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in compiexlby there will be an iucreaaed hauiilty to break-down on the part of nervous and mental machinery. The

responsibility of the medical man was therefore a grave andgrowing one in relation to mental defect; "he must be ableto understand men, matters, and things," and be ready togive opinions based upon an intimate acquaintance with

biological laws and the principles of heredity. The study ofsociology he considered to be as necessary to the study ofmental diseases as that of physiology is to the pathologist."One of the chief reasons," he said, "why the medicalstudent and practitioner should be familiar with these

ancillary studies is that mental defect is best and most

successfully treated in its early stages, and its recognition inthis stage becomes therefore of superlative importance. Theearlier that cases of mental disorder come under treatmentthe higher is the percentage of recovery, and the chances ofrecovery diminish progressively and considerably as the timebefore commencing treatment increases in duration. Thesuccessful treatment of all nervous and mental disordersmeans attacking them in the incipient stages ; the stages ofinsomnia, of distracted attention, of sleeplessness, of reverie,or of capricious appetite. Gross mental decadence is asso-ciated with great neuronal changes, and analogy supportsthe belief that functional disturbances are attended by slightneuronal changes. It is therefore within the limits of possi-bility that these may be initiated by mental causes, and ascells are composed of granules of chemical substances whichare not themselves alive, but whose activity determinesthe direction and arrangement of life processes, so themedical man, by a timely suggestion or by duly consideredadvice, may cause a change to occur in the working units ofthe cortical cells, thus arresting disease and openingthe storehouses of accumulated energy, diverting their forcesalong normal channels....... I have shown how importants the study of brain functions and how these concern thebiologist, the chemist, the physiologist, and pathologist,and I have enumerated the sciences which assist in theelucidation of mental disorders. To enable the student tograsp this difficult study, it is generally agreed that thedifferent forms of insanity should be described in a

systematic course and each lecture alternated with clinicalpictures, illustrative of the theoretical course. The studentshould be encouraged to come into actual contact with casesby filling up and signing certificates and making himselffamiliar with the different forms for receiving and detainingcases of insanity whilst under treatment; cases such as thosewhich come up for re-certification, and;recent admissions, andhe should also be permitted to watch the treatment, medicaland moral, of actual cases. The course should be inter-

rupted by microscopic and gross pathological demonstrationsof diseased findings of the brain and other organs, and these ’contrasted with the normal state."

Dr. Jones concluded a serious and practical address byoutlining what is being done in the different divisions of theUnited Kingdom for the prevention and treatment of mentaldisease. In Scotland he said that psychiatry has been morewidely recognised than in any other part of the three

kingdoms; in Ireland the teaching was mainly clinical;while in England lectureships were attached to the variousmedical schools and attendance at these and in the asylumsis compulsory. But he pointed out that there is no specialrecognition of mental disease as a subject worthy of a

diploma by the examining bodies.

THE WEST LONDON POST-GRADUATE COLLEGE.

INTRODUCTORY ADDRESS ON "SPECIALISM IN MEDICINE," DELIVERED BY DONALD W. C. HOOD, M.D. CANTAB.,

F.R.C.P. LOND., CONSULTING PHYSICIAN TO THEWEST LONDON HOSPITAL.

Dr. HOOD, after expressing on behalf of everyone presenttheir deep regret at the death of Mr. C. B. Keetley, pro-ceeded to point out in incontrovertible terms the necessitywhich nowadays exists for post-graduate teaching, alludingat the same time to the fact that not only the taught but theteachers obtained the greatest possible benefit from suchcourses of demonstrations as were given in the wards of theWest London Hospital." We often," he said, have with us those who come from

all quarters of the globe, and they bring information andexperience of those various tropical diseases with which wephysicians are but poorly acquainted. Personally I shall

always owe a debt of gratitude to many who have oein mycompanions in my visits to the hospital, and who have sooften aided my investigations by bringing their special know-ledge to our mutual benefit. Abroad in various climes thepractitioner is in daily touch with affections of the blood, liver,or spleen but rarely met with here, and thus in many instancesof abnormal symptoms or irregular course of disease we may,by a comparative study, obtain a better insight into thedisease process, and possibly we may be able to bridge overthe gap or supply that missing link which has been wanting,and which may enable us to make a correct diagnosis, other-wise impossible. The far-reaching effect of malaria condi-tions with its often perplexing sequels may be of dailyoccurrence in the life of many a graduate, and may permit hismaking a certain diagnosis which to those less experienced isbut a guess.", At this point Dr. Hood quoted Huxley’s apprehension lestscience should be crushed by the weight of the gifts whichshe demanded from nature. There was a time, said Huxley,when men of science would aspire to the possession of anall-round acquaintance with natural history, but nowadaysspecialism is the leading characteristic of science and is

becoming more and more embarrassing. What Huxley said20 years ago of natural science as a whole Dr. Hood foundto hold true now of medicine. " once of the most remarkablechanges," he said, " which has taken place in medicine bothwith regard to its scientific and practical side has been theenormous increase in specialisation. It is worthy of a

