate
and comfortable quarters. At Charing Cross,* the subject is taught in the room other-
^ I do not mean to imply, however, that the more elaborate the facilities, the more brilliant the outcome.
* Chapter vi.
' But as the hospital has no vivisection license, only the most elementary microscopic work can be
carried on there.
* As this report poes to press, it is reported that Charing Cross, following the example of St. George's
and Westminster, has abandoned the teaching of the sciences.
CLINICAL INSTRUCTION: GREAT BRITAIN 197
wise occupied by physiology; at Middlesex, in that belonging to bacteriology. Facili-
ties for the making of vaccines are common in London especially. Everywhere the cor-
relation is excellent, for the student knows the clinical history of the case from which
the material studied is derived; hospital and medical school are thus admirably
involved with each other. But the arrangements are too frequently limited, and for
that reason likely to reduce to the barest instrumental role the part that the labora-
tories play in the elucidation and management of clinical problems.
At the third level, that of clinical research, proper provision is almost altogether
lacking. A recent gift has equipped for the first time a research laboratory in one
of the pavilions of the Royal Infirmary at Edinburgh; but it forms a separate trust,
administered by three physicians and their coopted successors: the university is not
a party in interest. The laboratory occupies a suite of three rooms, one equipped for
obtaining graphic records, the second for radioscopy, the third for electro-cardio-
graphy. Space once required for the teaching of elementary chemistry and physics,
before that instruction was wisely abandoned, has been converted at St. George's
into research rooms under the direction of the lecturer in pathological chemistry.
A cancer institute is connected with Middlesex Hospital. The prospect of clinical
research in general is darkened by the prejudiced exclusion of animal experimen-
tation. St. George's has been bold enough to obtain the requisite license; but the
scientific spirit is not as yet sufficiently widespread in Great Britain to warrant the
expectation that British hospitals generally will soon defy the obscurantist minor-
ity of which they have so long stood in dread.
While weak in laboratory equipment, I hasten to add that whatever devices tan-
gibly contribute, or are credibly supposed to contribute, to direct therapeutics, the
voluntary hospitals introduce as rapidly as their financial resources allow. For the
care of patients they are therefore equipped in a progressive spirit. Great emulation
is displayed in this matter: the various institutions vie with one another in operat-
ing-room installation. X-ray plants, colored-light baths, etc. But back of these im-
provements lies largely only the practical, empirically assimilative spirit: the criti-
cal, aggressive, inquiring initiative that itself invents or discovers may and does crop
out in individuals, but it is not reckoned with in the structure and equipment of the
hospitals themselves. "Hospitals have been built by men who had no idea whatever
of their scientific needs," says Professor Osler.^
In their character of hostelries for the sick, the voluntary hospitals are practically
without exception capacious enough to furnish the student with the necessary mate-
rial. We shall shortly present this point statistically. Meanwhile, pursuing the con-
sequences of intense preoccupation with charity, just as though that were more or less
inconsistent with science or scientific education, the voluntary hospital goes but a
short way in differentiating cases. As opposed to the high degree of specialization of
topic necessarily brought about wherever investigation is prominent, — for research
1 Address on "The Hospital Unit in University Work," in the Lancet, January 98, 1911.
198 MEDICAL EDUCATION
and specialization go together, — the voluntary hospital makes about the same dis-
tinctions that are made by the family doctor. It has physicians, surgeons, obstetri-
cians; construction accommodates itself to these fundamental distinctions, — rarely
to anythinf more. Even where, as at St. Thomas's (London), separate buildings are
found, they are not distinctly appropriated to specific purposes. Pediatrics and psy-
chiatry are nowhere treated as specialties; dermatology not as yet invariably. Chil-
dren commonly occupy beds scattered through the women's wards. Though separate
wards Ix; provided for them, as at St. ]\Iary's, no separate department is constituted:
a few children's beds are attached to each medical service. Neurology is similarly
disposed of University Hospital (London) takes no advantage of the presence of
a distinguished neurologist on its staff. He gets no more psychiatric patients than
his colleagues; like them, he is burdened with a miscellaneous medical routine. At
King's, dermatology falls to a specialist; at Guy's and Charing Cross, to a visiting
physician; there is a special hospital for skin diseases at Liverpool; at jManchester,
apparently not even a special division in any of the infirmaries. At Edinburgh,
however, separate pavilions of the Royal Infirmary are assigned to ophthalmology,
otology, and dermatology.
There is a prevalent notion that breadth of training is in some way connected
with the lack of specialization, though, as a matter of fact, the shoe is on the otlier
foot. Thoroughness is dependent on differentiation. The German internist and the
German pediatrist being two individuals, not one, each in the first place an excel-
lently trained chemist, physiologist, and pathologist, are masters just because they
are content to work thoroughly a limited field. Is the outlook of a student who learns
internal medicine from the former and pediatrics from the latter really narrower than
that of the student who learns both from one instructor? Excessive sweep may indi-
cate vagueness rather than breadth.
We have spoken of the physicians, assistant physicians, house officers, etc., con-
stituting the staff of the voluntary hospital. But of the functional organization of
this body there is as yet hardly a trace. The German clinics are sharply differentiated,
each an entity, conducted by a "team." Professor Osier has very happily designated
this entity "the hospital unit." ^ The team composed of cooperating individuals, each
charged with certain specific duties, all properly subordinated to the ultimate and
appropriate purpose, forms the departmental staff. One may figure such a staff as
pyramidal in structure: at the bottom, helpers; above them a set of laboratory aids or
volunteers; next a series of assistants, each with definite responsibilities, all culmi-
nating in the professor, or, as he is aptly called in Germany, the director of the clinic.
Each of the components in this organization is relatively permanent; by reason of
the purposeful subordination of its parts to one another, the organization is so stable
that promotions when earned do not upset its working. By way of contrast, the Eng-
lish hospital staff consists of isolated units, like a dotted line, perhaps two parallel
'In the address above referred to.
CLINICAL INSTRUCTION: GREAT BRITAIN 199
dotted lines : the top row represents the visiting physicians and visiting surgeons, some
three to five of each, coequal in authority ; the next row, equal in number of individuals,
represents the assistant physicians and the assistant surgeons. No functional relation
really subsists between the two. They are called a "firm," — each phvsician or sur-
geon and his assistant, — but they do not form a team. Their activities are severed:
the physician looks after the patients in bed; the assistant physician is physician
to the out-patients. They do nothing together. When the physician is absent, the as-
sistant physician substitutes, as "locum tenens;" when the senior returns, the junior
slips back to his out-patients. In rare instances, the assistant physician has a few
beds: at Middlesex, through the courtesy of his chief; at the London, in virtue of
an arrangement, according to which, out of every five cases admitted, the chief gets
four, the assistant one. Lender such circumstances, they are still completely indepen-
dent of each other; the physician's beds are ^w, as the assistant physician's are his.
Each does practically all that is done for and with his particular charges. The labora-
tory men stand in the same instrumental relation to all members of the staff: they
report objectively on specimens of sputum, urine, and blood to Avhoever sends them.
Clerks and residents tarry for such brief periods — the former for three or four months,
the latter for six — that they cannot enter as definite elements into an organized
scheme. Under such circumstances, the hospital is hardly more favorable to intensive
work than the ordinary private house.
The management of the British hospital is highly centralized. Its business affairs
are intrusted to a single officer, — secretary or superintendent, — designated by the
governors, and acting under their instructions; the management would seem to be
highly efficient. At the London, St. Thomas's, Middlesex, this official is a layman; at
Guy's, the Western (Glasgow), etc., a medical man. The relations between the execu-
tive officer and the hospital staff are now, as a rule, excellent. For their respective
spheres are, as in Germany, shai-ply delimited. How effectually clean-cut demarcation
of executive from medical responsibility eliminates friction is strikingly illustrated
at Guy's, where Sir Cooper Perry is not only superintendent, but visiting physician.
He holds and exercises his several functions rigidly apart: as visiting physician, he
virtually ceases to be hospital superintendent; as hospital superintendent, he lays
aside the character of medical man. His medical knowledge and experience may affect
his course; but qua superintendent, he does not deliberately rely on it. The same
may be said of Dr. Donald Mackintosh, superintendent of the Western Infirmary at
Glasgow. The title of "medical superintendent" is a misnomer in Great Britain as
in Germany, if it is interpreted as in any wise qualifying the supremacy of the physi-
cians and surgeons in their respective wards. There is no interference with them from
any source whatsoever. Trouble has indeed arisen at times, when too busy consult-
ants have slighted their hospital engagements. But friction due to meddling would
be one thing, as friction due to neglect is quite another. The former is for all practi-
cal purposes unknowTi. A dietary and a pharmacopoeia are agreed on in advance;
200 MEDICAL EDUCATION
departures are exceptional, — usually allowed, but liable to scrutiny. In general,
then Great Britain bears out the experience of the Continent, that sharp differentia-
tion of function as between administration and medical oversight is conducive to effi-
ciency and carries with it no countervailing peril, provided only the staff members
hold definitely to their obligations.
In admitting patients, the voluntary hospital pays a certain deference to its sup-
porters: subscribers have the right of recommendation. Thus, at St. Mary's, "annual
subscribers of one guinea to the maternity fund may recommend three patients an-
nually to that department; and so on in proportion to the amount of the subscrip-
tion."^ Nor is this privilege anywhere limited to maternity patients. Recommenda-
tion, however, is nowhere conclusive. For in the last resort, the hospital retains the
right to refuse admission, if vacant beds are scarce, if the case lies outside the scope
of the institution, or if out-patient treatment will suffice. I am assured that, though
occasionally, in deference to requests, unsuitable cases may be taken in, the privilege
has had little appreciable influence from the standpoint of teaching; for patients thus
admitted are utilized like any other. The matter of admission is usually in the hands
of resident medical and surgical officers ; occasionally, as at St. George's, it is left to
the staff, attending in rotation. This method, apparently once quite usual, has been
generally discarded because it was discovered that one of the ways of making staff
positions serve consultant prosperity was through the admission by the staff of the
dependents of their patrons or those of their medical clients.^ The servants of the
well-to-do thus took precedence over the neighborhood poor.
We have now considered in Great Britain, as we did in Germany, the fashion in
which the teaching hospitals are built and manned. Let us see how the facts brought
out affect their threefold function, the care of the sick, research, teaching.
The brunt of the routine hospital work falls on the resident officers, — resident
physicians and surgeons holding for terms running from one to three years, internes
appointed for six months, medical and surgical registrars responsible mainly for the
case records, and the nursing staff. While visiting physicians or surgeons may be had
in any emergency, the regulations respecting their regular attendance vary. In many
of the London hospitals, they attend only twice or thrice weekly, for two hours, more
or less, on each occasion; but at St. Bartholomew''s, some staff members attend four,
others five days each week. In London, visits to the hospital are made in the after-
noon; in the provinces and Scotland, in the morning. The hours are not always sa-
cred; for Treves is mentioned as a striking instance of a surgeon who never permitted
a private patient to interfere with his hospital engagements. In Scotland, attend-
ance appears to be more frequent: at the Western Infirmary, Glasgow, the physicians
are in daily attendance from nine to eleven or later. One must not infer from the
* St. Mnryg Hospital Report, 1909, p. 33.
* " Taking in request rases from general practitioners" (private letter from the secretary of one of
the metropolitan hospitals).
CLINICAL INSTRUCTION: GREAT BRITAIN 201
generally brief periods of attendance that patients are neglected. As a matter of fact,
it is probable that nowhere else in Europe is the level of hospital comfort so high.
The resident officers do not spare themselves; and the nursing is in the hands of a
superior class of trained women. The continental observer, indeed, frankly admitting
the excellence of the nursing, is apt to regard the English trained nurse as having
usurped some of the staff physician's responsibility. Should this be true, it would
prove but another consequence of voluntary organization. Where the staff is unpaid,
promotion by seniority is their reward; the privilege of scanting their hours cannot
be strictly denied to them; residents and nurses must then step into the breach, as
occasion requires. It must have been long since obvious to the reader that to the
second of the three essential functions, clinical and surgical research, the voluntary
hospitals as now conducted are wholly unsuited. The absence of laboratory facili-
ties, the prohibition of animal experimentation, the unorganized character of the
staff, the lack of differentiation of material, — these conditions are all hostile. Re-
search is encouraged only where material is concentrated and differentiated. Definite-
ness favors the formulation of problems and provides sufficient material for their
investigation. And not only facilities, but reward and appreciation, are lacking. For
scientific achievement has no sure consequences. The line of promotion will not be
broken to take in outside talent. Fidelity is more profitable than originality. While
the German assistant trains for his promotion, the English junior waits for his, not
in idleness, to be sure, but in what for our purpose is almost as destructive, — in the
perfunctory, even if assiduous, performance of miscellaneous school and hospital jobs.
His spirit is crushed w'hen, at forty or later, he gets into the wards. Clinical research
is therefore occasional, precarious, and individual, not characteristic, systematic, and
institutional.^ And, it may be added, it cannot be otherwise where teaching-posts
are viewed as pawns in a professional game, and hospitals are keenly alive only to
claims for immediate medical and surgical relief.
The limitations bv which medical education in Great Britain is hampered have
now been candidly exposed. It is nevertheless true that in respect to the student,
nowhere else in the world are conditions so favorable. In our discussion of Germany,
we pointed out that its clinical instruction was overwhelmingly demonstrative ; that
the student saw and heard, but ahnost never did. Clinical education in England has
completely avoided this wasteful error. It is primarily practical. It makes, indeed,
the huge mistake of assuming that a more scientific attitude toward the problems
of disease is in some occult way hostile to practicality ; for it protests against the
adoption of modem methods of investigation, as though practical teaching would be
i In some places, a good deal of haziness appears still to characterize the notion of clinical research.
Applying for a government grant to encourage research in the Extra-Mural School of Edinburgh,
the chairman of its governing body recently testified : "The research question is chiefly bound up
with classes like physiology, ft is not so much bound up with the ordinary practical classes such as
medicine and surgery " Report of Committee on Scottish Universities and Minutes of Evidence, p. 64.
(London, 1910).
202 MEDICAL EDUCATION
in some inexplicable fashion endangered thereby. However that may be, the English
are indubitably correct in holding that sound medical training requires free contact
of the student with the actual manifestations of disease. It is the merit of English,
and, lis we shall also perceive, of French, medical education that the student learns the
principles of medicine concurrently with the upbuilding of a veritable sense experi-
ence in the wards, and that he acquires the art of medicine by increasingly intimate
and responsible participation in the ministrations of physician and surgeon. The
great contribution of England and France to medical education is their unanswer-
able demonstration of the entire feasibility of the method of insfruction which the
end sought itself imposes. The British schools have another important achievement to
their credit: they have proved that the most uncompromisingly sound and practical
instruction can be furnished in hospitals privately supported and managed. It is im-
possible to exaggerate the importance of this fact. Medical education of the exacting
type we have advocated appears on the face of the papers to be reduced to a choice
between bankruptcy and compromise: the former horn of the dilemma threatens, if
the medical school insists that the hospital should invariably constitute part of its
owTi plant; the latter, if it tries to hit off a viodus vivendi with a hospital not its
own. Experience disposes of both fears. Germany shows that municipal hospitals can
be just as satisfactory as state or universitv hospitals; Great Britain shows that
private hospitals are improved by their utilization for educational purposes. The
Germans still need to introduce student activity; but to this criticism the univer-
sity hospital is open equally with the municipal. The British hospitals still need to
adjust themselves to a new order of staff appointment. But it will be time enough
to announce this as impossible after it has been unsuccessfully attempted.
On the teaching side, the point to lay hold of, then, is this : given the ancillary
sciences, medical education is thenceforth essentially an "apprenticeship" in so far
as it must be acquired through actual handling of material. It is, of course, some-
thing more too; unlike plumbing or carpentering, medicine is not mere handicraft;
the practitioner of the medical art must grasp principles. And for two reasons": in
the first place, the emergencies in which he will be called on to act are infinite in
number and complexity. No amount of training will insure his having been drilled
in the medical school to act in the precise set of circumstances he is liable to en-
counter: only comprehension of principles abundantly, but at best partially, illus-
trated can guide him in the novel environments in which he will be placed. A sup-
ple and resourceful mind trained in principles and intelligently experienced will alone
avail in dealing with the inevitable surprises of medical practice. Again, the phy-
sician practises an art which changes from one day to the next. A literal practical
apprenticeship imposes upon him the limitations of the moment. He must grasp
prmciples, problems, and possibilities if he is to appropriate progress, if he is con-
tmuously to revise his methods and practices. The medical apprenticeship must there-
fore rxi shot through with ideas. Direct and continuous observation of disease must
CLINICAL INSTRUCTION: GREAT BRITAIN 203
famish the starting-point of discussion and reading, which illuminate, expand, and
relate experience.
To the installation of the apprenticeship there are two preconditions: the unham-
pered freedom of the staff within the wards, and a sufficient supply of clinical mate-
rial. Both conditions are universally met in Great Britain. Indeed, it may be laid
down as axiomatic that wherever in Great Britain medical teaching is carried on,
the staff is free and material is adequate ; otherwise, the attempt to teach would not
be made. I have already pointed out that hospital administration and medical care
are sharply sundered. On this score no friction arises. Trouble may come from fail-
ure of the staff to respect their engagements, but while insistence on obedience to
the hospital rules governing attendance may limit a physician's right to neglect his
duty, it can hardly be regarded as a limitation upon his discretion within his wards.
The hospital managers never interfere with the medical supremacy of the staff; nor
do they annoy them with fussy regulations governing the admission of students to
the wards. Students come and go informally, without let or hindrance. They feel their
responsibility, for they are utilized as important cogs in the hospital machine. \'ery
rarely, — at Birmingham, for example, — a rule limits the student's hours to the morn-
ing; but even there students come in the afternoon, nevertheless, and no objection
is made. Thoroughly characteristic is the attitude of St. George's, where it is ex-
pressly stated that "students are permitted to enter the wards of the hospital at any
hour except at meal times." These privileges are heartily, not grudgingly extended :
no pretense is made that the hospital confers a favor on the school, for their essential
interests are identical ; nor that patients suffer, for they clearly gain ; nor that sub-
scribers resent the connection, for they have been educated to desire it.
The supply of clinical material needed for concrete individual instruction must
needs be proportionately great. Two points are to be noted: the British medical school
is situated only in populous towns; its enrolment is, excepting only Edinburgh, never
excessively large.^ The smallest English town containing a complete medical school is
Newcastle-upon-Tyne, with 266,671 inhabitants; Sheffield has almost half a million,
Birmingham over half a million, Liverpool and Manchester over 700,000 each. Car-
diff, the seat of the only school in Wales, has a population of 182,280. The four
Scottish schools are situated in towns ranging from 169,409 (Dundee) to 578,478
(Glasgow parish only); Edinburgh has 320,315. None of the British schools is handi-
capped by local poverty of material.
The teaching hospitals undertake, as a rule, to supply beds mainly for internal
medicine, surgery, and gynecology. For these, the London schools run the gamut
from the 200 beds of Charing Cross ^ and Westminster to 922 at the London : inter-
1 The largest medical school in England is at Cambridge, a small town : but no effort at clinical teach-
ing is made beyond a few general lectures. The Oxford and Cambridge students go elsewhere, usu-
ally to London, for their clinical training, as I have already pointed out.
2 A few temporarily closed at the time of my visit on account of lack of funds.
204 MEDICAL EDUCATIOxN
veiling come St. George's, St. Mary's, Middlesex, and University, each with some-
thing above 300; St. Thomas's with slightly under, and Guy's with slightly over, 600,
and St. Bartholomew's with almost 700. The provincial schools at times are even
more richly provided: the lioyal Infirmary at ^Manchester contains 592 beds; the
fetlerated clinical school at Liverpool controls 1050 beds, that of Sheffield 427, the
amount of material being absurdly out of proportion to the facilities for educational
handling of it. Glasgow has access to some 1200 beds, — 600 in the Western Infirm-
ary, where male students are concentrated, and 588 at the Royal Infirmary, where
women students are sent. Aberdeen has a general hospital of over 200 beds; Dun-
dee, one of over 300. Edinburgh, despite its 910 beds, is confronted by something
of a problem, shortly to be considered. In general, it is clear that the schools run far
below capacity in the matter of clinical teaching.^
In the distribution of material, surgery as a rule slightly preponderates, but medi-
cine is amply represented. The following table exhibits the distribution of beds:
Skin Private
17
27
36
Hospital
M
Medicine
Surgery
' Gynecology
Children
Eye
Ear, Nose
Throat
London
314
343
33
77
26
10
St. Bartholomew's
236
315
32
25
20
Guy's
236
279
24
37
10
St. Ttiomas's
180
232
30
34
25
St. Mary's
85
112
12
28
7
8
Westminster
76
93
10
13
Royal Infirmary (Manchester)
240
300
^0
Royal Infirmary (Edinburgh)
40-2
350
53
52
22
25
The virtual capacity of some of the hospitals is considerably increased by the
possession of convalescent homes, to which at the proper moment patients may be
removed for recuperation : St. Bartholomew's Convalescent Hospital, at Swanley in
Kent, accommodates 70 patients; that of St. George's, at Wimbledon, 100; that
of the Western Infirmary (Glasgow), at Lanark, 42; that of the Royal Infirmary
of Edinburgh, at Corstorphine, 100. The material in the wards can thus be kept in
more rapid movement.
The open spaces in the above table are variously filled in. Contagious diseases —
fevers, as they are called — are abundantly provided by the fever hospitals main-
tained by the municipalities, — in London, with an aggregate of over 7000 beds;
mental diseases are found at insane asylums, the modern psychiatric clinic being as
yet nowhere established; the out-patient departments supply an immense quantity
of material in all the so-called specialties, the few beds occasionally devoted to them
being thus largely supplemented. Hitherto obstetrics, also, has been in London an
^ As a rule, no provision is made by English free hospitals for private pay patients; these are usually
attended at their residences or in "nursing homes.' Pay beds for patients of this description are
found, however, at St. Thomas's and Guy's. Any physician or surgeon inconsultant practice may have
patients in them; the fees are arranged between patient and physician, — with that the hospital has
no concern; nursing and maintenance cost 9 shillings adav at Guy's, 12 shillingsadayat St. Thomas's.
The number of beds thus available is small : some 27 at Guy's, 36 at St. Thomas's.
CLINICAL INSTRUCTION: GREAT BRITAIN 205
out-patient affair. In the provinces and Scotland, special lying-in hospitals exist,
usually affiliated with the medical school. The Glasgow student, for instance, has
access to a maternity of 108 beds. Under pressure from Oxford and Cambridge, the
London hospitals are at this moment introducing in-patient obstetrical teaching,
small wards being in process of creation for the purpose. Children's hospitals, with
from 80 to 100 beds, are found at Liverpool and elsewhere.
The distribution of beds to the visiting staff varies somewhat : at Charing Cross,
a staff officer controls 20 beds ; at Westminster and St. Mary's, 30 odd ; at Middle-
sex, 40 to 50 ; at the London, 60. At St. Bartholomew's, from 36 to 49 beds are allot-
ted to a physician ; 60 odd to a surgeon. At Manchester, the physician gets 35, the
surgeon 61. Assistant physicians and assistant surgeons have, as a matter of right
and generally as a matter of fact, no beds, though, as I have already mentioned, at
Middlesex and elsewhere they may receive them through the courtesy of the superior,
and at the London custom allots out of every five in-patients, four to the chief, one
to his junior. At Manchester, an assistant physician may have from 4 to 8 beds;
an assistant surgeon 3. At Edinburgh, the surgeons average 56 beds apiece, the
physicians something over 40; the gynecologist has 27.
The service is everywhere continuous, broken only when the chief is on vacation,
during which period the assistant substitutes. A peculiar — and decidedly bad —
arrangement has, however, been introduced at Sheffield, where, instead of dividing
the entire medical or surgical service between three individuals, each doing continu-
ous duty in his own division, the three visiting physicians succeed each other, taking
turns. During a physician's turn, all entering patients are his. \Vlien his period lapses,
the incoming patients all belong to the succeeding physician ; but the former officer
continues to look after the patients who came to him during his term of duty. When
they give out, he is without occupation until his turn comes round again. By this
strange system he is heavily overworked at one time and under-occupied at another:
meanwhile, as there is no bed that he can permanently caU his own, continuity of
interest or application is not to be expected.
In abundance and variety out-patient departments correspond closely with the
hospitals to which they are attached, as the following table shows. Especially notice-
able is the enormous number of casualties handled:
•206
MEDICAL EDUCATION
Itistitution
New
Cases ^
Med-
ical
Sur-
gical
Cas-
ualtv*
Mid-
wifery
Gyne-
cology'
c;ii7-
dren
Ortho-
paedy
.Eye
Ear,
Nose,
Throat
Skin
London
95,682
15,524
23,337
15,067
5,163
2,287
394
8,002
9,085
9.160
St. airtholomew's'
130,289
63.513
46,685
1,141
1,601
678
743
4,007
5,289:
3.321
Guy's
130.490
11,687
6,732
98,131
3,555
509
6.199
4,152
3,943
St Mary's
52.011
25,195
630
Middlesex
51,318
32,259
471
University
52,709
4,572
2,815
35,945
1,312
903
2,140
1,852
1.537
SL Thomas's
83,728
61,323
1,377
St George's
41,627
7.080
28,759
267
488
948
601
Royal Infirmao'.
Manchester
33,714
7,631
Royal Infirmary,
Liverpool
27.852
3,465
10,538
3,764
511
1,679
2,107
867
Western Infirmary,
Glasgow
29,254
Royal Infirmary,
Aberdeen
16,796
* Each case counts once only.
' Medical and surgical.
'Casualty cases not separate.
Unlike the German medical student, the Engli.sh student of medicine is treated
like a schoolboy. A record of his class attendance is carefully kept; from time to time
written tests are given in order to determine his standing. For this his immaturity
and lack of thorough preHminary education are dou})tless responsible. He hears a
certain, steadily diminishing, number of lectures, — usually three times weekly in
medicine, an equal number in surgery, and considerably less in midwifery, gynecology,
and therapeutics. They are of two kinds: clinical and systematic. The former turn
about a patient, and are analogous to the demonstrative clinics held in Germany.
But they differ from the German lecture in their more directly practical and less
scientific character: they are less stimulating than the German discourses bristling
with ideas and problems and always conceived from the standpoint of scientific de-
velopment. The didactic exposition kept up in Great Britain, though generally dis-
believed in, does little more than expound a text-book. Students capable of reading
a volume on the theory and practice of physic could assuredly disf>en.se with the.se
didactic lectures. Perhaps they are retained because the matriculation requirement
does not as yet furnish a satisfactory guarantee. As a rule, they are given in rotation,
the staff of three to five members dividing the field between them ; but as the British
consultant is only rarely an expert in a particular field, the divisions serve no purpose
but convenience. At Edinburgh, instruction by lecture is more prominent than else-
where. There I wa.s authoritatively told that "the high quality of the Edinburgh man
is due to the excellent quality of his .systematic lecture training." My subsequent ex-
perience led me to regard this claim as an unconscious apology for certain conditions
that hamper the university in its use of the Royal Infirmary. In general, it is hardly
CLINICAL INSTRUCTION: GREAT BRITAIN 207
an exaggeration to say that the didactic lecture might drop out perhaps almost
entirely without seriously crippling the instruction.
For the backbone of British clinical education is the actual and continuous parti-
cipation of the student in the care of the sick. Armed with an introductory know-
ledge of the underlying sciences, students "come over" from the college building
into the hospital, where they are first of all trained to obtain and to interpret
physical signs.^ The course lasts three months; but at the conclusion of a fortnight,
"clerking" starts. At the London Hospital, for example, the class is so divided that
six students are assigned to each "firm." The teaching unit consists there of physi-
cian, assistant physician, house physician, and half a dozen students: it has 60 beds
to work with; there are as many such units as there are "firms," The routine begins
with a practical exercise, in which the medical registrar ^ instructs the students in the
systematic taking of notes,^ whereupon the house physician escorts the group on its
first ward walk, allotting the cases in rotation with a brief description by way of
enabling the new clerk to take hold. As old cases leave and new ones come in, allot-
ment in turn continues. Each clerk is responsible for a complete history and descrip-
tion of each of his cases, including the requisite microscopical examinations. He has
all necessary freedom and facilities, entering the wards without ceremony and readily
procuring such material as he may request. The house physician or the clinical patho-
logist conducts general courses in the clinical laboratory and lends special assist-
ance in the difficulties and problems that the young clerk inevitably encounters. His
notes on the case must show what he has done. He is compelled, therefore, to be
definite in his statements. These notes, criticized by the medical registrar, revised,
and completed, frequently form an essential part of the records of the case.
The house physician makes rounds daily with the clerks from 9.30 to noon. Two
afternoons weekly the senior physician conducts the same group over the same ground.
At the appointed hour, all clerks assemble, — at St. Thomas's, in the great rotunda,
at St. Bartholomew's, in the ancient courtyard. On the appearance of their chiefs, the
men form into small groups, and quickly disperse to their respective labors : the quiet
of the long wards is not appreciably broken, for they move noiselessly from cot to
cot, conversing in low tones over the patient under discussion. House physicians and
clerks alike are subjected to a thorough "grilling" at the hands of an experienced
consultant. Though conducted in a charming spirit, the confrontation is necessa-
rily a severe trial. As each case is reached, the clerk responsible steps forward, reads
his notes, and defends his findings, his proposed diagnosis and suggested treatment,
in reply to the interrogations of the physician. The house physician is necessarily in-
volved; the kindliness and informality with which the conference is conducted enable
any student to take part in the examination of the patient, in the elucidation of the
1 This course is variously designated as elementary medicine, practical medicine, or physical diagnosis.
2 Who has charge of the case records ; see page 193.
3 Convenient printed directions for case-taking are furnished to each student.
208 MEDICAL EDUCATION
diagnosis, in the suggestion of appropriate therapeutic measures. I witnessed, for ex-
ample, the bedside work at St. Bartholomew's, where five clerks followed the visiting
physician. He took up three heart cases in succession. Though one clerk reported in
detail on each, every one of his fellows might, the patient's condition permitting,
make a brief examination. For every case that the student himself reports, he sees four
more demonstrated, and at such close range that more or less independent verification
is frequently possible. When a case terminates fatally, the teaching group repairs as
a unit to the dead-house to submit their entire procedure to the searching test of the
autopsy table. This routine continues during two terms of three months each, differ-
ing only in so far as more difficult cases are assigned during the latter term.
The method outlined fills every retjuirement of sound and thorough teaching. The
student observes the patient from all sides : he notes symptoms at the bedside, he
examines secreta and excreta, he sees both sets of facts in the light of the case his-
tory; he watches progress and development, for he visits his patient daily from the
time of admission to the day of dismissal; he can form his own conclusion, propos-
ing whatsoever procedure his experience or reading suggests to him. In all these steps
his faculties are in continuous and complete exercise, every activity germane to the
occasion — observation, inference, diagnosis, treatment — being intimately and con-
tinuously correlated with every other. And all the while the Avelfare of patient and
student are absolutely safeguarded, for the student's observations and suggestions
are promptly checked up, criticized, and revised by his superiors in the wards and
the laboratories. He has every inducement and opportunity to active and responsible
exercise of his faculties under conditions that entirely deprive the opportunity of the
peril of inexpert medication.
Substantially the same procedure is followed in surgery. Corresponding to the in-
troductory exercises in physical diagnosis on the medical side there is a six weeks'
preliminary training in surgical dressing in the out-patient department, designed to
drill the student in applying bandages and splints, dressing cuts, etc., followed by
a three months' practical course in elementary surgery, devoted to surgical diagno-
sis and the principles of aseptic and antiseptic procedure. Thenceforth the surgical
teaching unit, composed of surgeon, assistant surgeon, house surgeon, and six stu-
dents, enters upon a daily practical routine likewise lasting six months. The surgical
registrar instructs in the taking of notes; the beds are allotted by the house surgeon
in rotation. In the operations, which take place four times weekly, — senior and
junior staff surgeons each operating on two days, — the "dresser," as he is now called,
is, next to the house surgeon, first assistant in his ovm cases; he aids in their prepa-
ration, under strict oversight, of course. At the London, during three days of every
fortnight he lives in the hospital, now assisting in the receiving room, later making
ward rounds with the house surgeon, aiding in the application of dressings, the giv-
ing of anaesthetics, treatment of fractures, etc. On occasion of a bedside consultation
between a physician and a surgeon, the students of both attend. Toward the close
CLINICAL INSTRUCTION: GREAT BRITAIN 209
of his schooling, the student gets a course in operative work on the cadaver. Even
though it be admitted that this last-named sort of surgical instruction is nowadays
antiquated, operative courses on animals are impossible under the existing laws.
Midwifery is treated similarly : the student serves as in-patient clerk to the obste-
tric physicians for at least six weeks, during which period he takes histories, conducts
pelvic examinations under the supervision of the resident obstetrician and obstetric
registrar, and serves as second assistant at operations. Thereupon, for a fortnight,
he goes on duty in the out-patient maternity, — day duty one week, night duty the
next. Cases are assigned in rotation ; on a clerk's first cases he is accompanied by the
junior resident obstetrician; later, he acts alone, but under definite instructions as
to seeking aid, if difficulties arise. Material is so plentiful that a student may easily
procure from thirty to fifty cases, twenty being required. Recently, Cambridge and
Oxford have stipulated that students entering for their medical degrees must have
had also an in-patient obstetrical training. The provincial and Scottish schools have
long provided for this. The London schools are just beginning to do so : 8 beds
have been set aside at Guy's, 10 at Middlesex, 12 at St. Mary's, 8 at University, 9
at London, 20 at St. Thomas's.
The principles and methods above explained could be, if necessary, still further
exemplified in the required clerkships in gynecology, ophthalmology, and " fevers,"
in the last of which a six weeks' clerkship must be served in one of the contagious
disease hospitals maintained by the city. Optional clerkships are open in skin diseases,
diseases of the ear, nose, and throat, and anaesthetics. Vaccination is compulsory.
English clinical education amounts, then, to a series of posts or appointments,
each characterized by the active participation of the student incumbent. Though the
little coteries thus formed are short-lived, their members are for the time being on
a most intimate footing with one another. "The English clinical teacher," remarked
one of the most distinguished of them, " is the teacher of his clerks." No matter who
or how many attend his lectures, his pupils are specifically those with whom he talks
at the bedside. An intense loyalty is highly characteristic. There is no migration; the
student clings to the hospital of his original choice; and his personal attachment
to his instructors is the corner-stone on which the consultant system securely reposes.
The method transmits the prevailing type, — the "practical physician," as he is eulo-
gistically called. But it would be equally effective in transmitting a higher and more
modem type : it is not inherently limited to any particular kind of clinical training.
The posts open to the student vary somewhat from place to place. The appoint-
ments comprise in-patient and out-patient clerkships, in-patient and out-patient
di'esserships, clerkships in pathology, in clinical microscopy, and in each of the spe-
cialties. Over five hundred such appointments are annually made at the London Hos-
pital; elsewhere in proportion. Senior students are eligible to appointment as house
physician, house surgeon, junior obstetric assistant; to the posts next higher, salaries
are usually attached — those of resident medical or surgical officer, the registrarships,
210 MEDICAL EDUCATION
casufilty officers, clinical assistants, curator, etc. The period of tenure of clerks and
dressers varies slightly, being four months at University, St. Mary's, and Westminster,
three at London, St. Bartholomew's, Guy's, and St. George's. To some extent, posts
are optional, and so far elective opportunities are provided for the more energetic and
capable. But it must be noted that these additional opportunities do not differ in
intensive quality from the required appointments. A student may, in other words, lill
more posts than he is bound to fill; but they are all alike of limited, though fortu-
nately concrete, character: optional chances to forge far ahead along some line of
awakened interest are nowhere furnished as part of the system.
The number of beds assigned per student — and, it may fairly be added, the theory
of the subject — varies with the prevailing relation between the size of the hospital
and the size of the school. The small schools regard a large average of beds per stu-
dent as highly desirable, for, it is argued, the student thus sees a considerable vari-
ety ; the large schools aver that a smaller average of beds per student conduces to
thoroughness of study. On the whole, it would appear that the student (who has, it
must be remembered, other things to do) can occupy himself fully with 5 beds or there-
abouts; he has 6 at ^Middlesex, from 8 to 10 at St. George's and St. Mary's, from 5 to
10 at the Royal Free, 10 at Westminster, 5 at the Royal Infirmary (Manchester),
16 at Sheffield. At the Royal Infirmary (Liverpool), the registrar assigns each stu-
dent 5 or 6, and looks after the rest himself; a surgeon at the Northern (Liverpool)
has four dressers with 8 beds apiece. Not every patient is educationally valuable. For-
tunately, material is, as a rule, so plentiful that the useless can be freely discarded.
At Liverpool and Sheffield, it is indeed so plentiful that the school is lost in its
clinical facilities. An indefinite supply of material is of infinite importance to gradu-
ate workers or clinical investigators, for, according to the doctrine of chances, the
probability of finding precisely the cases they want, and in sufficient variety, increases
directly with the number of beds on which they can draw. But for the training of
students a certain degree of concentration is requisite : the student is largely formed
by the atmosphere and organization in which he acquires his clinical instruction.
A medical school with a small body of students needs, in the first place, not many
hospitals, but a hospital: a hospital sufficiently commodious, compactly organized,
well equipped, competently conducted, and permeated with educational ideals. In
London, one never escapes the school atmosphere while in the hospital. The student
has insinuated himself into its every nook and cranny. The atmosphere is redolent of
study and teaching. The Liverpool and Sheffield clinical schools are, on the contrary,
a congeries of hospitals containing beds in point of number out of all proportion
to the size of the student body: 75 to 100 Liverpool students are lost in wards con-
taining 1000 patients; 20 to 30 Sheffield boys make no impression on the 600 beds
nominally constituting the clinical school. Teaching is incidental, not dominant. ITie
clerk and the dresser lead an unreal life, for they are too casual to become calculated,
responsible, and uniform parts of the hospital mechanism.
CLINICAL INSTRUCTION: GREAT BRITAIN 211
How large a school can be conducted on the London plan? That appears to be
entirely a matter of organization. There are practically 240 medical beds at Guy's :
we may suppose five services of approximately 50 beds each. Each service would ac-
commodate 10 clerks with five beds apiece: 50 medical clerks could then simultane-
ously serve a four months'* in-patient clerkship. In the course of the year, — vacations
being at this stage abolished, as Professor Osier suggests,^ — 150 students would pass
through the medical wards. If, now, the other services were similarly in operation and
the out-patient departments properly utilized, it is obvious that the larger London
hospitals, properly equipped and manned, could carry much larger schools than now
exist there without derogation to the practical chai'acter of the training offered.
^Vhether because of its detachment from the service of the chief or because of the
relative abundance of in-patient material, the out-patient department plays only a
secondary role in medical instruction. It cannot be regularly employed — as in Ger-
many— as a reservoir, from which the chief can draw what the beds do not supply,
or supply too scantily, but is utilized for the specialties, for tutorial teaching, and for
the introductory courses in physical diagnosis, bandaging, etc. On the surgical side,
a required out-patient dressership always precedes the in-patient dressership. On the
medical side, it is held that out-patients are necessarily too summarily disposed of to
serve the formation of good working habits. During the formative period, the stu-
dent keeps to the wards.^ The out-patient department nevertheless gets its day, for
it is the arena in which, just preceding examinations, the tutors put the prospective
candidates through their paces. I witnessed an out-patient clinic of this kind at
Manchester; five or six students attended. The material was abundant; from it
the physician in charge selected the interesting material for distribution to the stu-
dents, who, retiring to adjoining rooms, went over their cases, while he attended to
those left on his hands. Reassembling later, the clerks described their own patients
and watched those exhibited by the others. But for the depressing foretaste of the
impending examination and the teacher's cautions to avoid this pitfall or that,
in his anxious interest for the student's success, the exercise was most valuable. At
St. Bartholomew's, I attended an admirable clinic in surgical diagnosis, serving the
same purpose ; the St. Bartholomew student gets nine months' practical experience
as surgical dresser, — three months each in out-patient dressing, casualty dressing, in-
patient dressing. Five assistant surgeons have charge of the out-patients, each with
eight dressers. Daily, one assistant surgeon withdraws from active work in the out-
patient department in order to conduct the class I am about to describe.^ It con-
1" Hospitals have no vacations, and the old-time vacations should be done away with, and the
school year divided into quarters, during which the work would proceed continuously." Lancet, Janu-
ary 28, 1911, p. 213. Most of the London schools already have clerkships all the year round.
2 At Manchester, however, out-patient clerking for three months is accepted in lieu of in-patient clerk-
ing for the same length of time. The mixture of new clerks with students getting ready for examina-
tion that results is hardly to be commended.
3 In this way the group passes th'-ough the hands of all five assistant surgeons.
oi<2 MEDICAL EDUCATION
sisted on this occasion of some thirty to forty men ; on one side sat the eight dress-
ers, one or another of whom had seen the patients to be exhibited, for they were
ambulant cases, reserved for subsequent clinical use; on the other were ranged the
candidates preparing for an imminent examination, wlio alone actively participated in
the instruction. Cases were assigned to them in succession. AMiile one student was en-
gaged in arriving at a diagnosis, the instructor carried on an informal quiz and dis-
cussion with the rest, a discussion that was interrupted to allow the dresser to present
his findings. That the English clerk and dresser are at this stage much more ready
and resourceful than the German Praktikant is not for a moment to be doubted. In
the present instance, the material was so selected as to require diagnostic differen-
tiation between superficially similar conditions : two abdominal cases analogous in
appearance were exhibited ; the physical examination disclosed decidedly discrepant
conditions, as the students themselves promptly made out; a series of scrotal swell-
ings— six in number — were shown, and the young dressers displayed considerable
acumen in discriminating between them. No more convincing evidence of the impor-
tance of abundant material and the proper use to make of it at the right moment
in the student's development could be given. Nor do the schools depend merely on
the indigent poor themselves in this matter : practitioners throughout the city have
been taught to avail themselves of the hospital facilities in the making of a diag-
nosis. They send their patients with an explanatory note and receive a courteous
and explicit reply, representing the combined efforts of students and instructor. As
the several patients withdraw, their respective dressers have the responsibility of
explaining to them the directions that they are to carry out. Characteristically, too,
the moment this arduous exercise was completed, the instructor hurried off to the
museum to drill a fellowship class in surgical pathology!
For, evidently, on the clinical as on the laboratory side, the schools train their
guns so as to insure the passing of their men; tutorial classes lead them up to the
cannon"'s mouth. The spoon-feeding of the student, the concentration of responsi-
bility for a mechanically adequate equipment upon the tutors, are undoubtedly im-
portant factors in bringing about the general sterility of English medicine : for the
ideal constantly held up is schoolboy mastery of the known, for which unstimulating
achievement the individual most concerned invariably leans heavily upon, and thus
sacrifices, somebody else. At St. Bartholomew's, for example, three separate tutorial
classes are formed yearly in medicine for Conjoint men; advanced classes are held
for those who go in for the ^NI.B. degree of Oxford, Cambridge, and London; still
other special arrangements are made by way of coaching those preparing for the
M.D. degree of London LTniversity. At the same school special and separate pro-
vision is made for four different examinations in operative surgery : courses are given
twice a year for the benefit of Conjoint men, three times a year for the university
bachelors, twice a year for candidates for the services, twice a year for candidates
for fellowships and higher degrees. Similar arrangements exist in midwifery, etc. As
CLINICAL INSTRUCTION: GREAT BRITAIN 213
a written paper forms part of the various examinations, didactic drill claims a share
in the exercise. For fear some student may stray from his proper fold, "police" offi-
cers, charged with their special supervision, are detailed. Meanwhile, the men to whom
these depressing tutorial duties are assigned are those whom we have previously ob-
served, busy in the discharge of heavy and varied routine tasks : the guardian of the
London University candidates is at St. George's an assistant surgeon, at St. Bartholo-
mew's an assistant physician, at the London Hospital a demonstrator of morbid
anatomy and instructor in elementary medicine ; the Oxford tutor at St. Bartholo-
mew's is an assistant physician, who is also chemical pathologist and physician to
the hospital for sick children ; at Guy's, he is assistant physician, medical drill-mas-
ter, demonstrator of morbid anatomy, and lecturer in forensic medicine. Some of the
designations in question might be more or less nominal without invalidating criti-
cism directed against the educational ideal implied. The motive power is not the
interest or possibilities of the subject, but dread of the examiner. Where has this
latter ever been a productive power ?
In Scotland, the clerkship is less prominent and thoroughgoing than south of the
Tweed. At both Edinburgh and Glasgow, the student selects and pays his own clini-
cal teachers. At Edinburgh, part of the staff of the Royal Infirmary is appointed
by the university, part by the infirmary governors, — the latter offering instruction
as the Extra-Mural School.^ But as the five wards belonging to the universitv are
obviously inadequate, the university recognizes all teaching carried on within the
infirmary. The students therefore distribute themselves at will, betraying a natural
predilection for teachers who are also examiners. Great inequalities result. Of 310
students in the medical wards last year, one physician had 120, another 10; the others
ranged from 20 to 60 apiece. There were 210 surgical dressers: one surgeon had 60;
another 10; the others between 30 and 50. At Glasgow, one surgeon, an examiner,
had a class of 60; in another division of 126 beds there were 3 students. Under such
circumstances, members of the more popular classes get only demonstrative instruc-
tion from the chief. The intimacy and regularity characteristic of the London rela-
tionship are quite out of the question. Beds may be assigned, of course. In the sparsely
attended wards, clerking and dressing may be regularly carried on. Elsewhere a rotary
system has been introduced: the beds are distributed in succession to two students
at a time, as far as they reach; when a patient is discharged, the two clerks to whom
he belonged go off duty; the in-coming patient goes to two students next in line.
How m.any cases fall to any one student during a clerkship depends on the rate at
which the patients move. The notes of the student are criticized by the tutor; the
extent of accountability to the chief at the bedside diminishes pari passu as the class
expands. In gynecology alone has a sound organization been effected in Edinburgh.
1 The regulations of the Conjoint Board in London permit a candidate for its quahfication to spend
not more than six months at a hospital not connected \vith a medical school, counting the same as
required hospital practice, thus also recognizing extra-mural clinical work. Not exceeding one per cent
of those seeking the Conjoint Board qualification avail themselves of this privilege.
2U MEDICAL EDUCATION
There, 60 beds are divided into two wards of 30 apiece. Twelve students at a time are
mlmitted into each: they take the cases in succession, making the necessary exam-
inations and keeping up the records. Limitation and organization thus favor each
other.
The obstacles to clinical reorganization in Scotland are not everywhere the same.
In Glasgow, where material abounds, the difficulty appears to reside largely in the
proprietary interest of the staff in the student fees; fortunately, a recent ordinance
gives the university the right to decide the number of students that any lecturer
mav accept for ward work. In Edinburgh, where clinical material is, as compared
with the size of the student body, relatively scarce, making economical organization
all the more important, the situation is aggravated by the separate existence of the
Extra-Mural School. Professor Woodhead calculates that even if a uniform distribution
were procured, surgical dressers would now obtain on the average less than two beds
apiece. As the university lacks control, it happens that material is wasted in one service
while dressers are wasted in another. In defense of this arrangement, it is still urged
that local competition provides a useful stimulus.^ This may well be doubted: the legit-
imate rivalries of science and education are now fought out on a higher and broader
plane. Edinburgh is no longer a closed arena in which university and extra-mural in-
structors can compete for students on the basis of the success of their respective candi-
dates before examining boards. New standards prevail; and the entries are world-wide,
— coming from the provincial universities, from London, from the scientific centres of
the Continent. Under such circumstances, the local ranks must be brought together.
Whatever hampers the university in its choice of men, its organization of insti-uction,
its distribution of students, is but a reminder of an era whose accounts are already set-
tled." Moreover, it must not be forgotten that while division between the Extra-Mural
School and the university adds nothing to the total resources of the Edinburgh school,
it subtracts a good deal; that is, Edinburgh actually has less to offer the student
now than it could offer if its resources were pooled. For scientific medicine asks not
only for courses, but for correlation of courses: instruction must converge upon the
patient from every possible avenue of approach, — laboratory and bedside. As long
as the laboratories of pathology and clinical pathology remain outside the university,
neither treatment nor teaching can be uniformly and thoroughly correlated.
Out-patient teaching conditions vary considerably as between Glasgow and Ed-
inburgh. At the former, a most attractive series of little amphitheatres has been
provided. Once more, students are not distributed. About twenty students might be
conveniently handled. When the numbers go higher, they are advised to scatter; but
^ " In Scotland we have gone in so much for the extra-mural teachinj? from the point of view of com-
petition; one would be very sorry if that were in any way impaired." lieport of Committee on Scottish
Unirfrsttiea and Minuter of Evidenre, p. 54 (822), London, 1910.
* .Sec Report of Committee on Scottish Universities and Minutes of Evidence (London, 1910), particularly
the extremely lucid and convincing analysis contained in the "note by Professor G. Sims Woodhead
on "Clinical Teaching in the Medical Schools " {Report, pp. 12-16).
CLINICAL INSTRUCTION: GREAT BRITAIN 215
they are persuaded or not, as they please. In any event, theatre teaching is essentially
demonstrative, even though students are called down into the arena episodically, as
are the German Praktikanten. Edinburgh utilizes six public dispensaries, situated in
different parts of the city. Students are required to take out three, and may take out
six, months in dispensary and district patient work. Some twenty students, reporting
two afternoons weekly, are attached to each dispensary. Cases are assigned in rotation
to two students, who make the examination and report later to the physician in charge.
Between them a consultation thereupon takes place.
From the preceding account, it is clear that, in the conception of the essentials
of clinical discipline, British traditions are thoroughly sound. In all that pertains to
the relation of the student to the hospital, the English model deserves tb be univer-
sally copied. On the other hand, it is perhaps equally clear that complete moderni-
zation of spirit and ideal, which nothing in the method itself in the least opposes,
is everywhere hindered by proprietary survivals. The original advantage of the Eng-
lish situation — the close association of teaching with the hospital — proves for the
time being an obstacle to better things. It is so good that its merits are alleged as a
sufficient excuse for not attempting anything markedly better. One cannot too em-
phatically insist that the modernization of British medical education does not contem-
plate the relinquishment of any of its valuable features; indeed, they are to be pressed
upon the attention of educational reformers in other countries. The curable defects
of the English situation refuse meanwhile to be explained away : as compared with
the German university department, the English medical school is unproductive and
the English medical student is handled hke a schoolboy learning a trade. Both con-
ditions will be remedied by one course of action; for when teachers of medicine are
university professors, they will insist upon a higher grade of preliminary training.
Thereupon the student can be trusted with larger individual freedom, can be tempted
by genuine opportunities to seek his own larger development, — an enterprise con-
genial to the spirit with which the university professors of medicine and surgery will
have inspired their departments.
From this point of view, a highly interesting effort now making in London will
repay close watching. On its face, London would appear to be marked out as the
Mecca of English-speaking medical students. It is, as a matter of fact, almost wholly
ignored bv them. The colonial continues to go to Edinburgh, where more students
than are now to be found in all London work in the wards of one hospital, for their
purposes about the size of St. Bartholomew's; transatlantic English-speaking stu-
dents resort to Germany. Nay, worse, the metropolis is even losing its insular pre-
eminence. Not only does it fail to attract students over seas; its magnetic force is une-
qual to drawing them from adjacent counties. While Berlin, Vienna, and IVIunich show
annual increases in student enrohnent, the British capital is headed downhill.
How is this astonishing phenomenon to be accounted for ? The current explanations
cite the rise of the provincial universities : Liverpool, Leeds, and Manchester students,
216 MEDICAL EDUCATION
who formerly resorted to the London hospitals, now stay at home, on the ground,
nrohablv well taken, that they do just as well thei'e. One hears, too, much of the so-
calletl "grievance of the London student," previously adverted to, — doubtless a factor
of some inHuence. The medical student of the Scotch and the provincial universities
obtains a degree at the close of his course. The London hospital schools confer no
degrees; to attain that, London students must qualify at London University, where
the matriculation requirements are higher, the course a little longer, and the profes-
sional examinations somewhat more severe. If this diagnosis is correct, the remedy,
even though difficult of application, is sufficiently obvious. In one way or another,
degrees can be made inevitable and cheaper. A solution thus arrived at would be,
however, of no general significance. It would establish peace in London and might
even restore the fallen fortunes of some of the hospital schools. But to what purpose .''
One cannot rid one's self of the notion that the British metropolis has a role of
larger importance to play.
The University of London discharges two functions: it examines for degrees and
diplomas students whose teaching it does not furnish or control; it federates, with-
out internally directing, a variety of institutions of incongruous character. Two of
them. King's and University Colleges, are genuine academic institutions; but the
medical schools, in which we are interested, are mere private ventures, affiliated, but
not transformed by the nominal university relationship.
With the general problem involved in the conversion of an unwieldy and ineffec-
tive congeries of institutions into a genuine university we have no concern. It is, how-
ever, necessary to point out that external work, whether carried on at a distance ac-
cording to official syllabi, or carried on close at hand in recognized institutions whose
spirit and aims are after recognition precisely what they were before, is not university
work in the sense in which the term has been used in these pages. Extension work
may be ever so useful, — it does not constitute a university; the holding of examina-
tions may within limits be expedient, — it does not constitute a university. In fact,
all work not carried on by teachers selected by the university or a university college
of uncompromising academic character, amid conditions determined by the univer-
sity, with ends set up by the university, is external work, even though those carry-
ing it on mav sit in the university senate. In this essential sense the medical schools
are "external." Proprietary schools in the first place, these schools remain what they
were, — after inclusion in the university as before.^ As far as medical education is con-
cerned, the University of London is only a circumference, a line drawn about what is,
* "They have never shown a real desire to cooperate (with the university). . . . Their relationship to
the university, which is something new, sits lightly on them. . . . They are not primarily educational
bodies. Their interest is only in a secondary degree educational. The hospital committees want a medi-
cal s<-hool to help to run the hospital and the interest of the staff is professional."
