KNOWLEDGE AND PRACTICE. BY CHARLES SEDGWICK MINOT. [Reprinted from Science, N. S., Yol. X., No. 236, Pages 1-11, July 7, 1899.] [Reprinted from Science, N. S., Veil. X., No. 236, Pages 1-11, July 7, 1599.~] KNOWLEDGE AND PRACTICE * The honor of delivering the address upon this occasion is great; the responsibility of appearing as the successor of the distin- guished men who have addressed you in previous years is also great, yet, as I thank you for your generous welcome, I feel, most of all, the pleasure of being the guest of Yale. To a Harvard man an honor be- stowed by Yale has a special and very pleasant value. Yale and Harvard have been working together for two centuries ; their aims have always been similar; their developments have been parallel, and they have long sought one another for those friendly con- tests, intellectual and athletic, which yearly renew the close bonds between the two uni- versities. I hope that their experience has been mutually helpful, for I am sure at least that Harvard has often learned from Yale, and they both have the same problems to solve if necessary. Just at present there is a whole series of urgent problems in medical education before both institutions, and I shall, with your per- mission, try now to contribute to the dis- cussion of some of those problems. You, who are upon the eve of graduation, know that you have received a far better prepa- ration for the practice of medicine than was possible for any one to obtain a generation ago. You owe this advantage to the con- * Yale University Medical Commencement Address, June 29, 1899. , - 2 stant recognition of the possibility of im- provement in medical education, and you should carry forth the feeling that it is now your duty to promote further progress in the organization and methods of medical schools. It is, therefore, eminently fitting to the occasion to examine some of the pos- sible ways of advancing medicine. Permit me, then, to lay before you certain sug- gestions which my experience as a teacher of medical science has brought to my mind. Others can deal far better than I with the strictly clinical problems. In the course of my address I shall have to emphasize cer- tain limitations which are detrimental to medicine and which progress must step over. We must, however, not forget that criticism in itself is of slight value, unless it guides us to possibilities of progress. This interpretation of criticism should pre- side throughout our discussion. The physician’s work is not a trade in which he can perfect his skill once for all, but a profession based on learning, without interruption, new facts, new methods and even totally new ideas. The conversion of a student into a medicincc doctor is too com- monly looked upon as the end of the period of learning, but the student ought rather to look upon it as a certificate that he is at last qualified to learn, with reasonable effi- ciency, and, above all, with reasonable se- curity as to his learning aright. Routine in medical practice is professional degrada- tion. There is one problem which we must all meet, the solution of which we cannot shirk, except by the supreme and final cowardice of suicide. So long as we live we are giv- ing our solution to this problem, the prob- 3 lem of conduct, solving it equally by what we do and what we do not do, by our ac- tivities and our inhibitions. Some men give a mean solution, a mere summing-up of whims and accidents ; others give the bad solution of selfishness, passion or vice. The great object of our universities is to aid men to reach a noble solution under the dominion of wisdom and uprightness. You will often hear the assertion that our col- leges have one of their most important func- tions in the building-up of character. The college of which this is not true deserves no students. But with this assertion is some- times coupled the implication that the pro- fessional and scientific schools do not exert as much influence as the college on charac- ter. Such an implication may be excused to ignorance, but that would be a sorry medical school of which it were true. A medical school must develop character as well as mind, or else fail to produce grad- uates who can solve their problems of pro- fessional as well as of personal conduct. Conduct presents to us a fourfold aspect : a physical, a social, an aesthetic and an in- tellectual. The physical aspect is that which the physicans chiefly deal with, it be- ing their work to regulate the doings of the body. To fit men for this work is the object of medical education. How to acheive this object I will ask you to discuss with me presently. The social as- pect of conduct, the relation of what the individual does in its bearing upon others, has endless phases, but there is no pro- fession in which the personal social relations are so much a part of the necessary profes- sional equipment as in the profession of medicine. The practitioner must abound 4 in conscientiousness, honor and tact, and it is a natural consequence that there exists a code of ethics wherever physicians have formed associations. The aesthetic side of conduct, the securing of beautiful things because they are beautiful, concerns the medical man less, although he pursues the art of healing, and healing is really an art, a very tine art, as well as a science. The intellectual aspect of his own conduct is to the physician sovereign over all the rest. Medicine is distinctively an intellectual occupation. Let this bare schedule suffice to emphasize the fact that the physician more than men in most occupations needs a varied endowment, a broad foundation of character