Chance and the Prepared Mind

Author(s): R. M. Pearce
Source: Science, New Series, Vol. 35, No. 912 (Jun. 21, 1912), pp. 941-956
Published by: American Association for the Advancement of Science
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 SCIENCE
__ -? .~~~~~~~~~~~~~~~~~~
CHANCE AND THE PREPARED MIND1
FRIDAY,
FRIDAY, JUNE
JUNE
21, 1912
21, 1912
(" In the fields of observation chance favors
only the mind which is prepared. I'-Pasteur.)
CONTENTS
IT was at the opening of the Faculte des
Chance and the Prepared Mind: PROFESSOR R.
Sciences at Lille on December 7, 1854, that
M. PEARCE ........................... 941 Pasteur, only thirty-two years of age at the
time, but already professor and dean of the
The Work of Colonel Gorgas .............. 956 faculty, uttered these words in upholding,
in his inaugural address, the value, on the
Scientific Notes and News ................... 957one hand, of practical laboratory instruc-
tion as an aid to the solution of industrial

University and Educational News .......... 960problems, and on the other the importance
of investigation in pure science, even
Discussion and Correspondence:- though the resulting discoveries might have
The Dome Theory of the Coastal Plain: no immediate application. The point of
CAPTAIN A. F. LUCAS ............. ...... 961 view may have been novel when it was
uttered, but in the sixty years that have
University Control:- elapsed how familiar it has become. How
closely it approximates the ideals of those
Letters from Yale University ............ 964
who are striving to improve the conditions
of medical education and of medical research
Scientific Books:-
in our own day and country. What bet-
Thomson's Biology of the Seasons; Gilbert
ter argument can the most ardent advocate
White's Natural History and Antiquities of
of detailed practical instruction in labora-
Selborne: PROFESSOR T. D. A. COCKERELL . 967
tory or hospital (medical training at first
hand) present, than that which Pasteur
The Hindu-Arabic Numerals: PROFESSOR
offered in 1854. He asks:
LOUIS C. KARPINSKI .................... 969
Where will you find a young man whose curiosity
and interest will not immediately be awakened
Special Articles:- when you put into his hands a potato, when with
The Source of the Current of Injury: DR. that potato he may produce sugar, with that sugar,
JACQUES LOEB, REINHARD BEUTNER ...... alcohol,
970 with that alcohol, Eether and vinegar?
Where is he that will not be happy to tell his
family in the evening that he has just been work-
Societies and Academies:-
ing out an electric telegraph? And, gentlemen, be
The Biological Society of Washington: M. W.convinced of this, such studies are seldom if ever
LYON, JR ............................. 971 1An address on medical education, by Richard
M. Pearce, M.D., University of Pennsylvania, de-
MSS. intended for publication and books, etc.,
livered at Syracuse University, May 21, 1912,
intended for
review should be sent to the Editor of SCIENCE, Garrison-on- under the auspices of the Alpha Omega Alpha
Hudson, N. Y. Honorary Medical Fraternity.

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942 SCIENCE [N. S. VOL. XXXV. No. 912

forgotten. It is somewhat as if geographyhis werelaboratory, to the industries of Lille, h

to be taught by traveling; such geography is says:
remembered because one has seen the places. In
the same way your sons will not forget what the Without theory, practise is but routine born of
air we breathe contains when they have once habit. Theory alone can bring forth and develop
analyzed it, when in their hands and under theirthe spirit of invention. It is to you specially that
it will belong not to share the opinion of those
eyes the admirable properties of its elements have
been resolved.2 narrow minds who disdain everything in science
which has not immediate application. You know
Pasteur was a chemist, a physical chem- Franklin's charming saying? He was witnessing
ist, if you will, and his illustrations were the first demonstration of a purely scientific dis-
drawn from the realms of physics and covery, and people round him said: "But what is
the use of it " Franklin answered them: "What
chemistry, but if one substitutes for "elec-is the use of a new-born child "
tric telegraph" any piece of apparatus now Do you know when this electric telegraph, one
in use in a medical laboratory or a hospital,of the most marvelous applications of modern
the principle of the better type of modernscience, first saw the light? It was in the mem-
medical instruction is embodied in his argu- orable year 1822; Oersted, a Danish physicist,
held in his hands a piece of copper wire, joined
ment. He was talking to those who, after
by its extremities to the two poles of a Volta pile.
two years of practical and theoretical On his table was a magnetized needle on its pivot,
study, were to enter industrial careers as and he suddenly saw (by chance you will say, but
overseers and foremen in factories, foun- chance favors only the mind which is prepared)
dries and distilleries. But neither time nor the needle move and take up a position quite
different from the one assigned to it by terrestrial
circumstance fundamentally alters the ap-
magnetism. A wire carrying an electric current
plicableness of his observations. Afterdeviated a magnetized needle from its position!
sixty years we may still urge his thoughtThat, gentlemen, was the birth of the modern
as the soundest of principles in the better
telegraph. Franklia 's interlocutor might well have
education of men and women who are ulti- said when the needle moved "But what is the use
of that?" And yet that discovery was barely
mately intended to enter careers as our
twenty years old when it produced by its applica-
overseers in matters of health and disease
tion the almost supernatural effects of the electric
and as the foremen of public hygiene. telegraph!
Have our present-day medical schools suc-
This, gentlemen, may seem trite to you,
ceeded in bringing to the training of their
for it is an argument oft repeated, but its
students the same practical and scientific significance, as far as medicine is con-
thoroughness which Pasteur demanded forcerned, lies in the fact that at the time
students in the industrial sciences and
Pasteur made these statements modern
which students of the latter sciences now
medical investigation was just beginning.
procure? If not, where lies the fault; in The celebrated physiological institute at
the college or the medical school, in the Berlin had been in existence only sixteen
state or the public ? Or are all more or less years; Schwann, following Schleiden, had
to blame? These questions will be dis-
elaborated the cell doctrine only fifteen
cussed in due time, but first, let us turn
years to and anesthesia had been prac-
before
Pasteur's other proposition, investigation tised for only six years. Claude Bernard
for its own sake. After stating his waswish
in thetomidst (1850-60) of his impor-
be directly useful, personally andtant through
discoveries concerning the pancreatic
2 Vallery-Radot, "The Life of Pasteur," Mc- juice, the glycogenic function of the liver
Clure, Phillips & Co., New York, 1902. and the vasomotor system; three years were