"There is a very great deal of jealousy between the different schools ; not so much educational rivalry
as jealousy. There is a tendency — I will not say more — to use various devices to catch .students. ... A
teacher obtains through his own students a great deal of consultative work." Principal Headlam in
appendix ioFint li^port of Royal Commuaionon Univernity Education in London, p. 88 (London, 1910).
CLINICAL INSTRUCTION: GREAT BRITAIN 217
a generously drawn line at that, — not an active embodiment of definite scientific and
educational ideals. For university education is a concept of precise and exacting sig-
nificance: it implies a faculty of homogeneous composition busily engaged in investi-
gation as well as teaching, facilities adequate to both, and a competent student body.
Other forms of science teaching have their uses and should go on. But as such they
do not represent efforts of university grade.
If, then, a solution is desired which will render the medical department of Lon-
don L'niversity a factor in medical progress, and draw students and investigators
to London, as they are attracted to Berlin and Heidelberg, then it is impossible to
compromise with the proprietary interest. A nominal solution which continues to dub
every hospital whose staff chooses to teach medicine a clinical department of Lon-
don University will not avail. For the provincial and for the foreigner, that net will
be spread in vain. Experience not confined to Great Britain proves that clinical
teaching incidentally offered by a hospital staff cannot be of university quality. An
adjustment which segregates and develops the underlying branches will also be in-
effective. Certain subjects can thus undoubtedly be theoretically developed — ana-
tomy, physiology, and pharmacology. But by setting up one ideal for some of the
laboratory branches and a different ideal for the clinical, the functional unity of
the medical school is destroyed: the student's fundamental training would be a shot
into the air. L^nsatisfactory is still another suggestion, that " recognizing" all exist-
ing schools, the university should leaven them by appointing professors of medicine
and surgery to be distributed among them : a university medical clinic, for example,
would be established at Guy's, a surgical clinic at St. George's, etc. The plan is recom-
mended on the ground that a similar arrangement is in operation at Paris, — where,
however, as our next chapter will show, it signally fails to produce medical training
or medical investigation of modern quality. And for obvious reasons. The detached
clinician or surgeon is an individual deprived of the stimulus and collaboration which
he acquires from the proximity of the other members of a properly organized school.
In the hospital where a university medical clinic is to be domiciled, physics, chem-
istry, physiology, surgery, pathology, would still remain of non-university complex-
ion : in such an environment, medical research will not thrive, nor will the under-
graduate's medical training be of academic grade. Finally, great store is set by
subsidies: let workers but enjoy subsidies, it is urged, and the present London medi-
cal schools will produce. Vain expectation! Productivity is, in the first place, a mat-
ter of leaders. No arrangement which perpetuates in the highest places sterile, even
if accomplished and skilful, practitioners will be fertile, no matter how liberal the
support of scholars, fellows, and assistants. Undoubtedly, such workers can be thus
procured in great numbers; but they will busy themselves on the fringes of recent
achievements, rather than blaze fresh paths through undiscovered country. Fellow-
ships, indeed, have — in limited numbers — their value; they can facilitate the es-
tablishment of a "school." Put they have no power of original creation. It is idle to
218 MEDICAL EDUCATION
assemble youthful workers by means of moderate stipends unless a source of ideas is
first secured. The sole indispensable requisite is the leadership of a fertile intellect
under conditions in which it is actually in command.
Tiiere is, therefore, no substitute for the creation of a school in which laboratory
and clinics of the same university texture will be intimately interwoven, unless the
substitute is merely an imperfect beginning which is expected to grow into the
oro-anization just described. If, however, the full step could be taken at once, the
university would select a single hospital to start with. It is plainly impossible to
or'^'^nize a dozen or even several complete university medical schools: neither funds,
nor teachers, nor students are procurable. As the secondary schools still supply prop-
erly trained students in small number, the London experiment is under no constraint
to essay the grand scale. Let us suppose that London University, reorganized on its
teaching side, cut adrift the hospital schools, creating its own hospital or retaining
for the present a single hospital, — the London, or Guy's, or St. Bartholomew's, —
in which a proper arrangement gave it unfettered scope, and where, on the basis of
weU-developed fundamental laboratories, it would organize a clinical department of
university quality. Or more simply still : let us suppose that, detaching the affiliated
hospital schools, London University should by subvention enable one of its constituent
colleges, viz.. University College, to complete its medical plant on an academic basis
by making with University Hospital a contract arrangement giving University Col-
lege the right to designate and organize its hospital staff. While not one of the largest
of the metropolitan hospitals, University Hospital is probably large enough to ac-
commodate all London medical students of university quality; and completeness of
academic control is at this moment too important in London to be sacrificed for mere
quantity of material, provided the material obtainable on an academic basis is ade-
quate to its purpose. University Hospital would, at the moment, perhaps answer the
needs of London medical students of university grade ; it would have to serve no other.
For, on the lines proposed, the education of mixed university and non-university
students would cease. The present is an auspicious moment to take this step, because
England is just on the threshold of secondary school expansion ; the experiment can
still be made on a small scale. The university would appoint to staff membership, in
whatever hospital it procures, men determined to make scientific careers in medicine
and surgery, and seeking only academic rewards. The notion that clinical medicine
and surgery are so devoid of inherent interest that only huge pecuniary and social
prizes can attach men to their pursuit will be promptly exploded: these prizes are
obstacles only. Once create the conditions in which scientific achievement is possible,
and scientists will enter just as certainly as the worldly will leave.^ Is it too much to
^ A staff thus appointed could not do all the clinical teaching of the medical school without exhausting
itself in routine, — the very thing to be avoided. They could be assisted by men engaged in practice,
especially in the out-patient teaching, in giving courses in physical diagnosis, etc. Objection to the
university scheme, on the ground that investigating professors will not be interested in teaching stu-
dents about trifling but common ailments, will thus be avoided.
CLINICAL INSTRUCTION: GREAT BRITAIN 219
believe that university clinicians and surgeons will equal the achievements of British
physiologists and chemists? that well-trained English boys would find difficulty of
matriculation and graduation an incentive rather than a deterrent ? that English-
speaking students from the New World would then seek the clinical opportunities of
the English-speaking metropolis of the Old ? Pending the development of the enter-
prise, the hospital schools would continue their present useful work. As secondary
education improved, the hospital schools would lose ground, the university school
would be more severely taxed. Ultimately, the non-university medical school will
become both superfluous and anomalous, for all intending physicians will have pro-
cured a secondary education adequate to the needs of university professional training.
At that moment, London would face the present situation of Berlin and Vienna, en-
deavoring to teach a thousand students with facilities meant for five hundred. There
is, however, no reason why London should be forced into the Berlin or Paris mould.
WTienever students become numerous enough to need another set of laboratories and
clinics, another hospital could be taken over or established by the university with
another set of fundamental laboratories. Each plant should be complete in itself.
Several complete schools, none exceeding perhaps 600 students, would be greatly
preferable to one school with reluctantly duplicated departments. Two or three de-
partments, each complete, would thus be in operation, — a novelty which might not
impossibly prove the solution of the problem of effectively educating without recourse
to mass teaching the throngs that normally seek the opportunities of a metropolis.
The other hospitals would in time cease to be undergraduate schools; for they can
remain undergraduate schools only if the personal interest of the staff is preferred to
the progress of medical science and the better training of medical students. It does
not follow, however, that they will not be open to students. Wherever progressive
men achieve, thither students — old, if not young — will find their way, A useful, nay,
even a distinguished career in the training of specialists and in the cultivation of
postgraduate studies, is open extra-murally to every hospital in direct ratio to the
individual merits of its staff members.
CHAPTER IX
CLINICAL INSTRUCTION: FRANCE
Havikg now discussed at considerable length clinical instruction under outright
university conditions in Germany and essentially non-university conditions in Great
Britain, we may deal somewhat more briefly with clinical teaching in France. It
adds to our previous survey little that is new. Externally, the university relation-
ship appears to obtain ; on closer inspection, decided limitations are discovered. The
teaching method resembles that employed in England.
Externallv, I have said, the university relationship appears to obtain ; for all the
complete French medical schools are university departments. But the French universi-
ties neither own nor control the hospitals in which their clinical training is given. The
French hospitals are municipal charities, the expression of the ardent humanita-
rian convictions of the Revolution, from which they date. On terms which will shortly
be stated, the Assistance publique — the bureau charged with the management of
hospitals, retreats, etc. — makes over to the university designated wards in scattered
hospitals, of which wards the university professors become ex-officio clinical heads,
and the contents of which they use for clinical instruction in such wise as their judg-
ment approves. In this fashion, clinical facilities are procured by all French univer-
sities. If I speak of Paris specifically, it is to be understood that, though the scale
varies, the same principle everywhere obtains.
Thirty-one hospitals, aggregating 15,584 beds, are comprehended in the Assist-
ance publique of Paris.^ They are classified as general hospitals, for the reception of
medical and surgical patients, of which the more important are Hotel Dieu, La Pitie,
Necker, Cochin, Laennec, and La Charite, with 607, 696, 475, 779, 336, and 651
beds, respectively; and special hospitals of definitely prescribed scope: St. Louis,
a vast establishment of 1335 beds, limited to cutaneous diseases ; Broca, 256 beds,
for venereal diseases of women; Tarnier, an obstetrical clinic of 206 beds; Enfants
Malades, a pediatric establishment of 704 beds ; Trousseau, — likewise for children, —
365 beds, etc. Originally, all were huge barracks, sometimes, like Hotel Dieu, of im-
posing external appearance, but designed for the accommodation of the maximum
number of sick. In recent years, a systematic reconstruction has been undertaken for
the express purpose of meeting modern conditions. In the new wards of Cochin, for
example, pavilion construction has been adapted. Each pavilion contains two wards,
lea<ling from a central building, of which one floor is devoted to administration, the
second to lalx)ratories ; the pavilion forms a complete working unit of modern type,
each ward service lieing in direct connection -vnth the laboratories appropriate thereto.
Since 1886, when the first laboratories were installed by private gift, marked pro-
* Adding orphan asylums, etc., the total reaches 30,000 beds.
CLINICAL INSTRUCTION: FRANCE 221
gress in procuring proper equipment has been made: in 1907, twenty-nine research
laboratories of one kind or another were to be found in the Paris hospitals; four radio-
graphic services, eleven for electro-therapeutics; eight laboratories had been set up
by the university for its medical faculty. The pathological department is usually a
dead-house, autopsies being made by internes. In the provinces, the provision is in
general inferior.^
In France, hospital administration is bureaucratic to the last degree. The central
administrator of the vast Parisian system sits at No. 3 Avenue Victoria. His au-
thority and duty are well-nigh incredible. Rigidly and minutely prescribed rules
govern all hospitals alike. Beyond the mechanical routine thus provided, no step,
however trivial, can be taken Avithout the express consent of the Director of the As-
sistance publique. He has indeed a representative in each hospital; but the repre-
sentative possesses no authority whatsoever. He is an organ of transmission only; he
cannot expend a franc, cannot dismiss an intoxicated servant, cannot authorize the
most urgently needed repairs. Before a broken window can be mended, five distinct
steps must be taken : the local representative must inform the director-general ; there-
upon the latter details an inspector to report ; the inspector makes his investiga-
tion ; the architect submits an estimate; the director-general gives the necessary
authorization. Neither the hospital as a Avhole nor any service therein possesses the
least measure of autonomy. Between administration and medical staff thei'e is no
friction because there is no intercourse. Physicians and surgeons are indeed supreme
in the wards; but they have the supremacy of total isolation. They resign themselves
to such conditions as they find. If improvements come — they come. Clearly, non-in-
terference may take either of two forms: it may represent functional cooperation or
supplementation, as in Germany ; or it may represent non-intercourse, as in France.
Nor are communications the less completely broken in France because the most scru-
pulous politeness is mutually observed.
The personnel of the Paris hospital consists of physicians, retiring on the basis of age
at sixty-five,^ surgeons and obstetricians retiring at sixty-two; internes, appointed
for four years, externes named for two years, but eligible for reappointment for a
third, fourth, fifth, or even sixth year; laboratory chiefs, etc. Each physician and sur-
geon thus possesses certain subordinateswho assist in the conduct of his service. Every
professor — not every hospital physician or surgeon — has besides a chief of clinic,
an assistant selected by examination and holding his post for three years. Never-
theless, the chief and his aids do not form a functional staff in the German sense. A
"team,'" the members of which participate in realizing through specialized and differen-
tiated efforts a large ultimate object, can be organized only where a controlling mind
having certain ends in view selects the required agents on the basis of their specific
^ " Structure administrative des hopitaux en France et a I'Etranger," by Dr. Leon Archambault, in
Coiujres des Practiciens, part ii, pp. 5-38 (Paris, 1910).
2 But clinical professors retire at seventy.
fstSt MEDICAL EDUCATION
(itnoss therefor. The several agents may cherish individual purposes as well; but
they must first of all enter the larger scheme. In the French hospital, physician and
sur"-eon have no voice in the selection of their subordinates, — internes,^ who forai
a stilaried resident staff; externes, who are usually unpaid assistants in the wards and
out-patient departments, laboratory heads, etc. All alike are selected by competitive
examinations, — "le concours,"" as it is called. Nor are examinations framed after
conference with the chief with a view to eliciting ability or training of varying and
specialized tvpes; thev follow a general pattern drawn up l)y no one knows who and
conscientiously adhered to, year after year, by the Assistance publicpie. Of candi-
dates for the externeship there are required an oral test in anatomy and an oral test
in elementary pathology or minor surgery; candidates are allowed five minutes to
think, and immediately thereafter five minutes to talk; the tinkle of a bell starts, and
five minutes later breaks off, the reflective process. The entire ordeal lasts exactly
twenty minutes. Obviously, the candidate must have his wits about him and his
knowledge within easy reach. In most cases, he has been dexterously coached by those
who have previously succeeded, thus acquiring considerable skill in neatly dispos-
ing of any likely topic in the period allowed. As all subsequent promotion depends
on success in the concours for the externat, it is highly important to note the dis-
j)osition which the initial competition fosters. For none but the 300 who annually
win the externeship ai'e eligible to compete for the 50 interneships yearly vacated;
and a hospital career open only on these terms must in fact, if not actually in law,
precede subsequent competitive efforts to become affreffe and then professor. The ex-
amination for the interneships differs from that for the externat only in elaborate-
ness; it includes a two-hour wTitten examination in anatomy and pathology and an
oral examination in the same subjects, the candidate being accorded ten minutes to
reflect and an equal period to answer.^ Neither examination involves practical tests;
one prepares for both in the library rather than in the laboratory or at the bedside.
Subordinates thus selected make up the minor staff. Thus, the personal touch and
the individual adjustment needed to constitute a "team" are obviously lacking: the
former might arise in the course of the lengthy association fortunately provided for
by the terms of the several appointments; as to the latter, only accident will intro-
duce into a service an externe or interne possessing the precise qualities which at a
particular juncture the chief might especially desire. For the hospital staff — whether
university or non-university — have no voice whatever at any stage in these appoint-
ments. They are made by the Assistance publique;' and the internes, arranged in the
' Internes are paid on a rising scale : 600 francs, the first year ; 700 francs, the second ; 800 francs, the
third ; 1000 francs, the fourth. The hospital lodges some of them ; the others receive an indemnity of
WXJ francs.
• '* Dix minutes pour d^velopper la question, aprfes dix minutes de reflexion." Provost: Carnet de
rKliuiiant en Midecine, p. 16 (Paris, 1905).
*. " ^i"*^""** ^^ I'extemat des hApitaux de Paris ne reinvent pas de la Facultd de m^decine, niais de
1 administration g<-neralc dc I'Assistancc publique." Prevost : Guide-Programme des Etudes midicaUs,
p. 5()( Paris, 1911).
CLINICAL INSTRUCTION: FRANCE 223
order of their examination grades, select the chief of service to whom they propose
to attach themselves. But the interne chooses his chief, — not the reverse. Meanwhile,
whatever the merits or demerits of the method of appointment, the appointees enjoy
unrivaled opportunities as far as facilities are at hand. The French interne serves a
protracted period amid conditions in which a dull man must improve, and a keen
man can find, every possible opportunity in the wards, the laboratory, and the dead-
house.
Competitive examination — more highly elaborated, to be sure, but always attrib-
uting inordinate importance to fluent command of accepted doctrine — selects also
the ranking appointees, hospital physicians, surgeons, etc., even those who may simul-
taneously be agreges in the university.
As to the agreges^ an additional word of explanation is necessary. The agreges —
of whom there are forty-six- — are practically assistant professors in the university.
They are in active service, attached to one or the other chairs — both scientific and
clinical — of the medical faculty for periods of nine years. Selected by competitive
examination, to which all legally qualified physicians are admitted, candidates submit
their published papers, write an off-hand essay, and deliver a lecture for the prepara-
tion of which only a few hours have been allowed. The various subjects are so grouped
that the candidate is liable to attack from any quarter of a very extensive field, —
pathology, therapeutics, internal medicine, and legal medicine forming, for example,
a single division. Quite independently of this examination, which makes the winner
a university lecturer, an agrege may also, like any other qualified practitioner, win
in competition a hospital post, and in virtue thereof be empowered by the university
to give its students clinical instruction, as will shortly appear.
The advisability of appointment to any post on the basis of examinations depends
rather on the dangers to be avoided than on the advantages to be gained. Exami-
nation— above all, written examination — is not calculated to disclose peculiar fit-
ness or unusual quality. Informal search is in general the more effective method of
selection. Unfortunately, where numerous appointments must be made, machinery
that costs less time and energy must be employed; moreover, in any case, personal
factors ousht to be eliminated by the conditions surrounding the choice. For ex-
aminations, it may at least be said that they rule out the conspicuously unfit and
exclude the cruder forms of personal partiality. For this reason the civil service, as
indeed any service requiring correct methodical performance within narrowly cir-
cumscribed bounds, can be thus most satisfactorily recruited. Nay, more, the nega-
tive virtues of the examination are convertible into positive benefits by the more or
less complete substitution of practical for written features. On this principle it may
be laid down as indisputable that examination is the safest way to fill minor hospital
posts.
But hospital physicians and surgeons are not nowadays employed to render correct
methodical performance within narrowly circumscribed bounds. They bear enormous
224 MEDICAL EDUCATIOxV
resiK)nsibility, " ield enormous power over life and death, and practically monopolize
enormous opportunity, for theirs is a monopoly of the clinical material on which
metlical and surgical progress depends. In merely excluding anything worse than
medii>critv, the concours is practically "damned with faint praise;" for an effective
method of selection must be calculated to lay hold of positive qualities of high order.
The forceful personality may not be expressly excluded by being compelled to win
opportunity by passing examinations; but he is unwittingly penalized, when the
conditions are such that patient mediocrity may fare just as well, or better.
Such being the general hospital situation at Paris,^ how is it affected by the neces-
sity of providing clinical facilities for the medical faculty of the university.''
In the general hospitals of Paris there are close to seventy medical services. The
Assistance publique assigns four of these to the university, one each at Hotel Dieu,
Beaujon, St. Antoine,and Laennec. Surgical services are somewhat less than half as nu-
merous as medical; of these, also, the university controls four, one each at Hotel
Dieu, La Charite, La Pitie, and Necker. In the same fashion, obstetrical clinics are
assigned to the university at Baudelocque and Tarnier; a pediatric service at the
Hopital des Enfants Malades, one in cutaneous diseases at St. Louis, in gynecology
at Broca, in urology at Necker. A sum total of eighteen dispersed services constitutes
the immediate clinical facilities of the university.^ Of the huge out-patient depart-
ment's, found in all the hospitals, no systematic teaching use is maude.
For the eighteen hospital services above named, the university selects the heads
among those who have previously won an agregeship in concours. To the appoint-
ment of university professors from a field thus artificially narrowed, there is rather
greater objection than is to be urged against the practice in general. In appointing
hospital physicians, the municipality may need to be artificially protected by an ex-
amination against political influences, but as it is hardly conceivable that the uni-
versity would in any event do worse than mediocrity, selection of professors, subject
to a previous concours, would seem to lack even negative recommendation. Exami-
nation does not, of course, exclude ability: Charcot, Marie, and Widal, to name only
comparatively recent examples, passed through the meshes of the sieve. Nay, more,
so strongly competitive a system tends to select vigorous, even if conventional, in-
tellects and to keep them at a high state of tension. It does at least require that tiie
* What is true of Paris hospitals holds in all the large towns of France: in all alike, hospital appoint-
ments are made by competitive examination.
* On a small scale, the same arrangement is made at Lille, where one of the two university professors
of medicine has a clinic at St. Sauveur, the other at La Charite; and at Lyons, where at Hotel Dieu,
the university controls two medical services out of eight and three surgical services out of seven ; be-
sides, at the Charite, the university controls one of two obstetrical services, and at St. Pothin, one
of two dcrmatological services. The hospitals at Lyons adjoin each other, lying almost directly across
the Rhone from the university; they can be rea<'hed by crossing a bridge in about ten minutes. This
separation, however, divides the department into two non<'ommunicating halves. The amount of clini-
cal material accessible is very large; Hotel Dieu contains 1100 beds, the Charity an equal number,
St. Pothin 1000. The crowded condition of the wards of Hotel Dieu interferes .seriously with bedside
tea<hing. A new hospital of modern design is about to be built, replacing the antiquated, though stately
structure ; in this it is hoped that all the university clinics may eventually be consolidated.
CLINICAL INSTRUCTION: FRANCE 225
winner shall be learned. For this reason, the written or oral test in vogue in France is
less inimical to eminence than the unwritten social scrutiny in vogue in England. For
an able man who would be utterly impatient of a club code might turn aside from
productive tasks long enough to prime himself for a competition for which, in his
heart, he entertains no respect: six months' industrious reading will assuredly not
wreck him. The objection to the concours is not, therefore, that it directly prohibits
the best, but rather that it attaches no particular importance to it. It does not deliber-
ately seek out the forceful; it is not adapted to doing so. On the contrary, it calls for
vigorous and unremitting exercise of the mental powers within the circumference of
the already known. It produces finished, ready, and fluent physicians, admirably skilful
and well informed. But it has no talisman with which to discover and to honor un-
conventional or unique capacity; nor can it profit by a surprise. Now in education as
elsewhere, mere conservation requires no special care; everywhere psychological habit,
the established order, and vested interest make for conservation, in the realm of ideas
quite as much as in the realm of practice. Progress meanwhile depends on aggressive
and resolute endeavor. Not that the creative personality despises the accomplished fact ;
it simply does not suffice him. Having taken it up, he pushes beyond it. While, then,
the modern university as an important engine of social progress demands initiative,
the concours is more apt to award the palm to learned than to forceful men. The
members of the jury are already well advanced in years; they have strong corporate
feelings; they are not apt to break up the homogeneousness of their own body. The
French system is efficient in conserving. Genius develops early ; the French give no
free or independent opportunity till late. By that time, fertility and idealism may
have disappeared or abated. As faculty vacancies are filled singly, the new agrege,
already in middle life, is more likely to absorb than to transform the prevailing
complexion of the body he enters. No outsider — minister, rector, or chancellor —
can at a crucial moment intervene to "break up adhesions." The series of examina-
tions which began at the externat tends thus to develop a pure strain from which all
qualities not directly making for examinability are progressively eliminated.
In actual operation, the concours is capable of proving rather worse than its own
theory. "Calling" does not necessarily exclude favoritism. A German faculty sug-
gests three names to the minister; in the making of these nominations, an influ-
ential clique may conceivably be governed by personal considerations; the minister
may even become a party to the transaction. Instances have indeed occurred in
which personal preferences have dictated choice. But frequent episodes of this kind
are most improbable. The fortunes of the entire institution depend on the strength
of the teaching body ; its prestige is damaged when a single chair is weakly ten-
anted. In any case, the "call'" cannot sail under false colors : the scientific world knows
when a prominent man has been passed over on account of Semitic origin, — as inva-
riably happens in Germany, — or because of unorthodox scientific or political views.
The concours may, however, conceal an injustice : for under the guise of an imper-
226 MEDICAL EDUCATION
sonal competition, it may decree superiority to the disciple who, as agrege more for-
tunate than briUiant, attached himself betimes to the winning professional patron.
The extent to which personal preference determines the outcome of the concours
camiot be accurately stated. Certain it is that the closed system, by which the pro-
fessoriate is restricted to agriges, in the selection of whom complete impersonal-
ity is incredibly difficult, results in occasional choices and occasional failures ob-
jectively more or less inexplicable. Failure to coincide with native estimate is, of
course, no proof of collusion ; but when general scientific opinion is nonplussed, the
argument against the concours is appreciably strengthened. Quite regardless of the
fjicts, however, the easy allegation of partiality is a serious objection to the entire
system.
The universities choose their clinical professors exclusively from the local pro-
fession. As the professors continue to engage in practice, the university appointment
is sought and valued partly, perhaps largely, because of the professional prestige it
carries. France and England are one in this respect. The more outspoken French
clinicians are under no illusions on this score. "There are no professors of medi-
cine and surgery, strictly speaking, in France," remarked an agrege in surgery to me;
"practice and science are implacable enemies." In consequence, only under highly
exceptional circumstances is importation thinkable. And this is equally ti-ue of Paris
and of the provinces. Paris, knowing itself to be the maelstrom to which ability hur-
ries, presumes that it has nothing to gain by seeking appointees elsewhere. It might
be supposed that first-rate men rebuffed there would seek larger and more tranquil
opj)ortunity in the provincial universities. Not so. The savant cannot rest until his
gold has been minted in the overshadowing capital; and the provinces indirectly
assist in strengthening its supremacy, for they assume that the best left to them is
superior to such talent as might confess itself unable to make a respectable Paris
career.
The bearing of these conditions on research is unmistakable. Excessive centraliza-
tion is fatal to the existence of many competing foci, reacting upon and reinforcing
one another. At Paris itself, the newly constructed clinics are admirably adapted to
research; but the organization of the clinic is precarious and scientific recognition
uncertain. Endeavor is therefore single-handed. There, as less commonly in the
provinces, brilliant individual contributions are made on both laboratory and clin-
ical sides. In this respect France and Great Britain resemble each other strongly.
But except at the Pasteur Institute, arrangements do not conduce to the exhaustive
working out of involved lines of inquiry by a clinical experimenter, his staff, and his
pupils. Moreover, the scientific branches in the university are entirely detached from
the clinical : between physiologist, pathologist, and clinical teachers, there is there-
fore no intercourse, no collal)oration, no mutual suggestiveness. Even on the clinical
side, compactness is lacking. The university phvsician is stranded in one hospital, the
surgeon in another. Tlic most vigorous and fertile minds may triumph over adverse
CLINICAL INSTRUCTION: FRANCE 227
conditions, but at a loss, nevertheless. French like English research is therefore indi-
vidual, not institutional; incidental, rather than systematic.
This fact is admitted in France, as it is admitted in Great Britain. It is interest-
ing to observe that in both countries the same suggestion has been made as to deal-
ing with it. Their present methods, it is urged, "turn out good practical doctors ;" in
respect to that, let us leave well enough alone. Research is a separate problem, solu-
ble by the endowment of separate professorships or fellowships, with such facilities
as they may require. Intending practitioners need receive only the lower discipline;
those with loftier ideals may train in the higher.^ The objections to this reversion to
a state of things which had to be suppressed by statute^ need not be fully restated at
this point. The physician must not be merely trained to know and to do certain things
to-day; medicine is progressing so rapidly that intelligence, skill, and interest must
insure his participation in its farther advance. The defects of medical education in
Great Britain and France are at bottom due to failure to recognize the practical
bearings of this principle. The proposal in question is not the outcome of disinter-
ested educational study; it is rather a compromise that will avoid the necessity of
disturbing the present order.
The Paris school contains several thousand students. As clinical study is obliga-
tory from the second year, and optional even during the first, almost the entire stu-
dent body must be accommodated in the hospitals. The intelligent attitude of the
authorities in freely opening the wards to teaching has made this seemingly impos-
sible feat entirely feasible: so much so that the strength of the Paris school lies, as
we shall observe, in its ward teaching. For this the eighteen university services plainly
do not suffice; they are therefore supplemented by "recognition" of hospital phy-
sicians and surgeons, to whom, by arrangement, the medical faculty assigns students
in groups of twenty. This is accomplished with less disorganization than would be
anticipated, because of the double position of many of the agreges. I have already
noted the fact that to every chair an agrege is attached. The agrege, as such, has no
hospital status ; but no objection is made when the agrtge to the chairs of physi-
ology, anatomy, medicine, or what not enters a concours for a non-university hos-
pital post. If successful, he becomes physician, let us say, to Hotel Dieu or Trousseau.
As agrege he continues to lecture on some branch to medical students at the Faculte;'
but, in addition, he can now undertake clinical teaching in his wards. For the Assist-
ance publique, with notable wisdom, has, as I have previously mentioned, thrown open
all the wards of the Paris hospitals to teaching : every physician or surgeon may, if
he so chooses, be followed on his ward rounds. In the same fashion, hospital posts may
be won by professors holding non-clinical chairs in the medical faculty. The univer-
1 Georges Hayem : "De la Reforme des jfetudes Medicales," in La Presse Midicale, November 26, 1910.
2 See chapter i.
3 The building of the medical department in the Rue de I'lficole de Medecine. where lectures are given,
is known as the "Faculte;" across the street is the newer building, in which practical courses are
held, called "I'^cole pratique.".
ff8 MEDICAL EDUCATION
sitv is thus in position to increase its clinical facilities. It recognizes the clinical teach-
iu'r offertil l)v hoklers of non-cliniciil medical chairs, by agregt-s, and by ej:-agrcges
who have won hospital posts. Chauffard, professor of the history of medicine, has, as such,
no clinic; but he holds through successful competition a medical service at Cochin: to
him, therefore, a group of stagiaire.s are sent. Marfan, professor of therapeutics, Pierre
Marie, professor of pathological anatomy, instruct stagiaires, as tenants of hospital,
not university, posts, the former at the Hopital des Enfants Malades, the latter at
liicc'tre. As agngc, Tuffier merely lectured at the Faculte on the principles of sur-
gery; his term had expired before he won his present gviiecological service at Beau-
jon: as hospital chief without university position, he receives the quota of students
that during his university incumbency he could not have handled. Thirty clinics are
thus recognized by way of supplementing the clinical resources of the university.
ITie clinical instruction consists of lectures, ward work, and special courses. The
lectures are of two varieties, — systematic lectures or conferences, given at the Faculte;
clinical lectures, given in the theatres of the several hospitals. The lectures at the
Faculte always take place in the afternoon, the entire morning being left free for
hospital work. \Miile lecturing and reading count heavily toward the examination,^
Paris medical teaching prides itself altogether on its practical scope in the hospital
wards. To that, therefore, we may profitably confine our attention.
The Paris hospitals, widely scattered through the city, are practically all con-
siderably removed from the university buildings in the Rue de TEcole de Medecine.
As ward rounds are made daily during the morning hours, all the teaching at the
Faculte, of whatever kind, takes place in the afternoon : dissecting, theoretical lectur-
ing, and special courses are alike remanded to the latter half of the day. Even first-
year students, of whom hospital attendance is not required, are encouraged to parti-
cipate to the extent of attaching themselves informally to ward groups, thus acquir-
ing at the outset the preponderant interest in clinical experience which the French
scheme tends to foster.^ Of the remaining three years, two are passed in the general
medical and surgical wards, the third is apportioned between obstetrics, mental dis-
eases, diseases of the eye, and those of the urinary tract.
The instruction begins and ends with the exhibition, examination, and obsena-
tion of cases; and that, too, without preliminaries. There are no introductory or spe-
cial classes in physical diagnosis or clinical microscopy. To acquire facility with the
stethoscope, less resorted to than in England and Germany, to learn percussion and
palpation, the student is left to his own devices; in laryngology, rhinology, and oto-
logy alone are practical courses in technique conducted at the Faculte.
ITie theory upon which the French school proceeds is extremely simple: one goes
\." •^I^f'"" d^ ceux qui sont re(,'us veterinaires ne peut se vanter, comniequelques-uns de nos etudiants,
d avoir obtenu un diplome sans avoir vu un seul malade." Professor Georges Hayem in La Pre^se
Mi'diralt, November -26, 1910, p. 891.
? I met a first-year student •'clerking" in a gynecological clinic.
CLINICAL INSTRUCTION: FRANCE 229
into the water to learn to swim. To know and to differentiate disease, the physician
must first of all see it, watch it, and handle it; if he sees and watches it intelligently,
continuously, abundantly, sheer iteration will both build up and differentiate an
experience. The method can be applied only where clinical material is exuberantly
plentiful and easily handled, — everywhere the case in France, and especially so, per-
haps, in Paris. The French student in general, the Paris student in particular, enjovs
practically unrestricted opportunity to gain thorough familiarity with the concrete
manifestations of disease.
Take, for example, Chauffard's service at Cochin, consisting of 120 beds, 60 occu-
pied by acute medical, 60 by tuberculous, cases. Twenty stagiaires daily accompany
him through the wards. In the first place, he is an admirable teacher : quick, incisive,
clear, and charmingly courteous, — qualities common, even if not universal, among
French teachers. Like his English analogue, the French student is entirely at his ease.
The utmost informality prevails. Each stagiaire has obtained by allotment two or
three beds. The appointment runs for four months, during which period he has un-
obstructed access to his cases; he is expected to see them daily before the arrival of
the chief. At the foot of each cot hangs a card bearing the names of the externe and
of the student in charge of the patient ; they are, to employ the English phraseology,
the "clerks," to whom, on reaching the case, the physician turns at once for a statement
covering history, physical examination, etc. In his two-hour clinic, the instructor will
exhaustively discuss some three or four cases, quizzing stagiaire^ externe, and interne
— and in this order — before himself supplementing, correcting, or summing up. At
this particular clinic, bedside observation and laboratory findings are closely corre-
lated ; the discussion continually expounds the one in the light of the other. Cases
terminating fatally are followed to the autopsy, performed by a hospital interne.
Meanwhile, students other than those in personal charge of a case — sometimes stu-
dents not officially belonging to the group — and visitors are free to interpolate ques-
tions or suggestions, and, the condition of the patient permitting, to verify by exam-
ination points of especial note. Not infrequently, the informality of procedure results
in gathering a throng so large that many hear, rather than see, what is going on;
the assigned stagiaires, however, are entitled to places immediately beside the bed.
At a bedside clinic at the Hotel Dieu, for example, I counted forty witnesses, not
an unusual number; hardly half of them could see the patient. Fortunately, positions
shift as the group moves: the student who remained out of range at one bed gets
the inside track at the next — an obvious improvement over the amphitheatre de-
monstration, where respective advantage or disadvantage of position is permanent,
and where professor and student necessarily occupy a formal attitude toward each
other. A skilful teacher, standing at the bedside, gradually works the student into
increasingly active participation and consultation. The patients — here as everywhere
in Europe — rather enjoy the exercise than otherwise, for it makes a break in their
monotonous day. Indeed, the quick and clear responses characteristic of the nimble-
230 MEDICAL EDUCATION
witted Pftrisirtu patients contribute largely to the success of bedside instruction. Their
remlv apprehension contrasts strikingly with the dull wit one not infrequently en-
counters in countries where the peasant answers "yes" or " no" indifferently, and will,
if sharply interrogated, obligingly replace the one by the other.
Gynecological teaching may be illustrated by Tuffier's work at Beaujon. Tuffier is
in daily attendance. Twice weekly he operates, on which occasions he urges his stu-
dents to visit elsewhere rather than to waste their time in looking at what they can-
not see; they are thus enabled to observe at other hospitals eminent teachers whom
thev cannot otherwise get to know. On the other three week days, Tuffier makes
ward rounds with his stag'iaires. His instruction is practically an exercise in diagno-
sis. To each student three or four beds have been allotted. By nine o'clock, or shortly
after, the clerks are at work on their cases. Interne, externe, and students have
their subject-matter well in hand, when about ten o'clock the professor enters. The
stagiaire reads his report first, giving a detailed history and describing such indica-
tions as he has made out. As he proceeds, externe or interne may interpose a word
here and there, and the professor keeps up a running fire of comment and criticism.
\Vhile three responsible individuals are thus cross-examined, the others get some-
thing more than close-range demonstrative instruction; their attention is called to
features that have been overlooked, and now one, now another, is permitted to sub-
stantiate an assertion. A small blackboard is in constant requisition : Tuffier draws
as he expounds, to show size and relation of the parts in question, or to depict a pro-
posed operation; and all muddiness is summarily expelled from discussion by requir-
ing the students or assistants to show what they mean through the same medium.
Accountability is thus at once swift and concrete. As the indications to be observed
are usually prominent and the logical processes involved relatively simple, the exer-
cise is admirably adapted to discipline in sound diagnostic habit.
By its clinical teaching, as above described, the French medical school stands or
falls; for the most part, French medical training begins and ends at the bedside.
Special practical courses are indeed offered ; but a brief description of them will
show the propriety of characterizing French medical instruction as essentially clini-
cal on conservative lines. For example, three agreges, the chief and two assistants,
give a course of thirty lessons in practical obstetrics at Tarnier; a course of twenty-
three exercises in normal and pathological nutrition is announced at I^aennec; twenty-
eight lessons in infant surgery at the Hopital des Enfants Malades; twelve lessons in
gynecology to a class limited to twelve members at Broca. These are doubtless all
excellent opportunities; but the fees are high — from fifty to one hundred francs
each — and the accommodations limited. Within the hospital, too, efforts are made
to round f)ut the chief's instruction. Once or twice weekly, the laboratory cliief at-
tached to the division conducts a practical course or conference. Nothing, however,
could l)ctter confirm my position as to the character of French medical training than
just such practical courses.
CLINICAL INSTRUCTION: FRANCE 231
Following a medical clinic at Hotel Dieu, for example, a weekly conference "in
which the students will be individually trained" Ms conducted by the laboratory head,
his assistant, and an interne. The program of topics includes the examination of tu-
berculous sputum, bacteriological diagnosis of diphtheria, typhoid, and pneumonia,
blood examination, sero-diagnosis, etc. The clinical group, with the attending phy-
sician, repairs in a body — thirty-three strong — to the Amphitheatre Bichat, where
for some thirty minutes the instructor discusses the topic of the day. Culture tubes
are passed round, rough drawings of bacilli made on the blackboard; thereupon, the
students approach the demonstration table, Avhere slides already spread lie alongside
appropriate staining fluids : each student immerses a slide in the stain and looks at
the result through one of the two microscopes provided. The "individual training"
extends no further. The extremely elementary character of the proceeding shows how
little practical discipline could have preceded.
The fact is, that at no stage do the laboratories get a fair chance. From the start
they compete with the fascinations of the wards : the student is hardly likely to in-
fer from his practically immediate induction into the hospital that clinical observa-
tion presupposes a technique elsewhere and previously acquired. Having once con-
tracted the bedside habit, he can hardly put it off in order to apply other methods,
for the practical mastery of which such inadequate provisions exist. Unless the under-
lying sciences have initially received treatment commensurate with their diagnostic
and therapeutic importance, they wi]l fail to play even an instrumental role in edu-
cation and practice.
Meanwhile, the merits of clinical teaching in France are indisputably great and
fundamental. If medical teaching has to choose between books and wards, or between
laboratories and wards, France has exercised its option wisely. Keen, resourceful
practitioners can be formed on the rich sustenance furnished by the Paris clinics.
Nay, more, let the medical school possess whatever else it may, without varied clinical
experience and lucid clinical exposition, doctors cannot be properly educated at all.
The choice which France thus exercises, scientific medicine, however, refuses to
recognize as valid or even possible. Fifty years ago, perhaps less than that, it urges,
medicine, empirical at best, had to be acquired in the rough-and-ready school of ex-
perience. So, essentially, it is still acquired, when stagiaires learn by the methods of
imitation, trial, and error, etc. But scientific medicine has set its premises in order.
Analytic study has worked out the basis on which applied medicine rests; while bed-
side observation has lost nothing of Aalue, new tools have been forged, new technique
devised, by which order, intelligence, increased certainty, and something more 'nearly
approaching completeness have been rendered attainable. Of this movement, French
clinical training takes no adequate account.
And for this reason, already adverted to: aside from the difficulties ascribable to
numbers, the French medical school is nowhere conceived as an organic whole. Be-
1 "Les eleves seront exerces ind'viduellement" — from the posted bulletin.
232 MEDICAL EDUCATION
tween the fundamental branches presented at the Faculte and the clinical branches
presentetl in dispersed clinics throughout the city, there is no intercourse whatsoever.
The anatomist and the physiologist, on the one hand, the physician and surgeon, on
the other, work oblivious of each other. Nay, more, the several university services
of medicine and surgery are lost in the various hospitals in which they are situated.
Suggestion, interplay, correlation, equally essential for both teaching and research,
are absolutely out of the question. The modernization of the French school requires
the integration of laboratories and clinics : not otherwise can they react upon each
other. To bring this about, the university must concentrate its clinics so as com-
pletely to control certain hospitals, in connection with which departments of patho-
logy, pharmacology, and physiology may be established. The underlying sciences will
thus attain the importance they deserve. Paris is frequently cited in proof of the
feasibility of a medical school living upon dispersed privileges. It rather furnishes
irrefutable demonstration that no medical school so composed can achieve an organic
or modern character.
CHAPTER X
CURRICULUM AND EXAMINATIONS: GERMANY
We have now completed the separate consideration of the several subjects pursued
in the medical school. How are they combined to form a course of study ?
The activities of the medical faculty in Germany extend far beyond what is imme-
diately teachable ; what is immediately teachable vastly exceeds what is immediately
teachable to any one student. The teaching range of the medical school is therefore ne-
cessarily a selection from its total range; the studies pursued by a particular student
are necessarily a selection from the contents of its teaching scheme. This could not be
otherwise: new divisions of subject-matter are in continuous process of formation,
whether by segmentation or original creation. As physiology and pathologv split off
from anatomy, so bio-chemistry is just now splitting off from physiology; bacteriology
is growing into a department of hygiene. On the clinical side, pediatrics, psychiatry,
and dermatology are rapidly attaining the independence already enjoyed by medicine,
surgery, and ophthalmology. Not less pronounced is the differentiation taking place
within each department : anatomy, once content with a dissecting-room, now presents
three facets, — morphology, histology, embryology, — within which certain subdivi-
sions, for example, neurology, cutting across all three, form an imperium in imperio.
Precisely how far such subdivision shall be carried depends less on the topics them-
selves than on the angle from which a particular individual proposes to approach
them. A given topic might fall u-ith equal appropriateness within the department
of bacteriology or within that of experimental medicine. At any moment a highly
theoretical line of investigation may prove of such direct practical importance as to
require transposition from the research to the teaching side. In vain do we cherish
the opinion that at least the foundations are secure, that only the superstructure will
require occasional remodeling. So fundamental a distinction as is now recognized
between anatomy and physiology may prove to have served its purpose. Not incon-
ceivably, the more explicit recognition of a functional point of view in the study of
structure, and the development of a more devoted race of clinical instructors, may
lead to a redistribution, in the course of which what now goes by the name of "medi-
cal physiology" may, as the diplomats say, be benevolently assimilated by anatomy
and the clinics : ^ in that case, space could be won for bio-chemistry and experimental
physiology within the undergraduate curriculum. It is an inevitable consequence of
research that no point of view, no logical arrangement of subject-matter, claims any-
thing more than provisional importance: the validity of a specific standpoint depends
on its capacity to develop new vistas, any one of which may supersede the standpoint
from which it was opened up. The subject-matter of the medical curriculum covers,
1 Such a proposition has already been made by Jacques Loeb : Anatomical Record, vol. v. No. 6,
pp. 306-308.
234 . MEDICAL EDUCATION
then, a continuously increasing range, within which no particular form of organiza-
tion can be either sacred or long lived. No two medical schools of modern type can
ptissiblv coincide. On the basis of an agreement as to what is currently held to be
fundamentid and indispensable, they diverge rapidly and considerably; and diverge
they must as long as modern science rejects ultimate and orthodox points of view
and therewith hard-and-fast territorial divisions.
For the undergraduate, as for the advanced student, the })rovisional and shifting
diaracter of the rapidly progressive medical sciences is a fact of prime importance. Let
us, for the time being, waive the question of research. At the teaching level, too, medi-
cal faculties differ, because, incapable from the very nature of the case of being exhaust-
ive, what they offer depends, at a given moment, more or less on personal and local
considerations : the point of view or training of individual professors, the laboratory
facilities or clinical advantages of the university. Theoretic exposition may be mapped
out on substantially similar lines, largely irrespective of local or personal peculiari-
ties; philosophers and philologists may entertain different views and yet expound the
same texts or discuss the same general topics. But modern medicine, the complex
outcome of a dozen disciplines, each with its ov.-t\ rapidly shifting complexities, lends
itself ill to systematic organization or uniform formulation. A typical curriculum is
therefore neither conceivable nor feasible.
^Vithin a single institution, a fixed curriculum might indeed be set up : can it be jus-
tified.'' Only if incontestably superior and overruling importance could be predicated
of one combination of subjects as against any modification thereof. We shall see that
this, too, is impossible : were it true, the logic that defends the fixed curriculum in one
medical school would require that it be forced upon every other. The moment we ac-
cept diversity among various institutions, we concede the principle of diversity within
each. We concede something more, too: the student cannot know everything; mental
attitude is more important than most positive acquisitions. Now, the right mental at-
titude is more likely to be developed by intensive than by extensive training. A sound
curriculum will therefore be characterized by simplicity and thoroughness rather than
by encyclopaedic fragmentariness; it will be a simple rather than a rococo edifice.
Moreover, variations are likely to grow more, rather than less, marked. The medical
school is destined to become at once richer and more various. Something will doubt-
less be simultaneously saved by elimination and redistribution. Certain subjects will
be outgrown ; others absorbed. But reorganization cannot keep step with progress.
The new and the old must both subsist, side by side, at least until the new has com-
pletely proved itself, or the exponents of the old have been peacefully shelved. A
growing organism is thus always in a stage of transition, involving logical inconsis-
tencies and maladjustments. In no event, therefore, can contemporaneous readjustment
l)e expected to offset the increasing scope and complexity of the medical school. The
curriculum may \ye lengthened — directly by adding a year, indirectly by pushing back
preliminary studies into the secondary schools; but, once more, the time thus gained
CURRICULUM AND EXAMINATIONS: GERMANY 235
or added will assuredly not suffice to accommodate the additions making at every
focus of activity. If encyclopaedic, or even schematically regular, training were im-
portant, not to say necessary, one might then well despair.
The considerations on the basis of which the problem of the curriculum can be
solved have been touched on in the preceding pages. What can be fairly expected
of a medical education.? Not that it shall produce finished and uniformly success-
ful doctors: the right minded physician will never feel himself to be that. Medicine
involves the intelligent application of knowledge, method, and experience to the prob-
lems of disease. It is a profession, rather than a craft, because of the emphasis which
it places upon intelligence as against mechanism. Now, situations that must be re-
solved by intelligence can never be exhaustively foreseen or provided for. The agent
destined to act in them may at the most have become familiar with the more impor-
tant data they are sure to contain and with the more important instrumentalities he
is bound to employ in dealing with them ; the knowledge and practical skill thus
severally acquired he may have used under disciplinary supervision in typical and
characteristic situations, calling for the sort of response that he must eventually
make. Obviously, these selected situations need be of no precise character; they need
only be sufficiently numerous and sufficiently diverse to require varied and accurate
knowledge and to form and to test a habit of action. When the medical school has
done so much, it has done its all: critical and conscientious experience in the wid-
est sense must fill in the outline thus dra\vn. Education has equipped the student
with his tools. It has trained him to use them ; it has provided some opportunity in
which he may demonstrate his capacity to use them. Such limited competency, rea-
sonably complete as far as it goes, marks the well-trained student of medicine at the
moment when he makes his exit from the medical school. But of greater importance
in the long run is the expansive impetus with which he has been endowed. The lim-
ited expertness above mentioned, a rigidly prescribed curriculum might unquestion-
ably produce; but momentum, so far as it is ascribable to educational policy at all,
can be developed only in conditions which by their heterogeneity suggest incom-
pleteness and defect, and by their invitation to the assertion of individual bent or
capacity fan the sparks of interest into flame.
The diversity of output which is thus obtained is not without important advan-
tages. The uniformity of a prescribed curriculum is at best a specious make-believe :
it looks completer and more secure than it really is. Smooth articulations and defi-
nitely adjusted hours convey an impression of wholeness not in keeping with the
facts. The student's knowledge is at best fragmentary, rough, and at loose ends. In
the course of a professional life of average length, the prop will inevitably be knocked
from under some of the things which at the moment seem most capable of support-
ing weight. Heterogeneity of accomplishment and performance tends to deprive the
student's faith of its absolute quality ; where each has something to learn from the
others, all are more apt to ba both curious and teachable.
236 • MEDICAL EDUCATION
Hie preceding considerations constitute, however, no argument for uncontrolled
freetloni. To understand and to manage disease, knowledge and skill separately ac-
(luired in eacli of a dozen different domains must be brought together. These parts are
not wholly indifferent to one another. A certain sequence lies in their very nature;
the goal to be reached in some sort controls their selection and arrangement. Thus
to some extent the several ingredients of the curriculum both require and support
one another. These essential inner relations the medical student cannot know in ad-
vance ; he cannot procure them for himself if he does not know them. Hence, as far
as sequence is required by different subjects of whose relations to one another, and of
whose comparative importance, the student is ignorant, the curriculum must be a re-
liable guide. For example: students the world over tend to slight the so-called theo-
retic branches. They have started out to become doctors; they are conscious of being
actually embarked on the achievement of their purpose the moment they enter the
hospital wards: left to themselves, they would for the most part go straight from ana-
tomv to medicine. Formerly, there Avas indeed nothing else to do. Latterly, however,
an important body of instrumental data and an indispensable instrumental technique
have been worked up. A method of approach has been established. Order enough must
characterize the curriculum to insure the student's respect for relations thus created.
Freedom to err through ignorance in matters where regret is unavailing is sheer waste,
of no educative value.
From a somewhat different side, there is also something to be said for a certain
measure of compulsion. From the viewpoint of society, the student of medicine is
in a different position from the student of Greek or philosophy. The latter may
be left entirely to his own devices ; his scholarship and qualifications are ultimately
passed on by a jury of his peers, — his fellow scholars and fellow philosophers. On
them he cannot expect to impose. Incompetency is followed by merciless and inev-
itable elimination at their hands; neither scholarship, nor philosophy, nor society
suffers: the individual himself pays. But the doctor's public is inexpert. His patients
are incapable of judicious appreciation of his merits — or otherwise. The public lacks
such summary means of protection against impostors as may be easily invoked by
scholars and scientists. The state does indeed interpose with its professional exami-
nation. But no examination alone is altogether fair to the candidate or altogether
adequate to the public. The general conditions under which a medical education is
obtained must themselves constitute such a presumption in favor of good train-
ing that both examiner and patient may fairly make considerable allowance on
that basis. We shall shortly see that, as now administered, the German state examina-
tions distinctly require such additional assurance. It can be and is partly furnished
by the terms of matriculation in the medical school : the unfit are thus largely ex-
cluded in tidvance. But the potentially fit are capable of much subsecjuent unwisdom.
Against this species of folly, arrangement of the curriculum must offer both the stu-
dent and the public a measure of protection. In this respect the education of phy-
CURRICULUM AND EXAMINATIONS: GERMANY 237
sicians resembles all educa,tion for definite social ends : it is so far a forcing process.
The public needs competent engineers, la^vjers, teachers, and doctors, in larger num-
bers than will be produced by the unregulated action of individual impulse, however
strict the scrutiny finally applied. In the public interest, therefore, the state sets up
certain conditions calculated to increase the numbers of those who will in the end
successfully satisfy its standards.
I repeat, however, that this line of argument cannot be adduced in favor of a rigid
and uniform curriculum. No complete agreement could be secured as to its contents,
because incontestable priorities cannot be made out; no complete agreement could
be secured as to its time order, because the possible interrelations and combinations
of fruitful character are infinitely various. Nor may we lose sight of a practical ab-
surdity involved in the very notion of a uniform required course of study. A curri-
culum that aims to fill the student's time is either too much for the average student
or too little for the best. Thus, even were the argument for uniformity stronger, the
argument against it from the ethical and intellectual standpoint would demand
recognition. In a profession which counts on progressive effort, eventual capacity to
advance can be generally promoted only by a regime in which active qualities have
been in some measure consistently cultivated. Four or five years of compliance with
prescription will result in the atrophy of the voluntary powers. It can be no mere
accident that in Germany the requirement of the practical hospital year has been
everywhere followed by a decrease in the number of volunteer assistants ready to
serve for longer periods. Very likely the importance of forcing a minimum compe-
tency upon all students before embarking in practice is a sufficient argument for
the hospital year, no matter what its incidental drawbacks; but these results place
the burden of proof on the partisans of increasing compulsion. The fact that prescrip-
tion tends to sap initiative pleads strongly against extreme measures. Such freedom
as then remains is not of course without its perils. But it is to be remembered that,
after all, the medical faculty is dealing with mature individuals.
Finally, the teacher may not be wholly lost sight of. On him rests at once the
double responsibility of training students and advancing knowledge. The combination
of these two functions in one individual has proved Germany's most fertile contribu-
tion to higher education. The prescribed curriculum tends to emphasize too strongly
the former element at the expense of the latter; it converts the professor into a
schoolmaster. It will be a dark day when this process is sanctioned as a functional
division of labor. At the professional level, where competency is a question not only of
particular kinds of skill and knowledge, but of method and inspiration, the student
must be trained by actively progressive scientists. In so far as he can safely be made
responsible to or for himself, the teacher is freed for the pursuit of original tasks.
