Pediatrics; Past, Present and Prospective. My S. W. Kelley, M. D., Cleveland, O. Professor of Diseases of Children. in The Cleveland College of Physicians and Surgeons, (Med. Dept. Ohio Wesleyan Univ.) Pediatrist to The Cleveland General Hospital, Consulting Physician to Cleveland City Hospital, President Ohio State Pediatric Society, Ktc., Etc. PEDIATRICS; PAST, PRESENT AND PROSPECTIVE.* BY S. W. KELLEY, M. D., CLEVELAND, O. Gentlemen: I had heard the term “ executive ability ” defined as “ an aptitude in getting other people to do your work,” and had been proceeding upon the idea that the principal duty of your chief executive officer was to get other men to read papers or make addresses rather than to do so himself. How- ever, it seems that the President of this Society is expected to add to his other duties that of addressing the meeting, and one could wish that the order of business went so far as to furnish him something to say upon such an occasion, after the handy manner of a liturgy. Left to my own choice of theme and matter, personal preference would have led me into the discussion of a topic of surgical disease in childhood ; but viewing more broadly the work that is before this Society and considering that not only scientific and purely technical phases of pediatrics may properly engage its attention, I have felt it a duty to present a more general subject related thereunto. This I do in the hope of increasing the interest felt in this branch of learning, and in this Society devoted to its cultivation. I shall not prom- ise that this small contribution be conclusive, but onlv suggestive in its scope. When first the words of the title were given out, I had in mind to sketch for you the past and the present of pedi- atrics as exhibited in its literature and in its practice, from the historical point of view, and then in the light of its history in the past and its progress in the present, and ♦An Address delivered before the Ohio State Pediatric Society, at Columbus, May 27, 189(1. Reprinted from The Cleveland Medical Gazette, September, 1896. 2 Kelley: Pediatrics; Past, Present, Prospective. judging by the signs of the times, hazard a prophecy upon its future. But a little thought convinced me that my short sketch would become a lengthy panorama which would require several hours to unroll before you. May I hope that this suggestion will lead some member of this Society to attempt a “ History of Pediatrics ” ? Who is to be the distinguished author ? Do I see him before me ? Who would not warm to such a theme ? But I have chosen for to-day another plan. By way of estimating the progress, present state and prospects of pediatrics, I have sent letters of inquiry to many teachers of this branch in various medical schools of this country, and a few in Great Britain. In these letters a number ol questions were asked which I will read to you together with a summarized account of the answers received. The replies to my letter of inquiry, were mostly from teachers of pediatrics., but quite a few of them from the Deans or Registrars of Colleges in the United States and Canada. Sixty-five of the replies were sufficiently explicit for tabulation. Some few I must present separately, along with those from abroad. In answer to my questions, I am told as follows : Of the 65 colleges in this country and Canada, Pediatrics is taught as a separate branch in 50, and in connection with another chair in 15. The teaching is acknowledged to be didactic only in 9 colleges, clinical only in 5, and claimed to be both didactic and clinical in 50. One of the writers failed to answer this question, and I have labeled this In- definite, 1. So far as one may judge by these answers (and this is corroborated by the general opinion of the profession in this country) it is expedient that there be a separate chair of Diseases of Children in the medical college and that the teaching be both didactic and clinical. The next question was : Does the Pediatrist teach the Kelley : Pediatrics; Past, Present, Prospective. 3 medical side only or also the surgical side? The answers indicate that the medical side only is taught in this depart- ment in 37 out of the 65 colleges, that both medical and surgical is taught in 26. The remaining 2 left the question unanswered. In 3 of the colleges in which both medical and surgical pediatrics is taught as a separate branch, there are two different teachers for the two sides, one teaching medical, one surgical pediatrics; 2 of these three are post graduate schools. This question is closely related to the next one which was : “ Does the teacher individually consider that pediatrics includes the surgical as well as the medical diseases of children?” This was answered affirma- tively 40 times; negatively 13 times. The remaining 12 leaving the question unanswered, or answering so indefin- itely that I could not tell where to place the vote. There can be no doubt that if medical diseases in children present peculiarities sufficient to warrant particular study, that surgical pathological states also are modified by the