SPECIALISM

The number of specialists in any town will no

^{doubt be}

determined in the long run by the laws of supply and demand, and of survival of the fittest. The number practising in Melbourne has undergone a marked increase of late, and it may be of interest to inquire into some of the conditions that have conduced to this sudden growth of specialism, and also into its attendant advantage or evils ; for the position of the specialist is one concerning which there is, apparently, some difference of opinion. The first and most natural reply to any such inquiry would probably be, that specialism is simply the outcome of natural causes, and is but a manifestation in the practice of th e

healing art of what has for long been the rule elsewhere' It is an exhibition, in short, of the great law of sub-division of labour, which prevails throughout all nature, and is especially noticeable in the evolution of organic life. Wha t holds true there also holds, so it is said, in the social and industrial -world. This, no doubt, is correct in the main, bu t to carry out the principle fully, every practitioner ought to be a specialist, and should perform a limited number of function s only—an arrangement for which we can hardly be said to be ripe yet, at least in the colonies. Admitting, however, tha _t specialism is to be accounted for as just suggested, may ther e

not be other reasons for its sudden growth ? Thus, th

e

position of a specialist is a much easier and pleasanter one, as

a rule, than that of the average general practitioner. He has regular hours, no night work, and larger individual fees.

Raving a smaller range, his knowledge of that range is more easily made thorough and exact, and so his work tends to become less anxious and more routine. The work is, Presumably, thoroughly congenial, and there is a precision and certainty about much of it which gives it a charm, l acking to the indefinite results of the often befogged Physician or general practitioner. When oculists, by correcting difficult errors of refraction, restore nearly perfect vision to previously pur-blind patients, or achieve the same result by extracting cataractous lenses ; when gynaecologists,

,13

37 removing diseased uterine appendages, or by a Irachelorrhaphy (in suitable cases), render previously Wretched and chronic invalids capable of resuming and eudnYing their ordinary position in life they must experience a peculiar satisfaction seldom felt by every-day Practitioners whose typhoids or pneumonias die or get well

W

ithout much regard to their treatment.

In these charms of specialism lie its temptations aid possible dangers. It is now not uncommon for a man deliberately to choose the career of a specialist at the very

"tset, and to study little else. Such a man is apt to be a

^,

dangerous man. No one can be a capable specialist who is not first and foremost a capable and experienced physician a nd surgeon, and the best specialists are, undoubtedly, those Who have gradually perfected themselves in the knowledge a

^,

technique of some particular branch while engaged

111

ordinary practice. To take the same instances of ophthalmology and gyn e cology, how wide and how intimate is their relation to general medicine, and how frequently does their practice demand operative interference and the

?

est delicate manipulation. Yet we see men unconcernedly

aknag up such specialties on the threshold of their medical

eareer, who openly profess ignorance of medicine, or who

have had that surgical training which can hardly be

acquired outside a general hospital, and who are, necessarily,

Pfactically unversed in the technique of the modern

Qeatment of wounds. Yet such men u talk with the

178 Australian .11ea'ical Journal. APRIL 15, 1889

utmost nonchalance of doing laparotomies, extractions, and sc on. Fortunately, the number of such in the colonies is not large, and it is, perhaps, rather a peculiarity 14 Melbourne, that a number of men practise as specialists in the city and as general practitioners in the suburbs, an d that there are very few who really confine themselves veil strictly to one specialty. Although such a custom perhaps does not find favour in the eyes of the stricter specialists , there is a good deal in its favour inasmuch as it prevents the would-be specialist getting confined in too narrow 3 routine.

The effect of specialism on the specialist himself, and as regards the advance of scientific knowledge, forms subject for debate. It depends, probably, almost entirely on th e individual, the extent of his general knowledge, and of his interest in subjects outside his specialty. A man like Jonathan Hutchinson can be surgeon, oculist, dermatologist' and even physician all in one, and a specialist in each, and can make one subject irradiate the other. Other men are mere machines, and openly profess ignorance of everything outside their own subject. It is frequently stated that all our advances in scientific knowledge are made by specialists, but it may be questioned whether they' more than others, are not apt to regard their p articular branch as very near finality, and to devote their titae and energy more to its details and to perfecting 't e technique than to advancing it as a science ; in fact, it is essentially in his superior command of detail and techniqu e that the specialist excels, and not in his appreciation of broad principles, or the discovery of general laws.

