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The Future of Medicine in the 
 United States 1 
 
 It is not fatuous optimism to believe that this country is the 
 most fitting place for the future center of medicine, nor is believ- 
 ing this to sin on the side of vain glory. However much the idea 
 may seem to be the product of over-ardent patriotism, looking at 
 it earnestly, we shall see it is nothing of the kind. It makes one 
 of the many demands upon us to prepare ourselves now for the 
 even greater struggle after the war. To us it comes as a summons 
 to a duty we should not neglect. 
 
 The reasons for this are many and easy to discern. During the 
 past four years war has swept the world with a power to destroy 
 more complete than ever before in history. If it revealed a 
 ruthless plan which menaced the race, at the same time it exposed 
 a nation which has lost its mental bearings. The Germans for 
 many years have been laboring under a delusion of grandeur. 
 They have been obsessed by the conviction of their own racial 
 superiority. This eventually led to the paranoid idea of world 
 dominion. It has been part of their unfortunate heritage as a 
 people to believe in the righteousness of might. They were even 
 more unfortunate because they have long been under the influence 
 of rulers who, by cultivating this belief, exploited a national 
 weakness. Their most serious misfortune is their present ruler. 
 Prepared for the coming of a war-lord by their successful aggres- 
 sion in the Franco-Prussian war, the German people were quickly 
 infected by the expansive ideas of the new ruler. He on his part 
 at once began to weld the old fetters of feudalism, and soon had so 
 controlled public opinion that the German standards of judgment 
 in morals, religion, science, art, and politics were no longer matters 
 
 1 The annual address at the opening, September, 1918, of the College of Physicians 
 and Surgeons. The corresponding address a year ago, on the opportunities of thegreat 
 war itself, is in the Quarterly for January, 191 8 (xx, 48) . 
 
302 Columbia University Quarterly [October 
 
 of independent decision. Our former ambassador to Berlin, Dr. 
 David Jayne Hill, epitomizes the tendencies in Germany when he 
 says: "Like money put out at usury, power in government 
 grows with astonishing rapidity. When it is both concentrated 
 and undisputed, as in the case of imperial absolutism, it soon be- 
 comes irresistible. No better example of this rapid centralization 
 of power can be found in history than the growth of Kaiser William 
 IPs personal control not only of German action, but of German 
 thought." In his instructive reference to the Verdun Prize this 
 celebrated student of Germany gives a striking illustration of the 
 method by which the Kaiser gained control over the universities. 
 The prize referred to was annually awarded for the most meri- 
 torious historical work of the year. In 1894 the Academy of Berlin 
 unanimously awarded it to the famous historian Von Sybel for his 
 work on the 'Foundation of the New German Empire'. To the 
 amazement of all, the young Kaiser drew his pen through the 
 name of Von Sybel, awarding the prize to a Heidelberg writer for 
 an inferior work on the Great Elector, one of the Kaiser's ances- 
 tors. Gradually, under such influence, the faculties of the univer- 
 sities and schools came to wear the King's coat, for in this way 
 only was advancement possible. But it did not stop with the sub- 
 ordination of learning. Soon it extended to the press and the 
 church. In time, baited by the avaricious expectations of German 
 world-dominion, commerce and finance came into the net, until at 
 length allegiance to the Kaiser on the farm and in the factory, in 
 the banking house and on the sea, meant power to the arm that 
 was to strike the swift, overwhelming blow for alluring plunder. In 
 this attitude we see them posed to strike for the predestined day, 
 infector and infected alike charged with the same venom, filled 
 with Prussian lust for power. 
 
 The blow that fell was neither swift nor powerful enough. It 
 did, however, strip off the mask and finally arrayed against the 
 transgressors the outraged humanity of most of the world. In this 
 way two great forces have, for more than four years, been engaged 
 in a process of irreparable destruction. Nearly every line of 
 human activity has been turning its product into the vortex until 
 the waste in all materials and in intellect has become stupendous. 
 