The inner relations of the various elements found in the medical curriculum proper
suggest a tripartite arrangement. There are at one end the fundamental sciences; at
the other, the clinical bran'^hes; between them, the sciences that bridge the gap, —
f38 ' MEDICAL EDUCATION
patliologv, pliarniacologv, and bacteriology. In the determination of amounts an
irretiucible minimum can be agreed on, — whether a little more or a little less is of
sHght importance; open spaces can be left in each of the three divisions, which the
student is free to employ intensively in any one of a dozen ways. The informational
side is thus not slighted. Neither does it overshadow all else. When one reflects on
the fate of acquired knowledge, one realizes the superior importance of the acquisi-
tive capacity and habit. Something of what the student learns betrays him, by prov-
ing false or inadequate; something simply escapes him through mere lack of use.
The positive knowledge of any particular epoch is at once uncertain and unsafe. But
method and technique abide : if good, to digest and appropriate subsequent experi-
ence; if poor, to infect it with their own insufficiencies. Information is of course not
to be contemned. It provides in any case the language, the terms, in which the stu-
dent acquires his art; but it must be so communicated as to assist the formation
of the searchingly inductive type of mind.
Some such conception as has been just outlined lies at the bottom of the German
treatment of the problem of the curriculum. "Lernfreiheit" indicates not an untram-
meled, but a qualified freedom, such as has been here approved. I shall shortly specify
the restrictions by which the student's freedom is curbed. But of ethical freedom —
the freedom to do his duty or not — he is never deprived. No police duty is asked of
the German instructor; as indeed it would be a doubtful service to the public to
require teachers to spend themselves in forcing unwilling students to learn enough
to enable them to qualify as practitioners at the minimum level, above which such
as they would probably never rise.
Compulsion is applied altogether through the examination. The medical student
entering the university is not informed that this or that course is to be pursued
during the first, second, or any other semester. But he procures a copy of the exami-
nation ordinance, from which he learns that he will have eventually to pass two ex-
aminations, the first called the "physicum," the second known as the "state examina-
tion;" that before admission to the first, he must present certificates testifying to
attendance on certain lecture and laboratory courses during not less than five semes-
ters; that before admission to the second, he must present similar evidence of attend-
ance on certain clinics; and that no clinical certificates are valid unless earned sub-
sequently to the complete discharge of the obligations represented by the physicum.
Thus indirectly the subject-matter of the curriculum is divided into two mutually
exclusive parts, together at least ten semesters in length. The subjects included in
the first half he finds to })e physics, chemistry, zoology, botany, anatomy, and physio-
logy. Thereupon once more indirection comes into play. The student is not required
to pursue any particular set of courses by way of preparing for the physicum. He is
simply required to present certificates showing that he has dissected during two semes-
ters, and has had a practical course in histology lasting one; that for one semester
he ha-s attended a practical course in chemistry and a similar one in physiology. He
CURRICULUM AND EXA^IINATIONS : GERMANY 239
ascertains that he must be prepared to stand both theoretical and practical exami-
nations in chemistry, anatomy, and physiology;^ theoretical examinations only in
physics, zoology, and botany. He is apparently free to obtain his theoretical informa-
tion where he pleases, and to devote to it as much or as little time as he pleases. It
is obvious that the prescription, direct and indirect, taken together, does not neces-
sarily exhaust the student's time; leeway is left for intensive performance. And this
play-room is increased for students who bring to the university prior equipment in
botany, physics, and zoology.
The clinical requirement, likewise dictated by the examination ordinance, is some-
what more complicated. It includes (a) certain subjects in which course certificates
must be presented and in which examinations are held; (b) subjects for which cer-
tificates are required, but in which no examinations are held; (c) subjects in which
examinations are held, but no certificates are required. The subjects (a) in which
certificates are required and examinations held are the following : medicine, surgery,
and obstetrics-gynecology, in each of which a certificate showing enrolment in the
appropriate clinic during two semesters is required; ophthalmology and psychiatry,
in each of which a certificate showing one semester's enrolment is required. The sub-
jects (6) in which the student must present a certificate representing one semester"'s en-
rolment, but undergo no separate examination, are the following: the medical poli-
clinic, children's clinic or policlinic, nose and throat clinic or policlinic, ear clinic or
policlinic, skin clinic, topographical anatomy, lectures in pharmacology, lectures in
legal medicine, vaccination. The subjects (c) in which the student is examined with-
out having to submit any certificates whatsoever are pathology and hygiene. Finally,
having passed the examinations, he must serve one year in a hospital, of which,
as a rule, at least one-half must be spent in clinical activity.^ In subjects in which
no certificate is required, the student is free to obtain his training as he will. And
wherever the examination requires skill or knowledge not to be obtained in the cer-
tificated lecture courses, he is free to follow his ovm devices, as indeed he is indirectly
compelled to do. The certificated courses in medicine do not include individual train-
ing in physical diagnosis; the certificated courses in surgery do not include indi-
vidual training in dressing and bandaging. Such details the student arranges for
himself, by attending special courses, serving as famulus^ or perhaps even taking a
chance without systematic instruction at aU.
It is clear that whatever compulsion exists, as far as study is concerned, is exer-
cised only by the examination. Let us assume (for the sake of simplicity we shall
revert to the point hereafter) that the examinations are serious affairs: the student
must then earnestly pursue up to the point determined by the indications of the or-
dinance, all the subjects included in the physicum, and in groups {a) and (c) of the
state or clinical examination; the subjects comprised in group (6) represent only a
1 The practical examination in physiology, however, is slight.
2 In exceptional cases, eight of the twelve months may be spent in laboratory work.
240 xMEDICAL EDUCATION
nominal requirement. They must be found in the course book, properly attested by
the instructor; but as no check is kept on attendance, the student may attend in
ortler to procure the necessary signatures, and no oftener afterwards than he chooses.
In pathology, for example, there are examinations and no certificates; in legal medi-
cine, a certiticate but no examination. It results that the student must learn some
pathology. The simjjlest and Siifest way to accomplish this end is to attend the lec-
tures and courses of the professor-in-chief; but at his peril the student may trust
to learning asjamulus in a pathological establishment, whether that of the univer-
sity or some other hospital. In legal medicine, the compulsion, apparently greater, is
really less: the student must indeed be signed up for the subject, — that is, he must
pay for it. He therefore carries his course book to the firet lecture, or, in extreme
cases, gets a friend to do so for him. In the large universities, this may represent the
whole of his connection with the subject; for "signing off" at the end of lecture courses
has been abolished, on the ground that the lecturer cannot know enough about
the individual student to give his signature any significance; in the smaller univer-
sities, where instructors know their students, greater conscientiousness necessarily
obtains.
For sake of clearness, the curriculum may then be formulated as follows:
First half (at least Jive semestersY
Certificates and examination required : Anatomy
Physiology
Chemistry
Examination only required: Physics
Zoology
Botany
Second half (completing at least ten semesters)
Certificates^ and examination required: Medicine, in which diseases of chil-
dren, nose and throat, pharmaco-
logy, and therapeutics are included.
Surgery, in which diseases of ear and
skin and topographical anatomy
are included.
1 There are two semesters yearly, stretching nominally from October 15 to March 15, and from April
15 to August 15. Both are in practice much foreshortened. Lectures are hardly well under way until
three weeks after the opening date; they begin to close full two weeks before the closing date, and
students fairly melt away a week or two before even that. The winter semester is an effective term
of about sixteen weeks, the summer of about twelve.
''The certificates must attest the following details : Two semesters' attendance as Prak/ikant in medi-
cine, surgery, and obstetrics-gynecology; participation in four deliveries; one semester's attendance
as / ralUiicnnl in the eye clinic, medical policlinic, children's clinic or policlinic, psychiatric clinic, nose
and throat clinic or policlinic, ear clinic or policlinic, skin clinic or policlinic ; one semester's lectures
in lopographual anatomy, pharmacology, and legal medicine; practical work in vaccination.
CURRICULUM AND EXAMINATIONS: GERMANY 241
Certificates and examination required: Obstetrics-gynecology
Ophthalmology
• Psychiatry
Examination only required: Pathology
Hvgiene
Certificates only required: Legal medicine
Vaccination
The dividing line between the two sections — physicum and clinical — is necessarily
respected; but on neither side is there enforced coordination of the constituent ele-
ments. In the former half, botany may be one of the first subjects pursued, or it may
be the very last; in the latter half, pathology may precede clinical medicine and
surgery, or follow them more or less remotely. What I have designated as necessary
inner relations may thus be wholly lost sight of mthin each division: chemistry and
physics ought obviously to precede physiology, in which they are applied ; pathology
ought, in part at least, to precede medicine and surgery, which deal with concepts
thence derived ; physical diagnosis and clinical microscopy are, in the nature of things,
preliminary to medicine, as are dressing and bandaging to surgery. Nor are these
time sequences inherent in the object important to the student alone. The teacher
must definitely know to what extent his presentation of a topic can assume the com-
prehension of his auditors. The physiologist, for example, can discuss the digestive
process on either of two presuppositions, that the student understands chemistry,
or that he does not. His presentation will vary widely according as he makes, or
does not make, the assumption in question. A definite understanding in the affirm-
ative sense can be warranted only by some sort of official assurance. Not a few lectures
begin by presupposing nothing.
By way of supplying more helpful counsel than is contained in the examination
ordinance, each medical faculty puts forth a recommended plan, in which the field
to be covered is arranged in a sequence running through ten semesters. While the
several plans do not fundamentally differ, they prove conclusively that orderly ar-
rangement, adhering to necessary internal relations, is still consistent with a consider-
able measure of variety. The Leipzig and Wiirzburg plans, starting from precisely
the same initial semester, never repeat each other in any subsequent one.
Leipzig WiJRZBiTRG
First Semester ( Winter)
Phj^sics Physics
Inorganic chemistry Inorganic chemistry
Systematic anatomy, part i (including osteology) Osteology
Systematic anatomy, part ii General and systematic anatomy
Dissection >. Dissection
24S
MEDICAL EDUCATION
Second Sertiestcr {Summer)
Botany
Physics
Organic chemistry
Histology
Zoi)lofr>'
Chemical laboratory
TViird Semeste7- (Winter)
Physiologj-
Dissection
Review anatomy
EUective work
Fourth Semester (Summer)
Physiology
Physiological chemistry
Embryology
Practical histology
Physical laboratory
Fifth Semester (Wmter)
Physiological laboratory
Dissection
Review physiology
Elective work
Physics
Organic chemistry
Systematic anatomy
Anatomy of the sense organs
Botany
Zoology
Dissection
Histology
Botany
Zoology
Physiology
Topographical anatomy
Physiology
Physiological laboratory
Topographical anatomy
Slrth Semester (Summer)
Physical diagnosis for beginners
Medical propaedeutics
Surgical clinic : hearer
Medical clinic : hearer
General pathology
Special pathology and therapy, part i
Pharmacology
Fractures and bandaging
Surgical propaedeutic
Sjjecial surgery
Seventh Semester ( Winter)
Women's clinic : hearer
Surgery
Medicine
Pathological anatomy
Skin diseases
General surgery
Obstetrics
Physical diagnosis for advanced students
Special pathology and theraiiy, part ii
Physical diagnosis for beginners
General pathology
Special pathology and therapy
Obstetrics
Clinical microscopy
Surgical propaedeutic
History of medicine
Special pathological anatomy
Surgical pathology and therapy
Special pathology and therapy
Experimental j)harmacology
Women's clinic
Laryngological course
Medical clinic : hearer
Surgical clinic : hearer
CURRICULUM AND EXAMINATIONS: GERMANY
243
Eighth Semeste?' (Summer)
Women's clinic
Surgery
Medicine
Surgical policlinic
Topographical anatomy
Pathological histology
Ophthalmology
Gynecology
Ninth Semester ( Winter)
Women's clinic
Ear, nose, and throat
Laryngological course
Surgical polichnic
Vaccination
Eye clinic
Autopsy course
Diet and nutrition
Pediatrics
Toxicology
Psychiatry
Tenth Semester {Summer)
District policlinic
Topographical anatomy
Eye clinic
Medical policlinic
Hygiene
Operative surgery
Legal medicine
Practical bacteriology
Forensic psychiatry
Special surgery
Toxicology
Pathological histology
Hygiene, part ii
Ophthalmology
Operative surgery
Medicine
Surgery
Women's clinic
Eye clinic : hearer
Prescription writing
Hygiene, part i
Pathological anatomy
Operative obstetrics
Autopsy course
Physical diagnosis for advanced students
Practical course in hygiene
Medicine
Surgery
Women's clinic
Eye clinic
Medical policlinic
Pediatric policlinic
Skin diseases : hearer
Topographical anatomy
Legal medicine
Practical bacteriology
Vaccination
Women's clinic
Medical policlinic
Pediatric policlinic
Psj'chiatry
Ear clinic
Skin clinic
Nose and throat policlinic
The plans above suggested both assume that the student's first semester falls
in the winter; a considerable transposition takes place if he starts in the summer
instead, for dissecting begins then in the second semester, instead of the first.^
The sequence may be farther disturbed by the student's decision as to his military
service. At Wurzburg the third semester, at Munich the sixth, is recommended to
winter matriculants for this purpose, ^^^^ichever suggestion is adopted, subjects as-
signed to that period must be redistributed, the semester being practically lost. The
1 A large amount of readjustment is also necessitated by the student's wandering.
244 MEDICAL EDUCATION
two plans above given are, it will be observed, strictly alike only in the first semes-
ter. Leipzig commends botany, histology, and zoology for the second; Wiirzburg pre-
fers to remand all three to the tliird. Leipzig suggests one semester of botany, Wiirz-
burg two. The clinical semesters vary so largely as to be scarcely comparable as far
as sequence is concerned. Yet, significantly enough, both recommend pathology and
phvsic'd diagnosis in the sixth, that is, the first clinical semester. In that semester
Leipzi" includes pharmacology, which AVlirzburg postpones to the next. Finally, a
comparison of the recommended plan with the contents of the examination ordinance,
which practically prescribes the minimum, shows that every student is expected to
achieve more than is absolutely required. The corresponding plans of other univer-
sities contain still further variations.
The defects of the plans lie on the surface. Sound in so far as the fact that they
\avy is concerned, they assuredly are not built on simple lines. Except perhaps in the
earlier semesters, they call for performance so extensive and so fragmentary that con-
sistent or thorough compliance is simply out of the question. Imagine a youth actu-
ally struggling with the contents of the eighth semester as recommended at Wiirzburg,
or with the contents of the ninth as outlined at Leipzig. Such multiplication of sepa-
rate courses does more than overburden the student: it goes counter to that simplicity
and concentration of study so highly to be commended in the interest of thorough-
ness and continuity of application. Neither scheme appears to prize intensive elabo-
ration at selected points. Practically every available moment — and somewhat more
— is frittered away upon heaped-up discursive lectures and clinics, plus merely the
most obviously essential instrumental courses. Thus both forget the peculiar advan-
tage for which the Germans themselves rightly value their own system.
As to practical courses in general, a word is in place. Excepting for anatomy, the
first five semesters at Wiirzburg contain only two practical courses, involving the
student's active participation, a semester each in chemistry and physiology, in both
of which a passive semester has preceded; at Leipzig, a practical course in physics
is also recommended, but meanwhile an entire year of discursive physiology precedes
the laboratory course in the same subject, as it does also in the plans put forth at
Munich and Berlin. This disproportion between witnessing and participation, along
with consistent postponement of participation, even where both occur, continues
throughout the various schemes. The Breslau program alone cautions the student
that the "practical course should be taken in closest possible connection with the
lectures."
Notable, too, is the absence of gradation, leading from the simple to the complex.
Students in different semesters attend the same clinics. The student is recommended
to break the ice by attendance on the medical and surgical clinics during a prelimi-
nary semester as hearer or onlooker, — a rather poor expedient, for the work is quite
l)eyoiul him. Propaedeutic clinics in medicine and surgery indeed exist in various
places, but no recommendation to attend them is officially made. Finally, the position
CURRICULUM AND EXAMINATIONS: GERMANY 245
of pharmacology and bacteriology is to be noticed: both come late in the clinical
semesters.
The faculty plans need not, however, detain us longer. Though one is informed
that the student is officially believed to be largely guided by them, such does not,
on closer investigation, prove to be the case. The actual distribution of time departs
greatly from the faculty suggestions, on the one hand, and the minimum requirements
of the examination ordinance, on the other. The plans commonly recommend two
semesters each of physics and chemistry, and at times two semesters of botan v ; very
rarely indeed are more than a single semester of physics or botany found. The exam-
ination certificates require two semesters each in medicine and surgery; the plans sug-
gest three. Not only do the course books frequently show more, but in point of fact
the more energetic often visit more clinics than appear on the record. A semester's
work each is advised in clinical microscopy and advanced physical diagnosis: only
a small proportion show the former ^ and still fewer the latter. Instead of the recom-
mended ten semesters, the average course runs thirteen and a half. Migration, mili-
tary service, and intensive work at one point or another would disarrange and prolong
the schemes even were they inherently sound.
When, now, we turn from the recommended plan to the details of the actual curri-
culum of the German student, difficulties abound. His courses are registered in a little
book kept for the purpose. But he may attend some lectures that he fails to register;
or, much more probably, he may fail to attend some that he has registered because he
finds them too difficult, uninteresting, or what not. How far the apparent intentions
reflected in the course book are realized, it is thus impossible to say. One is assured
that the German student attends practical courses with a high degree of regularitv ;
to lectures he goes or not, as the spirit moves him. The course books cannot therefore
be regarded as infallibly sho\nng the German studenfs working hours, though they
may probably be taken to indicate approximately the limits within which he works.
The sequence and correlation of his studies, if not their absolute seriousness, may,
however, be inferred from them. Aji inspection of course books taken at random in
Berlin, Leipzig, Vienna, Wi'irzburg, and other places discloses at once marked diver-
gence from the faculty schemes as well as significant divergences from one another.
It is, for example, pleasant to observe that the university environment is not totally
lost upon the German medical student. I find one who, passing the summer semester
at IVIunich, tucks in an art course, conducted in the galleries of the new Pinakothek.
A second tops off his descriptive anatomy, medical botany, and experimental physics
with a course in recent French literature; two years later, at Wiirzburg, the same
individual hears lectures on the Protestant Reformation; the next semester, at Berlin,
he attends a course in evangelical church music. A Konigsberg student in his first
semester registers for a philosophical course on the difference between Knowledge
and Belief, — a distinction which it will not harm a prospective physician to pon-
1 It is probably picked up by the student as fatmilus.
24(5 MEDICAL EDUCATION
der. One suspects that those who are thus susceptible of aesthetic, historical, or philo-
sophical stimulation do not prove the least zealous of students even in professional
sul)jects. More common still are courses that, close though they be to the professional
purpose, still lie a little to one side of the beaten path: here is a student who has
had two or three courses in evolution; another, who has worked at the physiology of
the circulation; one has studied immunity; another, pain prevention in surgery; a
third, comparative anatomy; still another, metabolism. The history of medicine ap-
pears, if not generally, at least not uncommonly. Variety assists students to find them-
selves; moreover, the reciprocal stimulus resulting is most important. For in casual
intercourse, every earnest individual is capable of contributing some fact, idea, or
point of view not femiliar to his fellows.
That elasticity is favorable to intensive application at selected points, so much
more effectually formative than conscientious execution of a prescribed plan, is equally
clear. Here, for example, is a student who, having obviously struck oil in the region
of anatomy, kept at it during each of five successive semesters: in addition to the
prescrilied minimum, he heard a course of lectures on heredity, and worked succes-
sively at the anatomy of the sense organs and the embryology of vertebrates. An-
other caught fire in the realm of physiology; his course book shows three successive
experimental courses in the subject in addition to the required lectures and practi-
cum. No practical work in physics is required; but here is a student who takes two
experimental courses in succession, nevertheless. For reasons to be subsequently
pointed out, this phenomenon is rarer during the clinical half. Evidently, the possi-
bilitv of choice stimulates active discrimination; it encourages independent work
within the prescribed number of semesters, thereby explaining the readiness of the
German student to spend himself freely in independent work afterwards. ITie stere-
otyped curriculum would work the other way: denying opportunity for the exercise
of initiative during four or five years, it cannot expect to be followed by an outburst
of assertive energy.
So effective, indeed, is the German scheme' in developing initiative by which the
period of training is lengtheneil and its scope deepened, that the various voluntary
activities, heretofore enumerated, deserve to be accounted parts of the curriculum.
Even if not universal, they are too common to be regarded as in any wase excep-
tional. A% faniidtui, volunteer, assistant, or advanced worker, every student who takes
his career seriously amplifies his necessary training and experience.
ITiere is, however, an obverse side to the picture, which must be carefully examined.
The two striking features of German medical education are the domination of the
lecture method and the elasticity of the curriculum. We have criticized the former
from the standpoint of pedagogic method; we shall shortly see that it seriously inter-
feres with elasticity, particularly in the clinical half of the curriculum. Aside from
this, let us see how far elasticity as now in vogue is itself open to objection.
I am not speaking of merely sporadic absurdities or occasional illogicalities. The
CURRICULUM AND EXAMINATIONS: GERMANY 24T
waste that they involve is not serious. Certainly, the helplessness of the spoon-fed,
who never lose a drop and never take in more than they can comfortably assimilate,
is in any case more deplorable than the results of an occasional case of mental indi-
gestion due to untimely or too difficult endeavor. I am thinking now rather of those
whose entire program is simply impossible. Hopelessly and needlessly overburdened
and misdirected, for example, would seem to be the individual whose course book indi-
cates eleven separate lecture courses in his fifth semester, twelve in his sixth, fifteen
in his seventh ; or another with fifteen in the eighth semester, seventeen in the ninth ;
or another with twenty in the ninth as against twelve in the next. A Vienna stu-
dent in the eighth, ninth, and tenth semesters cari'ied 36, 34, and 20 hours of work
respectively; another, 39, 43, and 21 ; another, 40, 45, and 40. The course book of
a Freiburg student in his ninth semester contains the following formidable array:
Obstetrical clinic and policlinic (also in sixth, seventh, eighth, and tenth semesters)
Medical clinic (also in eighth and tenth semesters)
Suro-ical clinic (also in seventh, eighth, and tenth semesters)
Psychiatric clinic (also in seventh and eighth semesters)
Practical bacteriology (also in seventh and eighth semesters)
Pharmacology (also in seventh and eighth semesters)
Otology
Ear clinic
Ear policlinic
Skin clinic
Lejial medicine
Medical policlinic (also in tenth semester)
Pathological physiology (also in eighth semester)
History of medicine
Topographical anatomy
Autopsy course (also in eighth semester)
Pediatric clinic
Infant nutrition
Infant care
Nose and throat clinic
Hvgiene (also in eighth and tenth semesters)
Protozoology (also in seventh semester)
The sixth semester of a Leipzig student runs as follows: clinical propaedeutic ; phys-
ical diagnosis; surgical clinic; medical clinic; general surgery with demonstrations;
special pathology; pharmacology with prescription writing; surgical propaedeutic
and minor surgtry; bandaging and fractures; operative obstetrics ; brain anatomy;
forensic psychiatry; disorders of the circulation; theories of reproduction; first aid
to the injured; clinical microscopy.
248 MEDICAL EDUCATION
On the otlier liand, a Wiirzburg student shows only the following, thus proving
that reasonable and sound combinations are also made:
Semester ^o. of courses
1 4
2 2
3 5
4 2
5 3
6 2
7 3
8 4
9 13
10 8
AMiether we look at the recommended plans put out by the faculties or at the actual
curricula as evidenced by the course books, it is indisputable that the cun-iculum is
not only confused, but badly congested. In the face of this generally admitted over-
crowding, it seems unfortunate that the medical curriculum is not at once freed from
the preliminary sciences, — at least physics, botany, biology. That they are neglected
in the university is indisputable: their removal to the gymnasium would be to their
own advantage, would facilitate the transposition of pharmacology and hygiene, and
would improve the possibilities of practical teaching in all branches.
Overcrowding is of coui*se an evil that to some extent cures itself. The student pays
for courses in which he must be certificated, not examined: he pays for them and
stays away. This is so well understood that it passes unchallenged.^ Its effect is appar-
ent. Certification was intended to reduce the number of examination subjects by fur-
nishing some other assurance of satisfactory achievement. Under the present practice
that assurance is quite lacking. It is abused to reduce the bulk of the curriculum.
The certificate rarelv lives up to its face. As we shall shortly see, it seems the means
of enforced contribution to the lecturer''s income, rather than a guarantee of the stu-
dent's training. Though one hears occasionally of instructors who refuse certifica-
tion, such action is decidedly exceptional. In courses where pralcticieren is not neces-
sary, the signature in the course book may be the merest form; in those in which
the student must serve as Praktikant, the student who answers to his name the re-
quired number of times and merely stands bv during the professor''s demonstration
is almost invariably credited for the performance. Overcrowding can thus be partly
relieved by neglecting certificate courses in which no examinations are held. But
other ways are open. Having taken on too great a load, the student endures a brief
period of discomfort, followed by spontaneous simplification of mental diet. Refen-ing
to his overcrowdcnl ninth semester, one Berlin student \mtes: "Topographical ana-
tomy never visited; nose and throat clinic only to procure the required certificate." A
second annotates his eighth semester: "Surgery and hygiene systematically ' cut.'" A
third writes of his fifth semester: "Visited regularly only the course in physical diag-
' A Vienna professor admits to his clinic as hogpitant (famulus) only those who agree to cut all lec-
tures during their term of service.
CURRICULUM AND EXAMINATIONS: GERMANY 249
nosis; the others practically not at all; instead, worked asfamuhu) in internal medi-
cine." Of his eleventh semester, including eight courses, another says: "Topographical
anatomy never visited ; ear clinic and eye clinic perhaps ten times in order to procure
certificate; legal medicine and hygiene, once each for the same purpose." On the other
hand, three students, enrolled in six courses each in their last semester, testify that they
attend all regularly. In the long run, neglect is perhaps less damaging than distrac-
tion. Hopeless indeed is the case of those whose days are filled by an unbroken suc-
cession of brief lectures or courses dealing with disparate topics. The attention
prematurely assaulted by ill-assorted facts and quickly exhausted by the stream
of indigestible novelties becomes dazed. The lectures last forty-five minutes each;
successive periods bring new topics, whose presentation is overwhelmingly theoretical.
Little practical skill is acquired, and only theoretical information.
I have urged that a sound curriculum is built on simple lines. Instead of splitting
up a single topic in such wise that each of its elements forms a separate course, which
tend to scatter centrifugally, the concentrated curriculum would weld them together,
and bring the student into contact with rather larger, more voluminous entities. Such
disciplines form a secure substratum; with one or two such at a time, the entire energy
of the student would be continuously engaged for substantial periods. Whatsoever
specialization is added thereto should take the form not of six weeks' courses deal-
ing with various technical tricks, but of protracted efforts to acquire sound habit
through effective dealing with a definite topic. Now, the overburdened cuiTicula
above cited are obnoxious to this principle, not only because too many general sub-
jects occur in each semester, but because the same general subjects recur in too many
semesters. Out of the five clinical semesters, the first course book I pick up at random
shows obstetrics, medicine, and surgery of general character in four semesters apiece;
the next shows obstetrics in four, medicine in three, and surgery in all five.
So much for content. Still more serious criticism may be directed against the lack
of such measure of logical correlation as seems indispensable if the student is to avoid
hopeless floundering and senseless waste. I have not now in mind innocent and pardon-
able absurdities; it is, I daresay, of little permanent consequence that the prema-
ture curiosity of one student hurries him into forensic psychiatry in his first clinical
semester; or that another hears, without obtaining credit for, venereal diseases along
with chemistry, physics, and anatomy in his second semester. But sequence cannot
be immaterial when the faculty schemes invariably introduce physics and chemistry
before physiology, and invariably insert physical diagnosis and general pathology
in the first semester of the clinical division (the sixth semester) : in that semester the
Wiirzburg, Berlin, or Munich student is warned away from the medical clinic; the
Leipzig student advised to attend only as listener.^ The advantages of the suggested
1 At Breslau, however, the student is advised to attend the medical clinic in his sixth semester. In
Austria, the fifth is the first clinical semester ; at Graz, the faculty plan postpones the medical cHnic
to the next, devoting the fifth^semester to pathology and physical diagnosis.
250 MEDICAL EDUCATION
sequence are self-evident: to the student, because he can form no definite coriception
of tlie conditions exhibited without previous training in physical signs and in patho-
loi»-ical Jis well as normal physiology and anatomy ; to the lecturer, because otherwise
he speaks a foreign language, unintelligible to his hearers. The student can of course
in no event complete pathology by way of a clinical preliminary; it necessarily
recurs, when subsecjuently his clinical training enables him to come to closer c|uar-
ters with the subject; the interplay at the latter stage is most intimate. From this
point of view, inspecting seventy-two transcripts of student course books, I find that
seven had done some work in pathology before taking up any clinical work; forty-
three entered pathology and the clinics simultaneously; nineteen began pathology
only after one or more semesters in a clinic, some of these after the lapse of two,
three, or even four semesters, with medicine, surgery, and gynecology sometimes
entirely completed beforehand; three are not signed up for pathology at all.^ In
these figures, I have reckoned as beginning pathology before and with clinical medi-
cine all whose course books mention any pathological course at all at those periods.
As a matter of fact, many of these heard only lectures of slight assistance toward
the end here in view. Von Hansemann maintains that concrete pathological expe-
rience is less apt to be found at the beginning of the clinical semesters than at
the close, when the examination in pathology heaves in sight, — too late, of course,
to be of service to the student in apprehending the phenomena of disease. Of 137
Jiumdi, serving with him at Friedrichshain, only 29 had recently weathered the phy-
sicum; 108 stood in the higher semesters. "I can state," he says, "that among the
latter there were intelligent and industrious students, who had already obtained
the certificates for practicieren from all the requisite clinics, without possessing the
remotest notion of pathological anatomy. To me it is entirely incomprehensible, how
a student can grasp the significance of auscultation and percussion, the meaning of
palpation, the normal and abnormal course of pregnancy, without accurate patho-
logical knowledge. I cannot imagine how a clinician can explain the course of pneu-
monia, Bright's disease, etc., to students incapable of forming the appropriate ana-
tomical picture."^
The faculty counsel is more diligently heeded in respect to elementary percussion
courses: for a veiy large proportion of my cases show such a course in the sixth, a few
even in the fifth semester; nevertheless, instances occur in which the art of physical
diagnosis appears to be systematically studied for the first time in the seventh, ninth,
and even tenth semester.' The advanced courses often recommended for a later semes-
' They were probably famuli at some time or other. I was told by one professor that twenty per cent
of the students enter the examination in pathology without havinfr had a course in the subject. As
to this, no accurate statistics are obtainable. The instructors in pathology urge the requirenient of
a certificate.
' " Die Bedeutung der pathologischen Anatomic fiir den medizinischen Unterricht," Zeitschrift fiir
Aertlliche i'urthUduntj, 1!>()4, No. 11.
• Some students who take a systematic course late may have learned the technique as /amu/i earlier.
CURRICULUM AND EXAMINATIONS: GERMANY 251
ter are attended by a very small, practically negligible numljer. Fractures and bandag-
ing occupy with reference to surgery a position similar to that of percussion and aus-
cultation with respect to medicine: an appropriate course is usually recommended for
the sixth semester. Twenty-five course books show that five students took such a course
on beginning surgery; nine later, most of them in the tenth semester, with an evident
eye to the examination; eleven not at all. Not uncommonly the student plunges at
once into the most intricate aspects of the subject.'^ A Berlin student is certificated
in surgery at the close of his second clinical semester without having had pathology,
minor surgery, or bandaging; having thus in his seventh semester satisfied the re-
quirements, two semesters later he is found in a course in operative surgery. A Wurz-
burg student takes the surgical propaedeutic in the ninth semester, having already
spent three successive semesters — the sixth, seventh, and eighth — in the regular surgi-
cal clinic. A study of the sequence in obstetrics discovers students working with the
manikin in the eighth semester after having spent the seventh in the obstetrical clinic.
To some extent, these anomalies are more or less tardily set right by experience as
famulus; but by no means generally, and in any event the waste and confusion are
serious. One cannot avoid the conclusion that failure to arrange a more logical order
results in widespread neglect of fundamental correlations of both theoretical and
practical nature.
The Germans have proceeded upon the theory that, protected as they are by uni-
versity standards and ideals, the state examination alone is capable of retroactively
regulating details. It is, as a matter of fact, an error of judgment to expect too
much of the examination. The policy of the examiners is and must be determined
bv the general educational scheme. The basis of matriculation and the quality of the
instruction constitute the point of view from which they regard the candidates be-
fore them. What they require inevitably flows from what the system fairly permits
them to expect. They will adjust themselves to the defects and peculiarities of the
system are they not themselves its product .^^ — rather than endeavor by ruthless
execution to force far-reaching modifications.
If, then, organic defects of correlation exist in an educational scheme, they must
be corrected by arrangement. The difficulty is to introduce order without saci'ificing
elasticity. This seems a not impossible achievement, if the cuiriculum is laid out on
lines at once broad and simple. Physics, chemistry, biology, and botany must precede
the medical course proper; anatomy, physiology, and pharmacology would then con-
stitute the physicum; pathology and perhaps physical diagnosis would occupy an inter-
mediate position ;^ theclinical branches would conclude the whole. Within each division
leeway could be preserved; coordination would itself effect economies of time and effort.
What is lost in elasticity by such regulation can be offset by resort to certification
1 Taking, for example, at the start, "select chapters in surgery" at Berlin.
2 Beneke proposes a special examination on these subjects following the physicum. " Vorschliige zur
Verbesserung des Studienplans der Mediziner," Berliner JClinische Wochenschrift, 1908, p. 37.
252 jMEDICAL EDUCATION
w-ithout examination; for the curriculum is stiffened by the necessity of deliberate
preparation for many separate examinations, as well as by the enforced sequence of
its contents. Certification seems an excellent method of relieving the examinations,
or preventing further increase in their number. For nothing is more certain than that
as examinations become mere numerous, they become more perfunctory and mechani-
cal. The more the expert coach or crammer is required by reason of the necessity for
carrving additional subjects at the tongue''s end, the more inelastic the course of study
and the less the net protective worth of the examination itself. Of course, certification
is itself an idle form unless the certificate represents actual value. The certificate ought
in all conscience to be a reliable evidence of practical participation; and if reliable, it
may very properly be substituted for examinations in the less fundamental topics,
specialties, etc. But, however legitimate in point of theory, the certificate cannot, as
a matter of fact, be regarded as expedient until, participative having succeeded de-
monstrative instruction, the student becomes part of the out-patient or ward service
on such a footing that duty, interest, and responsibility combine to foster regular
activity as his part.
Consideration of the German curriculum leads us, then, to the conclusion at which
we arrived after surveying the different subjects of instruction. A sound curricu-
lum is a simple curriculum, which requires all to pursue certain indispensable topics,
and each at some point to engage in more thorough intensive work. But in order
that instruction, economical of time, may be effective in attaining the desired result,
it must be soundly organized: participation, not demonstration, must be the keynote
of the method employed. Moreover, when once German medical instruction becomes
participative, the necessary degree of arrangement and correlation will at once be
forced; for where students take part, they must have acquired the necessary instru-
mental knowledge and skill before participation.
A serious obstacle to this improvement lies in the constitution of the university.
The change from demonstrative to participative instruction would probably involve
considerable recasting of the entire medical faculty. Originally, the German uni-
versity was a lecturing institution. By means of lectures, knowledge was for centuries
expounded and transmitted, and transmission by exposition remained the chief
function of the university up to the nineteenth century. The lecturing university
consisted essentially of a relatively small faculty of professors, the ordinarii, so called,
— forming the official teaching staff*, beside which there grew up an informal and un-
official teaching staff* of decidedly modest proportions, — the docents, and so-called
professors extraordinary.^ This unoflicial teaching body was originally little more
than the garden plot in which prospective ordmarii were grown. The ordinarii were
the teachers, as they were the sole governors of the university; departmental organi-
' In l"ft5. there was a total of 376 orrJlnnrtu S6 extraordinariu and 3S docents in all German universi-
ties; at the close of the century, the proportions remain practically the same: in 1796, the numbers
were 619. Ul, and 86, respectively. Eulenburg: Der Akademische Xachwucha, p. 10 (Leipzig, 1908).
CURRICULUM AND EXAMINATIONS: GERMANY 253
zation there was none; a single professor represented a subject, — the subject some-
times of vast extent : anatomy, physiology, and pathology constituted, for example,
one chair, whose incumbent covered the field discursively every semester or two. Fac-
ulty government was of a primitive kind; things ran on straight lines; every pro-
fessor followed his own preference; there was no attempt to bring about pedagogic
cooperation.
It is unnecessary to repeat what has already been said in reference to the changes
introduced in consequence of the scientific developments of the nineteenth century.
Suffice it here to state that additional chairs have had to be created,^ and that eveiy
department has undergone complex internal transformation. Numerous instrumen-
talities have had to be created to keep pace with the increasing specialization of
function required by research. A department ceased to be an individual ; it became
a complicated interacting group. The newly added members received no consistent
title. They were, in effect, laboratory or clinical assistants of varied status; now im-
portant enough to be head of a division independent in all but name, again hardly
more than an additional ann or hand. Now a docent, now a professor extraordinary,
again a titular professor, a mere assistant, or even a volunteer, — in number, variety,
and definiteness of function, the academic after-gi'owth embodies the response of an
institution splendidly vital, despite its mediaeval structure, to a wholly new set of con-
ditions. Its whole life has changed correspondingly. Departments could no longer
thrive in cloistral isolation ; active interrelations sprang up. More and more they had
to rely on and to cooperate with one another ; the university became, in fact, highly
complex, — an organic thing.
We should expect to find a change in university government and in university
teaching corresponding with the change that has taken place in departmental or-
ganization. It has not yet come about, and, as I hope to show, the maladjustments in
German medical education are partially traceable to this fact. I have said that a single
professor has ceased to be a department; chemistry, physics, medicine, and surgery
are each represented and cultivated by groups. But the necessarily organic constitu-
tion of the several departments, and the organic nature of their interrelationship, have
not affected the constitution and management of the official university. The ordinarii
are still the university, and each of them still goes his own way. Subdivisions within
the department pursue pretty much the same policy. A division chief in Berlin, who
three years before was called from a Swiss university, informed me that in all that
time he had never had a conference with any one in reference to the apportionment
or organization of either teaching or research. He did as he pleased, following the
example of his superiors. Neither the government of the university nor the offering
or conduct of courses takes explicit and adequate account of the changes which have
come about in the constitution and internal relations of scientific knowledge.
1 These new chairs are not always of full faculty rank. While ophthalmology was made a full profes-
sorship, dermatology and pedi'\trics are as a rule held by extraordinarii.
t54 MEDICAL EDUCATION
The lack of correlation which thus results is protected under the imposing name
of university freedom. Now, as a matter of fact, the student's freedom has already
been so often impaired — even though in many instances quite ineffectively — that its
further or different abridgment in the interest of intelligent coordination cannot be
consistently refused. The examination ordinance, as it now stands, violates academic
freedom in a dozen ways. Important as it is, from every point of view, not to use
up the professor in stereotyped teaching or the student in mechanized study, an
abstract principle already infringed cannot be permitted to obstruct the systematic
organization of the curriculum on such lines as are implied by the fundamental
necessities of the subject-matter, more especially as sufficient freedom will remain,
even after the essential correlations have been assured.
There is, however, another obstacle. The German professor receives his remuneration
partly, sometimes largely, in the form of student fees. An entirely different system of
financing would be required if the large lecture groups on which he relies for his in-
come were broken up.^ An oligarchical form of university government and pecuniary
necessity have thus combined to resist the expansion of the teaching body to keep
pace with the gro\\i;h in university attendance and the complications of subject-mat-
ter. In fact, the total number of ordinarii was greater in 1796 than in 1860, — 680
as against 600.^ Only since 1870 have the ordinarii groAvn in numbers; the main ex-
pansion has Ijeen in the ranks of the ejctraordinarii and the docents. Between 1880
and 1 906, the ordinary professorships in the medical faculties of Germany increased
from 19-i to 246, that is, 26.8 per cent; the extraordinary and docents from 330 to
725, that is, 119.7 per cent.^ While the total student enrolment in Prussia has in the
last three decades increased 159.6 per cent, the teaching staff has increased 41 per
cent.* The following table shows the development of the medical faculty of Berlin:
Tear
No.
Students
No.
Teachers
No. Ord.
No. Extraord.
No.
Docents
Hon. Professors
1855-1856
261
39
11
8
30
1875-1876
263
66
13
17
37
1895-1896
1226
119
15
30
70
4
1907-1908
1153
189
18
44
117
10
In other words, while the student body increased from 261 to 1153, and the teach-
ing staff from 39 to 189, the number of ordinarii grew only from 11 to 18.^ But the
disproportion is in fact even more marked than appears: for meanwhile both the teach-
ing method and departmental organization have altered. Where lecturing suffices,
indeed, the teaching staff need not grow pari passu ^nth the student body : a professor
' For a moderate statement in favor of the fee system, see Paulsen : German Universities (translated
by Thilly), pp. 90, etc. (New York, 1906).
' Eulenburg : Frequenz, p. 280.
3 Eulenburg: Academisrhe Nachwuchs, p. 31, note.
♦ Dig Ixijje dfr a^issernrdent lichen Professoren an der Preussischen Universit<iten, p. 36 (Maffdeburg,
Ifill). hulenburg {Xachxcurhs, p. 13). taking in all German universities, finds the student increase
119 per cent, the increase of ordinarii, 31 per cent.
• Pagcl in Deuttche Medizinische }Voclienjichri/i, October 6, 1910, p. 1844.
CURRICULUM AND EXAMINATIONS: GERMANY 255
can lecture to two hundred as readily as to fifty. But practical work, and specializa-
tion within laboratory and clinic requii-e augmented staffs, even where student en-
rolment remains stationary. Finally, the increase above noted on the unofficial side is
itself in part nominal, for the university status of an appreciable number of professors
extraordinary and docents is merely external : both titles, ha^'ing commercial value,
are at times sought and exploited for no other purpose. The holder announces courses
which attract, and are expected to attract, no students; meanwhile, his door-plate
bears the legend "university professor" or "university docent."
Let us bi-ing these considerations to bear on the problems of teaching method and
curriculum. Brief consideration will, I think, demonstrate that the composition of
the medical faculty is an important factor in explaining the persistence of the lecture
method, the splitting up and lack of coordination of the instruction. The persist-
ence and inordinate scope of the lecture are responsible for the overcrowding of the
curriculum through repetition. The required courses are invariably the courses given
by the ordinarii. All the courses for which the student is compelled to procure a
certificate before admission to examination are held by the ordinarii. As long as the
ordinarii are few in number, are paid mainly in student fees, and conduct well-nigh
all courses that the student is officially compelled to take, so long will mass teaching
prevail, so long will participative coordinated insti'uction remain undeveloped. No
other result is possible. Eighteen ordinarii at Berlin form the faculty for 1200 medical
students; 14 at Munich for 1908; 23 at Vienna for 1869; 10 at Leipzig for 618; 12 at
Breslau for 414; 13 at Greifswald for 258, If this relatively small body of teachers is
to have main charge of the students, at least to the extent that required certification
applies to the courses of the ordinarii and to those almost alone,^ then mass lectur-
ing is inevitable. The fact that in each university a certain number of extraoidinarii
have teaching-posts, representing the newer subjects, does not greatly relieve the
situation ; for the same arrangement prevails in those. The extraordinarius is in such
instances the ordinarius minus a seat in the faculty. Outwardly, he deports himself
like an ordinarius. He too must come into contact with the entire student body, — he
covets the prestige, he receives the fees, and at times serves as examiner. The lecture is
the only teaching method that keeps, or can keep, the professor, be he ordinarius or
extraordinarius, in command of the entire body, whether as teacher or as examiner.
Ways of correcting the most glaring insufficiencies of the lecture system have been
found without attacking the main structure. Students have somehow to learn to man-
age the stethoscope, the ophthalmoscope, bandaging, obstetrical manipulation, etc.,
— arts which can be taught only to small groups. I have already pointed out how this
has been accomplished by utilizing the subordinates in the laboratories and clinics.
Two birds are thus killed with one stone. Laboratories and clinics need larger staffs
of scientific workers; students need some individual teaching. As the funds of the
1 Excepting only the few instances in which certification involves extraordinarii in charge of an
important branch (for example, medical policlinic).
256 MEDICAL EDUCATION
university are inadequate to support proper staffs, the income of the docent from
practical courses furnishes an indirect support. The departmental head, — ordinarius
or extraonUnariii^, — who completely controls the resources and equipment of labo-
ratory and clinic, permits his assistants, docents, titular professors, or what not, to
use his material in conducting special courses of a practical kind. Despite their isolated
and wholly optional character, these courses represent one of the strongest assets of
the German university. For they support scientists during their period of probation,
make an arena where new ideas may be tried or disseminated, render the elasticity
of the curriculum a real and most important factor, and supplement the theoretical
lecture instruction with practical group instruction, excellent as far as it goes. Ger-
man medical education is thus concrete and practical to the extent that supplemen-
tary courses of this sort have been devised. But where they stop and the demonstra-
tive lectures begin, German medical education is not concrete and practical, but theo-
retic and passive. Tlie practical courses, therefore, leave the monopoly of the chief
untouched. The ordinarius, protecting his position, blocks the entry of complete prac-
tical training into his clinic.^ For the courses given with his tacit or express consent
are either merely instrumental, merely technical, or highly special: courses in aus-
cultation and percussion, for example, in clinical chemistry, or in sense-physiology.
These are only partial or special aspects of the general subjects, for which the stu-
dent must recur to the lectures of the chief. He has as to this no option: no one else
really gives clinical instruction in a total form, just as no one else teaches general
anatomy or general physiology; no one else examines, no one else can sign a course
book in the required subjects, no one else can issue a certificate that is legal tender.
As long as this power is concentrated in the hands of a small body of professors, lec-
ture instruction is their only recourse.
Repetition and overcrowding inevitably result : the official make-believe holds that
the student is expected to learn by attending lectures and witnessing demonstrations.
In good faith the beginner falls in with this tradition. He attends his first clinic;
finding little profit therein, he attends a second, a third, and yet a fourth. He takes
meanwhile a practical course — perhaps several of them — and returns to the attack,
endeavoring to correct the fundamental vices of the teaching method by sheer re-
petition. Six students taken at random attended respectively 4, 7, 6, 4, 4, and 6
lecture courses in medicine; the same individuals attended each from 4 to 6 lecture
courses in surgery; some of them from 4 to 6 in the women's clinic. Thev also show
respectively 8 practical courses out of 35, 12 out of 49, 13 out of 42, 6 out of 34, 6
out of 26. Overcrowding with lectures, viewed from this angle, is not a defect due to
abused ela.sticity, but the futile and frantic effort to con-ect by sheer multiplication
defects in method that persist because they are the bulwark of an antiquated and
narrow university organization.
» Private drill classes aiming to cover the entire field are, however, organized with a view to the im-
pending examinations.
CURRICULUM AND EXAMINATIONS: GERMANY 257
If, on the other hand, participative instruction is to be introduced, clinical mate-
rial must be divided; departments must be conducted on lines consistent with the
principles on which scientific knowledge is organized. Different departments must
explicitly recognize and calculate with each other. Moreover, the size of the student
body must be in some definite relation to the size of the staff and the extent of the
teaching facilities. When the capacity of an institute or clinic is reached, another
must be provided or enrolment must be halted ; for, while the lecture method adjusts
itself by enlarging the auditorium and raising the voice, practical instruction soon
encounters stubborn limits, to overpass which involves deterioration. But organi-
zation that complies with these terms leads to a wider diffusion of authority, -Hith
university government not through a small faculty, limited to ordinarii, but through
representatives of the entire university cosmos, — a democratic organization, in a
word.
There is indeed a notion current that the German university faculty is already
a thoroughly democratic affair. So it is — internally. The ordinariate, viewed as a
thing-in-itself, is an absolute democracy — a small society of equals. Viewed in rela-
tion to the university as a whole, however, it is a narrow oligarchy, a close corpora-
tion. The ordinarii alone govern ; they alone have rights ; no other rank has even re-
presentation. The rotating rectorate is not calculated to remove the defects to which
an organization of this type is exposed, for the rector is little more than an ornamen-
tal figure, — the official spokesman of the institution during his brief term, hardlv
more. Nor is a more democratic spirit likely to blow from the ministry, centraliza-
tion of authority in which, with all its advantages of intelligent general direction, is
not apt to facilitate easy and natural readjustments.
From an outside point of view, the important lesson to carry away is that the de-
fects in German medical education are not necessarily inherent in university methods,
but spring rather from failure to square university organization and government with
the requirements of modern science. There is no reason why university instmction
should be theoretic, and non-university instruction concrete. University instruction
is indeed already practical and investigative at the higher levels; it can be made
practical at the lower level, also, if a proper organization is installed. Meanwhile,
that freedom which is the life-breath of science and scientific teaching need not be
impaired; for every improvement in teaching will strengthen the student in the
power to make wise use of reasonable liberty, without in the least interfering with
his tendency to migrate.^ The overburdened curriculum would then disappear with-
out being forbidden; responsible duties at particular times and places would enforce
a wise distribution of time and an efficient correlation of activities.^
1 We have already noticed that in England the clinical instruction is concrete in character, without
being rigid in its sequences. Nothing but custom interferes with migration on the part of the English
student: he might well do some of his clerkships in Edinburgh, others in London.
2 For the sake of simplicity, I have made no separate account of Austria in the preceding discus-
sion. Differences between Aus^ria and Germany are not material where likenesses preponderate so
258 MEDICAL EDUCATIOxV
It remains still to descril)e and to discuss the last of the factors which contrib-
ute to the niakinir of German doctors, — the examination. In the German Empire,
state and university examinations are to be distinguished.^ On the former depends
the title of "praktischer Arzt," that is, the license to practise; on the latter, the
academic degree of M.D. The latter may be dismissed with a few words. Usually
taken after the state examination, it is in most instances little more than a costly
formality: the candidate contributes a brief autobiography and from fifty to one
hundred printed copies of a thesis,^ and the dissertation is usually compiled according
to formula. Nevertheless, exceptions occur: it happens sometimes that in the process
of preparing a thesis, a student may disclose to his teacher or discover for himself
a new kind of capacity and interest. In any event, the necessity of studying and re-
porting upon the literature of a theme is not without advantages. His thesis accepted,
the candidate appears before a committee of the faculty, the dean or his representa-
tive and at least two colleagues, by whom he is colloquially interrogated for fifteen
minutes each: perhaps the most formidable aspect of the ordeal is the expense — some
three hundred marks or more.
The state examination is much more serious. It is held at every university in
Germany under the auspices of a local commission composed of teachers, and well-
nigh wholly of ord'marii.^ As candidates are examined either singly or in small groups,*
the examinations constitute a fairly continuous performance during the entire
freatly. In Austria some of the extraordinarii have seats in the faculty. Two representatives of the
ocents also attend faculty meetings, without voting. It must be added that the professors there, being
salaried, receive no fees, though they are agitating for a return to the fee system. The practical year is
not required. The sixth semester is preferred for military service. There are three examinations, known
as the first, second, and third rigorosum respectively, the first coming at the close of at least four se-
mesters, the last six semesters later. The first rigorosum includes biology, medical physics, medical
chemistry, anatomy, histology, physiology ; biology and physics are onlj' theoretical ;the others the-
oretical and practical. The second rigorosum includes (r/) pathological anatomy and histology, {h) gen-
eral and experimental pathology, (c) pharmacology and prescription writing, (d) internal medicine,
(e) pediatrics, {/) psychiatry and neuropathology. Subjects (6) and (r) are theoretical only, the others
theoretical and practical. The third rigorosum contains surgery, obstetrics, gynecology, ophthalmology,
dermatology, hygiene, legal medicine, the last two only theoretical. In addition, certificates must be
presented covering vaccination and six weeks' courses in laryngology, otology, and dentistry. The
course book must show that the student has paid for twenty hours' instruction a week, except in the
last semester of the first rigorosum, when sixteen suffice.
The recommended plan does not differ in principle from the two German specimens given above.
1 Not, however, in Austria, where one suffices for both objects.
^ Leipzig permits the thesis to be in manuscript.
' Theoretically, the office of examiner in the state examination is open to any teacher; in effect, it is
restricted to ordinarii, and such ejtraordinnrii as hold definite teaching-posts. While examiners are
severely burdened, their income in examination fees is considerable. In addition, lecture fees are also
indirectly increased, for .students incline to enroll in the courses of their prospective examiners. The
considerations which recommend enlargement of the official teaching staff plead with equal force
in favor of enlargement of the examining staff. As to exceptions, see H. Waentig: Ztir Reform der
iMutsrlien I'n'trfrsdnte.n, pp. .5, ^2--2S ( Berlin, lf»ll ). In Austria, the state is supposed to be represented at
the second and third rigorosa by an assessor, but his attendance is apparently rare, as must be the case
where examinations are conducted through the entire year. The dean also attends for part of the time.
♦ In the German Empire not exceeding four candidates as a rule, but in Berlin and Mimich the groups
at tirnes include six to eight; in Vienna sometimes more. In the clinical examinations in the German
hmpire a single patient may, as a rule, be used with only one candidate.
CURRICULUM AND EXAMINATIONS: GERMANY 259
semester. Before admission, the student must strictly comply with all the required
formalities; he must submit a diploma of graduation from the gymnasium, proof that
he has spent at lea,st five semesters at the university, and certificates covering the
required courses and lectures. The first examination lasts as a rule four days, ana-
tomy consuming two, physiology one, and the remaining subjects one. The official
regulations specify that in anatomy each candidate is to describe a designated part,
to make a dissection, answering appropriate questions viva voce as he proceeds, and
to make two microscopical preparations, orally replying thereafter to questions cal-
culated to discover whether he is fundamentally trained in histology and embryology.
