'olume 6 WINTER 1950 Number 2Dr. O. H. RobertsonRetires in 1951The farewell dinner given in honor ofr. O. H. Robertson at the Quadrangleub called attention to his departureirn active participation in the affairs ofe Department of Medicine after morean twenty-two years of service. Thisnner, which was attended by more thannety friends and associates of Dr.ibertson, represented a spontaneousbute to his personality and contribulI1S as well as affording an opportunity: those present to wish him much suess in his projected work. Dr. Paulrdges as toastmaster described theckground of Dr. Robertson's activitiesChina while he was at Peking Unionedical College, and Drs. Franklin C.cl.ean, Lowell T. Coggeshall, and Clayn Loosli discussed the contributions of'. Robertson to the Department ofedicine of the University of Chicago.'. Thomas Park then described theckground of Dr. Robertson's ecologicalzestigations of fish populations and anipated even more significant contribu-ns arising from his contemplatedidies. The Department of Medicine.s represented in a short address by'. Wright Adams and the Universitylministration by Dr. Wendell Harrison.At the present time Dr. Robertson isleave of absence from the Universityeparatory to his retirement in 1951,d to forestall concern over his healthshould be stated that he is leaving aca-imic affairs in order to continue his= idies on the ecology and comparative1 :locrinology of salmonoid fishes at Stand University.t Because of his unusual attainments asinvestigator in various fields of bio-:ical inquiry and his prominence as anIIlividual, it seems fitting to review Dr.� .bertson's career at this time. Although• English birth, he came with his familyl the United States as a small boy and� -nt his youth in central California,"l ere he acquired his love for the out-of..1 ors which has so strongly influenced1 n. He graduated from the University.. California and then came east to medi� school, receiving his M.D. from Har., -d University in 1913.Following his internship at Massachu== ts General Hospital, Dr. Robertsoneltinued at that institution as a Fellow in Pathology until 1915, when he reoceived an appointment as an assistantbacteriologist and pathologist to theRockefeller Institute. At this time he wasprimarily interested in problems relatedto the physiology and pathology of blood.Thus in 1917, when he embarked on hismilitary career, it was a consequence ofthis interest that sent him to France,where he played a prominent role in thedevelopment of techniques of blood transfusion in the forward areas of combat.For this work he received decorationsfrom both the British and the AmericanROBERTSONarmies and in 1919 was discharged fromthey.S. Army after attaining the rank ofmajor.With the conclusion of the first WorldWar the establishment of an endowedmedical school at Peking, China, was undertaken by the Rockefeller Institute,and Dr. Robertson was one of the initialgroup of pioneers who went to China forthis purpose in 1919. At first he was anassociate professor of medicine, and thenin 1923 he became full professor and headof the Department of Medicine at PekingUnion Medical College. This was a periodof intense clinical activity on his part, andhis interests began to turn toward theproblems associated with the infectiousdiseases and especially pneumococcal infections.Finally, in 1927, Dr. Robertson re-(Cont. on page 2) Dr. Phemister Evaluates FullTime and Group-Practice forthe Clinical Faculty of aMedical SchoolThis address was presented by Dr. Dallas B. Phemister on the occasion oj his retirement as president oj the A merican College of Surgeons on October I7 in Chicago.It was first published in the J anuary ; I950,Bulletin of the American College of Surgeons and is here reprinted with their kindpermission.In an effort to bring to you a messageworthy of this office and fitting for thechanging times in medicine, I shall attempt an evaluation of full-time appointments and group-practice for the clinicalfaculty of a medical school.Full-time group-practice has been inoperation in private clinics in this country for more than half a century and hasachieved outstanding success in a number of institutions, the oldest and largestof which is the Mayo Clinic. Modern business methods of organization and operation have been applied in the care of thesick on both large and small scales with adegree of satisfaction to both patients andmedical staffs that leaves no doubt aboutthe great efficiency of the system. All feesfor professional services are paid to. theclinics, and all expenditures, including remuneration and travel expenses of theprofessional staff, are paid by the clinics.Some of the large private clinics have atthe same time made valuable contributions in the fields of medical research andpostgraduate teaching and graduatetraining of specialists in the various fieldsof medicine. It is appropriate to emphasize here that these achievements haveusually been realized by the utilization ofthe earnings of the clinics from professional services and not from gifts orgrants from outside sources.Full-time employment of members ofthe preclinical departments of medicalschools was a development of the Nineteenth Century and came into widespreaduse first in the German universities. Ithas met with such great success in bothteaching and research that at presentnearly all preclinical medical educationthroughout the world is conducted onthat basis.In the early stages of the reformation(Cont. on page 2)2 MEDICAL ALUMNI BULLETINRobertson-(Cont. from page r )turned to the United States from Chinaand again participated in one of the pioneering accomplishments of academicmedicine when he joined the newlyformed Department of Medicine of theUniversity of Chicago. For the next tenyears he was very active in clinical andlaboratory investigations related to thepathogenesis and immunology of pneumococcal pneumonia. His studies on experimental pneumonia have become classic in their field, and they subsequentlyled him into the wider field of air-borneinfection.Beginning in the year 1939, under Dr.Robertson's leadership, efforts were directed toward elucidating the factors ofsignificance in air-borne infection and,especially, toward the evaluation of techniques for aerial disinfection. Thesestudies culminated in the discovery ofthe germicidal action of glycol vapors onair-borne pathogens, and by 1941 it wasclearly demonstrated. that triethyleneglycol vapor was a remarkably effectiveaerial disinfectant.With the onset of World War II in1941, Dr. Robertson was appointed director of the Commission on Air-borneInfections of the United States Army,and for the next five years he was extremely active in directing field and laboratory studies related to problems in thisfield. As a result of these studies, moreprecise knowledge was secured concerningthe mechanisms of air-borne infection,particularly with regard to streptococcalinfection, and valuable information wasobtained as to the efficacy of controlmeasures such as the use of glycol vaporsand the oiling of surfaces and bedclothes.During the war years, as an avocation,Dr. Robertson became interested in problems related to fish ecology, and, on completion of his service as director of theCommission of Air-borne Infections in1946, he began to devote his summermonths to experiments in this field. Thisinterest led him into further studies related to the comparative endocrinologyof salmonoid fishes, and it is his intentionto pursue these investigations in California at the Department of