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JUNE 21, 1912] SCIENCE 943

to pass before Virchow established (1855) on the right than on the left molecules."
the first pathological institute and as many So did "chance" direct the "prepared
again before this great master was to an- mind" to those fundamental observations
nounce the doctrine of cellular pathology; which established our present-day prin-
and finally, it was thirteen years before ciples of fermentation, and which, as the
Lister's first publication concerning the result of work on alcoholic, acetic, lactic
antiseptic treatment of wounds. and butyric fermentation, led to Pasteur's
In all these activities and those which final dictum:
followed, the ideal of seeking for the truth
The chemical act of fermentation is essentially
no matter where it might lead-the ideal of
a correlative phenomenon of a vital act beginning
and ending with it.
pure science-was the secret of that won-
derful progress which medicine has made It was but a short step for the mind
in the last seventy-five years. thoroughly familiar with the principles of
Now, however, it is time to return tofermentation
our to embrace the opportunity
text, "In the fields of observation, chance
offered by the study of the etiology of the
favors only the mind which is prepared."
infectious diseases, and so through all his
What did Pasteur mean by "chance"? work, as that in connection with the silk-
His meaning is very evident in his example
worm problem, vaccination against chicken
of Oersted and the magnetized needle. The
cholera and anthrax and the treatment of
mind which is trained to observe the details
rabies, the "prepared mind" of the great
of natural phenomena, and to reason con- master saw and appreciated the significance
cerning the bearing of known laws on suchof every observation and every opportunity
phenomena, is the "prepared mind," that iswhich presented itself.
to say, it is a class of mind which, because
Many other examples might be presented,
it is endowed with a peculiar faculty, bestas Semmelweis and his observations on the
described as scientific imagination-grasps
high mortality from puerperal sepsis among
the significance of a new observation, or of
those under the care of students fresh from
a variation from a known sequence of the dissecting and autopsy room and the
events, and thus establishes a new law or low mortality among patients under other
invents a new practical procedure. To no supervision. So also Lister and his anti-
man perhaps is this adage of Pasteur more
sepsis; and best of all, perhaps, for pur-
applicable than to himself. It was his poses of illustration, the sequence of Ehr-
work in chemistry and his studies in crys-lich's discoveries. We are told that in his
tallography that gave him the "prepared student days Ehrlich was interested above
mind" which correctly interpreted the sig- all other things in the study of chemical
nificance of the chance observation that the
affinities and worked incessantly with the
presence of a vegetable mould, the Peni- new anilin dyes. Indeed the story goes
cilium glaucum, in solutions of salts of the
that so engrossed was Ehrlich in his work
tartaric acids, changed an optically inac-
that neglect of the required studies gave
tive to an optically active fluid. He rise to some question concerning his right
grasped at once the true interpretation of to receive his degree. The situation as;
this reaction. The disappearance of the described by Christian A. Herter3 was as
dextro-tartaric acid, the permanence of thefollows:
levo-tartaric acid, could be explained only 3 Herter, C. A., "Imagination and Idealism in
by the assumption that the ferments of this the Medical Sciences," Jour. Am. Med. Asso.,
particular fermentation "feed more readilyLIV., p. 423, 1910.

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944 SCIENCE [N. S. VOL. XXXV. No. 912

Although at this time Ehrlich was especially

is another example of the "prepared mind"
under the direction of the anatomist Waldeyer, he
properly interpreting a chance observation.
rapidly developed a capacity for chemistry which
Sometimes such discoveries are referred to
was a surprise both to himself and to the chemist,
as the result of scientific imagination-and
Adolf von Baeyer, whose lectures had been system-
atically cut by the gifted but unconventional it truly is this-but doubtless the same
student. For unconventional he then was, and ever "chance" came to many besides Pasteur,
has been, neglecting what he did not like and
Ehrlich, Laveran, Koch, Theobald Smith,
throwing himself with fervor and intense energy
into the solution of the themes that attracted him. Manson, Ross and Reed; it was the training
From the outset it was clear that Ehrlich would of these individuals, the mind prepared to
make a career as an experimental investigator. utilize scientific imagination, that enabled
Much of the time he was supposed to spend in them to grasp the opportunity offered by
taking the usual medical courses he devoted to
"chance" observation. Every one familiar
experiment. When Robert Koch was shown
through the laboratory at Breslau by one of the
with the history of investigation in medi-
professors, his attention was called to a young cine knows that before Harvey, men studied
student working at a desk covered with bottles of the circulation; that before Pasteur, bac-
dyestuffs. " There is our little Ehrlich," said the teria were seen in diseased conditions; be-
professor; "he is a first-rate stainer of tissues,
fore Lister, the effect of cleanliness upon
but he will never pass his examinations." The
prediction about the examinations came perilously
surgical mortality had been noticed; before
near fulfillment; Ehrlich made bad flunks and it Laveran, the plasmodium of malaria had
is hinted that he never would have received his been seen; before Manson and Ross, the
degree had he not made a discovery-namely, the
possibility of the transmission of malaria
existence of the peculiar type of leucocyte which
by the mosquito had been discussed. Truly,
is known to us as the "plasma-cell." The faculty
reasoned that it would be improper to keep so remarkable achievements are never unique occur-
promising and original a worker indefinitely in anrences in nature. Even the greatest men rest on
undergraduate position, and it is suspected that the shoulders of a large multitude of smaller ones
they mitigated the rigor of the examinations inwho have preceded them, and epochal discoveries
order to relieve their own embarrassment. emerge out of a period of intellectual restlessness
that affects many minds.4
These early studies were doubtless re-
sponsible for what must be considered asBut of these minds, it is that one which
the main theme of all Ehrlich's work-the is "prepared," trained in the methods of
specific affinity which exists between spe- observation, therefore possessing the price-
less
cific living cells and specific chemical sub- quality of scientific imagination, which
stances. The "prepared mind" is evident sees the proper block which when placed
exactly
in his study of the cells of the blood, of the where it belongs completes the edi-
selective action of methylene blue on the fice of a perfect theory, and thus estab-
nervous system, of the use of the same dye lishes a new landmark for future progress.
in the study of oxidation and reductions But what, you ask, has all this to do with
occurring in tissues, of his studies in im- the training of the physician? How does
munity, of the specific treatment of proto- it apply to medical education? We admit
zoan disease, and also according to recent the value of these qualities in the investi-
reports in his application of the same prin- gator, but of what value are they to the
ciple to the study of .cancer. Manson'sman seeking the education necessary to
studies of the relation of the mosquito to
4Flexner, S., "The Biological Basis of Specific
filariasis, which led to Ross's study of theTherapy," Ether Day address at the Massachu-
transmission of malaria by the same insect, setts General Hospital, October 16, 1911.

