No. 4551.

NOVEMBER 19, 1910.

An AddressON

THE PROSPECT BEFORE THE MEDICALSTUDENT OF TO-DAY.

Delivered before the Medical Students’ Association of the BelfastUniversity at the Opening of the Session

on Nov. 15th, 1910,

BY JAMES ALEXANDER LINDSAY.M.D. R.U.I., F.R.C.P. LOND.,

PROFESSOR OF MEDICINE IN THE UNIVERSITY.

GENTLEMEN,—Two problems confront the medical student:How to pass his examinations and how to obtain a footholdin professional life. The former is for the moment the more

pressing; the latter is likely in the long run to prove themore serious. Of medical education I do not propose to

speak to-night. It is at present in a state of flux, passingthrough a stage of evolution which will probably havesalutary results. We are beginning to realise that too muchhas been attempted in the past, and that some limitation andconcentration of the field of study must be effected. Wecannot in the course of a five years’ curriculum make evenof the most promising medical student a good physicist, agood chemist, a good botanist, a good zoologist, a goodanatomist, a good physiologist, a good pharmacologist, agood pathologist, and a good clinician. The thing is

impossible, even if Harveys, Sydenhams, Hunters, Pagets,and Listers were as common as they are, unhappily, rare.

What is now becoming clear-and one wonders that there wasever any doubt upon the subject-is that the preliminarysubjects of the medical curriculum must be shorn of much oftbeir detail, must be taught with a due regard to the ulti-mate destiny of the student, which in 19 cases out of 20, ata moderate estimate, is to become a practitioner of medicine.Further, medical education must steadily keep in view itstwo indispensable objects-viz., to enable the medicalstudent to acquire a secure grasp of the essentials of his art,both on its theoretical and its practical side, and to give himsufficient practice in scientific method-in other words, anadequate intellectual discipline and training.ALTERNATIVES OPEN TO THE YOUNG MEDICAL GRADUATE.But it is or your after-career that I wish to speak to-night,

of the life-work for which you are now, with more or lessindustry and earnestness, preparing yourselves. When youreceive your diplomas from the Chancellor you will feel atemporary glow of satisfaction-very natural and humanand proper. But the glow will not last long. A greatnovelist once wrote a novel with the title What will He dowith It ?" That is the question which you will be presentlyasking about your piece of parchment. Is it to be a magickey to unlock the doors of fame and fortune, or only a ticketto a back-seat in the gallery of an inferior play-house ? Timewill tell. Much depends upon circumstance and opportunity,but more depends upon the holder of the parchment. Speakinggenerally, five alternatives lie before the young medicalgraduate : 1. He may become a resident medical officer in ahospital. 2. He may become an assistant in a laboratory. 3.He may enter one of the public services. 4. He may becomea ship’s surgeon. 5. He may become an assistant in generalpractice.

I have not time to contrast these careers in any detail, butwill content myself with a remark or two. If you can, iffinancial and other circumstances permit, select an openingwhich will enable you to continue your education. However

great your diligence, however thorough your training, you willon graduation be conscious of many gaps in your knowledge,many limitations in your experience. Take time, if you can,for further observation and reflection-whether it be in a

hospital or a laboratory, or, better still, in both. Let yourknowledge settle and clarify, or, to vary the figure, let itferment and bring forth new forms and fresh combinations.There is no time in life when the mind is more receptive thanduring the two or three years following graduation, whenreleased from the burden and torment of examinations andfascinated by the expanding vistas of his art, the youngmedical man tastes one of the purest joys of existence.

If the services should early claim you, there will lie before

you a career with many attractions, and never more desirablethan to-day, but with some definite and not inconsiderablelimitations, with which you should acquaint yourselves beforemaking your choice. If you should become a ship-surgeon-and the desire of seizing the only opportunity of seeing theworld which may ever arise is natural, and even laudable-I have one or two cautions to suggest to you. Take two orthree voyages, and no more ; and then return to terra firma.The experience gained on shipboard is rarely of much value ;.the financial gains are in most cases scanty; the habits.formed are not the best preparation for future professionallife. In some ships in which I have been a passenger thedoctor’s duties seemed to be almost confined to taking whatone of them described to me as a "smell round " the steeragequarters in the morning, and arranging dances and theatricalsfor the young ladies in the evening. Unless the ship doctoris of quite unusual stiffness of moral fibre, he is apt to sleeptoo much, to smoke too much, to take too many whiskies-and-sodas, and to devote more attention to current fictionthan to Osler or Taylor or Rose and Carless.An assistancy in general practice may be either desirable