Biology ofStanford University.In briefly summarizing the career ofDr. Robertson, no mention has beenmade of the many younger investigatorswho received their training in experimental medicine under 'him and who contributed greatly to the success of the work.Considerations of space alone preventthis from being done. However, it must bementioned that the prominent role Dr.Robertson has constantly played in thetraining of younger men associated withhim, both in China and in the UnitedStates, will be reflected in their progressfor many years to come.Dr. Robertson has been the recipientof many honors, foremost among thembeing his election to the National Acad- Phemister-(Cont. from pa�e 1)in medical education in the United Statesthat began about forty years ago, certainuniversities started full-time appointments for a limited number of the members of the clinical departments in an endeavor to bring their work more nearly inline with that of the full-time members ofother university departments. There weretwo forms of appointments, namely, geographic full-time and strict full-time, andthe educational and resident training activities of each form were centered abouta teaching service of patients who paid nofees for professional service, Geographicful!-time was introduced first by HarvardUniversity and the Peter Bent BrighamHospital in 1913. The professor heading adepartment and some of his associateswere provided with offices in the hospitaland spent their time there and in themedical school engaged in academic workfor which salaries were paid. They werealso privileged to do private practice inthe institution and collect their own fees.The plan has since been extended to otherclinical units of the Harvard MedicalSchool, and the only limit placed on private practice is the broad statement that"private work is not to interfere with University ducies." There is no provision forany portion of the private earnings of afull-time appointee to go to the Universityor the hospital, This system, in either theoriginal form or variously modified, hasbeen adopted by other universities andtoday is perhaps the most widely usedfull-time plan, But under some of themodifications, it is possible for the appointee to spend so much time at privatepractice in the institution for his ownfinancial profit instead of at teaching andclinical investigation that the academicmotive of the plan is greatly weakened. Incertain universities there is a limit placedon the amount of income from privatepractice which may be retained by theclinical appointee, the balance, if any, going to the medical school to be used fora variety of purposes.Strict full-time was introduced first in1913 at Johns Hopkins University andshortly afterward at Washington University and Barnes Hospital, assisted in bothuniversities by grants from the GeneralEducation Board. Under that plan, theprofessor heading a clinical departmentand a few of his associates not only con-emy of Sciences in 1942. He is a memberof the American Association of Physicians, a fellow of the Society for ClinicalInvestigation, a fellow of the Society forExperimental Pathology, and a fellow ofthe Ecological Society, as well as havingmembership in many other scientific organizations. At the present time his bibliography consists of more than one hundred papers, and it is anticipated that itwill increase rapidly in the future as hecontinues his piscatorial investigations. fined their work' to the premises of tlmedical school and hospital but receiviuniversity salaries as the sole sourceremuneration aside from that derivfrom writing, outside lecturing; atawards which seldom have been substatial, Private practice was not absoluteobligatory, but if for reasons of reseanor otherwise a full-time staff membelected to care for private patients, as 1sometimes did, the professional fees wecollected and turned over to the univesity for use in a variety of ways dependi:.on the institution.The object of strict full-time was to rlieve the appointee of the necessityearning money by treating private ptients who were not used for teaching arwere estimated as being too often of littscientific interest. He would be' freeteach, direct the work of assistants, arparticipate in the care of the service ptients, with emphasis on those of eduetional and research value. He would also Iable to engage more extensively in labortory and clinical investigation than undany other system. In the course of twenyears following its introduction, strifull-time was put into effect for a limit,group of the clinical faculty of eight Ulversities-one state and seven privalFor that purpose, six of the universitireceived grants-in-aid from the GenerEducation Board. One of the eight susequently changed to geographic futime, and two changed to part-time. Duing this period, the General EducatkBoard also made grants-in-aid to tvuniversities, one private and the othstate, for the establishment of geographfull-time, and each has since retain,that status,In the past fifteen years, very few urversities have adopted the strict full-tinplan with the appointees freed from tlnecessity of earning money from privapractice. This is apparently related to icreasing costs and the fact that the Geeral Education Board has not contribuuto the establishment of full-time uniduring the period. But in rece�t yeaisome of the universities that are operatirmost successfully on that plan have epanded it, partly by making greater uof income from professional services fsupport.In nearly all universities cmployiieither form of full-time for a part of IIclinical faculty, there exists a much largpart-time clinical faculty whose appoinments vary widely according to specifields of work, amount of time devotescale of remuneration if any, and extrmural activities. Also there are Iannumbers of full-time fellows and membeof the house staff; and, when they are ieluded, the full-time personnel aproaches or exceeds that of the part-tinstaff.Despite the great success realized frogroup-practice in private clinics, it hbeen little used in the clinical deparments of medical schools. At Duke Urversity some of the members of the elirMEDICAL ALUMNI BULLETIN 3faculty receive smaller salaries thaniers who are on a strict full-time basis,t they carryon group-practice on prite patients in Duke Hospital and the.vate Diagnostic Clinic. The latter is.naged by a business organization indeident of the university. The income!s partly for operating expenses, partlya building fund in lieu of rent to theiversity, and partly for research in theticipating department. The remainder:livided among the department mem's according to the amount of workie by each individual. A somewhatiilar procedure is in operation for thegical staff of the Hospital of the Unisity of Pennsylvania.At The University of Chicago the mems of the clinical faculty are appointeda full-time group-practice basis andder services to both paying and nonling patients in both hospital and out.ient department. All fees for profesnal services are set and collected by theversity and go into a common fund toused for the best interests of the clinidepartments. The salaries of the clinifaculty are paid by the university andbased collectively but not individuallythree types of service, namely: acanic duties, professional services to paits who do pay professional fees, and,fessional services to patients who do, pay professional fees. All patients inh hospital and out-patient departIlt, except a small percentage of thevate class, are used in the educationalgram.After