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Popular Science Monthly/Volume 66/April 1905/Medical Research: Its Place in the University Medical School

< Popular Science Monthly‎ | Volume 66‎ | April 1905

MEDICAL RESEARCH: ITS PLACE IN THE UNIVERSITY MEDICAL SCHOOL.[1]
By THEOBALD SMITH, A.M., M.D.

GEORGE FABIAN PROFESSOR OF COMPARATIVE PATHOLOGY IN THE HARVARD MEDICAL SCHOOL.

IF there be one word which is heard most frequently in the most intelligent circles interested in professional education to-day, it is the word research. In our own country in recent years medicine has fallen under its sway, and on all sides efforts are being made to meet its demands by the erection and equipment of costly laboratories within whose walls research may be carried on in a continuous and orderly manner.

Granted that the governing bodies of our great universities have familiarized themselves with the significance of this word and are giving it out, some only with the lips, others with a thorough conviction that to it must be accorded a permanent place in our higher institutions, the problem of how to deal with such a costly, and in many ways unattractive, offspring, how to correlate it with the teaching function, how to cultivate it side by side with the routine methods of instruction, will occupy a prominent place for years to come.

Research signifies effort directed toward the discovery of laws and principles through the systematic collection of new, and the better correlation of existing, data. It also means effort directed toward the more efficient and economical application of discoveries to the welfare of man, in other words, the utilization of latent and hitherto wasted energy. The aims of research are not culture, not miscellaneous information, not a mood of leisure meditation upon the origin of things, but mainly utility and service to mankind.

The chief influence at work in lifting medicine from a mere teaching to a research level is the same as that at work throughout the world of science and in fact in all intellectual fields. If we examine it more closely we find it akin to the breaking away from authority and dogmatism in religious affairs and from autocracy in the government of nations. Its foundations rest far down in the great liberalizing wave of the nineteenth century. We no longer believe that each step in advance is the ultimate one, but only one in a series toward ultimate truth, and this fact makes us realize that we must keep on marching. Research recognizes no immediate boundary to its activities, and no limit to its possible acquisitions. In placing only a temporary value upon its constructive plans and using theories only as aids to new facts, science grows in candor and modesty with its achievements.

In biology and medicine, the spirit of research takes into account the continual movement and flux in living things and their environment. It is a study of change, of transformation, brought about by conditions which may or may not be under experimental control. We describe carefully and minutely, not for the sake of the picture and its details, but chiefly to be able to recognize the change. Unless we know the consecutive pictures how can we detect the movement and its trend? It is the moving picture of the kinetoscope that has gradually replaced the single view in repose.

But there is danger that we may move too rapidly and find our advanced positions untenable. The world is just now very optimistic and expectations run high. If we give way to the feverish haste of our day, the slow, sure advance of medical science may be brought into discredit. For it is one of the features of this feverish haste to leave the position held as soon as possible for one more advanced. We move away because we have some doubt as to the security and trustworthiness of our present position, and we hope to gain by pushing beyond it rather than strengthening it. As a result of this attitude we find the thing most characteristic of the day and age is the rapid remolding of our stock of information. Revolutionary views are uttered from an inadequate basis of observational and experimental data. Theories become kaleidoscopic in their variety. Old views long since discarded come to the surface like old fashions. All this change and ferment is both the cause and the effect of the enquiring attitude of mind. Research begets new data and the opposition to these begets new research. Thus the fermentation is kept up and a froth several years deep lies on the surface which few can penetrate.

This haste and hurry is part and parcel of what might be called nature's lavish waste of energy. The volume of our information increases more rapidly than our knowledge of the principles which underlie and support it. The progress actually made is more apparent than real. It is a swaying to and fro with but little forward movement. Like the driftwood of which the waves are endeavoring to unburden themselves, many excursions back and forth must be made before the fact is finally landed. It is often much battered and barely recognizable.

