The formation of clay balds in arid lands: DR. W. H. HAAS, Northwestern University, Evanston. The intercision of Pike River near Kenosha, Wis.: JOHN R. BALL, Northwestern University, Evanston.

The effect of sewage and other pollution on animal life of rivers and streams: DR. FRANK COLLINS BAKER, curator of Natural History Museum, University of Illinois, Urbana.

A possible interpretation of the synchronous flashing of fireflies: DR. CHRISTIAN A. RUCKMICK, University of Illinois, Urbana.

Animal physiological life histories and modern methods of representing climate: DR. V. E. SHELFORD, Natural History Survey, University of Illinois, Urbana.

Sexual dimorphism in the Acanthocephala: DR. H. J. VAN CLEAVE, University of Illinois, Urbana. Notes on the life history of the Crane-fly of the genus Geranomyia Haliday: C. P. ALEXANDER, University of Illinois, Urbana.

A review of the species of water mites: DR. RUTH MARSHALL, Lane Technical High School, Chicago.

The morphology of the antorbital process in the Urodeles: GEO. W. HIGGINS, University of Illinois, Urbana.

Some controlling factors in the use of fungous diseases in combatting insect pests: DR. R. D. GLASGOW and C. S. SPOONER, University of Illinois, Urbana.

A comparison of soil temperature in up-land and bottom-land forests: DR. W. B. MCDOUGALL, University of Illinois, Urbana.

An effect of topography and exposure on plant distribution: DR. H. S. PEPOON, Lake View High School, Chicago.

Topographic relief as a factor in plant succession: DR. GEO. D. FULLER, University of Chicago, Chicago.

On the plant ecology of Ogle County, Illinois: H. DE FOREST, introduced by DR. GEO. D. FULLER, University of Chicago, Chicago.

A note on the distribution of oaks in LaSalle County: DR. GEO. D. Fuller, University of Chicago.

Preserves for ecological study. (The work of the Ecological Society of America's committee): DR. V. E. SHELFORD, University of Illinois, Urbana.

Distribution of oaks on Lake Chicago beaches in Evanston and New Trier Townships: DR. W. G. WATERMAN, Northwestern University, Evanston.

Forest distribution in northern Evanston and southeastern New Trier Townships: LILLIAN MARGARITE SIMMONS, Northwestern University, Evanston. (Introduced by DR. W. G. WATERMAN.)

A probable cause of foot rot of wheat: DR. F. L. STEVENS and E. DUNGAN, University of Illinois, Urbana.

The sooty blotch of pome fruits: A. C. COLBY, University of Illinois, Urbana.

The genus Septoria, presented in tabulation, with discussion: PHILIP GARMAN and DR. F. L. STEVENS, University of Illinois, Urbana. Forest types and forest associations: (a) From the ecologist's point of view: DR. HENRY C. COWLES, University of Chicago, Chicago. (b) From the forester's point of view: R. B. MILLER, state forester of Illinois, Urbana. General discussion, by DR. GEO. D. FULLER and DR. A. G. VESTAL. The cause of increased oxidation in the fertilized egg: DR. W. E. BURGE, University of Illinois, Urbana.

Notes on the life history of Psithyrus, an inquiline in the nests of Bumblebees: THEODORE H. FRISON, University of Illinois, Urbana. Cnidosporidia in the vicinity of Urbana: DR. R. KUDO, University of Illinois, Urbana.

The cultivation of Spirochata Novyi without the use of tissues from animal organs: C. H. BEH. RENS, Purdue University, Lafayette, Ind.

The relation of legibility of the printed page to reading: MADISON Bentley, University of Illinois, Urbana.

The cumulative effects of rational increments: COLEMAN R. GRIFFITH, University of Illinois, Urbana.

FRIDAY, APRIL 2, 1920

THE UNIVERSITY DEPARTMENT OF

MEDICINE

THAT all is not well with medical education is obvious from the number of investigations, addresses, polemics, plans and schemes which at present center about this subject. In the writer's opinion the root of the difficulty lies in the extremely close association which has always existed and exists to-day between medical education and practise, and in the idea which generally prevails that the problems relating to medical education and those having to do with the practise of medicine are inseparable. While many persons admit for purposes of discussion that a line of separation exists between the science of medicine and the art of the practise of medicine, yet when these individuals begin to think in practical terms, they fail to take this fact into consideration. Indeed, in their inmost souls, most medical men refuse to admit that medicine is a science, or they think of the scientific side of the subject as something apart from medicine itself, as though scientific medicine were simply the group of underlying sciences upon which medicine depends for sustenance. Even Sir Clifford Allbutt, in his remarkable essay on the "New Birth of Medicine," speaks of the new birth as an "enlargement from an art of observation and empiricism to an applied scifrom a craft of tradition and sagacity to an applied science." Why is it that we can conceive of medicine only as an application of science to an "art" or "craft," and not as a new, real and independent science replacing an obsolete mass of tradition and empiricism?

ence

It is true that the science of medicine is in the process of making-but so is every other science. There is no such thing as a rounded, completed or finished science. At any given time any science is but the result of all previous attempts to arrange in order and to explain

the facts and phenomena relating to some field of knowledge which is more or less definitely outlined, and which is large enough and important enough to deserve such treatment. As new facts are constantly being discovered in all realms of knowledge, all sciences are in a constant state of development.