this survey, it is in order to sayiething of the influence which full.e and group-practice have had onching, research, patient care, graduateining of medical specialists and teach, and on medical economics as it af:s both the universities and the fulle members of clinical departments.viously this is a difficult task, apached with hesitancy, since there arenany variations of both strict and geophic full-time and the problems arenerous, some being very controversialI still unsolved.Teaching and research are the two acties in which a university is primarilyerested, and hut for them it assuredlylid never enter the field of clinicaldicine, The established facts and dislines of clinical medicine may beght equally well by part-time and fullre clinicians, provided they are equallyilified, and undergraduate educationclinical medicine is being well done inny schools without full-time members:Iinical departments. But undergradu-clinical teaching has been improvedthe full-time system because of theater attention that has been paid toching obligations. The best clinicalcher, whether part-time or full-time,.Iso an investigator, since the studentuld not only acquire a sound knowl'e of practical medicine but also be exed to the spirit of inquiry and themiques of advancing medical know 1- edge. All things considered, the researchincentive is more apt to be imparted bythe full-time clinician who is also engagedin investigation.That full-time has increased the quantity and improved the quality of basic research work of the clinical departments ofAmerican universities is a fact so welldemonstrated that it scarcely calls forfurther discussion. Many of the most important contributions to clinical medicineduring the past thirty years have beenmade by full-time clinicians. Good laboratories and budgets for research have practically always been provided as an essential condition for the establishment ofsuch appointments. Full-time, the strictmore frequently than the geographic,saves time and frees time that can be devoted to research; and both the contractual obligation as well as the desire toinvestigate assist the appointee in realizing his goal. Part-time staff membersmore frequently do good investigation ifworking in a department containing somefull-time members. But there are alsofailures at research under full-time, thefault most frequently of the man butsometimes of the system. If the head of adepartment is neither provocative norproductive, most of the members may follow in his wake, and no system will makea successful investigator out of a weak ormisfit man. But a potentially productivefull-time man may fail as a result of inadequacy of supervision or financial support.The care of patients may be as welldone on one type of appointment as another, depending on the amount of timeand attention which is devoted to them.Full-time men giving much time to otherduties including research may not andshould not necessarily be expected to doall-around routine clinical work as well asable and experienced part-time men who,in their daily professional activities, devotemuch more time to it. But the full-timemen who make the most important basiccontributions to knowledge usually restrict their clinical and research work tospecial fields. This plan makes it possiblefor them to develop a high standard ofspecialized professional service to patientsand at the same time make usc of many ofthe patients for clinical investigation.With specialization in a sufficient numberof fields and a liberal amount of overlap,it is thereby possible for the full-time staffto cover all of the work of a clinical department.The creation of medical specialists inthe various clinical fields by the residenttraining system is on the average betterdone when at least a part of the clinicalfaculty are on a full-time basis. If thereis a large ward service of patients receiving free professional care, mainly at thehands of the resident staff, the quality ofthe service is enhanced by the presence ofa full-time chief and associates for consultation, assistance, or actual renderingof professional care, such as the performance of a difficult operation. Research can more readily be made a part of the residen t training program if there are fulltime members of the attending staff whoare actively engaged in research. Also, thesurest way of making efficient clinicalteachers and investigators out of suitablecandidates who have completed the resident training is to have them continuefull-time work as junior members of thefaculty of their respective departments.The economic problems of the clinicaldepartments are among the most involvedand difficult to solve of all problems thatarise in the field of university education.It is the desire of the university, which isconcerned primarily with teaching andresearch, to have a financial policy for theclinical departments as nearly the same asthat for all other university departments,consistent with the difference betweenthe duties which the two groups arc calledon to perform. The duties of the full-timemembers of the clinical departments consist of teaching, research, and the practiceof medicine, while the duties of the fulltime members of other university departments consist of teaching and research.Although the practice of medicine isessential for clinical teaching and certaintypes of research, it is not primarily anacademic discipline but the rendering ofa human bodily service, frequently ofvital concern to the patient and an important responsibility for the doctor. It isthe execution of a legally binding agreement between doctor and patient underwhich the doctor undertakes the investigation and treatment of the disease of thepatient. The patient enters the universityhospital or out-patient department primarily not to be utilized for academicpurposes but for the purpose of havinghis health improved or restored. If mistakes are made in medical care, whetherrendered gratuitously or for pay, the doctor and not the university is held accountable regardless of the nature of hisappointment, and he may be sued forthem. And although the financial responsibility for malpractice of the strict fulltime clinician may be borne by the university, the stain of professional inefficiency or negligence is not removed fromhim thereby. It is obvious that in theseparticulars the care of patients differs extensively from the purely educational disciplines of teaching and research, andconsequently its financial implicationsmay differ extensively from those of otheruniversity departments. The universitiesclearly recognize the financial differenceand the magnitude of responsibility ofpatient care when, in dealing with payingpatients treated by full-time staff members, they usually make charges for professional services commensurate withthose made in private practice which aregreatly in excess of charges made for instruction. Under this policy the incometo the university from the paying-patientpart of the practice of a successful fulltime clinician who is also a successful(Cont. all page 5)4 MEDICAL ALUMNI BULLETIN� S_C_I_E_N__T_I_F_I_C__ S__E_C_T_I__O_N �A Pharmacological Relationship between Certain CardiacGlycosides and HistamineBy ALBERT S]OERDSMAThis article is a condensation of a dissertation which won the Borden Undergraduate Research A ward in Medicine a yearago.The idea that cardiac glycosides andhistamine might be related pharmacologically stemmed from an observation madein the course of experiments on the isolated hearts of rabbits, cats, and rats perfused