in itself and lead on rapidly to a partnership and a secureposition, or it may prove laborious, unprofitable, and dis--appointing. Some time ago I encountered on one of thecross-Channel steamers a graduate of this school who hadsettled in the East-end of London. He complained of thehardships of his lot. I remarked, "Well, at any rate youhave got your foot on the first rung of the ladder." " Yes,"he replied, ’’ and it is a 1Jery dirty rzcng." No doubt the lowerrungs of the professional ladder often leave a good deal to bedesired in point of cleanliness, as well as in other regards,but perhaps a little hardship at the commencement of one’scareer is not an unmixed evil. ’0 ,7 Otl-pEÌs aVepW7rO’; 0&7rtl-lOEÚETtl-l, says the stern Greek proverb-if one may stillquote Greek in these degenerate days-which may be roughlytranslated, " We are all the better for an occasional’

application of the rod." Where things are too easy-and nature too kind, where the savage lies in the sunand lets the bread-fruit drop into his mouth, nothing-much is achieved in the domain of character. A visitorto Barbados once saw a negro enjoying his ease and thusaddressed him : I I How do you manage to pass the time,Sambo ? " " I just lie in the sun, massa, and let the time-

pass me," was the reply. That is not a good model for themedical profession, which its worst enemies have never calledan easy life. The rough and the smooth come in most lives,and it is well when the rough comes early, before theheart is too faint and the brain too tired to bear it.The young medical graduate may at the outset of his

career be undecided what department of practice will

ultimately claim his attention-whether general practice orone of the special branches-and hence, he may be in doubt.how to shape his course. Here, I think I may suggest twoguiding principles. If there be a decided taste for,and early selection of, some special branch-e.g., publichealth or ophthalmic surgery-it is probably wise thatthe young graduate should soon bend his energies to hisfuture life-work. In the absence of such special tasteor early choice the best course is for him to cultivatehimself as widely as possible, to enlarge the field ofhis experience in many directions, to make his pro-fessional armour as complete as he can. Specialism is thegreat feature of modern practice. It is the necessarycorollary of advancing knowledge and the growing com-plexity of our art, and it is idle to impugn it. But we allknow the dangers of a too narrow specialism. I have heardof a throat specialist, consulted for a pharyngitis, who gavesome excellent advice as to the management of the throat,but overlooked the fact that the patient was in the earlystage of typhoid fever. Cultivate yourselves as variously asyou can, and do not be in too great a hurry to terminate yourperiod of preparation, your medical novitiate. Tout vientn point qui sait attendre," says the wise French proverb,which we very inaccurately translate, I Everything comes tohim who waits," thus turning one of the truest of proverbsinto one of the most false. Everything does not come to himwho waits-far from it. But everything, or nearly every-thing, does come to him who knows how to wait, to him whospends the waiting time well.

’

FINANCIAL REWARDS.

Let us now look at the career which awaits you in thefuture-the career of medical practice-in some of its

x

1464 PROF. LINDSAY: PROSPECT BEFORE MEDICAL STUDENT OF TO-DAY.

general aspects. Is medicine, as some assert, an over

crowded, arduous, and ill-paid profession, with little certauleisure, heavy responsibilities, and a relatively poor prospecof attaining length of days ? Or is this view undulpessimistic ? And first, as to the question of overcrowdingIt can hardly be denied that during the last three or fou]decades there has been in most civilised countries an UndUErush to medicine, that the supply has exceeded the demand.This rush has been even more marked in France, Germany,Italy, and America than amongst ourselves, and it has beer

contemporaneous with a notable dearth of candidates for thEChurch-a very significant circumstance. It is highlyprobable that if some of those whom I address had lived ageneration earlier, instead of handling the scalpel, or the

stethoscope, and attending to the sick, you would have beenengaged in expounding theology, baptising infants, and

joining happy couples in holy matrimony. Whether thisinvolves your loss or gain is a question which I shall notattempt to determine. But I do not think that overcrowdingof the medical profession is an urgent question in Ireland.Belfast, with a population of about 380,000, has 247 medicalmen on its register, of whom about 230 are in practice,which works out at about one medical man to 1650people, and this is a proportion which is supposed toafford a reasonable prospect of a livelihood to themedical practitioner. Cork, with a population of 76,000,has 93 medical men on its register; Limerick, with apopulation of 38, 000, has 35 medical men ; and Londonderry,with a population of a little over 40,000, has 34 medicalmen. If we allow for those recently qualified and not yetin practice, for those engaged in special branches, such as