The abnormalities and functional disturbances of man surely constitute a large and important field of human interest. Marked advances in knowledge concerning the phenomena and nature of disease have already been made, especially in recent years, and this knowledge is constantly being arranged, and the phenomena are being studied in their relation to each other and to other phenomena. Medicine, then, is developing just as other sciences have done and are doing; its subject-matter is receiving the same kind of treatment that is succeeding in other domains of human knowledge. Therefore, on account of the importance of the subject, and because of the advances which have already occurred in our knowledge concerning disease and the progress which has been made in the scientific treatment of this knowledge, medicine deserves to rank as an independent science.

If physiology may be an independent science, if anatomy may be an independent science, why not medicine? Why should medicine be only an applied science, any more than anatomy or physiology? Anatomical and physiological knowledge may be applied to practical affairs as well as medical knowledge. Why should medicine be inseparably associated with the doctor's consulting room any more than anatomy with the surgeon's operating room or the artist's studio?

Since definition is more important than argument, let us consider what we mean by medicine, or better, the science of medicine. First, let us consider what it is not. It is not anatomy, it is not physiology, for these sciences deal with the normal or healthy; it is not pharmacology, strictly speaking, for as this science has so far developed, it has dealt with the nature of drugs and their action on normal animals. These sciences, however, together with such fundamental sciences as chemistry

and physics, are frequently spoken of as the medical sciences, the institutes of medicine, or indeed collectively as the science of medicine. To define exactly what medicine is is not easy. Medicine deals with disease, the antithesis of health; it deals with the abnormal, the departure from the average. When we come to consider whether medicine includes all aspects of disease, or only certain ones, we meet with difficulties. The accepted use of the term does not aid us, for there is no universally accepted use, even among the most strict and thoughtful men. The dictionaries define medicine as the science and art dealing with the prevention, cure or alleviation of disease. Pathology, on the other hand, is defined as the science treating of the nature, causes, progress, manifestations and results of disease. According to the definitions, therefore, pathology has to do with the nature of disease, medicine with the application of that knowledge. That these definitions are purely academic, however, and not real, is made evident by referring to the textbooks dealing with these subjects, for we must consider that the text-books of the day present not only the accumulated knowledge concerning the subjects treated, but also the contemporary conception of the boundaries of these subjects.

If we refer to any text-book on medicine, whether it be labelled practical medicine, the practise of medicine, or merely medicine, and look up any disease, it will be found that nine tenths of the subject-matter deals with the "nature, causes, progress, manifestations and results" of the disease, under the headings etiology, symptomatology, complications, prognosis and so forth, and only one tenth deals with prevention and cure. On the other hand, most text-books of pathology do not treat of the "nature, causes, progress and manifestations" of disease at all; they consider only the morphologic changes resulting from disease. It is evident, therefore, that the definitions of pathology and medicine quoted above are obsolete, even though practitioners of medicine may not take cognizance of the fact. In my opinion, the old implied distinction between pathology and medicine has had a blighting

effect upon the development of medicine as a science. Twenty-five years ago, however, it became dimly recognized that this distinction between medicine and pathology is not a real one, at least that pathological anatomy is an essential part of the science of medicine. The improvement in the teaching of medicine which occurred at that time and the resulting increase in medical knowledge may be directly traced to this new conception.

It is of importance that medicine should now be generally recognized as an independent science, just as physiology and anatomy are independent sciences. Medicine may then be defined as the science dealing with the phenomena of disease.

Let us grant now that there is or may be a science dealing with disease. How can this science best be fostered and how can this new science be most effectively utilized? As our medical schools are now organized, they are composed, on the one hand, of a group of departments devoted to the teaching and development of the so-called contributing sciences, anatomy, physiology and pharmacology; and on the other hand, of a large group of distinct departments, the chief function of which is to train men for the practise of medicine. As I have previously stated, however, anatomy, physiology and pharmacology have only the same relation to medicine that chemistry and physics have to anatomy and physiology. That the departments of anatomy, physiology and pharmacology are not independent university departments, but are included in the medical school, is in my opinion only accidental and is not an essential condition for the development either of these sciences or of medicine. The inclusion of these departments in the medical school has occurred chiefly because almost all the students working in them expect later to study medicine. Not so many years ago, however, practically all students of chemistry likewise expected to study medicine, and in many colleges the department of chemistry was also included in the medical school. To-day only a relatively small number of the students of chemistry look forward to the study of medicine, and in consequence, the department of

chemistry constitutes a part of the medical school in only a very few universities.