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JUNE 21, 1912] SCIENCE 945

practise medicine ? Let me repeat Pasteur's

have seen as many individuals with the
adage-" In the fields of observation, malady as had the consultant, and perhaps
totally ignorant of the fact that his diag-
chance favors only the mind which is pre-
pared." Certainly all will agree that nosis was possibly based on a chance ob-
servation which meant more to his trained
medicine is largely an observational science
and one of the "fields of observation" of imagination than it did to minds unaccus-
Pasteur's definition. Medicine may not be tomed to weigh the significance of details.
Every clinician of experience can give ex-
all science, but clinical medicine in its most
essential phase-diagnosis-is essentially aamples of the importance of chance and
imagination in actual diagnosis. An inter-
science of observation, either of direct ob-
servation by the use of the unaided senses esting illustration is that
or indirect by the use of instruments ofof the two students who reported on the same
precision, or by chemical, biological or patient in competition for a clinical prize. The
other tests. Therefore, whatever force or patient presented, among other symptoms, a re-
markable discoloration of a certain area of skin,
whatever lesson this adage may carry, ap-
and the first student described this discoloration
plies to medicine. And now as to the inter-with the most careful minuteness. He measured
pretation of "chance." I have not been it in different directions and drew a rough sketch
able to obtain the original French of Pas- of its general outline. The second observed the
teur, but from his parenthetical phrase in phenomenon with equal care, but he exercised his
connection with the discussion of the tele- imagination and formed a hypothesis which he pro-
ceeded to put to the test. He asked a nurse for a
graph it is clear that he meant exactly what
wet towel, with which he wiped the discoloration
the translator has given us, chance or op- away. It is evident that the faculty which he thus
portunity in the sense of an unexpectedbrought to bear on the problem before him would
observation or an accidental occurrence. be likely to stand him in good stead in relation to
Pasteur's idea was that such unexpected or many others of a more complicated character; and
accidental occurrences would not arrest the that his exercise of the art of diagnosis would be
attention of the poorly prepared mind, but practically immune from the errors incidental to
the habit of taking all appearances at their face
that the well-prepared mind, trained to
value. Imagination at once points to the possi-
observe, to think and to compare, would
bility of more than one explanation of any given
grasp the significance of the unexpected, occurrence, or alleged occurrence, and compels
the unusual or occasional, put the observa- inquiry as to the existence of probable causes
tion to the test, by experiment or control,
beyond the particular one which may at first sight
and arrive at the correct conclusion. Is appear to have been in operation.5
not this a matter of daily occurrence in From what has been said, then, it should
clinical medicine? Does not chance (op- be evident that it is the first duty of a med-
portunity some would call it) and care icalin
school to prepare men properly for the
details play an important part in diagnosis ?
practise of medicine (and the most ardent
Is not every ailment the physician sees a
advocate of research in the university will
puzzle; every diagnosis, if correct, a solu-
not deny that this is the first duty). If so,
tion of that puzzle? One speaks of the
what are, conditions to be fulfilled to ensure
man who solves the puzzle which has baffled
half a dozen other men, as a keen or accurate
the "prepared mind" of Pasteur's adage?
The Preliminary Education of the indi-
diagnostician. They imply that he has an
added power, or that his skill is the result 6 , Imagination in Medical Research, Lancet,
of wider experience, forgetting they may 1912, CLXXXII., 179.

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946 SCIENCE [N. S. VOL. XXXV. No. 912

vidual is the first and in many ways the population is 1 to 5686 and the use of the
most important consideration. I know itautomobile is increasing. If the ratio
is bringing coals to Newcastle to discuss should change greatly, which does not seem
this question before the students and fac- likely, for only two states7 (North and
ulty of Syracuse University, for you have South Carolina) have a ratio of less than
been among the first to recognize the value 1 to 1000, the matter then becomes one for
of two years' college work which shall in- state regulation, for, as the report of the
clude physics, chemistry and biology. Still Carnegie Foundation has shown, we have
this principle is not generally recognized. enough physicians, but the difficulty lies in
Many of those in positions of authority in the tendency of physicians to seek the
our medical schools, while loudly proclaim- larger civic centers.
ing the right of medicine to a place among With the discussion of the cultural value
the sciences and indeed characterizing it as of humanistic as compared with scientific
the "Mother of the Sciences," deny that a studies, we are not concerned. It is suffi-
scientific education is a prerequisite to cient that in a university medical school a
medicine. True, the opposition is fre- man can not properly study modern medi-
quently due to a realization of the awk- cine without that knowledge which comes
ward financial position in which an admin- from a familiarity with laboratory work in
istration might be placed if students' fees physics, chemistry and biology. The value
diminished. Frequently also it is due to of biological training for those interested in
the claims of those who hold that a greaterpractical medicine was emphasized by Hux-
cultural Value lies in following the human- ley many years ago, and that in physics and
istic rather than the scientific school of chemistry has recently been emphasized by
thought. Naturally, there is also the "poor Friedrich Miillers in describing, for the
boy cry" and the closely associated cry benefit of the English Commission, the
that outlying districts will not be properlytraining of the German medical student.
cared for if the cost of medical education During his first and second year,9 the medical
student attends lectures and does laboratory work
is increased. The "poor boy" argument
in physics, chemistry, botany and zoology in the
may be dismissed at once, for those who philosophical faculty, and he has the opportunity
have had experience in teaching medicine of widening his views by listening to lectures on
know that the boy, poor or otherwise, who philosophical or historical subjects. His teachers
and laboratories are the same as for the students
knows what he wants in the way of an edu-
of the natural sciences, and this is right, because
cation, gets that education in spite of all
there is no such thing as special medical physics
difficulties, and as a rule, if he has to work
for it, is keen enough to get the best that is 6 Flexner, A., '" Medical Education in the United
States and Canada," Bull. No. 4 of the Carnegie
to be had. Such men will "come through" Foundation for the Advancement of Teaching,
despite all apparent barriers in the way of 1910.

higher preliminary requirements; if the in- 7American Medical Association Bulletin, 1910,
different "poor boy" fails, lacking ambi- V., 278.
tion and a clear conception of what he 8 Miller, F., "Memorandum on Medical Educa-
tion Submitted to the Royal Commission on Uni-
wants, so much in favor of the higher
versity Education in London.'
requirements. 9The German student seldom takes his state
As to the outlying districts, we need haveexamination until the end of five and a half years'
no fear as long as the ratio of physicians towork (Muller).