lunacy or public health, and for retired veterans, these figures,though ample, are not excessive. The case of Dublin, with twoUniversities and two other qualifying bodies, is exceptional.In England the ratio varies greatly, as might be expected.For example, Sheffield has a ratio almost the same as that ofBelfast, while Brighton has no less than one medical man to600 people-a very high rate, but accounted for by more orless obvious reasons.But granting that, speaking generally, the medical pro-

fession is somewhat overcrowded, are not other professionsin a like case ? The congestion at the Bar has long beennotorious. Of those called to the Bar it might be truthfullysaid, Many are called but few are chosen." A well-known

judge said recently to a friend of mine that there were

10,000 barristers in England, and only work for 500.I cannot guarantee the accuracy of these figures, but myauthority is good. Or take the scholastic profession. Inthe Times of Oct. 7th, 1910. there were some interestingfigures regarding the overcrowding in this profession. Of4836 students who left college in July, 1909, prepared forscholastic work, it was found that in the following October38 per cent. had not secured permanent work as certificatedteachers, while 31 per cent. had secured no work at all.Now, how many of the graduates of this school are unplaced

Ithree months after graduation ? Comparatively few, I think,except those who are lying out, waiting for some appoint-ment. The large majority find billets of some kind in a fewweeks or months. I grant that the billets are not alwayslined with swan’s down, that the work is often hard, and thepay rarely munificent. But billets of some kind are foundwith surprising rapidity. The young recruits of our pro-fession, whatever be their hardships, do not at any rate jointhe ranks of the unemployed. They do not frequent soup-kitchens, or go on deputations to the Home Secretary, or cryout for a ’’ living wage."

Is medicine an arduous, a hard profession ? Certainly itis. That is one of its glories. You will have" to endurehardness," many of you at least, and it will be good for you.If you are not prepared to have, occasionally at least, a roughtime of it, to rise often at the unwelcome tinkle of the night-bell, to leave the dinner-table sometimes before you havefinished your second cigarette, to resign the joys of the linkson occasion because the telephone summons you elsewhere,to encounter fatigue cheerfully and to face danger with alight heart, turn back before it is too late, for you havemistaken your vocation.

Is medicine an ill-paid profession ? That is a questiondifficult to answer. No doubt we all wish that it were betterpaid. "I should like to possess riches," said the poetShelley, " because I think I could use them well." That is

what we all think. Now I do not believe that finance is a

strong point of our profession. No profession does so muchfor nothing or is so often defrauded of its just dues. Our

legal brethren understand these things better. When youcompare a bill of law costs-magnificent in amplitude, richin detail-with the modest reminder which the practitionerof medicine sends to his patients at Christmas-time, you willrecognise that law has at least one point of superiority overmedicine. Further, there are no great financial prizes in ourprofession. If any of you have the ambition to becomemillionaires you have not started on the right path. Youhad better give up medicine and turn your attention torubber, or petroleum, or whisky. That some branches of our

profession are systematically sweated by the public canhardly be denied ; witness the Irish Poor-law service, wherein some cases I am credibly informed that the salary barelycovers the doctor’s car-hire. Those who expect good serviceon those terms are expecting too much from human nature.Again, medicine has no comfortable sinecures, no snug postswith light work and good pay, where virtue may enjoy itsease and suffer no hardship.But there is something to be said on the other side. The

financial rewards of medicine, if seldom brilliant, are oftensubstantial, and they are fairly secure. If the standard ofremuneration is in many cases too low, the fault is largelywith ourselves. With ourselves, too, might rest the remedy,but a too careful regard for the amount and the security ofour financial rewards is, upon the whole, opposed to thetraditions of the medical profession. Ruskin says that thedoctor likes his fee well enough, but that he would rather losehis fee and save his patient than gain his fee and losehis patient. I hope this is true, and that it always will betrue.