moment’s thought and reflection as to whether this is all’real gold,’ and whether the extreme specialisation ofmatters connected with pure medicine, as it is called, is ofbenefit to the common weal. Extreme specialisation inmedicine is a growth of about the last 25 years, andattention may be said to have been called to the fact atthat time in an article by the late Morell Mackenziewhich will be found in the ortnig7ttly Review for 1885.......There can be no doubt that some of our principal centres ofmedical education were slow in recognising the importanceof providing their students with the means and opportunityfor acquiring special information and dexterity in the use ofspecial instruments for research and inquiry. It is onlycommon sense that with the enormous increase in knowledgeof both surgery and medicine the ordinary practitioner,whether he be surgeon, physician, or engaged in generalmedicine, cannot be armed at all points. Specialism pro-perly regulated is a necessary corollary to increased, andrapidly increasing, knowledge of every branch of pro-fessional life. We all recognise the obvious truth, andour hospitals one and all maintain the principle in

forming those special departments which add so vastlyto their general utility, and which, as I have

already remarked, you will do wisely in following thepractice and technique. But there is a materialdifference in connexion with the special department of ahospital with its carefully-selected professors, and that ofspecialism as considered by a large proportion of the public.In hospital the special department is fed, maintained byskilled-if I may use the word-purveyors. There would be,I am afraid, a sad miscarriage of good if the selection ofappropriate cases were left entirely in the hands of a hospitalporter. Those of us who have had charge of wards

appreciate to the full the advantages which result fromour being able at any moment of day or night to call uponone of our colleagues who may have made special study ofany case in which the complicated, unusual, anomaloussymptoms are difficult of interpretation-cases in whichsome special symptom or congeries of symptoms lead us towish for more detailed knowledge than we ourselves possess.The same holds good in our private work, and we are allgrateful for those who frequently place at our disposal thatspecial, peculiar knowledge which may enable us to sub-stantiate our diagnosis, throw more light on the conflictingtestimony of physical signs and symptoms,, and so lead us toa more successful treatment of the sufferer we are called uponto advise. The seed of specialism is rich and good, and ifonly sown on appropriate soil must bear fruit a hundred-fold,and a bounteous harvest will follow in due course if onlyspecialism be regulated by those who, by reason of theirknowledge, are able to appreciate its advantages andlimitations. "

Dr. Hood proceeded to demonstrate that the abuses ofspecialism came from the misunderstanding of the public of

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the limitations of medicine and their apparent desire to betreated by the charlatan rather than by the physician. Heridiculed in vigorous language certain popular crazes in

therapeutics, and quoted the late Sir William Gull as onewho never felt himself sufficiently well informed in general Imedical knowledge to become a specialist. The public, saidDr. Hood, took a very different view from Gull, considering I

that it is essential to their proper treatment that a limitedand often prejudiced view should be taken of their symptoms,in proof of which he gave a typical sketch of the behaviourof a patient with Bright’s disease who flies from neurologistto dermatologist, from dermatologist to ophthalmologist, Iand so on, frequently failing to consult the man

who has made diseases of the kidneys his particularstudy. He closed his interesting address by - saying :" Ill-regulated specialism, then, must always lead to the

danger of routine treatment, and no better example could becited than that of the treatment of disease of the heart. Iknow no organ which has been so unkindly dealt with.Whatever the character or form of disease, whether valve,mnscle, fibrous tissue, as in pericardium, or nerve, or func-tional weakness, whether suffering from toxic conditions asseen with tobacco or influenza, whether showing signs ofweakened, failing circulation as in angina, one and all theyhave been subjected to the same’routine course. Why, I ask,do our heart cases do so well in hospital ? Mainly from thefact that in treatment we use common-sense principles, look-ing upon rest in bed as being our sheet-anchor in a vast pro-portion of cases, and we do not send our patients to Nauheim.I Has not rest been tried ? ’ said one of our most distinguishedphysicians to a patient suffering from mitral disease, who hadbeen subjected to every special form of treatment minus theone most essential and necessary. The more deeply we probeinto the recesses of the human economy the wider our know-

ledge and scope of medicine, the more we shall be impressedby the fact that a healthy specialism can only be grafted onto some one or other form of the parent stock, that beingclinical medicine. Specialism of a narrow order must

invariably lead to faulty diagnosis and therefore faulty treat-ment. It does much to promote that evil we all so muchdeplore, the growth and vigour of all sorts and kinds of

unqualified irregular practice. We may not at the momenthave a Cagliostro in our midst, but there are hundreds whorun that eclectic practitioner, that profound student of humancredulity, very close." "

THE WEST LONDON MEDICO-CHIRURGICALSOCIETY.

