August 11, 1922] 



SCIENCE 



153 



ments of preventive medicine have brought us 

 to a stage where we need to reorganize clinical 

 teaching on the basis of research. To my mind 

 this is the fundamental point and the final 

 argument. Up to this time, preventive medi- 

 cine has been left for the most part to chance 

 and to boards of public health who applied 

 what knowledge they had but attracted to their 

 services, for the most part, only men of mod- 

 erate ability. The reorganization of medical 

 schools consists in focussing the minds of the 

 ablest men in the profession on the problems 

 of advance in medicine in contrast to the ideas 

 associated with the practical applications of 

 knowledge. This is the meaning of stressing 

 research instead of -the practical side in edu- 

 cational institutions. 



On this plane, I believe that you will admit 

 the principle of the full-time scheme. What 

 are the practical difficulties? The first one is 

 due to the complexities of clinical problems. 

 If you analyze the progress of scientific medi- 

 cine, it is astonishing how many of the dis- 

 coveries that have really changed medicine in 

 any fundamental way have come, not from the 

 climes, but from the laboratories; for example, 

 diphtheria antitoxin, the whole treatment of 

 infections by means of serums, and the dis- 

 coveries of the action of the glands of internal 

 secretion. In fact, in connection wiith this 

 latter subject, there is abundant reason to 

 demand that clinical applications of our knowl- 

 edge shall measure up to the standards of 

 sound physiological experiments. It is ob- 

 vious that the materials of research are more 

 readily handled in the laboratory than in the 

 clinic. In the laboratory ideas can be sub- 

 jected to experiment and the number of varia- 

 bles can be limited in these experiments in a 

 manner not possible in dealing with patients. 

 In the early days of the application of the 

 idea of the full-time plan to clinical work, the 

 first research done in clinical laboratories was 

 pure anatomy, pure physiology and pure 

 chemistry and was done no better than it was 

 being done in the pre-clinic departments. It 

 was asked and asked legitimately if there is 

 such a thing as pure clinical research. Already 

 we see light in this matter. There have now 

 developed certain combinations between the 



workers in the pre-clinical departments and 

 the clinics of advantage to both. I may 

 instance the brilliant progress which has come 

 from the laboratories of mltritional chemistry 

 and the departments of pediatrics in the study 

 of rickets. Here three different techniqaes 

 have been brought to bear on a problem of pro- 

 found interest to clinical medicine, namely, 

 the nutritional experiments of McCollum com- 

 bined with the clinical and histological methods 

 by Park and Shipley. In the nutritional ex- 

 periments on rats, McGollum and Simmonds 

 have not only been able to produce rickets but 

 other bone deficiencies as well and are now 

 analyzing the effects of sunlight as well as of 

 diets on these deficiencies. Indeed, the bril- 

 liant results in nutritional chemistry of Hop- 

 kins in England, of Mendel and McCollum in 

 this counti-y, demand an extension to the clin- 

 ical field as a logical conclusion of their work. 



Surgery gives another example of a place 

 where such combinations are of value, for in 

 surgery we are now passing into a phase 

 where further progress depends on a utiliza- 

 tion of various methods of the pre-clinical 

 sciences. The actual technique of surgical 

 operations has now reached a high degree of 

 perfection and any great advance in surgery 

 now depends on a more searching analysis of 

 the reactions of tissues to surgical procedures. 

 Indeed, if I may cite a particular example, we 

 have in Dr. Halsted a man who has not only 

 contributed very greatly to surgical technique 

 during its period of marked development, but 

 has also used surgical technique and the 

 insight which his clinical experience has given 

 him toward solving the problems of scientific 

 medicine. Such an instance is to be found in 

 his work on the thyroid, where he demon- 

 strated that a graft of a thyroid gland does 

 not take in an animal until an artificial defi- 

 ciency has been produced. 



On the other hand, there are certain prob- 

 lems with which it seems to me that the hope 

 of progress lies with the underlying sciences. 

 There are certain subjects where all the results 

 which can be expected from simple methods 

 have been obtained and where progress mast 

 be made by going deeply into the underlying 

 causes. Such problems are to my mind illus- 