The examination in physiology covers general physiology, including physiological
chemistry, and requires both oral and practical work; the examinations in physics
and chemistry, oral only, are meant to keep in view especially the needs of the future
physician; in zoology, comparative anatomy and physiology are to be emphasized;
in botany, the anatomy and physiology of plants, especially those with medicinal
properties. Should the student fail to pass in any subject, he may be allowed two
more trials, from two to twelve months later. If two years elapse before the entire
examination is passed, the slate is wiped clean of all credit. If on the third round a
failure is scored, the student is denied further chance even to retrieve,^ though, as
we shall see, in practice this does not happen.
For the clinical examination, for which a similar committee is designated, two
periods are appointed, beginning about the middle of October and the middle of
March, respectively : it is presumed that the latter wnll not extend beyond the mid-
dle of August. The student must before admission furnish official proof that he has
passed the first set of examinations without condition, that he has now attended the
medical faculty for at least ten semesters, all told, — at least four of them since the
completion of the physicum; he must file his course book, properly attested for re-
quired courses, and the requisite laboratory and clinical certificates. The examiners
are directed to proceed as follows :
Pathology, divided into two parts, — pathological anatomy and general pathology,
— should occupy one examiner two days: the candidate must show his ability to
do a post-mortem, actually autopsying one of the three chief parts and writing the
protocol; he must make two or three microscopic preparations, expounding at least
one, and finally he must be subjected to a searching oral quiz on the principles of the
science. It is worth noticing that the examination, unlike the teaching in patho-
logy, is correctly placed between the two sets of examinations. The medical exami-
nation proper follows; it falls into two parts, and as nearly as may be is to be
completed in seven successive week days. In the first part, conducted by two exam-
iners in the medical w^ards or policlinic, the candidate must be required on two suc-
cessive days to examine two patients, making diagnosis, suggesting treatment, and
venturing a prognosis ; at home he must write a critical account, to be turned in the
1 In Austria, an application to the Emperor results in further trials.
2(50 MEDICAL EDUCATION
next dav; thereafter daily, for four days, he must visit the patients once a day or
oftener, reporting his observations to his examiners. Incidentally, the candidate is to
demonstrate his capacity in other directions, — in therapeutics, pediatrics, laryngo-
lofv, etc The second part consists of a written examination in prescription writing
and an oral examination in pharmacology and toxicology.
The surgical examination embraces four parts, to be discharged in seven successive
week davs. Two examiners are usually concerned; the scene is the surgical clinic or poli-
clinic, and for the final portion, the anatomical institute. In the first part, it is dii'ected
that, as in medicine, the student on two successive days examine two cases, making
diaignosis and prognosis and suggesting treatment, following which he must prepare
a critical account of both at home; he must look after and report on his two cases
for four days thereafter. Incidentally, opportunity must be sought by the examiner
to test the candidate's competency in other directions: does he understand anti-
and a-sepsis, can he do minor operations, has he sufficient acquaintance vnth diseases
of the ear, and skin, with syphilis, etc. ? In the second part, he is to be interrogated
viva voce on the principles of surgery and to be required to operate on the cadaver;
the third part is a practical exercise in bandaging, setting of fractures, etc. ; the
fourth is devoted to topographical anatomy.
Obstetrics and gynecology, divided into two parts and conducted by two examiners
in the women's clinic, are to occupy five successive da^'^ : in the first part, the can-
didate must be required to make an examination, explaining the conditions found and
their import, to take part in the delivery, and thereafter to hand in a critical ac-
count of the same; on four successive days he is to visit mother and child, reporting
on the condition of both; incidentally, he must be orally quizzed in such wise as to
test his general knowledge and competency in respect to both obstetrics and gyne-
cology. The second part of the examination is concerned with the manikin and the
use of instruments.
One examiner takes charge of ophthalmology. The test, spread over three days,
requires the student to examine a patient, make diagnosis and prognosis, and sug-
gest treatment. He must visit the patient on two successive days and submit a written
precis; the usual oral questioning accompanies. For psychiatry a single day is required.
The student examines a patient and undergoes viva voce interrogation. Hygiene
and bacteriology occupy a single day; the examination is altogether oral and theo-
retical. All examiners are warned to touch on the history of their branch and its rela-
tions to legal medicine. As a rule, though only a week is required to elapse, intervals
of six weeks usually separate a candidate's several examinations; if, for example,
he attempts pathology in mid-October, internal medicine would be reached about
December, etc. Failure in any subject may be removed bv reexamination, the respite
running from two to twelve months, according to the seriousness of the deficiency.
A third failure in even a single subject would be fatal to the student's ambition; he
would Ix; excluded from the profession. The practical year follows unconditioned sue-
CURRICULUM AND EXAMINATIONS: GERMANY 261
cess in the examinations. The student repairs to any one of a considerable number of
recognized estabhshments, in which he is counseled to improve his practical capabili-
ties and to demonstrate his fitness to enter upon the practice of the profession. His
year may be equally divided between the clinics and the laboratories of the hospital;
but for cause shown, two-thirds of his time may be devoted to the latter.^
What are the merits, what the demerits, of the German state examination.? The
former are obvious : in so far as in its application it conforms to the requirements,
its general tendency is to force the student to acquire practical skill. The fore-
knowledge that to pass in anatomy he must dissect, to pass in medicine he must make
a physical examination and a diagnosis, to pass in obstetrics he must participate in a
delivery, cannot but exert a wholly favorable influence on the course of his studies
and efforts. Moreover, the moral and practical aspect of the inevitable tete-a-tete
is indisputably great, particularly in the smaller universities, where professor and
student are acquainted with each other, and where to the mortification of failure there
would be added a kind of personal humiliation.
The theory and the practice of the examination are, however, far apart, — so far,
that it is quite clear that not even a practical state examination can be relied on to
force medical instruction to be markedly better than the general conditions under
which it is caiTied on. The examiner, in a word, is disposed above all to be fair; that
is, to require only what, under the circumstances, may be justly asked. His function
is judicial; and among the elements which determine his judgment will be found a
more or less generous allowance for the sort of instruction provided, for the failings
of youth, and for the traditions of the university. The detailed specifications of the
state are therefore none too scrupulously obeyed. They are, as a matter of fact, not
quite enforceable. I have said that the examinations are practically a continuous
performance; the clinician is expected to examine an almost endless chain of candi-
dates, each of whom he sees several times. Meanwhile, none of his other functions is
suspended; he lectures, investigates, writes, attends meetings, conducts his clinic,
and sees his private patients. Examining must accommodate itself to these current
engagements; it does, and is more or less hurried and crowded in consequence. Now,
haste is more apt to lead to laxity than to summary rejection. Time presses for another
reason. Theoretically, the test is a face-to-face encounter between a teacher and a single
student; in practice, as many as eight students may have to be handled at once. I met
a Berlin student who was one of twelve when examined in psychiatry. The entire
character of the transaction is thus altered. The practical test cannot be stringently
or thoroughly applied; oral facility on the part of the student enables a merciful
examiner to square himself with his conscience. In such subjects as are tested only
viva voce, — physics, botany, pharmacology, hygiene, and in Austria legal medicine
1 See Die gesetzUchen Bestimmiingen iiher die arztlichen Prilfungen fiir das Deutsche Reich (Berlin,
1908). The Austrian regulations differ only in so far as they are somewhat simpler, and do not require
the practical year. See Vorschilftenfiir das Studium der Medizin und die Rigorosen (Wien, 1904).
262 MEDICAL EDUCATION
and experimental pathology, — a single student at the larger universities is on the
stand for not exceeding fifteen minutes. The inevitable realization of the possible in-
justice of a decision arrived at on evidence so incomplete halts an unfavorable judg-
ment in any but extreme cases. It is possible that the examination would more nearly
conform to the official stipulations if it were concentrated in several days each term:
in that case, the professorial decks could be cleared for action.
The intended practical character of the examination is also in some measure be-
lied by the extent to which "cramming" flourishes.^ In Berlin, this industry reaches
laro-e proportions. Everywhere cramming is favored by the succession of examina-
tions at considerable intervals. The studentcrams foranatomy, having achieved which
lie prepares in the same fashion for physiology. A succession of hurdles sufficiently
far apart involves no more strain than leaping one hurdle at a time and preparing
in a leisurely way for the next. For cramming, one apology may fairly be made: it is
a way of bridging the gap between teacher and taught which mass teaching creates.
Moreover, the examination calls for some kinds of accomplishment hardly otherwise
to be acquired. The student's critical reports above mentioned must contain a case
history properly worked up. In all the authorized and required clinical teaching there
is never a moment when his teacher can or does require that of him. Unless Si?,fanui-
his he acts as clerk in a medical clinic, he would, but for the expert drill-master,
draw up his first case history in the process of final examination !
Cleiirlv, the state examination is less practical and more theoretical than the regu-
lations design; and both theoretical and practical examinations have deteriorated.
Pagel declares that the examination in botany has degenerated into a mere farce.^
Despite the state's detailed requirement, the examinations bear no uniform or con-
sistent character. Tliey vary greatly with the individual. One examiner may construe
the absence of required certification as imposing an additional obligation to be strict.
I met a pathologist, however, who took precisely the opposite view. Regarding as
indefensible a method which left the student free to attend lectures and courses or
not, as he pleased, he refused to visit upon students what he conceived to be the
defects of the system. A third pathologist confessed to me that a student could pass
his examination without having taken a practical course. One important clinician
described his examination as " very mild;" another begged me to stay away from his
^ Conditions appear not to have changed essentially since Billroth published his caustic Aphorismen
in iMSfi. " How do the j'ounfj folks pass their examinations? Why doesn't one reject all who know
nothing ? — Easy to say, but hard to do. Most students don't go to lectures : they are coached both
for questions and the operations on the cadaver. At the bedside it 's a gamble, and there indeed many
a one falls. ... I am known as a mild examiner. When I ask questions bearing on my own views, or
my own operative methods, I make the dismal discovery that most of these gentlemen have not at-
tended my clinic or don't care to accept anything from me. . . . Then again, throughout the semester
I examine weekly 10 or 1-2, sometimes 20, besides conferring with some .50 or fiO at the close of the
semester on the subject of fee exemption. One simply can't be always equally .severe ; one is bodily and
mentally worn out'" v//</iorMm/?n, pp. 22, 23 (Wien, 1H86). (Slightfy condensed.)
' "Thatsiichlich artet gerade das Examen in der Botanik vielfach zu einer rein forraellen Farce aus."
Einfiihruruj in tiat Stiuiium der Medizin, p. 41 (Berlin, 1899).
CURRICULUM AND EXAMINATIONS: GERMANY 263
examination on the ground that he was ashamed of the showing of some students
whom he passed. I witnessed a successful examination in operative surgery, in which
the professor took the instrument from the fumbling student and himself carried out
the procedure he had asked for; an oral in pathology in which a successful candidate
gave not one complete answer. On another occasion I attended the examination of
five candidates simultaneously in anatomy, in the presence of over one hundred wit-
nesses. Of the five, three were set to work dissecting, one was studying a special prepa-
ration, the fifth was undergoing lais oral examination. The quizzing was severe and
perhaps somewhat too urgent; the dissections were mercilessly criticized: the results
were uneven, a woman student making a particularly poor showing. Quite regardless
of the result, the performance must have been a wholesome stimulus to the onlookers.
How far the outcome is actually detennined by the practical test, it is impossible
to say ; no one knows. As the system is now worked, almost anything may happen.
A brilliant young Berliner admitted to me that he had shirked practical surgery,
obstetrics, and gynecology without consequences to his examinations; he was now
spending eight months of his practical year in the chemical laboratory of a children's
hospital. I do not mean that these are fairly representative experiences: but they
serve to establish the fact just mentioned, namely, that the examinations lack uniform
or general character. Subjected to no central supervision or inspection, they vary
enormously from one university to another and within each. Students are experts
on this point. Not infrequently, migration is calculated so as to bring the student
at the close of his course to a university with an established reputation for "sweet
reasonableness.'"
None the less, students are undoubtedly often rejected in this subject or that, —
occasionally a second time : on the third trial they always pass ! The practical pro-
tective value of the examination is, as a matter of fact, thus weakened by what is
apparently its most effective provision. At the critical moment when an incompetent
could be finally cut off, the barrier is lowered and he is invariably allowed to get
over. The explanation is easy: men hesitate to accept the responsibility of forbidding
a particular career. A faculty dean in one large university defended the custom of
final passing on the ground that no professor knows his students well enough to make
himself responsible for a fatal check. Undoubtedly many incompetents drop out
on the march: they lack staying power or patience; delay sifts; but if they persist,
they are sure to pass ! I searched everywhere for examples of students who had been
rejected on the third trial; I discovered practically none. One Berlin professor had
a vague memory of two instances in his twenty years' experience, but could not be
sure that they had finally and irretrievably failed; the chairman of the examination
commission in another, during an epoch in which seven hundred students were ex-
amined, recalled one failure on the third round. In Austria, the Emperor would on
application grant such an unfortunate another chance — or more. The dean at Vienna
recalled two instances: one, urged to withdraw as unfit, at length complied — "not
2(54 MEDICAL EDUCATION
cxat-tly a failure;" the other continuing to fail despite imperial intervention at length
desisted. But, except in such rare instances, persistence wins. These results assuredly
constitute no argument for examination by teachers alone: they contrast sharply with
those of the legal examinations, in the conduct of which outsiders take part, in con-
setiuence of which the moi-tality is reported to be considerable. Significantly enough,
medicine is occasionally the haven of refuge for a disillusioned student of jurispru-
dence !
The defects of the examination bring out once more the defects of the curriculum
in so far as the prescriptions of the curriculum are dictated, not by educational, but by
economic or historical considerations. Prescription cannot be effective unless courses
are prescribed because they are essential, — unless the curriculum and the examination
concur as to what they regard as important. The courses assiduously pursued must
tally with those prescribed and paid for. Under the present arrangement, courses are
prescribed in order that the professor may get an income. It is well understood that
many of the required courses may be and will be systematically cut. The natural
significance of prescription is thus almost inverted. Tlie student must pay for legal
medicine; a receipt is the only certification required; there is no examination. Other
professors are directed indeed to question on the topic. But they rarely do; nor
would they venture to reject a student for failure in a subject in which they have
no concern. The specialties — pediatrics, dermatology, etc. — are in some cases simi-
larly handled.^ The examination is so incidental as to be negligible; certification is
equally a matter of form. Assurance is thereby lacking at every point. Unfortunately,
as long as teachers — mainly ordinarii — are sole examiners, they will probably stand
together in defense of the present system. It is not without significance that at this
moment criticism comes almost altogether from the side of the general public and
the practising profession.
Can the system above described be fairly denominated a one-portal system.? It is
indeed a state examination controlled by regulations that bind the entire empire.
But the actual standard of performance required may vary for and within each uni-
versity. The unity and uniformity supposedly making a one-portal system are attain-
able only through central representation or oversight. As matters now stand, on the
professional side, one might plausibly reckon as many portals as there are universi-
ties employing diverse standards. The system has indeed but one portal as to ma-
triculation. Gymnasial graduation under the centralized German system beai*s a
definite value: every graduate in medicine starts from that precise point.
I hold this precision and elevation of the starting-point to be a fact of enormous
importance — probably the main fact — in deternnining the quality of the German
product. Defects enough have been cited. But it does not follow that the level of
German medical education is low. In the first place, the gymnasium inteiposes with
the assurance that every German student of medicine is an educated man. It may
* VVTierever an ordinariate is lacking, as a rule.
CURRICULUM AND EXAMINATIONS: GERMANY 265
well be that the elimination of the unfit through this unbending requirement is the
most important single fact we have encountered. The student is mature, intelligent, and
disciplined; and as the advantages from the standpoint of medical education of the
real gymnasium over the humanistic gymnasium are more fully appreciated, the pre-
liminary discipline will be better and better adapted to the proposed superstructure.
Other forces also operate strongly to make the product better than the system
as it looks when inventoried. The university student lives in an atmosphere of ideas,
and ideas stimulate and coerce. He is therefore something more than his positive
possessions ; a certain subtle and incalculable driving force must be added in. Against
a lack of practical skill, a turn for ideas makes no small counterweight. Finally, for
such as reach practice only after serving as assistants, this unique experience must be
reckoned in with their education. Statistics unfortunately fail again. Estimates as
to the percentage of those that go directly into practice vary widely ; it is rated now
at 50 per cent, now at 80 per cent. The assistants at any rate have enjoyed an unex-
celled practical opportunity ; and as subsequently they scatter through the empire,
their influence in elevating the profession above its education is not to be overlooked.
Summed up, the outcome of this already too lengthy chapter may now be stated
as follows. In the training of doctors no single precaution is alone efficacious. Great
as is the importance and retroactive effect of the examination, it must not be over-
weighted. Other safeguards must be added, to correct its defects, to relieve it of
total responsibility, to prevent serious consequences, in case it is loosely administered.
These safeguards we are now in position to specify: a definite and adequate basis of
matriculation, proper facilities, a trained and devoted teaching staff, and a curri-
culum which, while in its general arrangement representative of the elements that
medicine involves in their proper mutual relations, encourages the student to de-
velop the highest possible degree of individual interest and initiative.
CHAPTER XI
CURRICULUM AND EXAMINATIONS: GREAT BRITAIN
AND FRANCE
At first si^ht, the British medical curriculum appeal's to resemble the German in
elastic quality; for an inspection of school calendars fails to discover anywhere a
closely articulated prescribed course of study, although in practice, laboratory and
clinical branches tend to constitute two mutually exclusive groups of subjects. The
student usually completes his work in anatomy, physiology, etc., before taking up
the clinical branches.^ In dealing with the former division, the English student
probably follows more closely than the German the natural order suggested by the
relations of the subjects to one another: physics, chemistry, and biology are generally
finished before anatomy and physiology are attacked. Nevertheless, a rigid sequence
is not universally enforced. On the clinical side especially, as we shall observe, con-
siderable diversity is found. The teaching method employed — that of filling hospital
posts — requires indeed marked variations in order that the entire student body may
be at all times distributed through the hospital.
It does not follow, however, that the English and German curricula fundamen-
tally resemble one another. As a matter of fact, such is not the case. In Germany, free-
dom is valued because, avoiding uniformity of content or fixity of order, elasticity
is favorable to the development of individual interest or capacity. As against such
internally motivated assertion, the elasticity of the British arrangement amounts
practically to nothing more than an option, arbitrarily exercised by the student, to
elect one of several possible curricula, not materially different from one another, all
equally definite as to content and not significantly variant as to arrangement. British
elasticitv does not connote a large and breezy spirit in the schools; it signifies only
the existence of a variety of examining bodies, each competent within limits to define
its own policy. Strictly speaking, the several schools themselves are committed to no
particular policy. All schools stand ready to train candidates for any or all qualifying
1 If these divisions were everywhere absolutely maintained in such wise that the required periods of
study of the medical sciences could be counted only from the date of passing the preliminary sciences,
and "the required periods of study of the clinical subjects could be counted only from the date of pass-
ing the medical sciences, a "block" system would prevail. This is not, strictly speaking, anywhere
the case, though the Conjoint Board closely approximates it. The Conjoint Board requires that two of
the three preliminary sciences be passed before the study of anatomy and physiology is recognized
— not quite a perfect block; but the Board maintains a complete block as between the medical sci-
ences and the clinics, for it does not count clinical study as beginning until anatomy and physiology
have been passed. The Society of Apothecaries of London makes no attempt to enforce the proper
sequence between the preliminary and the medical sciences, permitting the latter to be jiassed before
the former, if the candidate so pleases. Although no candidate is admitted to the clinical examinations
before passing all the science examinations, no stipulation is made as to the length of time which must
clanse after passing in the sciences before coming up for the clinical subjects. Obviously, "blocking"
under thfse conditions is very faulty. In view of the general preference for the Conjoint Board cxnni-
inations, the statement in the text fairly covers the existing situation. For further variations, the regula-
tions of licensing bodies and the calendars of the universities may be consulted.
CURRICULUM & EXAMINATIONS: GREAT BRITAIN: FRANCE 267
bodies. The decisive factor as to which shall be sought is irresponsibly contributed by
the student and unquestioningly accepted by the school. The choice made, the curri-
culum is at once cut to suit: the arrangements are pliable in the sense that every
school must be put together loosely enough to facilitate certain adjustments, never
very extensive in character; but as the work of each student is at once ordered accord-
ing to the specification of the particular examining corporation to which the individual
in question has chosen to apply for qualification, elasticity is employed almost wholly
for the purpose of keeping performance to the minimum required by the licensing
bodies. In the United Kingdom there are twenty-four such bodies, their requirements
differing in certain respects. As a rule, the universities train men chiefiv for their
own examinations; the London schools instinct a somewhat more varied clientele, —
candidates for the Conjoint Board diplomas, and the London, Cambridge, and Oxford
degrees. Each of these qualifications is a definite thing. The schools must be extensive
enough to include the maximum variations. But so ingrained is the habit of conforming
to the stipulations of the qualification selected that only in very rare instances would
a candidate for a lesser, undertake a task attached only to a more difficult, qualifica-
tion. In spirit and content the curriculum approximates the fixed curriculum.
As in Germany, the content is indirectly specified, — by the supposed necessities
of the examination, not by the schools acting on their own educational responsibility.
The regulative apparatus in Great Britain is professional as contrasted with Ger-
many, where it is governmental. The General Medical Council, a body consisting of
thirty-four representatives, one from each licensing body, five designated by the crown,
and five chosen by universal suffrage by the registered practitioners, was originally set
up — as I have already briefly mentioned — for the purpose of keeping the medical
register, but has procured important supervisory influence in virtue of the statutory
right to inspect the qualifying examinations. It cannot mark out a curriculum or over-
haul a school. Over neither school nor qualifying body does it possess direct compel-
ling power. Itcan at mostvisit examinations and demand information asto the require-
ments of the several corporations. In the event that such observation or information
discloses unsatisfactory conditions, the Council can resort only to publicity and to
protest, — publicity in its own publications, protest to the delinquent corporation
and, if necessary, to the Privy Council. The licensing bodies thus actually determine
the course of study. Whether acting on their own motion or at the instigation of
the General Medical Council, whatever they require for examination, the schools are
bound to teach. In dealing with licensing bodies, inclined to laxity, the Council has in-
fluence rather than powei-s ; ^ but its influence has proved distinctly effective. For, while
it can in no case refuse to register individuals certified as passing even by bodies to
whose examination it takes exception, in practice the diploma of a body that has
incurred the displeasure of the Council suffers a heavy market discount. The minimum
course of study which the Council now countenances lasts five years and contains the
^ Address on General Medical Conncil, by Sir Donald MacAlister, Lancet, October 6, 1906.
268 MEDICAL EDUCATION
follow-ing subjects : (1) physics, (2) chemistry, (3) elementary biology, (4) anatomy,
(.5) physiology, (6) materia medica and pharmacy, (7) pathology, (8) therapeutics,
(9) medicine, (10) surgery, (11) midwifery, (12) vaccination, (13) legal medicine,
(14) hygiene, (15) psychiatry.
The Council makes only one recommendation as to aiTangement, viz., that the sub-
jects numbered (7) to (15) shall occupy a period of not less than twenty-four months
after the passing of anatomy and physiology, a recommendation not as yet universally
concurred in bv the qualifying corporations; but it urges the conclusion of all sys-
tematic work by the close of the fourth year, so that the entire fifth year may be de-
voted to clinical work. Further regulations are introduced by the varying stipulations
of the several licensing bodies: in general, the practical outcome results in devoting
the fii*st vear to the basic sciences, the next eighteen months to anatomy, physiology,
and pharmacv, the remaining two and a half years to the clinical subjects. With the
details of the divergences as well as wnth the disturbances due to retardation we shall
deal presently.
Of the twenty-four examining bodies in the United Kingdom, to which the state
has delegated the right to bestow^ the practice license, fifteen are universities whose
degree constitutes a legal qualification, the rest being either professional corporations,
like the Society of Apothecaries of London and the Apothecaries' Hall of Dublin,
or associations of corporations, such as the London Conjoint Board, representing the
Roval College of Physicians of London and the Royal College of Surgeons of England,
or the Triple Board of Scotland, including the Royal Colleges of Physicians and Sur-
geons of Edinburgh and the Royal Faculty of Physicians and Surgeons of Glasgow.
It is to be remarked that the degree of doctor of medicine is not an essential part of
the qualification to practise in either Germany or Great Britain, though the degree
in question alwavs includes the practice license: the degree is, as such, a high academic
distinction, carrying with it the practice right. But it is not necessary to the practice
right: in Germany the praktischer Arzt^ and in Great Britain the holder of the Con-
joint Board or Triple Board qualification, practise medicine with full legal right,
proceeding subsequently to the degree of jM.D. or M.B. only if they care to do so.
In Germany, the distinction between the two titles is merely formal, for all medical
education is university education; in England, the distinction is still significant and
likely to become increasingly so, as university education in medicine more fully attains
its proper character.
Much the most popular of the different qualifications in Great Britain is that of
the Conjoint Board of the Royal Colleges in London, — so much so, that a very large
percentage of those who hold the university degree of M.B. or M.D. pass the Con-
joint Board examination also, in order thus to become members of the two ancient
corporations.^ Out of 672 registrations in England in 1901, 484 were Conjoint Board
* In consequence, the following fif^Jres count sonae names twice, since a Conjoint Board diploma and
a university degree are often awarded to the same person.
CURRICULUM & EXAMINATIONS: GREAT BRITAIN: FRANCE 269
diplomas; out of 65^ in 1905, 418; out of 494 in 1910, 323; during the same years,
the Apothecaries' Society of London qualified 113, 50, and 49, respectively; London
University, 128, 112, and 108;^ Cambridge, 88, 70, and 59; Manchester, 64, 52, and
25. In Scotland, the university degree is the more general qualification; in 1901,
Edinburgh granted 193, Glasgow 107, Aberdeen 51 degrees, a total of 351, as com-
pared ^\-ith 172 qualifications of the Triple Board; in 1905, the universities qualified
354, as against the Triple Board's 144; in 1910, 441 as against 87.
The requirements of the London Conjoint Board may by common consent be fairly
taken as indicating what is generally regarded as at once an attainable and a satis-
factory level. The curriculum of a student expecting to qualify before it falls into
three parts, the contents of each minutely specified :
Part I includes chemistry, certificates of not less than 180 hours of instruction and
laboratory work being required, physics with certificates of 120 hours, biology (120
hours), and pharmacy. Synopses indicating the range of the examinations are fur-
nished. Two of these thi'ee subjects must be passed before any subject of Part II
can be started. It is obvious that as far as Part I is concerned, the cun-iculum, Avhat
with specified subjects and a synopsis in each, is for all practical purposes rigid and
prescribed. Nor, it may be added, is it easy to see how, as long as medical education
rests on the elementary basis previously described, this can be avoided.
Part II includes anatomy and physiology, for the latter a synopsis being famished.
Certificates must be presented showing the dissection of the entire body in not less
than twelve months, anatomical lectures during six months, lectures in physiology,
and a pi'actical course in physiology and histology covering six months. Both sub-
jects must be passed together.
At least twenty-four months must elapse after successful completion of Part II
before a candidate is admissible to Part III — the final examination. Before admis-
sion he must produce evidence:
I. Of having attended at a recognized medical school the following exercises :
(a) Lectures on medicine, six months.
(b) Lectures on surgery, six months.
(c) Lectures on midwifery, three months.
(d) Lectui'es on pathology, including practical instruction in histology, bac-
teriology, and clinical pathology, six months.
(e) Lectures on pharmacology and therapeutics, three months.
1 It is estimated that not exceeding one-third of the London students have matriculated in London
University and expect to obtain its degree. The rest are "Conjoint men." This has an important bear-
ing on the reform of medical education in the metropolis. If university education means a specific
thing, the one-third above mentioned ought to be in a genuine university medical department, the
two-thirds somewhere else. At present, they all attend the same mixed schools. As secondary school
facilities improve, the two-thirds will die out, the one-third increase till it includes all the medical stu-
dents in London. When that contingency arrives, the university will require adequate facilities ; just
now it needs facilities adequate only to the one-third.
270 MEDICAL EDUCATION
{f) Lectures on legal medicine, three months.
{g) Lectures on public health.
(A) Systematic practical instruction in medicine, surgery, and midwifery.
II. Of having attended at a recognized hospital :
(a) Practice of medicine and surgery during two winter and two summer ses-
sions.
(6) Post-mortem demonstrations during twelve months.
(c) Clinical lectures in medicine and surgery during nine months each.
((/) Twelve clinical or other lectures with practical instruction on diseases of
women.
III. Of having served as medical clerk and surgical dresser for six months, at least
three of them in the wards.
IV. Of having served a three months' gynecological clerkship. *
V. Of having received instruction in anaesthetics.
VI. Of having received clinical instruction in ophthalmology during three months.
VII. Of having attended a fever hospital, a lunatic asylum, and of having conducted
twenty labors and received instruction in vaccination.
Subject to the filing of certificates vouching for this elaborate bill of particulars, —
a bv no means formal affair, for class records are kept, — the student is examined in
medicine (including medical anatomy, pathology, pharmacy, therapeutics, and public
health), surgery (including pathology, surgical anatomy, and the use of appliances),
and midwifery. A good deal of latitude prevails as to the order in which the subjects
included in the final examinations are studied, — due to the fact, already pointed
out, that, as practical instruction involves appointments limited in number, no fixed
order can be followed. Still, precautions are everywhere taken to insure a preliminary
course in physical diagnosis before beginning clinical medicine, and a preliminary
experience with surgical out-patients before entering the surgical wards. As bearing
upon the question as to whether the inauguration of participative instruction neces-
sarily results in a rigidly articulated system under which migration of students would
l)e practically prohibited, it is worth noting that in England the variation of order
is greatest precisely in the clerkships, dresserships, etc., in which participative in-
struction is most highly developed.
Certain variations as to the time requirement in diffei'ent subjects should be speci-
fied a.s indicating the fashion in which the several qualifications vary. London Uni-
versity students are required to devote their first year to the basic sciences alone;
others occasionally begin anatomy in that year also; London University insists on
one and a half years of anatomy and physiology; one suffices elsewhere. London and
Conjoint men are required to show one hundred and eighty hours of physics; those
who (jualify Ix^fore the London Apothecaries may get physics incidentally with
chemistry. Six months of practical physiology at the two former shrinks to three at
CURRICULUM & EXAMINATIONS: GREAT BRITAIN: FRANCE 271
the latter.-' Cambridge and Glasgow insist on three years of clinical work; two are else-
where demanded. But the longer periods are themselves completely consumed in addi-
tional routine. They are not to be construed as implying larger and freer opportunities
here or there for the more forceful student. As between Conjoint and University stu-
dents in London, the differences in the required curriculum are practically negligible;
the differences in the severity of the examinations are met by somewhat harder drill.
Coaching to pass is the fatal blight. The schools are too solicitous for success to en-
courage any one to take chances with his fate, by indulging a marked predilection
at any one point : the school knife spreads him evenly over the entire conventional
surface. If required work leaves an odd hour here or there, tutorial drill is inserted
by way of making assurance doubly sure. The English plan offers a number of ways of
utilizing the student's time, no one of them including any allowance for idiosyncrasies.
Pathology is perhaps the most important variable. London University and the
Conjoint Board definitely require six months; at the Society of Apothecaries the
subject has no independent standing: it figures incidentally in each of the clinical
examinations. Cambridge, however, has taken the position recommended in the fore-
going chapter. On forsaking the laboratories of anatomy and physiology for the wards,
the student ought, we there urged, to command a certain technique and to be able to
think in pathological terms. Percussion and auscultation are important, but not alone
sufficient; they enable him to discern abnormalities, not to understand them; mean-
while he observes a discrete series of cases; hears from the very first much discussion of
inflammation, degeneration, hypertrophy, atrophy, tumors, exudations, etc. To build
up these concepts out of an experience otherwise swarming with novelties is doubtless
not impossible; but it involves enormous waste thi'ough readily avoidable confusion,
perhaps, too, no little danger of permanent muddiness. By way of insuring a general
grasp of pathological principles which will afford sufficient illumination from the
start, and serve, too, as an apperceptive basis to be intelligently and systematically
enriched day by day, Cambridge inserts an intermediate examination between the
fundamental sciences and the clinics. With a view to this examination, some twenty-
five lectures on the principles of pathology are given, somewhat less on bacteriology,
with fifty or sixty hours of practical Avork in the two subjects. The final examinations
in general and special pathology being still retained, the student is constrained to
build out, not rest content with, his introduction to the field.
The more orderly aspect of the English as compared with the German curriculum
is obviously attributable to several causes: the much more definite constraint of ex-
aminations, prepared for by syllabi or in their spirit, and the lack of such optional
offerings on the part of the schools as would tempt the student to digression. But
even should these two factors be altered, the practical nature of the instruction makes
for simplicity and coherence. A course of study in which definite laboratory, clerking,
1 For tabular exhibit see Sprigge, pp. 170, etc. In greater detail, a report issued by the General
Medical Council. May, 1908. .
o-o MEDICAL EDUCATION
/^ i rw
ftiid dressing duties figure prominently, naturally arranges itself in reference to the
hours of the dav. Congenial and imperative engagements involving real responsibility
give the day a backbone; not even a student makes two appointments for the same
hour, if they require that he be on the ground and take part. With lectures it is dif-
ferent: by distributed attendance, he can keep several sets going at the same hour,
as German ex{>erience shows; on occasion he may omit all.
The minimum length of the curriculum is five years; the General Medical Council
will register no diploma representing less; to this minimum the examining bodies all
adhere, excepting only the University of London, which insists on a statutory mini-
mum of five and one-half years.^ Exceedingly valuable statistical studies made by the
General Medical Council ^ indicate that the average cuiTiculum considerably exceeds
the permissible minimum, — in England by two years, in Ireland by one, in Scotland
by six months. In 542 English cases investigated in 1906, the average length of cur-
riculum was seven years; in 402 Scotch cases, five and one-half years ; in 167 Irish
cases, six years. Of 360 students qualifying before the Conjoint Board of London in
1906, less than 11 per cent completed the curriculum in the minimum period (five
years), and over 40 per cent had spent more than seven years.^ In 1908,* 14.3 per cent
of the Conjoint Board candidates qualified in the minimum period.
Elongation, whether statutory or voluntary, has not prevented, however, continued
denunciation of the curriculum as overburdened. Indeed, where retardation is already
so considerable, an added year, like a bank deposit succeeding an overdraft, makes
no positive impression. The English curriculum has expanded much in content and
lost little concurrently by way of relief. Its problem is somewhat more difficult than
the German because the inferiority of the student body in point of previous educa-
tion increases the responsibility of the schools : there is less assurance that on his own
initiative the student will repair such gaps as the school leaves. Of the less capable
student a large total performance must therefore be demanded.
Relief would appear to depend on elimination as well as on organization. Didactic
^ Subject to certain exemptions, for which see Calendar for 1910 (pp. 144-174).
* The highest praise must be bestowed on the General Medical Council for its admirable statistical
studies of every aspect of these complicated questions.
' Reports issued by the General Medical Council, November, 1906, May, 1907, and ^lay, 1908. Sir
William H. AUchin, testifying before the Royal Commission on University Education in London (ajj-
pendix to Third Report, Minutes of Evidence, p. 324), states that 7.3 per cent of English candidates
Qualify in five vears, 28.4 per cent in six, 22.8 per cent in seven, and 41.5 per cent take over seven.
Actording to the same authority, of those who take the Conjoint Board examinations, 8.5 per cent
qualify in five years, 33 per cent in six, 24 per cent in seven, 34 per cent take over seven.
Why should the Scotch boy get his qualification in so much shorter a period on the average? In part
the difference may be due to the fact that the Scotch students are largely examined (90 per cent) in the
institutions in which they have studied, whereas the English boys|are generally examined (80 per cent)
by a non-teaching body. The English average is closer to the Scotch in the case of boys who are trained
in the teaching universities; for example, the course averages 65.3 months at Glasgow, 65 months
at Durham. Moreover, the .Scotch universities are in closer articulation with the secondary schools,
thus eliminating waste. P'inally, the absence of the block system operates to reduce the length of
the period of study required.
♦ lieport. General Medical Council, November, 1908.
CURRICULUM & EXA^IINATIONS: GREAT BRITAIN: FRANCE 273
lectures, already greatly reduced, appear capable of still further diminution, more
especially in such subjects as anatomy, surgery, midwifery, materia medica, etc. It
is absurd, for instance, to teach materia medica along lines appropriate enough at a
time when the leech himself went to the fields to gather medicinal roots and herbs.
Were less literal compliance with syllabized suggestions expected at the examina-
tions, tutorial grind could be largely reduced. Again, if clinicians and laboratory
teachers were in closer sympathy, — a point to be touched on more fully in a mo-
ment,— the various parts of the cun-iculum would tend to sustain, instead of to
displace, each other. Unsympathetic or uncorrelated teaching tends to atomism, of
which the extra-mui'al schools are the best example: lack of interaction involves posi-
tive waste.
The transfer of chemistry, physics, and biology to the secondarv schools would prove
the most important single step. The General Medical Council holds — and doubt-
less with right — "that the schools of the country generally are not at the present
time in a position to take up the work."^ The Conjoint Board, however, not with-
out encountering the displeasure of the Council, has ventured to accept certificates
from recognized secondary schools as evidence of study in these subjects, provided
that the student thus admitted spends at least four and one-half years subsequently
in a medical school. Despite the fear in some quartex's that the presence of science
in the pre-medical period imperils the " schoolboy"'s opportunities for general educa-
tion," there appears to be a steady growth of conviction that relief lies that way.^ The
present preliminary requirement can be met at fifteen or sixteen years of age; students
enter at eighteen and a half: the intervening period represents the lost years of the
average English schoolboy, — a waste due largely to lack of articulation. When they
are retrieved, the medical student will know more, he will have less to do, and he
will attack his reduced task with increased training and maturity.
Of far greater importance than the statutory length of the cumculum, or the pre-
cise details of its content, is the principle upon which an adjustment is to be effected
as between the periods allotted respectively to the laboratoiy and the clinical branches.
Both England and Germany concur in demonstrating that adequate treatment of the
basic sciences — chemistry, physics, and biology — is impossible within the medical
curriculum. Now physiology, pathology, and bacteriology cannot be actively and fully
developed except on the sound basis of the pre-medical sciences. It may therefore be
wise to conclude that a predominantly clinical type along the current British lines is
the best possible solution wherever the pre-medical sciences still remain stepmotherly
parts of the medical course of study. Were these sciences, however, adequately taught
in the vacant spaces of pre-medical education, the stronger basis of the student and
1 Report of Education Committee, General Medical Council, 1910.
2 See, for example, Sprigge: Considerations on Medical Education, pp. 31, 3-2 (London, 1910); Schafer:
The Medical Curriculum, pp. 10, 11 (Edinburgh, 1903); T. P. Teale : Seed for Reform of Medical Ex-
aminations, p. 17 (Leeds, 1896).
274 MEDICAL EDUCATION
the enlarged opportunity of the medical school would at once raise the fundamental
problem respecting tlie relations of laboratory and clinical teaching.
As to projjer adjudiaition on this point, a tug of war exists generally. A fifth year
was added in England in the hope that it would augment clinical study: it "was to be
the make-weight that was to compensate for what we have lost in the disappearance
of the apprenticeship," etc.^ It has been captured, however, by biology and the other
sciences. How we feel about this outcome depends, I suspect, on the comparative
importance assigned to capacity for growth as compared Anth achievement at gradua-
tion. If we value most the ability to engage in practice at once, we shall deplore the
rape of the added year by the biologists; if we value more highly the prospect and
possibility of gro\\'th, our sympathies will perhaps incline in the opposite direction.
AMiich is the more modern calculation?
Medicineis changingwith unprecedented rapidity.lt has undergone greater changes
in the last three decades than in the preceding three centuries, — a rate of speed likely
hereafter to be accelerated, not retarded. On what terms can the physician or surgeon
participate in progress? To put the same question differently: the utmost practical
capacity and judgment attainable at school are in no event huge; as things now move,
thev are soon more or less antiquated. If a choice must be made between some por-
tion of this positive attainment and markedly greater ability to participate in the
developments of medical science, which alternative should medical education prefer.'*
To ask the question is to answer it. The proved medical possessions of the race
are not inherently difficult of acquisition; the skill necessary to their wise employ-
ment is slowly obtained, at school and afterward. But every day important diagnos-
tic refinements are suggested; every day new therapeutic agents or procedures are
proposed, — some out of the fullness of thought and knowledge, others but weakly
grounded in either experiment or experience. If discriminating but prompt apper-
ception is desired, then scientific knowledge, interest, and activity are in the long run
more important than additional bits of a clinical experience necessarily fragmentary
in any event. Partisans of attempted clinical completeness stamp the laboratory em-
phasis as remote; the student, they urge, needs what is practical. So be it. Confronted
by a meningitis of doubtful character, what could be more immediate or more prac-
tical than the intelligence to recjuire, and the ability to procure, a differential diag-
nosis, resulting in the employment of the specific serum appropriate to the case? De-
velopment of intelligence of this type is a question of fundamental training, as far
as it depends on training at all. Routine clinical education of the empiric type tends
the other way. The fact is, that the rapid progress of medical science has necessarily
changed the role of the medical school: a substantially stationary or slowly chang-
ing medical and surgical art could be communicated; the level did not appreciably
alter in the course of a professional lifetime. A boy who learned medicine at school
knew it for the rest of his life. But expanding sciences and the ai'ts dependent on
' Teale: Seed for Reform of Medical Examinations, p. 15 (Leeds, 1896).
CURRICULUM & EXAMINATIONS: GREAT BRITAIN: FRANCE 275
them cannot be totally, even largely, imparted in a few months. The greatest service
to be rendered the student is in giving him such training as will enable and incline
him to keep up and to go ahead.
I have already adverted to the existence of numerous examining bodies in England,
of which for practical purposes the most important is the so-called Conjoint Board.
Its examinations I propose to describe with some particularity,^
The Royal Colleges of Physicians and Surgeons are chartered professional corpo-
rations, admission to either of which after successful examination carries with it the
license to practise. In 1884, the two colleges which had up to that time conducted sepa-
rate examinations united to form a Conjoint Board, which conferred a single diploma
combining both qualifications. The board is managed by a joint committee, consist-
ing of three representatives from each of the constituent corporations. This committee
has general control of the examinations. While itself powerless to change the regula-
tions governing them, it can recommend such action to the colleges. The examiners
under the board are appointed by the colleges mainly fi-om the teachers of the Lon-
don schools. As clinical teachers are also practitioners, the practising profession
participates in the examination; it will be observed later that, while the student is
thus examined by teachers, he is never examined by his own teachers.
After complying with the general educational requii-ement,*^ the student is eligible
to the series of professional examinations. They begin with chemistry, conducted by
two examiners, chosen in rotation from the staff of the London schools. The exami-
nation is both written and practical: in the former, nine questions — five on inor-
ganic, four on organic, chemistry — are propounded, and not less than six must be
answered within three hours. The examiners cooperate in marking papers. Three days
later, the practical examination takes place in Examination Hall. Two examiners
with assistants can handle eighty candidates in one batch. In case of doubt as to a
candidate's passing, viva voce methods may be employed to resolve the difficulty.
Physics is managed on the same lines, excepting only that the groups ai*e smaller
(15 to 20), and the candidates are quizzed as they proceed with their experiments,
supposed to occupy about an hour. In biology, substantially the same procedure is
followed. The practical and Avi'itten marks are combined to determine the grading.
In anatomy and physiology, four examiners apiece are named. They work in pairs,
all being continuously engaged. In the WTitten part, eight questions are set in each
subject, of which six must be answered within three hours on consecutive days. Fail-
ure in the written portion estops the candidate from even trying the practical or oral
examination, two or three days later. In anatomy, the oral is conducted on a freshly
dissected subject, dissected specimens in alcohol, and on bones. A living model is used
for surface anatomy. In physiology, no experiments are performed, but apparatus,
1 For the details here given and for permission to attend the examinations while in progress, I am
indebted to the courtesy of Mr. Frederic G. Hallett, secretary of the London Conjoint Board.
2 See chapter iii.
276 MEDICAL EDUCATION
(iiui^ams, and histological slides are employed as basis of the questioning ; simple ex-
ijeriments in physiological chemistry must be carried out, however. Four candidates
enter the room at once, two going to each pair of examiners. Assuming that one pair
of examiners consists of teachers from Guy's and Charing Cross, a student coming up
from the former would be quizzed by the latter. The viva voce examiner never marks
the same student's written paper. Thus two independent judgments must concur.
After fifteen minutes, the students change, those who have tried physiology now try-
ing anatomy, and vice versa. Twenty-four candidates are handled in the morning at
the rate of eight per hour, and an equal number in the afternoon. At the close of the
session, the examiners meet and enter their marks: students who have passed in both
subjects are accounted satisfactory. If a candidate is slightly above in one subject and
slightly below in another, the examiners may in their discretion pass him, otherwise
he fails; and failure involves both subjects, for the board refuses to credit physiology
without anatomy, or vice versa.
Eight examiners officiate in medicine; they act in pairs, designated A, B, C, D,
respectively, so arranged that, for example, pair A will consist of teachers from
St. Bartholomew's and Westminster, pair B of those from St. Thomas's and St. Mary's,
etc. The candidates are so distributed that no student is examined by a teacher from
his own school ; moreover, the written and the clinical examinations of a given student
are never both conducted by the same pair. Teachers, — not the student's ovm, — and
several of them together, pass on the merits of each individual: summary and partial
judgments are thus both ruled out.
Two wTitten papers are set in medicine, one consisting of six questions, the other
of five: they are answered on consecutive days, three hours being allowed for each.
Every paper is read and graded by each of the two members of the pair to which it
is sent. The practical or clinical examination takes place in the Examination Hall,
temporarily converted into a hospital ward. Each examiner sends from his hospital
at least three patients (male or female), who are remunerated, so that for each day's
examination at least twenty-four patients are present. Every candidate is examined
on one "long" and one, two, or three "short" cases. For the "long"" cases, four can-
didates enter the room, one going to each pair of examiners. A candidate examines
an assigned patient for ten minutes; at the conclusion, he is quizzed by one examiner,
while the other listens. Thereupon the second examiner questions him on two or
three "short" cases, while the first stands by. During this latter period a second set
of four candidates are engaged on the examination of their "long" cases. Fifteen
minutes are allowed for prescription writing. The process described runs on for two
hours and ten minutes, during which twenty-four candidates will have been disposed
of: each will have had thirty minutes' examination by two teachers. On the evening
of the same day, the twenty-four are orally examined in medicine and medical patho-
logy, including the examination of urines, pathological slides, gross pathological
specimens, fresh or preserved: tlu*ee periods of ten minutes each are allowed to every
CURRICULUM & EXAMINATIONS: GREAT BRITAIN: FRANCE Til
candidate. By the same sort of overlapping previously described, the entire group
is rounded up between 7.50 and 10 o'clock.
In midwifery, including gynecology, eight examiners likewise participate, under
similar conditions and precautions. The written examination consists of six ques-
tions, four of which must be answered satisfactorily. Twenty minutes are given to
oral examination: between 7 and 9.40 in the evening, thirty-two candidates are
handled.
Ten examiners act in surgery. The examination is divided into five parts, and
each candidate is examined by each of the five sections. The examiners, selected from
the schools, are arranged as follows :
Section A. Mr. (from Guy's) Mr. (from St. George's)
Section B. Mr. (from University) Mr. (from King's)
Section C. Mr. (from Birmingham) Mr. (from Middlesex), etc.
The examination consists of (a) written paper, (6) clinical or practical work,
(c) surgical anatomy, {d) and {e) pathology (two parts). Each examining pair does
some work under each of these topics. The following table shows that such serial
distribution is readily feasible:
Candidate No. 1 goes before Section A for his written examination ;
before Section B for his clinical examination ;
before Section C for his surgical anatomy examination ;
before Sections D and E for his pathological examination.
Candidate No. 2 goes before Section B for his written examination ;
before Section C for his clinical examination ;
before Section D for his surgical anatomy examination ;
before Sections E and A for his pathological examination, etc.
Once more, a candidate is never examined by a teacher from his own school, for
as the examiners are always present in pairs, candidates are so numbered and assigned
as to avoid this contingency.
The written examination follows the model already described. For the practical
or clinical examination, the Hall once more serves as a ward: as every examiner
sends three patients, thirty are utilized, ten of them as "long," twenty as "short"
cases. Five candidates enter at a time, each examining two "long" cases for fifteen
minutes. Thereupon each candidate goes before the five examining sections in suc-
cession, being quizzed by each for five minutes on the "long" cases and for ten min-
utes on three or four "short" cases. As soon as the first set of five candidates, hav-
ing finished their private examination of their "long" cases, appear before the ex-
aminers, a second set enters. At the conclusion, the five candidates constituting a set
repair to a table, where each finds a microscope and slides, two of which latter he is
required to examine and to expound in writing. In the evening of the same day, the
278 MEDICAL EDUCATION
exnmiimtion in surgicftl anatomy, bandaging, instruments, etc., is held on the living
iiuKlel. I'ortv-Hve men are handled in two and a quarter hours. On the following day,
these forty-five are examined in pathology viva voce in the museum of the Royal
College of Surgeons. Five tables are supplied with specimens; at each table two ex-
aminers sit. Every candidate has ten minutes at each of two tables. On the comple-
tion of the examination, the examiners assemble as a court; the successful candidates
appear before them to be formally introduced and to sign the by-laws of the ancient
college to which thev are now admitted. No candidate receives the license of the
Roval College of Physicians or the diploma of the Royal College of Surgeons until
he has passed all examinations without condition.
The examiners are selected by the two colleges for periods of four or five years.
The service, requiring several days at a time, three or four times a year, is obviously
a severe one, but, to the credit of the profession be it said, the ablest and busiest men
in the kingdom regard it as at once a duty and a privilege to serve; and that, too,
not onlv in the metropolis, but in the provincial universities, in whose examinations
outside assessors are regularly invited to participate. The fees paid for the service are
too small to constitute the main or even a strong inducement. To insure fairness,
the wTitten questions are determined on in conference, and may even be revised by
the committee in general charge. The pairs shift at intervals of six months, so that
the examiners, becoming acquainted with one another's procedure, may maintain
an equality of standard. And this level is more or less diffused, since men who serve
now the Conjoint Board and now the Apothecaries may subsequently be called as
assessors to Oxford, Cambridge, Leeds, Manchester, or Edinburgh.
From the Conjoint Board examinations above described, the examinations con-
ducted by the other professional corporations do not differ essentially : they are all
alike "external" examinations, — examinations, that is, conducted apart from the
institution in which the student has been trained. The university degree examinations
in medicine, carrying with them the practice license, are, on the other hand, "inter-
nal" examinations; and yet not simply that, for while the student is examined in the
school where he has studied, an outsider participates as assessor.
I have taken occasion to object seriously to external examinations at the secondary
school stage on the ground that they convert teaching into drill. Undoubtedly, exter-
nal examination at the professional stage, if unintelligent, can be equally harmful.
But the cases are not quite analogous. A mature individual whose medical training
is complete, and who is about to embark in practice, may be fairly required to possess
resourcefulness and self-possession enough to convince disinterested outsiders in the
teaching profession that he has attained a certain minimum amount of knowledge
and skill. If the scope of the examination is determined by teachers, if the examina-
tion is conducted by teachers, and if all the factors that determine the result are
viewed together, an external "pass" examination at the professional stage ought not
to demoralize the student or unsettle his instructor.
CURRICULUM & EXAMEsfATIONS: GREAT BRITAIN: FRANCE 279
In point of severity, the various qualifying examinations do not greatly vaiy.
The London University degree is reputed the most difficult qualification : matricula-
tion is higher, the science requirement more prolonged, the clinical tests somewhat
more exacting. The provincial university degrees and the Conjoint Board diploma are
probablv not greatly dissimilar; in England, at least, the Scotch university degrees
are supposed to be somewhat easier. That the qualification of the Triple Board of
Scotland or the Apothecaries' Society of London represents a somewhat inferior per-
formance is hardly disputed. Finally, the license of the Apothecaries' Hall of Dublin
oscillates so closely to the minimum line that it has gone now and then a bit below it.
These discrepancies are generally regarded as undesirable, and forty years ago a
movement to establish a one-portal system all but succeeded. Theoretically, the plan is
still strongly championed, but vested interests, corporate, individual, or educational,
block the path. The General Medical Council is, however, not unsuccessful in main-
taining the definite minimum which is perhaps all that the one-portal system contem-
plates ; for it is not proposed in any event to wipe out the variety of degrees, diplomas,
and fellowships which go further. That is, even under a one-portal system, the student,
having once obtained the necessary state qualification, will still be tempted to win a
university degree, a corporate membership, or fellowship by submitting to further
examination on terms fixed by the body whose diploma he covets. The single state
qualification could undoubtedly be more easily protected than the present multipli-
citv; better still, it would lend itself to more ready manipulation in response to rising
or changing demands. A new departure, once approved, could be more speedily incor-
porated in the regulations, if it did not have to run the double gamut of ancient cor-
porations and modem universities, — for to conciliate both is assuredly no easy mat-
ter. Nevertheless, one suspects that the one-portal system would make less educational
difference than is expected, unless its establishment coincides with a modification of
the national predilection for examining and getting examined. At this moment, Eng-
lish medicine is less demoralized by the competition of examining bodies than it is
diverted from inspiring ideals by examinations as such. A strong case for the necessity
of the one-portal system could now be made out only if experience showed that can-
didates tend to seek qualification at the cheapest counter; or that the large numbers
rejected by the more exacting bodies enter the profession nevertheless by a back door
in the form of an easier qualification. Tliere is good reason to think that this happens
only exceptionally. The commercial value of the easy qualification is too low to make it
worth while. Hence, despite the large number of rejections by the Conjoint Board,
registration thi'ough the Apothecaries' Society of London has decreased from 113 in
1901 to 49 in 1910; through the Apothecanes' Hall of Dublin, from 8 in 1901 to 3
in 1910.^ In Scotland, the universities registered 351 in each of the two years in
question; the Triple Board, 172 in 1901, 87 in 1910.