PRESIDENTIAL ADDRESS ON " SPECIALISTS AND SPECIALISM,"DELIVERED AT THE COMMENCEMENT OF THE SESSION

BY PHINEAS S. ABRAHAM, M.D. DUB., F.R.C.S. IREL.,DERMATOLOGIST TO THE WEST LONDON HOSPITAL,

AND LECTURER ON DISEASES OF THE SKIN

TO THE POST-GRADUATE COLLEGE.

[Dr. ABRAHAM, after expressing his high appreciation ofthe great honour which his election as President of the societyhad conferred upon him, said that not many years agospecialists and specialisms in the medical profession were notheld in very high esteem in this country. Continuing, hesaid ]

I think I am not far wrong in saying that until some 40years ago most hospital surgeons considered themselvescompetent to perform any and every operation upon any andevery organ of the body, and that every physician thoughthimself able to treat any and every possible disease. Butscience has advanced so rapidly in the last few decades thatin these days he would indeed be a bold man who pretendedto be an expert in every department of medicine andsurgery, or tried to pose as a universal specialist. The

growth of genuine specialism has been gradual, and it is stillgoing on. Many a man who would deprecate being calleda "specialist" is really one, or at any rate is beingforced virtually to become one. In the course of his workhis attention may be directed to some particular class ofdisease or operation. He learns all there is to be learntabout it, and perhaps adds something to the existingknowledge. He widens his experience with similar cases,and by degrees gets the reputation of being an authority onthat particular subject. As is only natural, the generalpublic will go to the man who has, or is supposed to have,the largest experience of the particular affection from which

they suffer, and his brother practitioners also will seek hisassistance and advice in cases upon which he has become an

authority. Sooner or later he may find himself doing littleor nothing outside of that special area, and he has indeed’developed into a veritable "specialist," whether he likes tobe called one or not. Most of the great specialists have thusbeen gradually evolved. Legitimate specialists, however,are not only made in that way ; some go in for special workmalice prepense-from natural inclination or from some otherparticular reason. But the wiser men of this class-in this

country, at all events-do not "rush in" without agood general foundation or unless after long special study.In my opinion, the best equipped specialists in dermatologyas well as in every other special department are those whohave not only acquired a sound practical knowledge ofgeneral pathology and of the other subjects of the student’scurriculum, but have also gained before attempting to

specialise at least a few years’ experience in the generalpractice of the profession. A man may afterwards work inthe special department of his own or some other hospital.and I would advise him to attend the clinics of as manyteachers of the branch he has chosen as he can, both in thiscountry and abroad.

[Dr. Abraham then pointed out the harm that wasdone to "specialism" by the medical man, who with noparticular special study and with no extensive expert-ence of a subject suddenly decided to become a specialist.It was men of this class, he said, who were more proneto lend themselves to vulgar advertisement and to ignorethe ethics of the profession in other directions. Hecontinued :-] ]

It has been recently said that in the near future there willbe nothing but specialists, hospital physicians and surgeons,and medical men in the Government services; in otherwords, that there will be no place for the general practitioneras we know him to-day. I believe that such a stateof affairs is not likely to come to pass, for it wouldnot only be detrimental to the profession in general buta serious loss to the public at large. The family doctor-the medical "guide, philosopher, and friend" of thehousehold-will always be, I maintain, an important and,indeed, indispensable element in the medical world. Withthe more thorough education that is now at his disposal, andwith his daily advancing knowledge, his patients will be lesslikely to leave him and independently seek the advice of theconsultant and specialist, as some no doubt do at present.It is his function to advise in and treat all cases that he reallyunderstands and can adequately deal with ; but I venture tothink that in the long run he is well advised in obtainingassistance from experienced experts in cases which he is notsure of, or which are beyond his knowledge. It is true that

many of the general public still imagine that if the "doctor "does not know everything in medicine and surgery, andhonestly professes his ignorance, he cannot be a good doctor,or "clever," as they call it; but the laity are graduallybecoming more enlightened in these matters, and are now moreable to appreciate them in their true proportion than theycould a few years ago. I know that some practitioners avoidconsultations as far as they can, because after a consulta-tion they occasionally lose their patient and see him nomore ; and it is possible that certain consultants andspecialists have little hesitation in quietly appropriating suchpatients and regarding them as their own for the future. Iam sure, however, that an honourable consultant or specialistdoes not knowingly act in that manner, and that if a patientwho has been brought or sent to him by a brother practi-tioner comes again independently he informs the practitionerand tries to send the patient back. If this rule is occasionallybroken by reputable men it can only be by inadvertence orForgetfulness. The friction which may thus sometimes occurbetween general practitioners and consultants would, I ammre, be lessened, or be, indeed, non-existent, if only weicted generously-in fact, as gentlemen-and remembered;he old adage, " Live and let live."In a recent correspondence which has appeared on this

subject it has been suggested that no specialist or consultantshould ever see a patient unless accompanied, or sent, by ageneral practitioner, and that no general practitioner shouldiave anything to do with a specialist or consultant who seespatients independently. I am afraid that this idea must be

’egarded as a " counsel of perfection" and not practicable.Me must not forget that there is still a certain amount of

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