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JUNE 21, 1912] SCIENCE 947

or chemistry; the physician requires arequisite

broad to medical education. Five10
knowledge of the general sciences of physics
states and
have passed laws demanding that
chemistry.
for license to practise medicine an appli-
It is most important to have this state-. cant must have had two years of college
ment of Muller's at a time when an effort work as a minimum requirement, and
is being made to place physics, chemistry four" demand one year. This, we must
and biology in the medical curriculum. admit, is only the beginning. As state
With or without a fifth year it is a danger-after state adopts the same ruling, schools
ous policy. The experience of one schoolnot demanding such preparatory study
in this regard is enlightening. During the must see the territory open to their gradu-
period of change from a high school to aates (and therefore the territory from
two-year college requirement, conditioned which they draw students) gradually nar-
men were cared for by allowing time in therowed. Certainly, to-day, no school, and
first half of the first year to make up condi- certainly no university school, can face
tions. The procedure took eighteen hourswith equanimity, this discrimination; and
a week from the time which should have "disappointed indeed will be that student
been devoted to purely medical studies. who, after having spent a large amount of
In such an emergency as that of a changetime and money, finds on graduation that
of policy, this was perhaps justifiable, but his diploma is not recognized in a large
what university school with a four-year number of states." 2
course can afford this arrangement as a Methods of Teaching.-Within the med-
permanent policy? And if we are to have ical school itself the matter of educational
a fifth year, progress demands that it policy is clear. Here there can be only one
should be a clinical or hospital year, andprocedure, the constant and consistent em-
not a preliminary year for work which ployment of the "do it yourself " or "learn
belongs to the college. The modern cur- by doing" method; the student must be
riculum of a first-grade medical school de- taught to observe, experiment, reason and
mands a student's full time and attention act for himself. This, I know, is trite, but
and no amount of general culture can make the conditions out of which our present
up for absence of prerequisites in physics,methods of medical education have emerged
chemistry and biology. The school whichdemand that this point of view be continu-
allows mixed requirements, or low require-
ally emphasized. It is not long since the
ments or conditions does so at the expense
day of the two- and three-year course and
the imparting to undergraduates of all
of efficiency; the good men suffer on ac-
medical instruction, outside of anatomy
count of the slow progress of the poorly
and inorganic chemistry, by lecture. The
trained; the inefficiency of the teaching
under such circumstances becomes noised
development of the laboratory branches,
histology, pathology, bacteriology, physi-
about, and it comes to pass that the best-
ological chemistry and pharmacology-and
trained men go to schools which take only
the cheapening of physiological apparatus
their kind, and thus eventually low stand-
ards react on the school allowing them. 10 Colorado, Indiana, Iowa, Minnesota and North
Dakota.
But this is not all. Another factor, the
n Connecticut, Kansas, South Dakota and Utah.
state, is beginning to play an important12Jour. Am. Med. Asso., LVII., p. 1138, 1911;
part in determining the conditions pre-
LVIII., p. 487, 1912.

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948 SCIENCE [N. S. VOL. XXXV. No. 912

-have given a new turn to medical teach- for proper education-the laboratory exer-
ing, that of active participation by the cise and the ward or dispensary class-to
student. But still even in these branches assistants. No one has less desire to be-
the lecture still persists in most schools little
andthe work of assistants or to lessen
frequently is so magnified in connection their independence than have I, but in the
with the laboratory instruction as to make department in which the head lectures
it appear in the eyes of the student as thethe student naturally assumes that
only
most essential part of the course. Thethe ad-work of subordinates-in laboratory or
vance in methods and means of practical clinic-must be work of subordinate im-
laboratory instruction-that is, the visible portance, and thereby he comes to have a
machinery for developing the principle of estimate of the live part of his edu-
wrong
teaching by actual observation and experi- cation. The most ardent supporter of the
ment-would seem in some schools to be an lecture system can not say that he always
equipment for advertising purposes only. holds the interest of his class. He may
One does not have to go outside the group hold their attention and be flattered by
of our so-called "big" schools to find copious note-taking, but this has for its
a department of pathology, abundantly object only one purpose-the final exam-
equipped with apparatus and a wealth of ination. The real education-the training
pathologic material, offering five lectures a which means power and which character-
week; and one may find an elaborately izes "the mind which is prepared"-can
equipped student's laboratory of physiol- come only through independent but wisely
ogy manned by assistants while the head directed observation, experiment and rea-
of the department fulfills his duty to hissoning on the part of the student.
class with three or four lectures a week; I have discussed elsewhere13 how the lat-
and likewise, in the clinical branches, fewter system may be fostered, and am now
men have had the courage to do away withglad to be able to reinforce my position by
frequent and voluminous lectures. Even quoting from the recent very excellent ad-
schools controlling a large hospital, and dress on this subject by Professor G. M.
sometimes several, and thus having an Jackson.l4 As to the share of the teacher
abundance of clinical material, do the bulkProfessor Jackson says:
of their teaching by the formal lecture and It is evident that each teacher must understand
the amphitheater clinic. The ward class the curriculum as a whole. The laboratory man
and the clinical clerk system gain ground must be familiar with the clinical work. But this
but slowly. The reason for this attitude is not all. Since good teaching must take into
account that which has gone before as well as that
is easily found. The lecture is the easiest
which is to follow, it is equally evident that the
form of teaching, and the average teacher, clinical man must be familiar with laboratory sub-
whether he be the laboratory man over- jects and methods. We can not expect the best
burdened by executive detail and handi- results in medical education until there is a better

capped by lack of assistants, or the clinical understanding and more cooperation between
teacher limited in time by a busy practise, teachers of the various subjects all along the line.
follows the lines of least resistance, forget- "Pearce, R. M., "The Experimental Method:
ful, though sometimes resentfully so, of the Its Influence on the Teaching of Medicine," Jour.
Am, Med. Asso., LVII., p. 1017, 1911.
best needs of his class. Usually coexistent
14Jackson, G. M., "On the Improvement of
with a pernicious lecture system is the Medical Teaching," SCIENCE, XXXV., p. 566,
habit of leaving those most favorable fields 1912.