and a liberal education. I think that physicians as a class are distinguished by the breadth of their sympathies and by their manifold interests. This is the natural consequence of their having to deal con- stantly, for themselves and for others, with the problem of conduct in all its aspects. In contrast with all these liberal quali- ties we find too commonly an attitude to- ward pure science and toward biology which seems to me much the reverse of lib- eral. I must go farther and say frankly that this prevailing attitude marks an im- portant limitation of the medical profession, and that it points to defects in our system of medical education. Courageous acknowd- edgment of our needs is the first step to- wards satisfying them. I shall now en- deavor to convince you that the criticism made is not only just, but that it discovers the way for vast educational progress, and I trust that in the end you will feel the point of view to be both friendly and helpful. The mental attitude, the modification of 5 which seems to me so desirable, reveals it- self by distrust of pure science and by ignoring the relations of medicine to biol- ogy. Let us consider the case in its two phases. First, then, as to science. To the academic proposition that science is the basis of medi- cine every one w’ould assent, but, none the less, a great many practitioners still draw a sharp line between 1 theoretical ’ and ‘ prac- tical ’ doctors. Those who think this dis- tinction are, of course, ‘ practical? men, and they are guilty of a triple error: first, that scientific is theoretical; second, that theoretical is impractical; third, that prac- tical is superior to theoretical. This mis- conception still exerts influence, although it is certainly waning. Make it your part to hasten its extermination. The feeling against medical science as impractical has been very strong in Amer- ica, probably stronger than anywhere else in the world. Our colonial ancestors had to help themselves in every thing, and we have apparently inherited the belief that any way is the best way, and that expert capacity is a luxe de trop. We must remem- ber, too, that medicine grew up as an art, not as a science, and that such progress as it made until this century was well along was chiefly by empirical experience. It is only for about fifty years that re- search, properly so-called, has been an im- portant factor, only about twenty-five years that it has been the leading factor in med- ical progress. It is, therefore, not to be wondered at that older practitioners, espe- cially if without intercourse with university centers, are unconscious of the full measure of the change. The change is momentous, 6 yet it has been so rapid that it falls largely within the period of the medical experience of many here present. Another curious factor in establishing and maintaining the notion that science is unpractical was the conventional idea of a scientific man, which prevailed even within thirty years, and which I can perfectly recall as a half-ac- cepted standard when I decided to choose science for my career. This conventional scientist was a man past middle life, who wore an unfashionable hat, large spectacles, ill-fitting clothes, who was more or less ab- sorbed in abstruse ideas and in studies of no practical use, really learned, very absent- minded and more rather than less in need of being looked after by somebody with com- mon sense. It was almost necessary for a scientific man to cultivate absence of mind in order to sustain his reputation. It would certainly be an interesting study to trace the history of this phase of American sci- ence, since it was a phase, though a quaint one, of the eternal assertion that the best science is independent of immediate utilita- rian consideration. Resuming the direct course of our thought, we may say that on the one side the notion that ‘ scientific ’ is synonymous with ‘ un- practical ’ has its historical justification, but on the other side it is now only a survival, an unjust opinion, a prejudice to be sur- rendered unconditionally. The prejudice against science has been very influential. Even fifteen years ago a young physician could not afford, no matter how much leisure he might have, to work in a scientific laboratory, because he would have been stigmatized as 1 theoretical ’ and patients would have been turned away. I speak by 7 chapter and verse, for I know many in- stances of young men beginning good re- search work, and then soon being compelled to give it up, by the force of professional opinion. We now know that this opinion was in large part a prejudice, the disappear- ance of which removes the final barrier across the entrance to the new era, which it has taken our entire century to open. The establishment of science in its rightful place has been going on steadily for a long period, but within five years it has rushed towards its culmination. We owe the com- plete medical recognition of the value of pure science to Bacteriology. Listen to the following dates. In 1879 Koch introduced the method of solid cultures; in 1882 he published his monograph announcing the discovery of the bacillus of tuberculosis. In 1884 came Loffler’s paper on the bacillus of diphtheria. In 1891 appeared Council- man’s account of the amoeba of dysentery. At the International Medical Congress in 1893 Boux described the use of antitoxine in diphtheria, and about the same time McFadyean secured recognition for the value of mallein in the diagnosis of glanders. In 1896 came Vidal’s reaction for identify- ing the germs of typhoid fever. Here were results entirely beyond the ken of the