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An Introductory AddressON

SCIENCE AND THE ART OF MEDICINE.Delivered at the Opening of the Session at St. Mary’sHospital Medical School, London, on Oct. 1st, 1920,

BY GEORGE ADAMI, C.B.E., M.D., F.R.S.,VICE-CHANCELLOR OF THE UNIVERSITY OF LIVERPOOL.

(after introductory remarks addressed specially tothe students of St. Mary’s Hospital Medical School,Professor Adami continued:—]

The Present Financial Strccits of Universities.I want to-day to take up as my special text this

matter of initiative and independence, for there arewords of warning which I think need to be uttered.The universities and the professional schools ofEngland find themselves to-day in a parlous state;never, indeed, has their condition been more parlous.Students are pouring in to all the professions innumbers double those before the war, the demandfor extra accommodation is most urgent, and thecost of providing that extra accommodation hassoared to an unheard of height. Like coal-minersand bricklayers university teachers must live, evenif they manage to exist at stipends well below thewages received by the said coal-miners. So greathas been the increase in cost of living that whereasbefore the war a junior member of the staff wascontent with .8100, his personal fortune, what he couldmake by the side. and his expectations-to-day withthe rise in the cost of clothes, lodging, and boarding,250 is the minimum that suffices, and even thensecondary schoolmasters with three years’ universitytraining are receiving as much and more. Think a littleand you will realise how heavy is the additional strainthrown upon the medical school, especially when increasein the students demands increase in the junior staff inall departments. But this is far from being everything.There is to be considered the heavy increase in thewages of the administrative staff, the huge incrementin the price of supplies, microscopes and other apparatus,ilrugs and glassware and chemicals. The cost oftanning a medical school has risen by leaps and bounds.Simultaneously the income-tax has soared to an

appalling height, and on top of it for business men theexcess profit tax is eating the heart out of progress. Isit any wonder that the erstwhile wealthy supporters ofhospitals and medical schools feel so sorry for them-selves as to hold that charity begins at home, moreparticularly when a paternal government declines torecognise that gifts made to national objects should bedevoid of tax, or thinks it has done all that is possiblein making 12z per cent.. of such gifts free from excessprofits duty. 12k off 60 per cent. !

Is it a wonder that with expenditure rising rapidlyquarter by quarter, and income as steadily sinking, theuniversities and professional schools of this countryare in despair ’? Is it a wonder that realising thepublic duty performed by them, and knowing that inother countries like France and Germany the Statehas for generations assumed the cost of university andprofessional education the universities in their distressshould turn to the Government and appeal for furtheraid ?So the Vice-Chancellors and the university autho-

rities and representatives of the teachers went beforethe Chancellor of the Exchequer and the Minister ofEducation this summer and placed part of their casebefore him, only to be told-what was quite true-thathe had done more to aid the universities of Englandthan any previous Chancellor, that he was at his witsend to meet the financial needs of the nation, and thathe could do nothing for those who did not help them-selves. Everything had risen in price, even the ld. post-age stamp now costs 2d., but what university had raisedits fees ? And he as much as directed us to raise ourfees, and only when we had done all that was possible

to secure income from other sources to come to himagain. And like Paul, or Saul, Mr. Fisher was thereconsenting.Immediately following this pronouncement the

council of my university, just as did that of theUniversity of London, resolved to follow Mr.Chamberlain’s bidding. We sent to each student,present and prospective, a notice as to our decision.We wrote to the local papers a reasoned letterpointing out how the price of everything had increased,how before the war the student only paid between a,

quarter and a third of the actual cost of his universityeducation, the greater portion of the cost being met bythe endowments of great-minded citizens for buildings,equipment, and professorial chairs, by local grants andGovernment grants, and how, faced with a heavydeficit, we were forced to take these steps, adding thatthe University would do its best to aid deserving cases.And the response was all that could be desired. I didnot receive a single letter from parent or guardian orstudent claiming an’ implied contract. All admittedthat we had taken the right course, even thoughthereby they were hard hit.Here is the tragedy. As a loyal and public body our