anatomical and the physiological peculiarities of the devel- opmental stage of early life ; and some are met with in no other class of patients, and nearly all behave in a manner requiring a qualification of the statements concerning them when made upon the adult patient. Whether both the medical and the surgical side of pediatrics should be taught in college and practiced by the same man, will depend upon the circumstances and the man. My next question was : “ How many hours per week does your curriculum give to pediatrics?” One hour was given as the answer from 16 colleges, 2 hours from 21 col- leges, 3 hours from 3 colleges, 4 hours from 6 colleges, 5 hours from 1 college. One gave the answer as 21 hours, and one as 26 hours. It was explained, however, that out of the 21 hours only 4 were recitations, the rest being de- voted to clinical and dispensary work. I presume the 26 hours should be explained in the same way. The answer was omitted or answered indefinitely 14 times. 4 Kelley : Pediatrics; Past, Present, Prospective. My next question was: “ How many hours per session?” This seems to have been unfortunately worded, for it was in several instances misunderstood. Perhaps I should have said : “ How many hours per term, or per year, or per school year, or per semester?” However, 44 colleges answered this question definitely. 1 devotes 16 hours per session, 4, 20 hours, 3, 24 hours. 3- 26 hrs. 2- 36 “ 2- 48 “ 1- 56 « 2- 64 “ 2- 80 “ 1-120 “ 1- 30 hrs. 3- 40 “ 5- 50 « 1- 58 “ 1— 65 “ 1- 96 “ 1-144 “ 1-' 32 hrs. 1- 44 “ 2- 52 “ 2- 60 “ 1- 66 “ 1-112 “ The average of the 42 being 32.26 hours. I presume that at least a part of the discrepancy in these answers arises from reckoning the hours of recitation only or of didactic lectures only, in some instances, while in others the clinics or even the dispensary or out-patient practice-under instructors may be counted. For instance in my own teaching the curriculum gives 2 hours a week through the session of 26 weeks, that is 52 hours, and the hours may be devoted to didactic or clinical lecture or to operation or demonstration according to the nature of the subject and material in the children’s ward or dispensary. But no mention is made of the work in the out-patient department of the Cleveland General Hospital where on three days in the week from one to three hours are devoted to seeing children with a section of the senior class, and nothing is said of evening “quizzes” or recitations. The next question “Is pediatrics taught to Seniors only, or to Juniors also?” elicited the statements that of 55 colleges which gave definite answers, this branch is taught to both Seniors and Juniors in 2S, to Seniors only in 22, to Juniors only in 2, during 3 years in 1 and to post graduates only in 2, these being post graduate schools. Kelley: Pediatrics; Past, Present, Prospective. 5 One correspondent mentions that in his school Pediatrics is obligatory upon Seniors but optional with Juniors. By these figures it would seem that in the majority of schools in which pediatrics is taught as a separate branch it is taught to both Junior and Senior students. 1 next inquired “How much does the branch count in percentage necessary for graduation,” and this question seems to have been variously interpreted. However, most of the answers are to the point if not mathematically accurate. “Same as any other branch,” or words to that effect was the answer 27 times. A was the percentage given in two colleges and 4 in one college. The question was answered 70 per cent, or 75 per cent, in 4 instances, which I take to mean the percentage required to pass in this branch and not in relation to the other branches. One answered that it counted f/A. All these seem to indicate that pediatrics is regarded as a full department in 36 at least out of 63 colleges (really in 36 out of 51 which answered). While it is not required for graduation, has “no vote” or counts for zero in 8 of the number. In one it has £ a vote, and in 7 it is figured in combination with other branches—either ob- stetrics, gynecology and obstetrics, or general medicine. Fourteen of the 63 correspondents left the question not definitely answered. These figures are more significant when taken in con- nection with the answers to the next two questions. I next queried, “Can you answer the same questions regarding your school as it stood 10 years ago?” The idea of course being to get at the amount of progress in the past 10 years. Some answered “yes,” but still did not deign to do so. Twenty-one of the 63 replying thus or leaving the question unsatisfactorily answered. Ten of the colleges in this list were not in existence ten years ago. In 14, it was taught the same ten years ago as now. In 9, it was in com- bination with other branches, oftenest with obstetrics. Four acknowledge that it was not taught at all, and 3 that it was 6 Keli.ey: Pediatrics; Past, Present, Prospective. then taught “very little and no examination required,” or “only a few lectures” or “clinical only.” Four claim that it has become “much more prominent” or “greatly