practitioner, laboratory discoveries which he could only accept but not verify for himself, although in their application he could furnish dramatic proof of their value. No wonder that science now receives her meed. It is safe to prophesy that hereafter medical science and medical practice will be both more sharply divided and more intimately correlated than heretofore. We already 8 note that the experience of the clinician can rarely do more than effect improvements in methods, while the new principles come from the laboratories. The clinician may ask good questions, but he now depends so much upon the scientific worker for his an- swers that there is a sudden demand for laboratories in connection with every hospi- tal. This demand marks the final uncon- ditional surrender of the practitioner to pure science. The end is not yet. It is not enough that the value of scientific re- search is at last acknowledged, but the prac- titioner must also adopt the scientific method for himself. What do I meau by the scientific method ? There is much vague misconception con- cerning it, based upon the erroneous as- sumption that it is a peculiar method be- longing to science. It is really only the right method of ascertaining the objective truth. It is in the classic words of von Baer, Beohachtung und Reflexion, observation and reasoning. The student at the microscope looking at nuclei and protoplasm and de- riving therefrom a correct conception of the nature of a cell uses the scientific method, and he uses the scientific method again when he observes the symptoms of patients and reasons therefrom. There is nothing to distinguish the scientific method from the methods of every-day life except its precision. It is not a difference in kind or quality, but a quantitative difference, which marks the work of the true scientist and gives it validity. The definition of the scientific method seems simplicity itself, nevertheless it takes years upon years of the severest discipline to give even a par- tial mastery of the method, because to ob- 9 serve correctly and reason correctly are the most difficult accomplishments a man can strive for, and he who acquires them to a high degree is a great man ; such were Helmholtz, Darwin, Hewton and a few others out of all time. The two grades of observation and reasoning must be distin- guished, the lower repetitive grade and the higher original grade. Many a person of ability may be taught to see and under- stand that which has been seen and under- stood before. Such persons in medicine can make correct diagnoses of known diseases, but in the presence of the new unknown they fail. Such persons in science may do good work as followers, not leaders—pri- vates, not generals. To the few are accorded the privileges of the higher grade, right sight and right thought as they invade the unknown. The training in exact science does more than any other discipline to ele- vate those who have sufficiently great gifts into this highest intellectual grade. We say, therefore, unhesitatingly that severe scientific education is the principal addition we ought to make to our medical curricu- lum. So I come back to my opening asser- tion : We must teach how to learn, and how to learn from the unknown. If we admit the principle that science should have a more influential place than at present we must decide in what way that place can be provided. It is, I think, un- desirable to lengthen the medical course beyond the four years now required ; it is undesirable to omit any of the subjects now offered, and it is equally undesirable to en- large greatly the fundamental scientific courses in anatomy, physiology, pathology, etc. We seem surrounded by impassable 10 walls, but there are two considerations Which may guide us. On the one hand is the enormous growth of medical knowledge, which is beyond the power of any single student to master, so that some choice must be made for him or by him. On the other hand the science we are now seeking a place for is not that which is basal, but that which is to perfect and end the whole training; it is to be the top, not the founda- tion. Clearly, then, the way out is to in- troduce the elective system on a large scale into the fourth and perhaps third year. Make a series of these electives for advanced work in scientific subjects, such as anatomy, embryology, physiology, pathology, pharma- cology, bacteriology. As you know, this solution has been tried, and with most en- couraging results. May we not look for- ward to its becoming the universal method throughout America ? As regards the elective system I follow Dr. Henry P. Bowditch in believing that it should be greatly extended, and that the required studies in medicine should be re- duced to the minimum, and numerous elec- tives provided for every year of study. These proposed electives may be in subjects already taught and also may provide courses not usually offered, such, for example, as ex- amination of the blood, pathological chem- istry and psychology in its medical aspects. The elective system is the educational an- swer to the tendency toward specialization in practice, and I believe that we have no choice as to its adoption. We pass on to the consideration of the second phase of the case which we are de- bating. It will probably need a much longer and more sustained effort to bring 11 about a correct recognition of the relations of medicine to biology than is needed to win recognition for science at large. Medicine is one department of applied biology, just as dyeing is one department of applied chemistry, or electric lighting a department of applied physics. Now