units. In England, in the provinces, and in Scotland the uni- versities had had for many years the germ and often the essen- tials of clinical units, but in London, with its various medical schools loosely bound to a central university, this was not the case. But though the Board of Education were now in a posi- tion to carry out their policy, no further steps were taken, owing to the outbreak of war, until 1920. In that year clinical units in medicine and surgery were created at St. Bartholomew's hospital, St. Thomas' hospital, the London hospital and Uni- versity College hospital. The Board of Education undertook, through the University Grants Committee, to defray three- quarters of the cost, the medical school furnishing the other quarter. At two of these schools the directors of the units were expected to devote all their time to the duties of their office and were debarred from private practice. Early in 1921 the London School of Medicine for Women applied for and secured recognition of a unit in gynaecology and obstetrics, the first appointment to be made in that branch of the curriculum, while a little later units in medicine and surgery were created and recognized at St. Mary's hospital, under the same condi- tions and financial clauses that governed the grants in aid of the first four schools. Subsequently the appointment of the directors was vested in the Senate of the London University, who became not only responsible for the selection of the pro- fessoriat, but required to be satisfied that he has an adequate number of assistants, a proper and effective out-patient depart- ment, that he is allotted the control of a sufficient number of beds, and that the laboratory accommodation allocated to the unit for research and pathological work is satisfactory.
The unit system is designed to secure that the latest advances in science affecting medicine should be continually brought to the teaching of the clinical subjects. To achieve that end the teachers must themselves actively engage in scientific research, and should be provided with proper equipment, an adequate number of assistants and sufficient leisure *o prosecute re- searches. It is hoped to link up laboratory workers and clinicians and generally to introduce organization into clinical teaching, so that in the issue the defects of the older regime may be removed while its obvious merits are preserved.
A hopeful feature in the story of British medical education during 1910-20 was to be found in the provision of additional facilities for research, for which the Clinical Unit system and the Medical Re- search Council were jointly responsible. Together they have pro- vided paid posts for the best of the younger men, in which during the waiting years the more hopeful may find opportunities of re- search and scientific activity. Apart from the higher standard that may reasonably be expected of candidates who are elected to hospital appointments after such opportunities, research and all that comes of it should benefit by a constant stream of recruits drawn from the more promising elements of each year.
The possibilities of clinical instruction that lie latent in the Poor Law infirmaries have long been known, but the difficulties in the way of throwing their wards open to students had proved insuperable until early in 1920 they were overcome by St. Mary's hospital. This hospital entered into an agreement with the Paddington Board of Guardians under the terms of which students belonging to that medical school are allowed to work in the wards of the infirmary. The hospital furnishes bacteriological and pathological services, and a consulting staff who visit the infirmary on appointed days every week, and who hold regular classes in the wards. The significance of such a step becomes plain since there are in London approximately three infirmary beds to every bed in voluntary hospitals with teaching schools attached. In this connexion the Voluntary Hos- pitals Committee, appointed in Jan. 1921, issued in June a report in which they put on record that they deemed it unfortunate that these institutions should hardly be used at all in the training of medical students, and recommended the extension of the arrange- ments existing between St. Mary's hospital and Paddington infirm- ary to other hospitals and infirmaries. If this were carried out, not only would the clinical material available for the purposes of under- graduate instruction be greatly increased, but a class of case would be seen by students at these institutions that is not admitted to the voluntary hospitals, so that a gap that had hitherto existed in the student's education would be filled.
With a search for new facilities for clinical study has gone a grow- ing desire to remove from the student's path obstacles that appear to interfere at present with the true educational purpose of his training. Dissatisfaction with the existing examination system, which is never altogether absent, came to a head early in 1921 when a motion was brought before the Faculty of Medicine of the university of London
asking for permission to hold internal examinations at certain me_ ical schools, and that one of the two examiners should be the stu- dents' teacher. While there was point in many of the criticisms of the existing system, the feeling of the Faculty was that examinations should not be abolished, nor so modified that they no longer pro- vided adequate tests for granting a qualification which carries with it the right to practice, before an efficient substitute had been found for them, and the motion before the Faculty was accordingly de- feated by a large majority. It was felt however that this was not the last word, and many held that a reform of the present examina- tion system was overdue, that in its present condition that system exercised a baneful influence on the true educational purposes underlying the curriculum. On the other hand it appeared probable that many of the disadvantages laid at the door of the examination system were in fact due to the overcrowding of the curriculum. Subjects continue to be added to this, while much that is out of date or of little educational value is allowed to remain in the syllabus. While no sustained attempt has been made to unload the unwieldy vehicle which at present contains what the student is expected to carry away with him, there has been a growing tendency to consider and pave the way for ultimate reform, and these matters were in 1921 engaging the attention of the General Medical Council.
With regard to postgraduate instruction, the defects of the exist- ing arrangements had been exposed and opinion was ripe for action There was a consensus of opinion that undergraduate and post- graduate instruction cannot be combined at the same school, and that the facilities provided by hospitals in London not attache! to medical schools were totally inadequate. The way had therefor been prepared for the report of the Committee on Postgraduat Instruction, of which Lord Athlone was chairman. In substanc that report (June 1921) recommended that one of the London gener hospitals, with at least 300 beds and proper modern equipment should be set aside as a postgraduate centre. (C. M. Wi.)
United States. In 1910 there were in existence in Americ approximately 150 medical schools, mostly in fact, if not form, private ventures; even the few schools of high grade sessed meagre endowment and inadequate facilities. By a pr cess of natural selection, the number of schools was rapidlv reduced, having fallen in 1920 to approximately 85, and ther were grounds for the belief that this number would in the near future be still further reduced. The organization, endowment and facilities for instruction showed a notable advance. In 1910 few medical schools actually controlled the hospitals in which their teaching was done. Subsequently there was a distinct tendency to give the university medical schools exclu- sive and adequate control of hospital facilities for clinical teach- ing and research. Harvard, Yale, Washington, and other uni- versities thus came into much more intimate relations with the hospitals in which the clinical staff teaches. The city of Cincinnati built one of the finest public hospitals in the United States, and amended the city charter so as to give the univer- sity of Cincinnati (a municipal institution) complete control of the hospital for the purposes of its medical school.
On the financial side public opinion was brought to realize that the university school of medicine is an expensive enterprise, for which large investments must be made by the public in both facilities and endowment. Mr. John D. Rockefeller gave the General Education Board approximately $35,000,000 to be used primarily for the purpose of cooperating with institutions in raising larger sums for the development of their medical schools, and the late Mr. Joseph R. DeLamar gave $5,000,000 each to the medical departments of Harvard, Columbia, and Johns Hopkins. Upwards of $10,000,000 was raised for the establish- ment of a new medical department at the university of Rochester, Rochester, N.Y., and $8,000,000 for the reorganization of the medical department of Vanderbilt University, Nashville, Ten- nessee. Many other endowed institutions also procured consider- able sums for improved laboratory and teaching facilities. The current.budgets of the state universities were similarly increased so as to enable the institutions to go forward in developing their medical schools correspondingly.
In respect to organization the main change in the decade was the introduction of the full-time plan corresponding to the English unit system in the teaching of the clinical subjects. The aim and purpose of this movement are the same in both coun- tries, but in neither had sufficient time elapsed up to 1921 to allow a final verdict to be passed on the merits of the system. The complete satisfaction of the Johns Hopkins Medical Schc