University responded with open arms to the request ofthe Ministry of Education that we should acceptex-Service students; we accepted them to the verylimit of our capacity, we refused overseas and otherstudents on the ground that we held it our first duty toaccept those who had served the country. Our lastthought was to take advantage of the Government.We debited the Government for each student the samelow fees asked from ordinary students; when theMinistry was painfully long in paying the maintenancegrants to these students we became a loan office,advancing to the ex-Service students sufficient tocarry them over their difficulties. We charged theGovernment nothing for this accommodation. For theoffice work and clerical help required to look after theaffairs of 1100 and more ex-Service students we chargedthe Ministry much less than our expenses. To accom-modate the hundreds of these ex-Service students wefilled every available inch of space with wooden hut-ments at heavy cost, and at yet heavier cost equippedthem, again without specific Government aid. Andnow when we carry out the directions of the Chancellor,the Minister of Education consenting, and advise theMinistry of our action, we are told very decidedly thatthe Ministry will not meet the increase in fees for theseex-Service students already on the roll. Before takingaction we had carefully calculated what addition wouldwipe out the estimated deficit for the coming year.Our University is proud of its past record of never

having been in debt. Thanks to this decision of theMinistry we now, what with ex-Service and TrainingCollege students, face a deficit of what is nearer

;S15,000 than .610,000. And what is the worstpart of the situation is that our other students,those not receiving Government aid, when they hearthat Mr. Fisher declines to pay the increase for ex-

Service students, must inevitably doubt our bona fides andwill be incited to claim like consideration. For havingcarried out to the fullest the advice of the Chancellor ofthe Exchequer we find ourselves, through the actionof another Department, placed in a most embarrassingposition, unless with the full facts before it the Ministryreconsiders its decision.

Dy°ambae7rs of Government Conf1’ol.Let me say that as a Vice-Chancellor I am upon

principles strongly opposed to seeking help fromGovernment-that I found myself in cordial sym-pathy with Mr. Chamberlain in his answer to ourdeputation which had asked him to give the sametreatment to university staffs as it did to schoolteachers. It was a statesmanlike survey of the situa-tion. As the Chancellor pointed out, what throughthe generations had distinguished English univer-sities and university staffs had been their inde-

pendence of Government and Government control. Asa consequence each has developed along its ownlines according to its particular environment. Ouruniversities have been built up by private beneficence.

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As academic head of my University there is nothing ofwhich I am more proud than of the way in whichwithin little more than one generation the citizens ofLiverpool, in their large-hearted generosity and wiseforesight, have built up a great institution that serves notthe city alone but all the surrounding district, from NorthWales to Cumberland; aye, and already through itsSchools of Tropical Medicine and Architecture and ofPhysiology under Sherrington (now transferred to

Oxford), we have been of Imperial service, drawingstudents from far and wide. Mr. Chamberlain did wellto compare the results of English University educationwith those of the German system, to compare the

sturdy independence and resultant initiative of theBritish system with the formalism and repression of theGerman machine system. In three years the Englishscientists not merely caught up to but in every instanceadvanced further those positions in what I may termoffensive science gained by the Germans through 30years of laborious effort. It was through their sub-servience as Government officials that the Prussianand Prussianised professors supported the militarycaste in leading Germany headlong- into disaster.

It will be an evil day for England when our univer-sities and, I may add, when our hospitals come underGovernment yoke. If we are forced to ask aid from Govern-ment, let it be with a clear understanding that this is buttemporary, let it be with definitely expressed conditionsthat our hands are not tied, and that the officials ofWhitehall are not empowered to interfere.. Let thegrants be of such a nature as not to give excuse forinterference. These may seem almost impossible con-ditions, yet they may be fulfilled. If, for example, theGovernment gives grants in aid to individual scholars asit does at present with ex-Service and training collegestudents, if for these it pays to the universities the samefees as those exacted from ordinary students, suchaction gives it no right to interfere in the affairs ofthe university or school. If, on the other hand, theGovernment were to pay the pensions and super-annuation grants of university teachers, that wouldgive it the right to determine what staff the universityshall possess, the lines on which the university shallexpand, the stipends it shall pay. It would convert theprofessors into Government officials. Or, again, if theGovernment makes a grant of so many thousand perannum to the university, that act gives it an absoluteright, nay, a positive duty, to supervise and direct thespending of the grant. To-day we may be so fortunateas to possess in Mr. Fisher a Minister of Educationof the most distinguished university standing,the first expert in education to be appointed to thepost, a Minister of the highest ideals in whose handsthe universities are absolutely safe. But what about hissuccessors ? What security shall we possess that those I,successors do not leave us wholly in the hands of White- Ihall officials ? To-day, let me admit, there is an admirablespirit among all at the Ministry of Education. But how