if a man wishes to become an expert dyer or electrician he studies chemistry as a whole and physics as a whole, but the would-be physician begins at once with human an- atomy and human physiology, and probably to the end of his days never discovers that he has no conception whatever of biological science. Carl Semper used to say, die Medi- ziner sind lauter verdorhene Zoologen—the medical men are all spoilt zoologists—and the saying still remains only too nearly true. The first question is : What place shall be given to biology in medical education ? In order to answer this question we must re- member that biology should here serve a twofold purpose, that of making the be- ginning so as to lay the proper foundation for further study and that of inculcating the value of the comparative method. The fundamental principles of biology ought to be taught to every student of medi- cine before he is allowed to study medical anatomy or physiology. This great reform will surely come about, and has, in fact, been already effected by one important univer- sity, which has made biology a requirement for admission to its medical school. Or perhaps the necessary time can be secured, after the student has entered the medical school, by lessening the number of hours now required for anatomy. That far more time is usually devoted to anatomy than is advantageous to the student I am thor- 12 oughly convinced. Formerly, when gross anatomy gave the student almost his only training in exact scientific observation, the subject had a pedagogic value, which it has since lost in very large measure, because histology, experimental physiology, bacte- riology and pathology offer far better disci- pline of the observational power than anatomy alone can supply. It must be further remembered that a large part of anatomy is to the student sheer memorizing and without intellectual value. Finally, we all know that a large propor- tion of the facts of descriptive anatomy are speedily forgotten after the examinations are past, and that the practitioner finds no occasion to recall them. A study which occupies so many hours as to exclude other valuable forms of mental training and im- parts much information not of practical value may well be abbreviated. On the other hand, a thorough course in descriptive anatomy, exclusive of histology and surgical anatomy, must always be indispensable. The only question is concerning the propor- tionate division of time with the other studies, which within recent years have become equally indispensable. My second point is the inculcation of the value of the comparative method, to which the development of biological science is mainly due. Life presents itself in an im- mense variety of species, and the vital phe- nomena assume a characteristic manifesta- tion in each species. It is by comparing the structure and functions that we are able to distinguish the fundamental and essential part of the phenomena from that which is sec- ondary, and thus we gradually reach those generalizations which alone constitute true 13 science. A detail is a grain of earth, use- less for building until it is compacted with many other grains into a useful shape, which, hardened, like a brick, in the furnace of thought, can be added to the temple of knowledge. Now, since medical interest centers in man, medical investigators have cared little for comparative research, and have often failed to grasp the problems with which they dealt. Many an able physician, when he studies, say the physiology or pa- thology of a dog, a guniea pig or a frog, hon- estly thinks that he is studying comparative physiology or comparative pathology, al- though he is really doing nothing of the kind. He is studying, perhaps, gastric di- gestion or the hypertrophic degeneration of the liver; he seeks to understand the pro- cess in the one organ or the other, and the stomach is to him the stomach, the liver the liver. He may note the differences be- tween one animal and another if they are marked, but he does not attempt to deter- mine the process in the carnivora, the ro- dents and the amphibia, see what is com- mon to them all, and what is special modi- fication for each of these groups. One has only to read any accepted text-book of phys- iology or pathology to see that it is abso- lutely true that the narrow or anthropo- morphic view is the typical medical view. The medical man may learn from the zool- ogist and botanist, who have depended chiefly upon the comparative method for their most important results. Science can- not be hampered by any conventional re- striction ; it must be free to turn in every direction in which a discovery is possible. Now, medicine places a conventional restric- tion around the medical sciences, for by 14 custom and precedent it orders that, even* though the actual investigation be upon some animal, it shall be regarded solely as elucidating human structure and human function—in other words, the interpretation must be anthropomorphic. This conven- tion has led to some strange absurdities, of which I shall mention only one ; the micro- scopic structure of the kidney has been in- vestigated chiefly in animals, notably the dog and rabbit; all the text-books of an- atomy and histology known to me, with a solitary exception, describe the structure of the human kidney in accordance with the observations on these animals ; but, as the human kidney really differs in many im- portant respects from that of the dog and the rabbit, the structure of the human kidney still remains generally unknown. This error has been perpetuated through fifty years. Since zoologists are habituated