The question of the liability of specialists to abuse their position is a delicate one to handle. There is undoubtedlY' a prevalent suspicion that specialists are more apt than others to humbug their patients, and perform unnecessary operations in order to put guineas into their pockets. Ther e are black sheep in every fold, and no doubt they will creeP into that of specialism; but, in the majority of cases, tins suspicion is unjustified, and has probably arisen becaus e

specialists have greater opportunities, especially when

!onsulted directly by patients who place implicit confidence lh them. It is rather a noticeable feature in medical practice h ere, compared with older centres, that the aid of specialists, and of consultants generally is sought much more directly by t he public, and less through the intermediation of the general Practitioner, who generally has little power of choice in regard to the consultant in any case ; and this circumstance, Perhaps more than any other, renders specialism liable to abuse. On the whole, however, it must be conceded, that t he evils of specialism are few, can easily be avoided, and a re far outweighed by the advantages of a system that is natural and inevitable.

C ONJOINT MEETING

OF THE MEDICAL SOCIETY OF VICTORIA AND OF THE VICTORIAN BRANCH OF THE BRITISH MEDICAL ASSOCIATION—

ADOPTION OF THE AMENDING MEDICAL BILL.

Members of the above Societies met in the Medical Society's __

Ilan on Wednesday, April 10th. It may be remembered that

at the meeting

on November the 28th last, a resolution

was Passed

affirming the necessity of further legislation. A further

r

esolution was carried, by which the Amending Bill, published In the Australian Medical Journal for December 1888, was

r

eferred to the Committees of the two Societies for further

a

mendment. This amendment has now been completed, and the

members

of the two Societies were called upon to endorse, alter, or reject the changes made.

There was a fair attendance. Dr. Balls-Headley occupied

the Chair.

T

he

meeting

decided that the Bill should be read clause

by c

l

ause,

and this was accordingly done. Some slight changes were

(141:1e, and ultimately the Bill was adopted in its amended form.

It was

decided that the Committees of the two Societies should

b e

requested to take steps to have the Bill properly drafted, and

Pl

aced in legal form, and further, to take such steps as they might

fi

nd desirable to get the Bill introduced into Parliament.

-

A

^- vote of thanks was passed to Dr. Neild for the services he

h

,,t ad rendered the profession in bringing the Bill to its present age • The meeting

then terminated,

having lasted more than

tw

o

hours and a

half.

m 2

THE ACTION OF IODOFORIVI.

The use of iodoform is so very general that it may be of interest to summarise the results of recent observations on it s action. During the past year, evidence has been gradually accumulating to show that iodoform is not a parasiticide. There is complet e unanimity of opinion among almost all recent observers, that it hardly interferes at all with the development of the various forms of micro-organisms. It is believed by several observers to have destructive or antagonistic action on the ptomaines generated 11 micro-organisms, probably through the free iodine liberated in th e

wound. This may help to explain the favourable action of iodoform in situations where putrefaction and the formation of ptomaines is almost unavoidable, as in the mouth, rectum, 4"' It is claimed for iodoform that it is a local anaesthetic, and that it diminishes wound-secretion. The latter action is also probably due to its destructive action on ptomaines. One result of these investigations has been to try to combine with iodoform other agents that are parasitical. Dr. R. Jaksch (Pharmac. P°84

Sept. 30, 1888), finds that creolin is a good substance for this purpose, as it both sterilizes and deodorizes the iodoform—it 15 really antiseptic, and is free from any poisonous action on highe r organisms. The researches of Dr. J. Neudorfer are not quite accord with this latter statement, as he found that the intraveno us injection of creolin in dogs had a poisonous effect—a dose of 0.5 gramme to every kilo of body-weight causing death. He states,

however, that the danger of poisoning need not prevent the u se of the drug, which, as an antiseptic, is preferable to sublimat e' carbolic acid, or salicylic acid. In a concentration of 1 to 5 P er thousand, there is no fear of poisoning. It has no disagreeab le smell ; it does not blunt the feeling of the operator's hands, or the edge of his instruments. It dries up pus, and is haemostati c.