with Ringer-Locke solution. It wasfound that the perfusate contained a substance which caused a drop in blood pressure when injected into an anesthetizedcat and produced a contraction of the isolated guinea pig ileum suspended in atropinized Tyrode solution. This substancewas assumed to be histamine.There were other reasons for supposingthat an investigation relating the actionsof digitalis substances and histaminewould be illuminating. The relative toxicity of histamine to various species ofanimals has been shown to be roughlyparallel to the toxicity of digitalis in thesespecies. Thus, the rat is very resistant toboth drugs, while the cat, rabbit, andguinea pig are more susceptible. It is wellknown that small amounts of histamine(1-2 J.lgm) bring about a pronounced buttransitory increase in the rate and amplitude of contraction of isolated mammalian hearts and produce a marked contraction of the isolated guinea pig ileum.Digitalis will also increase the contractility of the isolated mammalian heart, and,furthermore, its ability to cause contraction of the isolated guinea pig ileum hasbeen observed. Finally, changes in theelectrocardiogram similar to those resulting from toxic doses of digitalis have beennoted following the administration ofsmall amounts of histamine.Preliminary experiments were done onthe histamine output of isolated rat, cat,and rabbit heart preparations perfusedwith oxygenated Ringer-Locke solution.The hearts were perfused through thecoronary arteries by means of a cannulainserted into the aorta. It was discoveredthat histamine was present in the perfusion fluid and that there was species variation in the amount present. The addition of digitoxin to the perfusion fluid in aconcentration of I :40,000 produced a significant decrease in the amount of histamine present in rabbit and cat hearts butno change jn the histamine output of theisolated rat heart. The rat heart was alsomuch more resistant to the toxic effect ofdigitoxin than the rabbit and cat hearts.To clarify further the possible pharma- cological relationship between digitoxinand histamine four groups of experimentswere undertaken: (I) the blood histaminewas measured in rabbits during acutedigitoxin poisoning: (2) histamine was determined in the venous blood of cardiacpatients before and during treatment withdigitalis; (3) the effect of small amounts ofhistamine on the toxicity of digitoxin toisolated mammalian heart preparationswas investigated; and (4), in order to ascertain the type of joint toxicity producedby the two substances, acute toxicitystudies on normal guinea pigs were carried out and the LDso of histamine anddigitoxin given separately and simultaneously in various proportions was determined.1. Following the intravenous injection of I mgm/kgm of digitoxin into rabbits a significant fall in the blood histamine level was recorded in blood samplesdrawn at 10 minutes and 3o-minute intervals after injection. At the end of 40-65minutes the animals were in a moribundstate, and the terminal sample in five outof seven rabbits showed a slight increasein histamine content.2. Blood histamine levels were determined in seven cardiac patients beforedigitalization and in seven normal controls. Various cardiac diseases were included in the first group, but all were inheart failure. The normal control valuesvaried between 0.016 J.lgm/gm and 0.045J.lgm/gm. There was much more variation in blood histamine levels of the cardiac patients, two show .. ing no detectableamount of histamine, and the remainingfive varying between 0.019 and 0.081J.lgm/gm. The histamine blood level wasdetermined again in the cardiac patientsfour to six days and seven to ten daysafter starting digitalis, and in all fivecases with measurable amounts of histamine in the control period there was a significant drop in the blood level after digitalization. One of the cases with no measurable quantity of histamine in the control period showed no change after digitalization. The other showed a markedincrease.3. In the third series of experimentshistamine dihydrochloride (I: 1,000,000)potentiated the lethal effect of digitoxin(I: 40,000) on the isolated hearts of rabbits, cats, and guinea pigs. The hearts ofrats were resistant under the same conditions. Histamine dihydrochloride (I:1,000,000) exerted a diphasic action onthe coronary outflow of isolated hearts asmeasured by the volume of fluid perfused.The hearts of cats, guinea pigs, and ratsexhibited an initial coronary dilation,while a constriction was observed withrabbit hearts.4. After determining the LDso of digi- toxin and histamine alone for the guipig using the intraperitoneal route,two drugs were combined in a I : I raa 3: I ratio, and 'a I: 3 ratio. It was foithat mixtures of the drugs produce,higher mortality rate than could becounted for by a joint toxicity which'due to independent and similar actiorthe two drugs. In other words, the 1drugs combined appeared to have a syrgystic toxicity.In a final series of experiments it ,found that histamine augurnented thesponse of the isolated pig ileum to digitin. In the course of these experiment:was discovered that the ethanol usedthe digitoxin solution had an antihisminic effect in the guinea pig intestineFrom the data presented it is reas:able to conclude that the toxic effectdigitoxin on isolated cat and rabhearts leads to a decreased histamine 01pu t. It has been shown by Anrep and (workers that, when the heart fails, thistamine output diminishes. My resuwith digitoxin-poisoned hearts corrolrate this observation. It was also shovthat digitoxin exerts an effect on the rabit blood histamine similar to its effect,the perfusates of isolated rabbit hearts.Since the meaning of the blood histmine level in heart disease is unknown,is impossible to explain the variationthe initial levels of cardiac patients. Pthough, as mentioned previously, the islated heart in failure releases less histmine, one hesitates to apply this principto the total circulation. It is certain hovever that digitalization changes the levof blood histamine. In all patients exceltwo there was a lowering of blood histrmine with digitalization.In the presence of sublethal quantitieof histamine dihydrochloride rabbit, caand guinea pig isolated hearts behavesimilarly and were arrested by mucsmaller amounts of digitoxin. A joint toxicity study on guinea pigs demonstratea synergism between the two drugs, thais to say, the total reaction was greatethan could be due to a summation of thindividual reactions. This potcntiatioiwas more pronounced in isolated guine:pig hearts than in the whole animal. Thsmall amount of histamine dihydrochloride used in this work had a pronounce:effect on the coronary flow as measurerby the volume of perfusate. With the exception of the rabbit heart there was arinitial increase in volume of perfusate followed by a reversal. The rabbit heart behaved in an opposite manner. Dale ancLaidlaw found a dilating effect of histamine on the coronaries of cat hearts, although Andrus and Wilcox found thatthe coronary outflow of the guinea pigheart was decreased when histamine wasMEDICAL ALUMNI BULLETIN 5dded to the perfusion fluid. Wilcox andeegallater stated that the effect of histaline on the guinea pig heart coronaryow was dependent on the dose. This is ingreement with my findings. It might bessumed that the initial effect is due tolie small concentration of histamine inIte heart, whereas the reversal which follWS is a consequence of a gradual accumlation of histamine in the heart muscleuring the