191 8] The Future of Medicine in the United States 303 
 
 In the end, Germany, vaunted the most efficient of nations, has 
 shown herself to be the most destructive organization in history. 
 Through forty years, while establishing German supremacy in 
 the pursuits of peace, the government built parallel to this, and 
 deliberately planned to use, the destroying engine of its military 
 power. This power has swept German commerce from the seas, 
 decimated her manhood, filled her cities with the maimed and 
 blind, prostrated her science and industries, and brought her to 
 spiritual as well as financial bankruptcy. Nor is this all. Had 
 the ruin been confined to Germany alone, the evil record might 
 have been less onerous to bear. But the destruction which Ger- 
 many begot has drawn all of the other productive nations into 
 the disaster. Their wealth and man-power, their intellectual 
 efforts and enterprises which go to make up civilization, have been 
 diverted into the conflagration. Years of readjustment and 
 recuperation lie ahead, years of we know not what extreme test 
 upon our faith, our courage, and our tenacity to adhere firmly to 
 the right. These are the times for which we must now begin to 
 prepare ourselves. 
 
 There can be no doubt that the struggle in Europe will be 
 severe. The entire effort of every European state must be con- 
 centrated upon the rehabilitation of the essentials of life. The 
 higher pursuits of civilization must for the time at least stand 
 aside, or bend their energy to the simpler purposes. The security 
 and plenty upon which German medical science grew to be the 
 commanding figure in the world of medicine have gone. Not for a 
 long time will the Germanic capitals be the centers of medical 
 learning which they have been in the past. This distinction must 
 pass into other keeping. France, henceforth the symbol of heroic 
 sacrifice and salvation, has given nearly all she had, and being 
 impoverished by the noble gift, needs time to replenish her re- 
 sources. England, the bulwark of civilization throughout the 
 struggle, has stripped her empire, and for years to come will be 
 handicapped in maintaining and advancing science. This is 
 particularly true in medical science ; for Great Britain early in the 
 war encouraged the mobilization of the entire medical profession, 
 and permitted medical students to serve with the colors, in this 
 
304 Columbia University Quarterly [October 
 
 way depriving herself of a large annual increment to the medical 
 ranks. Whatever handicaps we may labor under, due to our 
 present or future sacrifices, we shall inevitably occupy the point 
 of vantage in this regard as well as a position of responsibility. 
 We can understand how it must be our duty here in America to 
 carry on the constructive advance work in medicine while the 
 nations of Europe struggle through their period of reconstruction. 
 
 But there is a still more cogent reason why we should accept 
 this responsibility, namely, because we are now ready and able 
 to take the place we should hold in medicine. The war has brought 
 about far-reaching changes in the country. It has, as Lord French 
 says, made a nation of us. Under the great leadership of President 
 Wilson the whole essence of our destiny has been crystallized, and 
 we move forward unified by a national consciousness, no longer 
 North or South, or East or West, but one people irresistible in 
 the resolve to accomplish our purpose. The war has brought 
 about far-reaching changes in medicine because we have gained a 
 national consciousness. 
 
 The country no longer regards medicine merely as a learned 
 profession, but is coming to consider it one of the essential indus- 
 tries. Sound public health is a necessary element in the will to 
 victory. The civil population unduly enfeebled by disease or 
 discouraged by neglect cannot be expected to support a winning 
 army. All signs give assurance that the government in its wisdom 
 will provide adequate medical attention for the people, prevent 
 relaxation in the safeguards against epidemics, and restrict the 
 spread of disease to the limits normal in peace-time. In another 
 critical relation the efforts of the medical profession have become 
 indispensable to final success. The vast detail of the health of an 
 army is in the hands of its medical corps. Failure here is almost 
 as serious as defeat by the enemy. The selection of the fit and 
 rejection of the unfit, the supervision of sanitation, the prevention 
 of disease, the stamping out of epidemics, the early detection of 
 the physically and mentally unstable, to say nothing of adequate 
 care and reconstruction of the sick and wounded, are matters of 
 vital importance to troops in the field. The war has shown us the 
 possibilities of medicine carried out intensively in all its branches. 
 