OPPORTUNITIES TO EXTEND KNOWLEDGE.Let us turn to some wider considerations. Medicine offers

you, gentlemen, a work which is in touch with the realityof things, which is in contact with nature at first hand. Lawis man-made. Theology is trammelled by tradition. Medi.cine looks, or should look, at the facts of nature as theyare. She can afford to lift the Veil of Isis "-that thickweb of fiction which man has woven round nature," asHuxley says. You will be first and essentially practitionersof an art-the art of healing; but it may be the high privregeof some of you to extend the frontiers of knowledge, tosound a little more deeply the unplumbed sea of mystery, bywhich we are surrounded. Research is an essential functionof modern medicine, and, rightly understood, it is worthy ofevery encouragement. The difficulty is to find your true

researcher, the man who will not only seek butfind. When

you have got him, he is a very important person indeed, butthere are a good many imitation articles in the market. You

may be destined to extend knowledge, and as Bacon saysfinely, I I We see that voluptuous men turn friars andambitious princes turn melancholy, but of knowledge thereis no satiety. " The physician should also be a naturalist, andwhile man is his special field of observation, he must includein his purview everything which has a direct relationto man on his physical side, and that takes him far.Think of the revelation of the methods of nature, of hermysterious workings, which has come with the developmentof the comparatively new science of bacteriology. Our" invisible friends and foes " have become potent realities tous, and we are gradually learning how to avail ourselves oftheir assistance or how to guard ourselves against theirattack. Think of the light thrown on the problems of mindby the stupendous advance in our knowledge of the anatomyand physiology of the brain. A great metaphysician of abygone generation-the greatest of his time-once wrote apaper on the thesis that a knowledge of the structure of thebrain could throw no light on the phenomena of mind. Wesmile now at such a contention. The tables are completelyturned, and the metaphysician and the psychologist look tothe physiologist and the physician for light and leading. Itis hardly presumptuous to say that any true theory of humannature must come from the side of medicine. Two of themost eminent of modern philosophers-Wundt and WilliamJames-owe much to having laid the foundations of theirspeculations in the study of our art. Practise your art,then-this first and chiefly-but advance knowledge if youcan. It is probable that important facts, unrecognised, liearound us, if we had eyes to see. I once heard a

great preacher drawing a vivid picture of the miseriesof human life, and he described a man dying on a mountain

1465PROF. LINDSAY: PROSPECT BEFORE MEDICAL STUDENT OF TO-DAY.

"with, perhaps, the plant which might have healed him t

growing by his side "-a moving picture, rhetorical, but in fessence true and with many applications. We fail to see ) 5

many things because "there is a veil upon our eyes." " See i

that you open your eyes as widely as may be, that there benot upon them the veil of prejudice or superstition, of sloth Ior carelessness. 1Medicine offers you, further, a field which is ever extend- 8

ing its borders, ever touching life at more points. In the (

infancy of our art its attention was confined to the healing 1or alleviation of wounds and diseases. The famous leech in ithe Iliad," Machaon, knew a good deal about plasters and :I

ointments, purges and febrifuges, but he did not know how <

to prevent suppuration or ward off ague. He would have (

thought it most unreasonable to require such knowledge 1from him. It was at a much later date, in quite modern 1

times, that the prevention of disease, now justly regarded as (more important than its cure, became one of the essentialtasks of our art. And how vast is the field of preven- I

tion, how far in this matter does practice lag behind know- ’ledge ? It is not too much to say that if all the knowledgewhich science now puts into our hands were fully utilised,if there were no financial or economic difficulties, nearly allinfective diseases-that grievous brood of Furies which has Ipursued poor humanity from the dawn of history until now-would be banished or reduced to insignificant proportions inthe course of a single generation. Then, in even more recenttimes, the promotion of health-the science of hygiene oreugenics-has become organised, and just now there is

slowly rising above the horizon the fourth, and final, task ofthe art of medicine-namely, a care for the purity of thespecies, a thought for the interests of the unborn, a deter-mination that, as far as may be, the stern word of theHebrew Scripture shall no longer apply, that " the sins of thefathers shall not be visited upon the children." To heal

disease, to prevent disease, to promote health, to see thatthe fountain of human life is not polluted at its source-these are your tasks, gentlemen. They are worthy of Y01h;see that you are worthy of them.

MEDICINE AND SOCIAL EVOLUTION.