perfusion. The species differnces demonstrated rule out the possibil.y that changes in coronary flow could besponsible for the potentiation observedl isolated heart experiments.Work with the isolated guinea pigeum led to two new observations: (1)istamine greatly augments the contracon of a strip of gut under the influencef digitoxin and (2) 1 cc. of 0.6 per centthyl alcohol produces a SO per cent inibition of the gut's response to 0.2 ,ugmf histamine. There are three major posbilities which present themselves as exlanations for the first finding: (a) histaline may sensitize a receptor or enzyme(stem to the action of digitoxin, (b)·eatment of a strip of gut with digitoxinlay augment its sensitivity to histamine,nd (c) it may be a permeability pheomenon wherein histamine exerts its acon merely by increasing the penetraility of the cell for digitoxin. The firstrplanation is most likely for two reasons.ne is that the potentiation phenomenonmnot be elicited if a digitalized intestinewashed before the addition of histaline. Second, adding histamine coinciently with digitoxin does not quicken thesponse of the intestine to digitoxin. AsIr the action of ethyl alcohol as an antiistamine drug on the guinea pig ileum,) report of such an action has appearedthe vast histamine literature. FarmerI938 published the results of an invesgation concerned with the inhibitory acon of various narcotics on the histaminemtraction of the guinea pig intestine.thyl alcohol may now be added to the'oup of drugs which Farmer studied.This investigation indicates that histaine and the cardiac glycosides may haveme important pharmacologic interacIn. The results thus far do not elucidate.e mechanism of this interaction but dornonstrate that the cardiac glycosidesert an influence on histamine metaborn and that histamine alters certainological responses to digitoxin.The clinical implications of these reIts are as yet presumptive. It is reasonlie to assume that the clinician will proed with caution in carrying out a histaine test of gastric secretion on a dig ilized patient. The experimental results-tained offer a possible explanation fore high incidence of toxic manifestationsen in diphtheria patients who are treat-with digitalis for cardiac complicalOS. It may be that the diphtheria toxin�erferes with histamine metabolism ineh a way as to increase the toxicity ofgitalis administered to a patient whoseart has been damaged by the toxin. Phemister-(Cont. from page 3)teacher and investigator is often verymuch greater than that from his teaching.The most desirable plan for the clinicalfaculty of a university possessing adequate medical school and hospital facilities and desirous of carrying on clinicalteaching and research with as nearly aspossible the efficiency of the rest of theuniversity, should be some form of fulltime appointment and group-practice ofmedicine on both paying and non-payingpatients. The organization of all successful businesses, private medical clinics, andlarge engineering and law firms calls forfull-time employment of the entire personnel on a co-operative or group basis.Why should not the same organizationapply to the clinical division of a medicalschool? It would provide favorable teaching and research facilities for many moremembers of the clinical departments thanexist at the present time. However, suchappointments, in some ways, might notbe as advantageous as those enjoyed bymembers, particularly heads of departments, who serve on either a strict orgeographic full-time basis.There are universities in which the existing clinical departments could scarcelybe reorganized on this basis for a varietyof reasons, such as geographic separationof medical school and hospitals, disproportionate hospital facilities for payingand non-paying patients, an inadequatebudget for research, and failure of eitherthe university or the clinical faculty orboth to adjust to the financial and educational realities of the situation. However, in some of these institutions itshould be possible to realize much of thebenefit to be derived from the system,such as utilizing paying patients morefully in the educational program, if theprofessional services for both paying andnon-paying patients were performed bythe staff operating on a group-practicebasis but organized independently as anassociation of physicians similar to thatof some full-time group-practice privateclinics.There are other universities whichpossess the physical facilities and financial resources that would make it possible for them to operate the clinical departments on a full-time group-practicebasis. But this can only be done if theyrender professional services in both hospital and out-patient department to bothpaying and non-paying patients. A greatdeal of administration by opportunismwith unequal and unfair financial remuneration of different members of the sameclinical department could thereby beavoided. If only non-paying patients arecared for, it will be financially impossibleto operate on this basis, since sufficientfunds cannot be obtained for the purposeeither by private universities from endowments and voluntary contributionsor by state universities from tax appropriations. The only feasible way is to derive a large part of the budgets of the clinicaldepartments and of the hospital and outpatient department from fees paid by patients for professional and hospital services. That this can be accomplished hasalready been demonstrated in The University of Chicago School of Medicine.It has been accomplished mainly becauseof educational and economic adjustmentson the part of both the university and theclinical faculty to the recent economicand social changes that have taken placein the country, and to conditions resultingfrom changes in the quality of medicalcare.Within the past two or three decades,there has been a tremendous advancement in the quality of medical care including that rendered in the teaching hospitals and out-patient departments ofmedical schools. At the same time, therehas been a very appreciable elevation inthe economic standards of the masses ofthe people and also a reduction in theeconomic standards of the upper levelsof society. The quality of professionalservice in the hospital and out-patientdepartments at the various levels of accommodations has been high enough, andthe number of patients at the differenteconomic levels who are able and willingto pay for such service has been largeenough to make it possible for the university to collect money in professionalfees mainly from those of moderate andlower income levels to meet the majorpercentage of the budgetary requirement.An additional economic advantage ofutilizing a large percentage of patients ofthese economic levels is that they payfor hospital services either directly orthrough various forms of insurance. Andwith appropriate methods of assignmentand control of students and interns, ithas been possible to utilize paying patients for routine undergraduate teachingand training, and a part. of the trainingof the resident staff, with just as great adegree of success as that realized with nonpaying patients. Junior clerks are assignedto duty in the hospital and senior clerksin the out-patient department. However,it is also essential to have patients whopay no fees for professional services tomeet the necessary requirements of thedepartments for some of the teaching,for types of clinical investigation, and fora part of the training of the resident staff.The staff of each large department isdivided into groups, each group operatingan in-patient and an out-patient serviceand having laboratory facilities and timefor research. The organization varies withthe departments and divisions, but insurgery the internes and assistant residents rotate from one group to anotherand are trained under the attending staffmembers rather than under the chief resident surgeon who operates his own service similar to that of an attending man.Also during the period of resident trainingeach trainee spends at least one year atresearch.