The Relations of the Massachusetts Medical Society to the Public

Annual Oration 1924

By James S. Stone, M. D.

On November 9th, 1781, Dr. E. A. Holyoke of Salem called together the Fellows of the Massachusetts Medical Society for their first meeting to be held in the County Court House in Boston a few weeks later. In the charter granted by the General Court just before the call was issued the preamble reads thus:—

"Health is essentially necessary to the happiness of Society; and its preservation or recovery is closely connected with the knowledge of the animal economy and of the Properties and Effects of Medicines; the benefit of medical institutions, formed on liberal principles, and encouraged by the patronage of the law is universally acknowledged.”

Aside from prescribing the details of the organization of the Society the essential portion of the charter rests in these words:—

"Whereas it is clearly of importance, that a just discrimination should be made between such as are duly educated and properly qualified for the duties of their profession, and those who may ignorantly and wickedly administer medicine, whereby the health and lives of many valuable individuals may be endangered, or perhaps lost to the community.

"Be it therefore enacted by the authority aforesaid, That the President and Fellows of said Society, or other such of their Officers or Fellows as they shall appoint, shall have full power and authority to examine all candidates for the practice of Physic and Surgery (who shall offer themselves for examination, respecting their skill in their Profession,) and if upon such examination the said candidates shall be found skilled in their profession, and fitted for the practice of it, they shall receive the approbation of the Society in letters testimonial of such examination, under the Seal of the said Society.

At the same time that Dr. Holyoke issued the call for the first meeting Dr. John Warren wrote a letter to the public quoting the words of the charter and urging "the wise and observant of the Faculty and the curious in every profession to communicate whatever " observations might make which would further they the advancement of medical knowledge. Dr. Warren further points out "the purpose of enabling the people at large (who might otherwise be incapable of fully discerning the qualifications of candidates for practice) to distinguish the persons upon whom they may rely."

The Charter of the Society and the letter of Dr. Warren not only epitomize the purposes for which the Society was founded and for which it has stood throughout its life of one hundred and forty-three years, but they also serve as a guide for future progress.

The advancement of public health.
The advancement of medical knowledge.
The sound training of physicians.
The information of the public upon medical matters.

These are the purposes outlined. It may be worth while to review briefly the activities of the Society along these several lines and to consider how they have affected the relations of the Society to the public.

The betterment of public health must be brought about in great part by popular education. Upon these matters the Society has always taken advanced ground. In 1861 it petitioned the Legislature in favor of the establishment of a State Board of Health, and eight years later Massachusetts established the first board in this country. The establishment of local boards was stimulated by the epidemic of smallpox in 1872. Later the Society took a prominent part in perfecting the laws relating to the care of the insane. In 1894 the Society established a Standing Committee on State and National Legislation for the purpose of “promoting the sanitary interests of the community, medical education and the general interests of the profession as affected by registration laws, etc.” One of the chief concerns of this committee has been with reference to the laws safeguarding the public health.

Although the Society has had its opponents from the earliest days it is probable that of recent years active antagonism to the Medical Profession has increased. It is difficult to get at any specific reasons for this opposition or to say when it began. Yet in a general way the growth of medical science seems to have aroused antagonism among a portion of the public even in spite of the vast good which truly scientific medicine has done for humanity. The first active opposition to medical progress which appeared in the Legislature was in 1894 when the Massachusetts Society for the Prevention of Cruelty to Animals appeared against animal experimentation. But within twenty-five years thereafter the headquarters of that Society and the Angell Memorial for Animals were established next door to the Harvard Medical School. Of late years the opposition to animal experimentation has been limited in extent. The change in the attitude of the public is to be attributed chiefly to a better understanding of the accomplishments and aims of the profession.

As the public has become educated to the necessity and beneficence of reasonable animal experimentation the opponents of medical progress have curiously enough become active against measures intended to prevent disease. Under the appealing name of the Medical Liberty League Inc. they have actively sought to abolish such well proved and salutary measures as the compulsory vaccination of school children, and have shown their true spirit in an active campaign against vaccination for typhoid fever and against the use of toxin-antitoxin to produce an immunity to diphtheria, instances in which in civil life there has been no element of compulsion. The unreadiness of any individual to submit to slight temporary inconvenience in order to prevent an evil seemingly remote has helped them. The conditions resemble those regarding fire hazard. Insurance companies have tried for years to educate an indifferent public. At last the educational campaign against our barbarous fire losses is nation-wide. Medical Societies and health authorities have tried to arouse the public to the need of measures to prevent disease. Recently a new organization of laymen, The Friends of Medical Progress, which includes among its officers men of world wide reputation, has been formed to counteract the pernicious influence of those fanatics who may be sincere in their beliefs but who are often so dishonest in their intellectual processes as to make impossible any rational discussion with them upon medical matters.