That there is here a golden mean to be followed need not be emphasized. The spirit of research should be properly tempered by a true insight into the relation of enquiry to the great accumulation of knowledge and the reserve forces stored in the every-day experience of mankind and handed down from generation to generation.

In the meantime the optimism of the world which unknowingly assumes that medical science can rise above natural law and correct any and all excesses of individuals and communities must be met by a better education in natural science rather than abandoned to the manipulations of the charlatans of physical and mental healing.

Passing now to the more obvious external conditions which have tended to stimulate medical research, we may single out a few which have been of special importance. Perhaps the most ancient and strongest of all is the desire in the human breast to maintain health and prolong life. From its very beginnings the healing art has been weighed down with the greatest of problems, to save life and to cure disease, often in those of lofty estate, and its status for the time being frequently depended on its success or failure in accomplishing apparently the impossible. In our own day the crumbling of the formal religious belief that this life is but a preparation for that beyond the grave and the centering of our efforts to make it as much of a success as possible, the growth of wealth and leisure and the pursuit of sensual pleasure, these various motives, high and low, combine to exert a pressure upon medicine which is scarcely equaled in other professions. To save life, and to cure disease are imperative demands which grow more urgent, more impatient each year, and which suffice to quicken the efforts of the scientist and the true physician as well as the charlatan, and shape almost every problem which is considered worthy of attack to-day.

As a most important and timely contributory force to the advancement of medical research in recent years are the princely gifts of benefactors, with whom we especially associate the names of Johns Hopkins, Garrett, Fabyan, Rockefeller, McCormack, Payne, Morgan, Huntingdon, Sears, Stillman, and many others without whose aid medical research could hardly have commanded a corporal's squad today.

A factor not to be neglected in the advancement of medical science is the feeling of national pride. Most of the medical science of the past and much of the current knowledge has on it the mark 'made in Europe.' To-day this mark is occasionally being replaced by the label 'made in America' and without doubt the home market will soon be well supplied. Fortunately, tariff barriers and trusts do not interrupt the currents of knowledge. Without hindrance we have filled cur storehouses from the old world and I trust that we may repay in due time some of our huge indebtedness. Our national pride once awakened will see to it that our country, the wealthiest in material things, shall continue to give as well as to receive the fruits of the intellect.

These are forces acting chiefly from without. Perhaps the most important acting from within has been the use of animals. The study of the great domain of infectious diseases has revealed such a similarity between the diseases of man and the higher animals that we hesitate now less than before to apply courageously the knowledge gained in our experiments upon the highest mammals to human physiology and pathology. Without this aid from animal life, medicine as a progressive experimental science would dwindle into insignificance. Moreover, the artificiality, the rigidity and awkwardness of the medicine of a generation ago have been largely dissipated by its contact with biology, which brought with it the comparative point of view.

Side by side with the use of animals we may place the convenient use of bacteria and other microorganisms in our laboratories in producing disease as one of the great levers of pathological research today. They have enabled the investigator to establish important centers of research completely independent of and coordinate with those connected with the hospital and the dead-house. The latter, it is true, still remains a final court of appeal for all discoveries destined for the relief and cure of human diseases.

In the historical development of science the research instinct appeared at first sporadically, and until recently it was simply the spontaneous flowering of the scholarly mind in the highest institutions of learning. To-day it has been actually organized not so much to train youth as to produce useful knowledge. This new organization of research has been greatly favored by the promise of valuable returns in the suppression of infectious diseases of man and animals. Most of the institutions founded thus far were created by public authority for this purpose. It was realized that such work must be pushed forward rapidly to secure results of value to public health and economy.