ex- tended” since ten years ago. As to the condition of affairs 20 years ago, 1 says it was “not thought of,” and 1 says it was “not taught anywhere.” One says “taught as a separate department,” one of the few in this country.” Five say it was not taught in their school. One can’t answer. Six say it was taught but little, or in combination with other chairs. Twelve say that their school was not in existence 20 years ago, and 38 significantly leave the question entirely unanswered. I next ventured to inquire “How many practitioners in your city devote their whole attention to pediatrics and “none” was the answer from 41 cities in which medical colleges are located. Four different cities can boast of one each, one has two, one is said to have 8 and we are asked to believe that in one city there are 20 or 25 specialists in diseases of children. This I regard as a misconception or a mistake. The rest leave the question unanswered. Thinking there might be some who, not entirely limit- ing their practice to diseases of children did so to a great extent, I asked “How many enjoy a considerable reputation and practice in the diseases of children.” One man tells me that “all the 75 doctors in his town claim it.” Ten have no one thus distinguished in their city, 27 have numbers ranging all the way from 2 to 25 as follows : 3 have 2, 9 have either 3 or “several,” 8 have 4, 3 have 6 apiece, 3 have 10 each, 2 have 12, and one is blessed with 25 children’s doctors of more or less celebrity. The remainder of my correspondents remain silent on this delicate question, ex- cepting 5 of them who owned up squarely that they “didn’t know.” My next interrogation was a trident, a kind of a three pronged arrangement, calculated so that if it couldn’t stick them on one point it might on another. It read as follows : Kelley : Pediatrics; Past, Present, Prospective. 7 Do you consider it practicable? or desirable? to “specialize” pediatrics, (i. e. as eye and ear, or gynecology have been specialized) or probable that it will become so specialized in the near future ? Twelve dodged the first prong altogether, but I caught 23 who did answer it in the affirmative, “Yes,” they do con- sider it practicable to specialize pediatrics, and 30 who said “No,” they do not consider it practicable to specialize. Now as to whether it is desirable to specialize, 26 said “Yes” and 23 said “ No,” and 16 either answered too indefinitely to be classified or did not venture to answer at all. On the prong of “ probability ” I caught 48 answers evenly divided between yeas and nays—24 apiece. While 17 either held no opinion or did not care to air it. On the other hand quite a number expressed themselves further upon these points. Dr. H. A. Kinnaman of Keokuk, whom I have tabulated as not thinking it practicable nor desirable to specialize, nor probable that pediatrics will be specialized in the near future, has added “Not in this place.” Dr. Breysache says it is not practicable nor desirable in so small a city as Little Rock, (30,000) and he does not think it will be specialized in the near future, but will be after many years. Dr. Uzziel Ogden, Dean of the Med. Dept, of Toronto University, does not think it practicable nor desirable in that city whatever it may be elsewhere. Dr. John E. James, Registrar Hah. Med. College of Philadelphia, says “ No,” “No,” except in surgical parts and orthopaedics.” Dr. Hunter H. Powell, of Western Reserve, Cleveland, writes: “I believe it impossible to specialize pediatrics as other departments have been specialized. The pediatrist must be a specialist as regards special features of 'physiolog- ical and pathological processes associated with infancy; special features as compared with adult age. He needs himself, to practice medicine, surgery, ophthalmology, der- 8 Kelley : Pediatrics; Past, Present, Prospective. matology, neurology, and orthopedic surgery. His clinic is polyclinic. He must call in the specialists in unusually obscure cases only.” A physician of Baltimore, Dr. A. K. Bond, writes : “Dear Dr. Kelley: I have answered the above wil- lingly. I wish you success in your useful investigation. With us the obstetrician is the first choice as child’s doctor. I think it very difficult for anyone to make himself exclu- sively a child’s doctor. He may, however, be known as an expert in their diseases. I doubt if mothers would want him as child’s physician to do major surgery on the children. Orthopaedics, even, seems to have failed in this city as apart from general surgery. Although one man of wealth, at least, took it up as a specialty, I think he has ceased to practice in any line. One of our best child’s doctors (now deceased), trained himself as a gynecological surgeon, then became somewhat known as a child’s doctor, and after his marriage got a good practice as obstetrician, apart from pediatrics. He was poor and had to take what he could get for support. One of our best living children’s doctors here has his chief income from gynecological surgery. Two or three others are major surgeons (railroad sur- geons in private). One of the most