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h: The last seventy-five years have been roughly divided into three periods of about twenty-five years each accordbling to the predominant line of research underlying the practice of clinical medicine; the third quarter of the 19th century was pre-eminently that of morbid danatomy or the changes produced by disease, and of an intensive study of the physical signs produced by these changes which in more recent days have been spoken of as the end-results. The last quarter of the century was remarkable for the study of the causes of disease, as a result of the rise of bacteriology; and during this century special attention has been paid to the disturbance of the normal functions of the body. Pathology in its widest sense, or the study of morbid conditions, is largely based on physiology or the study of normal function, and the British school of physiology has long been pre-eminent. The first evidence of disease is disturbance of function, and it is only when this has existed for some time that changes in structure or morbid anatomy follow. The early symptoms of disease, or the disordered functions of organs of the body, can be well elucidated, as the late Sir James Mackenzie insisted, by clinical observation; but, and this he freely admitted, there are many laboratory methods which can be utilised to assist in the discovery of what is wrong, such as chemical analysis of the blood, for example, in diabetes and kidney disease, and the investigation of the changes in the metabolic rate, namely, how fast the body is undergoing changes analogous to those of the consumption of coal by an engine. The chemical changes in the blood and fluids of the body, long ago foreshadowed in the humoral theories of the past, are advantageously utilised in medical practice, and the newly named science of biochemistry is busy explaining the mysteries of health, disease, growth, and the influence of vitamins. The activity in this direction is most encouraging; for example, in the biochemical laboratory at Cambridge, opened a year ago by the Chancellor, Lord Balfour, there are more than forty research students, women as well as men, working under Sir Gowland Hopkins. The vitamins or accessory food factors are present in small amounts in foods and are essential for health, for their absence leads to failure of growth and to a group of deficiency

diseases of which scurvy, beri-beri, war edema, and probably rickets are examples.

The advance of physiology in all directions has enormously helped medicine; thus in diseases of all the systems-the nervous, the circulatory, the respiratory, the digestive, and the glands of internal secretion (endocrine), and so forth-physiology has directed the course of medicine. Sometimes researches, which at the time did not appear to have any practical bearing, have eventually proved of the greatest significance and assistance, and this unexpected application of knowledge should be borne in mind so as in no way to restrict the line of work that may seem to the individual most attractive. Thus experimental psychology, which studies the responses of individuals to definite prescribed conditions, was not very long ago regarded by many thoughtful physicians to be a barren occupation unlikely to be of use either to psychology or medicine. But the labours of the late W. H. R. Rivers and Dr C. S. Myers, the Director of the National Institute of Industrial Psychology, have established the economic value of the application of its results in improving the output of work in factories and workshops by modifications in the conditions, particularly by the introduction of intervals of rest and by minimising monotony and boredom.

The study of nervous disease has attracted a number of brilliant workers who have utilised the proved results of physiology in medicine so as greatly to advance our neurological knowledge. Aphasia, or loss of speech from inability to translate thought into the spoken word, was shown by Paul Broca in 1861 to be associated with disease of a part of the left side of the brain, and thus to be often associated with hemiplegia or loss of power of movement on the opposite side of the body. This observation stimulated experimental investigation of the use of the various parts of the brain, or the localisation of function, by Fritsch and Hitzig in Germany, Sir David Ferrier, Sir Charles Sherrington, Sir E. SharpeySchafer, Sir Victor Horsley, Sir Frederick Mott, and others in this country, and thus led to the regional diagnosis of disease in the brain. The exact position of tumours could thus be so accurately determined as to

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indicate the exact site of the operation for their removal, and the first successful removal of a cerebral tumour in 1884 was thus made possible. Knowledge of the diseases of the spinal cord and the nerves arising from it has undergone such a change as to constitute a veritable revolution. The influence of syphilis, at one time thought to be local or at any rate practically confined to the superficial and bony parts of the body, was shown, mainly by Sir Samuel Wilks, some seventy years ago to be exerted on the various organs of the body and has long been known to be universal. The use of the Wassermann test on the blood and the cerebrospinal fluid, which surrounds the brain and spinal cord, as a kind of protective water-bed, enables a decision to be made on the question whether the parasite of syphilis is or is not active in the body of a person who does not present any other obvious evidence of, or indeed may not have any knowledge that he ever contracted, this infection fraught with so many serious and often long-delayed results. General paralysis of the insane, one of the diseases popularly spoken of as 'softening of the brain' and locomotor ataxia, also called tabes dorsalis, have thus been proved, as was previously suspected, to be practically always due to syphilitic infection. Further, other diseases have thus been shown to be caused by this form of infection which is usually, though not invariably, contracted by sexual connexion.