About twenty-five years ago special laboratories began to appear. Our own government figured among the earliest in voting what were then very liberal appropriations for the study of infectious animal diseases. At the same time came the German Imperial Health Office and somewhat later the Institute for Infectious Diseases in Berlin, and the Pasteur Institute in Paris; more recently there have been established the Institute for Experimental Therapy in Frankfort, Germany, and the many sero-therapeutic institutes and public health laboratories, nearly all of which have become noted for their research work. In our own country we have last but not least the Rockefeller Institute for Medical Research of this city and the Memorial Institute for Infectious Diseases in Chicago. Most of these were created to deal scientifically with problems of immediately practical bearing. But it does not need a prophet to foresee that following them others will arise which will devote themselves to broader and more fundamental problems and which will attack those left unsolved by the former institutions. Of this latter class the Pasteur Institute in Paris and the | Kockefeller Institute are conspicuous examples.

The founding of research institutes does not guarantee their success. That will depend upon the men who work in and for them. It has become evident that our research workers must have more diversified training than the older generation possesses. The store of knowledge accumulated by science must be made available to medicine. The only way in which this can be accomplished is to have trained men continually examining and testing this accumulating store of facts and applying them to the problems of disease. Such men should have medical training and approach their problems from the medical point of view; but to them should be spared the necessity of learning ultimate details of the medical art and they should give their energy to some sister study, be it morphology, physiology, chemistry or pathology. Medicine has just begun to realize the need of drawing to itself the great talent which hitherto has had an open door only to the pure and applied sciences. Research is largely dependent for its successful pursuit upon an attitude of the mind which insists on following a clew that promises to reveal some relationship, some law of causality between phenomena hitherto apparently unrelated. This type of mind has many of the attributes of the inventor who is attempting to combine to our advantage the forces of nature in new and unlooked-for ways and to express them in the form of labor-saving machines. In order to attract these minds we must pay them a living wage and provide workshop and tools, and exercise but moderate restraint over their activities. To them the exterior of practical medicine has a forbidding aspect. "We must bring them to face its really wonderful problems through the portals of the laboratory.

After we have established research institutes and brought together a devoted, enthusiastic group of scientists we must not look too closely at the immediate practical value of research. Most of the epochmaking discoveries have had little, if any, direct influence on medical practise at the start and even for some time after. Some have wholly failed to yield hoped-for results, but they have had great influence in unexpected directions. This is chiefly because great discoveries are as a rule not ripe for use. To point out a hitherto unrecognized cause does not thereby enable us to overcome its effects. These may be grounded in centuries of adaptation. A great discovery frequently does no more than call attention to a new fact without defining its relationships. The discovery of the tubercle bacillus for example left the whole question of its complex relation to a given host untouched. The same may be said for most other microbes. The delicate equilibrium between parasite and host is the thing to be worked out before we can rationally proceed to upset it in our favor. There is therefor no need of hurrying to put discoveries to use. Many are discredited because of such ill-advised attempts and the investigator himself becomes discouraged in the futile effort to apply principles which fit only in part the practical condition to be influenced.

The tendency to make research directly prove pet theories, find short cuts to health, and cure diseases hitherto unsuccessfully treated will continue to give the investigator trouble for some time to come. What is needed is that at least a small number of scientists work at these problems of disease as we would at the other phenomena of the world around us. They should look them over from all sides calmly and objectively to get at the lessons expressed in them. They should look upon pathological manifestations as the normal sequences of causes operating under special conditions and for certain periods of time. They should endeavor to analyze phenomena rather than attempt to suppress or crush them. That function should belong to the health officer and the practising physician.

In order to take this calm attitude toward disease as a natural phenomenon and attempt to explain it, it may be necessary to move backward toward simpler problems from man to the higher animals, from these to lower types, from the complex processes of the human machine to the physical and chemical phenomena of the inorganic world. This has not always been the attitude of medicine, for standing as it does under the too near and impending shadow of suffering and death, it was but natural to attack the most difficult and complex problems first.

It is needless to say that the position of the research worker of the immediate future will not be an easy one. The strain to produce something is far more wearing than teaching. The mental play of the teacher's mind to produce something is relaxation compared with that of the investigator to carry out a contract for the delivery of new knowledge. The gap of years and even generations may yawn between the problem in hand and actual solution. It may indeed prove to be wholly impregnable from the point of attack. It may be solved by some obscure genius with slight facilities who happens to hit the combination which unlocks the secret.