to the comparative method, would it not be wholly impossible for a blunder of this kind to be kept up in their work ? I am so thoroughly convinced of the value of the comparative method, of the absolute necessity of its adoption in medical research, that I look forward to its accept- ance as the greatest advance in medicine which our time will know. Methods of obtaining knowledge are the means of prog- ress. Remember how much anatomy owes to the method of human dissection ; how much pathology owes to the method of stain- ing microscopical preparations ; how much surgery owes to the method of antisepsis; how much bacteriology owes to the method of artificial cultures. These are, however, merely technical methods, but that which I am now advocating is a mental method, a 15 way of successful thinking, a process of right reasoning, far more comprehensive than any technical method ; and, if we accept it, we can explore vast regions of knowledge, the very possibilities of which we barely recognize now. Let it encourage us that the comparative anatomist and com- parative embryologist are already well ad- vanced along the path which the physi- ologist and pathologist must now learn to follow. Medicine is destined to become compara- tive, because it must advance. The wise action for us is to facilitate that advance, and thus the question becomes : What shall we do practically to establish and promote comparative medicine? If we agree that our aim is to secure the very best kind of research in medical science the practical answer is clear: We must provide post- graduate instruction, with courses thor- oughly systematized and correlated, cover- ing at least two years, to qualify men to become professional investigators in the comparative sciences of morphology, physi- ology, pathology, bacteriology, preventive medicine, etc. It is remarkable that these sciences have never reached a university standing. It ought now to be a young man wishes to make a scientific career, if his interest is chemistry, physics, botany or zoology, he is received at one of our universities started upon a well-planned course properly systematized, he gives for two or three years most of his strength to his main subject, but he follows probably two cognate subjects as minor studies, and at the end of his time, if successful in his work, he receives a degree, which attests his proficiency in his special science. Should 16 the same young man elect to study one of the medical sciences, physiology, pathology or bacteriology, no university will give him corresponding recognition. The utmost he can find is opportunity for advanced work in his special subject, but with no university guidance, no plan of correlated studies, and he can look forward to no degree nor even to a certificate from the university. Must we not admit that here is a great omission in our university organization? Is it not a pressing duty to repair this omission? Surely to put these questions is to assent to them. We are thus brought to the conclusion that, though the primary function of our medical schools is to educate practitioners of medicine, yet they ought to assume now the further and higher function of training medical investigators. To succeed in this the medical laboratories must be expanded, their resources enlarged and the staff in- creased, so that the officers will have time and means for both researches of their own and for guiding the researches of advanced students. Yale has been teaching a needed lesson, for her laboratory of physiological chemistry has shown what splendid results ensue when one of the so-called medical sciences is set free and allowed to develop as the peer of other sciences. Untrammel them, strike off their bonds, and compara- tive morphology, comparative physiology and comparative pathology will develop and add to the good work and glory of your alma mater as physiological chemistry has already done. Laboratories are of very recent origin; seventy-five years ago there were none. There are but few laboratories which have 17 stood for as much as twenty-five years. Our experience with them has not been long, but we have learned two things concerning them : that they are absolutely indispensa- ble and that they are very costly, so costly that a university has become an enterprise of great financial magnitude. Formerly a college with an endowment of a million dol- lars was wealthy; at present a university with three thousand students and twenty millions dollars has to practice rigid econ- omy to keep running properly. We who are at work for universities are painfully conscious of needs, and it seems to me a common duty for us all to make known to the public, upon whose generosity Ameri- can higher education depends, the true scale of those needs. The requirements of comparative medi- cine call for more changes than we have yet mentioned. The very word comparative implies that animals shall be included in the range of study. It means that not only shall provision be made for investigating the structure of animals and for physiolog- ical experiments, but also for the observa- tion and treatment of sick animals, or, in other words, there ought to be a veterinary hospital in intimate association with the school of human medicine. Such a hospital wTould increase the range of experience and contribute a broadening impulse to all med- ical work. It is, I believe, quite a new project to consolidate the interests of veter- inary and human medicine, but it is, by the initiative of President Eliot, under ac- tual consideration at Harvard, and will, if carried out, be an epoch-making advance. It will be a