The medical profession of recent years has really appeared before Legislative Committees in a defensive attitude. This Society has advocated measures for safeguarding the public health by raising the standards for the practice of medicine and by extending measures to control disease. We have had to oppose measures with diametrically opposite purposes. Under an autocracy the success of measures for the prevention of disease has of course been most striking. The elimination of yellow fever in Cuba, the sanitation of the canal zone, the prevention of typhoid fever in the army are examples of what can be accomplished. It is notorious that a democracy is slow to learn the lessons acquired by the experience of a preceding generation.

It is futile to expect to make real progress at hearings before Legislative Committees. This Society must go to the people and educate them upon matters dealing with the prevention of disease and with the need of reasonable educational requirements for the right to practice medicine under any name. The public need not know the details of medicine but they should be kept informed of medical progress in an authoritative way. It is unfortunate that sensational claims which the future cannot sustain are often published in the daily press. But it is even more unfortunate that the really sensational progress made in matters of hygiene and the prevention of disease are not emphasized. One reason for this is that the progress is not made in a day. The public and even the medical students of the present day do not realize what typhoid fever and the summer diarrhoeas of infancy meant a few years ago, any more than the fanatics can understand what smallpox used to be. Much of the progress is due to the aid of laymen, such organizations as the Community Health Associations. Some of our local boards of health are strong and have taken a leading part in health education.

The next great steps forward must be in educating the people to submit to certain inconveniences and restraints for their own and the common good. Our boards of health must be kept strong. Their educational work must be increased and their activities broadened in the prevention of disease and the maintenance of health. Fortunately movements started long ago have led to the formation of a great school of public health. But we must see to it that there is no divorce of training in public health and preventive medicine from the education for the practice of medicine.

When the public understands what scientific medicine has accomplished and is accomplishing to make the lives of children safer and happier we may confidently expect that the opponents of this progress who have never raised a finger to better conditions will be swept aside. And when the public realizes the need of adequate training for dealing with the lives and health of the people we need have no fear that the standards for practice will not be kept high. This Society and our medical schools must however keep constantly in mind that they exist solely to serve the public and while popular clamor must not swerve our society and our schools from what they regard as right they must remember that at times there is a sound basis for popular criticism.

The advancement of medical knowledge is of course the chief function of all medical meetings and publications. In 1811 the New England Journal of Medicine and Surgery was established. In 1828 it became the Boston Medical and Surgical Journal, now owned and published by the Society and nearing a hundred years of existence under the present name. Thus this Journal is far older than that of the American Medical Association, the only other weekly medical publication in this country. It is impossible and unnecessary here to review the contributions to medical knowledge made by the members of this Society but the record of Massachusetts is one of which we may well be proud.

The advances in medical knowledge of recent years have been so varied and so rapid as to have led to great confusion. Articles dealing with special and general subjects have appeared in such profusion as to make it impossible for any individual to read more than a limited number of papers dealing with subjects of particular personal interest. It has been difficult for even the most careful to judge with accuracy the value to be attached to many papers. Much that is published has no bearing upon actual problems in medicine. The profusion of publications is due in part to an artificial stimulus given by medical schools. Productivity in lines of original research is one basis for promotion. Clinical knowledge and experience, the ability to inspire and direct students, even the ability to teach have been made at times matters of secondary importance.

The wonderful advances in organic and biologic chemistry have given tremendous aid to medicine, but our present knowledge is only the beginning of what we may confidently expect the future holds in store. As our knowledge increases new facts may alter conclusions which today seem fully warranted. The laboratory worker suffers not only from the limitations of our present knowledge but also from the impossibility of knowing many factors which may influence the chemical and biological processes going on in any given individual. Dr. W. B. Cannon has pointed out the effects of the emotions. The clinician must determine the cause of any temporary symptoms. The reactions to given stimuli vary in different individuals.

