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where an adenomatous goitre is present. The smallnodule still present in the region of the right lower polein case 2 makes this a possibility to be borne in mind.

SUMMARY

Two cases of cretinism are described.In both a soft-tissue swelling was present in the neck.

In case 1 this was not palpable but was demonstrated inlateral X-ray films of the region and was associated withpressure symptoms. In case 2 the mass was easilyidentified as due to thyroid enlargement.

In both cases symptoms of cretinism and signs andsymptoms due to the mass regressed rapidly on admini-stration of thyroid.

I am indebted to Mr. D. C. Corry, surgeon to the RadcliffeInfirmary, Oxford, who referred case 2. Dr. F. H. Kemp,radiologist to the hospital, kindly supplied the X-ray’photo-graphs and reports, and Miss Grace Rawlings investigatedthe mental development of the two children.

REFERENCES

Astwood, E. B., Sullivan, J., Bissell, A., Tyslowitz, R. (1943)Endocrinology, 32, 222.

Bartels, E. C. (1945) Surg. Clin. N. Amer. 25, 672.Eaton, J. C. (1945) Lancet, i, 171.Hughes, A. M. (1944) Endocrinology, 34, 69.McCarrison, R. (1917) The Thyroid Gland in Health and Disease.

London ; p. 122.Rienhoff, W. F. jun. (1940) Arch. Surg. 41, 487.

Medical Societies

ROYAL SOCIETY OF MEDICINE

SpecialisationA MEETING of the section of medicine on March 22,

with Sir ADOLPHE ABRAHAMS, the president, in thechair, was devoted to a discussion on the Value andAbuse of Specialisation.. Sir ROBERT YOUNG suggested that the chief factorspromoting specialisation had been : (1) the developmentof instrumental methods ; (2) the ample gifts of scienceapplied to medicine, as witnessed in physiology, patho-logy, biochemistry, and biophysics ; and (3) publicdemand, often fostered by the lay press, for specialknowledge and skill. Among the possible misuses ofspecialisation was a direct approach by the patient tothe specialist. In this respect the law managed itsaffairs better, for here the specialist must be approachedthrough a solicitor. Sir Robert looked now to the healthcentre to supply the patient with everything he needed ;and control of investigations and treatment should remainwith the general practitioner.

" I fear," he continued, " that we are witnessing thepassing of the general physician." The student wastaught by specialists, who were also enthusiasts ; butthe methods of the older physicians should not be castaside, for a full routine examination might make clearwhat form of specialist attention was needed. He was

-

convinced that training by the general physician pro-duced the best type of general practitioner ; and hehoped that when the pendulum of change had completedits present swing, some future Minister of Health wouldask medical schools to revive teaching of the old type,whereby the student’s eye would be fixed, not on thework of a special department, but on the make-up of thepatient. The practitioner was nowadays involved ina vortex of paper ; he must be freed from this to havethe unharried and unhurried care of his patients.Finally, patients must be protected from the myopicoutlook of the ultra-specialist.

Mr. A. DICKSON WRIGHT forecast the appearance ofa great rash of specialists, with at least temporaryeclipse of the general science of medicine and surgery.Already, he said, the general practitioner had rather losthis position in public esteem. Yet the specialist systemshould be integrated with a good general-practitionersystem. In the U.S.A., where development of the

specialist system had gone further than in Britain,tne practitioner was obscured ; and now patients drifcedfrom one specialist to another like a ship without arudder.

To the patient there were particular dangers today,when specialists were no longer well grounded in generalmedicine and surgery. People would no longer submitto an overhaul by a person they had learned to despise-the practitioner. Nevertheless the practitioner mightstill play a vital rôle, as the following case showed:A Service patient had a carbuncle on the face, which healed.

Subsequently a pleural effusion developed, and he was

admitted to a thoracic unit where detailed investigations ofthe respiratory system were made, all with negative results.Operation was contemplated, but the patient’s practitionermanaged to extract him from the unit, and sent him to ageneral surgeon who drained a perinephric abscess.

Mr. Dickson Wright went on to say that the pros-pective specialist could not afford, after qualifying,to dally wi_h general medicine or surgery ; for thus hewould fall behind in the race for appointments, and ifhe persisted in this dalliance he would be consideredsecond-rate by his colleagues and by the public. Inthe teaching hospitals the narrow specialist often thoughthis own work too advanced for undergraduate students;and thus, though he might be an excellent teacher, hisservices were lost to the student, who was taught by thefew remaining general physicians and surgeons. -Aboutspecialists there was a certain exclusiveness : the generalphysicians and surgeons were being rather left behindin prestige, although they carried the real burden.Fortunately, however, there were already signs .of amovement towards melting back a number of specialtiesinto the general sphere.As to abuses, the specialist xnight become bored

