These are not the official names of these hospitals, but the names by which they are generally known. The list is by no means complete, and there are dozens of other hospitals where equally good work is done, and where there is much good material for study. For example, the "Samaritan" is excellent for diseases of women, and "Moorfields" is one of the most famous eye hospitals in the world. At any of these hospitals the casual physician, on presenting his card to the house surgeon, will be invited to go round with the physician or surgeon whose day it happens to be, and will be freely shown all cases of interest. This invitation is not confined to a single visit, but is extended for any reasonable time, although if a visitor wishes to attend the practice of a hospital for, say three months, he would do well to obtain a ticket for which he will be required to pay a small fee, but which makes him free of all the general hospitals, and of the best known of the special hospitals. It is by far the best plan to take out this inclusive ticket, which relieves him of all further trouble. There is in London a very useful scheme admirably adapted for postgraduate students, known as The London Post-Graduate Association. The association has been founded with a view to encouraging the postgraduate study of medicine, particularly in its clinical aspects. With this object cards are issued to qualified medical men (British, colonial or foreign), which entitle the holder to the following privileges: Joint cards of admission are issued to the clinical instruction of the following metropolitan hospitals (general and special), and schools of Medicine: General. Charing Cross, Guy's, King's College, Middlesex, St. George's, St. Mary's, St. Thomas's, University College, Westminster. Special. Brompton Hospital, for diseases of the chest; Hospital for Sick Children, Great Ormond street; London School of Tropical Medicine, National Hospital for the paralyzed and epileptic, Royal London Ophthalmic Hospital. They admit the holders to clinical instruction in the wards and outpatients' rooms, to clinical lectures and post-graduate courses, and to attendance at operations and post-mortem examinations at all the hospitals mentioned. The academic year is divided into three sessions of three months each, viz.: January to March, May to July and October to December. The cards are issued at the following rates: Valid for three months, 10 guineas (that is: £10, IOs, or about $52.00). Valid for six months, 15 guineas. And any longer period at the further rate of 9 guineas for each additional six months, It may be mentioned that in England all professional fees are paid in guineas, although there is now no such coin in existence. It is equivalent to 21 shillings. Holders of cards may obtain an extension of their original term by paying the difference of rate at any time before the original term has expired. A general time-table of the arrangements of the different hospitals and schools is furnished with the cards. Any further enquiries must be addressed to the dean of the particular school concerned. A list of operations, clinical lectures and other arrangements can be seen daily at the secretary's office. This scheme is undoubtedly a very good one, although it will be noticed that two of the largest hospitals are not included in the "combine." What the explanation of this may be I do not know, unless they have sufficient students of their own, and do not care to lay themselves out for post-graduate work. That, however, is a matter of very little importance, as in all probability very few men taking out this ticket would find time to attend all the hospitals on the list, as it would involve a considerable waste of time. Another point which may be mentioned is that this ticket does entitle the holder to a certificate of attendance for examination purposes. When a certificate of attendance is required, and these certificates are not to be despised, the qualified practitioner would probably do better to devote his energies to and work at one of the general hospitals where there are special departments. Most of the hospitals afford facilities for this purpose. Usually graduates are admitted to the hospital practice and lectures for three months for a fee of 11 guineas, or 16 guineas for six months. Clerks and dressers in the special departments are periodically appointed, and there are also pathological clerks who work in the post-mortem room under the superintendence of the pathologist. It is well to mention that at most hospitals the visits are paid in the afternoon at 1:30 or 2 o'clock, but in all hospitals there is a morning. visit by one or more members of the staff, every day in the week, so that no time need be wasted. In addition to the London Post-Graduate Association, but entirely distinct from it, is the London Medical Graduates' College, commonly known as the Polyclinic. It is frequented mostly by practitioners in medicine living in London and the suburbs. It is not a hospital, as there are no wards and no out-patients, or special departments. Patients are brought in from outside, and are obtained either from other schools or through the influence of members of the polyclinic, and are utilized for the "consultations." Sometimes very good cases are shown, at others they are of a very ordinary description. The institution supplies a want, and is prob ably more useful to the neighboring general practitioner than to the American visitor who wishes to lay himself out for serious work. Short courses on bacteriology, pathology, dermatology, electricity and other special subjects are available both summer and winter in most of the hospitals, and the fees for attendance are very small. The facilities offered are quite as good as in Paris, Berlin or Vienna. For visitors wishing to take out a course of anatomy, or to perform operations on the dead body, Cooke's school can be recommended. It is a private enterprise not connected with any hospital, but the teaching is sound, and individual attention is given. I am often asked about the expense of living in London, and the only answer I can make is that you can live as expensively or as cheaply as you like. At a first-class hotel in the West End, you can easily spend six or eight dollars a day, whereas, in a boarding house in a perhaps somewhat less fashionable quarter, that sum will suffice for a week. For two men making a visit together, a good plan is to take rooms at one of the less-expensive hotels, and to dine at one of the cheap restaurants, of which there are many scattered all over London. This plan is not recommended for a solitary individual, however enthusiastic he may be, for dining alone, night after night, is, to say the least, depressing. It is best, if possible, to come with an introduction, and it may be hinted that the MEDICAL BRIEF, with its wide ramifications, might be found useful in this respect. I have dealt with the subject on the widest possible grounds, and have refrained from mentioning the names of