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JUNE 21, 1912] SCIENCE 949

As medicine progresses, all phases appear more remarks on this subject are therefore based
clearly as varied manifestations of the same under-
on the assumption that an elective system
lying biological science, and only when this is
is possible in every school.
realized will the clinical and laboratory work be
more closely knitted together. As every teacher knows, each class con-
tains a considerable number of men who
As for the student, it is suggested that he
desire to pursue work, to a greater extent
work out everything for himself by the method of
than the conventional course allows, on cer-
discovery. This applies not only to the original
observations, but also to the latter process of tain subjects or by special methods, or less
frequently, perhaps, they desire, and are
reasoning, whereby we proceed from particular
data to general conclusions, and thence to rational
usually well qualified to undertake, minor
action. The method of self-activity may therefore investigative work. To the former, as well
be expressed in a negative way by the following
as to the latter, any effort spent in work
practical rules: Never tell a student anything he
can observe for himself; never draw a conclusion beyond that given the entire class becomes,
or solve a problem which he can be led to reason necessarily, for them, the acquirement of
out for himself; and never do anything for him the methods of research and as this means
that he can do for himself.
a knowledge of the exact, painstaking
There are, of course, limitations to the methods by which the realms of the un-
application of this method, as lack of time,
known are explored, it is an exercise which
an overcrowded curriculum, inability on prepares the student for the daily routine
the part of the teacher to fully grasp the research work of the physician who truly
situation, and failure to always maintain practises his profession. As a training for
sustained effort on the part of the student, future work, its value is definitely known
but its value over the lecture system is so and the increased zest and enthusiasm ex-
great that it should be followed in "so far hibited toward their medical work by men
as practicable" (Jackson) and should be who have had this opportunity are always
supplemented by demonstrations and con-evident. Pedagogically, therefore, it would
ferences or recitations rather than by lec- seem advisable that every student should
tures, if one truly seeks to prepare prop- have the opportunity for minor investiga-
erly for the practise of medicine. tive effort, in order that he may become
Influence of the Spirit of Investigation. acquainted at first hand with the careful
-But aside from this training the univer- methods of experimental medicine. The
sity has another duty to the prospective bearing of the tangible results of his work
practitioner of medicine. This is its duty on the subject investigated is a matter of
in the encouragement of investigation, little or no importance; the vital thing is
which is indeed a double duty, a duty to its the increased power which he himself ac-
students and a duty to the community it quires.
serves. There is another way in which the en-
The question of allowing undergraduates couragement of research aids the student,
to undertake independent original investi- but which is possible only to those schools
gation is, I know, a debatable one. Cer- following the wise policy of appointing to
tainly in most schools our overcrowded cur- professorial chairs, teachers who are like-
riculum renders such work impossible un- wise investigators. The influence of such
less a wise arrangement allows elective teachers in the development of independent
studies, as at Harvard in the fourth year, and resourceful practitioners is the secret
or as at Johns Hopkins in each year. My of the great success of our better schools.

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950 SCIENCE [N. S. VOL. XXXV. No. 912

The correctness of this statement may befor several years, arbitrarily selected from
easily demonstrated. a large number of prospective matriculants
If one examines courses in the same sub- the certain definite number which it de-
sires; the rest, sometimes nearly fifty per
ject in a number of schools it is found that
those which are best presented are under cent. of those accepted, go elsewhere. Now
the control of men actively engaged in this
re- school has the highest requirements
search work. Such men are alive to the
and perhaps the smallest alumni body of
advantages of new methods in theirany own prominent school in the country. It is
subject and of new ways of applying oldtherefore, a question of easy entrance
not,
methods. Ever thinking and pondering or of the loyal influence of alumni, nor is it
about new methods of acquiring knowledgea question of better laboratory and hospital
for themselves and their science, they ap-facilities, for other schools have equally
preciate better than does the non-investiga-good equipment in both respects. Likewise
tor, that which will aid the student to ac-it is not a question of geographic location
quire knowledge, and in their teaching theyor center of population. The enviable posi-
bring to bear on the problems which thetion of this school is due solely to the policy
student has to face the same methods of of combining research with teaching and of
attack which they use in their own re- appointing to its staff teachers who, with
searches. On the other hand, one finds few the exceptions, are also investigators.
men who never or only occasionally con- As to the duty of the university to the
tribute to the literature of their science are community in the matter of research, there
the men who confine their teaching to per-can be only one opinion. If the purpose of
functory routine courses, with a profusion the machinery of medical education is to
of lectures, and who never bring the spirit"bring healing to the nations," if the busi-
or methods of the investigator into their ness of medicine is to "get people out of
teaching. So, likewise, it is with the stu-difficulties through the application of sci-
dent taught under these two conditions.ence and dexterity, manual and physical"
The student who knows that he is working (Cabot), then it is the duty of the univer-
in a department actively emphasizing new sity not only to teach known principles and
methods and striving to develop new truths, methods, but to advance knowledge and
knows that his instruction is presented in methods by research.
the spirit of the department, and thus re- It is futile to say that it is sufficient to
ceives that stimulus and inspiration which teach and to utilize known methods of
insures his approaching clinical medicinefreeing people from difficulties, for the
with a proper appreciation of the scientificmere statement of such an attitude implies
method. The student under the method of that an obligation exists to extend known
the non-investigator, on the contrary, hasmethods, or to invent new ones, in the hope
no incentive other than that of acquir- of overcoming difficulties acknowledged to
ing a knowledge sufficient to allow him tobe at present without remedy. The ethical
pass an examination. force of this statement can not be denied.
An allied argument lies in the fact that To teach a subject implies the attempt to
the medical school that fosters research at- diffuse the available knowledge of that par-
tracts the best-trained men as students. ticular subject matter among a number of
We have, as is well known to many of you, people for their good, as well as for the
a medical school in this country which has, good of the community in which they live

