charging simultaneously a philanthropic office may, as we have seen, be provided for independently of school funds and yet be as intimately a part of the educational organization as if teaching were its main purpose. The school will invariably have to equip and maintain its laboratories; the hospital may be separately financed without burden to the medical school. Further, the initial cost of the hospital establishment may vary within large limits : a plain, but serviceable structure, capable of accommodating 200 patients, with proper teaching facilities, may be erected for a few hundred thousand dollars; or it may cost millions. The cost of maintenance also fluctuates considerably according to situation and scale of support. In the city of New York, it is roughly estimated that it takes $1000 to maintain one bed for one year; a 200 bed hospital may thus readily involve an annual expenditure of $150,000 and upwards. This sum may be reduced by profits derived from pay patients, or by small contributions from charity patients. The extent to which the provision of proper clinical opportunities falls upon the medical school varies, then, from place to place. It is therefore not included in the schematic school budget we are preparing; but it is important to emphasize clearly that where independent endowment or state support does not furnish the medical school with a hospital in which it is thoroughly at home, the burden falls at once upon the school. The substitutes, makeshifts, and compromises now so widely employed in the United States do not relieve the medical schools of their responsibility.
From the standpoint of the medical school, it is perhaps immaterial how its hospital is supported. But it would be unfair not to point out briefly in passing that certain larger considerations give great importance to the source of hospital support. The hospital in the United States is not necessarily privately managed because privately supported, or publicly managed because publicly supported: it may be privately managed, even though in large measure publicly supported. The teaching hospitals connected with the Philadelphia schools and with the proprietary schools of Baltimore are of this description. In respect to management they are private concerns; but they have received large lump subsidies from the state for both buildings and support. It is not the sole objection to this policy that it strengthens proprietary medical schools, though that is surely a legitimate criticism. More serious is the general demoralization that log-rolling always entails. Schools and hospitals, competing in all other matters, join hands in assaulting the state treasury; for coöperative action increases the total largess to be divided. The state or city can indeed legitimately aid medical education by completely handing over to high-grade medical schools the ward service in hospitals financially managed by the proper state or municipal authorities. The public interest would be promoted, not injured, if, for example, Cornell, Columbia, and New York University were each left in unfettered possession of its division at Bellevue (New York); there is no possible source of demoralization there. The Pennsylvania plan, however, tends to transfer the making of appropriations and the accounting for the same from the hands of state officials to
