efficiency. Much of the criticism of the school has arisen from its unwillingness to search out and meet the standards set by economic and social conditions rather than from any failure on its part to measure up to its own standards. With right ideals and right methods, the right form of testing for general results should easily be determined and be just as effective as it may seem necessary. "While the examination cannot alone be relied upon to force high teaching level (or a proper course of study), it is undoubtedly capable of proving a most potent weapon in forbidding incompetent institutions.” In England this testing of the efficiency of the medical education is practically placed in charge of the General Medical Council of the United Kingdom, a body composed of 34 members, 5 of whom are appointed by the Crown, 5 by the medical practitioners of the kingdom, while the remainder are from the medical institutions themselves. As this plan has worked well in Great Britain, it raises the question whether any system of schools would not be benefited by having outside persons represented on its examining board.

4. Those dealing with medical education must also see it in its broader humanitarian and social relations and must not fail to have the instruction bear in this direction. "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." This does not mean that the solution of such problems is to form a part of the medical course, but rather that the pupils shall be so instructed that they will see not only the unity in the educational problem but also the relation of their medical course to social service. This bars out the selfish thought of pecuniary gain, and must be accomplished in all education or the nation will inevitably lack not only industrial power, but also social contentment and efficiency. No part of an educational system is to be despised or neglected, and none of the human interests for which it prepares the way may with safety be slighted. And this is true without regard to any large pecuniary returns coming to the individual himself. In regard to the emoluments of the physician, Doctor

Pritchett says, "In just such proportion as higher standards 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." And "the youth who is looking for fortune or the parent who seeks for his son a remunerative occupation should look elsewhere." In Germany physicians' fees are a matter of state regulation and in many cases have been reduced far below what a competently trained physician ought to receive. In the United States, on the contrary, Doctor Pritchett says, a commercial aspect is given to the whole fee question; "because certain successful physicians exact fees wholly out of proportion to the service rendered." This is especially true of the fees charged rich men.

5. The whole problem of fees, standards, and ideals of service has an important bearing upon practitioners for rural districts. One of the arguments most commonly advanced for a régime which turns out a large number of cheaply trained physicians is that it is only in this way that the requisite number of doctors for sparsely settled country districts can be obtained. The weakness of this argument lies in the fact that the cheaper doctor will go where he thinks he can do better, precisely as the more highly trained man will do. And, if he selects the rural district because he is conscious of lack of training, then he should not be a physician at all, and especially in the country, where more than anywhere else he must rely upon his own resources. The country physician, being far away from specialists and hospitals, must have at least the general knowledge of the specialist and must also have the skill and ingenuity that makes his general practice independent of the hospital. "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 the United States, however, there is apt to be, under any system, a lack of competent physicians in the country districts unless the State assists in solving

the problem. "A sanitary service, subsidized by the State, will alone render efficient relief in the backward districts without generally demoralizing the profession."

6. The newer medical education is making more and more provisions each year for post-graduate work. Such post-graduate work aims not so much to be helpful to the person interested in research work, which is intensive and original in character, as to give practical assistance and a wider outlook: (a) To the busy urban physician and surgeon who are in constant danger of losing touch with progressive developments; (b) to those lacking the broadening and stimulating effects of connection with a public clinic; and (c) to those who dwell so far from the centres of activity as to be in danger of stagnation. "How much post-graduate instruction can accomplish for any one person is largely dependent upon the quality of his original medical training." Such medical courses are usually brief and recur for most individual practitioners only at somewhat lengthy intervals. "If a man has been poorly trained what he carries away is apt to be superficial, mechanical, and may be perilous; but if he has been trained in the scientific spirit he may gain much by an occasional dip into these waters." What Doctor Flexner, who wrote the main part of the Report, has in mind in this post-graduate work is brief courses, each a few weeks in length, in such things as new methods in physical diagnosis, serology, or vaccine therapy. The best forms that the post-graduate work can take are in his judgment: (a) To organize the local medical talent and material and on occasion to import for their instruction the more prominent men within reach; (b) extension or vacation courses in the laboratories or clinics of the universities; and (c) selected hospitals that are made the centre of more or less regular instruction.

