January ii, 1900] 



NATURE 



255 



";)enefit of mankind by the advancement of knowledge. If we 

 ire right — as I am sure no one present doubts— in regarding a 

 hospital school as an academical institution of which it is as 

 much the function to make additions to knowledge as to 

 educate, the organisation of every hospital school should com- 

 prise a special department for research in medicine—that is, 

 that just as we have recognised for long the importance of 

 pathological anatomy by the establishment in each school of a 

 museum for the collection and display of morbid specimens, so 

 we should provide what is of much more importance to the 

 progress of medicine — a working place for the investigation of 

 morbid processes. And, inasmuch as in most instances such 

 investigation could be carried out much more effectually by the 

 cooperation of several hospitals, I should further desire to see 

 established a Hospital Association or an Association of Hospitals 

 for the advancement of medicine by research. The organisation 

 of such an Association would be simple. Each hospital would, 

 as I have said, provide a research laboratory, under the direction 

 of a working pathologist, the equipment of which would be the 

 best that the resources obtainable for the purpose would admit 

 of. The function of the Association would be the selection of 

 subjects suitable for combined investigation. 



Of the nature of these problems I need, I think, speak only 

 -very shortly. They would probably be of two kinds, namely, 

 •etiological and therapeutical, for it seems evident that for the 

 investigation of the action of remedies — including under this 

 term all the agencies which can be employed for the purpose of 

 modifying pathological states— the same combination of clinical 

 with physiological research is required as for the investigation of 

 the processes of disease. But the greater part of the work of 

 the Association would come under the other head. It would 

 be advisable to restrict the scope of the investigation undertaken 

 by well-defined limitations, and particularly to guard against 

 the attractiveness of topics deriving their interest from their 

 novelty, or from the rarity of the diseases to which they relate, 

 rather than from their intrinsic importance. Preference would 

 rather be given to the standing questions of clinical pathology, 

 as, for example, to the investigation of the nature and causes of 

 functional disorders or organic changes which, however frequently 

 they inay occur, are very imperfectly understood ; and among 

 these it might be well to select those in respect of which current 

 medical opinion appears to be less in agreement than could be 

 -wished with the data of science. Let us take, for example, the 

 <ase of gout. Here the difficulty which we find in harmonizing 

 what is ordinarily believed as to the etiological relation of gout 

 with uric acid, with the relatively complete knowledge we now 

 possess of the physiological significance of that substance, at once 

 suggests that it is desirable that the two kinds of knowledge now 

 apparently at variance should be, so to speak, confronted. 

 Another field in which it is difficult to reconcile the clinical and 

 (physiological aspects of the same phenomena is that of the re- 

 lation between chronic renal disease and the functional disorders 

 of the vascular and lymphatic system to which it gives rise. 

 Here, again, the light which has been thrown on these subjects 

 by such experimental investigations as those of Dr. Starling 

 (which, I may mention in passing, have since their publication 

 been confirmed by subsequent work in Germany) make us feel 

 a certain degree of disappointment in finding ourselves still 

 compelled to speak with the utmost reserve about such questions 

 as the etiology of renal dropsy. Here, as in many other in- 

 stances of a like nature, unsolved problems present themselves 

 in connection with even the best-known diseases from the 

 moment that we turn our attention to the underlying processes, 

 of which the familiar clinical characteristics are but the outward 

 and visible signs. 



I trust that the suggestion I have made to you may not seem 

 -wholly unworthy of your attention, however imperfectly I may 

 have been able to set it forth. I do not, myself, feel it to be 

 premature. I should not, however, have the "boldness to pro- 

 pose it even now, were it not that, as I have already told you, 

 the reason which would have forbidden its being entertained no 

 longer exists. We have now what we had not before— a suffi- 

 cient number of men who, with youthful enthusiasm and with 

 the best of their lives before them, have at the same time the 

 scientific training necessary for pathological research. 



