THE JOURNAL

OF THE ALUMNI ASSOCIATION

OF THE

COLLEGE OF PHYSICIANS AND SURGEONS,

BALTIMORE.

THE MATERIAL NEEDS OF MEDICAL EDUCATION. ADDRESS AT THE OPENING OF THE NEW BUILDING OF THE College OF PHYSICIANS AND SURGEONS OF BALTIMORE, DECEMBER 21, 1899.

BY DR. WILLIAM H. WELCH.

The opening of this new college building, in which provision is made for the teaching of medicine by modern methods, and especially for laboratory instruction, seems to me a fitting occasion to say something concerning the condition of medicine to-day, and particularly the material needs of medical education. In a country where appeal must be made to private beneficence for the support of higher professional education, it is important that the general public should be informed concerning the requirements for the best training of medical students at the present day.

The century now drawing to a close has witnessed a development in medical science and practice far surpassing that of all the centuries which have gone before. Of the half dozen great discoveries which in their day have revolutionized the science and art of medicine, only that of the circulation of the blood belongs to a past century, while surgical anæsthesia, cellular pathology, the demonstration of the germ doctrine of infectious diseases, antiseptic surgery, and the prophylactic and therapeutic applications of the principles underlying arti

ficial immunity have all been introduced during the nineteenth century. As regards the last, a partial but important exception must be made in order to include the introduction near the close of the last century of vaccination against small-pox. Around these great discoveries, and for the most part dependent upon them, cluster a host of others, and all have combined to change the whole face of medicine. In all directions the stock of medical knowledge has been vastly increased, so that no man can grasp it all, and only a relatively small part can be taught to the student of medicine. Specialization with all its advantages and its defects has become a necessity both on the scientific and the practical sides of medicine. Each of the fundamental medical sciences is now cultivated both for its own sake as well as in its relations to other branches of medical knowledge. We know a great deal more than our predecessors of the structure and workings of the body in health and in disease. Our insight into the causes of disease, particularly of infectious diseases, has been deepened, and hand in hand with this increase of knowledge, although not in direct ratio to the scientific advance, has expanded the power of the physician and surgeon to prevent and cure disease. The ability to prevent the accidental infection of wounds has greatly advanced the surgeon's art and made it one of the most rewarding and beneficent of human pursuits. Not less striking is the increase in our power to check the introduction and spread of many infectious disCivilized countries with proper systems of public sanitation need have little fear of the pestilences of former times. With the diminution in mortality from the diseases of early life, the incidence of disease is changing toward a preponderance in the diseases of old age. While on that side of the physician's activity with which the public is most familiar, the daily routine of general practice, the progress may seem less apparent, still here also there has been great improvement in methods of diagnosis and in the means of treating disease, even if we must admit that the untrained physician can now do harm in a greater variety of ways than formerly.

eases.

But it is only in contrast with past knowledge that the progress seems so great. If we consider what remains to be accomplished,

and what we may reasonably hope will be attained, we may well believe that the veil has been lifted only in relatively small part from the mysteries of disease and its prevention and cure. We cannot doubt that we shall advance further along paths already opened, as for example, in the direction of the specific antitoxic and antiparasitic treatment of infectious diseases, and that vistas of knowledge and power now undreamed of will be disclosed.

The great advances of the present century are due not to any improvement in the mental powers of man, but to the general recognition of the truth that the only way to learn the facts of nature is by observation and experiment. This scientific method of investigation seems to us so obviously the correct and fruitful one that we can only marvel that it was not equally apparent to our predecessors in past centuries. Of course from the most ancient times there have been those who have contributed to natural knowledge facts based upon observation, experiment and just inference, and we are the heirs of great scientific truths which have thus come down to us from past ages. But nothing is clearer to the student of the history of medicine and of science than the prevalence of the opinion, until comparatively recent times, that the secrets of nature could be learned by contemplation and reasoning. This erroneous belief, combined with reliance upon the authority of tradition or of some great name, was the great obstacle to progress and the source of the many speculative systems which are so difficult for us at the present day to comprehend, even if we think it worth while to make the attempt.

