Popular Science Monthly/Volume 81/September 1912/Research in Medicine V
|RESEARCH IN MEDICINE|
UNIVERSITY OF PENNSYLVANIA
V. Medical Research in American Universities; Present Facilities, Needs and Opportunities
IF the preceding lectures have a special value, it is in indicating, on the basis of past experience, the methods and mode of approach, which will presumably yield the greatest measure of success in the investigation of present and future problems. Looked at in this light what I have cited of the past shows four important aspects:
1. The epoch-marking labors of isolated individuals working independently.
2. The application of the exact methods of physics, chemistry and biology to medicine.
3. The development of laboratories for the organized and intensive investigation of the various problems of medicine.
4. The idea of diminishing suffering and ameliorating social conditions.
The first of these factors naturally suggest the names of Vesalius, Pare, Harvey, Hunter, Jenner, Morgagni and Haller. Some of these may have been influenced by antecedent work as Vesalius by Herophilus and Erasistratus; Harvey by his forerunners, who studied the circulation of the blood; and all, perhaps, by the old teachings of Hippocrates or the experimental side of Galen's work, but the actual achievement of each, whether the result of chance suggestion, original conception, or keen observation, was the fruit of labors unassisted, prosecuted with difficulty, and in most instances in opposition to the traditions of the profession. Such independent effort, though most prominent in the period previous to the year 1800, always has had and always will have a place in medicine. This is seen in the efforts of the individual, even after medicine was influenced by its ancillary sciences and, indeed, in the days of organized laboratory effort. In this connection, one recalls Sir George Baker's demonstration that a form of colic, epidemic in character, occurring in Devonshire, England, was to be explained as a poisoning by lead; Captain Cook's conquest of scurvy; Auenbrugger's invention of the method of percussion; Laennec's invention of the stethoscope; the theory announced independently by Holmes and by Semmelweis of the transmission of puerperal fever and many other independent efforts in the practise of surgery and medicine, as those with which we associate the names of Pinel, McDowell, O'Dwyer and Trudeau.
Modern effort in research in medicine, however, as in science generally, is, it must be admitted, organized laboratory effort, and upon this type of effort present-day progress would seem to depend. Nevertheless, the individual is as important as ever, for "it goes without saying that laboratory buildings alone, even when adequately equipped and with a liberal maintenance budget, are far less important than the men who work in them" (Barker), but the laboratory now offers to the individual, with original conceptions or special talents, advantages, facilities and opportunities which, by aiding and supplementing the work of the individual, render isolated effort unnecessary, time-consuming and often futile.
Under the second head, the influence of physics, chemistry and biology, fall such men as the English physicists and chemists and the French academicians—Boyle, Cavendish, Priestley, Galvani, Faraday, Tyndall, Lavoisier, Gay-Lussac and Berzelius. A more direct influence is seen in the entrance of Pasteur, a chemist, into the field of etiology; of Ehrlich, a physician, but chemically trained, into the field of immunity and specific chemical affinities; and of Metchnikoff, applying the methods of the biologist to the problems of pathology. Likewise Liebig and Wohler and organic chemistry; Hoppe-Seyler and physiological chemistry; Arrhenius and physical chemistry, Darwinism, Mendelism, all have had their influence, and the methods and views they represent have been taken over by medicine and applied to the solution of its problems.
The influence of physics and chemistry in establishing the third factor—organized laboratory effort in special fields of medicine—we have seen in the beginnings of laboratory research in the second quarter of the past century. Virchow at the time he was urging the establishment of pathological laboratories epitomized the history of organization in medical effort as follows:
Since then, the laboratory idea has spread rapidly; not alone laboratories of pathology have been founded, but also laboratories of bacteriology, hygiene, physiological chemistry, pharmacology and every branch of endeavor promising advance in the science of medicine. Not only have such laboratories come into existence in university schools of medicine and in hospitals, but many independent laboratories for research alone have been founded in the large medical centers, as the Pasteur Institute in Paris (1888), the Imperial Institute for Experimental Medicine in St. Petersburg (1890), the Institute for Infectious Diseases in Berlin (1891), the Lister Institute for Preventive Medicine in London (1891), the Institute for Experimental Therapeutics in Frankfort (1896), the Rockefeller Institute for Medical Research in New York (1901), the Memorial Institute for Infectious Diseases in Chicago (1902), the Henry Phipps Institute for the Study, Treatment and Prevention of Tuberculosis in Philadelphia (1903). Likewise, municipal, state, provincial and national laboratories, devoted to work concerned with the public health, have been established. Some, following the example of the first laboratory of hygiene, that of Pettenkoffer, founded by the Bavarian government in 1872, have been most active in investigation; others are devoted mainly to the routine work necessary for the conservation of the public health. How essential laboratories of the latter type are is shown by the fact that several states, New York among the first, have established county or district laboratories to care for the problems of communities distant from the state laboratory and the laboratories of the larger cities.