public and effectual assertion of the solidarity of all medical science and of 18 all forms of medical practice. It will be a boon to pathological and clinical research, for it will offer opportunities for the study not only of diseases specially characteristic of animals (such as the distemper of dogs), but also of those diseases common to man and animals. We are thus brought round to still another aspect of the beneficence of medical consolidation, the future develop- ment of preventive medicine. Preventive medicine is a term of recent currency. We have come to think more about it in consequence of the growth of our knowledge of disease-germs, which has led to the hope that we can control germs, so as to prevent or at least greatly diminish the danger of infections. Moreover, serum- therapy, the anti-toxin treatment and the discovery of the influence of the thyroid and suprarenal extracts have made us familiar with the conception that profound influences may be exerted by quantitatively slight changes in the chemical conditions within the body. Here are two illustrations of ways in which disease may be impeded. It is a field which might be considered a part of that of hygiene, but it is logically distinct. To stop disease is not the same as preserv- ing health. jS"ow, we are all agreed that prevention is a rapidly increasing part of medical practice, and, since many diseases, like tuberculosis, typhoid fever or the bu- bonic plague, are spread by animals, it fol- lows that we must look upon the study of diseases of animals as an integral and in- dispensable portion of preventive medicine. A hospital is as necessary for the observa- tion and treatment of sick animals as of sick men. Most of us, I am sure, anticipate in the 19 near future a magnificent development of preventive medicine. One of the best means to promote the fulfilment of these anticipa- tions is to bring the veterinary hospital into close and intimate union with the medical school. The veterinary profession, like the med- ical, is raising its standards rapidly, and we can only wish success to these efforts, for not only does the case of sick animals re- quire the highest skill, but also the advance of veterinary science calls for the best scien- tific ability. If veterinary schools are brought, by means of their hospitals, into close touch with medical schools it will hasten the elevation of the veterinary pro- fession, and will bring nearer the time we all shall say that the veterinary school is as worthy a place in the university organiza- tion as is the medical school. When that time comes, as the foundations of medicine will be broad and wisely laid, so will the superstructure be stable. As for the fear, which I heard expressed at a recent medical meeting, that doctors are destroying their own means of liveli- hood, because preventive medicine is limit- ing the supply of diseases to be cured, I may say that fear has not limited the eagerness of physicians to increase preven- tion. On the other hand, there is the con- soling hypothesis that there are likely to remain many diseases, especially those which are difficult to identify and to treat and also those of sporadic occurrence, which will keep practitioners busy in the future. As the time is passing away when a large part of active practice consisted in cases of typhoid, diphtheria and other preventable diseases, rarer forms of illness will be more thoroughly studied, and, as they will require a higher skill, the future physician will seek a better training than we can offer to- day. Thus one of the indirect results of the advance of preventive medicine is to raise the standard of medical education. I have said enough to indicate the far- reaching consequences of the conviction, which I hold and hope you hold, that the comparative method of biology is to direct the development of medical practice. The adoption of the comparative method will revolutionize both medical teaching and the organization of our medical schools. We must now turn our attention to cer- tain other questions of medical education. During the past year there has been going on a very widespread discussion in this country over the curriculum for medical students, and the prospect of consequent improvement is encouraging. I cannot venture upon attempting more than the presentation of certain definite ideas which have formed themselves in my own mind as the result of the late discussion, and must leave to others a more comprehensive treat- ment. Foremost in importance is the idea that the number of lectures is too great, prob- ably, in every course given, and that the laboratory work and the personal clinical work occupy too small a proportion of the student’s time. The practical work is the instructive work ; it is the source of real knowledge. The actual direct contact with the objects and with the phenomena is knowledge. The very best that can be said of a lecture or a book is that it describes well the knowledge which someone posses- ses. There is no knowledge in books, and 21 that motto ought to be inscribed over the library door. A book or lecture can serve only to assist a man to acquire knowledge with lessened loss of time. Knowledge lives in the laboratory ; when it is dead we bury it, decently, in a book. Now real knowledge is what the medical practitioner needs, the personal mental image of things seen, felt and heard; he needs to establish a short circuit between sensations and the true psychic concept, but if you train him to interpolate books you are likely to make the circuit so long that there will be no true concept at the end of such a resistance path. Our