578 



SCIENCE 



[Vol. LV, No. 1431 



placement of the general practitioner by spe- 

 cialists. Changes have been so varied and rapid 

 that medical education has been unable to keep 

 pace with the growth of new theories, new 

 methods, and new ideas of practice : with a 

 result that the medical student of the day is 

 subjected to a type of education which is, in 

 the words of a well known college president, 

 "about half a century behind other forms of 

 higher instruction." Research and prematurely 

 published articles are dominant features of the 

 time. Progress during this era of "specialized 

 functional-diagnosis" has unquestionably been 

 great, ' yet humanity comes very far short of 

 getting out of the medical profession the aid 

 which it is capable of furnishing. 



An analysis of these dominant factors in con- 

 temporary medicine reveals a timely and mer- 

 ited attempt to reduce medicine to the realms 

 of a pure science, or, as one particular enthu- 

 siast states it, "Medicine should now be gen- 

 erally recognized as an independent science, 

 dealing with the phenomena of disease." This 

 statement may be accepted if by science is 

 meant knowledge gained by systematic observa- 

 tion, experiment and reasoning. Reason, how- 

 ever, must always operate within experience, 

 never beyond it. Science is experience becom- 

 ing rational. Rationalized science becomes an 

 art through the skillful application of knowl- 

 edge to practice. 



Clinical medicine will always remain an art 

 expressing itself by the practical application 

 of all scientific experience toward the cure, 

 alleviation or prevention of disease ; in this 

 pursuit it does and must enlist in its service 

 all of the sciences. "A good internist will be 

 a better one if he is well trained in the so- 

 called medical sciences, but the sum total of all 

 the sciences does not make internal medicine, 

 nor is a brilliant scientifie education a pre- 

 requisite, for a useful clinical career." The 

 sciences give the true clinician some of his most 

 useful tools, but they do not constitute his art. 

 Many of the factors to which may be ascribed 

 the brilliance of contemporary medicine in a 

 scientific sense are, in part, at least, responsible 

 for some well recognized defects in the practice 

 of clinical medicine that may actually hinder 

 its progress. A brief consideration of some 

 of them would, therefore, seem timely. 



(A) The Menace op Excessive Laboratory 

 Procedures 

 The elaboration and perfection of a large 

 number of laboratory procedures has been a 

 natural development in the evolution of con- 

 temporary medicine. To deny their usefulness 

 would be absurd; to be forced to practice 

 clinical medicine without laboratory facilities 

 would be disastrous; to deny that important ad- 

 vances in clinical medicine have come from lab- 

 oratory studies would be untrue. Every one 

 admits that the patient dare not be studied at 

 the bedside alone. It is certain that laborato- 

 ries in the future will continue to play a dom- 

 inant role in the advancement of medicine. It 

 is equally true that medical investigation has 

 gone more and more away from men engaged 

 in clinical practice into the hands of laboratory 

 workers, many of whom possess but a limited 

 view of the problems which daily beset ' the 

 practitioner. The enthusiasm for more accu- 

 rate diagnosis .characteristic of contemporary 

 medicine, has, apparently, led many practi- 

 tioners to believe that the laboratory simpli- 

 fies everything; many actually seem to draw 

 the inference from reading current laboratory 

 advertisements, that clinical study can often 

 be dispensed with in favor of containers for 

 si^ecimens, gratuitously supplied by commer- 

 cialized laboratories. This excessive reliance 

 upon laboratory tests' has hindered the progi'ess 

 of clinical medicine in various ways as a 

 result of : 



(1) A tendency prematurely to accept and 

 apply new laboratory tests of promise. 



(2) The indiscriminate utilization of accept- 

 ed laboratory procedures that are in reality of 

 value only in a limited domain. 



(3) An improper interpretation of tests of 

 known value through ignorance of their clin- 

 ical significance. 



(4) An unwise reliance on positive labora- 

 tory findings to establish a diagnosis to the 

 exclusion of other data, that may, perhaps, be 

 much more important. 



One witnesses examples of these and other 

 errors almost daily. The total number of lab- 

 oratory procedures or tests in themselves patho- 

 guomonically diagnostic is very small. There 

 is practically none if diagnosis is understood 

 to include, as it should, not only the cause of 