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JUNE 21, 1912] SCIENCE 951

and work; equally true is it that such an

The Relation of the Hospital to Medical
attempt to teach available knowledge Teaching
im- and Research.-That the labora-
poses upon the teacher the obligation to tories of our better medical schools are fully
leave untried no means by which the knowl- equipped for the kind of instruction which
edge of his subject may be increased. It is I have outlined, and that many are already
not the privilege of the teacher to leave this fostering the "do it yourself" principle
extension of knowledge to others. His pro- and the spirit of investigation is well
fession of ability to teach a particular sub- known. In the clinical years, on the other
ject carries with it his obligation to the hand, the situation is not so satisfactory.
group or community he serves, of adding to Many a medical school while building and
his subject knowledge of which they may equipping modern laboratories has failed to
avail themselves. If this applies to the care properly for its clinical teaching, and
individual teacher, how much more forcibly has continued to foster the amphitheater
does it apply to the university with its ever-lecture. If the method of first-hand in-
widening community and ever-increasing struetion, which I have outlined, is to be
interests? followed, then the hospital must become the
On the other side of the question, the laboratory of the clinical years and a school
university should not forget that medical must own or absolutely control its hospital.
research tends to ameliorate social condi- This is necessary in order (1) that the
tions by diminishing the causes of physical
heads of the clinical departments may have
and mental ills. This ideal of medicine a continuous service under their immediate
the university and its community should charge and to the conduct of which they
foster and develop, for it is one of maythebring their own assistants; (2) that in
greatest influences in our modern concep-connection with such service they may de-
velop laboratories for teaching and re-
tion of social service; an influence indeed
which was back of all Pasteur's work, search in addition to the usual clinical labo-
and
which he expressed in the statement of his
ratory now used only for purposes of diag-
desire to contribute "in some manner to nosis; and (3) that resident physicians may
the progress and welfare of humanity." be appointed for indefinite service in order
But aside from this altruistic ideal,thatI trained teachers and investigators in
hold that research in the medical school clinical medicine may. be produced in the
offers important practical advantages to way as trained teachers and investiga-
same
the university and that these advantages tors in the laboratory branches are now
should not be forgotten by university produced,
au- and (4) that the head of the
department may provide adequately for
thorities, who pride themselves on applying
business-like methods to the problems thatof intimate first-hand clinical instruction
education. A policy which attracts a bet-which can be secured only by placing the
ter-trained class of students, which im- student in actual contact with the patient.
proves the character of the instruction, Some schools, as Pennsylvania, Hopkins
which stimulates the student to a better and Jefferson, have already solved the
type of individual effort and which en- problem by the establishment of their own
hances the standing of the university in the hospitals. This is naturally the ideal
community and the nation is a policy which course for all university schools and a fu-
can not be ignored by university president, ture for which every school should plan.
trustees or faculty. But in the absence of the possibility of im-

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952 SCIENCE [N. S. VOL. XXXV. No. 912

mediate consummation of such an ideal,

clinics is sufficient proof that both munici-
results almost as satisfactory may be
palob-
authorities and university authorities
tained by the actual affiliation of munici-
find it mutually advantageous.
pal or independent hospitals with the We should bring about the same state of affairs
stronger medical schools. A hospital has in this country and, in fact, a start has already
as much to gain by this arrangement as been made. At Cincinnati the large municipal
has the medical school, for while the chief hospital has been placed in charge of the clinical
teachers of the University of Cincinnati; in St.
duty of the hospital must always be the
Louis, the Washington University has made a close
care of the sick and injured, this duty, as affiliation with the new Barnes Hospital; in Bos-
well as its other functions-the instruction ton, Harvard has made an affiliation with the
of men who are to practise medicine Peter and Brigham and several other special hospitals;
the advancement of medical knowledgeinby New York, Columbia University and the Pres-
byterian Hospital have established similar rela-
research-is best served by placing the con-
tions; in Cleveland, Western Reserve University
duct of the hospital in the hands of men
has formed a combination with the Lakeside Hos-
highly trained in the methods of scientific
pital; in Chicago, Rush Medical College has had
medicine.15 This would not only enable for a number of years the medical control of the
the hospitals Presbyterian Hospital, and recently has made sim-
ilar contracts and arrangements with the Chil-
to fulfill a greater function in the development of
dren's Memorial Hospital, the Home for Destitute
thoroughly qualified physicians, but it would also
Crippled Children and the Hospital for Infectious
be best for the patients, since they would have the Diseases.-Bevan.17
benefit of the best methods of treatment under
recognized experts. A campaign of education How much better such an arrangement
should be carried on to show our municipal au- would be than that which now exists. At
thorities that the hospital will be the best con- present in most schools the clinical teacher
ducted in the interests of its patients and the
is a teacher mainly because he is fortunate
community at large, if at the same time it is ful-
filling its function as a great center of clinical enough to control a hospital service, and
teaching and research.16 for this reason has been appointed on the
university staff. In his appointment the
Many examples may be presented of the
school has no choice, for it must have for
ideal association of charity, teaching and
research as the results of such affiliation;
its students the advantages of the clinical
material which he controls. Whether he
the most striking perhaps being the mag-
nificent clinic of Muller in Munich and be good, bad or indifferent, as physician,
teacher or investigator, he must be re-
the clinics of the University of Leipzig.
tained as long as he holds his hospital posi-
Here, as in many other continental cities
tion. He, on the other hand, is handi-
and in England, the university authorities
capped by the regulations and restrictions
by agreement with the municipal authori-
of a not always sympathetic lay board of
ties appoint the heads of the hospital clin-
ics. The long continuance of this arrange- hospital management and, more important
ment and the great fame of most of these still, by the absence of proper laboratory
facilities and the aid of his own colleagues
15 For a discussion of ,the advantages to be
gained by the hospital, see Welch, W. I., "Ad-
in the departments of bacteriology, im-
vantages to a Charitable Hospital of Affiliationmunology, pathology and pathological
with a University Medical School," The Survey, chemistry. These departments are com-
XXVII., p. 1766, 1912. ing more and more into active participa-
16 Bevan, A. D)., "The Modern Medical School,'
Jour. Am. Med. Asso., LVIII., p. 652, 1912. 17 Bevan, loc. cit.