The present organization of the medical school, therefore, has been largely influenced by expediency and by the effort to obtain economy in administration. With a satisfactory university administration, the department of medicine (and under this term I include all the departments of the medical school that are engaged in the study of disease) might perfectly well constitute the whole medical school, probably with considerable advantage to the departments of anatomy and physiology. With the present laws governing medical practise, however, it is necessary that the grouping of various departments into medical schools be continued. There is no serious disadvantage in this so long as there is a full realization of the reasons for this grouping, and so long as the relation of the various departments to each other and to the university, and especially the relation of the department of medicine to the university, is kept clearly in mind.

During the past fifty years a marked improvement has taken place in the departments which are concerned with the so-called contributing sciences. In many schools these departments now rank among the strongest university departments, both in the quality of the instruction and in the contributions which they make to the advancement of knowledge. One of the most important of the factors which have contributed to this improvement has been the release of these departments from the restrictions imposed upon them by those engaged in the practise of medicine. No longer are the teachers themselves practitioners of medicine, no longer is the efficiency of the department judged entirely by the contributions made to the immediate demands of practise. That is, they have become true university departments.

The department concerned with medicine, however, has not developed in the same way. There the demands of practise and the needs of practitioners are still the controlling factors in organization and development. As one result of this there has been developed within the department of medicine numerous branches hav

ing little coherence and no general guiding principle of organization or function. In many schools some of these branches have become much more important than the parent stem, both as regards resources and as regards the character of the work which is undertaken. There are departments of surgery, of orthopedics, of psychiatry, of genito-urinary diseases, of gastro-intestinal diseases, of pediatrics, of ophthalmology, of dermatology, of laryngology, of endocrinology, of elecerotherapeutics, and so forth, and so on. Some of these departments, owing to the skill and prominence of the professors in practise, have acquired buildings and equipment of greater extent than the educational importance of the subjects warrants, and of far greater extent than the scientific development of these subjects justifies.

It is true that one additional circumstance has contributed to this extensive partitioning of the department of medicine. Most universities and medical schools have been compelled to employ general hospitals for teaching purposes, hospitals which were primarily planned and organized to care for the sick poor. Now, within limits, the larger the general hospital, the more efficiently and economically it can be conducted, and in the medical and surgical treatment of large numbers of persons, a high degree of specialization has been found to be most effective. It does not follow, however, that the same principles which should apply to the organization of a general hospital should also apply to the organization of a clinic designed primarily for investigation and teaching, merely because both have one function in common, namely, the care and treatment of the sick. The university department of medicine has an added function, the investigation of disease and the teaching of students, and if a general hospital is to serve this added function, its organization must be modified accordingly.

In the efforts which have been made to improve the teaching of medicine, not infrequently that division of medicine having to do with the study of so-called internal diseases has received the least and last consideration. These diseases, however, because of the suffer

ing and loss of life which result from them. are of far more practical importance than any other group of diseases. Of much more significance than this, at least from the educational standpoint, is the fact that the diseases of internal medicine are the ones which are most susceptible to scientific study, and thus far they are the principal diseases to which modern scientific methods of investigation have been applied. They are therefore the diseases with which the student of medicine should be chiefly concerned during his earlier years. It is in the study of these diseases that the student should develop his perspective and should obtain a knowledge of the methods which should be employed in the study of all other diseases. For this reason, in writing the following discussion of the department of medicine as a whole, I have had the division of internal medicine chiefly in mind, for this division should be a pattern for all the others.

Bearing in mind our definition of medicine and the conception of the boundaries of the department of medicine which we have adopted, let us consider what we mean by a university department of medicine. It is a department designed for the purpose of studying and investigating diseases, of accumulating and distributing the existing knowledge concerning disease and of contributing to the extension of this knowledge.

What is needed to create a university department? Exactly the same materials that are required in every other scientific department of the university-men, laboratories and books; and the most important of these is men. By men I mean students, of various grades. Some, the more advanced, we call teachers; the others, less developed, we call students; but they must all be constantly acquiring knowledge or the department is a failure. over, the essential requirements for admission must be the same for teachers and students, though differing in degree. They must all have the desire for acquiring knowledge, they must have the desire to add to knowledge, and they must have the training and ability to enable them to carry out their desires. While all science is complex and all sciences are mu

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