1 The Conjoint registrations in the same years were 4S4 and 3-23, respectively, whereas the totals in
England were 67-2 and 4-94, respectively; the Scotch totals were 499 and 397, "respectively.
280 MEDICAL EDUCATION
These statistics indicate that such variety as now exists is not acutely demoraliz-
ing: in the first place, the minimum existing qualification is not dangerously below
the standard that a one-portal system would set up ; in the second, the higher pro-
fessional Millie of a respected qualification is so well established that no large percent-
at'e of candidates entertain any other. The real mischief of the present situation —
a mischief which the single portal does not touch — is the competition of qualifica-
tions obtainable only after examination that succeeds the act of satisfying the law.
Having won the Conjoint diploma which entitles to practise, the student now in-
dulges the higher ambition for the London degree, a fellowship of the Royal Colleges
of Surgeons, or what not. If the establishment of the state qualification leaves this
tendency unchecked, no great improvement need be looked for. As long as titles, di-
plonijis, and distinctions depend on conscientious acquisition of the known, testable
by examination, rather than on productive individual performance, British medicine
will continue to be respectable rather than inspiring or stimulating,^
I have intimated that the supervisory activity of the General Medical Council
has been an important factor in establishing and preserving the educational mini-
mum. Its two visitors — one a member of the Council, the other an outsider ap-
pointed as inspector — attend and report upon examinations, separately or jointly.
They note the facilities provided, the time allotted, the quality of question and an-
swer in the oral tests, read papers taken at random, comparing their mark with that
actually given, and witness the conference at which the final marks are agreed upon.
The report of the visitors is communicated to the inspected corporation and printed
in the proceedings of the Council. Entire candor characterizes these utterances. The
inspectors at the Conjoint Board in November, 1903, praised highly the admira-
ble arrangements made for the examinations and the excellent collections of cases
providefl for the clinical tests in medicine, surgery, and midwifery. They regretted
that written reports of a medical and surgical case were not required, deplored
strongly the absence of a practical examination in operative surgery, and denounced
as "puerile" a substitute therefor, consisting of "pantomime" imitation of operative
procedure by means of "dummy knives of wood" on the body of a living person.'^
About the same time, a detailed report on the Apothecaries' (London) examination
connnends the care, thoroughness, and fairness of the ordeal in general, but remarks
significantly that in midwifery "there was also a 'phantom' on a side-table, which we
only once saw ma^le use of." ' The inspector of the examination at Cambridge in 1902
^ The establishment of the sinp^le portal brings up the question of the value of external examinations,
since a sinj^le porbil state examination would, like the examinations of the Conjoint and Triple Boards,
be conducted apart from the institutions in which the candidates were trained. Those questions have
in Great Britiin a quite factitious importance, because they are involved in problems touching vested
interests, traditions, etc. But the vital question there at this time is education, not qualification or ex-
amination. If British medical education is ultimately to be placed on a university basis, the one-portal
problem would better be postponed until that evolution has been accomplished, rather than be unsat-
isfactorily solved in a time of transition. It will be a different and simpler problem later.
'^Report, November, 1903, passim. ^ Ihid., p. 16.
CURRICULUM & EXAMINATIONS: GREAT BRITAIN: FRANCE 281
reports in reference to pharmacology that the answering of the majority of the candi-
dates he heard was poor: of one candidate in particular his examiners remarked that
he was "a poor man and that it was doubtful whether he should pass. But he did."^
Of London University examination in the same year, the visitors object vigorously
that in clinical surgery " the time allowed was much too short, no matter how emi-
nent and experienced examiners may be." ^ They call attention subsequently ^ to the
failure to comply with the University's own specifications in surgery and obstetrics;
to the fact that pathological specimens are not provided, and that the phantom,
though provided, is not used;* and that in medicine and surgery the written papers
are so much overweighted that "a man who has no real practical knowledge of clini-
cal medicine or of clinical surgery may by reading and 'cramming' be able to pass
on the marks he legitimately gets for them alone." ^ A report on the Conjoint Board
in Ireland in 1902 criticizes the examiner for giving "considerable assistance by the
manner in which he put his questions, and for telling the candidate the answer to
several of them."^ Praise, however, is not stinted where it is deserved: the Cambridge
examination in pathology in 1902 "was in every respect a most thorough one, and
the standard of marking high."' An experienced critic pronounces the practical chem-
istry and practical pharmacy of the Irish Apothecaries in 1903 "unusually difficult;
however this may appear to the candidate, it is pure gain to every one else,"® though
alive to the danger that this may prove "a pretentious fraud."
To the strictures above quoted, replies are generally made, — rather resentfully
at times. It is to be noticed that though the Council cannot compel amendment or
improvement, its constant hammering tells. A case in point is the Apothecaries' Hall
in Dublin. In 1893, the inspectors declared its examination in clinical medicine not
only unsatisfactory, but valueless. "The examiner paid no attention to the method
of physical examination followed by the candidates ; he did not read their case reports;
he did not attempt to verify or disprove the statements of a single candidate."^ From
such scandalous conditions it is a far call to the report seven years later, in which
the inspector, declaring the test "sufficient," states his conviction that the authorities
"are endeavoring to maintain their examinations at a level worthy of the confidence
of the Council." ^»
Meanwhile, the examinations themselves are both highly praised and severely cen-
sured,— made to suffer for defects in the educational arrangements, and for the defects
of examinations in general. The subject is one on which feeling is easily engendered.
We may as well begin by conceding that examinations are necessary evils : the state
is bound to scrutinize intending practitioners in the public interest. If invariably
conscientious teachers moved in sufficiently wide orbits, the function could be dele-
^ Report, 1903, p. 12. 2 m^^^ pp. u^ 13. 3 7^;^.^ p, 17. 4 /j;^/., p. 25.
5 Ibid., p. 24. 6 Jiid., p. 18. 7 jf)i(i., p. 16. 8 jJ4(i., p. 10.
^Report, November, 1893, p. 5*^ (abridged). ^'^ Report, 1900, p. 12.
2«2 MEDICAL EDUCATION
gatwl to the schools or consolidated with the school examinations. But that plan is
not feasible: it cannot be said to work satisfactorily either in Germany or elsewhere.
An examination bv outsiders alone is perhaps even more objectionable; for if the
schools and outside examiners are to understand one another, the examination is
j)ractical]v forced to lind its basis in a rigidly prescriljed course of study, in the con-
struction of which the notions of a generation passing away are deeply imbedded.
The British solution seems, therefore, in principle a decidedly happy one. The
profession governs itself; the examinations represent its pride in its own dignity
and competency. Conducted largely by teachers, they avoid a divorce between teach-
ing and examination. Moreover, they promote interaction between the schools and
the jjrofession, while demonstrating the feasibility of practically examining large
numl^ers by the combined action of teachers and practitioners. Not only is this prin-
ciple sound: the arrangements ai'e admirable. The examinations are so concentrated
that at appropriate periods the entire devotion of the examiners — laboratory men
and clinicians — is obtained; partiality is eliminated without depriving the student
of the privilege of judgment from an educational standpoint; the tests are increas-
ingly practical, evasion and vagueness getting short shrift when the student is asked
to put
" Jus finger on the spot,
And say, ' Thou ailest here and here."'
Finally, the bearing of the examiners is informal, sympathetic, and easy, even to the
point of joining in tea with the onlookers who happen to be present when that
national function comes due.
Defects the examinations undoubtedly have, but fortunately they do not affect
their fundamental merits. They are said to hamper teaching in the underlving sci-
ences; in respect to book knowledge of anatomy they doubtless do, by laying exces-
sive stress on anatomical information. Reform in this matter must begin with the
teachers of anatomy, who thus far have made no concerted or emphatic effort to de-
nounce the instruction which the examinations pass upon, and in reference to which
the examinations cannot alone initiate a radical modification. Criticism of the exam-
ination in physiology is better founded; for teaching so well conceived as that of
English physiology is not likely to complain seriously unless there is cause. Some of
the objections of the physiologists could be readily met; as, for example, that the
written and oral examinations are conducted by different persons, so that, despite
the fact that the marks are averaged, the individual examiners cannot view one of the
two |K'rformances in the light of the other. The brevity of the test and the limited
nature of the practical portion are more serious, but hardly irremediable, faults.
I iidouljtcflly all the written examinations are elaborate to the point of forcing a
(ktidwlly excessive amount of didactic teac-hing, book study, and tutorial drill; un-
doiiljtedly the examination in pathology represents a too narrow conception of the
present place and function of that topic; that in materia medica is well-nigh useless;
CURRICULUM & EXAMINATIONS: GREAT BRITAIN: FRANCE 283
doubtless there are too many separate tests. Finallv, it is possible that at some
points the practical tests are too hurried, so that the oral and written tests count too
heavily, — a circumstance of which the London tutors and the extra-mural school-
masters are not slow to take advantage. These are none of them matters of principle.
In part their remedy depends on the instigation of deep-seated changes in the direc-
tion of modernizing educational conceptions; in part they are at once remediable by
giving the professional teachers already permitted to conduct examinations a larger
voice in framing and regulating them.
This is indeed, as I see it, the heart of the matter. The English profession governs
and examines itself. But the active governors — those prominent in the cox-porat ions
— are in the main elderly men, w^ise, seasoned, and eminent veterans, to be sure, but
in large measure veterans still. I have already urged that though examinations may
suppress scandals, they cannot greatly accelerate innovations ; they may destroy, they
cannot create. To get a new point of view into the examination, chemical, patho-
logical, or other, it must first be got into teaching. The ultimate reliance for ideals
and intelligence must be on the schools as such, not on the schools acting under the
coercion of examining bodies. In England above all must this obviously be the order
of procedure. Now^ the official profession is eminent, dignified, and conservative, —
loyal to its past, deferential to the interests of the schools. English medicine is once
for all now so constituted; and this constitution is reflected in the composition of
the qualifying examinations. A change can be ^v^ought only if a new spirit takes
hold of education; it is not likely that stubborn or long resistance to revising the
examinations would be made, once a revolution in educational sentiment has been
accomplished.
The conscientiousness with w'hich men live up to their present lights is clearly dis-
played in the generous percentage of rejections. At the Conjoint Board of London
in 1894, out of 865 candidates in medicine and 916 in surgery, 42 per cent failed in
each subject; out of 831 who attempted midwifery, 32 per cent failed.^ Before the
same body, in the years 1905-1909, 37 per cent were rejected in medicine (total can-
didates 3279), 45 per cent in surgery (3598 candidates), 28 per cent in midwifery
(2957 candidates). Wherever the numbers are large enough to be significant, equally
decisive action appears : in 1909, the Triple Board examined 248 candidates in medi-
cine, rejecting 134 or 54 per cent; 263 in surgery, rejecting 142 or 53 per cent; 178
in midwifery, rejecting 57 or 32 per cent; the University of Edinburgh accepted 200
and rejected 62 in medicine, accepted 195 and rejected 52 in surgery; the Conjoint
Board of Ireland passed 70 and rejected 41 in medicine, passed 64 and rejected 42
in surgery, passed 86 and rejected 24 in midwifery. At Cambridge, 79 passed and 38
failed in medicine; at London L^niversity, in the same branch, 137 and 93, respec-
tively. Glasgow and Durham alone show averages distinctly more favorable: the
former in medicine, 103 successes as against 29 failures; in surgery, 103 as against 14;
1 Teale: Need for Reform of Medical Examinations, p. 16 (Leeds, 1896).
n^i MEDICAL EDUCATION
ill inichvift-rv, 109 as against 7-^ The latter passed 28 each in medicine, surgery, and
niidwiferv, with one failure in the first, and four apiece in the two others.
What is the si'niificuiice of these astonishing fatalities? Several factors must be
recognized. First of all, they appear completely to discredit the entrance basis. A
curriculum lias lx?en constructed in some sort representative of modern medicine;
it is pursueil by ill-trained students, who conspicuously fail to master it. What the
examination concedes to be at this moment the legitimate ideal of the medical school
is therefore largely unattainable on the matriculation basis at present accepted.
But another conclusion seems equally unavoidable. Conscious of the difficulties of
teaching modern medicine to untrained youths, British educators have sought to
force the impossible by making the student literally and elaborately accountable for
every detail of his training. In writing, orally, practically, he is to be compelled to
prove himself an adept: thus shall the stream rise higher than its source. With what
outcome? When bv sheer particularity the examinations endeavor to force an accom-
plishment bevond the educational competency of the students, instruction is perverted
to mere drill, and a rise in the percentage of break-downs infallibly evidences the
futility of the endeavor. Of the candidates appearing before all (jualifying bodies,
12.4 per cent were rejected in 1861 ; 16.6 per cent in 1871 ; 31 per cent in 1881 ; 39.3
per cent in 1891.^ I repeat, then, that if everything is expected of the examinations,
thev will corrupt instruction and disappoint anyway. A good result may be measured
by reasonable, not too numerous or prolonged examinations; it cannot be forced by
them, ITiat, in the end, depends on antecedent factors, — adequate preliminary train-
ing, proper facilities, competent and devoted teachers, and the right atmosphere;
and to the provision of these, effort must in the first instance devote itself.
A word mav here be in place by way of contrasting the German and English pro-
duct, as determined by all the factors that have been from time to time enumerated. At
graduation, the Englishman is indisputably more dexterous. He handles himself and
his patient more expertly. But the German is immensely more likely to be launched
with momentum : he has ideas, has brushed shoulders with aggressive workers; he will
probably grow. No inherent incongruity between the two disciplines appears to exist.
Indeed, neither can fully explicate itself alone: a practical discipline apart from ideas
is the discipline of an artisan ; a theoretic discipline more or less detached from practice
cuts itself off from the most plentiful source of its own inspiration. The German semi-
nary and the German laboratory for advanced workers are types of the stimulating
consequences of combining practical with theoretic training: the participation of the
student under direction is their keynote. The psychology of undergraduate instruc-
tion is not difTerent. What is essentially characteristic of me<lical education in Great
Britain and in Germany is therefore complementary : the former lacks ideas, the latter
lacks practice, and either may be grafted on the other. The Germans are concerned for
* Document No. fifK), General Medical Council (May 24-, 1910), pp. 10-U.
^ JUport on lifjtr.tionii. General Medical Council, November, 18f)3, pp. 11-16.
CURRICULUM & EXAMINATIONS: GREAT BRITAIN : FRANCE 285
the better student, the English for the average student, but a well-organized and prop-
erly equipped school can provide opportunity for the former without neglecting the
training of the latter.
The French curriculum may be very briefly characterized: it is at once simple and
concentrated. The preliminary sciences, physics, chemistry, biology, claim the first
year. Of the "block" system, which practically reserves the next two for the under-
lying medical sciences, it knows nothing. Anatomy, physiology, etc., are taught in
the afternoons in order that from the first the student may, if he chooses, follow
the clinics in the morning; after the first year, he is required to do so. His clinical
assignments come in turn, each forming the important feature of a four months'
term. The sciences are concuiTent with the clinic, not precedent thereto.
The banishment of the sciences to the afternoon continues them in a largely theo-
retical and distinctly subsidiary form. Discriminated against, they get no real chance.
It is not necessary to repeat the objections already urged against this procedure. It
is true that surgery lends new interest to anatomy, provided the student has already
mastered the elements of anatomy; otherwise, surgery is itself an impenetrable mys-
terv. Precisely the same situation holds as between chemistry and physiology, or
between physiology and internal medicine. The French notion is sound in so far as
it holds that anatomy and physiology cannot be studied once and for all. The stu-
dent's work in medicine and surgery repeats and amplifies them. But before he can
be clear as to anything he sees and hears in the clinics, he must have previously ob-
tained a fundamental discipline in both subjects, and in pathology as well. There is
the added reason that, if postponed, the sciences are permanently slighted. Medical
education in France is therefore practically clinical education, depending on the ac-
cumulation of impressions which tend in time to classify and distinguish themselves.
Clinical assignments come in no fixed order, which is of less consequence than that
propaedeutic exercises are not arranged to precede them. The various instrumental
procedures, properly antecedent to activity in the clinic, the student picks up hap-
hazard: so conservatively clinical is medical training in France still.
The curriculum extends through five years, thus apportioned :
First year: Chemistry, physics, and biology.
Second and third years: Dissections, two hours daily in winter semester.
Histology, four hours weekly in summer semester.
Physiology, four hours weekly in summer semester.
Biological physics, once weekly in summer semester, second year.
Biological chemistry, once weekly in summer semester, tliird year.
Fourth year: Pathological anatomy, four hours weekly in winter semester.
Parasitology, one hour weekly in winter semester.
Operative medicine, three hours weekly in summer semester.
aj^ MEDICAL EDUCATION
Fifth vear: Toxicology, two hours weekly in winter semester.
PathologicAl anatomy, four hours weekly in winter semester.
Bacteriology, four hours weekly in summer semester.
Legal medicine, twice weekly in summer semester.
Clinical appointments occupy the morning hours during the third, fourth, and
fifth years, general medicine and surgery in the third and fourth, obstetrics, psychi-
atry, ophthalmology, and urology in the fifth. The student is left free to follow the
clinics in the second year, if he will.
The four years forming the medical curriculum proper are divided into sixteen
"inscriptions," the five examinations being fixed in reference thereto. The French
student pays his fees every half semester — i.e., four times yearly. Each such payment
is called an "inscription." The subjects of a given inscription cannot be passed until
those included in the preceding inscriptions have been paid for and passed. This
device practically compels the student to pursue his subjects in regular order. The
first examination, devoted to a practical dissection and an oral in topographical ana-
tomy, may come at the student's option between the sixth and the eighth inscription ;
the second, viva voce in histology, physiology, and physiological chemistry, between
the eighth and tenth; the third, practical tests in operative medicine, topographical
anatomy, and pathological anatomy, and oral in topographical anatomy, general
pathology, parasitology, and obstetrics, between the thirteenth and sixteenth; at any
time after the sixteenth, the fourth and fifth, including therapeutics, hygiene, legal
medicine, materia medica, pharmacology, surgery, medicine, and obstetrics. Finally,
the student must submit an acceptable thesis.
CHAPTER XII
THE FINANCIAL ASPECTS OF MEDICAL EDUCATION
In the matter of university support in Germany, two facts stand out conspicuously.
First, the absolute cost of the universities has mounted with startling rapidity. Two
centuries ago, a small dowry sufficed to start a university on its way; the initial out-
lay at Strassburg in the early seventies — the last German foundation — was upwards
of 13,000,000 marks. Twenty years ago, 1891-1892, the annual appropriation of the
Prussian government for the operating expenses of its universities reached 10,559,392
marks, of which amount less than one-third was derived from endo\vments, the rest
being appropriated from current funds. In the same year, 3,248,862 marks were ex-
pended for purposes lying beyond the expense of maintenance, — construction, for ex-
ample. Eleven German universities outside Prussia spent contemporaneously 8,342,839
marks for maintenance (less than one-fourth derived from investments), and 1,119,212
marks besides. Important sums devoted to the support of the universities, as we shall
see, are omitted from these amounts, which purport to be merely the governmental
subvention: nevertheless, in 1891-1892, these aggregated 23,270,305 marks.^ Four-
teen years later, 1905-1906, Prussia alone was spending 15,426,684 marks for the
ordinary running expenses of the same institutions — an increase of over forty per
cent — and 4,079,205 marks for extraordinary purposes. To obtain the total cost of
the universities, one would have to reckon in that large portion of the professorial in-
come contributed by student fees, which cuts no figure in the governmental accounts,
and the hospital fees paid by patients or insurance companies in their behalf, of which
no notice has been taken above.^
The second characteristic feature of imiversity financing to which attention must
be called is the altering direction of expenditure. Between 1868 and 1908, the per-
centage of expenditure on salaries and residences fell from 46 per cent to 30.8 per
cent of the total outlay; the percentage of expenditure on laboratories and institutes
rose ft'om 40.3 per cent to 61.7 per cent. Average student cost, fluctuating considera-
bly in the meantime, had, nevertheless, mounted from 530 marks at the former date
to 762 marks at the latter. The changing nature of university education is apparent
without further elucidation.
In the following table these significant items, which in no case take account of
student fees, are brought together for the Prussian universities :
1 Statistics compiled from Preitssische Siatistik, 204 (Berlin, 1908) ; Etat des Ministeriums der Geistlichen,
Unterrichts- und Medizinal Angelegenheiten fur 1910 ; and Lexis : Deutsche Universitdten, vol. i (Berlin,
1893).
2 See below, pp. 290-292. ^
288
MEDICAL EDUCATION
PcrccnUige of Outlay
Yfrtr
Ordinary
Expenses
ilnrkx
Extraor-
dinarv
^farks
Total
ifarkit
Stu-
dent
Cost
Marks
Admin-
istra-
tion
Sala-
ries
Labs,
dt Insti-
tutes
Build-
ing
Resi-
dence
Allow-
ance
1868-1869
1877-1878
1887-1888
1896-1897
1899-1900
1902-1903
1905-1906
3.886. C33
7.162.555
9,180.603
11.417.345
12.591.267
14.033,521
15.426.G84
501.121
1.774,128
2.566.175
1.492.016
4.356,726
3,663.517
4.079,205
4.387,754
8,936,683
11,746,778
12,909,361
16,947,993
17,697,033
19,505,689
530
823
669
824
793
785
762
5.67
3.70
3.46
4.49
4.14
4.11
45.95
41.94
36
30.49
29.46
27.93
37.07
40.46
47.18
51.96
53.77
55.45
3.19
2.45
3.61
3.73
4.19
4.17
6.12
5.38
5.12
4.85
4.77
The several universities taken singly show marked differences, though all tend in
one direction.^ That the day of small beginnings is over, the calculations dealing with
the proposed University of Frankfort show : the initial budget, it is figured, would
fall just short of 3,000,000 marks. At Berlin, the ordinary expense in 1868 amounted
to only 748,332 marks, the extraordinary to 256,800 marks; by 1905-1906, the former
had increased to 3,672,701, the latter to 1,100,150; in the same period, Gottingen in-
creased on the current side from 545,790 to 1,497,717; on the extraordinary, from
59,440 to 434,450. The dissimilarities in student cost are not readily explicable: in
the nineties, each student cost the University of Berlin 489 marks, the University of
Munich, 264; at thesame date, Gottingen, Kiel,and Konigsberg expended 1300 marks
per student, Giessen almost as much, Strassburg a little less than 1100 marks. The
others range between 500 and 900 marks.^ Finally, the relative requirements of salaries
and lalxjratories in a single institution over a longer period may be illustrated by
Wagner's statistics Ijearing on the Univei^sity of Berlin:^
Year
Salaries
Percent
Iruititutei
Per cent
1811
116.550 M.
71.9
39,294 M.
24
1834
193.650 M.
64.6
78,434 M.
26.2
1880
321,000 M.
52.8
267,000 M.
40.1
1896-1897
865.000 M.
30.9
1,481,001 M.
52.9
More pertinent to our present inquiry, however, is the actual current governmental
' By the courteous permission of the Controller of H. B. M. Stationery Office and of the Royal Com-
mission on University Education in London. I am enabled to republish from the Third Report of the
Commission a series of tables showinpthe cost of medical education in the universities of Prussia and
Bavaria, supplied by the governments of those countries at the request of Professor Friedrich von
Miillcr. and handed in by him as part of his evidence friven to the Royal Commission. These tables
arc printed in the .\ppendix. papes 329, etc. Discrepancies between the figures given in the text and
those given in the tables in the Appendix are due to the fact that they represent different years and
in a measure different items; but tne differences are not material.
* Lrxis, vol. j, p. 158. For figures at the present time see Appendix, page 329.
* Quoted by Paulsen : German rnir«rr«Vi>j (Thilly's trans.), p. 219 (New York, 1906).
FINANCIAL ASPECTS OF MEDICAL EDUCATION
289
outlay for the medical faculty. The following table is illustrative of conditions in
several departments at universities differing greatly as respects size and situation:^
Anatomy
Berlin
Leipzig
Konigsberg
Greifswald
Giessen
Total Outlay
65,456 M,
62,308 M.
24,869 M.
23,451 M.
18,980 M.
Prof.'s Salary
9,000 M.
10,525 M.
7,000 M.
6,600 M.
5,700 M.
No.
5
3
3
2
2
Assts. and Cost
thereof
9,900 M.
13,200 M.
6,300 M.
3,850 M.
4,200 M.
Ko.
5
6
2
1
1
Servants and
Wages
8,480 M.
10,890 M.
3,080 M.
1,520 M.
1,500 M.
Lab. Expense
38,076 M.
27,693 M.
9,989 M.
11,091 M.
8,080 M.
Physiology
Berlin
Leipzig
Konigsberg
Greifswald
Giessen
91,576 M.
45,554 M.
16,700 M.
13,948 M.
10,300 M.
9,000 M.
10,125 M.
6,300 M.
6,300 M.
4,500 M.
5
4
2
1
1
8,400 M.
11,980 M.
3,000 M.
1,500 M.
1,200 M.
6
4
1
1
1
10,940 M.
9,320 M.
1,200 M.
1,110 M.
1,400 M.
63,116 M.
14,129 M.
5,840 M.
4,868 M.
3,200 M.
Pathology
Berlin
Leipzig
Konigsberg
Greifswald
Giessen
37,580 M.
56,511 M.
17,910 M.
19,296 M.
16,620 M,
8,000 M.
9,688 M.
7,000 M.
6,000 M.
7,200 M.
7
5
2
2
2
11,100 M.
9,055 M.
3,000 M.
3,000 M.
3,000 M.
2
8
1
1
1
3,280 M.
13,770 M.
1,200 M.
1,100 M.
1,320 M.
15,200 M.
56,511 M.
6,960 M.
8,686 M.
5,100 M.
Hygiene
Berlin
Leipzig
Konigsberg
Greifswald
Giessen
58,240 M.
34,442 M.
18,740 M.
15,275 M.
15,160 M.
8,400 M.
8,080 M.
6,300 M.
5,700 M.
5,300 M.
3
3
2
2
2
5,150 M.
5,150 M.
3,000 M.
3,000 M.
2,400 M.
7
5
1
1
11,040 M.
10,606 M.
1,450 M.
1,520 M.
33,850 M.
10,606 M.
7,990 M.
6,555 M.
7,460 M.
Pharmacology
Berlin
Leipzig
Konigsberg
Greifswald
Giessen
27,967 M.
23,046 M.
15,590 M.
12,570 M.
12,140 M.
8,000 M.
9,480 M.
7,000 M.
6,300 M.
5,900 M.
2
2
2
1
1
3,000 M.
3,150 M.
3,000 M.
1,500 M.
1,200 M.
2
2
1
1
2,265 M.
4,240 M.
1,450 M.
1,520 M.
14,002 M.
6,176 M.
4,540 M.
3,250 M.
5,240 M.
Expenditure on the same account in several other universities may be illustrated
in somewhat less detail as follows:^
1 For most of the material embodied in the following tables I am indebted to Professor Franz Eulen-
burg, Leipzig. It is to be noted that the salaries do not include student fees paid directly to the instruc-
tors ; professors, assistants, and helpers frequently receive living quarters, heat, and light besidessalary
or wages, as the case may be.
2 From Berichi des Sander- AnsscJmsses, pp. 18, 19 (Frankfort a. M., 1911).
290
MEDICAL EDUCATION
GoTTIKGEV
Marburg
Strassburg
Bonn
WiJnzBURGi
Anatomy
Pertonal Son-
Pergonal
13,930 14,050
27,980 M.
Personal Xon-
Personal
13,8-20 14,041
27,661 M.
Personal Xon-
Personal
20,250 8,400
28,650 M.
Personal Non-
Personal
19,045 17,000
36,045 M.
Personal Xon-
Personal
17,200 18,200
35,400 M.
Physiology
8,580 5,938
15,650 9,007
13,580 4,S00 2
14,260 7,000
39,640 M.
12,750 9,020
5,419 9,193
14,518 M.
24,657 M.
21,770 M.
14,611 M.
Pathology
7,439 6.766
15,196 M.
10,130 6,823
16,953 M.
16,650 6,700
23,350 M.
10,600 7,365
17,965 M.
13,100 17,030
30,130 M.
Hygiene
8,530 4,740
13,270 M.
32,220 18,583
50,803 M.
15,590 6,000
21,590 M.
8,950 5,750
14,700 M.
8,350 4,500
12,850 M.
Pharmacology
7,600 4,345
9,200 4,105
13,100 4,450
8,550 3,840
5,200 5,200
11,975 M.
13,305 M.
17,550 M.
12,490 M.
1U,400 M.
The most elaborate of German scientific institutes is the newly erected anatomical
building at Munich. This palatial structure cost some 2,000,000 marks. The annual
budget, exclusive of two professorial salaries,^ amounts to 118,000 marks, of wliich,
approximately, 8000 marks go to general service, 28,000 to heat, light, etc., 1200
to library, and 4000 to materials, instilments, photography, printing, etc.
The seven medical faculties of Austria required in the year 1909, 5,108,544 kro-
nen,* as against 5,629,479 kronen the following year. The budget for 1910 is distrib-
uted as follows:
Vienna
Graz
Innsbruck
Prag (German univ.)
2,127,582 kronen
473,898 kronen
424,102 kronen
769,398 kronen
Prag (Czech university)
Lemberg
Krakau
724,446 kronen
463,708 kronen
646,345 kronen
Of the increase — almost 600,000 kronen — Vienna obtained over one-half, 328,000
kronen, mainly to meet the increased running expenses occasioned by the opening
of the new women"'s clinic.^
On the clinical side, the actual or total cost of hospital maintenance is largely in
excess of the sums charged to the clinics in the government or university budget; in
other words, the university gets the use of clinical facilities far more varied and ex-
tensive than it pays for out of current funds. This is not explicable by the existence of
hospital endowments; for with a few exceptions, Gottingen, Greifswald, Strassburg,
and Vienna, the most impoi-tant of them, German institutions derive comparatively
little support from invested funds, — less than one-fourth of their annual expend-
iture. The running expenses of the Charite exceed 2,000,000 marks annually; the
' Omitting professorial salaries.
^ Physiology and physiological chemistry.
' Professor of gross anatomy and professor of histology and embryology.
* .\ krone ia about twenty cents.
» Dtu Otsttrrnrhitchs SaniUiUweten, p. 9(Wien. January 13, 1910).
FINANCIAL ASPECTS OF MEDICAL EDUCATION 291
charge upon the university, nevertheless, is not quite half that sum.^ Additional clini-
cal establishments cost 821,304 marks, the governmental subvention amounting to
less than half, — 388,547 marks. To put it differently, the state procures for the uni-
versity clinical facilities worth approximately 3,000,000 marks a year for less than
1,500,000. Substantially the same proportion holds elsewhere : of a total clinical ex-
penditure of 544,083 marks at Greifswald, the university provided 289,501 marks; an
outlay of 435,991 marks at Gottingen involved the state only to the extent of 206,926
marks. Expenditures on the medical clinic at Tiibingen approximate 200,000 marks
annually, to which the university (that is, the state of Wijrttemberg) needs to con-
tribute only 90,000 marks. How the difference is supplied I shall presently explain.
The expenditures above cited include not only administration and care of patients,
but the salaries of physicians and the promotion of research. Salaries will be touched
on presently; a w'ord here on the subject of research. The university encourages re-
search; so, also, to some extent do the municipalities. When, as at Vienna, Leipzig,
and Munich, non-university hospitals — whether municipal or endowed does not mat-
ter— affiliate with the university, both parties to the bargain make an appropria-
tion for laboratory support. The two appropriations are pooled, to be devoted to such
objects as the professor selects. Time to their conviction that research must be un-
trammeled, the Germans exact no accounting for sums thus earmarked. The money
is spent within and for the laboratories : beyond that, no inquiry is made. The ideals
of the university are the sole guarantee. Experience has taught that research is not
only costly, but venturesome : the mortality among ideas, inspirations, experimental
efforts, is prodigiously high. Waste is therefore inevitable ; but, granted the compe-
tency of the investigators, it is to be accepted willingly. A most effective safeguard
is, nevertheless, involuntarily present: for the total sums available are usually so small
that only by the most careful husbandry can they be made to suffice. At Tiibingen,
for example, the medical budget (200,000 marks) allows 83,000 marks for care of
patients, 29,000 marks for salaries, not including that of the director, 5000 marks for
laboratory expense, 2000 marks for books, 3000 marks for instiiiments, X-ray room,
etc. Laundry, heat, and light are paid for out of a general fund.
University clinics, then, may be said to be self-supporting to the extent of approxi-
mately half their cost; non-university clinics are even less burdensome to province
or municipality.^ Credit for this achievement belongs to intelligent legislation. The
public hospital in Germany stands wade open to all that need medical relief: no one
is turned aw^ay. Yet they are not, strictly speaking, free, charitable institutions. For
practically eveiy patient some one pays, — pays, that is, on the average about one-
1 There are 794,791 marks for general purposes, 196,fi95 marks for teaching. Etat des Ministeriums der
Geistlichen, Unterrichts- tind Medizinal Angelegenheiten fiir 1910, p. 323.
2 The cost of mere care of patients at the Cliarite averaged 1.26 marks per day in 1907 as against 1.40
marks in the municipal estabhshments of BerHn ; but, total cost being considered, the Charite spent
5.19 marks per patient, the municipal institutions, 4.52 marks. E. Putter : Verwaltungsbericht. Reprint
from ChariU-Annalen, vol. xxxiii, p. 23.
j{92 MEDICAL EDUCATION
half of the sum spent in his keep. By a system of compulsory insurance against acci-
dent jinii illness, the German artisan, laborer, and domestic servant are required to par-
ticipate in protecting themselves against incapacity: to any one of several author-
ized insurance funds or associations, the employer pays one-third, the insured indi-
vidual two-thirds, while the government grants the services of the necessary officials.
Tlie public hospital looks to these funds for its fees; in case patients are not included
in the list of those compulsorily insurable, — day laborers, for example, — the hospi-
tal sends its bill to the appropriate parish or municipality.^ The liability of the fund
runs for twenty-six weeks in case of illness, thirteen in case of accident, at the end
of which periods the responsibility is, if necessary, shifted. Patients ai'e divided into
three classes, according to the sum paid for maintenance: in the medical wards at
Giessen, the first class pays as a rule^ from 8 to 10 marks per day, the second from
4 to 5 marks, the third, in which we are mainly interested, from If to 2i marks;
children under ten pay li. The town pays the state — or university — a lump sum,
10,000 marks annually, for medical aid furnished its non-insurable poor. At Marburg,
close bv, the charges are on the average a little lower, — from 6 to 8 marks, from Sh
to 6, and li respectively. At TiJbingen, the charges range from 4 to 8 marks for sin-
gle rooms,' 1.80 marks and 1.20 marks for the second and third classes; the director
can also accept free patients (homeless or belonging to non-insured classes), of whom
he has usually 25 out of a total of about 200. In large towTis, on the other hand, they
are a little higher. At Strassburg, third-class patients from outside points with which
the Burgerspital has a contract pay 3i marks, others 3| marks, per day; the local
associations pay a rate of about 2i marks. At Berlin, the lowest rate is 3 marks per day.
Herewith the secret of the German clinic in the small university to\\Ti is laid
bare. Marburg and Giessen lie within reach of Frankfort. By making a slightly lower
hospital rate, and a low transportation charge, they attract the patronage of the in-
surance associations of these great centres. The artisan and peasant make no objec-
tion : to them the university professor is one of the important personages, — a great
dignitary, in whose hands thev feel secure. Even so, the consciousness that they are not
mere objects of charity stays with them. Occasionally, a patient declines to permit
himself to be used for teaching, as, under the circumstances, he has a right to do. His
wish is scrupulously respected.
Before leaving this topic, another word should be said in praise of the statesman-
like handling of the problem of clinical education by the German states and muni-
cipalities. For economic reasons, compulsory insurance was instituted; thus a situ-
ation was created in which immense clinics were sustained by means of relatively
1 For an exhaustive account of Workinf;raen's Insurance in Europe, with bibliography, see Twenty-
fourth Annufil Report of United States Department of Labor, 1909 (Washington, 1911).
2 Charges are a little higher in winter. The women's clinic is slightly less expensive. Where obstetri-
cal cases are badly needed, the fee may be suspended, provided the women assist as long as they are
able to do so in tiking rare of the clinic.
' Of which there arc about 25.
FINANCIAL ASPECTS OF MEDICAL EDUCATION 293
small outlay on the part of the authorities. Now, the university faculties of medicine
need clinical facilities. The long reach of a far-sighted government brings the two
together. The hospitals, the universities, the public, — all profit. In other countries,
too, hospitals and universities exist in the same towns: but Germany alone has
shown the statesmanlike capacity to link them together in ways that most effectively
promote the purposes for which they severally exist.
The university budget fails, as I have said, to convey a correct idea of the extent of
the clinical facilities of the medical faculty or the cost to the nation of their upkeep. In
still another respect does the budget present an inadequate picture of the situation. It
reckons as teaching cost only such salaries as are paid. Student fees appear nowhere on
the books, either as income or outgo; as a matter of fact, university teaching costs the
sum of salaries and fees; for tuition fees supplement salaries, at times constitute them.
An ordinance, effective April 1, 1908, fixes the salary of the ordinary professor at
Berlin on appointment at 4800 marks ; at intervals of four years, this sum increases by
400 marks, so that, at the close of twenty-four years'* service, it stands at 7200 marks;
outside Berlin, the Prussian ordinarius begins with 4200 marks and rises ultimately
to 6600 marks. Professors extraordinary and heads of divisions in laboratories and
institutes start with 2600 marks and cannot rise beyond 4800 marks, which they
attain after a score of years.^ An additional allowance — "house money," so called —
is also to be added in: 1200 marks a year at Berlin and Breslau; 880 at Bonn, Kiel,
and Konigsberg; 720 at Gottingen, Greifswald, and Marburg. Not every ordinarius
or ea:trao}'dinarius, however, receives a salary. At Berlin, 17 ordinarii in the medical
faculty are salaried,^ 7 unsalaried ; at Gottingen, 11 and 2, respectively; 13 and 4 at
Bonn. Among the extraordinarii, 32 are paid, 22 unpaid in Berlin; 8 paid, 6 unpaid
at Halle; 9 all paid at Marburg.^ Eulenburg found in July, 1907, the following
salary distribution among the extraordinarii of the medical faculties in Germany
and Austria : *
Number of Extraordinarii
receiving receiving above
1000-2000 M. 2000-3000 M. 3000-4000 M. 4000 M.
21 12 1
27 , 20 14
3 9 17
The remuneration of the assistant is even lower still. It is indeed amazing on
what meagre support the German assistant will make ends meet. He receives a few
hundred marks as salary, — sometimes not even that; in some instances board and
lodging, besides; and earns varying sums by giving special courses, now to ordinary
1 Professors who are also practitioners of medicine forego the periodic increase. Circular of the de-
partment, included in the Etat, referred to on page 291.
2"Etatmassig."
3 Etat, pp. 286-289.
* Eulenburg: Academische Nachwuchs, p. 134.
receiving
receii
no Salary
1000-20
Prussian Universities
29
23
Non-Prussian Universities
38
30
Austria
39
8
20+ MEDICAL EDUCATION
students, now to groups of visiting physicians, now to single individuals, foreigners
niostlv, who desire help in special lines. The precariousness of his livelihood has
developed a unique and unparalleled strain of idealism; but it has had other less
lovelv consequences. The hard lot of the German assistant excludes some from the
academic career; others it compels to marry from worldly motives, or to engage in
practice; at times, scientific competition takes on the character of jealous business
rivalry. But the last word concerning the German assistants ought in fairness to be
one of unstinted admiration: nowhere else in the world is there to be found so de-
voted a race of men whole-heartedly giving themselves to scientific progress with so
little hope of earthly reward.
However, the salary does not constitute the sole, sometimes not even the main, com-
pensation of the university professor. Examination fees form a substantial addition of
indefinite size : in large centres, the income from this source is considerable. Formerly,
student fees went the same way. Nowadays, the Prussian government turns over to
salaried instructors without discount tuition fees up to 3000 marks; 75 per cent of
the next thousand, and 50 per cent beyond that point. In Bavaria since 1909, salaried
teachers receive student fees up to 6000 marks yearly; one-half of all additional. The
portion retained by the state is supposed to be employed in helping out instructors
whose coui*ses enroll few students. Non-salaried teachers receive their fees in full.^
Obviously, the total cost of teaching in the German universities is greater than their
budgets by the amount of fees not taken into account. Whether the German plan is
on the whole a Avise one is somewhat fiercely questioned. Tlie great pecuniary prizes
help to make university life an attractive career to forceful and able men. But there
are strong countervailing disadvantages. It is not demonstrable that the greater finan-
cial inducement has procured for anatomy abler or more devoted scientists than go
willingly into the meagre service of pharmacology^ or hygiene. Enormous discrep-
ancies of income do not really mean that a far more able set of men are to be found
in one branch than in another. If, however, interest in science is really the selective
factor, then, as universities now go, excessive rewards at one point involve regret-
table denials elsewhere. This was of no consequence in the mediaeval university,
where every lecturer went his own way: the field was open and fair, and each was
perhaps entitled to his own. But the organic unity of the modern university creates
a different situation : the whole suffers if an important limb is under-nourished. And
as the cost of living has both relatively and absolutely advanced, under-nourishment
involves increasingly severe — even deterrent — hardship. Of 213 docents in the medi-
cal faculty respecting whose income Eulenburg collected accurate statistics, one-half
were also assistants in receipt of from 1200 to 2000 marks a year,— a poor recom-
> Sec Thf Firuiru-ial Status of (hf. Professor in America and in Germany, Bulletin No. 2, Carnegie
roundation for the Advancement ofTeaching, New York, 1908.
• On the other hand, the pharmacologist may increase his income by patenting his therapeutic dis-
coveries, which IS not forbidden by the prevalent ethical code.
FINANCIAL ASPECTS OF MEDICAL EDUCATION 295
pense for the heavy routine which they undergo. Their lot is not greatly altered by
the small additional income derived from special courses, or by such perquisites as
board and lodging. The other half received fees alone.^ Such outside practice as they
can obtain is not, on the average, considerable. Centralized administration with better
equalized remuneration will not repel men interested in the object: it will procure
a more equitable distribution of rewards and a more even and healthy development.
Agitation in this sense is active throughout the university world.
But an even more serious objection to the fee system arises from the creation of a
proprietary interest in obsolete teaching methods. In Germany, as in Scotland, the
personal prosperity of the clinical teacher is dependent on a pedagogically bad dis-
tribution of students. Mass teaching persists in the amphitheatres of Germany, and
in the hospital wards of Edinburgh and Glasgow,^ because it pays, — an advantage
greatly increased in case the teacher is examiner also. Austria has abolished the fee
system entirely ; the fees are paid into the university chest, and the general level of
salaries has been elevated. The extraordinarius starts at 3200 kronen, and reaches
4000 in a decade, plus the usual allowance.* The Prussian restrictions above noted
were introduced by AlthofF, as the initial step in a campaign for the sequestration
of fees. "The fee business is absolutely unethical," he is reported to have said shortly
before his death, "and I will yet get rid of it.""^ This, however, he failed to accomplish.
The hard conditions that have just been described have had as yet no noticeable
effect on German enthusiasm. The scientific spirit is nowhere overborne by economic
hardship. Salaries may be small; other income precarious; laboratory appropriations
scant. But the lamp burns brightly. If assistants cannot be hired, volunteers come
forward; they pay their o\m expenses and contribute to the general upkeep of
the laboratory. Their fees purchase materials, books, animals, and, above all, hire a
helper, the one indispensable factor in the German laboratory. Small sums achieve
impossible things: a single salary, for example, is provided for the serum division
of the pharmacological department in Berlin; yet there is an active staff of eight vol-
unteers and two helpers. In a chemical laboratory there were forty advanced workers:
the annual appropriation was only 4000 marks. Truly, a small sum in the hands of
devoted scientists proves a veritable widow's cruse.
Meanwhile, one hears occasionally that idealism is waning. Perhaps so, at the top.
A prosperous professorial surgeon or physician now and then disturbs the aca-
demic picture, but the rank and file are sound. With an enthusiasm hard to dupli-
cate elsewhere in the world, they give themselves to science and teaching in a spirit
of almost religious devotion. Undoubtedly they surrender too much ; undoubtedly
1 Eulenburg: Academische Nachwuchs, pp. 110, 111 (Leipzig, 1908). An occasional decent in Berlin or
Vienna prospers by giving special courses to foreigners.
2 A new ordinance of the University of Glasgow (July 7, 1910) gives the university the right to regu-
late the number of students attending a class for bedside instruction (sections 7 and 8).
3 Bermer : Die Rechtsiierhaltnlise der dsutschen Universitdts Professoren, pp. 96, etc. (Giessen, 1903).
* Quoted by E. Horn in Ethische Kultur, May 15, 1910, p. 73.
296 MEDICAL EDUCATION
manv are lost to science because, whatever their will, the sacrifice required is an im-
possible one. Science, too, suffers. Abclerhalden points out^ that successful research
is no longer a matter of a happy accident or a lucky inspiration occurring to an
individual: the dav of such simple strategy has passed. A campaign must be planned
and carried out bv a group of men supporting one another. But in that case, the
group must be relatively stable. Under present conditions, men cannot be retained
long enough. Large resources are needed, though the individual will still be content
with a modest competency. Once for all, the German scientist — be he laboratory man
or clinician — realizes clearly that in choosing a university career he has forsworn
mammon. The exceptions have lost caste: upon them the disapprobation of the uni-
versity world falls heavily. It is generally recognized that their place is outside the
university. "In the struggle of daily life for glittering possessions, the university,
unconcerned, must be the quiet home in which knowledge blossoms and the spirit
unfolds itself freely and purely."^ These words are still, on the whole, a fair charac-
terization of the tone of the German university.
The cost of a medical education to the student is heavy, varying less than one would
be disposed to think as between large and small towns. About 300 marks usually
are required for tuition fees, books, etc. ; ^ living expenses, exclusive of clothing, are
estimated at about 1200 marks for the two semesters; from 7500 to 8000 marks make
the minimum for the entire course, and leave the student without allowance for ex-
amination fees or vacations. Bickel estimates that, all told, a student requires from
12,000 to 15,000 marks.* Twenty years have made no material change in this respect.
Lexis, wTiting in the early nineties, reckoned the cost of a year to a medical student
in Kcinigsberg at 1515 marks, in Berlin at 2049 marks.^
The lot of the needy student may be variously relieved. The payment of fees is
a private matter in the hands of the professor: he is free to waive his rights entirely,
or to grant a respite, if he pleases. At certain universities, committees are appointed,
who, evidence of pecuniary incapacity being shown, grant a delay of six years, at the
close of which period the proper officials endeavor to collect the debt : further post-
ponement is common. Scholarship funds also exist, the income of which is annually
distributed. In the two semesters of 1905 and 1905-1906, out of a total attendance
of 40,509 in Prussian universities, 5023 enjoyed fee exemption ; 8435 (many of course
1 In Medi^nuche Klinik, 1910, No. 5.
2 Max Rubner: Uiuere Ziele fur die Zukunft, p. 9 (Leipzig, 1910).
• That this estimate is reasonable appears from the fact that the tuition fees in the recommended plan
at iierlin run as follows, taking the ten semesters in succession: 127 marks, -JS? marks, 163 marks,
238 marks, 115 marks, 167 marks, 267 marks, 232 marks, 302 marks, 303 marks. Much more formid-
able calculations are published by the professional associations, eager to deter young men from the
c^cer- ^^ne reac-hcs 22,0fK) marks, including everything. See Verhand der Aert'te. Dt^tsrhlnnds, Ver-
'_', No. 1«. "Wcr soil und wer darf .\rzt werden?" Weinbaum, pp. 6-9 (Leipzig, 1910).
■f n5,00f)marks, all told) is the estimate of Ostermann: Wiestvdiert man ^Jedicin/'pp. 7-10
(Leipzig, 1906).
* Wu MtuditH man Medicinf p. 13. ^ Deutsche UniversUdten, voL i, p. 163.
FINANCIAL ASPECTS OF MEDICAL EDUCATION 297
already counted among those exempted from fees) received additional aid: among
them 966,720 marks were distributed.-^
The economic outlook of the young practitioner cannot be described as cheerful.
Not only are eligible locations overstocked : the legitimate field of the physician is
curtailed by widespread resort to quacks (to be discussed in the next chapter), and
the employment of midwives,^ of whom Prussia in 1907 supported 20,878, — 1 to
1816 inhabitants. Moreover, the prevailing medical tariff is low, especially in the
sphere of contract practice. The Prussian law permits patient and physician to make
whatever bargain they choose; but in the absence of agreement, physicians on their
first visit may charge from 2 to 20 marks, for subsequent visits from 1 to 10; for a
first office consultation from 1 to 10 marks, for subsequent consultations of the same
kind from 1 to 5. An elaborate schedule of surgical fees is also legally prescribed in
default of specific contract to the contrary. The removal of a tonsil is valued at from
3 to 15 marks, a complicated tumor 20 to 200, amputation of a toe 10 to 30, setting
a fracture 10 to 30, a natural confinement 4 to 10, with half as much more in case of
twins.^The benefit funds have in some places taken advantage of competition due
to overcrowding to obtain at times for their clients terms hardly better than nom-
inal.* The number of separate funds or companies increased from 18,94<2 in 1885 to
21,376 in 1904; their membership from 5,398,478 to 11,418,000 in the same space
of time. In 1908, the total number of insured persons had reached 13,189,599,^ —
about one-fifth of the population of the empire. The total income of the funds rose
from 66,100,344 marks in 1885 to 216,294,954 in 1901 and 381,000,000 in 1908;
payments for medical services from 9,060,945 in the former year to 35,636,010 in
1901, and to 65,000,000 in 1908. The an-angements between physicians and funds
are made on the following lines: each fund makes contracts with a number of phy-
sicians, who serve for an annual sum, agreed on in advance, or for a specified sum per
case. This rate remains unaffected by the number of visits or consultations required
in each case. The insured member is compelled to seek the services of one of the con-
tract physicians. The Leipzig® funds have so contracted with so large a number of local
1 Preussische Statistik, 204, pp. 188-193.
^ Gesundheitswesen des Preussischen Staates, pp. 452-462 (Berlin, 1909).
3 Gebahrenordnung fur approbierte Aerzte, etc., March 13, 1906; printed separately or in Rabe, p. 255.
* The literature of the topic is voluminous and for the most part controversial in tone. My figures are
derived largely from the Statistisches Jakrhuch fiir das Deutsche Reich, 1910 ; Th. Rumpf: Soziale
Medizin (Leipzig, 1908); A. Rabe: Aerztliche Wirthschaftkunde (Leipzig, 1907). The former contains
bibliography and abstract of laws.
Among pamphlets dealing with the agitation may be mentioned :
H. A. MuUer: Diefreie Aerztewahl in Magdeburg in Lichte der Praxis (Magdeburg, 19n).
Haeseler: Der wirthschaftliche Ruin des Aerztestandes (Frankfort a. M., 1902).
Geffcken : Wesen u. Grundzilge der Arbeiterversicherung, Milnch. Med. Woch., 48, 49, 1901.
Sclioll : Stellung der Aerzte zu der Reform u. dem Axisbau der Arbeiterversicherung, reprint fTom Miinch.
Med. 'iVoch.
Lechler: Arzt u. Krankenkasse, Milnch. Med. Woch., 21-23, 1902.
5 Statistisches Jahrhuch fiir das Deutsche Reich, 1910.
6 For a complete study see: Die Entxcickelung und Tdtigkeit der Ortskrankenkassen fiir Leipzig und
Umgegend. ^
g<Xs MEDICAL EDUCATION
dtx-tors that something approaching free choice— for which the profession is continu-
ously agitating— prevails; but in some other places, the funds employ only a small
num'l>er, and thus by competition procure very cheap service. If statements issuing
from professional sources may be credited, an association at Lichtenberg, with 11,000
memljers, pays two physicians combined salaries of 4000 marks for their services; a
Hambur" sick benefit fund pays at the rate of 2 marks per head per annum, 3 for
man and wife, 5 for an entire family ; another Hamburg association, of 15,500 mem-
bers, is reported as paying its physicians 50 pfennigs (i mark) yearly for each person.
In Berlin, the rate paid to young graduates is alleged to fall at times to 17 pfennigs,
sometimes even to 5 pfennigs. More favorable terms are admitted to prevail in Koln,
Breslau, and Magdeburg. The protests of the profession, and fuller experience in the
operation of the insurance scheme on the part of the government, have led to rapid
improvements, which are not disputed even by the profession. Rumpf ^ states that
the average remuneration per head increased from 2.32 marks in 1885 to 3.69 in 1901.
Later statistics show that the average expenditure per case for medical services more
than doubled between 1885 and 1908. Nevertheless, in general the ordinary physician
earns an unsatisfactory livelihood. A small number of well-known consultants and
specialists thrive; so, too, the practitioners whose patrons are the well-to-do. But the
bulk of the profession are ill remunerated. At a conference held in 1892, it developed
that of the then 1747 practitioners in Berlin, j| had annual incomes of less than 3000
marks; of the other ^, only 250 were counted whose income was over 8000 marks,
and 170 — about ^ — who earned over 10,000.- Statistics compiled by the government
of Saxony are reported to show that 34.8 per cent of its physicians have an average
annual income, all told, of less than 4300 marks apiece. Of 23 physicians in one dis-
trict, with incomes exceeding 10,000 marks, only 12 earned that sum in practice; the
rest had additional sources of revenue.^ It must, however, in fairness be stated that
the general lot of the profession has never been financially enviable, and that its rapid
overcrowding and the spread of quackery — not the insurance scheme alone — are
responsible for deterioration.*
In Austria, conditions are declared to be practically identical. Benefit societies num-
bering from 1000 to 3000 members employ physicians on salaries ranging from 1500
kronen to 2500 kronen; the remuneration for office consultation is said to average
30 heller;'^ for a visit, 40 heller.« In 1905, it was calculated that of 1,600,000 inhabit<ants
of Vienna, one- third were thus insured in benefit funds employing 310 physicians. As
there were at that date 2800 physicians in Vienna, 2500 remained for a maximum
clientele of about 1,000,000 persons, a ratio of 1 to 400, which figure includes not
only the more prosperous, but those also who are too poor to insure.'