In Pathology and Bacteriology tremendous progress has been made. The most encouraging development of recent years has been the recognition by the Pathologist that in making up his opinion regarding what he sees under the microscope he must consult the clinician as to the history and progress of the disease.

The Roentgenologist is also recognizing the impossibility of forming a judgment as to the nature of the picture he sees without a knowledge of the clinical history. The shadows seen in the plate are merely indications of reaction to various stimuli, either bacterial, mechanical or chemical, and in order properly to understand what is seen one must take account of the rapidity with which the reaction has occurred and the stage at which the picture is taken.

The recognition by the pathologist of the dependence of his interpretations upon clinical facts has been a relatively slow development as compared with the recognition by the Roentgenologist of his inability to determine by the plate alone the nature of the conditions seen. The very wide use by the clinician of the X-ray has hastened the recognition of the fact that the conclusions of both the pathologist and the Roentgenologist must be dependent in great measure on clinical facts.

The increased interest in the microscopic findings in tumors that is coming about as a result of the recognition of the benign nature of giant cell tumors in bone, formerly regarded as malignant, and as a result of the studies being carried on by the Registry of Bone Sarcoma and in other similar ways, is bound to bring the clinician and the pathologist nearer together. The knowledge that the pathologist must depend upon clinical data in forming his judgments must increase the interest of the clinician in the microscopic study of the tissues with which he is dealing.

The physician must be wary in assuming that our present knowledge justifies the importance at times attached to purely laboratory data. It is unsafe to draw conclusions either of a positive or negative character, from our present limited knowledge. Yet there is a constant tendency for laboratory workers to make a diagnosis and suggest treatment based on the limited number of observations made. And again in the absence of positive laboratory findings there has at times been a tendency to assert that there is no organic disease in cases in which the less learned physician knows that there is serious trouble but is unable to determine its nature.

Perhaps in time our knowledge of psychology will be sufficient to help us in determining the influence of the mind upon physiological and pathological processes. But if the scientific physician of the future is required to correct accurate chemical determinations by uncertain psychological studies his difficulties in attaining scientific precision must be as great as those of the general practitioner of today who studies what facts he can obtain without the aid of elaborate laboratory tests.

Already our knowledge in chemistry has gone so far that the physician who has the opportunity for laboratory study must limit himself to some particular field and even then at the expense of wider clinical studies. As our knowledge grows, the problems of the individual laboratory worker increase in number and complexity to such an extent as to limit further the chances for clinical study of wide range. The laboratory worker and the clinician must work in cooperation. In this way the practitioner of medicine must again come into his old position of importance as the keen student of disease, aided as he will be in the future by the greater and greater advances constantly being made. The opportunities for scientific advance through clinical study have been emphasized by Sir James Mackenzie. Undue emphasis given to laboratory research has often been distinctly harmful. Specialization has been encouraged to an abnormal degree. Intensive work of practical value along one line may lead to wonderful results in diagnosis and treatment but it inevitably tends to distort and at times almost to destroy the sense of proportion and perspective. At times the methods of treatment adopted have been contrary to fundamental principles. In some instances the general welfare of the patient suffers in order that one particular condition may be benefited. At times the persuasive power of an investigator leads others as well as himself to attach undue weight to findings which have but limited application. The viewpoint of the student is distorted. The practitioner may follow one fad after another.

The desire to be is the front rank in progress has led at times to the publication of articles against which protest should be made. Fanciful dreams ought not be put forth in supposedly reputable journals and before educated assemblies in terms intended to give the impression that they are scientific facts. Fortunately New England has been comparatively free from this type of publication, but when such articles appear under the names of men prominent in the medical profession anywhere they react upon all of us. It is hardly fair to pass by without rebuke articles consisting chiefly of such fancies as make their authors entertaining companions who stimulate the imagination, while we justly expel from the Society a former fellow who agrees to cure for a large fee by the absolutely fraudulent methods called the electronic reactions. The regard for medical science cannot endure among educated men if we permit articles in leading journals to pass unnoticed when their character is such as to prevent rational scientific discussion. If increased medical knowledge seems to be responsible for some of the faults found with the medical profession of today the only remedy is further knowledge and better education.

Although the Massachusetts General Hospital was founded thirty years after this Society the development of hospitals in our large cities has occurred within the last fifty years and in the smaller cities within a much more recent period. The smaller community hospital springing up everywhere today.