1918] The Future of Medicine in the United States 305 
 
 From these lessons we have gained more cohesion as a profession. 
 We understand now more fully our obligation to civil communi- 
 ties; we recognize our opportunities for greater public service 
 and see the value in a more complete system whose development 
 will better safeguard the public health. In attributing these 
 changes to the war, it is but just to indicate that they are in 
 large part due to the efforts of Surgeon General Gorgas. He 
 has given us a demonstration of the efficacy of national or- 
 ganization in medicine. The organization of his own depart- 
 ment is one of the real achievements of the war. It is widely 
 admitted that the Medical Corps of the United States Army 
 is without peer. The public knows too little of its develop- 
 ment and management to appreciate the efficiency of one of the 
 most potent forces fighting for civilization today. Over twenty- 
 five thousand physicians have been called in from all branches of 
 private practise and given special training for some particular 
 work in the army. Provision has been made for the psychological 
 testing and grading of troops in training; specialists have been 
 developed for testing the flight capacities of aviators. Every 
 department and sub-department in medicine is manned by phy- 
 sicians who have had special courses of intensive training. Each 
 of the larger groups of diseases is provided with its special base 
 hospital, and plans are already perfected for the rehabilitation of 
 the maimed and blind who unfortunately will return in increasing 
 numbers to our shores. In a word, every contingency that a far- 
 seeing intelligence might anticipate has been provided for in a 
 scientific manner. With an organization in all branches of the 
 war department such as General Gorgas has built up, the United 
 States Army must certainly be invincible. 
 
 Alive to the significance of our position, we recognize that 
 American medicine can no longer be an overseas province on the 
 medical map. We are ready to make it what it should be. Our 
 tradition leads us to feel that we shall succeed. Our practical 
 instinct compels us, however, to take stock of our qualifications. 
 As to one of our assets there can be no dispute. American medi- 
 cine is supreme in surgery. In this most direct practical handi- 
 craft of the healing art, it is probable, we have no equals. Ameri- 
 
306 Columbia University Quarterly [October 
 
 can surgery has won its repute not alone for its ingenuity and 
 sound adherence to fundamental principles, but quite as much 
 through the brilliancy of its technic and enterprise. It has 
 produced a surprisingly large number of surgeons noted for their 
 exceptional skill in general and highly special regional procedure. 
 The number of these is still growing. In fact, no other country 
 possesses so many thoroughly trained surgeons who may be con- 
 sidered competent to assume the responsibilities of major opera- 
 tive work. The dominant position of America in surgery is wit- 
 nessed by the steadily growing influx of foreign surgeons in the 
 past few years to the famous operating amphitheaters of this 
 country. Our own surgeons understand that they have become 
 the instructors in their branch. 
 
 Another valuable factor ready to our hand is the diagnostic 
 clinic, or group idea in diagnosis and practise. This is essentially 
 an American conception, and its successful application as a 
 scientific method for the practise of medicine is an accomplishment 
 in which we have a just national pride. Not only is it the most 
 efficient way of bringing the ailments of each individual patient 
 under complete medical review through examinations by experts 
 in each particular department, but it confers a further benefit upon 
 the patient by furnishing the best medical advice in the most 
 economical way. To the physicians engaged in the work it serves 
 as a mutual inspiration and a constant incentive. 
 
 In the matter of equipment we are rapidly increasing the num- 
 ber of modern hospitals throughout the country. These institu- 
 tions have the advantages of modern management, which con- 
 ceives of the hospital as an educational factor as well as a place to 
 care for the sick. The idea is becoming more generally accepted 
 that a hospital, especially in large centers, which has no teaching 
 facilities does not discharge its full duty to the public. The per- 
 sonnel of the profession is fortunate in its admixture of nationali- 
 ties and races. This cannot fail to be ultimately advantageous, 
 as it tends to catholicity of view-point and furnishes a variety in 
 methods of approach. 
 