(Cont. on' page 8)6 MEDICAL ALUMNI BULLETINALUMNI NEWSDr. George M. Curtis, Rush '20, has beenselected to receive the 1950 honor award ofthe Mississippi Valley Medical Society. Thisaward is given from time to time to thosewho have made "distinguished contributionsto clinical medicine." The recipient of thelast award was Dr. Evarts A. Graham, Rush'07. The award will be presented at a banquetof the society to be held in Springfield, Illinois, in September.Dr. Curtis was a professor of surgery atThe Clinics in 1932. He is now chairman ofthe Department of Research Surgery, OhioState University; attending surgeon at University Hospital and White Cross Hospital,Columbus; chief surgeon at Franklin County Sanatorium, Columbus, and LickingCounty Sanatorium, Newark; and consultingsurgeon, Children's Hospital, Columbus.Among the many organizations in whichDr. Curtis is a Fellow are the American Association for Thoracic Surgery, the AmericanCollege of Surgeons, and the Central SurgicalAssociation, of which he was a founder. Dr.Curtis is also a member of the AmericanBoard of Surgery (Founder's Group), theAmerican Society for Clinical Investigation,and the Cen tral Society for Clinical Research.'34. Maurice R. Friend is a practicingpsychoanalyst and in charge of training inchild psychiatry at the Jewish Board ofGuardians in New York City.'36. Joan Fleming took part in the lectures arranged through the educational committee of the Illinois State Medical Society.On January 9 she addressed the Mental Hygiene Section of the Illinois Federation ofWomen's Clubs on "A Feeling of Hostility."'37. Ormand C. Julian spoke on "Portacaval and Splenorenal Anastomoses for PortalHypertension': before the Chicago SurgicalSociety on January 6.'39. Elmer W. Haertig is a clinical instructor in psychiatry at the University ofWashington School of Medicine in the Psychiatric Clinic for Children. He also has apsychiatric and psychoanalytic clinic foradults and children in Seattle.'40. Jack Kahn announces the opening ofhis new offices on Wilshire Boulevard in LosAngeles for the practice of proctology.Violet Horner Turner is on the staff ofDuke Hospital in Obstetrics and Gynecologyand is an associate in the Duke MedicalSchoo!' She was certified by the AmericanBoard of Obstetrics and Gynecology in May,1948.Edward Whiteley is now stationed atOliver General Hospital, Augusta, Georgia,doing otolaryngology in the EENT clinic. Hevisited The Clinics during the meeting of theAmerican Academy of Otolaryngology andOphthalmology in October.'41. H. Carey Coppock has been in generalpractice with two other doctors in Ellens- burg, Washington, for the last two years. Dr.and Mrs. Coppock and their three childrenlive near the heart of the hunting, fishing, andwin ter-sports area.Harry P. Maxwell has received the appointment of assistant professor of neurological surgery at the Marquette MedicalSchool, Milwaukee. One of the foundingmembers of the Neurosurgical Society ofAmerica, a new national society for youngerneurosurgeons, Dr. Maxwell was chairman ofthe program committee and toastmaster atthe meeting of that society at Quebec inNovember.Joseph Ransohoff announces the openingof his office for the practice of neurologicalsurgery at the Neurological Institute in NewYork.'42. Lyndon M. Hill was the author of arecent article on "Aureomycin in GranulomaInguinale," which appeared in the fA M A.He is on the Surgical Service of the HarlemHospital, New York City.Charles R. Mowery is completing his finalyear of qualification for his board examinations under Dr. Shuler Ginn, a board surgeon,at the Yakima Medical and Surgical Clinic,Yakima, Washington.Robert T. Stormont, formerly medical director of the Food and Drug Administration,in January accepted the secretaryship of theCouncil on Pharmacy and Chemistry of theAmerican Medical Association.'43. Michael Bonfiglio, instructor in orthopedic surgery, will leave The Clinics onApril I to become associate in orthopedicsurgery at the State University of Iowa College of Medicine, Iowa City.Arthur Connor is at the White Cross Hospital, Columbus, Ohio, an instructor in theDepartment of Research Surgery and a cabinet member of the Clinical Research Societyat Ohio State University. He received the degree of Master of Medical Science from OhioState University in I949. Dr. and Mrs. Connor have two children, Barbara, three, andArthur, two.Joseph Fleming is at the Guthrie Clinic inSayre, Pennsylvania, under the leadership ofDr. George Hammond in orthopedics. He reports that Ken Sponsel has gone to the MayoClinics. Dr. Fleming is very enthusiasticabout his work at the clinic as well as his previous work with the Occupation Army inFrankfurt, Germany.Anthony R. Furmanski is doing neuropsychiatry with the Ross Loos Medical Group,the largest prepaid medical group in the country, with over a quarter-million subscribers.Dr. Furmanski was certified in neurology bythe American Board of Psychiatry and Neurology in October.Chester B. Powell writes from Salt LakeCity that neurosurgical practice is not toobusy to prevent occasional trips to see more of the West. He sees Bill Stone and VaPond almost daily.Louis Rubin is a clinical instruct,dermatology at the University of Illinoislege of Medicine, has a private practicerecen tly passed the examinations of the Aican Board of Dermatology and SyphiloFenton Schaffner is practicing intmedicine at Woodlawn Clinic in Chicagireceived an M.S. in Pathology from Nwesi.ern University in August.'44. Bruce F. Grotts is a pediatriciathe Christie Clinic, Champaign.Bernard M. Stone is in his final yeresidency in radiology at Michael Reesepita!.C. A. Vander Laan is practicing dermogy in Chicago as an associate to Dr. Isky.'45. James Ahern is serving as ssurgeon for the Grace Lines until Jul:which time he will become a member 0Pratt Clinic Staff, connected with the'Medical School, Boston.Loren T. DeWind is an instructor ithritis at The Clinics.Ruth L. Nicholson writes that she is �struggling country doctor in Taos,Mexico.Ruth Perlsius and Jack Kahoun, '4�at the University of California HospitSan Francisco.Warren F. Wilhelm and George Krak:are at the Mayo Clinics. Dr. Wilhelm Ifellowship in medicine.'46. Gerald Barton, surgeon in chanthe U.S.P.H.S. Mid-Western Medical 0(rapid treatment center) in St. Louis,souri, visited The Clinics in early DecenHe was attending the meetings of the AIcan Academy of Dermatology and Syplogy.Richard S. Farr is working with Dr.Bruyn in the Department of Anatomywill be at The Clinics for another year ahalf.'47. Max E. Griffin is attending theversity of Pennsylvania Graduate SchoMedicine and will return as chief reside:the Akron Children's Hospital, Akron, (next July.William Lorton is at the Mesaba ClinKeewatin, Minnesota., 48. Ernest R. Jaffe is finishing his ncal internship at the Presbyterian HospitNew York City. He writes that he sees.Hogness, '46, a resident in medicine,Sanford Weissman, '49, intern in sur!f requen tly.'49. William K. Graves has just comed a year's internship at Queen's Hos:with