The influence of hospital development on the medical profession has been very great. The advantages are obvious. Better facilities in rooms and equipment, the advantages of concentration of work and greater opportunity to obtain nursing care necessarily go with any good hospital. Better laboratory facilities, the advantages of conference, contact, and cooperation are of inestimable advantage to physician and patient. The small community hospitals seem to offer the most reasonable solution of the problems of medical service in the country. Nurses are trained and knowledge is advanced in almost all hospitals today.

Surgery in its various branches has made tremendous strides. The work done today in the small town hospitals is infinitely better than the work done a short generation ago by the leaders in the metropolitan hospitals. The prompt and brilliant results often attained have made many eager even to seek surgery as a relief for their complaints and have led some surgeons to forget the limitations of their powers. The specialists are those most apt to magnify the results to be hoped for from intervention in the fields to which they confine their activities. It is not to be expected that there will ever again be such a wave of harmful surgery as the wholesale removal of ovaries for the relief of functional disturbances among women. Yet not many years ago castration for prostatic enlargement was very widely practiced for a few months. Already there is a great reaction against the needless removal of the tonsils and a growing feeling that there should be other indications than the wish of the school nurse. One of the most encouraging recent indications of the purpose of this Society to advance medical knowledge is the formation and the progress of the Section on Obstetrics which is studying the results of modern midwifery.

This Society must recognize and adopt safeguards against the dangers incident to the concentration of patients in hospitals, and be tolerant of those in official position who would also aid in this matter. And we must recognize that surgery is not justified unless the results to be expected are better, safer and more prompt than can be obtained by conservative means.

Fortunately the direct responsibility for the teaching of medical students was met by the founding of the Harvard Medical School a year after the organization of this Society.

In 1823 The Berkshire Medical Institution was founded in Pittsfield and within a few years rivalled the Harvard School in the number of students, but in 1867 this school passed out of existence. All are familiar with the growth of the other high grade medical schools in Massachusetts as well as with the continued existence in this state of two schools which maintain standards so low as to be deemed unworthy of recognition.

In the early days the responsibility for the right to practice medicine rested in part at least upon this Society. But with the increased authority given to Medical Schools the rather loosely defined powers of the Society in this matter grew less. For many years there was no restriction upon the right to practice medicine until the passage of the Medical Practice Act in 1894.

With all the changes that have taken place the Society still maintains its own standards for fellowship and cannot avoid a share in the responsibility for the training of physicians. The Society refuses to recognize certain unfit schools. It takes a perfectly definite stand against the practice of medicine in any form or under any name by those unfit or inadequately trained for their responsibilities.

An obligation however rests upon the Society to exert its influence to maintain a sufficient number of well trained physicians to meet the needs of the Commonwealth and to a less extent of the neighboring states which look to our schools for their future physicians.

Not long ago President Eliot pointed out the need of more physicians in the smaller communities and of more men in preventive medicine. It is interesting to note that the falling off in the number of those willing to take up practice in the smaller towns has coincided with the increasing importance of the laboratory in medical education. The increasing investment of time and money needed to secure a medical education makes it impossible for most students to consider settling in small country towns. The importance given to the laboratory during their education makes a general country practice seem undesirable.

Of recent years there has been a great reduction in the number of medical schools throughout the United States, brought about largely by the influence of a few men interested in medical education. The results have been for the most part very beneficial. Medical science has advanced so rapidly as to render the closing or the combination of schools very advantageous to the Commonwealth. On the other hand the Massachusetts Medical Society must regard with keen regret the closing in Maine of the Bowdoin Medical School after a most honorable record of one hundred years, and must rejoice over the continued prosperity of the Medical School of the University of Vermont, even in the face of many discouragements. These schools, both in large centres of population, and the Dartmouth Medical School while maintaining its full course, conducted and inspired by men of extraordinary ability, have contributed very definitely to the high standards of medical practice throughout New England. Many hope that Dartmouth may resume its full course.

The reduction in the number of Medical Schools has unfortunately been accompanied by an arbitrary limitation of the number of students accepted by very many of the high grade schools. The reasons assigned for this limitation of enrollment have been the impossibility of proper training of more students than the number admitted. The chief factor in determining this number has been the expense of modern laboratory training and of teaching students in smaller groups according to modern methods. An examination of the budget of a modern medical school reveals that a great deal of the money is spent for investigation as well as for training of students to enter the practice of medicine. Modern scientific investigation is an expensive undertaking, which should not be confused with the training of practitioners.