The Great War brought into prominence the causation of nervous disorders, for a time known collectively as 'shell shock,' due to the psychical effects of the bombardments, namely, mental strain, and the long-continued repression or active forgetting of dreadful experiences, fear and anxiety; as a natural result curative treatment on psychotherapeutic lines, such as sympathetic psychological analysis, re-education, and occupational therapy, made great advances. The effect of suggestion in improving functional disorders-the influence of the mind on the body-has been recognised and, indeed, practised from time immemorial, consciously and often unconsciously, by medical men; but has recently been placed on a more scientific basis. This is fortunate, as much of the success of irregular practice, such as Christian Science, is due to the strong mental impression

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made by those who direct the treatment, and is frankly professed by M. Coué. The danger about such proceedings, as with bone-setters, is that the morbid conditions present may be remediable or curable only by purely medical or surgical treatment, and that if this is not undertaken in time catastrophe may follow.

Brief reference should be made to the theory of Breuer and Sigmund Freud of Vienna and Jung of Zürich, which, under the name of psycho-analysis, has excited much and often rather severe criticism. The conception that mental manifestations result from the process of active forgetting or repression of an unpleasant experience, a mental trauma or injury, into the unconscious and the subsequent mental conflict, is a valuable addition to psychology. The process of detection and removal of this hidden disturbing factor by analysis of dreams, in which the unconscious comes to the surface, and the patient's 'associations' and an elaborate system of fixed symbols, is the form of psychological analysis spoken of as psycho-analysis. On the assumption that the sexual instinct is stronger than the instincts of self-preservation and of the herd, Freud and his followers laid great stress on the importance of sexual factors in the production of the mental conflict and its manifestations; it is on this point that most of the opposition to Freudism has arisen.

The treatment of the insane, as described in Charles Reade's famous novel 'Hard Cash' (1867), has undergone much change. It is true that, in France, Pinel, and William Tuke at The Retreat, York, almost simultaneously, in 1792, had advocated and practised humane treatment of the insane; but it was not until John Conolly went to Hanwell Asylum in 1839 that this method of abandoning mechanical restraint, such as strait-waistcoats, straps, and restraint-chairs, received any widespread attention. Thus there was a return to the humane and rational treatment of the insane practised by the Greeks from the time of Empedocles to that of Galen or later. Scientific research into the causes of mental disorder with a view to its prevention and cure has been ardently taken up, and the general aim, in sympathy with that of medicine as a whole, has been directed to the prevention in its earliest stage of

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Occurrence of mental disorder. Part of this effort is the system of mental hygiene or psychiatric prophylaxis, by means of social service workers, who investigate and correct the adverse factors in the home and other environments of the patient; this is the first line of defence against mental upset. Another method is the early treatment of those mentally disordered, the patients attending a special psychiatric clinic at a general hospital, not at an asylum or, as it is now preferably called, a mental hospital. This is important, not only in avoiding the necessity for certification by curing the patients while they are in a recoverable condition, but in breaking down the widespread tradition of something mysterious, such as demoniacal possession, and disgraceful about mental disorder, by allying it with ordinary physical disorders, as indeed was the view of Hippocrates, the Father of Medicine.

Knowledge of the circulatory system-the heart and the arteries-has been much expanded and altered in the course of the last thirty years. The accurate estimation of the arterial blood pressure by means of sphygmomanometers dates from 1876, when von Basch invented a machine; but it is only within the last twenty years that blood-pressure estimations have become a routine in ordinary medical practice. Other instruments of precision, such as the polygraph and the string galvanometer (the electrocardiograph), which was borrowed from the physiologists, for obtaining graphic records of the pulse and movements of the heart, were introduced, and much light was thus thrown on the irregularities of the heart by Sir James Mackenzie and Sir Thomas Lewis The attention formerly concentrated on the valves of the heart was thus largely transferred to the muscular walls of the heart, and more attention has been paid to the patient's symptoms, or his efficiency and sensations, than to the physical signs, namely, murmurs, or the evidence of structural changes in the valves of the heart.

Clinical medicine has sometimes helped physiology by drawing attention to morbid changes in an organ which are correlated with disordered function, and so throwing light on the use of the organ, thus stimulating research in the physiological laboratory into the

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