Ralph J. Coppola. He will be leaHonolulu soon for a one-year service witlAir Force at Clark Field in the PhilipIslands.RESIDENT STAFF NEWSJames F. Brusegard, former resident inOphthalmology, and his family are in RedWing, Minnesota. Their fourth child, a boy,was born December 23.James H. Ferguson is now an instructorin the Departments of Obstetrics and Gynecology at Tulane University. He also acts as obstetric consultant for the Mississippi StateBoard of Health and the Keesler Air ForceBase and has a private practice in New Orleans. Dr. Ferguson's marriage to MarieLouise Miltenberger of New Orleans tookplace in May, 1949.Mary Jane Fowler, formerly of 2376 EastSeven ty-first Street, Chicago, has moved toMedford, Oregon, Her Chicago practice hasbeen taken over by Barbara Spiro. Joel R. Husted is an instructor in thepartment of Internal Medicine at theversity of Michigan.Royal E. Stuart and Maxwell A. Joh:'43, are both located at the Glass-NcClinic in Tulsa, Oklahoma.Lucille Watt, a former member ofanesthesia resident staff, became direct.anesthesiology at Passavant Hospital,cago, on January I, I950'MEDICAL ALUMNI BULLETIN 7FACULTY NEWSDrs. William E. Adams, Lester R. Dragstedt, H. Close Hesseltine, and Huberta Liviogstone were invited to participate in amedical celebration in Guadalajara, Mexico,January 1I-14, by the University of Guadalajara, the Guadalajara Medical Society, andthe Cancer Society. This celebration markedthe fiftieth anniversary of the GuadalajaraMedical Society. At this time Dr. Livingstonewas made an honorary member of La Sociedad de Anestesiologia de Guadalajara. OnDecember I, Dr. Livingstone discussed "Anesthesia Problems in Cardiac Surgery" beforethe medical staff of the Veterans Administration Center, Wood, Wisconsin.Dr. J. Garrott Allen will lecture on "ThePatient with Abnormal Bleeding" at the Annual Clinical Conference of the Chicago Medical Society at the Palmer House on February 28.Dr. Arthur C. Bachmeyer was chosen president-elect of the Association of AmericanMedical Colleges at its annual meeting inColorado Springs in November. He will be installed as presiden t next September.Drs. T. Howard Clarke and DwightClark discussed "Evaluation of Neck Dissection in Carcinoma of the Lip" before theChicago Surgical Society on February 3.Dr. Lowell T. Coggeshall made a flyingtrip in December to Cairo, Egypt; London,Paris, and Rome. He was sent to review research activities for the United States Officeof Defense. Dr. Coggeshall also participatedin the Forty-sixth Annual Congress on Medical Education and Licensure of the AmericanMedical Association, held at the PalmerHouse, Chicago, on February 6. He was moderatorof a panel discussion dealing with "ThePlace of the Specialties in UndergraduateMedical Education." Drs. Percival Baileyand Robert G. Bloch were among the ninespeakers in this discussion.Dr. M. Edward Davis participated inthe program of the seventh annual WattsHospital Medical and Surgical Symposium inDurham, North Carolina, February 15-16.Dr. Davis flew to Havana, Cuba, to take partn the meeting of the Cuban Society of Ob-BULLETINof the Alumni AssociationThe University of ChicagoSCHOOL OF MEDICINEVOL. 6 WINTER 1950 No.2ROBERT H. EBERT. EditorHUBERTA LIVINGSTONE, Associate EditorMembers oj til. Editorial Board,'HENRY T. RICKETTSCLAYTON C. LOOSLlLEON O. JACOBSONBARBARA EVANS ZIMMER, SecreturyPrice of yearly subscription for nonmembers, $[ .00;price of single copies, 25 cents. stetrics and Gynecology, December 16-18.His subject was "Modern Role of CesareanSection."Dr. William J. Dieckmann flew to England in January and spent the month in theBritish Isles. He gave addresses at universities and maternity hospitals in nine largecities in England, Scotland, and Ireland.Dr. Lester R. Dragstedt has been electedtreasurer of the International Surgical Society. Dr. Dragstedt addressed the ChicagoMedical Society on December 14 at the JohnB. Murphy Memorial Auditorium; his subject was "The Present Status of Vagotomyin the Treatment of Peptic Ulcer."Dr. E. S. Guzman Barron spent two weeksin December in Lima, Peru. He was both aUNESCO consultant and a representativeof the University at the International Symposium on High-Altitude Biology.Dr. Paul C. Hodges gave three talks on"X-Ray Diagnosis of Skeletal Diseases" atthe Dallas meeting of the Texas RadiologicalSociety, February 3 and 4. Following themeeting, Dr. and Mrs. Hodges began a vacation in Mexico City in order to see theirdaughter and her family. In Mexico City, onFebruary 9, Dr. Hodges spoke at the jointmeeting of the Obstetrical and Radiologicalsocieties on the subject of "Obstetrical Radiology." On his return, February 20, he will bea speaker at Baylor University, Houston,Texas, firsl addressing the staff of the Department of Obstetrics on "X-Ray Pelvimetry and Fetometry," and later the juniorand senior medical students on "Present-DayDevelopment in Radiology, Including Obstetrical Radiology."Dr. Leon O. Jacobson has been appointedspecial consultant to the United States PublicHealth Service as a member of the hematology study section of the N ational Institutes ofHealth. He plans to participate in the SixthInternational Congress of Radiology in London next July and the meetings of the International Society of Hematology in Cambridge, England, in August. He will discuss "The Therapeutic Use of Radioactive Isotopes."Dr. A. C. Krause took part in a Decembermeeting of the National Society for the Prevention of Blindness in New York. Dr.Krause is a consultant of the Committee onResearch.Drs. John Lindsay and Heinrich Kobrakflew to South America, where they had beeninvi ted to participate in the Second PanAmerican Congress of Otolaryngology whichwas held in Montevideo and Buenos Aires,January 8-15. Dr. Lindsay has been appointed a member of the Committee of Hearing ofthe National Research Council.Dr. Clayton G. Loosli appeared on aWGN-TV program December 14 in a discussion dealing with "The Common Cold,"presented under the auspices of the Educational Committee of the Illinois State Medical Society.Dr. Leonidas Marinelli, formerly assistantprofessor of radiology, College of Medicine,Cornell University, has been appointed research associate in the Division of BiologicalSciences, University of Chicago. He is also onthe staff of the Argonne National Laboratory.The January 9 program of the ChicagoLaryngological and Otological Society wascomposed entirely of speakers from the University of Chicago. Dr. Henry B. Perlmanspoke on "Some Unusual Mixed Cell Tumorsof the Nose and Throat," Dr. Harold F.Schuknecht on "Deafness Following HeadTrauma," and Dr. Jacob J. Zuidema '44, on"Inner-Ear Deafness of Sudden Onset."Dr. William E. Ricketts, Instructor, Department of Medicine, addressed the Englewood branch of the Chicago Medical Societyon "Jaundice, Differential Diagnosis," onJanuary 3.Dr. William H. Taliaferro has been awarded the Mary Kingsley Medal by the Incorporated Liverpool School of Tropical Medicine. This medal was presented in recognition of his contributions to tropical medicine.BIRTHS-1949Dr. and Mrs. Samuel Martin (Dr. Ruth C.Martin)-William. April.Dr. and Mrs. A. R. Furmanski-Martin. May31.Dr. and Mrs. Gerhart S. Schwarz-MarionJanet. July 12.Mr. and Mrs. Wallace Fischer-ElizabethWallace. August 1.Dr. and Mrs. W. K. Graves-Peter Dorsett.August 12.Dr. and Mrs. John W. Partridge-JamesGilbert. August 22.Dr. and Mrs. Carl D. Strouse-Daniel. October 8.Dr. and Mrs. Irving Rozenfeld- DavidStephen. November 12.Dr. and Mrs. William P. Fox-Paul Clyde.November 13.Dr. and Mrs. Frederick V. Hauser-TheresaAnnette. November 13.Dr. and Mrs. Bernard Schweigert-JosephDaniel. November 23.Dr. and Mrs. Daniel M. Enerson-RusselBruce. November 30.Dr. and Mrs. Rex A. Pittenger-PatriciaLouise. November 30. Drs. L. and Dorothy Ritzman-Rebecca.December 3.Dr. and Mrs. Charles H. McCroskey-Diane Elizabeth. December 6.Dr. and Mrs. Asher Finkel-Barry. December 7.Dr. and Mi·s. Richard V. McKay, Jr.