The limitation in the number of students has rendered the profession liable to the suspicion of adopting the trades union methods. While it is absolutely untrue that selfish motives have been the basis for the action taken, it is true that the great increase in the cost of medical education has come in the training for scientific investigation rather than in the training for practice.

We would occupy a stronger position with the public if we had a little of the faith of President Eliot when, in dissenting from the policy of limitation he expressed the belief that if it were shown that the Harvard Medical School could not afford to accept more than one hundred and twenty-five students each year an appeal for larger funds should have been made to a generous public from whom in his opinion the needed money would have been obtained, especially as he pointed out that the great plant, with the construction of which he was so closely identified, was intended to accommodate classes of two hundred.

At the same time there have been proposals for a further lengthening of the medical course. The tendency has been to add constantly to the amount of detailed knowledge taught. It has become so obvious that no student can now be taught all that is known in medicine or even in any of its major branches that at last a reaction has set in. Time is now set aside in which the student is supposed to think for himself, rather than to be fed knowledge. Some of the details formerly taught have been eliminated but it may fairly be questioned whether minor changes made in the curriculum have reached the root of the evils of medical education. Though some details have been eliminated not much good can be accomplished until more emphasis is placed on the true essentials of anatomy, physiology and pathology. No detail of today is likely to be the detail of tomorrow. But the basic facts will not change.

If in surgery the principles of inflammation are fully understood much of the detail now taught might be omitted with definite advantage. Yet how little attention is paid to the pathology and the treatment of minor infections which make up the bulk of early surgical practice. A thorough knowledge of these simple processes would impart an understanding of appendicitis and osteomyelitis not otherwise obtainable.

As Osler said that all medicine could be taught in the study of pneumonia, typhoid fever, tuberculosis and syphilis, the surgeon might equally truly say that all inflammations could be taught by the study of boils. And if there were added an adequate study of simple epitheliomata a good knowledge of all tumors might easily be acquired. The study of the fundamental medical sciences has unfortunately been kept separate from their practical application.

In anatomy great attention is given to the details of osteology which have little significance, while the lymphatic system which is of such tremendous importance in both medicine and surgery is sadly neglected. The sympathetic nervous system and the ductless glands receive scant attention.

Fortunately in physiology more attention has been given to the practical bearing of the subject. Yet how little is taught medical students regarding the physiology and pathology of muscle. Muscles are constantly subject to disturbances of function for the relief of which advice is sought. Yet practically nothing is taught regarding organic and functional disturbances of muscles, and as regards treatment only a vague idea that electricity, various forms of heat and massage may be of benefit. The interest aroused of late with reference to infantile paralysis has stimulated interest in the methods of treatment of this severe form of organic disease.

The neglect in our schools of the various forms of physical therapeutics has made us ignore methods of treatment which definitely benefit patients. The importance given to laboratory methods has made us careless in the recognition and treatment of the common functional disorders which make up so large a part of medical practice.

The Massachusetts Medical Society cannot regard with indifference the growth of the various cults, which is in great part explained by the sins of medical education and practice as well as by the great truth enunciated by Mr. Barnum.

Homeopathy began before medical science had made much headway. It served a most useful purpose as a protest against heroic, unnecessary, and often harmful treatment. It brought out the truths that the vast bulk of ailments are functional disturbances and that most acute diseases are self-limited.

At the time when medical science was beginning to make great strides Christian Science had its origin. It is not too early to look back upon the growth of this cult as a protest against a neglect of the psychological factors in functional disorders. Sporadic and for the most part abortive attempts to combine spiritual and medical healing have been the direct result of the Christian Science movement. The waning power of this cult is due to the recognition on the part of physicians that psychological factors are of importance in treatment and to the growth of new fads which inculcate the doctrines of hope and optimism under new names and in new dress. Because the medical profession neglected certain truths the psychoanalysts came into prominence, and, taking advantage of the neglect of others, tremendously over-emphasized the importance of their work. There followed the psychological clinics in our hospitals which, crude at first, will gradually assume a useful place and one in proportion to their accomplishments. In the wake of all this ferment has come the development of the mental hygiene movement, admirable in its motive but certainly at times absolutely unreasonable in the extent of its pretensions. Yet through all these changes, among those who have been brought up to regard strict medical science as the chief reliance of the physician, there can be traced a growing recognition of the importance of the psychological factors in diseases. Scientific medicine lost sight of much that the wise old time physician never neglected.