exclusive pediatrists works a great deal in bacteriology of the faeces. I do not think his children’s practice large in private, nor that he touches orthopaedics. Several others, like myself, are gen- eral practitioners, compelled to take for support whatever comes along in the medical line almost exclusively. The difficulty is that the younger practitioner is often inferior, even if he wishes to be a pediatrist, to old physicians who do general practice. Only by mastering the more abstruse details of pediatrics, including nervous, developmental and other subjects unknown to the general practitioner can he compete with them. One of our medical pediatrists—the same who works on faecal bacteriology, does intubation ; but I think he who does intubation ought to stand ready for Kelley: Pediatrics; Past, Present, Prospective. 9 tracheotomy which may be instantly demanded to save the child’s life. I am, myself, much puzzled to know what can be made of pediatrics as a specialty and will be happy to receive your article when published.” My letter of inquiry to Tulane University of Louisiana, was referred to Dr. Rudolph Matas, Prof, of Surgery, and he writes : “ My personal impression is that the specialties of medicine and surgery will encroach in future as they do at present upon the domain of pediatrics to the extent of reducing the pediatric specialty subordinate to the other specialties. There will always be men who will be more skillful in the management of the diseases of children in all communities, but it is extremely doubtful that pediatrics will ever rank as a distinct specialty like oculistry, otology, or laryngology or orthopedics. The simple reason for this lies in the fact that a special knowledge of the diseases of children is largely a synthesis of the other specialties, and that what is not included in the other specialties will be of such a general character “ that the ‘ general practitioner ’ must claim it as a part of his special province.” The same letter being referred by Dr. Matas, to Dr. E. D. Fenner, Lecturer on Diseases of Children in Tulane, he endorses Dr. Matas’ remarks and adds, “ I think a man may devote so much of his time to the study of disease in child- hood as to become in effect a specialist, but it seems to me that such exclusion of the adult cannot but ultimately ren- der the specialist less broadminded in his view of disease than if he-studied and was familiar with the manifestations of sickness in grown people.” Dr. V. C. Vaughan, Dean of the Department of Medi- cine and Surgery of the University of Michigan, writes : “ In answer to your questions of recent date I will say : 1. Medical Pediatrics is taught by the Professor of Medicine, both clinically and didactically. Surgical dis- eases of children are taught by the professor of surgery. 2. There is no special number of hours set aside for the teaching of Pediatrics. 10 Kelley: Pediatrics; Past, Present, Prospective. 3. Pediatrics is taught to both Seniors and Juniors. 4. There are no physicians in our city devoting their exclusive attention to Pediatrics. 5. I see no more reason for isolating the teaching of Pediatrics from general medicine and general surgery than there would be in separating senile diseases in the same way.” Now to show how far opinions will differ I may mention that Dr. John Larrabee of Louisville, Ky., says “there is more reason for specializing than in any other branch.” Dr. Starling Loving writes “1, Pediatrics is taught in Starling Medical College as a separate branch, and not in connection with any other chair. 2. The teaching is mainly didactic. 3. The lectures are medical and surgical, but the sur- gical diseases of children are considered mainly by the Prof, of Surgery. 4. Instruction is given to Seniors and Juniors. 5. The candidate must have the vote of the teacher of pediatrics before he can pass. 6. Ten years ago we had no chair of Pediatrics, the subject being considered by the Prof, of Obstetrics. 7. I do not know of any one here who gives his entire attention to the subject. 8. I know several gentlemen who have reputation for skill in the management of diseases of children. 9. I think the well equipped general practitioner can do more good than the specialist, and do not think that pediatrics will become a special branch, here at least, for many years to come, and am of opinion that it will be bad for the children whenever it does become so.” Concerning this latter point, Dr. W. V. Anderson writes from Toledo: “I believe that the field is ripe for the harvest, and that very soon pediatrics will be recognized as honorable and scientific a specialty as gynecology or eye and ear.” Kelley: Pediatrics; Past, Present, Prospective. 