We have all experienced the burden and complexity of growing information which has not reached the stage of actual knowledge. Extensive tables of figures are laboriously built up around it and the worker himself becomes encrusted and almost asphyxiated with methods and technicalities. We find the laboratory growing hot and stifling as we painfully add one more fact to the heavy burden. Suddenly and quite unexpectedly the true discoverer comes with a simple explanation. At his approach the air is cleared and freshened. Tables and figures are shoved to one side, and we begin our work once more with improved vision along another road.

Such is frequently the mission of the true discoverer, to leap over mounds of facts and figures, bring us back close to nature and show us that her movements are often far simpler than we dared imagine.

Thus far I have dealt with research as a thing by itself to be furthered by endowment and prosecuted by specially fitted men for the sake of its value to mankind. This is only preliminary, however, to the main thesis of our remarks, the training of research workers and the relation of research to the medical school. As a humble representative of the school which has provided so liberally in its new buildings for both research and instruction I must endeavor, amid the tangle of changing conditions, to place before you the relation between teaching and research as it presents itself to me.

I am quite inclined to make a sharp distinction between the physician and the investigator, and I think the time has come to create as it were a separate genus. What may be said of the type research worker should also apply to the teacher.[2]

Some enthusiasts would go so far as to urge that all students be made research workers. This is clearly uneconomical, for not many are fitted and the world has no use for many. There are needed chiefly well educated, humane, upright and patient workers who are ready to do the routine tasks of their profession. The physician must keep step with the great procession as it slowly moves forward. He can not deviate much to the right or to the left nor move much faster than the rest. His activities are more or less defined by a consensus of opinion. No matter how much he may swing his pinions in the laboratory, they will have but little room to move in the practical work of life. It is one thing to discover, and another to apply, one thing thoroughly to believe in our results, another to make others believe and act accordingly.

The research worker on the other hand deals more with the undefined boundaries of knowledge and with the frayed edges of sound information. He does not march with the procession, but he must do lonely outpost and scouting duties. He must seek clandestine meetings with those of other sciences, for he learns mainly by breaking through conventional barriers. He makes his discoveries unknown to others, and the farther they are in advance of the times the less attention they will receive.

Again, the physician under the stress of practical life must be positive and aggressive in his dealing with disease. He must supply empirically what is lacking rationally, and his experience is therefore of the greatest value as it is in all vocations which couple science with actual life. The investigator, on the other hand, must be to a certain degree negative, skeptical of current theories, and suspicious of mere experience. He must frequently destroy before he builds up. He approaches the individual case of disease through general laws established through experiment. The physician must begin with his patients and through them reach general formulse governing disease. He studies the patient, whereas the investigator studies the disease.

The investigator should be free to a certain degree to create his material and his problems. The physician must accept his cases as they come to him and he can only exercise the skill of selection. Each patient is indeed a problem, but it is worked out under the illumination of the accumulated knowledge of the world, and not dealt with according to strange and hitherto unknown formulje. The physician can not control his patient excepting within a narrow range. Experiment as such, except when of a trivial nature, is forbidden by law and conscience. Statistics is the only court of appeal he has in attempting to prove success, and this method we know is open to serious error. On account of his peculiar and unique life work, the physician must build his education as broadly as possible and carry as much information as is compatible with normal thinking. The research worker, on the other hand, digs and delves and he must leave unnecessary encumbrances behind.

The main task of the medical schools will always be to train physicians. It does not fall within the scope of this address to define what this training should be, and I shall not attempt it, excepting in so far as it bears upon laboratory instruction. I believe that the medical school should make the future physician absorb as much as possible of the best medical science of the day and give him a certain initial skill and dexterity in carrying out the fundamental operations of the medical art. The power of the student to think independently, to digest the facts he has absorbed into some current theory which enables him to absorb more, and thus continually upbuild and rebuild his science, should be uninterruptedly stimulated by lectures, conferences and reading. To aid this constructive work laboratories have come quite generally into use. They are not research institutes at bottom, but originally a means to fix and illuminate through the senses facts otherwise meaningless. For the average student the laboratory is a review as well as a fixative of data which he is to carry with him and upon which he is to build his professional experience.