A resume of recent papers on iodoform, by Freyer, will be foun d in the

Ther. Monatshefte, June and July 1888 ; a paper by Rowing

in Fortschritte der Med., Aug. 1888 ; and one by Neisser in yirch Archiv., B 110, H 2 and 3 ; and an abstract of all in the American' Journal of Medical Sciences, October 1888 ; Neudorfer's paper 013 creolin will be found in

Med. Chir. Centrabl., No. 28, 1888 ' abstracted in Medical Recorder, Aug. 20, 1888.

180 Australian Medical Journal. APRIL 15, 089

tbietos.

The Skin Diseases of Infancy and Early Life. By C. M. CAMPBELL, M.D. Edin. London : Bailliere, Tindall and Cox, 1889.

This little volume of two hundred pages purports to be pub- 1

'sited especially for the busy practitioner, because, " while the bulk and price of the more recent standard works militates against their being thoroughly studied by those not especially interested in Dermatology, the remarks in treatises on the general practice of

m

edicine are often too bald to afford practically serviceable lhformation." The work thus confessedly belongs to a class much to be deprecated—that of books which are chiefly compilations from standard text books, and for which there is really no very (1/1171-ous demand, for the general practitioners must be few indeed who could not afford a guinea to pay for or the time to read a work, such for instance as that by Radcliffe Crocker, recently reviewed 111 the Journal, in which the skin diseases of childhood receive special attention, and which is written by a master hand. The author goes on to state that it has been his endeavour to record the most notable recent views on etiology, pathology, clinical evidences and methods of treatment, " emphasizing those 1)11137 which have commended themselves as of practical value in a somewhat extensive and extended experience." Where this experience was gained is not stated, but on page 16 reference is 1111, ade to St. John's Hospital, Leicester Square, an institution that

SS lately gained some notoriety in the London law courts, and if we are re not mistaken, Dr. Campbell was at one time a member of its staff.

The book is a fair resume of the salient points in modern

Der

matology, and has, moreover, a practical character that may probably recommend it to busy practitioners, who will be able to glean from its pages many plain and useful directions for ti

r, eattnent. Furthermore, the work possesses a certain personal element that makes it interesting to read. The author draws larargely on his personal experience, and occasionally puts forward gely some original and novel suggestions and observations. It must, however, be very reluctantly admitted, that we cannot help suspecting that the writer's experience and knowledge are not quite all that he would have us believe, and that his indebtedness t0 others is greater even than it appears. Dr. Campbell is to he

182 Australian Medical Journal. APRIL 15, 109 congratulated, however, on the manner in which his information has been assimilated and reproduced. His language is simple and clear, and his style sufficiently dogmatic. The difficulties of classification have been surmounted in

a

practical and satisfactory manner, and the following quasi pathologico-etiological division s are adopted :--I. Skin diseases initiated in utero.

II.

^Eruptive fevers.

III.

Chronic non-febrile bacterial diseases. 'IV. Diseases characterised by capillary flux in the derma. V. Diseases initiate d

by lesions of the epidermis and its involutions. VI. Neuroses..

VII.

Parasites. Lupus is placed in Class

III.,

but while Pr.

Campbell believes in its microbic origin, he does not accept Koch 's statement that the bacilli of lupus and tubercle are identical' The marked clinical differences between the two diseases appea r

to him to distinctly indicate a difference of origin. The treatment recommended for lupus is one introduced by th e author, and consists in punching out the nodules in the early stage of the disease, and dressing with perchloride of mercury an d lanolin. The only objection to this is, that one seldom sees cases where nodules that could be punched out are present . In all his treatment the author is essentially modern, an d manifests a strong predilection for new drugs and methods -- lanolin, ichthyol, resorcin, iodol, ol. pini pumilio, naphthol, an d menthol are frequently referred to with praise, as are severe' quasi-patent preparations, as olei sanitas, vinolea cream' cimolite, &c.

The explanation given of the pathology of eczema and its relation to erythema is worth recording. Our author suppos es that the epidermis of persons subject to eczema is inherently wea k and prone to disintegrate. Under stimuli from without or from within hyperaemia occurs, causing increased pressure in th e intercellular lymph spaces of the epidermis, a pressure whic h

a

normal epidermis is able to withstand, with the result of wha t is called erythema. When not normal, the cohesion of th e epithelium is overpowered, it breaks down, its superficial layer I s thrown off, exudation occurs, and then the condition called eczema is established.