 The American system of medical education is conspicuous 
 among our assets. It has an efficient organization which under the 
 
1918] The Future of Medicine in the United States 307 
 
 guidance of State boards and certain large national associations 
 has effected a standardization of medical instruction. This gives a 
 well-rounded training in all branches of medicine. The fifth 
 hospital year, already instituted, is designed to furnish a finishing 
 course in practical work. During this period the student will live 
 in the hospital, gaining clinical experience under the direction of 
 resident instructors. The establishment of separate faculties to 
 increase the opportunities and requirements of post-graduate 
 instruction in medicine is receiving serious consideration. Full- 
 time clinical professorships as proposed will materially advance 
 the interests of research in the clinical branches and provide more 
 time for teaching. Medical research has had an unprecedented 
 growth in recent times, as evidenced by the development of 
 special institutions for the intensive study of the human body and 
 its diseases. Notable among these are institutes for the investiga- 
 tion of cancer, tuberculosis, mental disorders, the development of 
 the body, the anatomy of the brain, and general experimental 
 medicine. In connection with these institutes the opportunities 
 for post-graduate teaching have been much enhanced. 
 
 We must not, however, neglect the other side of the question. 
 We have our defects. The most obvious of these, perhaps, is that 
 we have permitted our vision to become near-sighted and locally 
 introspective. Because of this limited view, we have gained no 
 sense of the possibilities and proportion of our mission; it would 
 even seem that we had no realization of a mission at all. A com- 
 placent isolation of the larger medical centers has cultivated an 
 exclusiveness which does not promote mutual understanding, or 
 inspire the confidence which engenders the spirit of progress. 
 There has been in consequence a lack of broad conception and 
 comprehensive organization. Our natural impetuosity, our desire 
 for quick results, have made us intolerant of delay and often hasty 
 where patience is more needed as a commodity than as a virtue. 
 We have had too little esteem for our own achievements and an 
 overweening regard for foreign work, especially of German 
 stamp. This is all the more discomfiting since the quality of 
 German production has fallen off in the past fifteen or twenty 
 years. It may now be seen how much of the mass of German medi- 
 
308 Columbia University Quarterly [October 
 
 cal literature was part of the ambitious scheme of exploitation 
 which has sapped so many good things of their worth and sincer- 
 ity. 
 
 These defects, although serious, should not retard us. Such is 
 not the American character, as we know from recent examples. 
 When the call for men came from France, our response was not 
 the difficulty of drafting, equipping, and transportation; but, 
 putting all obstacles aside, we have sent an army which is well on 
 its way to final victory. Let us be convinced that there is some- 
 thing which must be done, and its accomplishment is assured. 
 When the conviction is established that we owe this duty to 
 medicine, America will indeed become a new medical center. 
 
 It may be that the first step to secure this end will be a federa- 
 tion of American medical colleges and institutes. A council repre- 
 sentative of these institutions would cooperate in the interests of 
 medical education and medical science. If the satisfactory 
 diagnosis of the individual patient requires a group of diagnosti- 
 cians, how much more do the profound and baffling problems of 
 medicine demand large groups of special workers for their solution ! 
 Coordination of investigation might be carried to a high level of 
 efficiency by this intensive cooperation in medical research. The 
 distinctive advantages of each medical center would not then be 
 matters of local reputation, but part of the national endowment 
 in medicine. The large cities and the other noted medical lo- 
 calities, making their contributions to a common cause, would 
 attract to this country a vast number of the seekers for medical 
 knowledge who formerly would have been found in the capitals 
 of Europe. 
 