Osteopathy is undoubtedly having an influence on medical practice. Chiropractic flouts all medical knowledge and its followers are attempting to break clown the laws safeguarding the public from ignorant practitioners. The followers of these cults bitterly oppose each other. If either does good it is through mental suggestion combined with a limbering up of stiff muscles and joints and increased bodily activity.

The public is little concerned with the grotesque theories on which these cults are based. They look for somebody who by any means whatsoever makes them feel better. Constipation, physical inactivity, mental fatigue and depression are at the bottom of a great majority of human ailments. We have no right to ask that these ailments shall not be treated in any way which gives relief to the patient provided the practitioner is required to have sufficient knowledge to recognize and treat properly diseases dangerous to the individual or to the community.

Fortunately deaths resulting from neglect of treatment or from harmful treatment by the practitioners of the cults are becoming more rare. The public is being educated to a recognition of the conditions under which they can with safety receive treatment based in great part on mental suggestion, with the addition of either a physical or semi-religious factor. Any relaxation in the legal requirements for practice would however be most dangerous.

The best method of imparting information to the public is through the individual physician. The contact between physician and patient should be most happy, but in some ways the growth of medical science and the tendency to specialization have impaired the close and intimate friendship which was formerly the rule.

The results in the treatment of many serious organic diseases are infinitely better as a result of increased knowledge and better care given, but in the treatment of the more common functional disorders and milder diseases much has been lost. The specialist is ignorant of many conditions with which the family physician is familiar. Important factors are neglected. The greater the number of specialists the less is the sense of personal responsibility on the part of any. Multiple consultations whether initiated by the patient or by the family physician are often unsatisfactory. The expense involved is frequently excessive and can be justified only by results to be attained in no simpler way. Medical care must be so simplified that it shall not be unduly expensive. This can be done by eliminating consultations and laboratory examinations unless there is reason to believe that these will really aid in clearing up an obscure diagnosis or in assuring better treatment. It can be done if the family physician is qualified to take intelligent histories, to make careful and accurate physical examinations, to make the requisite routine laboratory tests, to differentiate functional from organic disease and to treat the patient intelligently and with understanding. The consultant then may be called upon to solve special problems which are formulated in the mind of the family physician. The medical consultant, however, must not be content to examine the one organ or part of the body in which his interest is greatest, nor must the surgical consultant become content to do any operation unless in his own independent judgment it is wise. Under no conditions whatever is it justifiable for one consultant to refer a patient to another consultant. The consultation in the office of the specialist must be solely between the referring physician and the consultant. If further consultations are needed these must be arranged by the regular physician and according to his judgment. In the vast majority of cases diagnosis is perfectly clear without consultation.

All will admit the value of the diagnostic clinic in the difficult and obscure disease, but the value of the findings must always depend upon the assembling of all the facts, a careful estimate of their relative importance and determination upon a course of treatment by one physician with reference to the one particular patient and his peculiarities and environment. The clinician must be the final authority.

The people should know what is and is not possible in medicine. The discoveries in so many lines of science have been so amazing that vast opportunities are open for fraudulent claims in medicine. Popular education is the only method of combating the credulity which leads a portion of the public to accept quackery as progress. It is not enough to state that scientific advances do not apply to the fraudulent claims of impostors. We must show why they do not apply. The elaboration of diagnostic methods, the multiplicity and expense of surgical operations, the increasing cost of medical, nursing and hospital care are all matters which affect the public in their relations with the medical profession. Contact between patient and physician must be kept as direct, as intimate, and as personal as modern medical science will permit.

Allied professions should not become too much carried away by scientific advances. The proposals to make Dentistry a branch of medicine and surgery seem to many a move which will not be for the public good. Relatively few dentists intend to become oral surgeons. The way is open now for those who so desire to fit themselves.

The Profession of Nursing is supposedly auxiliary to the Profession of Medicine. Modern medicine and surgery would be impossible but for the aid of trained nurses. The multiplication of training schools in association with an increasing number of hospitals has been of great benefit to the public, but the demand for nurses has far exceeded the supply. The fields opened up by industrial, school, district, public health, tuberculosis and infant welfare work have absorbed so many nurses that the laws of supply and demand have increased terribly the cost of sickness. It makes little difference how nursing care is attained. Whether by the training of attendants or by simplifying the basic training of the nurse who intends to do private work the good of the community demands less elaboration, while at the same time even better training may be given those intending to take up more specialized lines of work. Much educational work, particularly in the fields of public health and infant welfare, must be done by nurses. It is absolutely essential that such work be done by those well trained and of such character that their teachings will be so sound, conservative and practical as to command the respect of the community.