Medicine, again, may be fairly described as a professionwhich is growing in public esteem, and more and moreapproving itself to an age of which the ideals are largelyutilitarian. The great discoveries of Pasteur and Lister,of Koch and Behring have profoundly impressed the

imagination of the world. It has been recognised thatin some important fields the veil was truly being removedfrom nature. Turning to another field, the spectacle of aregenerated Cuba. a Panama Canal with a moderate death-rate, a West Africa partially rescued from the scourge ofmalaria-all the fruit of applied medical science-has seemedto herald the dawn of a new era for humanity, when manmight hope for a final victory over infective disease.And the success-still partial, but none the less ultimatelyassured-of the Anti-tuberculosis Movement amongst our-selves tells the same tale. In many fields medicine is Isteadily extending its scope. Only the other day England,following in sadly-belated fashion the example of con-

tinental nations, admitted the doctor to inspect her schoolsand scholars. He is not yet admitted to a similar duty andprivilege in Ireland, but this cannot be long delayed. Whenthat day comes, as come soon it must, and the doctor entersthe primary schools of Ireland as an official with authority,he will find a fair field for his energies, and if his languageshould be a little warm, let us hope that the Recording Angelwill be lenient, due account being taken of the nature of theprovocation. Our profession is still much under-representedin Parliament, and we have still to wait for a Ministryof Public Health. If we had a solid phalanx of medicalmen in the House of Commons who would cry out for atten-tion to the health of the people with the same energy as otherscry out for Dreadnoughts and Territorials, it would be betterfor the nation. We spend .670,000,000 a year on defence-on men, ships, guns, and powder--and how much on anorganised attempt to stem the tide of disease and improve thenational physique? A mere song by comparison. Themachinery for destroying life is much more elaborate andmuch more costly than that directed to its preservation andimprovement. Why ? The only answer which I can suggestis that we are still barbarians, with a thin veneer of civilisa-tion ; still heathens, with just a slight tincture of Christianity.

Man is a fighting animal-especially the Irish man-and thefighting instinct has its uses and is not without its noble side.Yet it is probably destined ultimately to disappear, but notin our day.

Medicine is probably destined to take an ever-increasingpart in the work of social evolution. The great task whichlies before the twentieth century is the organisation of

society upon a scientific basis. We have got to rid ourselvesof the dead hand of a past which we have outgrown. Wehave got to open our eyes to the light which is now streamingin upon us from so many quarters, to avail ourselves of everyfresh insight gained into the powers of nature, to make

opinion and practice really accordant with fact and

experience. In this great work medicine must take a

prominent part. Problems such as those of infant mortality,the increase of insanity, the falling birth-rate, the hygieueof trades and occupations, physical education and eugenics,and many kindred questions lying at the very root of socialefficiency, cannot be settled, cannot, let us rather say, evenbegin to be understood, without the intervention of medicalscience. The medical man is, no doubt, primarily a healer-that is his indispensable function ; but he must also be aneducator, a pioneer of progress, a social reformer, a leader ofopinion. He possesses knowledge which is useful, not only inthe sick room and the hospital ward, but in the school, thefactory, the farm, the senate. He must spread the light." There is no darkness but ignorance," says our great poet,and Schopenhauer speaks shrewdly when he says, 11 all

ignorance is dangerous and most errors must be dearly paid.And good luck must he have that carries unchastised an errorin his head unto his death."

THE QUALITIES OF THE MEDICAL PRACTITIONER.Once more, medicine offers you a career which includes a

certain ethical training and discipline. What do theseinclude, and are they altogether on the right side ? Well, Ido not claim for our profession that it produces any excep-tional proportion of saints or heroes. It does produce some- Dr. McClure does not stand alone ; but let that pass. Ishould rather claim that as medicine sees things as they are-man and nature unveiled-as the medical man is intouch, close touch, with realities, he should be first andforemost a man of common sense, level-headed and discern-

ing, sympathetic but not sentimental, helpful but self-

respecting, and he should be specially on his guard againstvagaries of thought, opinion, and practice. The history ofi our art, which is far too little studied, affords many warningsagainst the follies of medical practice, the fleeting fancies ofthe hour. The popular folly of the hour just now is that. soured milk is a panacea for most of the ills that flesh is heir: to, and that if we can only introduce a sufficient number ofl the Bacillus bt&Ucirc;gar&ugrave;J1ls into our large intestine all will bei well. And leaders of our profession and eminent scientific, luminaries lend their sanctitn to rubbish of this kind. Weshall see how long this ad will endure. Probably it will- have a brief day, but when it has " mingled with the infinite3azure of the past " there will still remain the fact that butter-, milk does possess some useful nutrient properties.- But it is often hinted that our work tends to make uss callous to suffering. Now, by an absolutely invariable law1 of human nature the frequent repetition of any impressions weakens its intensity. Even the twentieth cigarette is not