To these demoralizing conditions the profession has responded by the organiza-
1 Rumpf. pp. 33, 34. « Bickel, p. 11. 3 Lechler, in Munch. Med. Woch., 21-23, 1902.
* Sec below, pages 311-313. » Six cents. « Eight cents.
' Gustav Dintenfass, in Briiuh Medical Journal, June 3, 1905, p. 1205.
FINANCIAL ASPECTS OF MEDICAL EDUCATION 299
tion of a union/ which has already extorted better terms from the insurance associa-
tions and more favorable legislation from the government. Into the details of the acrid
controversies which have raged, it is impossible for us to go. Suffice it to say that
the professional union has resisted the further extension of compulsory insurance,
has struggled with the benefit funds for more generous contract prices, and for free
choice of physicians on the part of subscribers. These efforts look to the economic re-
habilitation of an independent, competitive profession. However, there are not want-
ing those who believe the outcome may be radically different. I have urged that the
physician is a social instrument, the medical profession an organ for effective social
protection against injury, disease, and untimely death. If society as a whole requires
that all its individual members should, for the general as well as their personal good,
receive prompt, competent, and sufficient medical service, the charge for the mainte-
nance of a staff capable of rendering the necessary aid may in part at least have to be
borne by society as a whole. Those who are financially able to employ a physician will
continue to do so; in procuring similar attention for others, society, the better to pro-
tect itself against loss, contagion, etc., will itself take a hand. The scattered peasants
of Pomerania, Posen, and Galicia can be helped in no other way: is the underpaid
laborer of the towns in an essentially different or essentially better situation.? What
both need in the way of medical care, the general welfare — their own, too — de-
mands that they should have; neither can pay what the relief — if it be satisfactory
relief — is worth or costs to render. It may turn out that the restoration of competi-
tion would benefit part of the profession without even then bringing full medical atten-
tion home to the hearth of the German workman and his children ; in that event, a
case may be made out for a next step in the organization of an efficient sanitary service.
It is unfortunately impossible to make an equally complete financial exhibit re-
specting medical education in the other countries with which this report has en-
deavored to deal. In Great Britain, for example, the government has no supervisory
authority; it can procure statements only from such institutions as participate in
an Exchequer grant. The hospital schools and non-participating endowed institu-
tions conduct their affairs at will, accounting only to themselves. In general, medical
education may be said for many years to have paid its own way. Endowments were
negligible; fees were retained by the teachers, minus such sums as were required for
buildings and unavoidable running expenses. For many years, items coming under
the last-named head were kept down as much as possible, and teaching was impov-
erished and mechanized in consequence, — a fair characterization of the old-fashioned
proprietary regime. Recently, the general government has come to the relief of the
universities with increasing liberality; just now it is turning an interested eye upon
their medical departments. It has even gone so far as to grant a subsidy to some of
the London hospital schools, — an act of misjudged generosity if it tends to strengthen
1 Verband derAerzteDeutschlands zurWahrungihrerwirthschaftlichen Interessen, with headquarters
at Leipzig. The association publishes a journal, Dns AerztUche Vereinsblatt fiir Deutschland.
300 MEDICAL EDUCATION
an obsolescent form of medical education. Hospitals, as such, have relied practically
altogether on private subscriptions and gifts.
As compared with the continental conditions which we have observed, university
expenditure in Great Britain is modest, though now developing with considerable
rupiditv. The several colleges at Oxford and Cambridge are indeed old and rich; but
the scientific institutes belonging to the universities as distinguished from the con-
stituent colleges live on scanty fare. The total income of six universities and the two
constituent colleges of London University, as shown by their return to the Board
of Education in 1908-1909, was as follows:^
Endow-
Local
Exchequer
Institutions
Total Income
Fees
ments
Gifts
Grants
Grants
Misc.
£
£
£
£
£
£
£
University of Birmingham
0+.362
17,176
8,462
1,344
£7,081
15,070
5,229
Bristol
14,9+6
6,636
411
1,419
770
4,918
792
Leeds
56,563
14,641
7,183
2,285
15,522
15,167
1,765
Liverpool
72,599
19,721
16,198
4,863
14,350
16,132
1,334
Manchester
80,124
25,141
24,938
2,900
5,250
19,034
2,861
Sheffield
41,010
6,722
3.770
1,522
16,112
11,505
1,379
University College
55,867
23,686
11,066
3,421
1,960
11,250
4,485
King's College
49,394
26,387
1,582
4,473
4,171
9,704
3,077
It is evident from the above table that endowing of universities by the rich and
noble has had little more development in England than in Germany. The sense of
public obligation appears, however, to be forming in the provincial towns. The suc-
cessful man is loyal to the birthplace that he left in order to make his way in the
metropolis or across the water in the colonies ; handsome laboratories at Liverpool,
^lanchester, and Birmingham testify to the genuineness and increasing strength of
this sentiment. But more significant far, in view of British tradition, is the relation
l)etween income derived from endowment and income contributed by governmental
grant, municipal or national. The eight institutions in question received from pro-
ductive endowment in 1908-1909, sums varying from 2.7 per cent at Bristol to 31.1
per cent at Manchester; they averaged 14.6 per cent. During the same year, their
receipts in the form of municipal grants ran from 3.5 per cent at University Col-
lege to 39.3 per cent at Sheffield; in the form of treasury grants from 19.6 per
cent at King''s College to 33 ])ercent at Bristol; the local grants averaged 15.4 per
cent of total income, the Exchequer grants, 25.2 per cent. Both local and treasury
grants already exceed in importance income from invested funds, the treasury grants
ver>' markedly. Moreover, these last-named subventions have advanced with highly
significant liberality. In 1889, the total government grant in aid of university colleges
in Great Britain w'as £15,000, in 1902, £27,000, in 1909-1910, £99,100;' in eight
years the subvention increased 367 per cent. These figures indicate nothing less than
a right-about face in the national attitude towards higher education, in keeping with
1 Board of Edurntion: Reports from Universities and Unirersity Colleges, pp. xiv, xv (London, 1910).
Fuller information will be contained in the forthcoming Report.
FINANCIAL ASPECTS OF MEDICAL EDUCATION
301
the same policy already remarked in connection with secondary education. It is to be
noted, further, that while the government exacts a statement from the institutions
assisted, it does not interfere with their internal management. The Scottish and
English universities enjoy, therefore, practically untrammeled freedom in working out
pedagogic problems.
The Scottish universities make the following showing in 1907-1908 as contrasted
with 1894—1895, in reference to the significant items: ^
Institutions
Total Income
Fees
Endowments
Local Grant
Parliamentary
Grant
No. of Students
1894-5 1907-8
1894-5
1907-8
1894-5
1907-8
1894-5
1907-8
1894-5
1907-8
1894-5
1907-8
St. Andrew's
£
15,836
£
28,882
£
2,745
£
6,547
£
5,231
£
10,047
£
£
4,500
£
7,800
£
6,300
261
548
Glasgow
55,094
76,587
22,799
39,333
10,860
14,973
8,700
8,700
12,180
12,180
1,941.
2,557
Aberdeen
31,367
42,705
10,605
16,185
6,100
8,387
6,000
6,000
8,400
8,400
789
932
Edinburgh
72,050
93,085
35,783
49,660
9,979
13,374
10,300
10,800
15,070
15,070
2,939
3,292
The ratio of income from endo^\^nent to total income has remained almost un-
changed during the thirteen years in question; grants have decidedly decreased in
relative importance. The parliamentary subvention to St. Andrew's represented, in
1894-1895, 49.3 per cent of its income, in 1907-1908, only 21.8 per cent; at Glas-
gow, the percentage has dropped from 22.1 to 15.9; at Aberdeen, from 26.7 to 19.7;
at Edinburgh, from 20.9 to 16.2. Tuition fees, on the other hand, play a distinctly
more important role: 17.3 per cent at Aberdeen in 1894-1895, 22.7 per cent in
1907-1908; 41.4 per cent, 51.4 per cent, at Glasgow; 33.8 per cent, 37.9 per cent, at
Aberdeen; 49.7 per cent, 53.3 per cent, at Edinburgh, The outlay per student could
obviously fluctuate but little under these circumstances within a single institution,
though varying greatly among them :
Average Outlay per Student
1894-1895
1907-1908
St. Andrew's
£58
6 s. 4d
£51
'2s. 4d.
Glasgow
28
0 1
29
19 0
Aberdeen
39
10 1
43
12 4
Edinburgh
25
0 7
27
13 10
The medical budgets of the universities — Scotch and provincial — concern mainly
the laboratory branches. The universities incur little expense for clinical instruction
beyond the payment of salaries to professors of medicine and surgery. In some of the
Scotch universities the salaries are quite considerable. At Edinburgh, the chair of
pathology cairies a salary of £1400, that of materia medica, £1290; medicine andsur-
gery, £900 each ; midwifery, legal medical medicine, and clinical surgery, £800 apiece :
certain of the incumbents receive as much as £200 each additional for other teach-
^ Report of Committee on Scoff'ish Universities, pp. 41, 42 (London, 1910).
sot
MEDICAL EDUCATION
jiig services. Of a total outlay of £31,447 on the department, £4270 suffice for up-
keep, laboratory, and class expenses, as against £23,263 for salaries. At Glasgow, the
professors of medicine and surgery receive each £800 annually; second professorships
recently established carry with them a salary of £500 apiece. A further expenditure of
£500 is incurred for assistants to the four chairs. The laboratory expense in medicine
is practically nil; in surgerv,£300, including wages. Clearly, little systematic provision
or appropriation is made by hospital or university for laboratories beyond what the
routine conduct of the hospital itself requires. Small sums are donated now by a staff
member interested in some line of work or instruction, now by the hospital, with-
out attempting strictly to discriminate between hospital and school charges. In this
respect, the clinical situation of the universities is not in essence different from that
existing in the hospital schools, shortly to be described.
On the laboratory side the following tables show the expenditure of seven institu-
1
lions .
Anatomy'
Dept. Maintenance (icages
Institution
Total Outlay
Prof, cfc Teaching Assts.
and laboratory expense)
£
£
£
Birmingham
1,444.
11,165
279
Liverpool
1,256
977
279
Manchester
1,406
1,211
275
Sheffield
710
558
1S4
University College (London)
1,216
1,057
159
King's College (London)
998
793
204
University College (Dundee)
757
600
157
Glasgow
2,94^2
Physiology
2,560
385
£
£
£
Birmingham
965
756
208
Liverj>ool
1,259
1,094
433
Manchester
1,428
1,077
350
Sheffield
828
543
219
University College (London)
2,121
1,745
376
King's College (London)
1,225
954
270
University College (Dundee)
670
500
170
Glasgow
2,576
Pathology
2,100
476
£
£
£
Birmingham
2,107
1,494
613
Liverpool
1,705
1,265
440
Manchester
1,516
1,100
416
Sheffield*
1,217
750
383
Glasgow *
2,010
1,725
285
From li^prirt of Board of ^duration above quoted, passim. In case teaching and maintenance do not
quite equal outlay, the balance represents exceptional expenditure.
* Not including official residence. Professor's salary, X'1200.
' Including bacteriology.
♦ To this should he added an item of £750 for the second professor and assistant maintained by the
university at the Royal Infirmary.
FINANCIAL ASPECTS OF MEDICAL EDUCATION 303
Properly speaking, the three university colleges have no pathological departments,
but utilize the pathological departments of the hospital with which they are respec-
tively affiliated. Their pathological instruction is therefore on much the same footing
as their clinical teaching.
The most costly departments of anatomy and physiology are found at Edinburgh,
where of course the number of students calls for enlarged outlay. The stipends of the
teaching staff, with other items of expense, appear in the following table:
Total
£
Professor's Salary
£
Asst.
£
Lab. Exp.
£
Museum
£
Spec. Grants
£
Anatomy-
Physiology
3278
3242
1600
1400
915
800
330
700
231
182
342
Other laboratory branches are too occasional for classification. Bacteriology and
parasitology,^ forming an independent department, are found at Liverpool (outlay
£992), Cambridge (outlay £1549), Manchester (outlay £1000), University College,
London (outlay £846), and King's College (£840). Pharmacological laboratories are
found at three institutions, — University College, London, where £679 are annually
expended; King's College (expenditure £264); and Cambridge (expenditure £250).^
Tropical medicine' is adequately represented as a department only at Liverpool on
an outlay of £931 yearly, where, too, bio-chemistry forms an independent department,
enjoying a budget of £973.
The outlay of the reporting universities for clinical teaching is little more than
nominal, as the following schedule indicates; probably the whole of it goes into salaries:
Institution
Medicine
£
Surgery
£
Oper.
Surgery
£
Midmf. <&
Gynecol.
£
Psych
£
Ophth.
£
Birmingham
Liverpool
Manchester
105
143
648
105
245
105
30
58
112
264*
62
18
26
25
18
25
15
Bristol and Leeds do not attempt to tabulate or classify their expenditures for medi-
cal education: the former reports an aggregate outlay of £2330, of which £1878
represent salaries; the latter of £3368, of which £2562 represent salaries.
The figures just reviewed confirm our previous characterization of British condi-
tions. The clinical teaching of the universities is not university clinical teaching: it
cannot be until the universities supply the cash nexus. Nor is it of modern clinical
type: for it requires no material but sick persons, — not laboratories, scientific assist-
ants, animals, etc.
On the other hand, the laboratory development is at once uneven and predomi-
1 These departments vary considerably in object, sometimes being pubHc health estabhshments (Man-
chester, for example), sometimes pure teaching and research institutes (Cambridge, for example).
The earnings of the public health departments are used to expand them.
2 Plus special grants made by Royal Society, Grocers' Company, etc.
3 For independent schools of tropical medicine see page 322.
* Of which £40 is for laboratory expense.
304 MEDICAL EDUCATION
natelv undcrfn"atluate. Anatomy and physiology are the only two branches organized
on a university basis in all the reporting schools. Pathology is similarly represented
in but four; it is little more than a dead-house department in most others.^ llie ratio
Ijetween total ex{wnse and laboratory expense betokens the precarious state of re-
search : in anatomy, 81 per cent of the total outlay goes into salaries, the remaining
19 per cent discharging the cost of material, wages, and other laboratory items; in
physiology, as we should have expected, laboratory maintenance consumes a relatively
larger share, 24 per cent as against 76 per cent for salaries. Sherrington at Liverpool
sj^nds 34 per cent of his budget on laboratory maintenance.
On the financial sheets of the London hospital schools a hopeless struggle against
overwhelming odds is depicted. Income is falling at a time when unavoidable expendi-
ture is as steadily rising: from which in education, as in business, only bankruptcy
can result. It is, however, idle to suppose that all would be well if attendance were
large and growing. Endowinents, government grants, and student fees combined do
not, even in the provincial and Scottish universities, sustain more than a few de])art-
ments in acceptable shape. Some departments are wholly omitted, and hardly any-
where is allowance made for research; the clinical situation has as yet hardly been
touched. A lavsxe student enrolment would not alone alter the situation of the London
schools. Thev would still recjuire large sums, of the bestowal of which there is little
indication. Sir Donald Currie's generous donation of £100,000 to the University Col-
lege Hospital School is unique: and of this sum thi*ee-fourths was put into a build-
ing, only one-fourth left as the nucleus of a permanent sum. Guy's has lately come
into possession of £8000, the income from which is to be devoted to pathology. Occa-
sional sums have been also obtained to wipe out accumulated deficits or to enable
the smaller schools to continue awhile longer their hand-to-mouth existence. This is
practically all. And for good reason : educational endowments may greatly increase
in Great Britain without essentially benefitting the hospital schools. For the hospital
school is a private affair, in which the staff is enormously more interested than the
public. Such enterprises appeal hardly at all to benefactors seeking to advance the
general good. For the same reason, little is to be hoped from the government, despite
a hesitating step or two in the direction of aid to these essentially private ventures.
If, now, the London schools are to fight it out with fees, their prospect is indeed
gloomy. The most prosperous of them are in receipt of total incomes of from £10,000
to £12,000 annually; those with dental annexes receive a third more, the surplus
of the dental department being used in carrying the me<lical. Four or five schools of
me<lium siz^ obtain total incomes of from £4000 to £5000 yearly. The total receipts
of the others are too small to speak of The larger sums mentioned are required to
meet all the expense connected with the instruction of some 300 students. Approxi-
mately one-half of the gross receipts is paid out in salaries; one-quarter goes for rent,
I From this stAtcmcnt separately supported work, such as is in progress at University College or Guy's,
is. fif course, excepted.
FINANCIAL ASPECTS OF MEDICAL EDUCATION 305
rates, taxes, interest; the remaining quarter pays wages, equipment, laboratory mate-
rials, prizes, etc. The salaries are mainly those of the instructors in the underlying
sciences, — anatomy and physiology, especially, — ranging from £200 to £400. These
entirely inadequate pittances have failed to hold in London the more competent
teachers developed there. The current flows from London to the provinces and Scot-
land, not vice versa : London physiologists have migrated to Oxford, Cambridge,
Liverpool, Edinburgh, Montreal, and Toronto; London anatomists to Birmingham;
a London pathologist to Cambridge. The clinical teachers receive little or nothing;
but the diversion of pay from them to the scientific teachers has not sufficed to meet
the need, for the total available is simply inadequate. Nevertheless, this diversion has
well-nigh robbed medical teaching in London of its direct profits : only a few schools
still pay the clinicians a dividend, — a mere honorarium, even then. One school, that
was within the memory of men still alive worth £1000 to each lecturer, now returns
a paltry 50 guineas.
As the entire fund available for salaries is in any case too small, it occasions no sur-
prise to find that such laboratories as exist live on very slight sustenance. The pub-
lished statement of one school shows an expenditure of £2000 on salaries, as against
departmental expenses of £28 in physiology, and of £55 in chemistry and physics
together. The business aspect of medical education comes out unpleasantly when one
notes that in this institution, whereas £455 were expended on museum, library, and
all laboratories, £615 were bestowed in prizes, £202 were consumed in advertising,
and £74 were donated to the students'" club. A much larger school spends £9000 in
salaries and wages, £2500 in general expenses, into which laboratory maintenance is
reckoned. Still another, out of total receipts of about £5000, expends £400 on adver-
tising, as against £175 on the laboratories of physiology, chemistry, physics, and
biology : indeed, the allowance for rent of the students' club exceeds the cost of sup-
porting four laboratories. An even more prosperous school spent £300 in excess of
laboratory fees for materials, wages, and expenses in the laboratories as compared Avith
£500 each for prizes and advertising.
In some institutions, part of the burden has been undertaken by the hospital on
the ground that the school connection is valuable enough to pay for. As a rule, the
title to the school property is in the hospital board. Money has been advanced from
hospital funds to put up school buildings, on which sum the school pays an annual
interest charge. In addition, the school uses the hospital dead-house and clinical
laboratory without charge, both parties contributing to the salaries of pathologist
and bacteriologist. Finally, certain hospitals have made their schools annual grants,
occasionally of large sums: within the last five years, one of the smaller schools has
received from its hospital annual sums running from about £300 to almost £1500.
In 1905,^ the Fry Committee reported that in the case of King's, L^niversity, the
1 Report of Committee appointed to inquire into Relation of Hospital and Medical Schools in London
for King Edward Hospital Fund (London, 1905).
a06 MEDICAL EDUCATION
Roval Free, and Guy's, the services of school and hospital fairly canceled each other;
the other schools hjul been assisted out of hospital funds, the London Hospital School
to the extent of £2500, Middlesex £701, St. Bartholomew's £1122, St. Mary^s £652,
St. Thomas's £788. If the recommendation of the Commission results in less informal
relations, the tether of the hospitixl school wiU. be still further shortened.
Meanwhile, the British hospitals have been liberally sustained. Their resources,
whether gifts, subscriptions, or investments, all represent at bottom voluntary dona-
tions. In the year 1907, the twelve London hospitals used for medical teaching had
a total ordinary income of £4'21,312; the twelve provincial hospitals similarly em-
ploved, a total income of £193,193; five Scotch school hospitals,^ £116,085. Lega-
cies of considerable size simultaneously swelled their permanent resources. In the
following table the main items have been arranged:^
Annual Share King's Invest-
Subscript. Donations Hospital Fund ment Total Legacies
12 London Medical School £ £ £ £ £ £
Hospitals 42,408 59,639 36,000 228,558 421,312 242,334
12 Provincial Medical School
Hospitals 51,650 18,239 62,223 193,193 27,072
5 Scotch Medical School In-
firmaries 32,508 8,471 33,087 116,085 55,583
With the exception of contributions to the schools as above noted in London,
and perhaps of a similar nature elsewhere, these sums are entirely used in immediate
ministrations to the sick.
London, then, may be viewed as the final and complete demonstration of the im-
possibility of teaching medicine out of fees. St. Thomas's calls attention to the fact
that it has to teach the same number of medical students as Victoria University, Man-
chester: whereas at Manchester student fees form onlv 50 per cent of the cost of the
department, St. Thomas"'s must make its fees cover all expenses.^ Unquestionably,
consolidation of several small departments would improve matters; and if, as has
been urged, such concentration involved total surrender of all laboratory instruction
to London University, the situation in the metropolis might thus become at least
as good as that in the provinces and Scotland. But if, meanwhile, clinical instmc-
tion remains where it now is, England will still lack a complete and modern medical
school.
The effort to keep insufficiently endowed schools above water has led to a steady
increase of tuition fees, which have thus doubled in the last half century. About 1870,
the total cost of an education at St. Bartholomew's was 95 guineas; in 1880, 132;
at present, 180. The smaller metropolitan and the provincial schools are slightly
chca{)er, Liverpool costing about £150. The expense varies somewhat with the choice
of the qualifying agencies: it costs perhaps £10 less to prepare for the Conjoint Board
' Infirmaries, so-called. 2 Burdett : Hospitals and Charities, 1909, p. 172.
* Pamphlet issued by school, p. 34.
FINANCIAL ASPECTS OF MEDICAL EDUCATION 307
diploma than for a university degree. Scotland has not yet adopted the composition
or combined fee: at Edinburgh, the sum total of separate fees amounts to £162; at the
Extra-Mural School, a candidate for the Triple Board qualification pays about £115
in fees; in Glasgow, matriculation, class, and examination fees for the entire course
leading to the M.B. degree approximate £150. Adding in the expense of living, we
may estimate the total cost involved at £350.
As against this heavy expenditure, the economic prospects of the practitioner
are probably not much better than in Germany. The consultant may achieve a splen-
did financial success; but even then, only after a severe struggle. Sir Andrew Clark is
reported as saying that for ten years he lived on bread, for ten on bread and but-
ter, and finally for ten on bread and jam. The general practitioner is too commonly ill
requited. Even those who remain unconvinced of overcrowding admit "that in certain
places competition becomes too acute with an inevitable cheapening of medical ser-
vice.''^ How the economic outlook of the practitioner will be affected by the recent
insurance legislation remains to be seen. It will be interesting to observe whether,
despite its strongly individualistic leanings. Great Britain may not lead in a more
comprehensive organization of medical service. The suggestion has already been forci-
bly made.^ Whether in any other way efficient medical aid can be brought within the
range of all who need it remains to be proved. Highly significant, meanwhile, are the
facts that, even on the low entrance standard prevalent in Great Britain, the physi-
cian does not go where he cannot be decently supported, and that he makes at least
as high claims in the matter of support as the continental physician trained at
the higher level. In respect to distribution, therefore, the chance to make a living is
the decisive consideration. Where there is no such chance, society must intervene or
medical aid will not be rendered. Assuredly, if society must act in any event, the ser-
vice, in the interest of the pui-pose for which it is maintained, should be brought to a
high educational standard.
1 Sprigge, p. 51. 2 By B. Moore: 'The Daicn of the Health Age.
CHAPTER XIII
SECTS AND QUACKS
Sectarian- medicine is all but unknown in Europe; and this, although the laws nowhere
place the least obstacle in the way of its practice. The state neither favors nor dis-
criminates against any particular school of medicine; a qualified physician may call
himself what he chooses. It makes a single and unifomi stipulation : every legally
qualified physician must comply with the same educational conditions. He must meet
the retiuirements in respect to preliminary general education; he must pass the usual
professional examinations in the basic and medical sciences and in the clinical branches.
That done, he may freely elect the object of his professional allegiance. Significantly
enou"-h, only a negligible fraction prefer a sectarian badge. The incentives to medical
sectarianism appear to vanish if the sectary enjoys no special prerogative.
The homeopath is the only sectarian found at all in Great Britain or on the Con-
tinent. As he is not only prescriber, but also dispenser, of medicine, he is in Germany
required, after qualifying, to pass an examination in dispensing. The commission hav-
ing this examination in charge is composed of a botanist, a chemist, a pharmacolo-
gist, and a practising homeopathist, and sits permanently in Berlin. At present, out
of a total of 30,558 physicians in the empire, 211 physicians designate themselves
as homeopaths.^ During the last twenty years, the annual average of those passing
the special examination above named has been a little below 7; from 1904 to 1910,
inclusive, the totals have been 3, 6, 3, 6, 6, 5, 4, respectively.- Obviously, homeopathy
is a negligible and disappearing quantity in Germany.
The sect fares no better in England, where not even the additional precaution as
to dispensing is taken. Any qualified physician may without further ado announce
himself as homeopath.^ According to the Homeopathic Directory of 1907,* 193 regis-
tered phvsicians in Great Britain and Ireland have chosen to do so, 55 of these being
located in London : assuredly an insignificant fraction of a practising profession that
in the same territory numbers 31,154.^ Nowhere in Europe do special educational
institutions of sectarian character exist. On the Continent, indeed, there are no edu-
cational provisions whatsoever. In London, two brief lecture courses — one on homeo-
pathic materia medica, the other on homeopathic therapeutics — are annually given
at the I^ndon Homeopathic Hospital, an establishment of 170 beds iji Great Ormond
Street. Outside the metropolis, the hospitals of the sect are pathetically meagre: the
Hahnemann Hospital, Liverpool, described as a "general hospital for medical and
' Census, May 1, 1909.
^ Fijcures courteously supplied by Geheirarat Obermedicinalrat Kirchner.
* This holds also of France, where homeopaths are very scarce. Exact figures are not obtainable.
* Inttntalional Ilrmieopathic Mediral Directory (London, 1907).
* This fij^re is arrived at by subtracting from Churchill's total (40,64-2) 9488, who belong to the army,
navy, and other services, or practise "abroad."
SECTS AND QUACKS 309
surgical cases, with special departments for Diseases of Women, Children, Eye, Ear,
Nose, Throat, and Skin," possesses a total of 50 beds; a Birmingham institution,
similarly pretentious, has 38; another in Kent has 18; one at Tunbridge Wells, 20;
one at St. Leonard's-on-Sea, 18. "Smaller hospitals'" are said to exist at Bristol,
Eastbourne, and Leicester.^
The statutory theory on which European countries proceed in dealing with this
subject is unassailable, and the practical outcome thereof inevitable. The sole differ-
ence between sectarian and regular or scientific medicine is in the region of thera-
peutic theory. Now, quite apart from the right and duty of the state to take in such
a matter the standpoint approved by the weightiest authorities, it happens that
therapeutics is only one item out of many, and educationally by no means of over-
shadowing importance at that. The main work of the medical school is its training
in the fundamental sciences, in diagnosis, and in certain urgent practical procedures.
The completer therapeutist is mainly built out subsequently. Without making light
of such therapeutic differences as exist, one cannot for a moment contend that, as
weighed against all the other constituent factors of the medical curriculum and the
medical examination, these differences are bulky enough to warrant a separate ordi-
nance or establishment. Medicine is primarily a question of fact. Treatment depends
first on knowledge of normal conditions, then on the ability to discern and to inter-
pret abnormalities. No matter what abstract principles as to cure one may enter-
tain, the law occupies firm ground in insisting that all physicians must alike satisfy
the single standard set up for the testing of proficiency in matters of essential fact.
The sectarian makes no pretense that his anatomy, physiology, and pathology are
peculiar, or that they involve any less or any different chemistry and physics. So far,
at least, there is as little warrant for a special or sectarian medicine as for a special
or sectarian engineering.
Sound policy suppresses sectarianism without cherishing the least hostility to it.
Nothing else could be expected in an era whose pride is the increasing authority
of science and scientific logic. This position does not imply a complacent view as to
actual achievement. As a matter of fact, despite the positive increase of knowledge,
in no age have men been more acutely and uncomfortably conscious of defect. But
never before have they been so averse to relieving the discomfort of gaps by gratui-
tous intellectual or imaginative vaulting. The scientific mind confesses much igno-
rance, but no mystery. The preconceived notion \vith which the non-scientific mind
spares itself arduous details of investigation and experimentation must prove itself
or be dropped. For what is such a generalization except an alleged fact, to be proved
or disproved, like any other ? Between the practical requirements of the law, demand-
ing compliance with established criteria, and the ceaseless beating of scientific intelli-
gence, requiring that abstract assumptions submit to experimental accounting, the
outlook for sectarian medicine in Europe is entirely and properly hopeless.
"^Homeopathy — Educational Farnlities, 1911 — a pamphlet issued by the London Homeopathic Hospital.
310 MEDICAL EDUCATION
Meanwhile, everywhere the medical charlatan thrives. He has complied M-ith the
law, and is therefore a legally qualified practitioner. Occasionally he is doubtless the
honest victim of his own unbalanced judgment. Having, as he supposes, successfully
relieved what he had adjudged to be cases of Bright's disease, gallstone, appendicitis,
pleurisy, and headache, by cold baths, electrical applications, or what not, in his
incautious enthusiasm he insists that "but one thing is needful."" But the misguided
fanatic answering this description is less common and less formidable than the clever
and insincere charlatan who is too lightly led by the prospect of gain to trade on
credulity and despair. To deprive him of his opportunity to victimize the gullible
portion of the public is indeed a difficult undertaking. The very candor of scientific
medicine gives him his chance, for, just where the scientific physician admits
his inadequacy, the charlatan is most positive. There lurks in many men a lingering
fragment of the primeval fjiith in magic; others still retain, in part at least, the
conception of disease as a just retribution for sin and error. Still others, impressed
by the surprising powers found to reside in electricity, the ultra-violet rays, etc.,
invoke any expedient whose potency is not clearly demarcated or understood in the
hope of encountering some unsuspected efficacy favorable to themselves. What won-
der, then, if, when the physician admits or shows his helplessness, some fly to the
magician, others resort to spurious mysticism, in the attempt to escape from the grip
of phvsical or psychological law, and still others fall into the hands of unscrupulous
practitioners, willing to deal with human beings on the theory that what is not demon-
sti-ably harmful may in obscure cases work some benefit?
The situation in respect to quackery^ is entirely different. In Germany, owing to
the ill-judged action of the medical profession, complete cure-freedom {Kunerfrei-
he'it) now prevails. Up to 1869, special statutory provisions applied to practitioners
of medicine. They paid a tax, were — at the peril of damage suits — required to
attend urgent calls, and were likewise obliged to render certain unrequited services
1 The literature on the subject is enormous, mostly controversial in tone. A fair idea is obtainable
from the following :
IXiJi Preugsijcrhe Medizinal- und Gesundheitsicesen, 188S-1908, pp. 403-465 (Berlin, 1908).
Das (ifjtHmihf'itsxrfsfn ties Preussnsrhen Staatas, 1907, pp. 451, 452; 463-467 (Berlin, 1909).
C. Keissig: Meiininisrhe Wissenschaft und Kurfuscherei (Leipzig, 1900).
Max Rubner: Ueher Volhff e^undheiLtpfle^e (BerV\n,li^99).
Dns Knrfujtrhertum und seine Behimpfunff (Strassburg i. E., 1904).
On the opposite side :
Die Kurifrfrfiheit, ein heiliges Out des Leutsclien Volkes (Berlin, Deutscher Verein der Naturheil-
kundiiren. vMrx).
Also : Publications of the Zentralverband fiir die Paritat der Heilmethoden, etc. (Berlin, E. Ebering).
The progress of the agitation is fully described in the AerztVirhes Vereinsldatt, published in Leipzig.
Truly prophetic is a little pamphlet entitled Die aerztUche Praxisfreiheit und ihre Folgen, by L.Ro-
scnfeld. printed at Tauberbischofsheim in 1872.
I owe sp<-cial acknowledgment to Dr. Gustav Siefart, Charlottenburg-Berlin, for much assistance
in the study of his topic.
The General Medical Council of the United Kingdom published in November, 1908, a valuable
yiput of ih* /aiv* in the Ilrilish Empire ntul Foreign Countries for the Prevention of Medical Practice
hy Other than (^alif^d J'ersont.
SECTS AND QUACKS 311
to the poor. In return, the state suppressed illicit and unlicensed practice. The pro-
fession resented these obligations and attached no value to the compensating protec-
tion. A new statute, passed at their behest, abolished practically all the above-named
stipulations. Medicine was placed on the same legal footing as the trades.^ Nothing
could be required of a doctor that was not required of a plumber; on the other
hand, it was made practically as easy to prescribe drugs as to mend pipes. Special
exactions fell to the ground; and with them, all special prerogative and protection.
The university degree (M.D.), the governmen tally confeiTed title {praktlscher Arzt\
and other official titles were indeed safeguarded. Unwarranted assumption of any
one of them was made a punishable fraud; only a legally qualified physician was
authorized to sign a certificate; finally, the unqualified physician was subject to fine
or imprisonment if he showed a culpable measure of ignorance or unintelligence,
or was stupid enough to be in charge at the moment of a fatal result. But earning
a livelihood by unqualified practice was not in itself a penal offense. The precautions
above specified have proved of little or no protective value. The difficulties in the way
of proof are well-nigh insurmountable. Prosecutions are comparatively infrequent
and rarely successful; the punishments inflicted are not common enough or severe
enough to prove effectual deterrents. The profession, in fact, attached at the time
little weight to this aspect of the affair. Warned as to the possible consequences of
the proposed legislation, they replied that they trusted confidently to the intelligence
of the German people,
Neverwas confidence more disastrously misplaced. Quackery in Germany has reached
unparalleled dimensions. It has become a serious factor in reducing the possible in-
come of the legitimate physician and surgeon; it cloaks immorality and vice. Both
the public and the profession have suffered grievously. Medical practitioners strug-
gling for economic rehabilitation, and social reformers eager to improve moral and
hygienic conditions, are now united in an effort to place more intelligent legislation
on the statute-books. Thev have, however, yet to overcome the bitter opposition of
fanaticism, ignorance, and the strongly intrenched proprietary interest of a highly
lucrative occupation. Unfortunately, too, sympathizers with quackery are often found
in the ranks of the conservative aristocracy.
The evil takes many shapes. In its most specious form, it is hardly distinguishable
from sectarianism. Quasi-scientific schools of healing, exploited by qualified men, are
organized into associations, and have organized their victims along with them. Of
these, the most flourishing are at this moment the nature-healers, who, denouncing
all medication as poisoning, pretend to rely wholly on the normal constituents of the
body: water and air make the regimen which will infallibly restore the diseased
frame to health. Knowledge of anatomy and physiology is held to be superfluous.
""\\Tiere in the world did the deer in the forest learn anatomy.^ — Yet he gets well
1 Under the Geirerheqesetz of June 21, 1869. At first a Prussian law, this was made an imperial regu-
lation on the establishment of the empire.
312 MEDICAL EDLCATION
if out of sorts."^ The association of nature-healers and nature-healed is said to num-
ber 200,000 members. Less highly organized and numerous, but still aggressive and
prosperous, are the practitioners and devotees of occultism, Christian Science, Baun-
schcitism, electricity, — notably blue and green electricity, — all claiming a scientific
basis. IVom these more pretentious forms, quackery tapers off to the sheer madness
of the utterly untrained. Some cure all diseases by vegetarian diet, others by mixed
diet; some with uncooked food, others with a combination of vermicelli and sour
beans; one believes in water, the next in total dryness. The cruder advertise the most
disgusting expedients: dirt and the very excrement of men and animals are vended
as possessing magical curative properties. Though the quack is forbidden to procure
practice by traveling from place to place, he may use the mails and advertise. The
newspapers swarm with announcements of secret remedies. It is said that the annual
turnover through proprietary remedies in Prussia alone exceeds 30,000,000 marks.
Efforts have latterly been made to ascertain the sources from which the army of
quacks is recruited. Among them weavers, stocking-makers, shepherds, barbers, con-
fectioners, and domestics abound. IVIost of them are quite uneducated. Rubner esti-
mates that in Berlin perhaps a fourth of the quacks had progressed as far as Ober'
Urtia in the Gymnasium ; of the female contingent, only one per cent have had a fair
education.^ A Prussian statistic^ of 1900 finds among 1735 male quacks, 258 small
farmers, 587 workmen, 300 tradesmen and artisans, 76 laborers, 35 priests, 99 teachers;
among 669 female cjuacks, there were 49 midwives, 14 masseuses, 15 nurses, and 220
witliout regular calling.
In recent years, governments have interested themselves in ascertaining the extent
to which quackery flourishes. Partial police returns exist as far back as 1879, — ten
years after the inauguration oi Kurierfre'iheit. The growth in Berlin since that time
is more or less correctly reflected in the following figures:
Date
Registered Quacks
Date
Registered Quacks
1S79
28
1897
476
1889
231
1902
976
1894
355
1903
1013
The number of registered quacks increased 1600 per cent,* while the population of
the imperial capital increased 60 per cent. In Prussia, compulsory registration began
in 1902; but it was very imperfectly carried out, as is obvious from the fact that in
188 districts no quac;ksatall are reported; in 1903, 149 districts are still devoid of
quacks, according to police returns. Nevertheless, the registration mounts as follows:®
' Quotfd from Malten's "Medizin und Naturheilkunde," by C. Reissig, in Medizinwche Wissenschaft
und Kur/utchfveu p. 22 (Leipzig', li»(X)).
' V^er Volkjipuuruiheil»pfe</f, p. 10. 3 Communicated by Dr. Siefart.
♦ The fifoires for the earlier period, before registration was made compulsory, are of course too low ; but
an enormous increase in indisputable.
* Iku O'fjiiindheilsrceten des J'reusaUchen Slaates, p. 463 (Berlin, 1909).
SECTS AND QUACKS 313
Date
Registered Quacks
1902
4104-
1903
5148
1904.
5529
Date
Registered Quax:ks
1905
6137
1906
6260
1907
6873
In Saxony, they grew in number from 432 in 1878 to 2112 in 1905; in WUrttem-
berg, from 85 in 1880 to 329 in 1904.^ But the role of unhcensed practitioners is not
exhausted when we reckon those registered as such ; for apothecaries, midwives, and
others often engage in ilKcit and unacknowledged practice.
The conditions just described seriously aggravate the results attributed to over-
crowding of the profession. Saxony, where there is already one doctor for every 2000
persons, registers half as many quacks as doctors ; Prussia, at least one-third. A dozen
years ago, it was estimated^ that one-third of the entire practice of the country was
in the hands of quacks, and since that date the mischief has spread.
Our interest in the topic is, however, educational, not professional. I have gone into
details because the phenomena just described are not infrequently referred to as cast-
ing grave suspicion on the wisdom of the high standard maintained by the German
government in the matter of medical education; just as if the extraordinary devel-
opment of quackery were a compulsory adjustment, — a spontaneous outgrowth to
occupy a gap left by the enforced depletion of the medical profession.
As a matter of fact, the two phenomena stand in no causal relation whatever.
Quackery originated in thoughtless legislation designed to relieve the medical man
of certain responsibilities and hardships ; ignorance and unscrupulousness were quick
to take advantage of the opening thus made. Education had nothing to do with it at
the time, and has had nothing to do with it since. Doctors were much scarcer in 1869
than in 1899, and general health was inferior. Yet there were few quacks and no
fear of them at the former date, while there were thousands at the latter. The pro-
fession had meanwhile increased in numbers far more rapidly than population. When
the rise in quackery coincides with progressive overcrowding of the profession, how
is it possible to explain it as due to depletion of the profession by a high educa-
tional standard ? German quackery is the result of vicious and ill-considered laws.
Precisely as abolition of laws against theft will create thieves, so abolition of laws
against unqualified practice produced, and will anywhere produce, quacks.
These general considerations become even more convincing in the light of the fact
that quacks and doctors are alike most abundant in large and prosperous communi-
ties. If the quack invaded chiefly locations abandoned as too unpromising by quali-
fied practitioners, it might plausibly be argued that local need due to a too prolonged
or expensive education gives him his opening. But such is not the case. The neigh-
borhood that cannot support a physician possesses no attractions for the quack. His
fees are amazingly large,^ and his methods the more expensive because long drawn
1 For these figures I am indebted to Dr. Siefart. ^ Rubner, p. 7,
3 See Reissig, pp. 71, 104-107.
3u MEDICAL EDUCATION
out. He prefers, therefore, to fish in the rushing waters of big towTis. Berlin, with 3584
physicians, registers 1349 quacks. Other towns show the following:^
DUsseldorf 2-U Koln 22T
Hildesheim
108
Breslau 229 Cassel 116
Stralsund
51
entii-e districts, the following table shows
their relative status:'*
District Fhvsicians
Quacks
Kdnigsberg 4-20
33
Frankfort 395
3T6
Potsdam 1189
333
Schleswig 805
409
Hanover 435
98
Wiesbaden 1020
142
Sigmaringen 27
1
Obviously, quacks are very unevenly distributed, the ratios varying enormously:
in the province of Saxony, for example, 51 for 100 doctors; in Hessen, 18 for every
100. In the district of Frankfort, 90 quacks to 100 doctors; in that of Sigmaringen,
3. But so much at least is certain: quacks and doctoi-s tend to be plentiful together.
In some instances, doctors are more and quacks less plentiful; in a few others, quacks
are more and doctors less plentiful. But nowhere are quacks common where doctors
are scanty. The sole exception would appear to be occasionally some remote district
incapable of supporting either a qualified physician or a fairly intelligent quack.
There the deluded peasantry may be imposed on by a farm hand or a shepherd pre-
tending to heal wounds, mend limbs, and exorcise disease by crude charms or equally
crude medication. One sees in the clinics of the adjacent towns the havoc that re-
sults. But here again the law, not education, is to blame. Competent physicians can-
not there earn a livelihood. Under these circumstances, decent laws should prevent
imposition that is far more disastrous than temporary neglect; for in the absence of
the quack, the unfortunate peasant, after simply enduring for a while, would betake
himself to a qualified practitioner in a neighboring town.^
But still stronger proof that quackery and education are unrelated phenomena is
forthcoming. If Germany's high educational standard produces quackery, England's
low educational standard should prevent it. The two countries are fortunately com-
paral)le Ijecause they disagree only in respect to the single factor whose alleged part
in the causation of quackery we are concerned to investigate. Their statutes on the
subject are substantially the same; but the countries differ widely in regard to the
educational prerequisite to medical study. Quackery flourishes in both. Is the com-
mon phenomenon to be causally attnbuted to the factor as to which they differ, viz.,
* f^ftutulheit$we$«n, p. WS. ^ Ihid., p. 4fi5.
' The Austrian law is far suj>erior to that of the German Empire. It makes unqualified practice for
the sake of earning a livclihootl a punishable offense ; but as the police must initiate measures, prose-
cution lags. Moreover, proof is not easy, for habitual offense is not readily demonstrated. Patient
and quack insist that gifts were made rather than fees paid, in which event no crime has been com-
mitted.
SECTS AND QUACKS 315
the general educational requirement, or to the factor as to which they agree, viz., the
law? The common factor — and, luckily for this inquiry, the only prominent com-
mon factor — is obviously the causal agent. The factors as to which the two countries
disagree — educational standard, for instance — may be cast out as without responsi-
bility. The high standard of Germany does not itself produce quackery; neither does
the low standard of Great Britain prevent it: in both countries the law that permits
it causes it.
The English situation is thus not essentially dissimilar from that which we have
just surveyed in Germany. The Medical Act of 1858 established the General Medi-
cal Council, charged with the duty of keeping a list of qualified physicians. It be-
came the business of the Council to maintain the Medical Register for the informa-
tion of "persons requiring medical aid," in order that they might "distinguish quali-
fied from unqualified practitioners." The existence of such a directory was supposed
to be enough : of course it would be used. As a matter of fact, the Medical Register
makes a volume of something more than 1700 pages, not found in every household.
The Englishman does not consult its pages before intrusting his health to a clever
charlatan, any more than the German dupe protects himself by requiring proof of
university training. In both countries negative protection has completely failed.
And negative protection is practically all that either country provides. The Eng-
lish law runs along much the same lines as the German : the state recognizes only the
qualified practitioner; he alone can sign a death certificate, give medical evidence in
a suit at law, or sue for fees. But any person at all may give or sell medical advice;
one is simply forbidden, under pain of a fine "not exceeding twenty pounds," to pre-
tend to be registered or to pretend to possess a registerable title. As long as a quack
avoids assumption of one of the definitely established titles, he may with impunity
use any other specious or misleading description that ingenuity can devise. A re-
markable inconsistency may be pointed out in passing: the British anti-vivisection
laws stipulate that license to experiment upon lower animals can be procured only
by properly qualified scientists and under severe restrictions; but medical and sur-
gical interference may be practised upon human beings without evidence as to train-
ing, competency, or skill, provided only the practitioner do not assume an unearned
title.
Lack of a registerable qualification is in Great Britain, as in Germany, much more
than offset by unbridled license in advertising. The hypochondriacal, the hysteri-
cal, the superstitious, the hopelessly ill, and the merely ignorant and foolish make
a numerous, varied, and uncritical constituency, to which the newspapers, the bill-
boards, and the 'bus give the charlatan easy and continuous access. There is profound
truth in Lewis CaiToll's line, "What I tell you three times is true." Midwives, op-
ticians, nurses, prescribing chemists, and manufacturers swell the army of iterating
impostors. In the absence of the police registration, lately introduced into Germany,
it is impossible to make n'mierical statements as to the British quacks. But a few
316 MEDICAL EDUCATION
straws will show how the wind blows. In 1894-1895, 31,592 licenses, at five shillings
apiece, were issued for the sale or manufacture of proprietary remedies; a decade
later (1904--1905), this number had increased to 40,734, — a gain of almost 30 per
cent. A stamp dutv — for revenue, not for suppression of the traffic — yielded in 18C0,
£43,366; in 1880," £135,366; in 1900, £288,827; in 1906, £324,1 12.^ A recent blue-
book issued by the Privy Council Office, tabulating opinions gathered from more
than 1600 ^Medical Officers of Health in the United Kingdom, leaves no doubt what-
ever that unlicensed practice is vicious, widespread, and utterly unscrupulous.^ It
takes everywhere the same forms: the titles in most frequent use are herbalist, bone-
setter, faith-healer, nature-healer; abortion, venereal disease, consumption, hernia,
and cancer furnish the most common and profitable field for exploitation. "Heavy
fees are usually charged,"" remarks the government report.^
France has a better law than either Germany or Great Britain, but it is not en-
forced. Practice is limited to those holding the university degree and the few surviv-
ing holders of the diploma of "officier de sante." Anj other individual habitually
or continuouslv undertaking to treat disease is liable in the first instance to fine, and
for repetition of the offense to imprisonment. Usurpation of the doctor's title con-
stitutes a still more serious breach. The law is thus sufficiently explicit and rigorous;
but magistrates enforce it so leniently that it is in many places a dead letter.*
It is idle to pursue the subject further. The roots of quackery penetrate deep. Its
complete extirpation need not at this moment concern us; in the first place, because
some of it is intra-professional and thus escapes prosecution; in the second, because
some of it burrows underground and thus escapes detection. But the bulk of it is
certainly preventable. Effective legislation, making successful prosecution feasible,
has been proposed by the associated physicians of both Germany and Great Britain.
No interference with sound educational conditions is needed in order to render this
legislation safely enforceable. On the contrary, Avith quackery suppressed, the pro-
fession will offer better sustenance to the well-trained practitioner. Quackery is no-
where due to lack of doctors. Doctors are indeed not lacking in either country, —
especially not in the places that quackery finds most profitable. But by reducing the
clientele of the honest practitioner, charlatanism and quackery, if unchecked, tend to
impair the efficiency of the qualified profession.
* W. E. Dixon : " Proprietary, Patent and Secret Medicines," Proceedings of the Royal Society of Medi-
cine, London, 1910, iii (Therapeutic and Pharmaceutical Section), p. 88.
' R*pfjrt as to Practice of Medicine ami Surgery by Uruiualified Persons in the United Kingdom (LondoQ»
1910).
» Ihul.,^. 20.
* The subject is fully dis<-ussed by Brouardel : U Exercise de la Midecine et le charlatanisme (Pa.ris, 1899)»
The volume also contains all the statutes bearing on practice, license, etc.
CHAPTER XIV
POSTGRADUATE EDUCATION
As distinguished from research, which is intensive and original in character, post-
graduate instruction is practical in object and outlook. It wants to be helpful to prac-
titioners of several types: to the busy urban physician and surgeon, in constant dan-
ger of losing touch with progressive developments; to those who lack the broadening
and stimulating connection with a public clinic by reason of a hospital system that,
despite its heavily predominating advantages, nevertheless has the defects of its vir-
tues; finally, to those who, dwelling remote from centres of activity, are in danger
of stagnation. How much postgraduate instruction can accomplish for any one person
is largely dependent upon the quality of his original medical training. For postgrad-
uate courses are, as we shall see, brief, and recur for most individuals only at some-
what lengthy intervals. Whether a practising physician, torn from his routine occu-
pations, will profit by a two weeks' course in new methods of phvsical diagnosis,
serology, or vaccine therapy, his previous training and intelligence decide. For the ill-
trained man such instruction is hardly more than an exhibition of technical tricks,
which he lacks apperceptive basis to comprehend or skill to apply. WTiat he carries
away will be superficial, mechanical, and perhaps perilous. On the other hand, men
whose training has been scientific in spirit may gain much by an occasional dip into
deep waters. The general quality of German medical instiniction and the strong
national predilection to scientific ideas gives postgraduate instruction of the right
types an exceptionally favorable opportunity in Germany.
Occasional instruction of postgraduate character has long been in vogue. Prac-
titioners have always visited and been welcome in the wards of the Paris hospitals,
and in the great amphitheatres of Berlin, Munich, Leipzig, and Vienna. In the Ger-
man universities, the extraordinarii, laboratory heads, and docents have also long
been in the way of giving courses to foreign students applying for instruction on
special points. But several circumstances have now combined to recommend more
effective systematization, — among them, the ease and frequency of traveling, and
the increase of pedagogic opportunity by reason of the rapid development of diag-
nostic and therapeutic art.
Various forms of organization are ob\iously feasible : postgraduate instruction may
be made one of the functions of every local medical society, — utilizing native talent
and local material, and on occasion importing the more prominent men within reach;
it may take the shape of extension or vacation courses for physicians in the labora-
tories and clinics of the universities; finally, selected hospitals may be made centres
of more or less regular instruction.
These various devices are all employed in Germany. A far-reaching but as yet im-
perfectly developed project for postgraduate instruction has been worked out by a
818 MEDICAL EDUCATION
voluntnrv organization, known as the Central Committee for Postgraduate Medical
Edumtion, established in 1900. The Prussian government lends its indorsement to
the enterprise, and has assisted in a limited way with funds. Chiefly with private
subscriptions, an attractive home has been erected, — the Kaiserin Friedrich Haus —
provided with lecture halls, exhibit rooms, and loan collections, available for use in
anv part of the empire. The Central Committee holds that professional enlighten-
ment, as a rule, must be effected without interference with the practitioner's routine,
because most men cannot frequently drop their work in order to repair to Berlin or
Diisseldorf for concentrated courses occupying several weeks. For those compelled to
remain at home, the Committee initiates local courses, free of charge, conducted partly
by local men, partly by lecturers from adjoining towns, both university and non-uni-
versity. The courses take different shapes, being now weekly addresses on non-related
topics given by successive lecturers, and again, weekly clinics held by different indi-
viduals; sometimes a series confines itself to one field; at times, practical courses are
instituted requiring two or three hours weekly, and lasting from two to three months.
At present, gratuitous courses thus arranged by the Central Committee are held in
forty -eight of the larger cities of the German Empire. The lectures cover a wide range
of topics and enjoy a fair degree of popularity. A clinical course given at Aachen in
four different hospitals had an average attendance of 28; a winter course, laboratory
and clinical combined, of seven exercises at Altona was attended by 63 physicians;
in the summer of 1908, nineteen lectures at Berlin were attended by a total of 563.^ In
some places — Berlin, for instance — both university and non-university lecturers
participate; in others — Bonn, Greifswald, Halle, Gottingen — the instructors are
well-nigh wholly university teachers.
Side by side with the body just described, a distinctively university organization
has growTi up in the Association of Docents at Berlin.^ Vacation courses, four weeks
in length, are offered at the university twice yearly. They touch all topics likely to
interest the practitioner, and are systematically arranged: the spring course in 1910
offered fourteen exercises in pathology, which took up the better part of every day for
the appointed period, including autopsy work, regional pathology, surgical diag-
nostic, etc. ; six exercises in physiology and pharmacology touched on clinical physi-
ology, nutrition, calorimetry; thirteen in bacteriology included serum diagnosis of
syphilis, immunity, etc.; internal medicine was presented generally, and in such sub-
diNisions as the diseases of the heart and lungs, of the digestive and urinary tracts,
and clinical laboratory exercises. Pediatrics, surgery, obstetrics, and other branches
were similarly treated. These courses, for which fees are charged, differ from those
^ Rfirhtniunchwu fiir dn» drztliche Forfhildungg^opgen, Jahresberlrht 1908-1009, Naumburj? a. S. Further
details can be obtained from the publications of the organization, distributed from the Kaiserin Fricd-
rirh Haus, Luisenplatz, Berlin. A succinct account is given by Professor R. Kutner, Director of the
Ijaus. in .ymiuinuche Anslalten auf dem Oehiete der Volksgesundhe'Uspflege in Preussen, pp. 13-2-159
2 For details, see J. Pof^el: J «rzte/fihrer durch Berlin (published by H. Caspari), or Das Medizinische
B*rUn (published by S. Karger).