 It would be difficult to estimate the impetus which such a 
 combination would impart to the newer, important trends in 
 medicine. The influences of civic interest are becoming con- 
 tinually stronger because medical supervision is proving itself 
 indispensable in many fields of community life. The well-trained 
 physician of the future must be versed in the requirements of 
 public service. 
 
 Preventive medicine particularly is destined to undergo much 
 expansion. To its many present activities others equally neces- 
 
1918] The Future of Medicine in the United States 309 
 
 sary will be added. Among these might be mentioned the need of 
 medical registration for the detection of disease in its incipience. 
 Those connected with draft exemption boards have been astonished 
 at the inroads into possible military effectives made by preventable 
 diseases or disorders curable in early life. 
 
 Industrial medicine will soon have a field of its own. The 
 health of operatives is calculated as an essential of efficiency, and 
 medical departments have already been installed in a number of 
 large corporations. 
 
 Public mental hygiene is an urgent national problem which 
 must engage medical attention more seriously in the future. 
 The significance of insanity as an economic loss will be realized 
 by the fact that one-third of the entire budget of New York State 
 is annually appropriated for the care of the insane. Under the 
 guidance of the National Committee for Mental Hygiene a nation- 
 wide investigation is being conducted in order to determine the 
 prevalence and causes of insanity. The Committee has already 
 done much to improve the care of the insane, and has stimulated a 
 real interest in the effort to reduce the prevalence of mental 
 disorders. Feeble-mindedness as a burden to the community has 
 assumed such proportions as to necessitate the appointment of a 
 special commission for its management in this state. The govern- 
 ment attaches such importance to this problem that it has called 
 one of the most distinguished physicians of this country to the 
 chairmanship of the Committee. 
 
 The necessity of medical cooperation in court and prison mat- 
 ters has become apparent. To distinguish between the feeble- 
 minded, a psychopathic delinquent on the one hand, and the 
 criminal on the other, to differentiate between the necessity of 
 therapeutic and of punitive measures in each case, and to study 
 the pathological factors in the development of the criminal are 
 necessary functions of the state. 
 
 If the country is to avail itself of the obvious advantages of 
 universal military training after the war, military medicine must 
 be still further developed in the colleges. It seems advisable that 
 permanent courses in military medicine be introduced into the 
 curriculum of medical schools. 
 
310 Columbia University Quarterly [October 
 
 These higher requirements of medicine make unusual demands 
 upon those of us who are working in this field today. Yet only 
 as we devote ourselves with intelligence and redoubled energy to 
 our duties will it be possible for us to reach the object to which we 
 seem destined by circumstance. In so large an undertaking the 
 work is not ours alone. The nation already begins to understand 
 our purposes. When it appreciates the full importance of our 
 relation to its welfare, we shall, as a recognized economic necessity, 
 have its liberal support. It is especially necessary in all parts of 
 the country that those who have the interests of medical develop- 
 ment in their keeping shall make their efforts decisively construc- 
 tive. In the future, no doubt, a reliable index to the intelligence 
 of a community will be the degree to which it has mobilized its 
 medical resources. 
 
 If our eyes seem fixed on the future, it is because we understand 
 that although civilization must be defended against the ravages 
 of war, it owes its continuance and growth to the security of 
 peace. We remember at what cost we delayed in preparing for 
 war. We are loth to make the same mistake again and would 
 prepare in time for the severe burdens after the conflict is over. 
 Education, the surest guarantee of social stability, should be the 
 subject of our most earnest attention. How much the events of 
 the war have converted public opinion in England to the belief 
 that the future of that nation depends upon the better education 
 of the coming generation, has been shown by the reception 
 accorded the Fisher Education Bill in the House of Commons and 
 in the country. The cardinal features of this bill are the continua- 
 tion of elementary education for all children and the establish- 
 ment of secondary education for girls and boys on a national 
 basis. It also provides increased emolument and pensions for 
 teachers, in this way aiming to bring into the teaching profession 
 and retain there the brains of the country. 
 