11 Verily every man has a right to an opinion. I shall express mine by and by. First I asked another question— this time a double-header—warranted that if it couldn’t “ find what it was sent after, it would fetch something else.” It read like this : “ Do you predict for pediatrics a moder- ate progress as a science and in the estimation of the pro- fession and the public? or a very rapid advance relatively to the other branches? This question fetched one man who averred that he was “no prophet,” and so escaped; 30 expressed their faith in “moderate progress while 12, more enthusiastic, expect a very rapid advance ; 20 are silent, whether dead or only sleeping I do not know. Upon this point I quote again from Dr. Starling Loving, who says : “ I think the department will grow with practical medicine and only in proportion with the advance in that branch. My opinion in this regard is based on ex- amination of the later works on diseases of children, which contain very little which is not found in all the good works on general practice.” Observe that he did not say the latest works but the later works, but even then, I’ll leave it to any man familiar with the literature of pediatrics to say whether or not it contains “very little which is not found in all good works on general practice.” If I am not trespassing too much upon your time I would like to present in this connection a couple of letters from over the water. The first from Edinburgh bearing date April 17. It reads as follows : 24 Melville Street, Edinburgh, April 17, ’96. Dear Dr. Kelley: Dr. John Thomson and I have concocted the enclosed between us. We hope it is what you want. The new or- dinance recognizing Pediatrics or Ear Diseases as compul- sory to graduation in the University was just published a day or two ago. I enclose it. I really can’t tell you much about the rest of Scotland or about England—in fact I had better leave that part of 12 Kellf.y : Pediatrics; Past, Present, Prospective. your letter unanswered. Prof. Stevenson of Aberdeen University might be able to tell you something. Yours faithfully, I. W. Ballantyne. 1 a. Edinburgh University. Pediatrics is taught as a separate branch by two teachers called Lecturers but not Professors. The instruction they give is wholly clinical. Hitherto the attendance at the course of instruction given by these gentlemen has been wholly optional and the number of students has been exceedingly small. The Professor of Midwifery is supposed to impart systematic instruction in diseases ot children to his compulsory class in the form of three lectures in a course of 100. New ordinance, slip enclosed, q. v. Nozucompulsory in a certain sense. 1 b. In the School of Medicine of the Royal Colleges (otherwise called the extra-mural school) of Edinburgh there are five lecturers on diseases of children who give courses of various length, partly didactic, partly clinical. As the subject is one not examined upon for either the colleges or university degrees, the number of students attending these courses has been very small. 2. In Edinburgh (in both University and Colleges) the diseases of children is regarded as entirely medical— that part which is surgical is taught in the Surgery and Clinical Surgery classes. The two surgeons in the sick children’s hospital, however, give lectures on Surgical Diseases of Children. 3. The amount of teaching has rested entirely with the teacher’s estimate of what was needful—viz : from 40 to 12 lectures including clinical demonstrations. 4. The classes are usually composed of 4' 25" year students, i. e., seniors. 5. Nil. 6. Ten years ago there was no teaching in the Uni- versity save that given as above by the Professor of Mid- Kelley: Pediatrics; Past, Present, Prospective. 13 wifery. In the extra-mural school there were either one or two clinical and one didactic course. 7. Two decades.—Don’t know.—Believe Prof. Stev- enson (now of Aberdeen) used to lecture in extra-mural school. 8. One devotes almost all his time to Pediatrics—the others all take Midwifery as well. 9. Consultations in diseases of children are probably divided among about 10 men. 10. In Edinburgh, not practicable. The Pediatrist ought to be thoroughly in touch with all branches of science. 11. Tendency to it being more specialized than hitherto. 12. ?” The clipping referred to is from the “Scotsman,” giving an account of the meeting of the Edinburgh University Court at which they made some additions to the require- ments for graduation. “The Court resolved as follows :— a. Every candidate for these degrees shall be required to attend in addition to present requirements :— 1. A course of instruction in mental diseases, given by the University lecturer or by a recognized teacher, consisting of not less than six class-room meetings for lectures and demonstrations, and ten meetings in the wards of a recog- nized asylum for the insane. • 2. Post-mortem examinations in a recognized hospital for a period of at least three months, during which practical instruction is given in the methods of making -post-mortem examinations, and in framing reports. 3. A course of clinical instruction in infective fevers, given at not less than twelve meetings in the wards of a recognized hospital where clinical instruction is given on cases of infectious diseases. 