So also laboratories as an integral part of hospitals, the so-called clinical laboratories—the first of which was established by Ziemssen in Munich about 1886—have become a necessary part of every hospital which makes any pretense of accurate diagnosis and adequate therapy. The list might be extended to include also laboratories devoted to special diseases, as cancer and tuberculosis, diseases peculiar to the tropics, and diseases of animals, or to special branches as surgical pathology, neuropathology and psychopathy. This wonderful extension of the laboratory idea in medicine dates only from the simple beginnings of Purkinjé and Liebig in 1824-25. At the present day, Germany alone is said to have over two hundred such medical institutes, and to this policy of establishing laboratories must be ascribed her leadership in the medical sciences since the third decade of the past century.
From this brief recapitulation of the important influences affecting research in medicine, only one conclusion is deducible; that although the individual will continue to be the most significant factor in the situation, it is unquestionable that his perception will be constantly stimulated, his imagination quickened and his hands aided, by the opportunities, ideals and facilities of the laboratory. In the laboratory only can "the prepared mind" of Pasteur's adage ("In the fields of observation chance favors only the prepared mind") be properly fostered. It is in the laboratory, and under this term I include the properly conducted hospital as the laboratory of clinical medicine, that medicine keeps in close touch with new discoveries in physics, chemistry and biology, the second of the three important factors we have discussed. The situation in regard to the auxiliary sciences has not changed since the time of Liebig, Müller and Virchow. The investigator in the laboratory and the investigator in the hospital still look to these sciences for assistance and eagerly apply the discoveries in each of these his own problems. The result is a decided advantage to medicine, not only in that this revivifying and suggestive influence leads to accelerated progress in the science and art of medicine, but also in that it directly influences the health and therefore the welfare, commercial and social, of the community.
This brings us to the fourth factor which has influenced medical research in the past and should—indeed must—continue to be an ever-increasing influence in the future—the desire to ameliorate social condition, by diminishing the causes of physical and mental ills. This, in a word, is the desire for social service; the impulse which actuated all of Pasteur's work, and which he himself expressed as the desire to contribute "in some manner to the progress and welfare of humanity." It is not sufficient that the individual as an investigator should be actuated only by his ambition and his investigations, or alone by his desire for exact abstract knowledge. If medical research is to be a vitalizing, reforming, uplifting factor, not only for the practise of medicine, but for the good of the community at large, then the whole man must be interested, heart and soul, not only in the technical and abstract results of his problems, but in their practical applications to medical and social conditions. What does this mean for medical research? That the laboratory shall be not only the brains, but the hands, of the community! It must recognize not only the problems of the community, but, solving the technical aspects of these problems, must demonstrate how they are to be met and cared for. In short, the investigator in medicine must be stirred by not only an abstract interest in human ills, but a direct interest in the problems, prophylactic or therapeutic, hygienic or social, of the community, with all its differentiation into industrial, commercial and domestic , of which he is a member.
If I am right concerning the importance of these various influences it would appear safe to conclude that progress in medicine may be expected in the future, as in the past fifty years, through the opportunities afforded the well-trained individual in well-equipped and well-organized laboratories, through the cultivation of the methods of auxiliary sciences and through the ideal of social service. And here I may say that in using the term "laboratory" I do not limit the term to the ordinary sense, but include the idea of research work in the hospital. One of the great influences of the application of the laboratory idea to medicine has been the recognition of the principle that hospitals should be utilized not only for the care of the sick, which is the first and most important function of a hospital, but for purposes of teaching and investigation as well. With such a conception, a hospital becomes the laboratory of the science of clinical medicine and in it the clinician as an investigator studies disease by the same exact methods as are utilized in any other laboratory.
If, then, the laboratory and the hospital are the tangible means of progress in medicine which our universities offer, how may research in the university be best served and what advantage does the university gain by fostering research?
By limiting the scope of this discussion to the university I do not wish it to be thought that I desire to minimize the importance of the work done by independent institutions for research or by state and city laboratories. The important work done by the Rockefeller Institute for Medical Research, for example, has placed this institution in one group with the Pasteur Institute, Koch's Institute in Berlin, Ehrlich's Institute in Frankfort and the Imperial Institute for Experimental Medicine in St. Petersburg. The character of its present staff, including as it does, your former professor of physiology, promises as great work for the future as has been accomplished in the past. Likewise, the Memorial Institute for Infectious Diseases in Chicago and the Henry Phipps Institute of Philadelphia are doing valuable work in the study of the diseases for the investigation of which they were founded. Such institutions point the lesson of the economic importance of research, which, if fully grasped by the public, would guarantee the support of independent institutions in every large center or wherever special facilities for the study of particular diseases could be found. Moreover, all these institutions have recognized the necessity of an intimate connection with a hospital in order to render their investigations most effective.