Those who are inclined to claim for the laboratory more than this in the education of the physician, I would ask to consider how little of medical science can actually be presented there to the student. Certain functions can be demonstrated in physiology, certain processes and products in chemistry, certain anatomical facts and certain parasites as etiological factors in pathology. The prolonged impact of untoward conditions, the silent movement from health to disease, the shadowy boundary between the two who can adequately demonstrate them in the laboratory. There the days, months and years of disease processes must be concentrated into minutes and hours. Much of the laboratory work is like the ward visit, a fragment, to be pieced out through the agency of books, lectures and the imagination.

I am of course fully aware of the great importance of thoroughly training the senses and the powers of observation. The chief means of communication of the physician with his patient is through the medium of the senses, and the more avenues of intercourse are opened between him and the diseased body by increased delicacy of sense perceptions and by instruments of precision which aid and control the sense impressions, the more precise the diagnosis.

Lest I be misunderstood, I wish to emphasize the importance of bringing the student who is to be the future practitioner in as close contact with laboratory research and its immediate fruits as possible. For he will be the one to apply new points of view, gained experimentally, in the prevention and treatment of disease. Unless he gains some confidence in the laboratory and its methods and is ready to welcome its fruits how can medicine make any progress? His own contact with the laboratory should be for him a strong support and create in him faith in the ultimate triumph of science over the problems and mysteries of disease. Its influence should reach far beyond his years of training. When in practice he is disturbed by the confusion of voices, which, like the will-o'-the-wisp, lead neither here nor there, or when he is perplexed by the movement of fads and fashions pointing now in one, now in the diametrically opposite direction, when he comes to realize that much of his professional work is still empiricism and that it moves from precedent to precedent, he will look back upon his best laboratory work with a feeling of relief and recognize in it the germs of the science of medicine where his results came true if he worked accurately, and where he could predict the outcome. This power to predict which characterizes science should stimulate the trained physician to urge on in every way his profession toward the scientific ideal. If the laboratory succeeds in creating a desire to aid in realizing in the student this ideal its work will be well done. This craving to place his profession on a more and more scientific basis will lead to steady intellectual growth and insight and a proper receptive attitude toward the progress of science.

Much confusion can be avoided, I think, by classifying laboratories into two categories, those that inculcate principles of medical science and those which subserve clinical diagnosis. In the latter, clinical medicine or medical practise seeks to lay hold of the acquisitions of experimental science and to utilize them in the interpretation of symptoms. The clinical or hospital laboratory approaches medical problems from the professional side and is thus an extension of medical practise into a territory where science and practise meet and shade into one another. Here the future physician should receive most careful training when he begins to direct his studies toward some branch of medicine. For this important stage the Harvard Medical School has left the fourth year open. In this year the student should utilize all possible means of combining his practical training with the more analytic methods of the laboratory and exploit whatever it may offer in more accurate methods of making and recording observations. At the same time, we must not make the mistake of calling this research. It may later on shade into research, but it is at first simply increasing and perfecting the means of identifying already well-known disease processes.

We are just now passing through a period of reaction against so-called book learning which is likely to lead us too far in the other direction. So much weight has been placed upon the training of the senses that we are in danger of neglecting the mind behind them. It is vaguely assumed by some that laboratory work is per se research. This is far from the truth. We might with profit carry on researches in the published work of others without entering the laboratory. We might, on the other hand, spend our whole life in a laboratory without acquiring more than a little manual and optical dexterity. We are in danger of forgetting that the training of the observational powers is simply developing another language made necessary by the expansion of medicine as a biological science. The true investigator may have but imperfectly trained senses, but he may still succeed in discovering and opening up a new country to us. With his intellectual power to grasp and arrange data, largely worked out by others perhaps, he finds his way through the unknown.