4. Instruction in diseases of the eye, given by the University lecturer or by a recognized teacher, at not less than twelve class-room meetings and twelve meetings for clinical instruction in the wards of a recognized hospital or 14 Kelley: Pediatrics; Past, Present, Prospective. in the wards of a hospital and in a dispensary both recognized for the purpose. The course to include efficient practical instruction in the methods of examining the eye. 5. A course of operative surgery, conducted by the Professor of Surgery in the University or by a recognized teacher. b. Every candidate shall also be required to attend any one of the two following courses :— 1. Clinical instruction in children’s diseases, given by the University lecturers on this subject, or by a recognized teacher or teachers in a hospital recognized for the purpose, at not less than four lectures and ten meetings for clinical instruction in the wards, together with four meetings in the out-patient department of the hospital, with attendance at post-mortem examinations. 2. Instruction in diseases of the larynx, ear, and nose, given by a University lecturer, or by a recognized teacher, at not less than six class-room meetings, and twelve meet- ings for clinical instruction in the wards of a recognized hospital, or in the wards of a hospital and in a dispensary, both recognized for the purpose.” Dr. Henry Ashby, Lecturer on Diseases of Children in Owens College and Examiner in Victoria University, Man- chester, writes : “In reference to the above, 20 lectures are given during summer to a class of about 70 or 80 students, all seniors. Some of them in addition attend outpatients and also inpatients at the children’s hospital.” In answer to the list of questions, he says Pediatrics is taught as a separate branch, on the medical side only. He considers that the subject includes the surgical as well as the medical side. The curriculum gives 2 hours per week or 20 per session (during summer only). In final examination it counts 150 as a part of medicine which counts 800. Ten years ago it was the same as now ; 20 years ago there was nothing taught. There is only one man in Manchester who devotes his entire attention to children and perhaps not more than one who has any great reputation in this line. He thinks it “partly” practicable and “partly” desira- Kelley: Pediatrics; Past, Present, FS'osfiective. 15 ble to specialize but does not think it will probably be specialized soon. Mr. Edmund Owen of London answers “No” to the first three questions. The teaching is clinical only. The question whether the surgical should be included he leaves unanswered perhaps thinking it too obvious to need an answer. When he comes to the word “pediatrist” he writes : “ I do not know this word but guess its meaning.” Under “pediatrics” he writes“I have never heard this word used in England.” It was taught just the same ten years ago. As to the number in London who devote their whole attention to children, he says : “Not a single one I think—it should not be a “specialty.” As to the desirability of specializing he says “A thousand times No.” “I should think it the worst thing in the world for a man to give up his life to the study of children'1 s diseases. The effect would be “cramping” on the individual and prejudicial I think to the interests of sick children. At the Gt. Ormond St. Hos- pital, the mother of children’s hospitals in England, we will not have a man on the stall'unless he is, or is likely to be shortly on the stall' of a general hospital. You will not like my reply, my dear Kelley, but at least you will not find fault with it for want of clearness. I have a great dread lest the field of children’s diseases should be tilled and cul- tivated by persons who neither could nor would look over the hedge. You cannot draw a line between children and “non-children and the girl who is a child in New Eng- land is a mother and house-wife in New Orleans.” Now, gentlemen, I said at the beginning that my paper was intended to be rather suggestive than conclusive, and when I offer a few propositions in closing they are not meant as a necessary conclusion reached through the testi- mony collected and spread before you. They are only an expression of my own opinion, albeit that opinion has been in a measure influenced I believe corroborated by the facts and expressions offered by all these various men. There is no denying the fact, that the peculiarities 16 Kelley \% Pediatrics ; Past, Present, Prospective. of children and their diseases have grown to such propor- tions as to require separate treatises and text books and special teachers, as has been found necessary in the division of the work of teaching in the majority of our colleges. There can be no doubt that pediatrics should be taught both didactically and clinically, and that those colleges which do not teach it clinically as well as didactically will soon be regarded as “back numbers.” Venerable old Edinburgh has at length concluded to make it a compulsory branch and the conservative gentlemen of the south of England will get around to it after awhile— only give them fifty or a hundred years yet and don’t hurry them. And they will get used to the term pediatrics and pediatrist just as they have