any particular physicians or surgeons who have gained distinction as clinical teachers. In conclusion, I should like to make a few remarks on the social position of the medical man in England, remarks founded on an admirable article on the subject which recently appeared in the Medical Press of London: "It is a fact, and one worth noting, that in ordinary society a medical man is not only always sure of a cordial reception, but he is always regarded among his patients as a peculiarly intimate friend, and one whom they are especially pleased to honor. Inasmuch as a medical man has no ready-made position of authority such as has a clergyman, nor the prestige of one of the destructive professions, such as the army or navy, nor the prospect of wealth that may be garnered from business, but simply his own attainments and personality to rely upon, it follows that the calling of medicine must attract men of higher potentiality than other lines of life, and endow them with an unusual degree of urbanity and kindliness, for them to attain such a position. "The cause of this social estimation lies in the humanizing influence that the practice of medicine exerts on its followers; the knowledge of men and women at their best and at their worst, a knowledge which fails to make doctors cynics, but succeeds in making them sympathetic friends. "The reward of the medical man's work and the pleasure of his existence must be measured by the benignity he acquires as he grows older, and certainly not by his balance, if balance there be, at the banker's. The man who sets out in practice with the intention of making a fortune and 'founding a family' is rapidly undeceived; the conditions of work and its remuneration leave no scope for such tokens of worldly success. If, through a happy combination of private means, professional success, and influential friends he finds himself attached to the Court and the recipient of a baronetcy, the highest external honors available for a medical practioner in England will have been attained, but he will figure but ignominiously in the eyes of society when he sits down to dinner with an archbishop, a lord chancellor, a field marshal, a belted brewer, and a bacon king. In fortune, in influence, in importance in the councils of the State, the medical man can compare with none of these." COMPLETE ALOPECIA. BY JOHN V. SHOEMAKER, M. D., LL. D., Professor of Materia Medica, Therapeutics, Clinical Medicine and Diseases of the Skin This young woman whose case I shall report is suffering from an infirmity that is quite common and most difficult to cure. She is twenty years of age; nativity, United States; occupation, dressmaker. Three years ago the hair of her scalp first began to fall out in small areas, giving rise to what is known as alopecia circumscripta. Treatment to the scalp had absolutely no influence upon the condition to ameliorate it. The hair continued to come out rapidly and in the course of four months she was completely bereft of hair on the scalp. The eyebrows and eyelashes had also dropped out and, in fact, there is now not a single hair to be found over her entire body. She knows of no one among her relations that has had the disease. In her immediate family not one of them is partially bald, though her father is sixty years of age. As a child she had measles, scarlet fever and whooping cough. Since her tenth year she has not been ill, except that during her last year in the high school she became markedly nervous, which was three years ago. She then had a slight attack of chorea. Sudden and rapid loss of hair, occurring in the course of from a few days to twelve or sixteen weeks, constitutes acute alopecia. It may or may not be attended by a change in the appearance of the hair, and inflammation or other cutaneous alterations of the skin may or may not supervene. In some cases the scalp is not changed in appearance and the hairs fall, or are combed or brushed out daily to the number of from fifty to hundreds. The individuals so afflicted may not experience any subjective symptoms at all. In other instances the rapid loss of hair is preceded or accompanied by an inflammation or eruption. Formation of crusts or scurf, which may be either slight or marked, and itching, smarting, burning and even painful sensation may be experienced. Chronic alopecia, the most common form, may or may not-like the acute-be accompanied with primary or secondary changes in the scalp. At times before or during the loss of hair, the scalp is affected with dry seborrhea or some other cutaneous disease. In very many cases, however, no alteration is apparent, either in the general appearance of the hair or on the surface of the scalp. Chronic alopecia usually begins at the vertex and extends forward on the frontal bone, and on each side, over the parietal bones to the pinna of the ear. Sometimes the loss of hair commences just above the forehead, and so spreads to the parts already named. It proceeds so gradually that it often escapes the most observant, until the second stage is reached, when baldness is almost certain to follow. Senile alopecia is due to an alteration and atrophy of the hair-forming apparatus. It begins on the crown of the head where the vascular supply is poorest. The hairs become short, thin, rough, dry, turning gray and are cast off, not to be restored. Diagnosis. It is essential to ascertain early the causative element in each case, and distinguish between acute and chronic alopecia. In the acute form, shedding is diffuse and rapid, the hairs, on examination, show no evidence of disease in change of diameter toward the root end or any change of color. In the chronic form the very opposite condition is present. Shedding is gradual, the thickness of the hair is lessened and the color of the hair is often altered. Pathology. The hairs loosen and fall, owing to the lack of nutrition caused by the shedding of the epithelial cells of the sebaceous glands and hair follicles. In the advanced stages the wall of the hair follicle becomes the subject of ascending hypertrophy, the cavity being obliterated from below upward by a new development of fibrous tissue. The derma itself finally becomes atrophied, the muscular fibres in it decrease and its connective tissue elements becomes more abundant. The sebaceous glands are first enlarged, later atrophy takes place and the subcutaneous connective tissue becomes adherent to the derma. The blood vessels and nerves remain unaltered. Etiology.-Premature loss of hair is more common in men than in women, and this fact no doubt is due to the large quantity of subcutaneous fat in women, and also because women pay more attention to their hair than do men. Constitutional and local causes are often the forerunners of. alopecia. Among the internal causes are improper diet in children as well as in youths and young adults. The nervous system which controls circulation, secretion and nutrition of the entire organism, if impaired, will give rise to alopecia as readily as any other causative |