7. The admission of women to the full medical courses is rapidly extending. Access to the medical schools on the terms enjoyed by men was granted to women by the Swiss universities as early as 1876. Despite deeply rooted domestic traditions, the German universities are now also opening their doors to women. Prussia did so at the beginning of the winter semester of 1908. "Economic necessity and social awakening," Doctor Flexner says,

"have overborne the conservative traditions that sought to confine women to the nursery, the kitchen, and the church." Until quite recently women in Germany had difficulty in being able to present the certificate of the nine-year preliminary education that is required for matriculation. This was because they had to procure the required secondary training chiefly through private study and tuition, the cost of which was for many prohibitive. Prussia, however, has since 1908 thrown open its secondary schools to girls.

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Co-education is the general practice in medical education on the Continent. "Three hundred women mingle on even terms with three thousand men students in the hospitals of Paris; in Rome, Geneva, Brussels, Upsala, Copenhagen, and the Swiss universities, no distinction whatever is made between the sexes.' A long contest in Great Britain has now resulted in the opening to women all qualifications except those of the ancient universities of Oxford and Cambridge, neither of which will examine women medical students, though Cambridge is willing to teach them." On the other hand, the University of Edinburgh will examine but not at present teach women in medicine, owing to the claim that its present facilities do not suffice for its male students alone. The other Scotch universities, however, provide equal facilities for men and women medical students, and in most of them they work side by side excepting in anatomy. Doctor Flexner says, "It is interesting to observe, as doubtless significant of the quality of the material of which this body of women practitioners (in Great Britain) is composed, that women complete their studies in shorter time than the men." On the contrary, however, the proportion of women medical students who subsequently engage in practice is, at least as far as Swiss experience goes, not large. This is due to marriage and the usual lack of the incentive of necessity.

Health and the Schools.

The new attitude toward disease, which is placing emphasis upon preventing it (a) by discovering and removing the causes of ill health, (b) by discovering and promoting the conditions of good health, and (c) by fostering

the influences that bring about the physical vigor which is the most successful agency in warding off disease, places a great responsibility upon the school. This is true, partly because the child at its most susceptible age spends so many hours of the day in the school-room under all the physically trying conditions that are apt to be presented by the free intermingling and grouping of numbers, but even more largely because the possibilities of instilling helpful knowledge and habit are so much greater in youth than in adult life. The responsibility for providing the conditions and agencies for good health in the schools rests in part upon the school board and in part upon the school executives and the teachers. The school board is pledged to the duty of providing the more or less helpless and physically ignorant child with a safe and sanitary school building, with proper facilities for healthful exercise and play, and with the medical inspection that safeguards against contagion and other menaces to health. The executives and teachers are responsible for such use of these agencies, and of the formal instruction which gives them meaning and purpose, as will tend to lead the pupil into intelligent habits of health. Of course, without intelligent help from the home and sympathetic coöperation from the community much of the benefit of these provisions will be lost. But it still remains true that a properly equipped and properly conducted school will make impressions that, even under the most unfavorable conditions, never entirely disappear. And this is more true of the work of the school than it is of any other single agency; hence, society makes no better investment for public health than through the money it expends for this purpose on its schools.

SCHOOL SITES AND BUILDINGS IN THEIR RELATION TO HEALTH. It has been estimated that approximately $70,000,000 are now spent annually in this country for the erection of school buildings; and this does not include the buildings erected for the use of the higher institutions of learning. It follows without the saying that this money should be spent only for buildings that are safe, sanitary, and suitable to the highest possible degree. Anything less than this is a menace to the welfare of the child, an economic and social waste, and a more or less blameworthy