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JUNE 21, -19123 SCIENCE 953

tion in hospital work, in diagnosis, oftentimes

prog- prolonged examinations under
nosis and treatment, and should be as the hospital roof or at least within the
closely affiliated with the hospital as are boundaries of the hospital yard, and under
the clinical chairs. Those of you who havethe control not of assistants or internes,
read "The Corner of Harley Street,"18 a or dependent on occasional visits of a
most delightful series of letters by an Eng- professor of pathology, bacteriology or
lish consultant, may remember the words chemistry, but under the constant super-
quoted by the author from a lecture of a vision of such experts who do their teach-
brother consultant to postgraduates. Said ing and research in the hospital and con-
the lecturer: tribute their share to the diagnosis, care
Gentlemen, I should like the day to dawn whenand treatment of the ills of the patients.
I could be met at the door of my hospital by a This is the ideal of social service in medi-
trained chemist, a trained bacteriologist, a trained cine, the goal of all effort in medical edu-
pathologist, so that when I come to some compli-
cated case I could say, "Chemist, a part of this
cation and research; and it is not Utopian.
problem is yours, take it and work it out. Bac- Already the University of Toronto has
teriologist, perform your share in elucidating this transferred its departments of pathology,
difficulty. Pathologist, advance, and do likewise." bacteriology and pathological chemistry
These are not idle words. Since Ziems- to the grounds of the hospital which fur-
sen in the middle eighties established in nishes its clinical instruction. Here not
Munich the principle of a clinical labora- only the elementary instruction is given,
tory in the hospital, the idea has spread largely aided by an abundance of fresh
rapidly, until now every hospital worthy material from the hospital, but each ad-
of the name has its clinical laboratory for vanced student serving as clinical clerk in
the routine procedures of diagnosis. But the wards has always his desk, well-
equipped locker and special outfit for the
this is not sufficient. The clinical chief must
have the close cooperation of his colleagues detailed investigation of his clinical ma-
in the departments of pathology, bacteriol- terial by laboratory methods, and more-
ogy, physiology and chemistry, and the over, has always at hand his teachers in the
student likewise must have the outfits of laboratory branches to aid him in his clin-
these departments at hand to aid him in investigations. It was my good for-
ical
his clinical studies. It is no longer tune recently to go over these departments
enough to depend on the simpler proced- with Professors Leathes and MacKenzie,
ures for the examination of urine, sputum, who explained 'their workings to me.
blood and other body secretions and fluids. When I expressed my satisfaction at the
ideal
The transportation -across the city of tissues union of clinical and laboratory
or fluids for examination in the laborator- methods Professor Leathes said quietly,
ies of the school can no longer be counte- and as if there could be no other point of
nanced. The progress of modern medicine, view, "Yes, we expect a student working
especially in pathological chemistry and in the wards to use in diagnosis the meth-
immunology, demands for the benefit of ods of pathological chemistry as he does
the patient as well as for the proper his
in- stethoscope." Do you know what this
struction of the student, detailed and means? It means that the amphitheater
clinic and the didactic lecture are to follow
18 'The Corner of Harley Street, being some
Familiar Correspondence of Peter Harding, the two-year and three-year course and
M.D.," Houghton Mifflin Co., 1911. that the methods and instruction of the

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954 SCIENCE [N. S. VOL. XXXV. No. 912

laboratory years are no longer to be di-

hospital should leave the matter of ap-
vorced from the clinical teaching of the
pointments, subject to its nominal ap-
later years of the curriculum. It means proval, entirely in the hands of the school,
that men are to be trained by the "do it with the understanding that withdrawal or
yourself" method to become practitioners resignation from the school automatically
with power of accurate diagnosis and thewould sever connection with the hospital,
"mind which is prepared" to take advan- and vice versa. Such an arrangement
tage of every "chance" observation and settles most of the problems of medical
opportunity. It means that the newer education. Continuous service and free-
methods of biological, physical and chem-dom in the appointment of clinical teach-
ical diagnosis, evolved through laboratoryers come as a matter of course. Teaching
effort, are to work a transformation in and investigation can be carried on with-
medical teaching and medical practise out interruption. The student becomes a
analogous to that which came in the middle part of the hospital routine and is not an
of the past century through the introduc- onlooker with limited privileges. The lab-
tion of exact methods of physical examina- oratory departments of the first and sec-
tion. As physical diagnosis raised medi- ond years unite to aid the work of the
cine above the plane of objective diagnosis clinicians in the hospital. Clinical teach-
and revealed the morphological changes ers may be promoted, if deserving, or may
in diseased organs of the interior of thebe called from any part of the country, or
body, so now the methods of physiological from abroad; the choice no longer depends
chemistry and immunology are destined on local hospital appointments or on the
to reveal the changes in the cells and selfish interests and friendships of local
fluids of the body which are dependent consultants,
on but on fitness, eminence and
intoxication, infection and altered meta-
skill.
bolism and thus bring about an advance Teachers may be appointed on a uni-
in methods of diagnosis, the fruits of which versity basis, devoting all or most of their
are almost beyond our powers of imagina- time to the care of the patients, to teaching
tion. and to investigation. The heads of the de-
Herein lies the most potent argument partments of internal medicine and sur-
for close affiliation of school and hospital. gery certainly should be so appointed.
The task, both from the teaching side and Under such circumstances these men with
from the research side, demands united ef- their staffs could control a large body of
fort, common use of material and common students working relatively independently
financial responsibility. While any con- among the patients in the wards and in the
tract between university and hospital must special laboratories in or near the wards.
leave the general support of the hospital In these clinical laboratories every student
in the hands of the hospital management, should have his own desk and outfit for
the school must be prepared to pay the sal- microscopic, chemical and other methods
aries of attending staff, the cost of equip- of examination. Not merely apparatus for
ment and the expenses necessary for teach- the simpler tests should be supplied, but
ing and research and to assume the respon- as well every facility for prolonged bac-
sibility for the medical and surgical care teriologic examination, animal inoculation
of the patients and the general conduct of and detailed chemical and physiologic
the scientific work. On the other hand, the study.

