HISTORIC STATEMENT.

At the meeting of the Missouri Valley Medical Society held at Council Bluffs in September, 1912, following the reading of a paper entitled "A Plea for the establishment of Medical Laboratories in the Cities of the Missouri Valley," a committee was appointed to recommend such plans for the promotion of laboratories as its investigations may indicate are feasible and wise."

INTRODUCTION.

This report is predicated upon the following premises:

(1) In order that the sick may receive all the aid that modern medical science can give, the great advance of scientific knowledge has so revolutionized the practice of medicine and surgery as to make it necessary to provide for a new factor in the scheme of medical service, the "Medical Laboratory."

(2) The Medical Laboratory here advocated is intended to be a definite, independent factor in the scheme of medical service, having a physical plant of its own and supported by endowment, donations and fees. and conducted by a board of trustees. It is not to be an adjunct to a hospital, but an essential unit of coequal or greater import ance, making available to the public scientific medical knowledge not now available, and available through this agency only.

(3) The establishment of medical laboratories must be accomplished through the social agencies now at work in society for social welfare. The government will not assume it and the medical profession should not nor cannot.

(4) The great majority of civil medical practitioners in city and country alike are unable to do their own laboratory work because of lack of time and training. For this essential aid dependence must be placed upon a central medical laboratory located with reference to tributary country and to facilities of rapid and efficient communication by rural route, parcel post, automobile and telephone. A medical laboratory thus

located would supply the need in the geo graphical and trade zone of its home city.

(5) That there is a real demand for central medical laboratories is proven by the constantly increasing number of commercial medical laboratories springing up in the cities that are trade centers. The patrons of these laboratories are the doctors in the tributary territory. Medical journals abound with the advertisements of medical laboratories, that are commercially exploiting laboratory work.

(6) The term "Medical Laboratory" is here interpreted to mean a laboratory of both a clinical and a research character. Clinical work and research work cannot be separated without doing violence to each. One applies to the relief of the sick old truths in medicine; the other is "striving to develop new truths in medicine." are for the healing of the nations." "Investigation and practice are thus one in spirit, method and object" (Flexner).

Both

The

THE RELATIVE POSITION OF THE MEDICAL LABORATORY AND OF THE HOSPITAL IN THE SCHEME OF MEDICAL SERVICE. Medicine is divided into two great fields, that of prevention and that of cure. medical laboratory is the great material agent for advancement in the field of preventive medicine and is an absolutely essential factor likewise in the field of curative medicine. Its work is fundamental to progress and efficiency in either department. The hospital is the great material agent for work in curative medicine and is dependent upon the medical laboratory for the scientific basis of its work.

In a hospital the direct benefits are confined to the sick coming within its walls, necessarily a limited number. The medical laboratory may be made to reach the suffering in the entire territory tributary to the city in which it is located. Thus the benefits of modern medical science may be carried to the patient on the distant farm sick at home, as well as to the patient in the city hospital. hospital. The medical laboratory reaches both groups, hence its influence is more farreaching than the hospital. The returns,

in number of persons helped, from equal amounts of money invested in the two types of institution, would be greatest from the medical laboratory.

Hospitals abound on all sides but endowed medical laboratories are few. Our present system of laboratories is wholly inadequate to meet the needs of the suffering with the result that the conservation of human life and efficiency falls far below what it would be were all the benefits of modern medical science available and applied to that portion of society physically ill.

Medical research work adds little by little to the sum total of medical knowledge. In the medical laboratory there is always the possibility of bringing to light some unknown medical truth that will be a boon to a suffering world. It is in the medical laboratory that the problems of tuberculosis and of cancer will finally be solved. Some day some tireless worker will discover a cure for these dread maladies, or some method of preventing them, and thus the world will be blessed. It was in the medical laboratory that the cure for diphtheria was found; that the remedy for hydrophobia was discovered; that the cause and cure of meningitis were brought to light; that the vaccine for typhoid fever was first prepared.

The work done in medical laboratories constantly broadens the horizon of medical knowledge. It is therefore fundamental and essential to progress. Medical research is ever seeking for the solution of definite medical problems its field being unlimited as is evident by a mere mention of the subjects of immunology, protozoology, chemotherapy, biological chemistry, experimental pathology and experimental pharmacology.

However, both the hospital and medical laboratory are essential for completeness of medical service and efficiency. Neither can do without the other. A medical laboratory lacking a clinical constituency both in the hospital and in the homes is an anomaly. Clinical material, that is, sick people, are as essential to the study of disease in the one as in the other. A hospital without adequate laboratory facilities is little better than a hotel for the sick.