POSTGRADUATE EDUCATION 319
previously described in being concentrated so as to engage a large share of the time
of the participants, and in expecting the attendance of non-residents.^
The academies of practical medicine at Koln and Diisseldorf were intended to
embody a somewhat different conception. Fault having been freely found by the
practising profession with the too theoretical instruction offered by the university,
AlthofF undertook to supplement university education by utilizing for instruction
the clinical opportunities of great non-university towns, and perhaps also to diminish
the overwhelming predominance of the medical faculties through the creation of non-
university academies. The scheme appears not to have been completely thought out ;
and its author's resignation and death left it in a somewhat uncertain position. As the
matter now stands, the government has made an arrangement with the municipali-
ties of Koln and Diisseldorf, whereby the city hospitals of both are accredited teach-
ing institutions of postgraduate character, the staffs receiving the honorary title of
professor. Extension courses are conducted for the benefit of local physicians through
the winter: some of these are practical and special, running from one to two weeks;
others are weekly lectures on miscellaneous topics, attended by perhaps seventy-five
physicians dwelling in the city and its vicinity. Practically, the academies are now
covering in two cities the field undertaken by the Central Committee, except that
the teachers are identified with but one hospital in each, possess nominal professorial
titles, and present the appearance of an organized teaching body.
Thus far, however, the academies^ have hardly justified their separate establishment.
The local profession begrudges the hospital staff the additional importance it thus
acquires; the university is distrustful of a possible competitor. Meanwhile, the muni-
cipal hospitals of these prosperous towns are, in construction, equipment, and organi-
zation, essentially university clinics. Their pathological departments are admirably or-
ganized and manned; the laboratories attached to the clinics are excellently equipped
for both teaching and research. Those attached to the institution enjoy thus splendid
opportunities; I have already pointed out that university chairs are not infrequently
filled with men whose reputation has been made in these city institutions. The utili-
zation of their facilities for the training of internes and the upbuilding of the local
profession is all the more necessary just because their effective organization results
in shutting out the bulk of the local profession. Even though no other academies be
organized, the great municipal hospital can be made to count in the life of the entire
medical body, on the lines favored by the Central Committee above mentioned.
In addition to these formal, though still imperfectly developed, opportunities of post-
graduate character, the informal and unorganized opportunities already mentioned
have not disappeared; they still constitute, perhaps, the most important part of the
continuation work. Hospitals and laboratories generally are all potential workshops;
a competent individual desiring opportunity can always obtain it. At every univer-
^ A descriptive pamphlet is issued twice yearly by the Dozenten -Vereinigung at Berlin.
" See in Med. Anstalten, etc., a.ticle by Brugger, pp. 159-183.
320 MEDICAI. EDUCATION
sitv, younger instructors, assistants, etc., eagerly embrace the chance to give such
special instruction as may be called for. Supply speedily responds to demand. Short
courses of almost every description can be arranged by consultation ; those in com-
mon demand are regularly announced. Especially at Berlin and\'ienna, to some extent
at Leipzig and Munich, there is great activity in this direction. It is the main support
of many docents and assistants, and constitutes the " foreign study " of most of the
foreigners who for brief periods frequent the continental universities. The classes are
usually limited to ten ; at Vienna, they run five weeks, and are held at one or another
of twenty-six different institutions.^ Some instructors enjoy international repute for
their skill in hitting off the needs and preferences of the foreign sojourner; native
students are rarely found in their classes. The actual value of the instruction is very
uneven. I attended a popular clinical course of this sort in Vienna. The instructor
shows and discusses one case a day ; his auditors are seated about the bed, only rarely
verifying his pronouncement as to the condition of heart, lungs, tongue, or pupil;
none participate actively. In Berlin, I observed similar classes in pathology and
serology: all the students were foreigners, and the instruction elementary enough to
amuse the docent who, with great skill, vigor, and intelligence, was doing precisely
what his little band of transients had paid for. Serious study in the great clinics and
laboratories of the Continent makes indeed a memorable experience in a physician's
life history. But students who are ignorant of the language, or whose original train-
ing has been inferior, get no contact with what is characteristic or valuable in con-
tinental medicine.
An independent organization, the Vienna Policlinic, merits a word at this point.
Certain peculiarities of the university system, already pointed out, are responsible for
its existence. The university creates exlraordinarn and docents, without giving them,
as such, material with which to teach. In history, economics, or mathematics, this
matters little; it is a simple thing to procure an unused room. But in science, an ad-
ditional appointment as assistant, with further permission of the chief, is requisite;
and if the assistantship lapses, the teaching opportunity always falls with it. In Ber-
lin and Leipzig, the ex-assistant clinician sets up a private policlinic, where he gives
courses in virtue of his docentship. The university announces these courses in its cata-
logue, though it has provided no material and assumes no responsibility for them. At
Vienna, former assistants have combined their forces to establish a large policlinic, to
which a hospital has now }>een added. ^ It is governed by a committee, who fill vacancies
as they arise from the ranks of university docents not at the moment enjoying teach-
ing facilities in the universities. The courses offered may be taken by univei-sitv stu-
dents; but they are mainly of continuation character, and are followed by physicians
visiting Vienna for brief periods.
> AmruVxrhf ForthUdnnnthirsf. <Ur rniversifat Wien (Berlin and Wien, 1911). A Bureau of Information
(AiukunftuttlU) is lo<ated in the Allgemeines Krankenhaus, I Hof.
* .Sec Jahresherirht (Ur AUgerMinen PoUklinik (Wien, 1910). Also, Slaluten of the same (Wien, 1905).
POSTGRADUATE EDUCATION 321
The Vienna Policlinic is of university complexion and hence does not occupy the
field cultivated by the Central Committee of Berlin. The local medical fraternity
outside the university has therefore begun to arrange continuation courses at uni-
vei'sity and non-university institutions, for the especial benefit of the Viennese practi-
tioner. Latterly, on the occasion of a cholera scare, a special cycle was at once arranged
to take place at the Institute of Experimental Pathology. The profession attended
in large numbers; the topics presented included differential diagnosis of cholera, pro-
phylaxis and therapy, municipal precautions, etc. Similar undertakings are to be
found at Graz, Prag, and other centres.
The upshot of these somewhat various arrangements may be fairly summarized as
follows: the need of postgraduate education to fill in the gaps left by a defective med-
ical education will disappear as medical education itself becomes increasingly sound.
Meanwhile, well-trained men require renovation from time to time. Some of these
may have to obtain the requisite opportunities at or near their home, and provision
may well be made for them in connection with local hospitals; others, more fortunate,
can at intervals repair to great centres of medical education, where more or less in-
formal opportunities to witness recent work and methods will be highly stimulating.
Well-educated men can profit on either plan. The formation of special postgraduate
schools appears to be quite unnecessary: they would probably be inferior in equipment
and range to the university departments. If practitioners can and must leave home
to procure opportunities, they will probably do better if free to select from the varied
abundance of the metropolitan hospitals than if restricted to a single specifically
postgraduate establishment.
Little special provision for postgraduate study is made in Great Britain or France,
though visitors are readily welcomed in both places. In Paris especially, the rounds
of well-known physicians are daily follow^ed throughout the year by throngs that
sometimes seriously overcrowd the wards. But the instiniction offered is not primarily
or systematically designed for visiting practitioners. In Edinburgh and Glasgow, vaca-
tion courses for graduates are held at the Royal Infirmaries, — the University and the
Extra-Mural lecturers cooperating. The subjects dealt with are general medicine and
surgery, the class in the latter being restricted to tw^enty-five. In London, a Post-
graduate Association has been formed,^ which sells a composition ticket, admitting
to all clinics, clinical lectures, operations, and autopsies of the constituent hospitals,
eight general and six special in character, but the exercises in the general hospitals
are simply the routine exercises of the medical school. At the National Hospital for
the Paralyzed and Epileptic, in Queen's Square, a special course of eighteen lectures
is given in the month of November. Brief courses, running from three to six weeks, are
also offered at the Medical Graduates' College and Polyclinic in Chenies Street, and
at a few hospitals, St. Bartholomew's among others. But the profession at large has
thus far shown much less interest and activity than are in evidence in Germany and
1 The address is 20, Hanover Square, W.
322 MEDICAL EDUCATION
Austria. Much the most active hives of postgraduate training are the Schools of
Tropical Medicine at Liverpool and London. At the latter, three months' courses
are given, running dailv from ten o'clock to one and from two o'clock to five. A class
ranging from forty to fifty is trained for the special needs of missionary or service
activity in the tropics; advanced courses, lasting three weeks, may follow the regular
class work. In consetjuence of the proximity of a hospital for tropical diseases, the
training is of both laboratory and clinical character. Should medical education in
London be at anv time reorganized on a university plane, many of the hospitals now
used for undergraduate medical instruction will forfeit that function. The strong
teaching tradition that fortunately pervades them can perhaps be diverted into the
postgraduate channel. A qualified practitioner returning to London for observation
and study would then find there, as he already finds in Berlin and Vienna, a wide field
of experience open to him: regular university courses, courses specially arranged for,
and the chance of following the hospital work of every distinguished physician or sur-
geon. The broader and more informal these opportunities are made, the better they
are, provided medical education is itself fundamentally sound.
CHAPTER XV
MEDICAL EDUCATION OF WOMEN
Access to the medical faculty on the terms enjoyed by men was granted to women
by the Swiss universities in 1876. The constituent states of the German Empire
have reluctantly, one by one, adopted the same policy. Bavaria, Alsace-Lorraine, and
Wiirttemberg had removed all restrictions, while Prussia still allowed women to
attend lectures only as hearers, dependent, from one semester to the next, on the
express written permission of the rector of the university supplemented by that of the
instructors concerned. There, as elsewhere, the doors have now been opened.^ The
women^s movement, as it is called, has indeed attained formidable proportions in
the German nation, despite deeply rooted domestic traditions. Economic necessity
and the ethical and social awakening have overborne the conservative traditions that
sought to confine women to the nursery, the kitchen, and the church.
The privilege has, so far, made no great difference to the profession. The woman
student of medicine must, of course, comply with the regular matriculation require-
ments, by presenting the leaving-certificate of a nine-year secondary school. Up to
very recently, women had to procure the requisite training chiefly through private
study and tuition, a procedure almost prohibitive on account of the expense. The
total enrolment of women in the medical faculties of Germany has therefore been
small, and no insignificant proportion foreigners,^ The figures for four successive
recent semesters are as follows:
1908-1909 (winter semester) 188
1909 (summer semester) 183
1909-1910 (winter semester) 266 (202 being fully matriculated)
1910 (summer semester) 241
1911 (summer semester) 268 (253 being fully matriculated)
But important steps were taken by the Prussian government to provide adequate
secondary education for girls when, in 1908, the university bars were let down. The
upper girls' school had consisted often classes; the newly established secondary institu-
tions intended to lead into the university, articulate with the seventh class of the upper
girls' school. Instead of going into the eighth class, the prospective university student
enters a girls' Gymnasium, offering a six years' course. These Gymnasien, of which there
are now thirty-one, are of three types, following the lines of the corresponding schools
for boys: the classical Gymnasium, with a curriculum largely composed of German,
Latin, French, and Greek; the Realgymnasium, with Latin, French, English, mathe-
matics, and science; and ihe Higher Realschule,v>\ih. French, English, German, science,
and mathematics. History, geography, and religion are common to all in practically
1 In Prussia since the winter semester, 1908.
2 This is likewise the case in France and Switzerland, many of the women students in medicine be-
ing Russians. ^
824 MEDICAL EDUCATION
the same amounts. Prussia thus at this moment provides the same sort of secondary
school fiicihties for both sexes, though so far the higher schools for girls are not yet
numerous. The Prussian girl, like the Prussian boy, may get a university education
on the basis of a secondary education largely made up of Latin and Greek, or one
containing Latin and no Greek, or one containing neither Latin nor Greek.^
The numljcr of women practitioners is inconsiderable, but gradually increas-
ing. Between 1900 and 1905, 46 women qualified, 13 of them locating in Berlin;"
in 1908, 55 were in active practice; in 1909, 69; in 1910, 85, of whom 52 were en-
gaged in private practice, the remaining 33 being attached to institutions. The most
recent statistics for Austria show 80 registered women physicians, as compared with 9
in 1905, 34 in 1908; 39 of the 80 are settled in Vienna.^ The proportion of students
who subsequently engage in practice is, as far as Swiss experience goes, apparently
not large.
For these small numbers no special provision is anywhere made, excepting in Berlin,
where women students possess a dissecting-room of their own. Elsewhere, men and
women attend the same classes and demonstrations, and, as at ^'ienna and Paris, dis-
sect at the same tables. Co-education is the general practice on the Continent. Three
hundred women mingle on even terms with three thousand men students in the hospi-
tals of Paris; in Rome, Geneva, Brussels, Upsala, Copenhagen, and the Swiss univer-
sities, no distinction whatever is made between the sexes. The enrolment of women
in the philosophical faculty of the universities is so rapidly increasing, however, that
the advantages and disadvantages of co-education as against segregation of sexes are
now occasionally discussed.*
Both methods are illustrated in Great Britain, where a long contest, dotted with
highly diverting incidents, has now resulted in opening to women all qualifications
except those of the ancient universities, Oxford and Cambridge, neither of which will
examine women medical students, though Cambridge is willing to teach them. From
the first, women have been registrable on the same basis as men, "practically, though
probably not intentionally,""^ according to a memorandum filed in 1884 by the then
president of the General ^ledical Council. The first Medical Register published in
compliance with the Act of 1858 contains the name of one woman practitioner, a grad-
uate of Geneva; seven years later, the Apothecaries' Society of London examined
and qualified the second. Educational facilities for women were as vet non-existent.
Edinburgh accepted several women as students in 1870, but a student riot and an
'For a brief arcount, see J. F. Brown: Training of Teachers for Secondnn/ Schools, pp. 13. 19 (New
^ ork, 1911); also C. W. Prettyraan : " Higher Girls'^ Schools of Prussia," Teachers College Record (New
^ork. May, 1911). y v
' Rabe, supra, p. 85.
» Fifrures taken from AerztUches Vereinshlatt, Wiener Klinische Wochenschrift, and other similar pub-
ucattons.
r^li^"^ example, Waldeyer : Ueher Aufgahen und Stellung unserer Universitaten, pp. 1-2, etc. (Ber-
* Mtmorandum concerning Medical Education of Women in England, March, 1884, p. S.
MEDICAL EDUCATION OF WOMEN 825
unfavorable judicial decision abruptly terminated its connection with the medical
training of women. Feeling ran so high at the time that the entire board of examiners
of the Royal College of Surgeons resigned rather than examine two women who came
up for examination in midwifery. Favorable action on the petition of women to be
examined for their qualifications was taken by the London Royal Colleges only in
1909.
The most important step on the educational side occurred in 1874, when the Lon-
don School of Medicine for Vv'^omen began its career with fourteen students. Three
years later, the school perfected a close relation with the Royal Free Hospital, while
in the same year the College of Physicians in Ireland opened its qualifying examina-
tion, and London University its degree examination, to women. Resident posts in the
Royal Free were made accessible to women in 1896. Up to the present time, nearly one
thousand students have passed through the institution. At present, the hospital con-
tains 165 beds, with out-patient, casualty, and externe midwifery departments; in ad-
dition, fifteen special hospitals in London admit its women students to their wards.
The laboratory facilities compare favorably with those of other London schools; the
pathological department, in which every student is required to serve a three months'
clerkship, forms a separate establishment adjoining the hospital ; a few minutes' walk
removed is the medical school building. Its provision for anatomy, physics, and
chemistry follows the usual London lines. Physiology is best represented. Individual
provision in histological and chemical work is made for 62 students; 18 students can
be accommodated at one time in experimental work. The teaching follows the sound
British tradition, practical work leading the way. Research, also, is in progress. Un-
fortunately, English women are too largely sympathetic vnth. anti-vivisection to
make it prudent for a school largely maintained by subscriptions to seek a vivisec-
tion license.
To the other hospital schools of London, no women are admitted. But of the provin-
cial universities, Durham, IManchester, Liverpool, Birmingham, Leeds, and Bristol are
co-educational. Their enrolment of women students of medicine is slowly creeping
up. In the five-year period, 1901-1905, 371 women were registered as students in the
United Kingdom; in a period of equal length, 1906-1910, 397. There was a decrease
in England and Wales, — from 172 to 159; practically no change in Scotland, — 171
and 169,respectively ; in Ireland, the registration rose from 28 to 69.^ Nowhere, except
at the Royal Free Hospital, do women share hospital appointments subsequent to
graduation. This obvious anomaly still remains to be removed.
The unhappy relations of the University of Edinburgh to the subject have already
been mentioned. In 1872, the courts decided that the university could not give its
degree to women ; twenty years later, this difficulty was overcome through action of
the Scottish Universities Commission. The university will now examine, but not teach,
women in medicine, — a decision which on practical grounds is perhaps not to be
^ Figures compiled from annuai students' registers.
326 MEDICAL EDUCATION
iTgrettccl, for its present facilities do not suffice for its male students. An effort,
meanwhile, to found a separate medical college for women in Edinburgh has proved
unsuccessful. At this date, the instruction of women in Edinburgh is in the hands of
the extra-mural lecturers, whose laboratory facilities are meagre; three wards of the
Roval Infirmary are reserved for women students, one of 46 beds in surgery, one of
40 in medicine, a third of 30 beds in gynecology. In view of the inadequacy of the
clinical resources of Edinburgh, this arrangement can hardly be regarded as fortunate.^
Scotch women would doubtless do better for themselves to reject the hard conditions
unavoidably imposed at Edinburgh, in favor of Glasgow, where at Queen IMargaret's
College and the Royal Infirmary the university provides facilities quite as complete
as those enjoyed by the other sex; or in favor of Aberdeen, Dundee, and St. Andrew^^s,
where no difficulties are encountered; in these latter, the women students, forming
onlv a small proportion, work alongside of men in the clinics and in all the labora-
tories except anatomy. Practically the important thing would appear to be to train
women students well rather than merely to train them in Edinburgh.^
A medical education at the Royal Free Hospital in London costs £161, if the com-
position fee is paid; £10 more, if paid in instalments; books and laboratory fees
bring the sum up to an estimated total of £225. Official and hospital posts in con-
siderable number and variety are being so rapidly opened to, and established for,
\\()men that the financial prospects of women physicians are at the moment rather
more cheerful than those of men. In Scotland, a medical education is somewhat less
expensive: the total fees for a five years' course at Glasgow amount to about £120.
There are at this date about 600 women practitioners in England and Scotland,
distributed as follows: between 1908 and 1910, 70 women registered as practitioners
in Scotland ; Ijetween 1906 and 1910,16 in Ireland; between 1907 and 1910, 75 in Lon-
don. The Medical Directory for 1911 gives the number and distribution of qualified
practitioners as follows:'
London 187 Provinces 272 Wales 10 Scotland 127 Ireland 48
It is interesting to observe, as doubtless significant of the quality of the material
of which this body of women practitioners is composed, that women complete their
studies in shorter time than men. Of the 117 who have qualified since 1900, 66 per
cent qualified in between five and six years, 19 per cent in between six and seven
years.*
' It must be admitted, however, that the Edinburgh authorities appear to no slight extent to be
governed in their position by hostility to co-education in medicine. See testimony of the principal.
Sir \\ illiam Turner, in Minutes of Evidence taken be/ore Committee on Scottish Unirersilies, pp. 75, 16
(London, 1010).
^ Women may be licensed to practise after examination by the Royal Colleges, but membership and
fellowship are denied to them.
» These figures were gathered for me by Miss K. Haslam, M. D., Secretarv of the Association of Regis-
tered .Medical Women.
* Minutu of Eri(Unre taken hy Royal Commission on London University (Third Report), p. 334.
APPENDIX
APPENDIX
Statistical Tables with regard to the Cost of Medical Education in the Universities
of Prussia and Bavaria supplied by the Governments of those countries for the infor-
mation of the Royal Commission on University Education in London, at the request
of Professor Friedrich von Muller, — reprinted here with the permission of the Con-
troller of the H. B. ]\I. Stationery Office and of the Commission.
CLASSIFICATION OF THE EXPENDITURE ON THE MEDICAL
FACULTIES IN THE PRUSSIAN UNIVERSITIES.
A. Standing Charges at 1st of April, 191I. (1st Statement.)
UNIVERSITY,
1.
Current Expenses of the
Medical Faculty.
Personal
Expenses.
Equipment
Expenses
of the
Institutes.
Total of
columns
■2 and 3.
The Totals in column 4
are defrayed from the
following sources in the
proportions given below;
From the
Income
of the
University.
From State
Funds.
5^0(3
!^5
„„. ^
Expenditure per
annum on each
Medical Student.
Total.
Out of
State
Funds.
Konigsberg
Berlin and Charite
Hospital
Greifswald
Breslau
Halle
Kiel
Gottingen
Marburg
Bonn
Munster
Total 2,318,398 0
M. Pf.
177,050 0
713,302 0
165,726 0
258,720 0
223,626 0
219,225 0
145,350 0
191,200 0
206,660 0
17.640 0
M. Pf.
507,217 0
2,963,760 13
611,696 0
772,384
709,351
811,634
498,016
447,314
638,866
10.500
7,870.725 13
M.
Pf.
684,267
0
3,677,062 13 |
677,420
0
1,031,104
0
932,877
0
1,030,859
0
643,366
0
638,614
0
846,515
0
28,140
0
10,189,123 13
M. Pf.
213,208 0
,702,751 66
235,259 48
410,676 0
465,441 0
505,174 0
282,480 0
207,201 50
387,169 0
4,409,359 63
M. Pf.
471,059 0
1,974,310 48
442,160 62
620,429 0
467,436 0
525,686 0
360,886 0
431,312 50
458,346 0
28,140 0
5,779,763 50
M. Pf.
370
1,850 0
1,995
1,840 0
248
2,730 0
530
1,945 0
326
2,808 0
536
1,926 0
277
2,322 0
383
1,667 0
496
1,704 0
206
136 0
5,365
1,900 0
M.
1.270
989
1,780
1,170
1.437
982
1,302
1,126
924
136
Pf.
C
0
0
0
0
0
0
0
0
0
1,077 0
Re.marks. To the amounts in columns 3 and 6 must be added the cost of the maintenance of the in-
stitute buildings, which absorbs at least half of the estimated building funds, and amounts altogether
to 391,459 M.
The participation of the medical students, particularly in the non-clinical session, in the lectures
and practical work in some natural science institutes (of the philosophical faculty) affects both the
accommodation required and the equipment expenses of these institutes, and the number and com-
position of the teaching staff in the philosophical faculty. It is impossible to estimate how much the
expenses of this faculty are increased by the presence of medical students.
B. Capital E.xpenditure on Account of the Medical Faculties for the Years
1887 to 1911 INCLUSIVE. (2d Statement.)
U.N'IVERSITY.
For the Pur-
chase of Land.
For Buildings
and Fittitigs.
For Instru-
ments and
Apparatus.
Deficits.
Total.
KonifiTsberfiT
M. Pf.
246.000 0
1,057.410 0
215,150 0
377,200 0
M. Pf.
2,138,266 0
16,264,666 0
2,779,233 0
6,178,420 0
M, Pf.
200,700 0
729.660 0
1M,300 0
171,400 0
M. Pf.
226,614 0
3,487,830 0
176,605 0
361,676 0
M. Pf.
2,810,679 0
Berlin and Charite Hospital
20,629,645 0
Greifswald
3,325,288 0
Breslau
7,078,696 0
Carried forward
1,895,760 0
26,350,673 0
1,256,060 0
4,241,724 0
33.744,107 0
8;30
APPENDIX
B. CAPtTAL Expenditure on Account of the Medical F.\culties for the Years
1887 to 1.011 INCLU.S1VE. (2d Statement) [continued].
UNIVERSITY.
For the Pur-
chase of Land.
For Buildings
and Fittings.
' For Instru-
ments and
Apparatus.
Deficits.
Total.
M. Pf.
1.895,760 0
296,612 0
574,800 0
75.716 0
14.600 0
M. Pf.
26,360,573 0
2,069.300 0
4.230.230 0
3.187.820 0
2,473,340 0
2.332,466 0
M. Pf.
1,266,060 0
146,090 0
140.470 0
96,150 0
105,100 0
203.460 0
11,000 0
M. Pf.
4,241.724 0
115.420 0
380,460 0
344,690 0
266.106 0
121.619 0
33.460 0
M. Pf.
33,744.107 0
Hnlle
2.626,322 0
Kiel
6,326,960 0
(li'it t iniron
3.628.660 0
2.919.262 0
I^-)!)!)
2,671,934 0
MQnster
44,460 0
Total
2.857,288 0
40,643,728 0
1,967.310 0
6,502,279 0
60,960.606 0
Total of miscellaneous
contributions for 1887-
1911
508,000 0
Sum total of capital ex-
Denditure
51,468,606 0
1. KoNIGSBERG UNIVERSITY.
Number and Designation
State Contributions to the
Total of
of the
In
stitute for the
estimated
following purposes:
Private
Incomeand
Incom.e of
the
Expendi'
INSTITUTE.
ture of the
Scientific Offices
Other Offices.
Personal
Equipment
Total of
Institute
(in addition
Expenses.
Expenses.
columns
{columns
to the Director).
It and 5.
6 and 7).
1.
2.
3.
4.
5.
6.
7.
8.
M. Pf.
M. Pf.
M. Pf.
M. Pf.
M. Pf.
Anatomical Insti-
1 prosector.
2 servants.
10,990
0
9,989 0
20,979 0
20,979 0
tute.
2 assistants.
Physiological Insti-
tute.
2 assistants.
1 servant.
4,660
0
6.840 0
10,400 0
10,400 0
Pathological Insti-
tute.
2 assistants.
1 servant.
4,710
0
6,960 0
11.670 0
11,670 0
Pharmacolo(?ical In-
stitute and in-
struction in Phys-
iological and Pa-
thological Chem-
istry.
2 assistants.
1 servant.
4,780
0
4,640 0
9.320 0
9,320 0
Hygienic Institute.
2 assistants.
1 servant.
4,710
0
7,990 0
12,700 0
12.700 0
Medical Clinic.
1 bead physician,
6 assistants.
1 porter.
12,840
0
49,661 0
62,491 0
66,429 0
127,920 0
Surgical Clinic.
1 head surgeon,
4 assistants.
1 porter.
10,050
0
87,049 0
97,099 0
66,051 0
162,150 0
Women's Clinic.
1 obstetrician,
1 head doctor,
3 assistants.
1 porter.
11,010
0
60,305 0
71,316 0
52,295 0
1'23,610 0
Eye Clinic.
1 head surgeon,
3 assistants.
1 porter.
8,840
0
32,117 0
40,967 0
34,233 0
76,190 0
Psychiatrical in-
10,868 0
struction.
2 assistants.
3,000
0
7,868 0
10,368 0
Institute for Foren-
3,860 0
sic Mc<licine.
1 servant.
1,660
0
2,300 0
3,860 0
Ear Clinic.
1 assistant.
1,500
0
12,500 0
14,000 0
6,200 0
20.200 0
• Out patients' De-
partment for Skin
Diseases.
3,300 0
3,300 0
3,300 0
• Out-patienU' De-
»rtmcnt for the
:)iscascs of Chil-
dren.
2.000 0
2.000 0
2.000 0
Carried fortoard
78,660
0
291,909 0
370,459 0
213.208 0
688.667 0
• SnbTention.
APPENDIX
331
1. KoNIGSBERG UNIVERSITY [cOtltiuued].
Number and Designation
of the
State Contributions to the
Institute for the
following purposes:
Private
Income of
the
Institute.
7.
Total of
estimated
Incomeand
Expendi-
INSTITUTE.
1.
Scientific Offices
(in addition
to the Director).
2.
Other Offices.
3.
Personal
Expenses.
4.
Equipment
Expenses.
5.
Total of
Columns
h and 5.
6.
ture of the
Institute
(columns
6 and 7).
8.
Brought foritmrd
* Dental Institute.
11 ordinary,
9 extraordinary,
and district
superintendent.
M. Pf.
78,560 0
M. Pf.
291,909 0
2,100 0
M. Pf.
370,459 0
2,100 0
M. Pf.
213,208 0
M. Pf.
583,667 0
2,100 0
TotaJ
t Salaries of the pro-
fessors in the Med-
ical Faculty.
78,550 0
98,500 0
294,009 0
372,559 0
98,600 0
213,208 0
585,767 0
98,500 0
Sum total
177,050 0
294,009 0
471,069 0
213,208 0
684,267 0
Number of matriculated medical students according to the average of the summer and
winter sessions, 1910 370
Total expenditure for the year on one medical student 1850 M.
Out of state funds 1270 M.
2. Berlin University and the Charite Hospital.
Anatomical Insti-
tute.
Anatomical-Biologi-
cal Institute.
Physiological Insti-
tute.
Pharmacological In-
stitute.
Hygienic Institute.
Out-patients' De-
partment for In-
ternal Medicine
(comprising aMed-
ical Out-patients'
Department, a Hy
dro-therapeutic
Department, and
an Out-patients'
Department
for Pulmonary Dis-
eases).
Royal Hospital (com-
prising the Surgi-
cal, Eye, and Ear
Clinics).
Carried forward
2 prosectors,
1 assistant and
custodian,
3 assistants.
1 prosector,
2 assistants.
1 district
superintendent,
6 assistants.
2 assistants.
2 district
superintendents,
2 assistants.
7 assistants
(that is, 4 in the
Medical
Out-patients'
Department, 3 in
the Hydro-
therapeutic
Department).
1 head assistant,
14 assistants
(that is, 1 head
assistant, 6 assist-
ants in the
Surgical Clinic,
5assistantsinthe
Eye Clinic,
3 assistants in the
Ear Clinic).
1 inspector,
1 preparator,
3 servants.
1 preparator,
1 servant.
1 secretary,
5 servants.
2 servants.
1 clerk,
5 servants,
1 mechanician
and machinist.
1 clerk of
inspection
ofBce,
1 servant,
Ibath
attendant.
.1 administra-
tive director
(in the sub-
offlce).
2 clerks of
inspection
office,
1 clerk,
1 machinist,
1 housekeeper,
3 porters,
1 anatomy
attendant.
20,600 0
7,040 0
22,360 0
6,180 0
17,150 0
19,540 0
45,230 0
138,100 0
37,076 0
11,300 0
63,116 0
14,002 0
33,840 0
35,549 0
131.689 0
326,572 0
57,676 0
18,340 0
85,476 0
20,182 0
50,990 0
65,089 0
176,919 0
464,672 0
1,000 0
53,201 0
272,503 0
326,704 0
58,676 0
18,340 0
85,476 0
20,182 0
50,990 0
108,290 0
449,422 0
791,376 0
•Subvention.
+ The average salary of the ordinary professors amounts to 5600 M., of the extraordinary professors (district su-
perintendent) to 3600 M., with additional allowance for a house when an official residence is not provided. The
salaries of the ordinary professors vary from 4200 to 7200 M., and those of the extraordinary professors from 1800 to
4200 M.
332
APPENDIX
2. Berlin University and the Charite Hospital [continued].
INSTITLTE.
Numl)er and DosiKniition
of the
Scientific Offices
(in addition
to the Director).
2.
Other Offices.
State Contributions to the
Institute for the
following purposes:
Persoiial
Expenses.
4.
Equipment
Expenses.
Total of
colwnns
U and 5.
Private
Income of
the
Institute.
7.
Itrough t foncard
Women's Clinic.
Collection of surr-
eal and obstetrical
• instruments and
banda«res.
• Institute for Or-
thopedical Sur-
gery.
Institute for Practi-
cal Instruction in
State Pharmaco-
lof>-.
Out-patients
Department for
Throat and Nose
Diseases.
Institute for Ront-
(ren R.iy Investiga-
tions.
DenUil Institute.
• Institute for Me-
chano-therapeu-
tics.
t The Charite Hospi-
tal, with the fol-
lowinsr University
Institutes:
Patholog-ical-Ana-
tnmical Institute.
2 Medical Clinics
with Out-p>T.tients'
DepartraenL
1 Surgical Clinic.
1 Clinic for Psychiat
rical and Nervous
Diseases.
1 Women's Clinic.
1 Children's Clinic.
1 Clinic for Skin Dis-
eases.
1 Eye Clinic.
1 Clinic for Throat
and Nose Diseases.
1 Ear Clinic.
8 (assistants.
2 assistants.
2 assistants.
1 assistant.
9 assistants.
Pathological
Institute:
2 district
superintendents,
1 custodian,
6 assistants.
/. Medical Clinic :
1 head physician,
2 assistants.
II. Medical
Clinic:
1 head physician,
3 assistants.
Surgical Clinic:
1 head surgeon,
4 assistants.
Psvchiatrical
Clinic:
1 assistant.
Women's Clinic:
1 head doctor,
6 assistants.
Children's
Clinic:
3 assistants.
Skin Clinic:
1 head doctor,
5 .assistants.
Eve Clinic:
1 assistant.
Carried forward
2 clerks of
inspection
office, 1 porter.
1 servant.
3 servants.
1 medical
director.
1 managing
director,
1 head
apothecary,
3 dispensers.
3 ministers of
religion,
13 clerks and
cashiers,
1 controller's
clerk,
1 sui)erintend-
ent's clerk,
4 assistant
clerks,
7 departmental
clerks,
1 preparator,
2 servants
in the
Pathological
Institute,
1 servant
in the
Psychiatrical
Clinic,
1 machinist,
1 sacristan,
1 gardener,
3 office boys.
1 foreman,
7 porters.
1 assistant
clerk.
M. Pf.
1.38.100 0
26,170 0
5,180 0
3,000 0
3,400 0
19.760 0
245,842 0
M. Pf.
326,572 0
113,847 0
1,360 0
4,000 0
1,830 0
3,074 0
8,260 0
13,974 0
2,500 0
785,601 48
M. Pf.
464,672 0
140,017 0
1,360 0
4,000 0
7,010 0
6,074 0
11,650 0
33,734 0
2,600 0
1,031,443 48
M. Pf.
326,704 0
106,863 0
Total of
estimated
Incomtand
Expendi-
ture of the
Institute
{columns
6 and 7).
8.
3,000 0
47,826 0
1,219,368 65
M. Pf.
791.376 0
246,870 0
1,360 0
4,000 0
7,010 0
9,074 0
11,660 0
81.660 0
2,500 0
2,250,812 13
441,462 0 ll,2C1.00» 48 1,702,460 48 1,702.761 66 3,406,212 13
• SubTcntion.
t The Charity Ho«pital also provides the instruction of military surgeons. Staff doctors are employed as a.ssistants.
APPENDIX
333
2.
Berlin University and the Charite Hospital [continued^
Number and Designation
of the
State Contributions to the
Institute for the
following purposes :
Private
Income of
the
Institute.
7.
Total of
estimated
Income and
Expendi-
ture of the
Institute
{columns
6 and 7).
8.
INSTITUTE.
1.
Scientific Offices
{in addition
to the Director).
2.
Other Offices.
3.
Personal
Expenses.
4.
Equipment
Expenses.
5.
Total of
columns
It and 5.
6.
Brought foricard
Ear Clinic:
1 assistant.
17 ordinary,
32 extraordinary,
and district
superintendent.
In Sub-Qfflce
1 justiciary,
1 Catholic
priest,
1 organist.
M. Pf.
441,452 0
M. Pf.
1,261,008 48
M. Pf.
1,702,460 48
M. Pf.
1,702,761 65
M. Pf.
3,405,212 13
Total
* Salaries of the pro-
fessors in the Med-
ical Faculty.
441,452 0
271,850 0
1,261,008 48
1,702,460 48
271,850 0
1,702,751 65
3,406,212 13
271,850 0
Sum total
713,302 0
1,261,008 48
1,974,310 48
1,702,761 65
3,677,062 13
Number of matriculated medical students (including the students of the Kaiser Wilhelra's
Akademie for the training of army doctors) according to the average of the summer and
winter sessions, 1910 1995
Total expenditure for the year on one medical student 1840 M.
Out of state funds 989 M.
3. Greifswald University,
Anatomical Insti-
1 district
1 preparator,
5,940 0
11,091 0
17,031 0
17,031 0
tute
superintendent,
1 prosector.
1 servant.
Physiological Insti-
1 assistant.
1 servant.
3,000 0
4,868 0
7,868 0
7,868 0
tute.
Pathological Insti-
2 assistants.
1 servant.
4,375 0
8,686 0
13,061 0
13,061 0
tute.
Pharmacological In-
1 assistant.
1 servant.
3,350 0
3,250 0
6,600 0
6,600 0
stitute.
Hygienic Institute.
2 assistants.
1 servant.
4,640 0
6,225 0
10.865 0
10,866 0
University Hospital
Medical Clinic:
2 clerks of
29.840 0
122,866 32
152,695 32
141,766 68
294,462 0
(comprising the
Ihead physician,
inspection
Medical and Sur-
4 assistants.
oflBce,
gical Clinics).
Surgical Clinic:
1 head surgeon,
6 assistants.
1 head doctor,
3 assistants.
1 head doctor,
1 machine
minder,
1 servant.
Women's Clinic.
1 stevi^ard.
8,820 0
44,713 60
53,533 60
24,737 40
78,271 0
Clinic for Psychiat-
1 inspector.
15,770 0
39,779 0
56,649 0
36,821 0
92,370 0
rical and Nervous
2 assistants.
1 porter.
Diseases.
1 attendant,
1 female
attendant.
Eve Clinic.
3 assistants.
4,860 0
20,027 60
24,877 60
31,944 40
56,822 0
t Children's Clinic.
t Out-patients' De-
12.240 0
1,800 0
12.240 0
1,800 0
12,240 0
1,800 0
partment for Skin
Diseases.
Carried forward
80,585 0
276,535 52
356,120 52
236,269 48
591,380 0
* The average salaries of the ordinary professors amount to 6600 M., of the extraordinary professors (district super-
intendent) to 3600 M., with additional allowance for a house when an official residence is not provided. The salaries
of the ordinary professors vary from 4800 to 9000 M., and those of the extraordinary professors from 1600 to 4800 M.
+ Subvention. ^
S3+
APPENDIX
3. Gheifswald University [continued^.
Number and Hesitation
of the
State Contributions to the
Institute for the
following purposes:
Private
Income of
the
Institute
7.
Total of
estimated
Incomeand
Expendi-
ture of the
Institute
(column*
6 and 7).
8.
INSTITUTE.
1.
Scientific Offices
(in addition
to the Director).
2.
Other Offices.
3.
Personal
Expenses.
4.
Equipment
Expenses.
5.
Total of
columns
It and 5.
6.
Brought fonrard
• In.struction in Fo-
rensic Medicine.
12 ordinary,
5 extraordinary,
and district
superintendent.
M. Pf.
80,685 0
M. Pf.
275,535 52
900
M. Pf.
356,120 52
900 0
M. Pf.
235,269 48
M. Pf.
591,.S80 0
900 0
Total
t Salaries of the pro-
fessors in the .Med i-
cal Faculty.
80,585 0
85,140 0
276,435 52
357,020 52
85,140 0
235.269 48
592,280 0
85,140 0
Sum total
165,726 0
276,435 52
442,160 52
235,259 48
677,420 0
Number of matriculated medical students according to the average of the summer and win-
ter sessions, 1910 248
Total expenditure for the year on one medical student 2730 M.
Out of state funds 1780 M.
4. Breslau University.
Anatomical Insti-
1 district
2 servants.
9,320 0
19,510 0
28,830 0
2,165 0
30,995 0
tute.
superintendent.
1 prosector,
2 assistants.
Physiological Insti-
1 district
2 servants.
6,200 0
8.868 0
15,068 0
16,068 0
tute.
superintendent,
2 assistants.
Patholo^cal Insti-
3 assistants.
2 servants.
7,770 0
9,047 0
16,817 0
311 0
17,128 0
tute.
Pharmacological In-
1 assistant.
1 servant.
3,490 0
5,910 0
9.400 0
9,400 0
stitute.
Hygienic Institute.
4 assistants.
2 ser\'ants.
11,670 0
13,703 0
26,373 0
25,373 0
Clinical Institutes
Medical Clinic :
3 clerks ot
81,530 0
261,602 0
343,032 0
341,418 0
684,450 0
(comprising the
1 head physician.
inspection
Mediral Clinic, the
4 assistants.
office.
Surgical Clinic. the
2 assistant
KyeClinic.the Wo-
Surgical Clinic :
clerks.
men's Clinic, the
1 head surgeon,
3 dispensers,
Clinic for Diseases
4 assist-in ts.
7 caretakers.
of the Skin, the
1 servant.
Children's Clinic.
Eve Clinic :
1 machinist.
andtheE^arClinic).
5 assistants.
Women's Clin ic :
1 head doctor,
4 assistants.
Clinic for Skin
Diseatea :
1 hrAd doctor,
3 assistants.
Children's
Clinic :
3 assistants.
Ear Clinic:
2 assistants.
Carried forward
119,980 0
318,540 0
438,520 0
343,894 0
782,414 0
• SubTetition.
rJi7tr*** ^J*'?.""*' "'*•** profciwors is as at K5nigsberg. The salaries of the ordinary professors vary from 4000 to
rwjg M., and those of the extraordinary professors from 2600 to 4000 M.
APPENDIX
335
4.
Breslau University
coniinued^.
Number and Designation
of the
State Contributions to the
Institute for the
following purposes :
Private
Income of
the
Institute.
Total of
estimated
Incomeand
Expendi-
ture of the
Institute
(columns
6 and 7).
INSTITUTE.
Scientific Offices
(in addition
to the Director).
other Offices.
Personal
Expenses.
Equipment
Expenses.
Total of
columns
h and 5.
1.
2.
3.
4.
5.
6.
7.
8.
M. Pf.
M. Pf.
M. Pf.
M. Pf.
M. Pf.
Brought forward
Clinic for Psychiat-
rical and Nervous
Diseases.
Dental Institute.
Institute for Foren-
sic Medicine.
1 head doctor,
3 assistants.
3 assistants.
2 clerks of
inspection
ofBce,
1 machinist,
1 porter,
1 attendant,
1 female
attendant.
1 servant.
119,980 0
22,180 0
4,500 0
1,600 0
318,540 0
33,869 0
5,800 0
3,600 0
438,520 0
56,049 0
10.300 0
6,060 0
343,894 0
64,981 0
1,800 0
782,414 0
121,030 0
12,100 0
5,060 0
Total
148,220 0
361,709 0
509,929 0
410,675 0
920,604 0
♦Salaries of the pro-
fessors in the Med-
ical Faculty.
14 ordinary,
11 extraordinary,
and district
superintendent.
110,500 0
110,500 0
110.600 0
Sum total
258,720 0
361,709 0
620,429 0
410,676 0
1,031,104 0
Number of matriculated medical students according to the average of the summer and
winter sessions, 1910 530
Total expenditure for the year on one medical student 1945 M.
Out of state funds 1170 M.
5. Halle University.
Anatomical Insti-
1 district
1 preparator.
11,660 0
12,739 0
24,299 0
390 0
24,689 0
tute.
superintendent,
1 prosector,
2 assistants.
2 servants.
Physiological Insti-
2 assistants.
1 servant.
4,990 0
3,644 0
8,534 0
8,534 0
tute.
Hygienic Institute.
1 assistant.
1 servant.
3,810 0
5.260 0
9,060 0
9,060 0
Pathological Insti-
2 assistants.
1 servant.
4,990 0
6,594 0
11,684 0
20 0
11,604 0
tute.
Pharmacological In-
2 assistants.
1 servant.
4,710 0
4,000 0
8,710 0
8,710 0
stitute.
Clinical Institutes
Medical Clinic :
2 clerks of
68,520 0
164,333 0
232,863 0
338,136 0
670,988 0
(comprising the
1 head physician,
inspection
Medical. Surgical.
10 assistants.
ofBce,
Women's, Eye, and
2 assistant
Ear Clinics).
Surgical Clinic:
1 head surgeon,
5 assistants.
Women's Clinic:
1 head doctor,
4 assistants.
Eye Clinic:
3 assistants.
Ear Clinic:
2 assistants.
clerks,
1 first-class
mechanician,
1 servant,
5 porters.
Carried foru-ard
98,580 0
196,460 0
295,040 0
338,545 0
633,585 0
* Average salary of the professors is as at Konigsberg. The salaries of the ordinary professors vary from 3900 to
6600 M., and those of the extraordinary professors from 2400 to 4000 M.
3S6
APPENDIX
5. Halle University [continued].
Number and desi^ation
State Contribution
^ to the
Total of
of the
Institute for t
le
estimated
following purposes:
Private
Income of
the
Institute.
Income and
Expendi-
INSTITLTE.
ture of the
Scientific Officer
Otfier Offices.
Personal
Equipment
Total of
Institute
(in addition
Expenses.
Expenses.
columns
(columns
to the Director).
U and 5.
6 and 7).
1.
o
3.
4.
5.
0.
7.
8.
M. Pf.
M. Pf.
M. Pf.
M. Pf.
M. Pf.
Brought foripard
98.580 0
196,460 0
296.040 0
338.&4.5 0
633,586 0
Clinic for Psychiat-
1 head doctor.
1 clerk of
24,':46 0
38,460 0
63,196 0
126,896 0
190,092 0
rical and Nervous
4 assistants.
insjDcction
Diseases.
office.
2 assistant
clerks,
1 flrst-cla.ss
mechanician,
1 porter,
1 servant,
1 attendant,
1 female
attendant.
\
Instruction in Fo-
900 0
900 0
900 0
rensic Me<licine.
6,000 0
6.000 0
6,000 0
•Out-patients' De-
p.^rtraent for Skin
I)i<casos.
• Dentil Institute.
2,100 0
2.100 0
2,100 0
Total
123,326 0
243,910 0
367.236 0
465,441 0
832,677 0
t Salaries of the pro-
14 ordinary.
100,200 0
100,200 0
100,200 0
fessors in the Med-
7 extraordinary.
ical Faculty.
and district
superintendent.
Sum total
223,626 0
243,910 0
467,436 0
465,441 0
932,877 0
Number of matriculated medical students according to the average x>f the summer and
winter sessions, 1910 3-25
Total expenditure for the year on one medical student 2808 M.
Out of state funds 1437 M.
6. Kiel University.
Anatomical Insti-
1 district
1 servant.
5,215 0
10,920 0
16,135 0
16,135 0
tute.
superintendent,
1 prosector,
1 assistant.
Physiolo^cal Insti-
1 district
1 servant.
4,710 0
5,378 0
10,088 0
10,088 0
tute.
superintendent,
2 assistants.
Pathological Insti-
1 district
1 servant.
7,560 0
13,000 0
20,660 0
20,560 0
tute.
superintendent,
4 assistants.
Pharmacoloifical In-
1 assistant.
1 servant.
3,140 0
3,600 0
6.740 0
6,740 0
stitute.
Hyirienic Institute.
3 assistants.
1 servant.
6.060 0
9,300 0
15.360 0
15.360 0
Arndfm irn I Med icnl
Medical Clinic :
3 clerks of
64,110 0
207.296 0
261,406 0
396,940 0
658,346 0
Injititutions from-
1 head physician.
inspection
prifiinir the Mcrli-
6 assistants.
ofBce,
cal and Surjrical
1 assistant
Clinics, the Wo-
Surgical Clinic :
clerk.
men's Clinic, with
1 head surfreon,
2 porters.
Institution for the
5 assistants.
1 first-class
InstrurtionofMid-
mechanician.
wifery. and the
Eve Clinic :
Clinic for Skin
3 assistants.
Discasoi).
Carried foncard
80,796 0
249,494 0
330,289 0
396,940 0
727,229 0
• Subvention.
^AveraKP salary of the professors is as at KoniCTbersr. The salaries of the ordinary professors vary from 4200 to
7300 M.. and those of the extraordinary professors from 800 to 3100 M.
APPENDIX
337
6. Kiel University \continued\
Number and Designation
State Contributions to the
Total of
of the
Institute for the
estimated
following purposes:
Private
Income and
Expendi-
ture of the
INSTITUTE.
Income of
the
Institute.
Scientific Offices
Other Offices.
Personal
Equipment
Total of
Institute
{in addition
Expenses.
Expenses.
columns
{columns
'
to the Director).
U and 5.
6 and 7).
1.
2.
3.
4.
5.
6.
7.
8.
M. Pf.
M. Pf.
M. Pf.
M. Pf.
M. Pf.
Brought forward
Women's Clinic:
1 head doctor,
S assistants.
Institution for
Instruction in
Midwifery :
1 assistant.
Skin Clinic:
2 assistants.
80,795 0
249,494 0
330,289 0
396,940 0
727,229 0
Clinic for Psychiat-
1 head doctor.
2 clerks of
27,490 0
33,166 0
60,656 0
108,234 0
168,890 0
rical and Nervous
4 assistants.
inspection
Diseases.
office,
1 assistant
clerk,
1 first-class
mechanician,
1 attendant
cashier's office,
.1 porter,
1 attendant,
1 female
attendant.
* Out-patients' De-
6,000 0
6,000 0
6,000 0
partment for Ear,
Throat, and Nose
Diseases.
* Children's Out-pa-
13,000 0
13,000 0
13,000 0
tients' Department.
Instruction in Den
2,100 0
2,100 0
2,100 0
tistry.
Institute for Foren-
2,700 0
2,700 0
2.700 0
sic Medicine.
Total
108,285 0
306,460 0
414,745 0
505,174 0
919,919 0
t Salaries of the pro-
14 ordinary.
110,940 0
110,940 0
110,940 0
fessors in the Med-
8 extraordinary.
ical Faculty.
and district
suiJerintendent.
Sum total
219,226 0
306,460 0
526,685 0
506,174 0
1,030,859 0
Number of matriculated medical students according to the average of the summer and win-
ter sessions, 1910 535
Total expenditure for the year on one medical student 19-26 M.
Out of state funds 982 M.
7. GoTTiNGEN University,
Anatomical Insti-
tute.
Physiological Insti-
tute.
1 district
superintendent,
1 prosector,
1 assistant.
2 assistants.
1 preparator,
1 servant.
1 servant.
7,220 0
4,570 0
14,150 0
6,03!^ 0
21,370 0
10,608 0
21,370 0
10,608 0
Carried forward
11,790 0
20,188 0
31,978 0
31,978 0
* Subvention.
+ Average salary of the professors is as at Konigsberg. The salaries of the ordinary professors vary from 3000 to
6600 M.. and those of the extraordinary professors from 2600 to 4800 M.
338
APPENDIX
7. GoTTiNGEN University [continued].
Numlx;r and Designation
State Contributions to the
Total of
of the
Institute for the
estimated
following purposes :
Private
Income of
the
Incomeand
Expendi-
ture of the
Institute
INSTITLTE.
Scientific Cftflces
Otfter Offices.
Personal
Equipment
Total of
(in addition
Expenses.
Expenses.
columns
(columns
to the Director).
UandS.
6 and 7).
1.
2.
3.
4.
5.
6.
7.
8.
M. Pf.
M. Pf.
M. Pf.
M. Pf.
M. Pf.
Brought fortcard
11.790 0
20,188 0
31,978 0
31,978 0
Pathological Insti-
tute.
Ph irmacolofrical In-
2 assistants.
1 servant
4,860 0
6,826 0
10,676 0
10,676 0
1 assistant.
1 servant.
3,000 0
4.086 0
7,085 0
7,085 0
stitute.
Hyifionlc Institute.
1 assistant.
1 servant.
3.950 0
4.800 0
8,750 0
8,750 0
United Cniverxitv
Medical Clinic:
2 clerks of
35,720 0
146,286 0
182,006 0
239,316 0
421,321 0
Clinics (compri*-
1 head physician.
inspection
infc the Medical,
6 assistants.
office.
Surifical. Women's,
1 first-class
and Children's Cli-
Surgical Clinic:
mechanician.
nics).
5 assistants.
Women's Clinic:
1 head doctor,
S assistants.
Children's
Clinic:
1 assistant.
Eye Clinic.
S assistants.
5.000 0
15.861 0
20.861 0
34,764 0
65,626 0
Psychiatrical Clinic
1 assistant.
2.100 0
9,740 0
11,840 0
8.400 0
20,240 0
withReteption De-
1 voluntary
partment and Out-
assistant.
riatients' Depiart-
ment for Nervous
and Mental Dis-
eases.
Institute for Foren-
2,360 0
2.350 0
2,350 0
sic Medicine.
•Out-patients' De-
4,300 0
4.300 0
4,300 0
piartment for Dis-
eases of the Ear.
• Dental Institute.
2,100 0
2,100 0
2.100 0
Total
66,410 0
216,635 0
281.945 0
282,480 0
564,425 0
t Salaries of the pro-
11 ordinary.
78,940 0
78,940 0
78,940 0
fessors in the Med-
6 extraordinary.
ical Faculty.
and district
superintendent.
Sum total
145,360 0
216.635 0
360,886 0
282,4(50 0
643.365 0
Number of matriculated medical students according to the average of the summer and win-
ter sessions, 1910 277
Total expenditure for the year on one medical student 232-2 M.
Out of state funds 1302 M.
8. Marburg University.
Anatomical Insti-
1 prosector.
2 servants.
8.680 0
14,041 0
22,721 0
22,721 0
tute.
2 as<:istants.
Physiological Insti-
1 district
2 servants.
6,480 0
8,819 0
16,299 0
188 0
16.487 0
tute.
superintendent.
2 .is-iistants.
Pathological Insti-
tute.
2 assistants.
1 servant.
4,740 0
6,823 0
11,563 0
11,563 0
Carried forveard
19,900 0
29,683 0
49,683 0
188 0
49.771 0
• Sabvention.