In our zeal to further the educational methods of the day, there is just as much danger that we overload the mind with too many sense impressions, as with too many facts gathered through the medium of books. Have we not heard of the absurd waste of time in some laboratories over work employing laboratory technique which is as empty as the written page to many a student? Have we not seen many a laboratory servant whose senses were sharper than ours on occasion; many a butcher who detected abnormalities of the tissues more quickly than we? Yet they were not 'doing research.' Let us not deceive ourselves concerning the true inwardness of research. It does not consist in trained senses alone. It is a quality, an attitude of the intellect working through the senses. Claude Bernard clearly recognized this when he said: 'He who does not know what he is looking for will not lay hold of what he has found when he gets it.'

Though research may be carried on and is going on in all departments of medicine to-day, yet the true home of the investigator is the modern laboratory. Here we have a kind of reproduction in miniature of the actual field of work, where, by means of physical, chemical and biological methods of analysis, the problem in hand may be reduced to as simple terms as possible or at least confined within more or less governable conditions. When it has reached a certain stage of maturity, then facilities should be at hand which enable the investigator to approach cautiously the very complex conditions of actual disease in the hospital and its special laboratories.

The university medical school has thus two duties to perform, to train practical men, physicians and health officers, and to encourage the few who incline to research. The methods of training for both coincide for a large part of the course, but they must eventually diverge, the practical man to enter the actual field of conflict with disease and forge his weapons as well as he can from the storehouse of the world's accumulated experience and science, the investigator to continue his struggle with the stubborn and evasive facts of nature.

To carry out this program the university school must have teachers who are investigators, well-equipped laboratories both for large classes and for individual advanced workers. It must have satisfactory stables and operating rooms for small and large animals, for the experimental and observational study of animal diseases is the logical outcome of laboratory research. It is another intermediate station on the way to human pathology. It frequently presents such strikingly clear solutions of difficult problems and permits us to introduce the comparative method which has been so fruitful in the biological sciences. Closely associated with the school should be hospitals and clinical laboratories. Let us look at a few of these requisites very briefly.

The training and encouragement of research as well as thorough teaching in our medical schools lead by implication to the doctrine that professors should be investigators themselves. For the purpose of elementary class work it may be maintained that it is enough for teachers to instruct with the aid of all the paraphernalia of the day. But what shall they teach? Shall they go no faster than the successive editions of text-books allow, or shall they express an opinion about or actually teach the newest doctrines? As I stated before, the knowledge of the world is covered with the froth of research fermentation of several years' depth, and the latter yields about as much genuine knowledge as the froth does actual fluid. The teacher can not well sound its depths unless he has made some independent studies of his own. Then he will be able to say something definite, whether he has been at work in this very field or not. His critical view will enable him to take sides and be positive rather than negative in his teaching.

It will no doubt be maintained by many that to teach undergraduates the latest information is out of place or at any rate not necessary. All that they need for their daily subsistence pertains to fundamental conceptions. But I answer that we really know little of fundamental conceptions and what we believe we know is being affected and modified by every new discovery of any value. It is of the utmost importance that the theories which the graduate takes with him be as sound and withal as fresh as the teacher can make them, for they will form the scaffolding of his thinking for some time to come, possibly for many years.

The teacher who is called upon to direct the work of students who are beginning to feel their way into unknown territory or who have already left the beaten path far behind must of necessity be an investigator. Without going ahead of them himself his counsel is apt to be wavering and at times he feels himself wholly helpless to advise. In other words, to direct research the teacher must be playing the chief part while his students, of whatever rank, should take subordinate parts all definitely working toward a given end. Only by such cooperative coordinated work can both the worker and the task become a success. The teacher's capacity for research is not necessarily measured by his productivity. This may be curtailed by his high standards of what should be put on record. At the same time his capacity for research should somehow make itself felt through those whose labors he is directing. His fruitfulness should be manifested through them. If a teacher remains sterile both in himself and his students he has missed his vocation.