long will it last ? Timeo Danaos et dona ferentes. Norwith the University Grants Committee can we alwayshave Sir William McCormick with us. , Already you,the medical schools in London, have your experiences.I need not mention here the names of certain unfor-tunate schools, which in their mingled innocence,poverty, and cupidity, accepted Government grants andforthwith fell into the toils and are now as defunct as theleaves of yesteryear ; unable to fulfil the conditionsimposed upon them ; killed by kindness. I confess, too,that I am more than a little nervous about the presentstrong movement, I will not say directed from Whitehall,but which has been blessed by Sir George Newman, amovement in which Whitehall may be said to -take astrong paternal interest. I mean the movement for full-time professorships in Medicine, Surgery, and Midwifery,and the development of the unit system.

The Development o.f the Un-it System.Let me crave your patience to dwell upon this matter

for a little while. Admittedly this movement hasreached us from America, and the apostle to theGentiles in this case was Mr. Abraham Flexner,himself not a medical man, but one who, acting onbehalf of the Carnegie Foundation, had in his Report

upon Medical Education in the United States utilisedthe data collected by a committee of the AmericanMedical Association to such good effect as to producean astounding and most healthy revolution. It isdifficult for us in this country to comprehend the stateof affairs revealed by that report: the existence ofthree, four, and five schools in one city, each giving itsdegree in medicine; of schools without laboratories,without dissecting-rooms, without hospitals; of schoolsinnumerable whose students were not permitted toenter the hospital wards, gaining all their knowledge ofclinical medicine and surgery in the medical amphi-theatre into which the patient’s bed was trundled, inthe operating theatre, where similarly they viewedeverything from the benches, and in some poorlyequipped out.patients’ clinic. There were nightschools of medicine, where Government clerks andothers employed during the day could obtain a licenceto practise after a three or four years’ course,and eclectic schools galore-physio-medical, homoeo-pathic, osteopathic, and the like. And at the otherend of the scale were schools like Johns Hopkinsand Harvard, magnificently equipped, with endow-ments, hospitals, and buildings on a scale whichwe in England cannot approach. As a result of

that report, published less than ten years ago,the number of medical schools in the States, withits hundred million of inhabitants, has dropped rapidlyfrom 148 or so to under 80. In ten years half of theschools operative in 1910 no longer exist.One of the many movements of reform during this

period has been the establishment of full-time chairs inthe major subjects. The movement was initiated earlyin the century by a memorable address delivered byDr. Llewellys Barker, author of the well-known workon the nervous system, at the time professor of anatomyat Chicago. It was some years before any universityor school was in the position to take action along thelines laid down by him. The first in the field wasJohns Hopkins, where in the meantime Dr. Barker hadsucceeded Osler as professor- of medicine, and by apainful nemesis Dr. Barker was the flrst to have todecline to give up private practice and take up a full-time professorship. Since then Harvard and severalother leading universities, with local modifications inthe plan, have joined in the movement. A popularmodification is that which permits the professor tohave consulting-rooms inthe hospital, where at statedbut limited- hours he can be consulted by privatepatients. With this a certain number of private bedsin the hospital may be allotted to him, although con-sultations at a distance are forbidden. Thereby thewhole working day is spent in the hospital precincts.It is this system which was described and extolled byMr. Abraham Flexner before the London UniversityCommission, and it is to establish this system thatto-day the Ministry of Education is willing to contributevery material aid. Is the time ripe ? Is it advisable ?Can this system of German origin be securely graftedon to our English method of teaching medicine ?

Its Restilts iii vorth America ancZ Germany.In the first place let me point out that, however

admirable it may appear in theory, in practice amongthe English-speaking peoples it is still in the experi-mental stage. Certainly the impression that I havegained discussing the matter with leaders of the pro-fession in the States is far from being one of unalloyedsatisfaction. Even those who in their loyalty to theirschools and the profession have accepted these full-timeposts have not spoken with unreserved content, unlessthey were young and full of enthusiasm, promoted tothese posts because of their high promise, withoutextended experience of practice in the outer world, towhom appointments meant very definite promotion.At this stage it seems to me it would be wiser to letothers make the experiment and observe the results.