-Katherine Anne. December 7.Dr. and Mrs. Graham Vance-Mary Martha.December 21.BIRTHS-1950Dr. and Mrs. Joseph M. DondanvilleMichael Pierre.Dr. and Mrs. Frank E. Hesse-David Earle.January 5.Dr. and Mrs. Edward Doezema-Margaret.January 14.Dr. and Mrs. Emmett E. Woodward-Christopher. January 17·Dr. and Mrs. Peter Vincent Moulder-PeterVincent III. January 26.MARRIAGESDr. Jack Kahn-Vera Laserson. December 4.Dr. Edward D. Robbins-Sidney Lindsey.December 31.8 MEDICAL ALUMNI BULLETINASSOCIATION ACTIVITIESPlans for a SecondQuestionnairePlans are being made to send a secondquestionnaire to members of the AlumniAssociation concerning an evaluation oftheir medical education and a summary ofpresent activities. The reasons for thisare twofold. First, the response to thefirst questionnaire was incomplete and,second, we have learned from the first alittle more about what information isneeded.The University of Chicago School ofMedicine has performed an experimentin medical education which in many waysis unique. It is fair to say that the organization of the school was based on the bestideas of what medical education shouldbe, and Dr. Phemister has traced the history of these ideas in the paper which isreprinted in this issue of the BULLETI:--I.How successful has the experimentbeen? In the final analysis the success of amedical school and the ideas which havecreated it must be based on what it produces, and a school produces three things:(I) standards for medical practice, (2) investigative work, and (3) physicians.Items 1 and 2 are important and can bemeasured with reasonable accuracy. Butthe most important product is the physician, and it is much more difficult tomeasure the success of a school in termsof the individual, for it can only be donewith his careful self-analysis.That is why we need your co-operation. The University of Chicago School ofMedicine is constantly searching for the IN THIS ISSUEDr. William Lester reviews the careerof Dr. O. H. Robertson, who is retiring.Dr. Phemister's address on the occasionof his retirement as president of theAmerican College of Surgeons is reprintedin its' entirety by the kind permission ofthe Bulletin of that organization. Dr. Albert Sjoerdsma's article on the relationbetween cardiac glycosides and histamine, which won the Borden ResearchAward in 1949, is finally reproduced.Don't forget your dues.AIMS Holds Convention HereThe Association of Internes and Medical Students' Annual National Convention was held at the Reynolds Club andMandel Hall of the University of Chicago,December 27-30, 1949. Among the speakers were Drs. Lester Dragstedt and Walter L. Palmer, who took part in a "Symposium on Gastroenterology"; Dr. HenryBrosin, who appeared in a "Symposiumon Psychiatry and the Social Order"; andDr. R. W. Gerard, who spoke on "NeuralMechanisms of Behavior, or, The HeadIs Not Hollow."best answers to the problems of medicaleducation, and your answers to the newquestionnaire, which is being prepared fordistribution this summer, will help greatly to evaluate the results of this important experiment and aid in charting thefuture of the medical school. Second Call for DuesThe initial response to the first call jdues was disappointing, and it is hopthat many of the members who disregaied the first call will send their citpromptly on receipt of the second notiYour alumni association, like every otlorganization, has expenses to meet; awith continued growth these expensescrease rather than diminish. So ppromptly and keep up the good recordthe last two years. .Inevitably some of you will receivesecond notice for dues after you wekind enough to pay the first time. Acceour .apologies in advance, and, if younot wish to waste the notice, a gift willmuch appreciated.The following statistics show the elipaid memberships in order of decreasipercentage. A similar list will be piIi shed when the dues from the seconotices are recorded.CLASS PERCENTAGE OF PAID MEMllERSHLife Annual To1"30 50% 34% 8�1933 23% 31% 5�1935 21% 33% 5�1937 38% 16% 5�1938 29% 23% 5:1934 29% 21% 5(1940 15% 35% 5c1932 33% 13% 4l1943 (Dec.) 20% 26% 4{1944 16% 30% 4l1936 29% II% 4(1942 24% 15% 3�1945 21% 17% 3f1939 13% 23% 3{1943 (Mar.) 12% 22% 3'Phemister-(Cont. from page 5)The most important advantage of fulltime group-practice for the clinical facultyis in research and the training of futureinvestigators, since more members in proportion to the number of the staff aregiven the opportunity of carrying onclinical and experimental investigationthan under any other existing system.With proper leadership and a good departmental organization, the basic contributions to knowledge of relativelysmall departments or specialized divisions may exceed those of very muchlarger institutions in which there is a lesssystematic approach to research. The accomplishments in the other educationaldisciplines have been of such a nature asto commend this type of organization forthe clinical departments of a medicalschool.The problem of working out a financialarrangement for the care of patients whopay fees for professional services that issatisfactory to both university and mem- bers of the clinical faculty is an old one,difficult of solution. The university is interested primarily in education, and prefers clinical faculty members who are primarily interested in clinical education. Ifa clinician uses university and hospitalfacilities, which are operated not for profit, to engage in private practice, and if heprofits financially far in excess of his educational and research contributions in return, he may be exploiting the universityor an affiliated hospital. On the otherhand, if the university employs a fulltime clinician on a salary to do practice,teaching, and research, all of which hemay do efficiently, and in doing so heearns during the part of his time spent atpractice on paying patients a sum markedly in excess of what he is paid in totalsalary, the university may be exploitinghim. The clinical staff should not exploitthe university nor should the universityexploit the clinical staff. If the clinicalstaff adheres to the policy that their primary goal is educational, and if the university adequately supports them finan- cially in performing the duties and shodering the responsibilities which are callfor, one of which must be the care of Itients paying fees for professional serices, there is no doubt, as indicated by (perience, that the plan will succeed. Saries may most fairly be based, collectiily but not individually, on academic cties, professional services to patients IVdo not pay professional fees, and prof,sional services to patients who do pprofessional fees. The professional hshould go into a common fund to be usfor the best interests of the clinical (partments.Under existing economic and socconditions in the United States, the mepromising way of gradually placing eccation in clinical medicine on a unifoibasis of organization and on an educaticallevel that most nearly approximates teducational level of other university (partments appears to be by the emplcment of full-time group-practice for tclinical departments of the medi.school.