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MEDICINE1

IN the old-fashioned, proprietary type of medical school which flourished in this country during the nineteenth century scientific research was neglected. Even where nominally associated with a university, the medical school was usually dominated by a rather narrow professional purpose, in which investigation was largely ignored. Though incidental research might be tolerated as a harmless diversion, it was more often discouraged as a mere waste of time and of no practical value. Contributions to the medical literature were usually superficial in character. As a rule, the highest ambition of the professor was to publish a text-book, which might establish or extend his fame, even though it represented no advancement of the subject through original research.

The revolution in medical education at the close of the past century brought many radical changes. The proprietary type of organization has been abandoned. We now recognize that the medical school must necessarily be an integral part of a strong university. In the reorganization of medical schools, the university ideal has become dominant. This ideal involves the search for the unknown, as well as the dissemination of the known. The modern medical schools have accepted this responsibility, and have made systematic efforts to provide for research as well as for teaching. They have recognized their duty to advance the science of medicine, in addition to the training of practitioners. Vast expenditures of money have been made to provide the personnel and facilities necessary for this purpose.

But revolutions tend to be followed by counterrevolutions. Especially in this restless, post-war period of discontentment, when all our social institutions are being challenged, it is not surprising that our medical schools are again subjected to criticism. Their efficiency has been questioned and their methods closely scrutinized. Among other things, doubts have been expressed concerning their present policies in the promotion of research. A reconsideration of the

1 An address given at the commencement exercises of the Medical Department, University of Georgia, Augusta, June 2, 1924.

whole question of medical research and its relation to medical education therefore appears desirable.

Scientific research in general may be considered in two different aspects. Its first purpose is the increase of knowledge. With all our boasted progress, how little as yet we really know of the physical universe. Recent developments have shattered our former ideas about even the structure of matter, the fundamental theories we had vainly supposed to be firmly established. And if our knowledge of the relatively simple phenomena of physics is still so inadequate, how much greater is our ignorance of the vastly more complex living organisms with which biology and medicine have to deal! Yet even the little we know forms our only basis for progress. Though still groping in darkness we have occasional glimpses of a promising future. The only hope for improvement is through continued investigation, which therefore demands our earnest attention and our continued support. The need is beyond question.

The scientific method is generally recognized as the road leading toward the desired goal. Yet there is apparently a prevalent misconception concerning the manner in which knowledge actually grows. This misunderstanding hampers the progress of all science, including medicine. To make adequate provision for continued progress, it is highly important to understand the actual mode of the growth of knowledge, which is really a process of evolution.

We may perhaps profitably compare the general process of the growth of knowledge to the development of America. First came Columbus and the other discoverers and explorers, who led the way and revealed the main features of the country and its various regions. Next were the colonizers, who established settlements at numerous convenient or strategic points. From these sources, the pioneer settlers slowly spread in various directions. The subsequent actual occupation of the country and the development of its resources were accomplished through the enterprise and energy of thousands of leaders in agriculture, industry, commerce and associated activities. But the efforts of all these numerous leaders would have been quite fruitless without the assistance and support of the millions of individual workers. Each of these played his part in making the latent resources actually available for us all. Even to this

day every citizen participates to some extent in the making of America, a continuous, never-ending process. Thus leaders and followers alike are indispensable for social progress.

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A somewhat similar process occurs in the extension of the bounds of knowledge. A popular but erroneous idea is that advancement is accomplished solely by the inspiration of a few great geniuses. These are, of course, essential and invaluable, but their discoveries are never entirely independent. They always represent the culmination of a series of steps or stages, including the thoughts and efforts of numerous previous workers in the same or related fields. a very real sense, "there is nothing new under the sun." So interrelated and interwoven are the infinite parts of our common body of knowledge that they seem to form a vastly complicated mechanism, like a living, growing organism. The new develops from the old. From the very nature of things, an entirely new discovery would be quite incomprehensible to our minds. It could not be assimilated, and is therefore a practical impossibility. Every apparently new idea has its roots reaching far back into the past, and also its branches extending into the future.

By extension into the future, I mean that no discovery is completely established on first appearance. By sad experience, we have learned that caution is necessary in accepting even the most plausible new theory. Before its merit as truth is finally determined, it must be repeatedly tested and tried in its various relations. Its range and its limitations must be determined. It must run the gauntlet of skepticism by its opponents on the one hand, and of unwarranted enthusiasm and credulity by its advocates on the other. Through the inevitable test of experience, every new idea or discovery, whether great or small, thus gradually passes from the realm of uncertainty, and as confirmed approaches (but never quite reaches) the goal of absolute certainty. This applies to abstract truths or general principles and likewise to their applications, to both discoveries and inventions. The evolution of human knowledge is thus a process in which we all participate, consciously or unconsciously. In admiring the achievements of genius, we should not forget the important aid of the many plodders of lesser talent.

Nowhere is this more true than in the field of medicine. No discovery in the basic medical sciences, no advancement in the art of healing is to be credited to any single individual. Even the greatest heroes of medicine, those most richly endowed with the precious gift of creative imagination, are indebted to their predecessors for instruction and inspiration, to their contemporaries for criticism, and to their successors for the final adaptation and evaluation of their most original products. The pages of the history of medicine are crowded with examples with which you are all familiar.

The important discovery of the hormone secretin by the English physiologists, Bayliss and Starling, may serve as an instance. In referring to this work, Starling recently said:

It was of no practical use to any one, but a source of nuch gratification to ourselves, since it seemed to open up a new chapter in our knowledge of the body. But there were at that time half a dozen workers skating along the edge of the discovery, and it is difficult to comprehend why, for example, Wertheimer and Lepage did not take the one further step which would have made them and not us the discoverers of secretin. Every discovery, however important and apparently epochmaking, is but the natural and inevitable outcome of a vast mass of work, involving many failures, by a host of different observers, so that if it is not made by Brown this year it will fall into the lap of Jones, or of Jones and Robinson simultaneously, next year or the year after.

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Similarly, credit for the recent discovery of insulin belongs to no one man, nor even to any small group of men. Banting and Macleod, to whom the Nobel prize in medicine was awarded, very generously and properly shared it with their colleagues, Best and Collip. While these Toronto investigators fully deserve the greatest praise for their achievement, it is nevertheless well known that many others had previously worked on this problem, clearing up various preliminary stages and even coming very close to the final solution. It is unnecessary to rehearse the interesting story, which involves the unconscious cooperation of hundreds of workers, even to go back no farther than the discovery of the pancreatic islets by Langerhans in 1869. The subsequent elucidation of the nature and function of these islets required the patient labor of a long series of morphologists, physi

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