If, as I trust may be the case, the new Metropolitan university 

 as successfully constituted, it may be hoped that the economy of 

 ■resources consequent on a better organisation of scientific teach- 

 ing may set free the hospital medical schools from obligations 

 which at present seriously impair their efficiency as academical 



KO. 1576. VOL. 61] 



institutions. At present, as \*^ all know, elementary chemistry, 

 elementary natural philosophy, and natural history are taught in 

 schools of medicine ; and large sums have, no doubt unavoid- 

 ably, been spent in providing accommodation for subjects which 

 lie outside the legitimate scope of medical study. It is surely not 

 too much to hope that when these preparatory disciplines are 

 duly provided for elsewhere, the resources hitherto required for 

 their maintenance may be devoted to purposes in which we, 

 as the representatives of medical science, can take a deeper 

 interest, and particularly to the establishment in all hospital 

 schools of well-equipped working places for clinico- pathological 

 researches.' 



In all that I have said this evening my aim has been to 

 advocate the claims of scientific research in medicine ; I have 

 made no reference to the teaching of science. It is, however, 

 easy to see that if the organisation of pathological research were 

 to become more distinctly recognised as a function of a hospital 

 medical school, the tendency of the change would be to infuse 

 into the teaching of the science of medicine a reality and life 

 which it has not as yet possessed. 



Under present conditions there is much too wide a gap 

 between the scientific and the practical part of the course oi 

 study for medicine. Let me take, for example, the case with 

 which I am most familiar — that of the Oxford or Cambridge 

 student, who, after receiving his preliminary instruction in 

 the exact sciences in biology, and then acquiring a more 

 thorough knowledge of anatomy and physiology, repairs to 

 a Metropolitan medical school for the most essential part of 

 his medical education. A considerable portion of these com- 

 paratively well-trained students are able to grasp the connection 

 between science and practice, so as to appreciate the bearing of 

 the science they have learned with the practical work in which 

 for the rest of their lives they are to be engaged. But as regards 

 the rest, we know what happens as soon as they have got rid of 

 their last examination in science. It would be of little conse- 

 quence that the details of the knowledge which has been so pain- 

 fully acquired should fade from the memory, if one could believe 

 that some notion of the scientific way of looking at questions was 

 retained. 



Whatever plan of study is followed, it is inevitable that the 

 competent should succeed and the incompetent fail ; but in our 

 medical course there are causes of failure which it seems possible 

 to obviate. One of these is no doubt the over-loading of our 

 preparatory scientific curriculum with subjects which have no 

 bearing on future work, an evil against which the General 

 Medical Council has failed to protect us. The other is the un- 

 fortunate interruption of continuity which exists between the 

 practical and the scientific stage in medical study. 



It may, I think, be stated generally that every student when 

 he enters on his hospital career feels that he is turning over a 

 new leaf. It is quite natural that he should do so, and quite 

 right, provided that he does not lose his interest in what he has 

 previously learned. How is this to be prevented } 



I have submitted to you this evening the proposition that 

 research ought to be a recognised function of every medical 

 school that lays claim to an academical position, on the ground 

 that research is necessary for the advancement of medical 

 science. The more this principle is acted upon the more 

 effectually will the .science of medicine be taught, for there is no 

 qualification so essential to a teacher of science, and especially 

 of pathology, as that he should himself be engaged in trying to 

 master its difficulties. 



Every advance in the direction I have indicated will have 

 a direct efifect upon teaching. The breach will cease to exist. 

 The physiologically-minded student will no longer feel that in 

 approaching the bedside he must leave his scientific precon- 

 ceptions behind. In turning over the new leaf he will not for- 

 get what was inscribed on the old, but will rather find that the 

 old has acquired a new v^lue from its intimate connection with 

 the work of his life. 



But, gentlemen, all depends on whether you accept the 

 proposition I have submitted to you — namely, that the science 

 of medicine, even more than the art, holds the promise of the 

 future. 



1 At the Middlesex Hospit.M a systematic investigation of the pathology of 

 cancer is now in contemplation. _ I learn that it is intended to appoint a 

 highly-quahfied young pathologist to conduct the proposed research, and 

 that in the necessary clinical work he will have the co-operation of the 

 Registrar of the Cancer Department of the Hospital. The whole will be 

 under the direction of a Committee of the Hospital staff. I refer to this as 

 an example of the kind of work that can be done, and of the way of doing it. 



