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tually dependent, medicine seems the most complex of all. To know the abnormal we must have knowledge of the normal. That is, whatever is known of structure of the human body and the little that is known of function must be available. In other words, knowledge concerning anatomy and physiology must be in the possession of every student, and knowledge of these sciences requires knowledge of chemistry and physics. These are well-recognized These are well-recognized facts that need not be dwelled upon further. Are men available for such a department, as teachers and students, men who are interested in the study of disease and who desire to increase the knowledge concerning disease without any other material reward than the rewards of the student and scholar? Or has scholarship gone out of fashion? Or is this such an uninteresting subject that no men can be found to undertake its study? As long as men will study the stars with scientific methods, as long as men will study the stones with scientific methods, men will be found to study disease. The men are ready and waiting, the opportunity only is needed.
The second essential is laboratories. The astronomer must have his telescope through which to observe the stars; he must also have his chemical and his physical laboratories. The student of medicine must also have his observatory, the hospital, and in this he should also have laboratories his laboratories and not be a guest or intruder in laboratories belonging to other scientific workers-chemists, physiologists or others. It is just as impossible that the science of medicine can be studied at the bedside alone, where only superficial observation is possible, or that it can be studied only in the laboratory, where disease as it occurs in man is never present, as that astronomy can reach its highest development by observation through the telescope alone, or by spectroscopic and chemical studies alone. It is not uncommon that the contributing sciences in the medical school are spoken of as the laboratory branches and the medical divisions are spoken of as the clinical branches. This in my opinion reflects the mistaken opinion which prevails concerning the nature and
proper methods of the study of medicine. For the development and teaching of medicine, laboratories are as essential as they are for the study of physiology. But if they are to be used, they must be in close proximity to the wards, and they must be so arranged and organized that the work in the laboratories and in the wards can go on simultaneously and harmoniously in both. This conception of the hospital, however, is rare even among those who take the most advanced views concerning medical education. I know of one university hospital which is being planned before the professors or staff that are to work in it have been appointed. No architect or hospital superintendent can possibly accomplish this task. For instance, the superintendent of a general hospital must, of necessity, take an entirely different view of a hospital from the one which has been sketched. It would be just as sensible to have a foreman of a machine shop design a laboratory for the department of physics as to have a hospital superintendent design a university hospital. In each case the superintendent or foreman might be of great assistance and give useful suggestions, but he would be as incapable of conceiving the purpose, and therefore of working out the idea, in the one case as in the other.
It can not be denied that it will be expensive to install in each clinic of the hospital well-equipped laboratories in which the varieties of technique already developed in bacteriology, physiology and chemistry, can be used, and in which entirely new methods may be devised. This is essential, however, if the science of medicine is to develop. In a given clinic probably all the laboratories would not at any one time be of equal importance. In each clinic the development would probably be mainly along special lines. If the division of internal medicine, for instance, was a large one, there might be several clinics or units, in one of which the chief attention would be given to one variety of disease, in another, to another variety. In the study of human disease, however, much is gained in economy and effectiveness if studies take not only one, but several directions at the same time. The sub
jects studied are so complex that it is wasteful to confine an investigation to a single narrow path. Thus in studying a group of patients suffering from an infectious disease, it is frequently important that they be studied not only from the standpoint of etiology, in which the chief work will be done in the bacteriological laboratory of the clinic, but it may be of great importance that, at the same time, alterations in metabolism and disturbances in function of the circulatory and respiratory systems be investigated, in which case the laboratory and technique of physiology or possibly of physics will be required, and on the same patients chemical studies of the blood or excretions may be valuable, all of which must be carried out in the special laboratories of the clinic. By carrying out all these procedures on the same patients, not only is expense saved, but each observation gains much in importance by being supplemented by the others.
In the university department of medicine there should not only be facilities for studying disease as it occurs in man, but there should also be facilities for carrying out experimental studies on animals. In many cases only by animal experimentation can the suggestions obtained from detailed observations on patients be confirmed or disproved.
With regard to the library, little need be said here except that it must be alive, not dead.
The above is my conception in brief of the essentials of a department of medicine in a university. Grant a central concept such as this on which to build, and it will not be difficult to elaborate the details, at least it will not be impossible. For instance, let us consider the number and kinds of the divisions into which any given department of medicine shall be divided, or in other words, the kinds of diseases for the study of which special clinics shall be provided. There can be little question that the diseases spoken of as surgical (because operative technique is employed in treating them) are of such great importance and the technique of their therapy has become so specialized, that one or more clinics of the department should be devoted to the study of these diseases. This does not mean, however,
that the methods employed in studying these diseases differ from those used in studying any other group of diseases. Exophthalmic goiter is the same disease whether we treat it by removal of the thyroid or by rest and drugs. Whether we call the professor who studies especially those diseases in which the chief therapeutic procedures are operative, a professor of surgery or a professor of medicine, is unimportant so far as the principle is concerned. His methods should be those of the professor of medicine as I have sketched him, and the surgical clinic should be exactly like the medical clinic with the addition of facilities for employing complicated operative procedures. The same principle should also govern the organization of the division of pediatrics or any other one of the divisions into which it is decided to separate the department of medicine.