I remember so well in the early" nineties," shortlyafter going to Canada, my elation over the progressive-ness of the country of my adoption in inauguratingelectric tramways in all the big cities. I remember theyears that elapsed before England on any large scalefollowed suit: the supreme contempt of my young

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daughter, who had never known other than electriccars, upon arriving in London, at Liverpool Street Ithink it was: " Why they have horse cars’" Thisafter I had taught her that London was the first andgreatest of all cities. And then when after leisurelyyears electric traction was established in the greatcities of England, my discovery that in road-bed andsmooth running, in the construction and amenities ofthe cars, England was far ahead of anything in theStates or in Canada. She had waited and investigatedand benefited and come out on top. The delay haddone no harm. On the contrary.Next, how has the system succeeded in Germany ? P

There for generations the universities have possessedfull. time professors appointed and paid by the State inall the main departments. What have been the results?The results it seems to me have been very signifi-cant, not to say sinister; such results as none of uswish to see accrue in these isles. Admittedly, theprofessors have devoted themselves to the wards andto the laboratory ; the study of individual cases andindividual conditions has been intense ; there has beennothing like it in this country; the output of papershas been remarkable. If classification and mastery ofdetail is science, then assuredly Germany during ourlifetime has been par excellence the home of scientificmedicine. If, on the other hand, not mastery andclassification of - detail but the deduction of broad

principles from those details is the highest form ofscience, then it is not a little remarkable that the

great advances in medical science of the last centuryhave come not from Germany but from outsideGermany-they are anaesthesia, antisepsis, and asepsis;the development of neurology, from the recognition ofmotor and sensory nerves through the work ofGull, Hughlings Jackson, and Ferrier, to the lateststudies of Sherrington and Head; the recognitionof the internal secretions, of hormones and vita-mines ; cardiac physiology-and I might give you alengthy list. The Germans have, it is true, excelled indetailed studies of particular diseases, but where theyare to be credited with notable discoveries it is not alittle noteworthy that those whose names are knownto all are not the university professors of medicine andsurgery, are not the clinical but the laboratory men-men like Virchow, Koch, and Ehrlich.We have to acknowledge that great men of original

mind are few and far between, but the less trammelledEnglish system has favoured their development,whereas the German system has repressed it. Duringmy generation, without any full-time chairs of medicineand surgery the brighter and keener students haveobtained for themselves most of the advantages claimedfor the unit system ; they have spent years in prepara-tion for their life’s work, they have been for years atphysiology, anatomy, pathology. If their school did notgive them opportunities they have gone abroad towork and obtain inspiration at the leading centres.What has been the weak point in London has been theintense competition which has made a man fearful toleave his school for six months or a year lest someoneshould in the meantime seize a vacancy and gainseniority. A wholly mistaken policy, for the man ofadventure who does good work abroad and gains newideas is safe to be recognised and to make his mark.But it is very striking how the great men in our

profession during our lifetime have been not those whoconfined themselves from the first to clinical medicine,but in medicine those who spent years over pathology,in surgery those who similarly spent long years in thedissecting room-Bright, Addison, James Paget, AndrewClark, Samuel Wilks, again I could lengthen the list,were all devoted to the post-mortem room and themuseum. In our generation you will find that it isthose who have gone for special work abroad, or

worked in other schools, who are the notable men in theprofession. There is more than one way of obtaining asound medical education and of preparing for advance.

English and German Systems Contrasted.Here I may note another weakness of our English

system; it makes for the solitary leader, not for the

establishment of schools. Men like Bright andAddison, and even those of yet greater calibre likeJohn Hunter, remained isolated, and had no successorsto maintain their tradition. The most their hospitalscould do for them was to put them on the senior staff,to become forthwith involved in a fashionable practice,and when they died not their best pupil but the nexton the staff in seniority, the one of all others least

likely to have acquired the master’s tradition, carriedon the hospital work, and he might be of little account.I do not say that the English system is perfect or

incapable of being improved. Very far from it.But let us now turn to the tendencies manifested by