ADVANTAGES OF A MEDICAL LABORATORY TO THE COMMUNITY.

Twenty-five years ago the mechanical equipment necessary for the general practice of medicine consisted of an obstetric bag, a pocket case of instruments, a fever thermometer, a wet cell battery, a stethoscope, a few test tubes and a low power microscope. With these facilities for scien

tific work at hand the young graduate felt that he could outstrip his older competitor and meet all the demands made upon him by the exigencies of an active practice. In this belief he was quite right, for with these aids there was brought to the patient the best that the medical science of that day could offer. Their application was so simple that the practitioner could put them into use himself, and that without serious loss of time from his actual bedside minis trations. The chemical and microscopical procedures were few and easy of execution and familiar to all. Each practitioner was his own pathologist and did not require aid from outside sources.

Out of

Between the graduate of today and his predecessor of a quarter of a century, the contrast is very great as regards the problems which he has to face and the facilities. at hand with which he has to face them. During this time the practice of medicine and surgery has been completely revolutionized by the application of the inductive method to medical research and by the ap propriation from biology, chemistry and physics of discoveries found applicable to the prevention and relief of disease and to the prolongation of human life. The prac tice of medicine is therefore an applied science drawing upon every field of human knowledge for facts that may prove useful. But with the multiplication of agencies at the disposal of the physician, of the surgeon, there has necessarily come a physical inability on his part to personally execute laboratory methods and at the same time apply the results in his practice. this state of affairs has grown a division of labor, one physician confining himself to the execution of laboratory methods, another to the application of their results in actual practice. Under present day conditions the practice of medicine is no longer a matter of the ministrations of one man from whom must emanate all help and upon whom centers all responsibility. Today the practice of medicine consists of co-oper ation between the various departments of a highly organized profession, each depart ment thereof dependent in some wise upo every other department, if the highest re sults are attained in the application of hu man knowledge to the prevention and relief of human suffering. Today the great ma jority of civil practitioners in city and country alike have no laboratory facilities at command, their patients receiving only a portion of the benefits to be derived from modern medical science. The per cent of population in the United States without the benefit of laboratory facilities is very close

home and on the farm might just as well be living in colonial days so far as betterment of his sickness goes in the matter of many of the most beneficial discoveries of modern medical science.

To illustrate the advantages to a given community of the medical laboratory let us take a concrete example. Suppose that an independent medical laboratory existed in St. Joseph, Mo., what useful part might it play in community life? It should be a communal laboratory, doing all the laboratory work for all the agencies connected with the medical social service of St. Joseph and its tributary country. It would engage the entire time and attention of a number of laboratory men. It would be the agent by which a diagnosis would be made in many, many conditions of disease, and the only agent. It would be the agent by which remedies would be prepared for many of the most serious diseases that afflict man. It would be the agent by which investigations would be conducted among unknown disease to discover their causes and cures. It would discover the nature of disease, the cause of disease, the means to prevent disease, and the remedy for the cure of disease. Its part therefore as a factor in the community for the conservation of human efficiency and human life would be second to none. St. Joseph and the tributary territory have a population of 1,054,389. Here, then, is a vast number of people, only a very small per cent of whom ever have done for them in time of sickness all that could be done. Suppose that every practitioner in this ter ritory knew that in St. Joseph he could get all laboratory facilities for those under his care, would he not avail himself of this great help in his daily work? The benefits of modern medical science would thus be carried to the patient on the farm as well as to the patient in the city hospital. These conclusions would be equally true of Omaha, Sioux City, Kansas City, Topeka and other cities in the Missouri Valley. ADVANTAGES OF A MEDICAL LABORATORY TO THE MEDICAL PROFESSION.

The qualification of the medical profession may be ideal, the hospital facilities all that can be desired, and yet medical practices will remain unscientific and incomplete without the facilities afforded by a medical laboratory. This is a fundamental necessity, upon which the whole superstructure of scientific practice is built, it matters not whether that practice is in hospital, in home, in city, in town, in country.

The urgent need of medical practice is better diagnostic facilities. To the country practitioner an accessible laboratory is the best asset he can possibly have. It places him on an equal footing with the city doctor so far as diagnostic facilities are concerned. The responsibility, satisfaction and credit of making a correct diagnosis properly belong to the first physician in the case. It is for lack of proper laboratory aids that he finds it necessary to send his patient from home. Diagnosis arrived at through the co-operation of doctor, patient and medical laboratory are scientific deductions and should be the desire and aim of every practitioner.