Medical progress accounts in part for some most unpleasant relations between the physician and his patient, or more often his lawyer. The number of suits for malpractice is appalling.

Among the members of this Society insured under the policies issued specially to them more than one in every twenty has been sued or threatened with suit in the past year and a half. Surgical operations with results or complications displeasing to the patients; results from fractures which do not satisfy the patients; infections occurring as a result of accidents; disagreeable effects from the use of the X-ray, are the more common grounds upon which these suits are based.

In many cases the suit appears to be instituted purely for blackmail. There is good reason to believe that often the cause is bolstered up by perjury. The number of cases is increasing. Standing together and fighting to the limit in defence of honest medical and surgical practice is the first duty of the profession, and as a necessary corollary the condemnation of improper practice is equally essential. But that is not enough. Conspiracy, perjury and subornation of perjury must be detected and prosecuted. The conviction and adequate punishment of one blackmailing patient or lawyer would instantly stop a great proportion of this abuse.

Education of the public regarding what surgery can and cannot do and regarding the qualifications of surgeons for their work; regarding the results to be attained in the treatment of fractures; regarding the infection from accidental wounds; and regarding the dangers of the X-ray are also essential to such an understanding as will limit unjust litigation. Thus will the popular feeling of confidence in the medical profession be enhanced.

The outlook for the future is bright. In medical as in other educational matters the pendulum swings. There are clear indications that many men influential in medical education realize what has always been plain to the thoughtful rank and file of our profession and to the great mass of the people: that the first function of our schools is to supply the Commonwealth with intelligent, thoughtful, sane and resourceful clinicians. Such men are essential for the standing of the profession in the estimation of the public. There is as much reason to expect great advances and discoveries from such men in the future as in the remote and recent, past. The laboratory worker recognizes the value of clinical observations. The clinicians will more and more seek the aid of the laboratory as the laboratory becomes an aid to the physician. There need be no fear regarding the lure of the laboratory failing to attract the thoughtful practitioner of medicine. The discovery of insulin is too recent to make this a possibility.

The Medical Schools by means of lectures have for a number of years undertaken to inform the public upon medical methods in a splendid way. Various District Societies have made a beginning along similar lines. Other societies are holding public meetings. In these movements there is great promise of a better understanding on the part of the public of the limitations and the resources of modern medicine and surgery. As the public realizes how our limitations have been made less year by year the sound respect of the vast majority of the people for the medical profession must increase. And with a better understanding of what is being done for individual and public health the public will pay the necessary price in money and more particularly in the slight sacrifice often necessary in personal comfort or convenience. Legislative recognition of the tremendous advances in public health is inevitable.

The purpose of the Society to take its part and to cooperate with the people in matters relating to public and individual health is shown by the activities of the past, by the cooperation in numberless public movements for better health conditions, by the formation of recent committees upon cancer control, health examination and public information.

The activities of the Society and of the individual members in working together and in cooperation with the public for better conditions have begun. They must increase in numberless ways, some of which are not yet foreseen.

The fads of medicine have in the past been self-limited diseases. There is no reason to suppose that the character of these diseases has changed. The more virulent the infection the more quickly is resistance developed.

From the cults we have learned some painful lessons in the past. If they contain any element of truth, no matter how grotesquely set forth it is seized by the regular profession and the cult dies. Fraud can never endure long.

This Society is maintaining higher ideals of service to the community than it ever has in the past. Today the facilities for exerting its influence are greater than ever before. The Journal now voices the sentiments and upholds the ideals of the profession of Massachusetts as never before. But the Massachusetts Medical Society and the other New England Societies are working individually. The ideals and the standards of the medical profession of New England are not surpassed in any part of the world. It is not too much to hope that in some manner or other the various Medical Societies of New England, while maintaining their identity and initiative unimpaired, may unite to gain for the Medical Profession the power as a civic force to which it is entitled by what it has done, is doing and will do for the public good.

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Stone, James S. "The Relations of the Massachusetts Medical Society to the Public." The Boston Medical and Surgical Journal 190, no. 24 (1924): 1005-12.


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