gotten used to the term ovariot- omy and ovariotomist and anesthesia and anesthetist, although it may be as new to them at first as Sim’s position or as intubation. In the meantime our English friends will continue to be frightened at the name specialty and specialist although a few of them will continue to become expert in special lines, while the general practitioner will not be as good an “all around” practitioner as his American confrere. Notwithstanding his dread of specializing, Mr. Owen himself has written, as you all know, an admirable book on the surgical diseases of children, and other lectures and essays as “special” as anything we propose to do to-day. Mr. Owen has mistaken my position in this matter, for he says “you will not like my reply,” and lest others may, let me state it. I am just as anxious as he that the field of diseases of children be not “tilled and cultivated by those who cannot and will not look over the hedge.” And while I do not think there would be as much danger of a “cramp- ing” influence in confining oneself to this branch as there would in some other departments (because of the breadth and variety in the field), it is infinitely desirable for the sake of all concerned that the special knowledge of this as of any other department be built upon a broad and deep foundation Kelley: Pediatrics; Past, Present, Prospective. 17 of general knowledge and experience, and keep its due proportions in comparison with the other parts of the structure. When this is done there is no danger of cramping. I am opposed to the making of specialists in college ; and always take in hand seriously the undergraduate who expresses his intention of paying particular attention to a certain branch with a view to making it a specialty when he shall have graduated. It is this kind of specialists who as much as the advertising quack have brought the very word into disrepute. I tell my young friend that it will be time enough when he has thoroughly grounded himself in the general principles and practice of his profession, and had ten or fifteen years of experience, to think of devoting his time in great part to some one line more than others. I would not discourage any young practitioner from endeav- oring to increase his knowledge and perfect his skill in cer- tain particular lines or line according as he may have talent, taste or opportunity to study in that direction, for the field has become too wide for one to become expert in everything ; and with quaint old Norris “ I think a little plot of ground thick sown is better than a great field, which, for the most part of it lies fallow.” If bye and bye a man becomes wise or skillful beyond his fellows in a certain line of work, and they keep him so busy therein that he has no time for any- thing else, I can see no objection to his doing that work, whether he is called a specialist, or whether he is called an expert in that line. And if all specialists were made in this way there would be no cause for complaint from anybodv. In regard to pediatrics (whether it is practicable or desira- ble depends upon the way in which it is done) it is probable, that in all large centers of population certain doctors will become known as particularly expert in diseases of children, and whether they are called pediatrists or specialists matters little—they will be called frequently in consultations, and their practice will be largely, perhaps in some instances entirely, among children. 18 Kelley: Pediatrics; Past, Present, Prospective. In regard to the progress that is likely to be made in the near future, I cannot agree with those who expect ped- iatrics to do no more than keep pace with the march of general, medicine and surgery. The progress it has made in the past twenty years, the degree to which it has been differ- entiated from the other branches and separated even from those which were until recently associated with it (obstetrics and gynecology), the number and value of recent additions to its literature, the promptness with which not only every discovery in general medicine and surgery and all the specialties is tried and if practicable modified to suit the cases of children, and the zeal with which earnest workers are pursuing special investigations in this branch, all tell me that pediatrics is destined to make a rapid advance in the near future. I believe it will lead out perceptibly and distinctly in the next decade like gynecology has in the past decade though not to the same degree. Heaven forbid that it should be “boomed” to that extent. It became at one time very little short of disgusting when every Tom, Dick and Harry, I beg their pardon, every Thomas, Richard and Henry in the country seemed possessed with the idea that nothing less than God’s final and finest piece of handiwork was good enough for him to practice upon. I do not think pediatrics will ever be so overdone. It has not the same attractions. But it has attractions for all of us here present, and we have a good programme before us. I have kept you from it too long already. I thank you for your patience.