One of the problems which every busy practitioner faces is that of keeping in touch with the advance of medical science. Busy with the cares and perplexities of every day work, how can he know what is going on in the great world of science. In the army and navy medical men are required to take examinations before promotion to higher grades to determine their fitness for increased responsibilities and their knowledge of modern science as regards its latest discoveries. How many practitioners in the United States in city and country alike are practicing medicine according to the principles and methods taught them at medical school years previously, and are not in touch with the latest and best knowledge available. The medical laboratory more than any other agency will solve the problem of keeping the general practitioner in the front rank of scientific medicine.

PROMOTION OF MEDICAL LABORATORIES.

A medical laboratory is a social institution, intended to serve the needs of rich and poor alike, of all comers, without reference to race or religion. Such an institution cannot in the very nature of things be selfsustaining.

The agencies that may be brought into operation for the creation of medical laboratories may be discussed under the headings: (a) private endowment; (b) co-operative endowment; (c) incorporation.

Private Endowment.-No field of social service for humanity offers greater returns for money invested than the medical laboratory. No method of establishment and maintenance is better than endowment.

Unless the amount of money given is large and ample for its intended use the trustees are often greatly embarrassed in carrying out the wishes of the donor. It is often the case that enough money to do this is not available. When a gift is

made during the life of the donor, however, these difficulties are avoided and there seems to be a growing tendency for philanthropists to direct the course of their gifts in life, in order that they may be sure that their purposes may come true of accomplishment.

When trustees are named in the will to carry out the bequest they are usually chosen with reference to their ability as business men skilled in finance, this being considered necessary in order to insure the preservation of the bequest itself.

It would seem, however, that the ideal board of trustees of a medical laboratory, or any other institution for medical social service, would be composed of men (and women?) some of whom were familiar with the work intended to be accomplished, not by hearsay, not incidentally, not as amateurs, but as persons who had devoted their lives to such work and who had a life inter

ness.

Private philanthropy frequently avoids the whole trouble of administration, through private boards of trust, by giving out-right the bequest to a religious denomination. The church in turn selects trustees and holds them accountable for the proper ad. ministration of the bequest. In this way the church exercises a visitatorial power over the board of trustees. The trustees and church thus act as a check, the one upon the other and thus make more certain the carrying out of the purposes of the bequest. Where no visitatorial power exists, boards of trustees have been known to fail in carrying out the full intention of the

trust.

Co-operative Endowment offers another method for financing medical laboratories and affords opportunity for open investigation and discussion before action and investment. It calls upon a large number of people for support instead of one. It be comes an educational factor of great value to the supporting organization and through it to the entire tributary county. The best type of co-operative endowment is that of church foundation of social service agencies. As an illustration we will cite one of the churches now occupying the north half of the State of Missouri. It has a membership of 48,464, its ministry numbers 226,

who preach in 437 churches. This territory is subdivided into nine districts with an official in charge of each. The church is therefore pre-eminently connectional. The controlling body meets annually and is com posed of delegates from each district, lay and clerical. Before undertaking an enter prise of this nature the controlling body would thoroughly investigate the whole question. It would appoint a board of managers, to administer it and a perma. nent endowment fund would be started, the members being urged to provide in wills Every member of the for its growth. church would thus become the authorized agent of the medical laboratory, every member of the church would be, as it were, a stockholder with the personal interest which such relations entail. The annual contributions toward maintenance would thus become the equivalent of interest income from a large endowment fund.

Thus would be established a financial

constituency participating in the benefits of the institution, deriving personal advantage therefrom, and offering to friends and Most church enneighbors like benefits. terprises are altruistic in nature. Hère is one not only altruistic but likewise emioently advantageous to the supporting conIt would be difficult to find a stitutency. scheme of organization combining more of financial strength with opportunity for keeping the advantages offered by the medical laboratory, constantly before the people it was intended to serve. The supporting membership of the church would make known to neighbors and friends outside the church the opportunites offered for help in time of sickness. Could a better advertising scheme be devised?

Incorporation.-A group of individuals recognizing the need of a medical laboratory may under the law of the state associate themselves together and secure a charter from the State. This group should be selected with reference to the fitness of its members for social, scientific and business service, for the same remarks apply here regarding trustees that applied to the trustees of private endowments. A board of trustees could then proceed to raise the amount of money which might be determined upon as necessary for the inauguration of the enterpise and to provide likewise for the subsequent annual upkeep budget. Having demonstrated the usefulness of such an institution, there would come to it from philanthropically inclined persons support in the way of donations and endowments. Nearly all philanthropic en