the German system. The professor, highly trained, isappointed head of the clinic; he must show himselfworthy of the choice, nay more, he must seek to bepromoted to a higher position as head of the service insome more important university. How is he to do it?To make a reputation as a great teacher takes years,and then for Government officials in whose hands pro-motion lies, it is only a matter of hearsay; whereas if theteacher and his staff turn out a succession of papers, allpublished as emanating from his clinic and with hisimprimatur, the very volume must in time make animpression, and his name will be kept before themedical world. The first duty then of the professorand his assistants is to publish. Each individualadmitted to the wards inevitably comes to beregarded not so much as a human being, needingsympathy and help, as material for publication-asa case pure and simple. There, to anyone whohas visited the great German hospitals, is the out-standing difference between English and Germanmedicine. Here the human being is the flrst considera-tion, in Germany and Austria hospital patients mightaltogether too often be so many animals. Heedless ofmodesty and natural emotion man, woman, maiden, andchild are ordered to expose this part or that to thecrowd of students, are subjected to this or that test.They might be a herd of cattle or a company of Prussianprivates. Ask anyone who has been at the AllgemeinesKrankenhaus at Vienna if this is an exaggeration. Theideal physician, it has been truly said, is he who knowsand makes it his duty to treat the patient and not thedisease.

It may be said that this is only one manifestation ofnational spirit-that such things could never be in

England. Perhaps so ; but this also I will say, that thestudent trained by those who are in daily touch withprivate practice must learn from them the approach tothe patient-must learn what, reading his reports,Abraham Flexner does not yet seem to have discovered,does not once mention in appraising what is best inmedical education, that knowledge of instruments ofprecision and of exact methods of diagnosis is by nomeans the whole corpus of medicine ; that, call it whatyou like-applied psychology, personal magnetism, theunderstanding of the character of the patient, theestablishment of trust and confidence in his or hermedical adviser on the part of the patient-is of primeimportance.

*T6 Dangers of Specialisation.it cannot be gainsaid that where the object of a

service is not primarily treatment but research and theadvance of scientific medicine, and where the head ofthe service and his leading assistant are cut off fromprivate practice, there must be a singularly strongtemptation to regard the ward patients as cases.

Further, the students admitted to the wards, the pickedstudents more particularly, who study the cases underthe chief and the first assistants and take part in theobservations-these students will be brought up withwhat we in this country do not regard as the highestideals.Here is another weakness in the system that is most

pronounced in Germany-namely, for the promisingstudent alone to be considered and the ordinary every-day student to be neglected. The German youthleaves the gymnasium far more highly trained thanthe English boy leaves school, but his general trainingin the medical school is not nearly so sound andthorough. There is not nearly the same amount of

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practical laboratory work or work in the wards; hemay or may not take up practical histology; the prac-tical physiology course may last three, six, or ninemonths, as he pleases; he can devote himself, if helikes, to a restricted group of subjects and do little or

no practical work in the others; nor is there any adequatesystem of practical examinations. As a result, theordinary product of a German medical school has had afar less thorough and all-round general medical trainingthan has the English medical student-he is a poorerpractitioner. This is all an outcome of the same system.We in England feel the responsibility of the schooltowards the whole body of students ; our first duty tothe State is to turn out a good well-qualified practitioner,our second to encourage and help forward the man ofspecial qualifications. If we establish the unit system,we will encourage the German defects-namely, neglectof good general all-round teaching for all, and overmuchencouragement of the student to specialise too early inhis career.

I will not dwell upon the exceeding great difficulty ofgrafting the unit system with full-time professorshipsin clinical subjects upon the old-established hospital-staff system. That is obvious to all. I would only saythis, that whereas we may meet with exceptions withthose who, having made a high position for themselvesand already endowed with a sufficiency, are willing toeschew private practice and devote their days to thehospital, nevertheless so great is the difference betweenwhat the university or the school can offer as a stipendand what a consultant of the first class can expect tomake in practice, that inevitably the tendency will befor the full-time posts to fall to young men of promise-young men of 30 or thereabouts-who will take and holdthese posts for ten years or so until they have made awell-deserved reputation. Then the temptation will begreat to take advantage of that reputation and reap thebenefits of the same in consultant practice. This appoint-ment of young men to the position of highest standing inthe school will not make conditions easier for the oldermembers of the visiting and teaching staff in full

practice, who must from all considerations be retained. ’,Altogether you will see that, though throughout my lifeI have been a laboratory man and keenly interested inmedical research and the advance of scientific medicine,I am very doubtful as to the wisdom and practicality ofthe establishment of the unit system in England. I amas doubtful to-day as I was ten years ago when I tookup this subject on a similar occasion at the Universityof Toronto and made a like comparison between Englishand German systems. All these years I have seen nooccasion to alter my judgment.

Pathological Department as Gitiding Centre.