greatest discovery in scientific teach- ing is the discovery of the value of the lab- oratory and its immeasurable superiority to the book in itself. A lecture is a spoken book, and must, therefore, also yield to the superior claims of first-hand knowledge. It is the corollary of the value of labora- tory instruction that the examinations should be practical, or, in other words, that the conventional written examination should be given up. All the clinical work is, of course, to be classed as laboratory in- struction, and the time ought not to be far distant when students will be required to make diagnoses from patients directly as the test of their proficiency. Ko one who has examined students in both ways is likely to question the superiority of the practical examination over the written. It is a real test of real knowledge, and is fair to the student for that very reason, and it avoids the two defects of the old-fashioned examination paper : first, the defect of test- ing memory rather than mental power ; second, the defect of offering rewards for cramming. A practical examination has 22 the great advantage of emphasizing to every student the necessity of personal familiarity with the objective basis of his studies. A second important idea is that the re- quiremeuts for a medical degree shall no longer be uniform for all candidates. That this idea wall be adopted is necessarily the belief of every one who advocates the elec- tive system. A new arrangement of studies has been adopted by the Faculty of the Harvard Medical to go into effect next year. It is the result of prolonged careful debate. It is based upon three leading principles, con- centration, correlation and sequence of sub- jects. The system consists in a division of studies by half years and by half days within the half year. The elementary anatomy will be confined to the first term of the first year, but will occupy half of every day ; the other half of every day will be occupied by histology, embryology and a special course on the brain. In the second term a similar system will be followed, half a day for physiology and half a day for physiological chemistry. In the first term of the second year this simple dual plan is pursued with pathology and bacteriology ; beyond this the arrangement is more elabo- rate, and for the third and fourth years is not yet fixed. The new plan is, of course, an experi- ment, but is fully expected to prove a suc- cessful one, because it will make the work of the student easier by concentrating his thoughts upon one subject instead of dissi- pating his attention among many subjects. If a man wishes to accomplish intellectual labor he seeks instinctively to apply him- self wholly to that one task until it is com- 23 pleted. The capacity for sustained effort is the power by which the man surpasses the child. The child needs constant change and variety, and the system, which -we have had in our school, of running from one lec- ture to another and from one laboratory to another, appears to many of us more suit- able for school children than for young men studying medicine, and we expect, therefore, the new plan of studies to be jus- tified by its results. Here we must pause, although we have merely touched upon general principles and looked at a few details as illustrations. It seems to me that the wdiole problem of medical education is just now one of the most interesting and important ever pre- sented in the history of American universi- ties. If I have stimulated your interest in it I am rewarded. Before I close I will venture to address to those of you who are to-morrow to re- ceive your medical degrees a few words upon the deeper signification of your pro- fession. This is not the time to enter into a discussion of the assumed antagonism be- tween practical science and Christian faith. Each year brings the two into closer and more helpful relationship and increases their mutual understanding. The dignified agnosticism of Huxley and the lofty spirit- ualism of Brooks meet in the common con- viction that the growth and development of man to a higher and better physical and spiritual life is alone what makes existence worthy. We are living in an epoch of great scien- tific discovery and of consequent material progress, which among its many results in- cludes numerous new facilities for inter- 24 course between nations. In contemplating these facilities one recalls how great a part the free intercourse under the great Eoman Empire played in the first spread of Christi- anity, so that one involuntarily asks : Is not science now aiding the same cause in a similar way? Science does more. By its steadfast pursuit of truth; by its broad- minded ability to acknowledge the truth whatever found ; by its freedom from nar- row dogmatism on the one hand, and from ignorant materialism on the other, science can do a noble work in the great battle be- tween good and evil in the world. The antagonism of science and religion is unreal. Our intellectual Quixotes take it for one of their windmills, but I very much doubt if it be more than the phantom of a windmill. When you, young men, begin your life’s campaign, fight real foes, be blind to threatening phantoms and deaf to their noisy shibboleths. Attack real diffi- culties. Bemember always that as physi- cians you will have to help others, and that it will be peculiarly your obligation to up- hold the standard of faithful service and to defend what I may call the creed of science : that the advancement of knowledge is a duty because it serves mankind. Faithful scientific research is Christian service. Charles Sedgwick Minot.