The exact number of divisions in any department of medicine will have to depend upon the men and resources available and upon the contemporary state of knowledge concerning the various groups of diseases, and upon the immediate importance of increasing this knowledge. There seems to be no good reason, however, for dividing the department of medicine into a great number of divisions and subdivisions. Indeed, from the educational standpoint very great disadvantages are inherent in this method, owing to the scattering of interest which results. The efficiency of a department of medicine does not depend upon the number of its clinics or instructors, or upon the variety of subjects treated. The attempt to present to the student every known fact and theory concerning disease and to exhibit to him examples of every known form of disease only causes him to become confused and bewildered. What is much needed at present in medical education is the elimination of the unessential and the untrue. No student can be expected to learn all that has been thought about disease and all the theories that have been proposed. He should have, however, opportunities to learn what is actually known about important diseases and to receive the
kind of training that will enable him to discriminate between the true and the false.
A further detail of the organization of the department of medicine concerns its relation to the department of pathological anatomy. From what has been previously stated, it is obvious that the department of pathological anatomy should constitute an integral part of the department of medicine. The laboratory of pathological anatomy should be closely connected geographically, as well as in organization, with each one of the clinics. It should not be a block or a mile away from the clinics, or even in an isolated building on the hospital grounds. It should be physically a part of the department of medicine. There would be a great advantage in having at all times at least one assistant from each clinic acting as a member of the pathological staff. Each of these assistants should be engaged, under the direction of the professor of pathological anatomy, in studying and teaching the anatomical changes resulting from the special group of diseases which is being studied in the clinic which he represents. On the other hand, the professor of pathological anatomy should be a member of the administrative staff of the department of medicine. The effect of such an association as I have described would not only be of great educational value, but I believe that it would bring about a new birth" of pathological anatomy.
The objection will probably be raised by some that, although the introduction of the proposed principles and plans into the department of medicine might result in a greater and more rapid accumulation of knowledge concerning disease, it would have no immediate effect upon society at large or upon the practise of medicine. If this were so, the value of the plan might be questioned, though I would not go so far as to deny its value even under these circumstances. I assume, however, that one of the most important functions of the department of medicine must be to train men in order that they may become capable practitioners of medicine. Now the practise of medicine, or the practical application of the
science of medicine, may be considered to be directed in several lines:
1. Prevention of disease or decay.
2. Diagnosis, care of the sick and alleviation of pain.
3. Cure of disease.
At the present time the first function of the practising physician is exercised in a very minor degree. The medical schools take little cognizance of it. Therefore we may omit discussion of it here, though in my opinion it is the most important of the three, and the department I have in mind would exert great effort upon the development and extension of this function.
The second important function of the practising physician is to make diagnoses, that is, to bring the particular symptoms from which a patient suffers and the most striking features of his malady into relation with a group of symptoms and signs which have already been described and given the name of a disease. This is of great importance from the standpoint both of prognosis and treatment. Originally the classification of disease was empirical; later it was founded, in part on an anatomical, in part on an etiological basis, and in part merely on the presence of some striking feature. There is much that is empirical, superficial and traditional in this subject; nevertheless, in the present state of the science, it is important. The physician, therefore, must be trained in the methods of diagnosis. He must be trained in the method of Zadig. There are many tricks, short cuts and simplified methods in diagnosis with which the practising physician should be familiar, though they have not an essential place in the funda
mental science of medicine.
At present, however, the chief efforts of the department of internal medicine in our medical schools are directed towards the cultivation of diagnostic skill in the student. Much time is frequently devoted to the recognition of some rare disease, even though only a half dozen cases have ever been recognized and although nothing essential about the disease itself is known. Indeed the more unusual the special group of signs and symptoms, the more im
portant does it seem to become. An analogy may be drawn to the state of affairs lately existing in botany when the chief attention was given to the classification and naming of plants. We now know that this is only a part, and a relatively unimportant part, of the science of botany. A man may still be a great botanist even though on walking through a field he may not be able to name correctly every plant or tree which he meets. While diagnosis in medicine is important, its position in the educational scheme is misplaced. Instead of placing it at the beginning of the study of medicine, it should come later, after a knowledge of the more fundamental principles of medical science has been acquired. If a student knows much about a few of the common, more important forms of disease, the recognition of the rare forms will be relatively
Another function of the practising physician is the care of the sick and the relief of pain, mental and physical. Part of this labor is borne by the nurse, but the physician must bear the larger share, and if he is able to analyze disturbances in function, he is oftentimes able to bring relief even though he can not cure.