Of importance equal to that of an efficient body of teachers are adequate laboratory facilities both for teaching and research. Medical science has moved beyond that stage when a student could be kept profitably employed with a microscope and a box of slides. With the growth of laboratory methods of diagnosis, more varied and costly apparatus is needed, more space to place it and more laboratory service to guard it.

In research the demands are similar, but more exacting in certain directions. Some still believe that abundant space and work room with cases full of the latest instruments will certainly lead to great discoveries. These are, to be sure, necessary; but without the motive power behind them they are more barren; they create the debts rather than the assets of research. This motive power consists of enough assured income to carry on research and develop the research powers of meritorious students. There should also be ample means for laboratory service. Research is in one sense a business, the laboratory a workshop. Here all sorts of processes are under way and as no one would expect a workshop to be carried on with only a foreman, so a laboratory can not be kept in use without laboratory service. Hitherto assistants have been made the motive power and the laborers; but this system should no longer be maintained. Not only is it wasteful to fill the time of assistants with routine manual labor, but it is wasteful in so far as the laboratory is dismembered at the end of each year. Every laboratory should be in working order even if all assistants are lacking. The trained laboratory servant should represent the routine and conservative, the assistants and investigators the progressive, element.

With the growth of the cost of research it becomes of great importance to exercise care and selection in admitting men to research positions. Fortunately there are not many collateral attractions in a life of research and the process of elimination acts as a rule automatically. Still there is danger just now that some of the flotsam and jetsam caught in an eddy or else afraid of the current of practical life may seek the quiet of the laboratory, because of some imagined taste or capacity which fails to materialize later on. It is far better not to have any research workers than poor ones.

The leaven of research which has so completely permeated and revolutionized all doctrines and practises of medicine in the past quarter century is still acting and no one can foretell how it is going to mold the medical science and practise of the coming decades. No one can foresee what it is going to do with the medical schools.

There will come without doubt much change in the artificial boundaries of the present so-called departments. Created for purposes of teaching and administration, they are a veritable bane to the investigator who can not stop mining because his vein happens to dip into another man's superficial territory. Even in the routine of teaching many changes are likely to come. I believe there will be developments in two main directions. The present laboratory studies, or propædeutics, will be deepened and extended in the direction of the more exact sciences, or toward the physical, chemical and biological work of the university proper. As a necessary result of this movement much of the work now done by these departments will move forward into clinical medicine and surgery, and there will be a corresponding growth and strengthening of the clinical and pathological laboratories of the hospitals. To illustrate: Much of what is taught to-day in pathology belongs to clinical medicine and surgery, for it is largely special and diagnostic in character. The pathologist is now the servant of the physician and surgeon in completing and rectifying their diagnoses. The pathologist of the future will deal with more general phenomena derived from experimental and comparative data, just as the physiologist has moved onward, or backward if you please, into general and comparative physiology. Similarly, the burden of other now scientific departments will be shifted into the more practical branches to make way for more fundamental problems. The logical outcome of such a rearrangement of studies would be eventually a college course arranged wholly with a view toward medicine and sanitary science, in which the bulk of the present early studies of the medical school would find a place, and, secondly, a practical course in medicine, surgery and sanitary science, in which clinical, hospital and public health laboratories would take a prominent part. It may be that in this way the time and energy of the student aiming for two degrees and a livelihood could be saved, while the efficiency and scope of the course could be increased at the same time.

The establishment of research institutes by governmental authority and private munificence marked the beginning of a new epoch in medical science by organizing research and giving it an assured status. The influence of these institutes upon research in the university medical schools will be watched with much interest. Unless the latter take a more definite position and furnish opportunity whereby investigations of a more serious and exhaustive scope may be undertaken, the research institutes will absorb the best men and the highest class of work and leave research as heretofore a by-product of the schools, often desultory, discontinuous and trivial. To avoid this impending calamity, the professors should be relieved of various routine duties incidental to the management of laboratory workshops. There should also be appointed investigators of definite rank whose teaching should be subordinated to research in such a way that the latter will not be seriously impaired by long interruptions.