s quite so sweet as the first or the second. The spectacle of, disease and death is our daily portion. We come to regarde them with comparative calmness. It could not be otherwise,,1 and to quarrel with this fact is merely to tilt against humane nature. Yet I think we may claim without presumption thatd the medical man’s sympathy, so long as there is anything toy be done, is rarely wanting. His instinct is to act rather than,1 to talk, and perhaps he is not always sufficiently mindful ofL- the fact that there are occasions in life when kind wordss mean a great deal. But medicine is essentially a sympa-:r thetic profession. The Bar can never shake off the taint of-contentiousness. The priest is always to some extent a mann apart. But the doctor is a man amongst men, whose businesse it is to help them, who stands by them in the hour of theirLe extremity, who places whatever knowledge or skill he mayd possess at their disposal, and who is often sorry that he cannotd domore. "Weshouldneitherweepnorlaughathumanbeings,"st says Spinoza, "but endeavour to comprehend them." I thinki- our profession fulfils that ideal at least as well as any otherr. profession. A very eminent living physician once said to me

1466 MR. D. C. L. FITZWILLIAMS : HEREDITARY CRANIO-CLEIDO-DYSOSTOSIS.

that the most important quality for a practitioner of medi-cine was-what do you think ?-skill ? wisdom ? courage ?resource (! -No; but hopefitlness. Christian Science has

played, and is playing, such vagaries before high heaven asmight well make the angels weep, but it has done us oneservice-it has emphasised the importance of the mentalfactor in the treatment of disease, of the weight to beattached to the expectation of cure and the determination toget well. Hope is, indeed, the sheet-anchor of poorhumanity in the dark hour of sickness and suffering, as inother dark hours. There are times in most lives when if itwere not for hope-hope that the clouds will some daybreak, that the dark night will be succeeded by some bright-ness of dawn-where should we be ? Therefore when youenter the sick-room beware of the clouded brow or themournful voice. You must for the moment at least dismiss

your own troubles if you wish to relieve the troubles ofothers. You must have " a heart at leisure from itself " ifyou would cheer other sad hearts. Hence, as a pro-fession, doctors are cheerful men by a sort of necessityof the case, an inherited professional habit of mind, for

which, perhaps, we deserve little credit. The "weepingphilosopher " may have his uses in the world, but let him notattempt to practise physic.

STATE MEDICAL SERVICE.One last topic I suggest to you, but it is too vast to be

dealt with adequately at the close of an address. A proposalhas recently been put forward for the nationalisation of the Imedical profession---i.e., the reorganisation of the medicalprofession as a department of the Civil Service. If thiswere effected, doctors would become servants of the State,they would be subject to the supervision, direction, and con-trol of the State, and private practice would cease. Medicalmen would be distributed according to the circumstances ofthe case and the needs of the locality ; overlapping and com-petition would come to an end, work would be more evenlydistributed, remuneration would be more equally awarded,sweating of the profession would be abolished. It is anattractive programme, but the practical difficulties in the

way of its realisation are enormous. I must just hint at one.The value of a medical opinion varies from something lessthan zero to any figure you like to name. How will theState adjust the corresponding fee ! 1 Yet the suggestionis one worth thinking over. It must be remembered thatthere is at present a strong disposition to extend the area ofState action, and that this tendency is sure to grow. It is

impossible to say with any approach to certainty what, inthe future, the State may or may not do, what functions it

may or may not undertake to discharge. An organised State,medical service is not an impossibility. Amongst its advan-tages would be the adoption of the One-portal Method ofentry into the profession-on the lines of the Staats Examen ofGermany&mdash;a reform towards which medical opinion in thiscountry is steadily tending.

In conclusion, let us not lend too attentive an ear to thoseCassandras who would assure you that in selecting themedical profession you are choosing a hard and thanklesslot. You will not have an easy life, but it will be an interest-ing one. You will make many friends, and you will meetwith some gratitude-perhaps as much as you will deserve.The patient whom you cure, and the patient who gets wellwhen you happen to be in attendance-the two things arenot quite synonymous-will probably let the world knowabout it. Few of you will achieve wealth, but all of

you will, I hope, have bread-and-butter, and occa-

sionally cheese. You will be members of a great brother-hood, in which there is much fraternal feeling andnot more jealousy than might fairly be expected under thecircumstances. Your work will tend to keep you in touchwith the progress of science and all the wonders which areyet to be. Some of you may even live to pay your dailyrounds by aeroplane or dirigible, without too much risk to