So also laboratories of state or city departments of health as of the state of Massachusetts and the state and city of New York and the Hygienic Laboratory of the Public Health and Marine Hospital Service, supported by the national government, have made original investigation of the infectious diseases an important and often major part of their work. In addition the Hygienic Laboratory has made most important investigations in pharmacology. Other non-university research institutions, as the New York State Laboratory for the investigation of cancer, the Rockefeller Commission for the Study of Hook-worm Disease, Trudeau's laboratory at Saranac for the study of tuberculosis and that for the study of problems of nutrition supported by the Carnegie Institution at Boston, are of great importance. Such institutions, and I have not exhausted the list, devoted to the of the problems of medicine and without affiliation with teaching institutions must be counted as among the most important factors in our social system.
Research in the medical school or the hospital, on the other hand, has developed slowly and has been in most institutions a matter of secondary importance. The reason for this is not difficult of demonstration when one remembers that even schools of university rank emerged only a short time ago from the proprietary state and that most physicians just past middle age can remember the two-and three-year course. Large classes, the belief in the didactic lectures, and the expense of laboratory equipment retarded the development of proper laboratory facilities and therefore the development of men trained to exact methods in the medical sciences. Likewise in the clinic the ideal teacher, with a few notable exceptions, was the busy consultant who devoted only a few hours of oratorical effort to clinical instruction and who disdained investigation as beneath the notice of a practical physician—an ideal which still holds in many of the more conservative schools and is responsible for the slow progress in the development of a science of clinical medicine. This type, however, is rapidly passing away and another generation may look back upon it as we do upon the age of the proprietary school, the two years' course and the amphitheater lecture.
It is not my intention to trace the beginnings of research in medical laboratories in this country, or, fascinating as it would be, if time allowed, to analyze early conditions and influences. A few men, however, stand out prominently, as, for example, Leidy, of Pennsylvania, teacher of anatomy and investigator in comparative anatomy, one of the greatest of American investigators in general biology, and Bowditch, who offered at Harvard in the seventies the first opportunity for organized research in physiology in this country. Laboratories of anatomy, that is, dissecting rooms, had always existed, but the modern type of anatomical investigation in anatomy is due to the influence of Minot, of Harvard, and Mall, of Hopkins. Likewise, laboratories of inorganic chemistry and so-called medical chemistry existed, but research in physiological and biological chemistry goes back only to Chittenden, of Yale, and Macallum, of Toronto; Delafield, Welch and Prudden in New York and Fitz in Boston appear to have been among the first to control university laboratories of pathology in which at least a few men gave much of their time to teaching or investigation, but the great impetus to research in pathology and bacteriology coincides with Welch's affiliation with the Johns Hopkins Hospital, and experimental pathology as a sustained effort was first broadly cultivated by Flexner. Investigation in pharmacology by modern exact methods, in laboratories devoted to that subject, is the result of the labors of Wood at Pennsylvania, of Cushny at Ann Arbor, of Abel at Baltimore, of Herter in New York and of Sollman in Cleveland. The first university institute of hygiene was that established at Pennsylvania in 1892. These are the names which the compiler of American medical history one hundred years from now will compare, in discussing the development of our laboratories, with those of the period of 1820 to 1860 in Germany. Why? Because these men established not merely teaching laboratories, but stimulated investigation, inculcated exact methods and trained men, and thus made an impression upon the medicine of their time. This is true not merely of their influence in furthering research, but of their influence in advancing the fundamental principles of proper medical education. As soon as it was demonstrated that laboratories were indispensable to proper medical education, the day of the medical school worthy of university rank arrived and the proprietary medical school as an important factor in medical education became a thing of the past. Moreover, as I have intimated, the principle of laboratory instruction and laboratory research which gave to laboratory effort the strongest place in the curriculum has had a distinct effect on the clinical teaching of medicine and surgery, so that in some of our better schools the individual student now has that opportunity for immediate contact with the patient which allows the direct exercise of his powers of observation, of the use of instruments of precision and of exact procedures which assure the acquirement not only of knowledge, but power to obtain knowledge. The result is the recognition of the clinic as a place for the exercise of exact methods in the teaching of the clinical branches and in the investigation of disease. Both fields of activity, the hospital and the laboratory, now have the "common purpose to advance medical knowledge and thereby bring healing to the nations."
With this conception of a common purpose guiding medical education and medical research and with the present unanimity of opinion concerning the absolute necessity of control of a hospital by the university, the duty of the latter to research is clear. If the purpose of the machinery of medical education is to "bring healing to the nations"; if "the business of medicine is to get people out of difficulties through the application of science and dexterity manual and psychical" (Cabot), then it is the duty of the university not only to teach known principles and methods, but to advance knowledge and methods by research.