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JUNE 21, 1912] SCIENCE 955

Such a plan insures diagnostic ability Such a law not only protects the com-
and therapeutic skill by training the pow- munity against the improperly prepared
ers of direct observation as well as by in- graduates of the poor school, but it encour-
struction in the methods of indirect obser- ages the good medical school to increased
vation through the use of instruments of efforts.
precision and the procedures of the chem-The hospital year as a prerequisite to
ical and biologic laboratories. The experi-licensure is to-day a live topic of discus-
mental method emphasized in the labora- sion; to-morrow it may be in this and in
tory years is thus continued through the other states a requirement legally stated.20
clinical years. Laboratory procedures nat- Indeed it is difficult to see how the progres-
urally fall into their proper place in re-sive state of New York, the educational sys-
lation to the methods of direct observa- tem of which is so wisely controlled by a
tion, and as the student approachesspecial eachboard of regents, can much longer
new disease in the spirit of the investiga- delay in establishing such a requirement.
tor and not as an onlooker he gains a But why wait for the regents to force this
point of view which can not fail to have
upon the schools? Already 80 to 90 per
an important bearing on his work as a cent. of the men in the better schools se-
practising physician. cure hospital appointments. Why should
The Hospital Year.-So much for the not the schools compel the small minority
preparation which the training, facilities of those who do not secure a hospital to
and opportunities of the modern medical take a fifth year in clinical instruction in
school should offer as leading to the degree the hospital which it controls and thus be
of doctor of medicine. Should the state prepared for the requirement which must
and the public demand more? Yes, inevitably
the come in this and other states.
state, through its machinery for the pro- fully that the deans of our various
I realize
tection of the individual, should demand
schools are divided on this question. Some
a fifth year of hospital work, and this
takethethe position that although the hospital
public would force the state to demand
year ifis an excellent requirement, the bur-
the easy-going public was thoroughly denfa-
of finding the hospital instruction for
miliar with the insufficient requirements of graduates should not be placed on
all its
many of our state licensing boards. theIn-
school; that the duty of the university
deed, some states are already drafting
is laws
ended when it'has given four years of
to protect their citizens from the products
instruction and that the fulfillment of the
of the poor medical schools of a neighbor-
added requirement is an affair of the indi-
ing state- vidual. What does this mean in the last
For example, the state of Minnesota has enacted
2 There is only one school at present which re-
a law enforcing an educational qualification as to
quires the fifth hospital year, and that is the
the training of physicians who are allowed to
University of Minnesota. No state boards at
practise in that state. The law was adopted in
present require the hospital interne year. Those
order to protect citizens of Minnesota against the
which to a certain extent have initiated practical
graduate of commercial medical schools in neigh-
tests at their examinations are Massachusetts, Min-
boring states, and particularly of Chicago. In the
nesota, Ohio and North Dakota, and to a lesser
present state of medical education such a measure
extent practical tests are being used in Colorado
is entirely justifiable.19
and Michigan. (Personal communication from N.
" Pritchett, H. S., "Education and the Nation,"
P. Colwell, secretary, Council on Medical Educa-
The Atlantic Monthly, April, 1912. tion of the American Medical Association.)

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956 SCIENCE [N. S. VOL. XXXV. No. 912

analysis? Simply this, that a school hold- should guide the modern medical school.
ing this point of view is either lax in its They can not, perhaps, in every community
entrance requirements or at fault in its be enforced at once in their entirety, and
methods of instruction; otherwise it would doubtless now and then their adoption may
not fear the failure of its graduates to se- be followed by backsliding, but no one who
cure interneships. If this is true it has has given the subject serious thought can
under the circumstances but one duty: as doubt that the future of medical education
an educational institution, it must itself in this country depends on (1) the univer-
provide the fifth year of hospital work forsity school with a high entrance require-
its lame students. This is the point of view ment, (2) instruction, in both laboratory
which is gradually forcing itself upon the and clinical branches, based on the method
school of the better grade, which, now that of observation and experiment, (3) clinical
the pioneer stage of medical education is instruction in a hospital which the univer-
past, desires to itself complete the student's
sity owns or controls, (4) the principle of
preparation, instead of turning him "over a fifth year of hospital instruction and (5)
to others during this most valuable and the fostering of the spirit of research.
important part of his preparatory work." 21 And now finally let me congratulate
The proposition of Professor Peterson, of Syracuse University on the high ideals
Michigan, that the council on medical edu- it has set for itself in the conduct of its
cation of the American Medical Association medical school. Your course has been
should conduct an inspection and classifica- watched by all who are interested in med-
tion of hospitals on the same basis as the ical education. Your responsibility is
inspection of medical schools is most timely. greater than perhaps you realize; there are
The data thus obtained would do much to
those praying for you to continue your
clarify the situation, and, doubtless, mutual
present progressive system, others hoping
agreements between certain schools and cer-
you may fail. Each group desires to point
tain hospitals of the same class could be
to you as an object lesson. I have full con-
reached as to the distribution of graduates
fidence, however, that the wise trustees of
for interne service. Such a systematization
your university, supported and encouraged
would allow school and hospital alike to
by your alumni and the physicians of Syra-
see their defects and to so rearrange their
cuse and its surrounding territory, will not
work as properly to care for the greatest
only maintain the present high standards,
number of properly prepared men. Only
through the hospital year can we give the but will inaugurate still greater advances
and thus ensure for the practitioner of
best type of practitioners to a most de-
serving but too confiding public; but to medicine in this community the "prepared
mind"
bring about the consummation of this ideal of Pasteur's adage.
every university school and every com- R. M. PEARCE
munity possessing a modern hospital must
do its share. THE WORK OF COLONEL GOBGAS

These general remarks cover, in my THE degree of doctor of laws was conferred
opinion, the cardinal principles which on Colonel W. A. Gorgas by the Johns Hop-
kins University on June 11. In presenting
21 See Peterson, R., "The Relation of the Med-
ical School to the Interne or Hospital Year," him for the degree Dr. William H. Welch
Jour. Am. Med. Asso., LVIII., p. 723, 1912. said:

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