!;^'T[V ■*#?!?' °' ^^'^ profcs.sors is as at Kdniirsberir.The salaries of the ordinary professors vary from 3000 to 6600 -M.,
and thoM of the extraordinary professors from 1600 to 3000 M.
APPENDIX
8. Marburg University [continued].
339
Number and Designation
State Contributions to the
Total of
of the
Institute for the
estimated
following purposes:
Prix^ate
Income of
the
Institute.
Income and
Expendi-
ture of the
INSTITUTE.
Scientific Offices
Other Offices.
Personal
Equipment
Total of
Institute
{in addition to
Expenses.
Expenses.
columns
(columns
the Director).
U and 5.
6 and 7).
1.
2.
3.
4.
5.
6.
7.
8.
M.
Pf.
M. Pf.
M. Pf.
M. Pf.
M. Pf.
Brought forward
19,900
0
29,683 0
49,583 0
188 0
49,771 0
Pharmacological In-
1 assistant.
1 servant.
3,240
0
4,105 0
7,346 0
7,345 0
stitute.
Institute for Hy-
3 district
1 secretary,
17,380
0
18,683 0
35,963 0
36,963 0
giene and experi-
superintendents.
4 servants.
mental Therapeu-
tics.
Medical Clinic.
2 assistants.
1 head physician,
1 inspector,
17,000
0
48,745 70
65,745 70
75,263 30
141,009 0
5 assistants.
1 porter,
1 servant.
Surgical Clinic.
1 head surgeon,
4 assistants.
1 inspector.
11,620
0
49,344 80
60,9&4 80
76,656 20
136,620 0
Women's Clinic.
1 obstetrician,
4 assistants.
1 caretaker.
9,490
0
50,617 0
60,007 0
36,082 0
96.089 0
Eye Clinic.
S assistants.
1 caretaker.
8,370
0
15,347 0
23,717 0
17,913 0
41,630 0
Clinical laundry.
14,987 0
14,987 0
14,987 0
Instruction in Fo-
900 0
900 0
900 0
rensic Medicine.
* Out-patients' De-
4,300 0
4,300 0
4,300 0
partment for Ear,
Throat, and Neck
Diseases.
Dental Clinic.
3,600 0
3,600 0
2,100 0
6,700 0
Total
87.000
0
240,112 50
327,112 50
207,201 50
534.314 0
t Salaries of the pro-
12 ordinary.
104,200
0
104,200 0
104,200 0
fessors in the Med-
9 extraordinary,
ical Faculty.
and district
superintendent.
Sum total
191,200
0
240,112 50
431,312 50
207,201 60
638,614 0
Number of matriculated medical students according to the average of the summer and
winter sessions, 1910 383
Total expenditure for the year on one medical student 1667 M.
Out of state funds 1126 M.
Anatomical Insti-
1 district
1 preparator.
11,170
0
16,500 0
27,670 0
27,670 0
tute.
superintendent,
1 prosector,
2 assistants.
2 servants.
Physiological Insti-
3 assistants.
2 servants.
8,210
0
8,680 0
16,790 0
16,790 . 0
tute.
1 amanuensis.
Pathological Insti-
2 assistants.
2 servants.
6,120
0
7,965 0
14,085 0
14,086 0
tute.
Pharmacological In-
1 assistant.
1 servant.
3,560
0
4,000 0
7.560 0
7,560 0
stitute.
Hygienic Institute.
1 assistant.
1 servant.
3,960
0
6,260 0
9.210 0
950 0
10.160 0
Clinical Institutes
Medical Clinic :
2 clerks of
61,940
0
183,621 0
245,461 0
332.819 0
578,280 0
(comprising the
1 head physician.
inspection
Medical Clinic, the
6 assistants.
office.
Clinic for Skin Dis-
2 assistant
eases, the Surgical
Skin Clinic:
clerks.
Clinic, and the
4 assistants.
1 machinist.
Women's Clinic).
5 servants.
Carried forward
94,960
0
225,816 0
320,776 0
333,769 0
654,545 0
* Subvention.
+ The average salary of the professors is as at Konigsberg. The salaries of the ordinary professors vary from 4200 to
7500 M., and those of the extraordinary professors from 2600 to 4800 M.
840
APPENDIX
f
1. Bonn University [continued].
Num»)erand Designation
State Contributions
5 to the
Total of
of Uie
Institute for the
estimated
following purposes :
Private
Income and
Income of
the
Expendi-
INSTITUTE.
ture of the
Scientific Offices
Other Offices.
Perso7uxl
Equipment
Total of
Institute.
Institute
(in addition
Expenses.
Expenses.
columns
{columns
to the Director).
It and 5.
6 and 7).
1.
2.
3.
4.
5.
6.
7.
8.
M. Pf.
M. Pf.
M. Pf.
M. Pf. 1 M. Pf.
Brouoht forward
Surgical Clinic :
1 head surgeon,
6 assistants.
Women's Clinic:
1 head doctor,
3 assistants.
94,960 0
225,816 0
320,776 0
333,769 0
664,645 0
Rye Clinic.
3 assistants.
1 caretaker.
6.540 0
9.970 0
16.510 0
87.230 0
53,740 0
Psychiatrical Clinic
1 assistant.
2,100 0
6,400 0
8,500 0
16,170 0
24,670 0
withlReception
Department and
Out-pjitients' De-
partment for Men-
tal and Nervous
Diseases.
Instruction in Fo-
900 0
900 0
900 0
rensic Medicine.
• Out-patients' De-
6,500 0
6,500 0
6,500 0
partment for Ear,
Thrortt, and Nose
Diseases.
• Dental Institute.
2,100 0
2.100 0
2.100 0
Totil
103.600 0
251,686 0
355.286 0
387.1G9 0
742.455 0
t Salaries of the pro-
11 ordinary.
103,060 0
103,060 0
103,060 0
fessors in the Med-
7 extraordinary.
ical Faculty.
and district
superintendent.
Sum total
206,660 0
251,686 0
458,346 0
387.169 0
846,515 0
Number of matriculated medical students according to the average of the summer and
winter sessions, 1910 496
Total expenditure for the year on one medical student 170-t M.
Out of state funds 92i M.
10. MiJNSTER University.
Prefatory Note. By agreement with the town of MUnster, the instruction in the Philosophical Faculty
of the University is so organized that medical students can take all the subjects of their course in that
Facultj' up to the first medical examination. There is no Faculty of Medicine as such. There is an ordi-
nary professor of .\natomyand one of Physiology in the Philosophical Faculty ; there is also an Anatomi-
cal and a Physiological Institute, for which the town of Miinster has provided suitable accommodation.
The city bears the cost of the upkeep of these buildings and the household expenses including domes-
tic .ser\-ice. The state assumes all expenditure for scientific purposes, both on the staff and materials.
Anatomical Insti-
tute.
Physioloffical Insti-
tute.
2 assistants.
1 assistant
2 ordinary.
1 preparator.
5,640 0
1.500 0
7,000 0
3.500 0
12.640 0
6,000 0
12,640 0
6,000 0
Total
t Salaries of the pro-
fcMors.
7.140 0
10,500 0
10,600 0
17,640 0
10,500 0
17.640 0
10.600 0
Sum total
17,640 0
10,500 0
28,140 0
28,140 0
Number of matriculated medical students according to the average of the summer and
winter sessions, I'tlO 206
Total expenditure for the year on one medical student 136 M.
Out of state funds 136 M.
• Snbrention.
• .\\.r i;:- salary of the profeswors ii a.s at Konigsberg. The salaries of the ordinary professors vary from 2600 to
1 those of the extraordinary professors from 2600 to 4800 M.
• salao' of the professors is as at K5nigst>erg.
APPENDIX
341
Explanations.
1 . Salaries of scientific and other offices :
Scientific offices:
Professors and district superintendents. See remarks under each University.
Head physicians and surgeons and prosectors, 2:200 M.
Assistants, 1500 M.
Intermediate offices:
Inspecting officers (controllers, superintendents, secretaries, clerks and cashiers, &c.), 2100
to 4500 M. as maximum salaries attained in 21 years by annual increment; additional allow-
ance for a house when an official residence is not provided.
Departmental offices of the Charite Hospital, 1800 to 4200 M. as maximum salaries attained
in 21 years by annual increment ; official residence according to position.
Assistant clerks, 1650 to 2300 M. as maximum salaries attained in 21 years by annual incre-
ment ; oflBcial residence according to position.
Under offices:
Preparators, 1650 to 2300 M. as maximum salaries attained in 15 years by annual increment;
official residence according to position.
Caretakers in the University Women's Hospitals at Greifswald and Marburg, and the machi-
nist at the Charite Hospital at Berlin, 1400 to 2000 M. as maximum salaries attained in
12 years by annual increment ; official residence according to position.
Mechanical engineers in the University institutes, sacristan, and gardener at the Charite Hos-
pital, 1400 to 2000 M. as maximum salaries attained in 21 years by annual increment;
official residence according to position.
Servants, caretakers, porters, &c., 1200 to 1700 M. as maximum salaries attained in 21 years ;
official residence according to position.
2. Institutes receiving subvention are those in which the Governing Body of the Institute provides
the accommodation and meets the total cost of management, towards which the state makes
only a fixed contribution.
SUMMARY OF GRANTS MADE FOR MEDICAL UNIVERSITY INSTITUTES
1887-1911. EXTRAORDINARY BUDGET.
1. KoNIGSBERG UNIVERSITY.
Grants in the Financial Years 1887-1911 for
INSTITUTE.
Purchase
of Land.
Buildings
and
Fittings.
Instru-
ments and
Apparatus.
Deficits.
Total.
Anatomical Institute
M.
62,600
73,500
120,000
M.
153,100
120,140
138,000
120,145
44,800
474,800
198.400
141,600
320,830
119.600
300.000
6,950
M.
14,500
9,516
9,000
19,485
106,800
13,900
10,000
10,000
6,600
1,000
M.
15.000
2,000
2,090
9.169
80,900
71,345
45,110
M.
235,100
Pathological Institute
131.665
Hygienic Institute
149,090
Pharmacological Institute
139,630
Physiological Institute
44.800
Medical Clinic
657,469
Surgical Clinic
386,100
Women's Clinic
226.845
Eye Clinic
375.940
Ear Clinic
129,500
Clinic for the Insane
426,600
Institute for Forensic Medicine
6,950
Dental Institute
1,000
Total
246,000
2,138,265
200,700
225,614
2,810,579
2. Berlin University and the Charite Hospital.
Anatomical Institute
633,110
352,800
722,900
15.000
31,000
40,000
18,.S00
19,670
666.410
Anatomical-biological Institute
383.800
Hygienic Institute
782.670
Carried forward
1,708,810
86.000
37,970
1.832.780
APPENDIX
2. Berlin UNivERsi-n" and the Charite Hospital [continued].
Grants in the Fin.incial Years 1887-1911 for
INSTITLTE.
Purchase
of Land.
Buildings
and
Fittings.
Inttru- I
mtnts and
.4pparatxLS.\
Deficits.
Brouffht foncard
ratholofhcal Institute
}'h .r.,, iriiiiitrical Institute
r il Institute
Ci •.*■ Department for Internal Medicine
H>iJrollitrapeutic Institute
Outpatients' Department for Pulmonarj- Diseases...
Royal Hospital (Control Department)
In the Koy;il Hospital :
Surpical Clinic and Out-patients' Department
Kyc Clinic and Out-fxitients' Department
Ear Clinic and Out-patients' Department
Institute for Orthopedical Surgery
University Women's Clinic
Out-patients' Department for Throat and Nose Diseases
Dental Institute
Institute for Ront^en Ray Investigations
Charite Hospital (General)
I. Medical Clinic
II. Medical Clinic
Institute for Cancer Research
Surfdcal Clinic and Out-patients' Department of the
Charite Hospital
Clinic for Psychiatrical and Nervous Diseases
Women's Clinic of the Charite
Clinic and Out-patients' Department for the Diseases
of Children
Clinic for Skin Diseases
EyeClinic and Out-patients' Departmentof the Charite
Clinic for Throat and Nose Diseases
Clinic and Out-patients' Department for Diseases of
the Eat
Out-patients' Medical Department of the Charite....
Total 1.067,410 16,2&1.6S5
M.
17,930
300,000
439,480
300,000
M.
1,708.810
1,909,600
26.700
88,000
1,018,800
418,550
618.000
5.700
14.300
335.970
660.000
12.850
2.084,026
2.018,660
53.000
1.219.700
1.501.300
426,300
687.200
655,600
243.900
548.800
M.
86.000
5i.400
14.000
64.500
21.000
4,450
27,000
2.400
19,000
22.600
45.000
147.500
40.000
18.000
15.000
90.000
6.000
11.900
42.000
729.650
M.
87.970
4,600
26.800
22,800
12,000
96.800
364.600
1,800
65,890
1.600
81.700
2,563.470
188.000
10.000
21,600
2,000
53.000
4.600
TotaL
M.
1.832.780
1.368.600
39.71K)
178.300
1.062,600
4.450
12.000
533.280
1,209.500
5.700
16.100
2.400
410.860
1.600
1,063,680
12,850
4.937.495
2.063.550
147.500
241,000
1,269,700
1.519.300
447,800
604.'200
698.600
5.000
266.800
690,800
4.500
3.487,830 I 20,629,545
3. Greifswald University.
Anatomic.ll Institute
215.150
116.4<:>0
i7.eoo
73.900
71.950
455.090
66.960
787.278
386,570
83.700
7.000
722.800
21.600
8.000
14.000
16.000
2.300
36.000
22.000
9.000
3.000
6.000
3.000
15.600
4.000
4.000
2.000
16.000
46,400
66,680
16,636
26.890
141,900
Pathological Institute
22,600
Hygienic Institute
30,000
Pharmacological Institute
73,900
pj . . , .: ..^1 Institute
87,950
I: lIospitaKbothMedicaland Surgical Clinics)
Ml I ..nic
717,940
92.960
Surgical Clinic
809,273
Women's Clinic
462.250
Eye Clinic
102,336
Out-patients'Department for Skin Diseases
6.000
Oiilflren's Clinic
10.000
Clinic for Psychiatrical and Nervous Diseases
766.190
Dental Institute
4.000
ToUl
216 160 ' 9 r:a fxt
154.300
176,605
3.326.288
4. Bresl.\u University.
A itiitc
190.000
37.200
661.100
262.600
180.000
161,200
299.200
693.040
726.280
19.800
14.500
20,200
8,000
15,000
4,600
21.000
4.800
8,480
22.500
2.700
239,960
676 200
r -itute
285,480
II •
222 700
1' •.itute..i
171,900
1'! . ..^le
314 200
Climral Innitute* (Control Department)
1.027.490
Medical Clinic
783,480
Carried foncard
227.200
2.872.320
103.000
277.930
3.480.460
APPENDIX
343
4. Breslau University [continued].
Grants in the Financial Years 1^7-1911 for
INSTITUTE.
Purcfiaae
of Land.
Buildings
and
Fittings.
Instru-
ments and
Apparatus.
Deficits.
Total.
Brought forward
Surg-ical Clinic
Women's Clinic
Eye Clinic
Ear.Clinic connected with Out-patients' Department
Clinic for Skin Diseases
Children's Clinic
Clinic for Psychiatrical and Nervous Diseases
Institute for Forensic Medicine
Dental Institute
Total
M.
237,200
160,000
M.
2.872.320
798.800
612.750
258,000
175.200
419.8150
248.000
862.6.50
17.860
13.000
M.
103.000
16.700
10.000
15,900
5.800
12.000
8.000
377,200 6.178.420
171.400
M.
277,930
14.000
40.000
10.665
6.410
2.670
3.51.675
M.
3.480.460
798,800
529.450
272.000
185.200
476.750
2&1.466
1,031,060
17,850
23,670
7,078.695
5. Halle University.
Anatomical Institute
Pathological Institute
Hy^enic Institute
Pharmacological Institute
Physiologrical Institute
Clinical Institutes (Control Department)
Medical Clinic
Surffical Clinic
Women's Clinic
Eye Clinic ,
Ear Clinic
Clinic for Skin Diseases ,
Clinic for Psychiatrical and Nervous Diseases.,
Dental Institute ,
Total
32.000
8.000
40.000
52.000
62.000
32.600
21.500
64.100
57.800
14.000
71.800
2,600
2.600
282,660
33.000
90.100
405.760
246,060
28.500
274.5.50
113,460
113,460
279,400
12.990
5,000
9,150
301,640
6.000
66.200
7,000
65.200
7,000
296.512
916,530
14,100
1,000
16,170
1.242,312
1,000
296.512
2.069.300
146.090
115.420
2.626.322
6. Kiel University,
Anatomical Institute
Pathological Institute
Hygienic Institute
Pharmacological Institute
Physiological Institute
Academical Medicallnstitutions (Control Department)
Medical Clinic
Surgical Clinic
Women's Clinic
Eye Clinic
Out-patients' Department for Diseases of the Elar
Clinic for Diseases of the Skin
Children's Out-patients' Department
Clinic for Psychiatrical and Nervous Disea.ses
Institute for Forensic Medicine
Dental Institute
Total
172.0.50
6.000
507.700
10.400
161.360
17.000
43.300
12.000
23.900
172,600
228.600
76,000
273.700
18,000
97,300
834.870
25,000
421.260
7.000
378.400
10.000
1.070
96,000
79,200
10.000
6.000
134,000
1,116,000
14.000
6.000
1.000
574.800
4.230.230
140,470
1,790
342.900
35.770
380,460
177.050
519.890
168.350
66.300
23.900
743.900
366.700
957.170
428.260
388,400
1,070
185.200
5.000
1.299.770
6.000
1.000
5.3-25.960
7. GoTTiNGEN University.
242.600
217.600
26.000
15.000
3.330
393,150
703,650
21,000
11.200
10.000
11.000
23.000
11,850
3,000
1,600
324,610
266.600
Patholoe'ipfll Institute
228.700
T-Tv^ipnir' Institiitf*
35.000
27.500
PIivftiolft^ipAl Trmtitutf*
26.330
717.000
Medical Clinic
n6.466
Ccmricd forifavd
i.eoo.130
88.0,50
329.010
2.017. liO
344
APPExNDIX
7. GoTTiNGEN University [conti}iued'\.
INSTITUTE.
Grants in the Financial Years 1887-1911 for
Purchase
of Land.
Buildings
and
Fittings.
Instru-
ments and
Apparatus.
Deficits.
Total.
M.
M.
M.
M.
M.
1,600.130
541,000
588,9,t0
373,l'.t0
15,500
88,060
6,100
329,010
6.000
9.580
2,017,liK)
541,000
694,950
387,870
16,500
49.060
20,000
2,000
1,000
61,050
20.000
1,000
3.187,820
96,160
344,690
3,628,660
BrouoM forward
Surirical Clinic
Women's Clinic
Eye Clinic
Out-pnticnts' IX-partment for Diseases of the Ear
Psychiatrical Clinic witli Reception Department and
Out-paticnls' Department for Mental and Nervous
Diseases
Institute for Forensic Medicine
Dental Institute
ToUl
8. Marburg
iG University.
620,000
6,000
4,000
630,000
146,880
146,880
30,050
57,800
71,900
159,750
34.360
9,000
43,860
128.730
3,000
131,730
33,776
81.050
114,826
161,450
13,300
63.656
228.406
918.300
10,000
76,500
1,004,800
295.030
35,200
330,230
39.500
13.850
63,850
18,500
18,600
41,940
41,940
9.500
6,000
15,600
76,716
2,473,340
106,100
265,106
2,919,262
Anatomical Institute
PatholoKical Institute
Hygienic Institute
Pharmacological Institute
Physiological Institute
Clinical Institutes (Control Department)
Medical Clinic and Out-patients' Department
Surgical Clinic and Out-patients' Department
Women's Clinic
Eye Clinic
Out-patients' Department for Diseases of the Eiir
Psychiatrical Reception Departmentand Out-patients'
D<.p.irtmeiit
Dental Institute
Total
9. Bonn University.
Anatomical Institute
14,600
170.000
44,100
32.960
44.800
64,900
358,300
321,900
496.630
144.886
361,270
6,000
129,600
169,220
26.000
15,000
22.200
2.500
46,000
22,250
14,500
3,600
26,000
25,600
1,000
8,500
9,124
18,785
86,110
204,500
59,100
64.284
47,300
129,686
457,910
,344,160
510,180
148,386
861,270
6,000
164,500
194,720
1.000
Pathological Institute
Hygienic Institute
Pharmacfilogical Institute
Physiological Institute
Clinical Institutes (Control Department)
Medical Clinic
Surgical Clinic
Women's Clinic
Eye Clinic
Out-patients' Department for Diseases of the Ear
Clinic for Diseases of the Skin
Psychiatrical Clinic with Reception Departments and
Out-patients' Department for Mental and Nervous
Dineases
Dcnt-il Institute
Total
14,500
2,332.466
203,450
121,619
2,671,934
10. MiJNSTER University,
At
Institute
8,000
8,000
31,460
2,000
34,460
10,000
PI.
il Inotitiite
ToUl
11,000
3,3.460
44,460
APPENDIX
345
General Grants for Medical University Institutes (Financial Years 1887-1911).
M.
Contributions for Rontgen ray investigations 98,000
For instruments and apparatus of Out-patients' Departments receiving subvention 16,000
For instruments and apparatus for Instruction in Forensic Medicine 58,000
For mechanical medical instruments and apparatus 15,000
For the supply of instruments and apparatus for Dental Instruction 61,000
For supplementing the provision of the apparatus of non-clinical medical University Insti-
tutes 40,000
For the provision of the apparatus of University Clinics and Out-patients' Departments . . . 2-20,000
Total 508,000
CLASSIFICATION OF THE EXPENSES NECESSARY FOR THE STUDY OF
MEDICINE IN THE BAVARIAN UNIVERSITIES
ACCORDING TO THE ESTIMATES FOR THE YEAR 191O-1911.
UNIVERSITY.
Expenses
for the
Teaching
Staff.
Expenses for Medical Institutes.
Institute.
Amount.
Remarks.
Munchen.
Wurzburg.,
M. Pf.
167,814 41
128,507 0
Anatomical Institute
Eye Clinic
Surgical Clinic
II. Gynsecological Clinic
Institute for Histological Embryology
Hygienic Institute
Institute for Forensic Medicine
Medical Clinical Institute
I. Medical Clinic
II. Medical Clinic
Otiatrical Clinic
Pathological Institute
Pharmacological Institute
Physiological Institute
Psychiatrical Clinic
Out-patients' Departments
Clinic for Venereal Diseases
Dental Institute
Diagrams of Remarkable Cases
Hospital
Women's Clinic
Children's Clinic
Anatomical Institute-GeneralKonservatorium
Physiological Institute - General Konservato-
rium
Total
Anatomical Institute
Hygienic Institute
Pathological Institute
Pharmacological Institute
Physiological Institute
Demonstrations in Forensic Medicine
Eye Clinic
Surgical Clinic
Women's Clinic
Medical Clinic
Clinic for Skin Diseases
Out-patients' Department for Otiatrical Dis-
eases
Out-patients' Department with Children's
Clinic
Psychiatrical Clinic
Rhino-laryngological Clinic
Dental Institute
Total
M. Pf.
79.143 91
60.039 96
38.040 0
4,800 0
20,610 0
29,593 77
6,100 0
44.371 33
11,927 50
13,227 50
8,100 0
29.913 44
15,606 67
8,858 36
98,608 60
88,869 40
2,768 0
63,200
1,000
966
67,232
46,405
14,218 26]
12,772 Oj
766,172 35
36,336 60
12,800 0
35,263 33
9.200 0
14,588 0
80 0
61,274 50
36,810 50
97,560 0
16,406 0
14,975 0
11,680 0
10,595 67
60,656 0
8,510 0
9,299 33
426,023 83
In Anatomy and the
Physiological Insti-
tute in Munchen,
one part of the al-
lowance is provided
for in the estimates
of the University
and another part in
the estimates of the
General Konserva-
torium.
346
APPENDIX
UNIVERSITV,
Expenses
/or the
Teaching
Staff.
Expenses for Medical Institutes.
Institute.
Amount.
Remarks.
Erlangcn .
Summary:
Mum lien...
Wurzburg..
Erlanfreri...
Total
M. Pf.
96,119 16
167,814 41
128.607 0
96,119 16
381,440 57
An.itomical Institute
Ivir Clinic
Women's Clinic
Hygienic and Bacteriological Institute
Children's Clinic
Hospital
Rar Clinic
Pathological Anatomical Institute
Pharmacolofrical Institute
Physiological Institute
Psychiatrical Clinic
Dental Institute
Total
Sum total
M. Pf.
19,904 0
62,662 66
81,989 17
8,983 33
32,970 0
137,063 66
7,600 0
18.112 0
16.776 0
14.377 0
8,633 33
9,750 33
418.721 48
766,172 35
426.023 83
418,721 48
1,610,917 66
381,440 67
l,992,a58 23
INDEX
INDEX
Aberdeen, University of, 54, 204, 206, 269.
Income, 300.
Women, 326.
Abernethy, 12.
Addison, 13, 129.
Age of medical students in Germany, 32.
Agrigis, 22, 223, 225-228, 230.
Algiers, University of, 30.
Althoff, 295, 319.
Anatomical :
Aquarium, 76.
Demonstration, rarity of, 3.
Institutes, 74-81.
Laboratories, 76.
Libraries, 75.
Material, 77, 78.
Museums, 75.
Photographic outfit, 76.
Teaching staff, 76.
Anatomy, 3, 4, 22, 26, 59, 62, 275.
Cost of teaching, 289, 290, 302, 303.
in England, France, and Scotland, 12, 1 13-
120.
in Germany, 73-81, 240.
Angers, Medical School of, 30.
Animal experimentation, 9.
Anti-vivisection legislation, 123, 127, 138, 197.
Apothecaries' Act, England, 1815, 11.
Aquarium, anatomical, 76.
Athletics, 118.
Auscultation, 5.
Austria, early medical distinctions in, 10.
Legal medicine, 107.
Medical education in, 25, 61, 93.
Autopsies, in England, 133, 135, 136.
in Germany, 95-104.
in legal medicine at Vienna, 107.
liacteriologj', 105, 106.
in England, 138.
Baden, ratio of physicians in, 18.
Baillie, Matthew, 13, 129.
Barlow, Sir Thomas, 195.
Basel, University of, 147.
Bavaria, ratio of physicians in, 18.
Behring, von, 107.
Bell, Charles, 188.
Bell, Sir Charles, 134, 188.
Bell, John, 114. ^
Berlin, University of, 3, 5, 7-0, 20, 22, 23, 37,
61, 109, 288, 289, 292, 296, 318, 320.
Anatomy, 74-80.
Autopsies, 96, 102, 103.
Clinical teaching, 146, 147, 149, 154, 156,
159-161, 164, 177-179, 182, 183, 185, 186,
Cost, 329, 331-333, 341, 342.
Curriculum, 244, 245, 248, 249,
Hygiene, 106,
Legal medicine, 108.
Pathology, 94, 98, 104.
Pharmacology, 89, 90, 107.
Physiology, 82, 84, 86.
Salaries, 293.
Women, 324.
Bernard, Claude, 120.
Besan^on, Medical School of, 30,
Besredka, 140.
Billroth, Albert C. T., 25, 99.
Quotations, 24, 86.
Biology, 42, 48, 57, 59, 61-63, 67, 69, 273.
Birmingham, University of, 45.
Clinical teaching, 203.
Cost, 302, 303.
Income, 300.
Women, 325.
Boerhaave, Hermann, 4, 6, 91.
Bonn, University of, 23, 37, 75, 290, 318.
Clinical teaching, 160.
Cost, 329, 330, 339, 340, 344.
Salaries, 293.
Bordeaux, University of, 30.
Botany, 240.
Bowman, 129.
Brauer, 147.
Breslau, UNivERSiri' OF, 3, 9, 23, 37, 61, 109.
Autopsies, 96, 103.
Clinical teaching, 147, 154, 155, 160, 164,
181, 184.
Cost, 329, 334, 335, 342, 343.
Curriculum, 244.
Hygiene, 106.
Legal medicine, 108.
Salaries, 293.
Bright, 13, 129.
Bristol, L^niversity of:
Cost, 303.
Income, 300.
Women, 325.
350
INDEX
Brodic. Sir Benjamin, 1-2, 191.
Brunton, Lauder. 127, ISS.
Bnissrus L'sivKHsrrv ok, 324.
Buihheira, Rudolf, s<9.
Burdon-Sanderson, 120.
California, laws regulating medical practice,
xiii.
CAlmette, IW.
Cambridge. Uviveusitv of. 14. 13, 4o, 30, 31,
53, 34, 66. 67. 114, 136, 203, 209, 269-271,
281, 283, 300, 324.
Anatomy, 118, 126.
Bacteriologj-, 138, 139.
Cost, 303.
Patholog)-, 134.
Pharmacologj', 1-27.
Physiology, 120, 123, 124.
Champneys, Sir Francis, 195.
Charcot, 138, 224.
Charing Cross Medical School, London, 66,
138, 139, 194, 198.
Anatomy, 117.
Clinical teaching, 203, 205.
Laboratories, 196.
Pathologj-. 129, 132, 134.
Pharmacology, 128.
Chauffard. -2-2^, 229.
Chemistry, 3, 42, 48, 57, 59, 61-63, 67-€9, 273,
275.
in Germany, 240.
Cheselden, 188.
"Christian Science," 312.
Clark, Sir Andrew, 307.
Classics, 42.
Clinical teaching, x, xiii, 3, 4, 6, 8, 9, 14, 15, 22.
in England, 188-219.
in France, 220-232.
in Germany, 145-187.
Cohnheira, 99.
Cooper, Sir Astley, 134, 188.
Copenhagen, U.vrvERsrrv' of, 334.
Cor\-isart, 5.
Countrj- physicians, xvi, xvii.
Cullen, 188.
Curie, Pierre, 70.
Curriculum, early medical, 8.
France, 295, 286.
Germany. 233. 266.
Great Britain, 267-285.
Overburdening of medical, ix, 64.
Currie. Sir Donald, 134, 304.
Curschmann, 178, 179.
Cushny, 127.
JJarwin, 12.
Dav5% 12, 41.
Dermatolog}-, 8.
Dewey, 168, 171.
Diagnosis, 167.
iJiener, 60.
Dissection, at Berlin, 80.
at Edinburgh, 115.
in German uni%'ersities, 77, 78.
at Paris, 120.
Prejudice against, 3.
DORPAT, UxiVERSI-Ti" OF, 3.
Pharmacology, 89.
DrBLiK, Apothecaries' Hall of, 268, 279, 281.
DuBux, CoxjoiNT Board or the RoyalCollzge
OF, 48.
DUBUK, UxiVERSITi' OF, 51.
Dundee, U.vivERsrri' of, 204.
Cost, 302.
Women, 326.
DuRHA.M, University of, 4.5, 54, 283.
Women, 325.
Dusseldorf, Academy of, 319.
Jcjclectic sect in medicine, xiv.
Edinburgh, Extra-Mural School of, 68, 188,
307.
Anatomy, 115, 119, 124.
Clinical teaching, 213, 214.
Pathologj-, 136.
Edinburgh, Royal College of Physicians and
Surgeons, 268.
Edinburgh, Royal Infirmary of, 188, 198.
Clinical teaching, 213.
Laboratories, 196, 197.
Edinburgh, L'mversit^' of, 4, 8, 13, 15, 2^, 52,
34, 66, 188, 193, 195, 203, 215, 269, 283.
Anatomy, 114, 119.
Clinical teaching, 204-206, 213, 214.
Cost, 303.
Hygiene, 139.
Income, 300.
Legal medicine, 140.
Pathologj-, 129, 131, 136.
Physiologj-, 122, 123, 126.
Women, 325.
Ehriich, 88.
Elementarj' education, need of, for medical edu-
cation, vii, viii.
INDEX
351
Embryology, 6, 120.
Engineering education, analogy to medical edu-
cation, vii, viii.
England, medical education in, x, xi, xiii, xv,
xvi, 9-15, 26, 44-57.
Anatomy, 113-120.
Clinical teaching, 188-219,
Curriculum, 267-285.
Examinations, 267-285.
Graduate teaching, 321, 322.
Pathology, 128-138.
Pharmacology, 127, 128.
Physiology, 120-127.
Preliminary sciences to medicine, 65.
Quackery, 315, 316.
Women, 324, 325.
England, Royal College of Surgeons of, 268.
Erlangen, University of:
Anatomy, 76-78.
Autopsies, 102.
Clinical teaching, 186.
Cost, 346.
Pathology, 98.
Examinations, medical, x, xi.
in general education, 48.
in Germany, 238-266.
in Great Britain, 267.
of Conjoint Board, 275-278.
Experimental pathology', 8.
Famulus, 176-179, 182.
Faraday, 12, 40.
Fees, medical, xviii.
Fees, university, 294, 295.
Financial aspects of medical education, 287-307.
Financial rewards of medical practice, xvii.
Flexner, Abraham, author of bulletin, v, vi.
Foster, Michael, 120, 121, 123.
Fothergill, John, 4.
France, medical education in, 12, 15, 30, 57, 58,
70.
Anatomy, 113-120.
CUnical teaching, 220-232.
Curriculum, 285, 286.
Graduate teaching, 321, 322.
Hygiene, 140.
Pathology, 128-138.
Physiology, 120-127.
Frankfort, proposed university of, 288.
Fraser, 127, 188.
Freiburg, University of, 20, 21.
Curriculum, 247. ^
Frerichs, 9.
Fry committee, 305.
Cialen, 3.
General Medical Council, England, 11, 47,50,
55, 56, 65, 69, 268, 272, 273, 279-281, 324.
General pathology, 8.
General surgery, 8.
Geneva, University of, 324.
German, knowledge of, in England, 54.
Germany, medical education in, ix, x, xiii, xv,
x\i, 7-10, 12, 108-112.
Anatomy, 73-81.
Clinical teaching, 145-187.
Curriculum, 233-266.
Education of women, 323, 324.
Examinations, 238-266.
Graduate teaching, 317-321.
Hygiene, 104-107.
Legal medicine, 107, 108.
Mediaevalism in, 4.
Pathology, 91-104.
Pharmacology, 87-91.
Physiology, 82-87.
Quackery, 310-315.
Ratio of physicians to population, 17, 18.
Sciences prehminary to medicine, 57-65.
Gibson, 188.
GiESSEN, University of, 3, 22, 24, 95, 288, 289,
292.
Anatomy, 75, 79.
Autopsies, 97.
Chnical teaching, 157, 160.
Gifts to medical education, xviii, xix.
Glasgow, Royal Faculty of Physicians and
Surgeons of, 268.
Glasgow, Uni\t:rsity of, 15, 54, 66, 206, 269,
270, 283, 307.
Anatomy, 115, 116.
Chnical teaching, 204, 205, 213, 214,
Cost, 302.
Income, 301.
Legal medicine, 141.
Pathology, 129, 131-134.
Pharmacology, 127.
Physiology, 121-123, 126.
Salaries, 302.
Women, 326.
Glasgow, Western Infirmary of, 199, 200.
Gottingen, University of, 23, 37, 288, 290,
291, 318.
Autopsies, 97.
352
INDEX
GbmKGEW, University or, clinical teaching,
158, 160.
Cost, 3^, 330, 337, 338, 343, 344.
Hygiene, 106.
Legal medicine, lOS.
Pharraacologj', 89.
Salaries, 293.
Graduate teaching:
England, 331. 322.
France, 321, 322.
Germany, 317-321.
Graduation, amount of annual, in Germany, 23.
in England and Scotland, 26.
Gba2, Uxiversity of, 11, 290.
Anatomy, 78.
Clinical teaching, 151, 154, 157, 162, 186.
Hygiene, 106.
Legal medicine, 107.
Pathology, 95.
Greifswald, Umveusitvof, 21, 23,37,146,289,
291, 318.
Anatomy, 77.
Autopsies, 97.
CUnical teaching, 147, 155, 158, 160, 162,163,
182, 184.
Cost, 3-29, 333, 334, St2.
Hygiene, 106.
Legal medicine, 108.
Pathology, 104.
Pharmacolog)', 89.
Physiology, 82, 85.
Salaries, 293.
Ginr's Hospital School, London, 52, 138, 188,
198, 199, 218, 304, 306.
Anatomy, 115, 117.
CUnical teaching, 193, 204, 206, 209-211,
213, 217.
Legal medicine, 141.
Patliology, 128, 131-13t.
Pharmacolog)', 128.
Physiology, 122, 123, 126.
Gymnasium, curriculum of, 32-44.
Gynecology, 8.
IlALLE, UvivERsm- OF, 9, 23, 37, 318.
Anatomy, 76.
Clinical teaching, 160.
Cost, 329, 330, 335. 336, 343.
Pharmacology, 89.
Salaries, 293.
Halliburton, 126.
HarTcy, 7, 188.
Hauseman, van, 104.
Heidelberg, University of, 9, 21, 24.
Clinical teaching, 163.
Legal medicine, 108.
Pharmacology, 89.
Physiologj', 82.
Helmholtz, 5, 37, 40, 41.
Herbart, 177.
Hering, 157.
Hippocrates, 3, 6.
His, Wilhelra, 79, 147.
Histological methods, 9.
Histology, 74, 78, 101, 124.
at Berlin, 80.
at Lyons, 120.
at Munich, 80.
Hochstetter, 78.
Hodgkin, 13, 129.
Homeopathy, xiv, 88, 308, 309.
Home, Everard, 12.
Horsley, Sir Victor, 126, 188.
Hospital year in Germany, 179, 180.
Hospitals, xiv-xvi, 3.
English, 12, 13, 129, 188-219, 306.
French, 220-232.
German, 93, 100, 149-187, 189, 198.
Humboldt, Wilhelm von, 7, 8.
Hunter, John, 7, 12, 131, 134, 188, 191.
Hunter, William, 191.
Huxley, 12, 121, 128.
Hygiene, 8.
Cost of, 289, 290.
in England. 139.
in Germany, 104-107.
HyrtI, 76.
Illinois, laws regulating medical practice, xiii.
Innsbruck, University of, 11, 290.
Legal medicine, 107.
Internal medicine, 8.
Ireland, Conjoint Board of, 281, 2S3.
Jenner, Edward, 12, 188.
Kiel, UNrvEHsm- of, 9, 21, 23. 37, 288.
Cost, 329, 330, 336, 337, 343.
Legal medicine, 108.
Salaries, 293.
King's College, London, 14, 53, 66, 138, 188,
198, 216, 305.
Anatomy. 1 16.
Cost. 302, 303.
INDEX
353
King's College, income, 300.
Pathology, 134.
Pharmacology, 127.
Physiology, 122, 126.
Koch, 105.
Koenig, 147.
KoLN, Academy of, 319.
KOKIGSBERG, UNIVERSITY OF, 23, 37, 288, 289,
296.
Anatomy, 75.
Clinical teaching, 160.
Cost, 329-331, 341.
Legal medicine, 108.
Salaries, 293.
Kraepelin, 111, 162.
Kraus, 158.
Krehl, 192.
Kuttner, 184.
-L/aennec, 5.
Langley, 127.
Latin, medical teaching in, 3, 62.
Laveran, 140.
Laws regulating admission to practice of medi-
cine, xii, xiii.
Laycock, 195.
Layman, responsibiUty of, in medicine, xii.
Lecture method in medicine, 2-2.
Lectures, 61, 110.
in anatomy, 78.
in Germany, 170.
Leeds, University of:
Cost, 303.
Income, 300.
Women, 325.
Legal medicine, 107, 108, 140.
Leipzig, University of, 9, 20, 65, 289, 291, 320.
Anatomy, 75-78.
Autopsies, 96, 97, 103.
Clinical teaching, 149, 152, 159, 177-179,
181, 184, 185.
Curriculum, 241-245, 247, 249.
Hygiene, 105.
Legal medicine, 108.
Libraries, 97.
Pathology, 94, 95, 98.
Pharmacology, 89.
Physiology, 82, 83.
Leyden, University of, 4.
Libraries, anatomical, 75.
at Leipzig, 97.
Liebig, 3. ^
Liebreich, M. E. Oscar, 89.
Lille, University of, 28, 30.
Anatomy, 116, 119.
Patliology, 137.
Physiology, 122.
Lister, Lord, 188, 195.
Lister Institute, 138.
Liverpool, University of, 26, 27, 51, 66, 67, 198.
Anatomy, 115, 116.
Clinical teaching, 204-206, 210.
Cost, 302-304.
Hygiene, 139.
Income, 300.
Legal medicine, 141.
Pharmacology, 127.
Physiology, 123, 126.
Women, 325.
London, Apothecaries' Society of, 48, 52, 268-
271, 279, 280, 324.
London, Conjoint Board of, xi, 48, 52, 53, oo,
65, 68, 118, 119, 268, 271, 273,279, 280, 283,
307.
Examinations, 269, 275-378.
London, Royal College of Physicians of, 268.
London, University of, 14, 27, 49, 51-53, 66, 68,
216-218, 269-272, 279, 281, 283, 306.
Anatomy, 118.
Women, 3-35.
London Hospital School, 138, 188, 189, 195,
199, 218, 306.
Anatomy, 117.
Clinical teaching, 193, 203, 205-210, 213.
Legal medicine, 141.
Pathology, 129, 132.
Pharmacology, 128.
Physiology, 126.
London School of Medicine for Wojien, 117,
325.
Louis, 5.
Ludwig, Karl F. W., 9, 82, 120, 148.
Lyc4es, French, 57.
Lyons, University of, 30, 71.
Anatomj-, 115, 120.
Hygiene, 140.
Legal medicine, 141.
Pathology, 137.
JVlackenzie, James, 195.
Mackintosh, Donald, 199.
Mall, quotation, 74, 79.
Manchester, University of, 66, 67, 142, 195,
198, 269, 306.
So4
INDEX
Manchester, Uxivehsity of, anatomy. 115, 116.
Clinical teaching. i0^i06, :?10, JIl.
Cost, 3l>^, 31)3.
Hygiene, 139.
Income, 300.
L-iboratories, 196.
ratholog>-, 131-13+.
Physiologj', li^-US.
Women, S;?5.
Manson. Sir Patrick, 138.
Manual methods, discrimination against. 3.
Marburg, UxiArzRsrrr of, ^, 24, 95, 109, -290,
?92.
Anatomy, 76-79.
Autopsies, 97.
Clinical teaching. IW. 147. 155, 15S, 160, 1S5.
Cost, 329, 330. 338, 339, 344.
Hygiene, 106. 107.
Legal medicine, lOS.
Patholog}-, 98, 104.
Pharmacology-, 89.
Physiolog}', 86.
Salaries, 293.
Marchand, 96, 103.
Marfan, 228.
Marie, Pierre, 224, 229.
Marsoi-les. Medical School of, 30.
Massachusetts, laws regulating medical prac-
tice, xiii.
Materia Medica, 8.
Early teaching in England, 12.
Mathematics, 42, 63.
Mediaeval universities, 3.
Medicine in, 5, 6.
Metaphysics, baneful influence of, 4-6, 8, 9, 12.
Metchnikoff, 140.
Middlesex Hospital School, 138, 141, 188, 199,
306.
Clinical teaching, 204-206, 209, 210.
Laboratories, 197.
Pathologj-. 129. 132-134.
Pharmacology, 128.
Midwiferj-, former regulations in Prussia in re-
gard to, 10.
Early teaching in England. 12.
Migration of German medical students, 21.
Minkowski, 103, 147.
Missouri, laws regulating medical practice, xiii.
Modem medicine, essence of, 6.
Monro, .\lexander. primus (1697-1767). 4. 114.
188.
Monro, Alexander, secundus (1733-1817), 9, 114,
188.
Moxtpelier, University of, 30.
^lorphology, 6.
Morris, E. W.. quotation, 189.
Miiller, Friedrich, 9, 146, 153, 163, 167, 170.
Miiller, Johannes, 5, 8, 9.
Munich, Uxiversitv of, 9, 20-23, 288, 291, 320.
Anatomy, 75-80, 290.
Autopsies, 96, 102.
Clinical teaching, 150, 152, 159, 160, 162,
163. 170, 177, 181-186.
Cost, 345, 346.
Curriculum, 244, 249.
Hj'giene. 104.
Legal medicine, 108.
Pathology, 93, 98.
Physiology, 82, 83, 86, 125.
MuxsTER, Uxiversitv of:
Cost, 329, 330, 340, 344.
Museums, Anatomical, 75.
Pathological, 98, 134.
^AXCY, Uxivt:rsity of, 30, 117.
Naxtes, Medical School of, 30,
Naunyn, 9.
New York, laws regulating medical practice,
xiii.
Nicholas. 117.
Noorden. von, 147.
Number of physicians necessarj-, 16.
Nursing :
English, 201.
German, 166.
Obstetrics, early lack of, 5, 10, 11.
Practice in England, 209.
Ophthalmologj", former Prussian regulation re-
garding, 10, 11, 95.
Orth, quotation, 101.
Orthopaedics. 8.
Osier, Sir William, 195, 197, 198, 211.
Osteopathy, xiv.
Ostwald, 37, 79, 103, 172, 177.
Oxford, Uxiversity of, 14, 15, 45, 50. 51, 54,
66, 114, 136, 195, 205. 209, 300, 324.
.\natomy, 116, 118, 126.
Bacteriology, 139.
Patholog>', 134.
Pharraacolog}', 128.
Physiolog}-, 1-20.
INDEX
355
x ADUA, University of, 4.
Pagel, 62.
Pare, 3.
Paris, U.viversity of, 4, 30, 70, 143, 144.
Anatomy, 115, 117, 120.
Clinical teaching, 220.
Hygiene, 140.
Legal medicine, 141.
Pathology, 137.
Physiology, 122.
Women, 324.
Pasteur institutes, 140, 226.
Pathological anatomy, 8.
Pathological Institute of Berlin, 98.
Pathological Institute of Leipzig, 94, 98.
Pathological museums, 98, 134.
Pathology, 3, 8-10, 59, 64.
Cost of, 289, 290, 302.
in England, France, and Scotland, 128-138,
271.
in German universities, 91-104.
Paton, 124.
Payr, 184.
Pediatrics, 8.
Percussion, 5.
Perry, Sir Cooper, 199.
Pettenkofer, von, 104.
Pharmacology, beginning of, 3.
Cost of, 289, 290.
in England, France, and Scotland, 127, 128.
in Germany, 87-91, 95.
Photographic outfit, anatomical, 76.
Physicians, ratio of, to population :
in Austria, 25.
in France, 31.
in Germany, 17.
in Prussia, 17.
in other German states, 18.
in United Kingdom, 29.
Physics, 42, 48, 57, 59, 61-63, 67, 69, 240, 273, 275.
Physiological chemistry, 8.
Physiology, 3, 6, 8, 10, 13, 59, 62, 64, 275.
Cost of, 289, 290, 302, 303.
Great schools of, German, 9.
in England, France, and Scotland, 120-127.
in German universities, 82-87, 240.
Pick, 104.
Pragi-e, University of, 11, 28, 100, 290.
Clinical teaching, 157.
Legal medicine, 107.
Praktikant, 174-180, 182-184, 248.
Preceptors, College of, 48-50, 52, 54.
Preliminary sciences for medicine, viii, ix, 3, 6,
42, 59-72.
Prevost, 138.
Proprietary medical schools, xvi, 16, 28, 29, 55,
67, 142.
Prussia, ratio of physicians to population, 17.
Prussian universities, 4.
Medical regulations, former, 10.
Psychiatry, 8, 161.
Purkinje, 3.
(c^uacks :
England, 315, 316.
Germany, 310-315.
xVamsay, Sir William, 49, 66.
Recklinghausen, von, 98.
Rennes, Medical School of, 30.
Research institutes, 111.
German, 166.
Richet, 122.
Ringer, 127.
Ritchie, 136,
Rokitansky, Carl F. von, 5, 92, 93.
Rome, University of, 324.
Rostock, University of, 20.
Anatomy, 75, 76, 78, 79.
Pharmacology, 89.
Roux, 140.
Royal Free Hospital School, 139, 305.
Clinical teaching, 210.
Pathologj-, 132.
Women, 325.
Ruckert, J. M. Friedrich, quotation, 76.
Rutherford, 188.
OT. Andrew's Universiti' :
Income, 300.
Women, 326.
St. Bartholomew's Hospital, London, 12, 52,
138, 188, 195, 200, 218, 306, 321.
Anatomy, 115, 117, 118.
Clinical teaching, 193. 204-207, 210-213.
Legal medicine, 141.
Pathology, 129, 132-134.
Physiology, 122, 123.
St. George's Hospital School, London, 12, 66,
139, 141, 188, 194.
Clinical teaching. 203. 204. 206, 210, 213, 217.
Laboratories, 196, 197.
Pathology, 129.
856
INDEX
St. Maby's Hospital School, London, 138, 141,
198, ^X). 306.
Anatomy, 116. 117.
Clinical teaching. 157, 205, 206, 209, 210.
Patholopj-, 128, 132, 134.
St.Tuomas's Hospital School, 52, 138, 141, 189,
1!»8-2CK).
Anatomy, 117.
Clinical teaching. 204, 206. 207, 209.
Pathology, 134.
Physiology-. 126.
Saxony, ratio of physicians in, 18.
Schiifer, 126.
Schelling, 4.
Schmiedeberg. J. E. O., 89.
Science teaching in English universities, 66.
Scientific viewpoint, introduction of. 5-7, 9, 13.
Scotland, Edixational Institute of, 49, 50, 55.
Scotland, medical education in, 26.
Anatomy, 113-120.
Clinical teaching, 188-219.
Curriculum, 267-285.
Examinations, 267-285.
Pathology. 129-138.
Pharmacology, 127, 128.
Physiology, 120-127.
Women, 325, 326.
Scotland, Triple Boabdof, 52, 68, 69, 268, 269,
279, 2^, 307.
Secondar}' education, need of, for medical edu-
cation, vii, viii, xiii.
in England, 44-57.
in France, 57, 58.
in Germany, 32-44.
Sects, medical, xiv, 308, 309.
SertUmer, Friedrich W.. 89.
Sharpey, William, 120.
Sheffiei-D, University of, 138.
Anatomy, 116.
CUnical teaching, 204, 205, 210.
Cost, 302.
Income. 300.
Patholog>-. 131, 132.
Pharmacology, 129.
Sherrington, 1-23, 126. 304.
Simpson, Sir James, 7, 13, 188, 191.
Skoda, 5.
Smith. Elliot. 116.
So<-ial importiince of medical education, xi.
Sperialization in medicine. 11.
Stoffiairet, 229, 230.
Starling, 126.
State aid for medicine in thinly settled districts,
xvii.
Stokes, William, 191.
Strassburg, University of, 9, 109, 287, 290, 292.
Anatomy, 75.
Autopsies, 97, 102.
Clinical teaching, 150, 154-156, 160, 185.
Pathology. 98.
Pharmacology. 89.
Physiology, 83.
Strieker, 99.
Struthers, quotation, 4, 114.
Students, number of medical :
in France, 30.
in Germany, 19, 24.
Striimpell, 153.
Surgeons, different grades in Prussia formerly,
10.
Surgery, 8, 10, 11.
Early teaching in England, 12.
Swieten, van, 4.
Swiss universities, 323, 324.
Sydenham, 13.
1 andler, 78.
Thackeray, William Makepeace, quotation, 11.
Todd, 129.
TocxousE. University of, 30.
Traube, 9, 89, 99.
Treves, Sir Frederick, 189, 200.
Tropical medicine, 139. 140, 322.
Trustees of hospitals, xiv-xvi.
Tubingen. University'of, 4, 291, 292.
Clinical teaching, 159, 160, 163.
Pharmacology, 99.
Tuffier, 228, 230.
Tutors, 118.
Tyndall, 12.
United States, medical education in, xii-xvi.
University' College, London, 14, 66, 138, 142,
188. 198, 216, 218, 304, 305.
Anatomy. 115.
Clinical teaching, 193, 194, 204, 206.209, 210.
Cost, 302, 303.
Income, 300.
Legal medicine, 141.
Pathology, 132-134.
Pharmacology. 127.
Physiology, 120. 121, 126.
INDEX
357
University relationship to medicine, 10-16, 19.
Upsala, University of, 324.
Vesalius, 3.
Vienna, University of, 4, 5, 9, 10, 22, 25, 100,
109, 290, 291, 320.
Anatomy, 76, 78-80.
Autopsies, 96, 97, 102, 103.
Clinical teaching, 147, 151, 153-157, 159,
160, 162-164, 176-179, 181, 183-185.
Curriculum, 245, 247.
Hygiene, 105, 107.
Legal medicine, 107.
Pathology, 94, 95, 104.
Pharmacology, 89.
Physiology, 86.
Women, 324.
Vienna Policlinic, 320, 321.
Virchow, Rudolf, 3, 5, 9, 92, 93, 98, 104, 131.
Vitalism, 5.
Voit, 9.
Waldeyer, Wilhelm, quotation, 74, 75, 78, 81.
Weber, 82.
Westminster Hospital School, London, 66,
138, 194.
Clinical teaching, 203, 205, 210.
Pathology, 128, 132.
Widal, 224.
William II, German Emperor, quotation, 32.
Women, medical education of:
in England, 324, 325.
in Germany, 323, 324.
in Scotland, 325, 326.
Woodhead, 214.
Wright, Sir Almroth, 139, 15T.
Wunderlich, 177.
Wurttemberg, ratio of physicians in, 18.
WiJRZBURG, University of, 3, 9, 20, 24, 109,
290.
Anatomy, 79.
Autopsies, 97, 102.
Clinical teaching, 147, 150, 154, 162, 179,
182, 184, 185.
Cost, 345, 346.
Curriculum, 240-245, 248, 249.
Legal medicine, 108.
Pathology, 98.
Pharmacology, 89,
Physiology, 83.
Young, Thomas, 188.
Zoology, 61, 240.
Zuckerkandl, 76.
370.6273 C2894 B no.6 c.2
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