 We should cooperate with the Government to prevent any 
 unnecessary interruption in the work of our schools and univer- 
 sities, and urge that all institutions of science and advanced learn- 
 ing shall be stimulated rather than curtailed in their efforts. "Win 
 the war first," says Lloyd George; "but when peace comes I don't 
 
19 1 8] The Future of Medicine in the United States 311 
 
 want the nation to be taken unawares." There must be healthier 
 conditions in the workshops and more attention to the schools. 
 There are disturbing symptoms all over Europe which those at 
 home will be wise to note and provide against. "Let us take heed 
 in time," he continues, "and if we do, we shall enjoy settled weather 
 for the great harvest which is coming when the fierce heat of 
 summer now beating upon us in this great war is over and past." 
 Let us in America also take heed of the demands for national 
 health, both economic and intellectual; and, being sure that the 
 lamps of learning are the lights of the future, let us keep them 
 bright. 
 
 It is not in medicine alone that we are looking to the future. 
 An era of expansion in all our activities and in our sphere of in- 
 fluence is in sight. The day to which we look has no taint of 
 avarice ; for the motives which raised the nation to a high place 
 of esteem, the sacrifices which have ennobled the republic, will 
 increase our capacity of service to mankind. Again, as in our 
 past, after the wounds of a great war, that day for us is to be one 
 of justice and without malice. Every calling has its allotted task. 
 The obligation of the medical profession is clear, and some portion 
 of it rests on each one of us. The materials are ready and only 
 await assembling for the creation of a new Mecca of medicine. 
 
 Frederick Tilney 
 
Rumania and the War 1 
 
 Tswo years ago, when I was in London, I saw in a newspaper a 
 sketch, representing a newspaper boy in 1935 crying 'Rumania 
 coming in'. That sketch depicted sarcastically the anxiety and 
 the puzzled state of mind of the public as to the attitude of 
 Rumania. From 19 14 until 19 16 Rumania was the political 
 sphinx of the time. Is Rumania to come into the war? On whose 
 side, and when? Why has she not yet come in? These questions 
 remained unanswered. No one was able to say anything definite. 
 Later on, long before 1935, Rumania did enter the war on the 
 side of the Allies. After some ephemeral successes at the begin- 
 ning, when her sons after three centuries of waiting since the time 
 of Michael the Brave entered again into Transylvania, the calvary 
 of her misfortunes began: the loss of Dobrudja, the retreat in 
 Transylvania, the loss of Wallachia, hunger, and exanthematic 
 typhoid. Instead of the enthusiasm which greeted the entry of 
 Rumania into the war, a sort of disillusionment and disappoint- 
 ment was felt in the West, where 'failure' was the only word used 
 of Rumania. The long awaited ally on whom so many hopes had 
 been built had become a burden difficult to support and a trouble- 
 some companion in the fight. Only quite lately, during the sum- 
 mer of 191 7, after the Homeric battles of Mareshti and Mara- 
 sheshti, when a good many allied officers and soldiers had the 
 opportunity to be eye-witnesses of the bravery of the Rumanian 
 soldiers, public opinion in the West immediately altered its ideas 
 and sentiments toward Rumania. And now after the Russian 
 
 1 A Rumanian physician, member of the Parliament, and representative of Rumania at 
 the Congress of Rome last spring, interprets here not only a difficult chapter of the war, 
 but the international aspects of Rumanian political ideals. Through the courtesy of 
 Professor A. M. Lybyer of the University of Illinois, two statistical notes have been 
 added where reports appear to differ. These corrections of detail, however, and others 
 that might be made are the less important since the peculiar value of this article is far v 
 less in its review of facts than in its interpretation of national tendencies and aspirations. ^ 
 A comprehensive survey of the part of Rumania as seen through Rumanian eyes, it has 
 significance not only for the past, but for the future. — ED. 
 
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