Why, finally, I would ask, adopt this German system,which has come to us through the United States, whenthere is an English method, a method the beginnings ofwhich are in action here in St. Mary’s? If you want to

develop the study of the science of medicine, andsurgery, why for Heaven’s sake pass over the one

department of the medical school specially devoted tothe scientific aspect of medicine, to the study of thecauses, the progress, and the results of disease-namely, the pathological department, a departmentheaded and manned by a full-time expert, and that, Imay add, on a strictly moderate stipend, by one of agroup of men who have in their love for sciencevoluntarily accepted the simple life with all its priva-tions ? You have made a start here at St. Mary’s.You have established a pathological institute at the iservice of the whole hospital, to which members of all ’,departments can apply, and it owes its inception to oneof the greatest and most practical of pathologists,through whose work St. Mary’s is known the world over.What is more, you have put aside beds in the hospitaland given these into the control of the pathologist.There is the British and the rational solution. You

only need to add to that, under the pathologist asdirector, laboratories of pathological chemistry and ofclinical or applied pathology to have all the equipmentthat is desired, unless, perhaps, following in this thelead of Edinburgh-for pathology does not deal with

treatment-you establish a parallel Institute of Thera,peutics and Pharmacology with a similar director of theLaboratories of Experimental Pharmacology, and withbeds in the hospital. It may at times be necessary inpathology to follow the Edinburgh example in there-peutics and to make two appointments, a directorhead of the department and working with him a clinicalprofessor; but this is a secondary detail.Another suggestion I would make, based upon my

experiences at McGill University : in association withthe school establish a laboratory of experimentalmedicine and surgery, with a director chosen by them-selves from among the junior attending staff, open asby right to all members of that staff, there to undertakeexperimental work at their own volition, subject onlyto the nature of the proposed work being first reportedto a small committee of senior members of the staffand approved by them-a laboratory with fully equippedpreparation and operation rooms, with trained nurseand laboratory attendant. At McGill work of thefirst order was done under these conditions, which, itseemed to me, would never have been undertakenotherwise.These Institutes of Pathology and Pharmacology

together should fulfil all that is necessary. It is under-stood that the institute is both for teaching andresearch-that the director, either himself or througha paid full-time assistant, should have charge of thewards assigned to him, with the power of filling thebeds with particular orders of cases, medical or surgical,according to the condition or conditions under specialinvestigation for the time being. The experience atthe small special hospital under Dr. Strangeways out-side Cambridge, the first of its kind, is that patientswill come from all over the country when assured thatthere will be an intensive special study of their cases.One more word: To assure the possession of a

thorough knowledge of modern methods of diagnosis,chemical, physical, and serological, those recentgraduates appointed to resident posts should spendspreliminary period of six weeks or three months in thepathological institute before undertaking their specialwork in the wards, and, further, while residents theyshould be given places or tables in the institute, there tocarry out such examinations and analyses as are askedfor by their chiefs.The grave mistake made in Germany, and following

Germany in too many schools here and in America, hasbeen in establishing the pathological laboratory awayfrom the hospital. This and the divorce between

pathology and bacteriology, and placing the teachingand research in the latter under the chair of hygiene,explains the barrenness of academic German pathologyduring our generation. It is the hospitals and theliving, and an intimate knowledge and comparison ofsymptoms in the living with the findings in the post-mortem room, that keep pathology a live subject, andto-day certainly it is the problems of infectious diseasethat are most fertile. Pathology, let me remind yon, isthe whole scientific investigation of disease, not asVirchow, and following him Germans in general, con-sider it-merely the restricted field of the study of deadtissues-the gross and minute morbid anatomy.

I am, or I was, a pathologist, but in my presentposition I have no axe to grind. I can speak freely,only assuring you that throughout my course I havefought for the wider, more liberal conception of mysubject. It is with this- ’wider conception that theInstitute of Pathology should become the centre forscientific research in connexion with the wards andthe individual patient. Once this Institute of Pathologyor Institute of the Science of Medicine takes its rightplace in the school in closest association with thehospital and with every department of that hospital;once the staff become accustomed to turn to it forthe solution of their problems, then surely, with all thejunior members of the staff trained in that institute,within ten years the whole staff will be animatedand leavened with the spirit of the science, over andabove but not excluding or even damaging, the spiritof the art of medicine. That is the true education,tota, teres, atque rotunda.