by the monotony, and worried by the narrowness, of hisfield. Then he might-as some indeed were alreadydoing-expand into adjacent territory. For example,one day the thoracic surgeon might find that a number ofinteresting things passed through his cavity; thesetissues, like the Polish corridor, were not now his con-cern, but if he made them so he would be led into anumber of other fields. Secondly, Mr. Dickson Wrightdeplored the tendency of specialties to become narrower,and he particularly decried specialisation by diseases.He also had a word for the ultra-specialist, who engagedin over-elaborate examinations, often wrapped up in

ritual ; of-gastroseopes he said, " I hope I’ll never see

one pointed a,t me."Specialisation was having a bad effect on the public

and on students ; and general practice was commandingfewer and fewer good men. He believed, however,that many of the evils would be overcome if recruitmentto the specialties were deferred, to allow of groundingin general medicine and surgery.

Sir HENRY COHEN pointed out with regard to researchthat the narrower the field the deeper it was possible todig. As to undergraduate training, the teaching hospitalssometimes contained a great deal of unsuitable material;the student might spend several months in a surgicalward without seeing an instance of some of the com-moner disorders such as hernia and whitlow. Theteacher of undergraduates should aim at inculcatinga philosophy of medicine ; one teacher should demon-strate how the principles of medicine can be translatedin terms of clinical medicine, wherever in the bodydisease manifests itself.Every patient who was ill should consult a general

practitioner, who ought to have a general training.Sir Henry Cohen argued that the practitioner shouldhave at his disposal the assistance of specialists-such as radiologists and clinical pathologists-whocould give him any diagnostic or therapeutic help thathe required. But when there remained difficulties in

diagnosis or treatment he should also be able to referpatients to a consultant. The consultant, whatever hisspecial interests, must be primarily an experienced generalphysician. He in turn might refer the patient to one ormore specialists, and his job was to synthesise theinformation thus obtained. Whereas from some specialiststhe practitioner sometimes got the unsatisfactory replythat " there is nothing wrong in my department," theconsultant should be able to express a positive opinion.One danger of specialisation was that the specialist

so often discovered, and insisted on treating, disordersin his own department unrelated to the patient’s com-

569

plaint. Sir Henry quoted as examples of such disordersfocal sepsis, gastroptosis, displacements of the uterus,and chronic cholecystitis. Moreover, specialists mightbecome so technically competent in a certain procedurethat they took a pride in the performance of it, withoutquestioning the need. Then again, man was more thanthe sum of his parts ; no one system could be isolatedfrom another. Certain specialties were justified-forinstance, surgery and some of its branches, where crafts-manship improved with practice. Specialisation was alsojustified where the conception of the whole patient wasretained-as in paediatrics and geriatrics. But specialisa-tion on the basis of a diagnostic or therapeutic machinewas never justifiable. Students, he concluded, shouldbe trained in the general concepts of medicine as anindispensable basis for any later specialty.In the course of the discussion, Dr. MAURICE DAVIDSON

urged that, as in the last century, the student shouldreceive at the university a more general education.

For some years he had felt that the responsibility forpresent deficiencies lay at the top. In the last twenty-fiveyears the medical committees of the great teachingschools had tended to make appointments on the score ofprominence in a narrow field. The question " what hashe done ? "—meaning what research-had replaced thequestion " will he be a good servant of the hospital ?"-meaning would he be able to observe and deal withthe whole of the sick man. Dr. Davidson hoped that theRoyal Colleges and the senior members of teachinghospitals would exert their influence to obtain for thestudent a broader education.The PRESIDENT observed that the remedy for some of the

defects exposed in the discussion lay in proper recognitionof the general physician and the general practitioner.Certainly it was for the general practitioner to decidewhen, and from whom, specialist advice should beobtained. Present evils had many roots, one of whichwas the examination system.

Reviews of Books

Bacterial and Virus Diseases

Antisera, Toxoids, Vaccines, and Tuberculins in P1’ophy-,

laxis and Treatment. H. J. PARISH, M.D., clinical researchdirector, Wellcome Foundation: Edinburgh : e E. & S.Livingstone. 1948. Pp. 168. 7s. 6d.