One of the chief efforts of the physician is to establish a feeling of confidence in the patient and in the family, and to relieve anxiety. The success of this effort depends largely on personality, but consciousness of real knowledge is a most important factor contributing to such an inspiring personal relationship.
In our present system the student learns less about therapeutics than about any other feature of disease. For a system of education that claims to be essentially practical, it obtains most impractical results. However much we may rail at the ineffectiveness of treatment -and the best practitioners are accustomed to do this there are at least a few therapeutic measures that are of great effectiveness and a few diseases over which the physician has absolute control. Yet how little does the student actually learn during his student days of the really practical methods of employing these
measures! How ill prepared he is to meet actual conditions, unless the procedures to be employed are of the greatest simplicity!
By present methods, therefore, students are not well trained, even in the elements of practise, except as concerns diagnosis. They should be better trained for practise.
In order to judge of the probable effect of the proposed plan, not only on the development of the science of medicine, but on the practise of medicine as well, let us sketch briefly the proposed organization of the division of internal medicine and the nature of the work which it is intended should be carried on.
The number of clinics which compose the division of internal medicine will depend upon the funds and men available and upon the size of the university or school. Each clinic, however, should have, let us say, a hundred or a hundred and fifty beds, its own independent laboratories equipped for the prosecution of chemical, physical, physiological and bacteriological studies, as well as laboratories for pathological anatomy and facilities for animal experimentation. The number of students admitted should be limited; these students should have had a general college, scientific training, preferably with specialization in chemistry, physics or biology. Before admission to the department of medicine, they should have studied anatomy, physiology and bacteriology. This work may have been done in any university. The custom of studying one subject in one university, and another subject in another university, should be encouraged. This would result in bringing into the department methods and points of view derived from many
The teachers should be carefully chosen young men who have had a good training in clinical methods and who are also well grounded in at least one of the contributing sciences, some in chemistry, some in physiology and so forth. Before appointment, they should have given evidence of ability not only to teach but also to aid in extending the boundaries of medical knowledge. In this department brief courses should be given in the methods for observing and recording the more
superficial features of disease, history-taking, physical diagnosis, X-ray examination, etc. There should also be courses in pathological anatomy, including study of the blood and other tissues that can be obtained during life, courses dealing with the application of physiological and chemical methods to the study of disease, and courses devoted to the study of the pathogenic bacteria and other parasites. As soon as possible, the students should begin the actual study of disease as it occurs in the patient, and the results as seen at autopsy. The students should spend a large part of their time in the wards and laboratories, making their study at first hand and relating all that they do to actual cases of disease. Reading must be encouraged and the student should be urged to consult original sources. It might be advisable to have the student devote a given period of his course to the study of infectious diseases, during which period much of his time would be spent in the bacteriological and pathological laboratories of the clinic. In another period the time would be spent mainly in the study of so-called diseases of metabolism, during which period he would have his working place and spend much time in the chemical laboratory of the clinic.
During his course the student should make an intensive study of at least one disease, making an attempt to learn all that is known about that disease, repeating with his own hands the important steps which have led to present knowledge, and if possible, he should add something, however slight, to existing knowledge concerning this disease. By means of seminars and conferences, both at the bedside and in the laboratory, each student would at all times be kept in touch with the work of all the other men in the clinic-students and teachers. The student would himself become an instructor of his fellow workers. The teachers would be engaged in directing and assisting the students in this work and in carrying out their own investigations.
At the end of two years the student would have acquired a great deal of knowledge about a considerable number of diseases, their prevention, nature, causes and treatment, and
would be well trained in the methods of studying disease. He would also be familiar with the methods and principles of diagnosis.
It may be true that the department of medicine I have sketched will not provide the student with the wide experience with disease in its various manifestations which would make him an able practitioner. But even with present educational methods, no one assumes that immediately after a student obtains his degree he is a capable, or even a satisfactory practitioner of medicine. It will be asked, where, under the system proposed, will the student get this wider experience and practise in technique. He will get it exactly where he gets it now, in the hospital year or years, or where he used to get it, in actual practise. No better system for producing good workmen, be they physicians or bricklayers, has been devised than the apprentice system. It is of great importance, therefore, that a good example be set in the hospitals in which students obtain experience and skill in the practical application of medical principles; this is almost as important as it is that the work in the university should be of the right kind. While the hospital can only occasionally and with difficulty make good practitioners of men who have had little or poor training in the science of medicine, it can very easily ruin men, however well they may have been fundamentally trained. There will always be the opportunity and need for good practitioners who teach by example. The preceptor system is of great value in its proper place. The trouble with the present system of medical education is that it consists almost exclusively of the old preceptor system employed in a wholesale and frequently inefficient manner. Modern developments require for medical education a scientific basis, with a final polish added by a preceptor system correctly applied.
The question will now be asked: Should the professors of medicine in the university department of medicine be trained in clinical medicine, or may they be men who have been trained only in physiological methods or chemical methods, or who have had experience with disease only as it occurs in experimental ani