It is futile to say that it is sufficient to teach and to utilize known methods for freeing peoples from difficulties, for the mere statement of such an attitude implies that an obligation exists to extend known methods or invent new ones in the hope of overcoming difficulties, acknowledged to be at present without remedy. The ethical force of this statement can not be denied. To teach a subject implies the attempt to diffuse the available knowledge of that particular subject matter among a number of people for their good as well as for the good of the community in which they live and work; equally true it is that such an attempt to teach available knowledge imposes upon the teacher the obligation to leave untried no means by which the knowledge of his subject may be increased. It is not the privilege of the teacher to leave this extension of knowledge to others. His profession of ability to teach a particular subject carries with it his obligation to the group or community he serves, of adding to his subject, knowledge of which they may avail themselves. If this applies to the individual teacher, how much more forcibly does it apply to the university with its ever-widening community and ever-increasing interests?
But ethics are frequently set aside in our practical, every-day world and even if they are not the great expense of maintaining laboratories and a hospital, an expense greatly increased if research is properly prosecuted, causes university presidents and trustees to ask what are the practical advantages of research to the university; and in those institutions which are supported, in part or entirely, by the state, this question must be squarely met.
In presenting the arguments in favor of research in the university, I will consider only conditions in this country and will not, though it would greatly strengthen the argument, utilize the experience of the German universities. One of the most important advantages, and one which should appeal to those controlling the policy of a university, is the influence on the student.
If one examines courses in the same subject in a number of schools, it is found that those which are best presented are under the control of men actively engaged in research work. Such men are alive to the advantages of new methods in their own subject and of new ways of applying old methods. Ever thinking and pondering about methods of acquiring new knowledge for themselves and their science, they appreciate better than does the non-investigator that which will aid the student to acquire knowledge, and in their teaching they bring to bear on the problems which the student has to face the same methods of attack which they use in their own researches. Under these men are assistants of the same point of view, who, ever enthusiastic about their duties as teachers, nevertheless find time for research. And it is of further interest that in these departments assistants do not long continue in a subordinate place, or at least if they do it is of their own desire, for they are early called to independent positions in other institutions. On the other hand, one finds that the men who confine their teaching to perfunctory routine laboratory courses, with a profusion of lectures, are the men who never or only occasionally contribute to the literature of their science.
In these departments, too, the teaching is a routine which, so the assistants say, gives no time for investigation; and so they remain assistants indefinitely. So, likewise, it is with the student taught under these two conditions. The student who knows that he is working in a department actively emphasizing new methods and striving to develop new truths, knows that his instruction is presented on the same basis, and thus receives that stimulus and inspiration which ensures his approaching clinical medicine with a proper appreciation of the scientific method. The student under the method of the non-investigator, on the contrary, has no incentive other than that of acquiring a knowledge sufficient to allow him to pass an examination.
An allied argument lies in the fact that the medical school that fosters research attracts the best-trained men as students. We have, as is well known to many of you, a medical school in this country which has, for several years, arbitrarily selected from a large number of prospective matriculants the certain definite number which it desires; the rest, sometimes equal to 50 per cent, of those accepted, go elsewhere. Now this school has the highest of entrance requirements and perhaps the smallest alumni body of any prominent school in the country. It is not therefore a question of easy entrance or of the loyal influence of alumni. Nor is it a question of better laboratory and hospital facilities, for other schools have equally good equipment in both respects. Likewise it is not a question of geographic location or center of population. The enviable position of this school is due solely to the policy of combining research with teaching and of appointing to its staff teachers who, with few exceptions, are also investigators.
My contention that research in the medical school has important practical advantages to the university is, therefore, not visionary or theoretical. A policy which attracts the better-trained class of students, which improves the character of the instruction, which stimulates the student to a better type of individual effort, and which enhances the standing of the university in the community and the nation is a policy which can not be ignored by university president, trustees or faculty.
Another phase of this subject is the duty of the university in public health and other medical matters of interest to the community and essential to its welfare. State and city have always felt at liberty to call university experts to their aid in the solution of problems of administrative policy and public weal. Not infrequently, as in the case of Harvard University and the Massachusetts State Department of Health and that of New York City and New York University, the university shares with the state or city the service of expert investigators in the preparation of curative sera and the study of new methods of combating disease. In some states the university laboratories of hygiene, bacteriology or pathology are the research laboratories of the state. The problems of agriculture, of animal industry and veterinary medicine are, in the states of the middle west, largely under the control of university laboratories. It is not my desire to discuss in its general application the question of the part of the university in social service but that the mid-western state universities have solved this question in the matter of animal and plant disease and in agricultural and certain industrial problems is evident from the occasional references to the university as "the people's organized instrument of research" or "the scientific adviser of the state." This idea of social service must, and already does, to some extent, include the study of diseases of man. To what extent the latter shall develop in state universities depends upon the liberality of the state, or, as in non-state universities, upon endowment by individuals. This matter of endowment is the crux of the research problem in its connection with the university. It is no longer possible for a medical school to be supported by the fees of its students. In the old days of the proprietary school, when instruction was almost entirely didactic, and the only laboratory work was the dissecting room, with perhaps a room for workers in inorganic chemistry and the simple procedures of so-called medical chemistry, fees sufficed and the faculty could pocket a good dividend. The increased cost of laboratory instruction in its many phases, the increase of equipment, of assistants and attendants, have made this impossible and have forced the medical schools to the shelter of universities which have resources sufficient to support medicine. But even with this aid, few schools have sufficient funds to satisfy the demands of adequate instruction and leave a balance for investigation. The result has been that universities seek special endowment for specific lines of investigation and it is unquestionably along such special lines that an increase in the facilities for research is to be expected.