your neck. You will probably witness an ever-increasingvictory of man over disease, the gradual lightening of thedark shadows cast by malaria and plague, tuberculosis, andtyphoid fever. You may watch the gradual evolution of atrue sanitary conscience in the nation, a conscience whichwill banish those plague spots in our civilisation-the slum,the fever-den, the sweater’s workshop, the insanitary school-house, the foul dairy. You may, if you use well your oppor-tunities, "see life steadily and see it whole." Few men

have a better "conning tower " than ourselves. And ther,

when you are nearing what Kipling calls "the end of thepassage," you will probably feel that your work has not beenwholly in vain, that the world is a little, even if only a verylittle, the better and the sweeter because you have lived in it

HEREDITARY CRANIO - CLEIDO -

DYSOSTOSIS,WITH A REVIEW OF ALL THE PUBLISHED CASES OF THIS

DISEASE : THEORIES OF THE DEVELOPMENT OF THE

CLAVICLE SUGGESTED BY THIS CONDITION.

BY DUNCAN C. L. FITZWILLIAMS, CH.M. EDIN.,F.R.C.S. ENG. & EDIN.,

SURGEON IN CHARGE OF OUT-PATIENTS, ST. MARY’S HOSPITAL.

CONGENITAL defects of the clavicle occur and are usuallyassociated with imperfect ossification of the cranial bones.This disease is undoubtedly rare, but its effects are so strikingas to lead observers to place on record any instances whichoccur. So long ago as 1766 Morand noticed a typical example,but it was not till 1903 that Marie and Sainton accuratelydescribed the main features of this condition under the nameof hereditary cranio-cleido-dysostosis. In 1905 Villaret andFrancoz tabulated 45 cases, and reported an instance in whicha mother and her three children were all affected. Twoexamples have come under my own observation, and I havebeen able to collect 58 others. A tabulated analysis of these60 cases is appended to this paper. The records were oftenimperfect, but in all the identity of the condition is, I think,indisputable.The first of my cases was a girl, aged 8 years, whose

father, mother, brothers, and sisters were all free fromdeformity. Her right clavicle was in two portions, thedivision occurring at the junction of the middle and outerthirds. The sternal end was tilted upwards at its outer ex-tremity, so as to over-ride the inner end of the acromialportion and form such a prominence in the neck as to inducethe parents to seek treatment for the child. The acromialportion, owing to the weight of the limb, drooped and swungforwards and inwards, as in the ordinary fracture of theclavicle; its inner end lay under the sternal fragment andpointed upwards, backwards, and inwards, so that the rightshoulder was lower, further forwards, and nearer the middleline than the left. An asymmetrical appearance was thus givento the upper part of the trunk when seen from in front, whileposteriorly the vertebral border of the scapula on the affectedside was more prominent than that of its fellow. The two

portions of the clavicle were united by a ligament whichbecame more evident on attempting to separate them. The

point of the right shoulder could be forcibly adducted towardsthe sternum through a considerable distance, the point ofdisunion acting as the hinge. The prominence in the neckalready referred to was not altogether due to the over-ridingand tilting of the one fragment by the other, but was alsoaccounted for by the fact that their adjacent ends werethickened in a very characteristic manner, contrastingmarkedly with the thin peg-shaped extremities seen in un-united fractures. There were no cranial, facial, dental, orother structural defects discovered. The arm movementswere unimpaired. There was no history of trauma in infancy,nor had any pain or inconvenience ever been associated withthe deformity. The lump had first been noticed when about5 or 6 years, and was thought to have gradually become moreprominent.

I have no hesitation in asserting that the condition in thischild was a developmental defect. As regards the degree ofdeformity and position of the fragments, this case was typicalof a class in which only one clavicle is affected. The positionof the fragments may vary, so that the acromial overlies thesternal portion (Hultkrantz), or end-to-end fixation may befound (Carpenter).The second case was that of a male child, aged three

months, who died from marasmus. It had the large skulland shrunken-looking face so frequently mentioned in thereports of these cases. The ossification of the skull cap wasextremely defective, the bones thin and translucent, thesutures widely open, and the fontanelles abnormally large, sothat fully one-half of the vault was still in a membranouscondition. In the shoulder girdle the scapulas were wellformed, but the clavicle on each side was represented by a