On the 1st inst., Dr. Taafe, of Rochester, was shot by a man recently ill ^his employ, who had been accused of misappropriating moneys which passed through his hands. The patient is now rapidly recovering.

ffiospitat ntelligente.

MELBOURNE HOSPITAL.

At the meeting of the Committee held on the 19th ult., a report the received from the medical superintendent, stating that since

e

Previous meeting of the Committee, 45 cases had been refused

ad

mission for want of beds. Mr. Derbin Willder urged the

Pre

ssing necessity for increased accommodation. The Committee ,

Were providing for 26 additional beds, but no fewer than 45 cases h

ad

been refused admission. The Government should undertake scheme for the erection of a large metropolitan hospital. It was

rt

„, disgrace to the City of Melbourne that such a report as they ,s4 just heard should have to be read. Mr. B. Rappiport thought

t

he Committee should bring the matter before the Government,

and

suggested that a letter be sent to the Treasurer. The airman, however, considered that such action would be inadvis-

a

ble and the matter then dropped.

At the meeting of the Committee held on the 2nd inst., it was

r

eported by Dr. Lewellin, that the Council of the Melbourne

U

niversity had appointed Dr. Moore, one of the assistant surgeons lecturer the hospital, to act as locum tenens for Professor Allen, the

1

,cture r on pathology, and the demonstrator of morbid anatomy,

d

uring the absence of that gentleman from Melbourne. Dr.

L

ewellin pointed out that Dr. Moore, if he accepted the appoint-

ale

at) would have to perform post-mortem examinations, and

con

sequently, might convey contagion from the dead-house to the arc's of the Institution, if he were allowed to fill the dual positions of Pathologist and assistant surgeon. The action of the University

"thorities was strongly condemned by the Committee, and they

w

ere charged with having transgressed the rules of common sense as well as violated an agreement come to with the Committee

so

me time ago, by which it was stipulated that before any gentleman was appointed as pathologist, his name should be

su

bmitted to the Committee for its approval. It was decided to inform Dr. Moore that if he undertook the position of lecturer on Pathology, and demonstrator of morbid anatomy, he must that discontinue visiting the wards of the Institution, and

at

his appointment could not be recognised until the concurrence of the Committee in it had been sought by the Council of the

U

niversity and obtained.

184 Australian edical Journal. _APRIL 15, 1 889 The pressing need of additional hospital accommodation for the sick poor, was again brought under the notice of the Committe e at its meeting on the 2nd inst., when the Committee previously appointed to consider the matter, submitted a report on the subject , which was adopted. It stated that it was the duty of the citizens and of the country to provide sufficient hospital accommodation for the sick poor of the community, and that it was not considered to be part of the duties of the Committee of that Institution to provide such accommodation beyond that allowed by the building s' and money placed at its disposal. The report added that whil e the Committee might suggest means whereby relief from the present state of affairs might be obtained, it was the duty of the citizens and of the Government to give effect to those suggestions. I t

was suggested by the Committee that the Government should provide suitable hospital accommodation for chronic and con' valescent cases, either at the site of the present Benevolent Asylum or elsewhere, as this would permit many of the beds at th e

Melbourne Hospital to be devoted to legitimate cases, such es accidents, cir,c. The medical superintendent reported that during the last fortnight, 58 deserving cases had to be refused admittanc e

for want of sufficient accommodation. It was decided before again appealing to the Government, to endeavour to rouse public opinion on the matter, and with that object in view, a Committe e was appointed to arrange for holding a large public meeting in th e Town Hall on an early date. A preliminary meeting of gentlemen interested in providing increased hospital accommodation for the sick poor of the coin' munity, was held on Thursday, April 11, at the Town Hall, nuclei' the presidency of the Rev. Dr. Bevan. It was explained that the Melbourne, Alfred, and Homoeopathic Hospitals were greatly overcrowded, and many deserving cases had to be daily turned away for want of sufficient accommodation. It was proposed to hold a large public meeting at the Town Hall on the 29th inst .' for the purpose of enabling the citizens to express an opinion as to how the funds should be obtained for providing tha t accommodation, and whether the money should be spent in th e erection of a large hospital, or in building several small olio in the various suburbs. Resolutions were passed to the effect that the meeting was convinced of the necessity which existed fo r providing additional hospital accommodation for Melbourne an d its suburbs, and appointing a working committee to draft motions

In document Australian Medical Journal - Digitised Collections (Page 32-42)