A consideration of the special departments of research now existing, of the factors determining their establishment, and of the influence such departments have exerted may be worth while. It has been said by some authority on university affairs, that "the best way to get endowment is to deserve it"; and this is the principle which actuates a not inconsiderable body of men scattered over this country who by their efforts are attempting to bring forcibly before the public and university trustees the value of investigation, particularly of the preventable diseases, as a necessary and dignified type of university effort.
It is of interest to note the various ways in which research chairs or departments have been established. Some have been the result of the multiplication of chairs devoted to one general subject, as at Harvard, which has in the medical school chairs of comparative pathology, comparative physiology and comparative anatomy, each of which is quite distinct from the chairs responsible for the fundamental undergraduate instruction in pathology, physiology and anatomy. The establishment of these chairs, in part through special endowment, has greatly increased the facilities and time available for research in these fundamental branches and for special or more detailed instruction in the various activities which they represent. Likewise the splitting off from bacteriology of independent departments of preventive medicine (Harvard and Washington universities) has increased the opportunities for the study not only of the infectious diseases, but also of those due to industrial conditions, to poverty and insufficient methods of preparing and handling food-stuffs.
Of similar origin are the departments established recently at Pennsylvania and Tulane for the study of tropical diseases. So also at Harvard an opportunity for similar effort has been made possible through the endowment of a traveling professorship in the department of bacteriology. In the same way increased facilities for investigation in chemistry has been brought about by the founding of departments devoted to physiological chemistry, independent of the older chairs of chemistry and toxicology; by the recognition of a sphere of usefulness in experimental pharmacology independent of materia medica and applied therapeutics; by departments of experimental pathology and pathological physiology, neuro-pathology and surgical pathology cooperating with or independent of the traditional departments of pathology; by the evolution in surgical teaching and research of laboratories of experimental and veterinary surgery, and, in our hospitals, of laboratories of clinical pathology. These departments, in most instances, having some instructorial duties, have an enormous influence in furthering research and in indicating the need for its extension. For the most part, whether founded on special endowment or otherwise, they are the result of an influence from within, the desire of the university authorities to increase opportunities for investigation and to improve facilities for teaching. Both these objects have been attained, and the success of many of these laboratories is a most potent argument in favor of increased endowment.
That such efforts are beginning to yield fruit, that the public is awakening to the importance of endowing research in medicine and is bringing to bear an influence from without, is shown by the increasing number of gifts, often spontaneous, for the support of investigation under the control of the university. Many of these have heen made with definite specifications as to the problems to be studied, which is encouraging evidence of a special study on the part of the donors and of a keen appreciation on their part of the limitations of medical knowledge and of the need of enlarging its boundaries. Of departments thus founded, some of the best examples are those at Harvard, Cornell and Columbia for the study of cancer, the Henry Phipps Institute and Hospital, now a part of the University of Pennsylvania, for the study and treatment of tuberculosis; the department of experimental medicine at Western Reserve; the department of research medicine at Pennsylvania for the study of chronic diseases, the recently founded Sprague Memorial Institute affiliated with the University of Chicago for the study of the general problems of medicine and that recently announced by Northwestern University for the study of tuberculosis and other infectious diseases. Here also should be included the Wistar Institute of Anatomy at Pennsylvania, the work of which at present is devoted largely to research in problems of the nervous system. Of special interest in connection with many of these foundations is the provision for investigation in the hospital in connection with laboratory work. Thus the foundation for the investigation of cancer at Harvard has its own hospital, the Phipps Institute at Philadelphia provides for the laboratory and clinical study of tuberculosis, the new Sprague Institute of Chicago has a hospital affiliation, the pians for the Memorial Institute for Infectious Diseases include a hospital for the study of such diseases, and some of the smaller foundations have been established with the understanding that the university shall ensure access to the wards of the hospital under its control. Surely the universities through the endowment of medical research will have opened to them invaluable opportunities for service not only in the investigation of special diseases, but in the broader field of the relation of social conditions to disease. In connection with the latter Dr. Richard C. Cabot has called the attention of the profession and hospital authorities most forcibly to their duty and to the opportunity for special research which this field offers. Already the Rockefeller Commission for the Study of Hook-worm Disease has undertaken the study of social conditions determining the occurrence of hook-worm disease and the University of Pennsylvania, by establishing, in connection with the Phipps Institute, a department for the sociologic study of tuberculosis, offers the first instance of a university uniting laboratory, clinical and sociologic methods in an effort to elucidate the problems of a single disease. The experiment is an important one in that union of effort in the study of a single disease, if based on the principle of social service as illustrated by the work and writings of Cabot, promises to give to university research a new field of activity; to medicine a powerful ally; and to society, an ideal, of great promise for the good of the community.