KNOWLEDGE of immunological principles and theproper application of that knowledge is often foundwanting among practitioners of medicine, perhaps becausethis branch of pathology is badly caught or difficult tocomprehend. In this small volume, both student andpractitioner-and it is for them that the book is primarilywritten-will find the theory and practice of immunologyset out in simple language and with just enough detailto guide the doctor when seeking advice on how andwhen to protect a child against measles, diphtheria, or avariety of other bacterial and virus infections. Althoughtoday serotherapy has been largely replaced by chemo-therapy, chapters are devoted to the use of antitoxinsand antibacterial sera for both prophylaxis and treatmentof the appropriate infections. There is advice abouttuberculin-testing and the use of B.c.G. vaccine, a timelydiscussion of the techniques and readings of anti-smallpoxvaccination, which nowadays will more often fall to thelot of the private practitioner, and simple instructionsabout the use and sterilisation of syringes (but the

appropriate size of needle for different injections is notmentioned). No doubt the teacher and public-healthworker would have welcomed a fuller discussion on thepros and cons of the more debatable practices, but abook of this small compass is obviously meant to be avade-mecum for the practitioner rather than a referencebook for the expert. As such it will meet a real need,particularly if the general practitioner plays his part inpreventive as well as in curative medicine.

Cytologie sanguine, normale et pathologiqueM. BESSIS, directeur du laboratoire de recherches du

- Centre National de Transfusion Sanguine. Paris : Masson-1948. Pp. 298. Fr. 1500.

THIS interesting product of the French school ofhsematology is well worth looking at. Most of the contentswill be familiar to any English reader, and the techniquesand nomenclature now used in France are evidently verysimilar to those used here. The 19 colour plates are welldone in a somewhat diagrammatic manner that showsa clearer picture of nuclei and cytoplasmic detail, andpurer, more contrasted colours, then one actually seesdown the microscope. There are many photomicrographs,

, some of which are first-class.The interesting parts of this book are the sections that are

- unfamiliar. Bessis does not limit himself to blood and bone-marrow ; many of the cells he pictures are obtained fromlymph-gland puncture-a technique he uses extensively. Itis material from lymph-glands that enables him to illustratethe appearance in smear preparations of histioblasts, histio-cytes,

’’

mastocytes," and the " eosinocytes " that are promi-nent in Hodgkin’s disease. A striking series of 4 colour platesillustrate the evolution of Sternberg-Reed giant-cells fromreticular macrophages.

Bessis diverges notably from Anglo-American practice inhis description of the most primitive forms. He distinguishesa

" haemohistioblast " resembling a reticulum cell that givesrise to : (1) a hsemocytoblast from which derive all blood cellsexcept the monocyte, and (2) a histioblast from which allfree tissue cells and blood monocytes derive. Plasma cells

develop from the histioblast. Like many Continental writers,he describes paramyeloblasts and a paramyeloblastic leuk.aemia ; he goes further and distinguishes parahsemocytoblastsand paramonoblasts-and here it is difficult to follow him.Qlassification of the red-cell series is on familiar lines ; hebelieves in " intermediate " forms between normoblasts andmegaloblasts, but he admits that " certains Anglo-Saxons "are not convinced about this.

Despite the very detailed morphology, Bessis does notlose sight of the general picture, and in a typicallyFrench passage he puts succinctly a principle that manyhave emphasised : " comme toujours en cytologiemorphologique, c’est le contexte qui compte." In anequally French manner, the literature is almost entirelyconfined to the French. The book is printed on excellentpaper, but wretchedly bound in paper covers.

Religion and PsychotherapyA. GRAHAM IKIN, M.A., M.so., Ps.F., national president,British Federation of Psychologists, 1948-49. Birming-ham : Rylee. 1948. Pp. 112. 5s. 6d.

Tms is an age of specialism in which one kind ofexpert is prone to dismiss the ideas of another kindof expert as fantasy. The author of this book is wellequipped for her attempt to further a rapprochementbetween psychotherapy and religion. She wants themedical profession and the clergy to act as allies and notas enemies, and she believes this will happen only whenpsychologists recognise that religion is an integral partof human experience and when the clergy are able tospeak in the name of religion rather than of particularsects or denominations. Both professions at presentsuffer from holding limited views. " The medical manwho limits insight and knowledge to his own professionfalls into the same mistake he so condemns in theclergyman’s attitude towards some denominationalchurch. Exclusiveness is the expression of narrowness,not of wisdom."

The Hormones

Physiology, Chemistry and Applicatiotis. Vol. 1. Editors :GREGORY PINCUS, KENNETH V. THIJI;IA.J.’<N. New York :

. Academic Press. 1948. Pp. 886.$13.50.

Tms is the first of two volumes in which an effort willbe made to give " a comprehensive presentation, at theresearch level," of all our knowledge of hormones. Thelist of contributors is a guarantee that the treatmentwill be authoritative and thorough.About a quarter of this volume is devoted to plant hormones,

and hormones in insects and crustaceans : the chapter oninsect hormones contains a short’ but fascinating discussionof the gene hormones," a subject where chemistry andgenetics meet. The remainder is concerned with mammalianhormones ; the material dealt with is largely a matter ofconvenience rather than principle " and perhaps a more

rational division might have been worth attempting. The