I cannot better illustrate the value formerly attached to mere reasoning as a basis of scientific discovery than to quote from one of the Essays of Jean Rey, Doctor of Medicine, entitled "On an enquiry into the causes wherefore tin and lead increase in weight on calcination," first published in 1630. These essays are of such interest and importance in the history of science that they have been recently republished by the Alembic Club. Rey to some extent anticipated the results of Lavoisier a century and a half later. His work is a curious combination of well chosen experiments and of metaphysical speculations. The quotation to which I call your attention is as fol

lows: "My chief care hitherto has been to impress on the minds of all the persuasion that air is heavy, inasmuch as from it I propose to derive the increase in weight of tin and lead when they are calcined. But before showing how that comes to pass, I must make the observation-that the weight of a thing may be examined in two ways, viz., by the aid of reason, or with the balance. It is reason which has led me to discover weight in all the elements, and it is reason which now leads me to give a flat denial to that erroneous maxim which has been current since the birth of Philosophy-that the elements mutually undergoing change, one into the other, lose or gain weight, according as in changing they become rarefied or condensed. With the arms of reason I boldly enter the lists to combat this error, and to sustain that weight is so closely united to the primary matter of the elements that they can never be deprived of it. . . . But not presuming that my statements are on a parity with those of Pythagoras, so that it suffices to have advanced them, I support them with a demonstration which, as I conceive, all men of sense will accept. Let there be taken a portion of earth which shall have in it the smallest possible weight, beyond which no weight can subsist; let this earth be converted into water by the means known and practised by nature; it is evident that this water will have weight, since all water must have it, and this weight will either be greater than that of the earth, or less than it, or else equal to it. My opponents will not say that it is greater, for they profess the contrary, and I also am of their opinion; smaller it cannot be, since we took the smallest weight that can exist; there remains then only the case that the two are equal, which I undertook to prove."

This somewhat lengthy citation, upon which no especial comment is necessary, will suffice as an example of the study of nature by unaided reason and dialectics, and the interest attaching to it is enhanced by the circumstance that Rey himself made ingenious experiments in natural philosophy, and that he belonged to the century of Galileo, Kepler, Newton and Harvey, a century which has often been compared with our own in respect of interest in scientific discovery.

Rey, in the foregoing quotation, incidentally furnishes an illus

tration of another characteristic of past systems of doctrine in science and medicine. You may have noticed that he implies that, if he possessed the authority of Pythagoras, his statements would be accepted without demonstration. This blind reliance upon authority is exemplified by the saying of one of the great Arabian physicians: "If Aristotle and Galen are both of one mind we may be sure of the truth; but if they differ, it is very difficult to determine what is true."

Systems of medical doctrine, which profoundly influenced practice, were thus constructed upon the basis of speculation and traditionalism. The Galenic system held sway for nearly fifteen hundred years, and was displaced by other systems which, although marking an advance in knowledge, rested largely upon dogma. The eighteenth century is often characterized as that of the great medical systematists, and during the first four decades of the present century German medicine was bound in the trammels of the so-called philosophy of nature. The greatest factor in releasing medicine from the shackles of dogma and turning it into the paths of science, was the foundation of cellular pathology by Virchow in the middle third of the present century.

It is of course not to be inferred that the exercise of reason, logical deduction and imagination is not essential to fruitful scientific inquiry. Indeed, it may well be, as pointed out by Clifford Allbutt in his admirable address on "Medicine in the Nineteenth Century," that we could learn much from the old dialecticians in the use of the weapons of logic, but experience has demonstrated that the real basis of progress in medicine, as in all the natural sciences, is the discovery of new facts by means of observation and experiment. It is by following the path thus indicated that medicine has advanced with such rapid strides during the latter half of the present century.

These great advances in medical knowledge, secured by the employment of truly scientific methods of investigation, have largely increased and modified the material needs essential for the promotion of medical science and for proper systems of medical education. It is of the highest importance that the general public, at least in this country, should be informed of the necessities of medical teaching and investigation, for if they want good doctors they must help to make them.