To these various influences which I have presented at some length, we may, I believe, ascribe what little advance has been made in university research in medicine in this country. The same influences will continue to operate. The breaking down of the hard and fast lines which were drawn originally around the institutes of medicine will continue. As in the past, so in the future, the formation of new departments from the older departments will limit the field to be cultivated by a single individual and thus the time devoted to teaching a single subject will be divided, and as a result more time and opportunity for productive investigation will be allowed. Already immunology clamors to be released from alliance with bacteriology, hygiene or pathology; protozoology claims a domain distinct from that of bacteriology; pathological physiology demands greater recognition; and a new field—experimental therapeutics—distinct from pharmacology, is already well defined; all such expansions mean greater freedom and greater opportunity for investigation. These tendencies and the closely allied factor, the increased recognition of the hospital as a place for research (and especially the planning of groups of special hospitals, as at the Harvard Medical School), represent the forces within the university which have made progress possible. Of the forces from without which exert an influence, one, already discussed, is endowment for special investigation. A second is the influence exerted by independent institutions for research, as the Rockefeller Institute and Hospital, which by its magnificent work has stimulated the better university schools to greater effort in the advancement of medical knowledge.
A third factor is the demand of a gradually awakening public opinion that medicine should take a more prominent part, active and advisory, in the affairs of the community. The effect of this demand is already seen in the fact that the limitations and aloofness that characterized medicine in the past have already begun to disappear, and we can confidently look forward to a day when the activities of medicine, on its research and preventive sides, at least, will be—if I may so express it—imbedded in the social system, and shall live by and for it. In this connection, the university should not forget that the science of bacteriology and the knowledge which it has popularized concerning the etiology and control of disease and pestilence, formerly considered as foreordained and without remedy, has brought to the race a new hope concerning many of man's afflictions, and this hope is tinctured with an impatient demand that all preventable diseases, whether due to infection or occupation, should be thoroughly investigated. Preventive medicine has become a great educational movement, the onward sweep of which has been accelerated by modern views concerning the treatment of tuberculosis, by municipal experience with the efficacy of water filtration against typhoid fever, the "cleaning up" in a hygienic sense of Havana during the American occupation, the wonderfully healthy state of the Canal Zone under Gorgas as compared with that in the time of the French control, the influence of a better understanding of the effect of hook-worm disease on social conditions in the south, and the importance of the destruction of the mosquito in the prevention of yellow fever and malaria. The public looks first, and naturally so, to its state and municipal laboratories for assistance, but it looks also to the laboratories and hospitals of the universities for that wise guidance and direction which, untrammeled by political expediency, is the result of impersonal scientific observation and experiment.
The problems which may be attacked by the university are both general and local; in many instances a most promising field of investigation lies at the university's door. As is pointed out in Abraham Flexner's Carnegie Report on Medical Education, the port of New Orleans offers to Tulane a great opportunity for the study of tropical diseases, and the industries of Pittsburgh offer to its university unusual material for the study of occupational diseases. The port of San Francisco, draining as it does the Orient, and soon to feel the influence of the Panama canal, offers to the university which will grasp it a field for the study of tropical and unusual imported diseases not open to any other city in the temperate zone. Industrial centers other than Pittsburgh offer advantages for the study of occupational diseases and the influence of industrial conditions. New York, Chicago and other large cities with compact populations present their own problems and even in sparsely settled rural districts arise questions of great importance.
So also every community has the problems connected with the diseases of infancy and of advancing years. The influence of bacteriology in focusing the attention of investigators and of the general public on the acute infectious diseases, though an influence of the greatest importance to medicine and one responsible for much of the endowment of research in this country, has had a tendency, on the other hand, to retard the study of diseases not due to bacteria or protozoa. The pendulum now, however, is swinging the other way, and the time has come to attack, with the aid of the methods of chemistry and physiology, the chronic diseases, the disturbances of metabolism and of internal secretion and the affections peculiar to infancy and old age. Only recently have the diseases of advanced life attracted an attention commensurate with their incidence and importance. As the fruits of the investigation of the acute infectious diseases have increased the expectancy of life by diminishing the mortality of infancy, childhood and early manhood, so the study of the chronic diseases incident to middle life and advancing years, should, by the determination of predisposing causes and methods of prevention, lead not only to a still greater stability of life, but also, and what is more important, to a prolongation of years of useful activity and, perhaps, to a serene instead of painful final deletion.