In conclusion I wish to dwell briefly upon a phase of our subject which is perhaps the most important of all and toward which the various lines of our discourse have been converging.

The relatively large endowments given to medical education and research in recent years have created as it were a trust to be administered by the medical profession in the interest of human society in the broadest and highest significance of the term. This I interpret to mean that we must endeavor to make all advance in our knowledge of health and disease common property so far as this may be possible, to disseminate broadcast the benefits of research into the laws of health, so that they may enter into and form an integral part of the life of the individual and the community. We all know that much of the daily work of the physician goes to charity, that the public health authorities and sanitary officers are but scantily compensated for their arduous and often dangerous labors. There can be no question that as a profession medicine stands at the head in disinterested service; but there is still room for improving the relation between medicine and the public. How can this be done?

Perhaps, next to the education of physicians of the highest standards, the immediate duty of the university medical school is the development through research of preventive medicine and sanitary science and the education of sanitary officers. This, it seems to me, is the best way in which our debt to society can be discharged; for it is the way through which medicine has moved during the past quarter century to its present commanding position; it is, in fact, the way of least resistance for the human race to evade or mitigate the penalty incidental to advancing civilization. Preventive medicine is the application of medical science to the mass as well as to the individual. It attempts to arrest disease before its momentum has carried it beyond the means of help. It is the truly modern as contrasted with the medieval point of view.

Nobody will deny that much has already been done in the development of preventive medicine and sanitary science. It will be claimed, and with justice, that more has been done than the public is willing and prepared to accept and live up to. We know that today municipalities continue to permit the unnecessary sacrifice of lives to epidemic disease, that politics is permitted to disorganize efficient boards of health in large and small communities and to put the best material interests of family and social life into untrained hands. We know that the public continues, in spite of warnings, to consume noxious drugs, widely and boldly advertised in the daily press. These difficulties are very real, but they should not discourage us. The medical profession is in a sense to blame for this condition; for the household remedies and cures of to-day are those of the doctor of a generation ago, and the medical practise of to-day will crop out in the daily life of the next generation. Likewise, the indifference of the physician and health officer of a generation ago is reflected today in the attitude of the mass of the people.

The university medical school has here a great function to perform, for it is the legitimate source of knowledge pertaining to hygiene and sanitation. There are few problems which have not been suggested by contact with disease. Sanitary science is broad and rests upon many foundations, and the means of disseminating its teachings are many, but its origin is in pathology. Without the stimulus of the continual presence of disease its problems may become trivial and its practise ineffective.

The university medical school may in still another way hasten the diffusion of sounder views concerning health and disease by creating more interest among the educated in the general problems of pathology. This is but the obverse of physiology, and its principles once scientifically founded and objectively developed along general and comparative lines, should form an attractive study in all biological laboratories. We are still some distance from the realization of this suggestion, but the task is worthy of the best men in our best schools.

If we take this broad view of the work of the university medical school and try to put it into effect, medical science will come out of its somewhat isolated position and take its proper place beside the other sciences. The work of the physician will then be rated more justly, because the great complexity of the problem of health and disease will be more appreciated. His services will then be sought more frequently before rather than during the calamity of illness, because it will be better understood why he can more easily forestall and prevent than cure disease.

  1. Address before the Harvard Medical Alumni Association of New York City, November 26, 1904.
  2. The time is not so distant when it will become necessary to separate the functions of teaching and research. The teacher will then investigate to improve his teaching, the investigator will teach to clarify the aims of research. One merges insensibly into the other. The attempt to set apart the teacher and investigator is simply another tributary of the current which is tending to make all teachers independent of the practise of medicine, by urging adequate compensation for their entire time.