This leads to the discussion of a new type of department in the medical school, departments or chairs for research only. That such departments are now necessary is the direct result of the unwise policy which, in the past, has led university presidents and medical faculties to appoint as heads of departments men who have little or no training as investigators and no interest in research. As the modern view of the duties of a medical school—teaching, the first duty, but investigation the corollary, essential not only for its own sake, but also for its influence on teaching—gains ground, university authorities find their chairs encumbered with men incapable and disinclined to conduct genuine university departments. New chairs, for research only, are therefore established in order to evade the penalty of a wrong policy and at the same time to secure men with the training and ideals of the investigator.
When university presidents learn that every professorship, clinical and otherwise, ought to be in some measure a research chair, and that research must be combined with teaching, the need for special departments of research will not be so urgent. It is true that clinical teachers are not united on this point; indeed, the weight of their opinion is often thrown in the opposite direction. For example, the anti-university conception of the university clinical professor has recently been very clearly presented by Professor Barker in an extremely plausible argument, in the course of which he proposes that two chairs should be created in the department of medicine—one for teaching and the financial prosperity of the incumbent, and the other for resarch! No more objectionable proposition from a university point of view has ever been made. Officially recognized and sanctioned separation of research from teaching, especially in the clinical chairs, would not only place the university on the level of the secondary school, but would delay all progress in medicine, and, more important still, destroy what little confidence the public is beginning to have in the altruism of university medical education. Let us hope that such counsels may not prevail. Let us work for the recognition of the principle that teaching and research should be combined in every department of the medical school. In the meantime, special departments of research may well be created, not only to make up for the sterility of the other chairs, but in order to attack problems that are of such magnitude and complexity that they may well engage the entire time of those devoted to them. But neither research professorships nor research institutes can ever relieve the professor of medicine or of surgery from the duty and obligation to continue to be creatively occupied in the development of their respective departments.
Existing departments of research are variously described as departments of experimental pathology, experimental medicine or research medicine. The title matters little, but the plan of the department should be broad enough to care for the problems of clinical medicine, and for this reason the word "medicine" should appear in the title rather than the word "pathology." Such a department should keep in close touch with the department of clinical medicine, should supplement the facilities of the various hospital laboratories, and should also work in cooperation with the fundamental laboratory sciences in order to insure no loss of opportunity in the prosecution of its problems and thus a realization of the greatest good to the school. The head of the department should be a man familiar with the problems of clinical medicine, trained preferably as a pathologist, and with sufficient knowledge of the possibilities of physiology and chemistry to apply the methods of these subjects to clinical problems. I say preferably a pathologist because the pathologist is more apt to combine clinical training with a knowledge of pathology, bacteriology and the principles of immunity than is the physiologist, chemist or pharmacologist, though any one of the latter might well head such a department. Certain it is that whatever his own training may have been, the director should, with his assistants, be able to utilize in the work of the department the methods of physiology, chemistry, bacteriology and experimental pathology. In other words, he should have a department capable of attacking a problem in medicine from any or all sides, including that of experimental therapeutics; and in order to make the work effective, he should have the use of beds in the university hospital.
The work of this department should be the investigation of clinical problems, and not of academic problems of pathology, chemistry or physiology. General practitioners, clinical assistants in the school and even those at the head of clinical departments are constantly meeting problems which demand solution, but find no adequate opportunity to investigate them in departments as now constituted. These men would find a place in the department suggested and should constitute an enthusiastic working staff which should be exceedingly productive in the advance of medical knowledge.
I may be over-enthusiastic about this matter, but I believe that departments such as I have outlined are a necessary part of every large university medical school, and must be developed eventually through the combined efforts of the pathologist and the clinician, who have naturally a greater interest in the problems of disease than have the men of other departments and who must have a research department devoted to their common interests.
A department of this type, whether independent or affiliated with the chair of medicine, I would recommend to every university which sees its way to procure endowment for research in medicine, for in a department of such broad scope lies the possibility of attacking many problems in the broadest way and of assuring the best utilization of endowment and the greatest good for the greatest number.
This discussion might be lengthened by the presentation of other phases of the subject of medical research, but I may well end with Mr. Eliot's all-inclusive characterization:
If my presentation of the subject of research in medicine, which now comes to its close, has any value it lies in an attempt to demonstrate two things: (1) That, wonderful as were the isolated achievements of the great discoverers in medicine in the early centuries, the great continuous advance in medicine during the past eighty years resulted from organized laboratory effort based on the principle of exact experimental methods, and (2) that it is the duty of the university so to organize its laboratories and hospital that this advance of medicine by research may continue, side by side with teaching, as a university function of benefit to student and faculty, as well as to the state and the general public welfare, and thus as an aid to the advancement of civilization.
The many and varied sources of the material presented in these lectures it would be difficult to set down. The following list represents the more important books, addresses and other publications used as constant guides in the epitomization of various eras, or for the purpose of direct or indirect quotation.
|Cabot, E. C. Social Service and the Art of Healing.|
|Cambridge Modern History. The. Vols. X. and XII.|
|Darmstaedter, L., and DuBois-Reymond, E. 4,000 Jahre Pionier—Arbeit in den exakten Wissenschaften.|
|Draper, J. W. History of the Conflict between Religion and Science.|
|Flexner, A. Medical Education in the United States—Bulletin No. 4 of the Carnegie Foundation for the Advancement of Teaching.|
|Foster, M. Masters of Medicine—Claude Bernard.|
|Gorton, D. A. The History of Medicine.|
|Harrison, F. The Meaning of History.|
|Herter, C. A. The Influence of Pasteur on Medical Science.|
|Lawrence, R. M. Primitive Psycho-Therapy and Quackery.|
|MacFie, R. C. The Romance of Medicine.|
|Merz, J. T. History of European Thought in the Nineteenth Century.|
|Mumford, J. G. Surgical Memoirs.|
|Mumford. J. G. A Narrative of Medicine in America.|
|Neuberger, M. History of Medicine.|
|Park, K. An Epitome of the History of Medicine.|
|Russel, J. R. The History and Heroes of the Art of Medicine.|
|Stirling, W. Some Apostles of Physiology.|
|Traill, H. D. Social England.|
|Vallery-Radot, R. The Life of Pasteur.|
|Williams, H. S. A History of Science.|
|Encyclopedia Britannica — 11th Edition|
|Allbutt, T. C. Medicine, History of.|
|Payne, J. F. Medicine, History of.|
|Addresses and Papers|
|Allen, F. The Twofold Function of the University, Science, 1910, XXXII., 901.|
|Barker, L. F. Medicine and the Universities, Amer. Med., 1902, IV., 143.|
|Barker, L. F. Medical Laboratories; Their Relation to Medical Practice and to Medical Discovery. Science, 1908, XXVII., 601.|
|Barker, L. F. Some Tendencies in Medical Education in the United States, Jour. Am. Med. Assoc., 1911, LVII., 613.|
|Buchheim, R. Ueber die Aufgaben und die Stellung der Pharmacologie an den deutschen Hochschulen. Arch. f. Exper. Path. u. Pharmak., 1876, V., 261.|
|Cabot, R. C. Ethical Forces in the Practice of Medicine. (An address delivered before the students of Harvard University, on April 13, 1905.)|
|Cabot, R. C. On the Relation between Laboratory Work and Clinical Work, Boston Medical and Surgical Journal, 1911, CLXIV., 880.|
|Calkins, G. The Scope of Protozoology, Science, 1911, XXXIV., 129.|
|Councilman, W. T. The Relation of Pathology to Medicine, Trans. Mass. Med. Society, 1898.|
|Eliot, C. W. Address at the Formal Opening of the Laboratories of the Rockefeller Institute for Medical Research, Science, 1906, XXIV., 13.|
|Jacobi, A. An address before the Medical School of McGill University, New York Medical Journal, 1905, LXXXII., 729.|
|Keen, W. W. The Debt of the Public to the Medical Profession, Phila. Med. Journal, 1899, III., 939.|
|Marks, L. H. Ehrlich's Biochemical Therapy, Its Conception and Application, Journal American Medical Association, 1910, LV., .|
|Minot, C. S. The Relation of Embryology to Medical Progress, Popular Science Monthly, 1906, July.|
|Park, W. H. A Critical Study of the Results of Serum-Therapy in the Disease of Man, Harvey Lecture, 1906.|
|Pearce, R. M. The Experimental Method; Its Influence on the Teaching of Medicine, Jour. Am. Med. Assoc., 1911, LVIL, 1017.|
|Schweitzer, H. Ehrlich's Chemotherapy — A New Science, Science, 1910, XXXII., 809.|
|Sedgwick, W. T. The Relations of Public Health Science to Other Sciences, American Medicine, 1905, IX., 975.|
|Vincent, G. E. The Purpose and Spirit of the University, Science, 1911, XXXIII., 977.|
|Welch, W. H. The Endowment of Research, Science, 1906, XXIV., 6.|
|Welch, W. H. The Relation of the Hospital to Medical Education and Research, Journal American Medical Association, 1907, XLIX., 531.|
|Welch, W. H. The Interdependence of Medicine and Other Sciences of Nature, Science, 1908, XXVII., 49.|
|Welch, W. H. The Evolution of Modern Scientific Laboratories, Johns Hopkins Hospital Bulletin, 1896, |VII., 19.|
- The Hitchcock lectures, delivered at the University of California, January 23-26, 1912.
- Presented also before the Academy of Medicine, Toronto, Canada, March 5, 1912.
- Caroline Brewer Croft Fund Cancer Commission.
- Collis P. Huntington Fund for Cancer Research.
- George Crocker Special Research Fund.