trends in clinical pathologists1 · j. clin. path., 1970, 23, 744-750 trends in clinical...

J. clin. Path., 1970, 23, 744-750

Trends in clinical pathologists1

A. G. SIGNY

I am deeply appreciative of the honour you havebestowed on me in asking me to deliver thisFoundation Lecture which marks the 43rd yearof the foundation of the Association of ClinicalPathologists. I am also taking this opportunityto thank the ACP publicly for the Festschriftwhich appeared in January to celebrate both myretirement from active practice in pathology andthe 25th (or so) anniversary of the Journal ofClinical Pathology2. I was so impressed by thecontributors and their delineation of the trendsin pathology that I thought I would address youtoday on the 'trends in pathologists' as a recipro-cal essay to see whether we have matched up tothe changes which have already occurred, andparticularly whether we are prepared for orpreparing for the inevitable changes and trendswhich are now taking place.

The View Behind Us

If you will forgive me for taking you a littleearlier than the 25 years and nearer the 43 yearsof the life of the ACP I should like to recall myfirst introduction to pathology as a medicalstudent. It was in the necropsy room where,strangely enough, a famous physician, John Ryle,was conducting a necropsy on one of his ownpatients who had died. This was the commonpractice at the hospital and the four assistantphysicians each did the hospital necropsies onone day a week, leaving only one day for theDepartment of Pathology. I was very impressedby the technical skill of this physician and

'A shortened version of the Foundation Lecture given at theAnnual Meeting of the Association of Clinical Pathologists on24 September 1970.

'Trends in Clinical Pathology (£3 from the British MedicalAssociation, Tavistock Square, London, WCIH 9JR.)

particularly by the breadth of the teaching at thenecropsy table. I was certainly not given to thinkthat the teaching and practice on Fridays, whenthe pathologists took over, was in any sensesuperior. This was later changed when a youngpathologist, newly appointed, began to draw thecrowds with his splendid technique and teachingability-young Keith Simpson produced thenthe remarkable technical skill that he still main-tains today. This situation in morbid anatomy wasin the accepted tradition of this hospital which hadproduced an astonishing series of physicianssuch as Addison, Bright, and Hodgkin, who hadcombined their clinical and pathological skills toelucidate so many clinical problems. Today thefall in the numbers of necropsies in so manyhospitals reflects the lack of enthusiasm for thisaspect of pathology both by pathologists andclinicians, apart from a handful of scientificallyorientated physicians who are still anxious to seethe lesions which they are treating and their endresults from which so much can still be learnt.

Perhaps the greatest change which has pro-duced real trends in pathology has been a tran-sition from the anatomical approach, which wasthe dogma of all the earlier pathologists of thefirst third of this century. to the realization of theimportance of the functional aspects of diseaseprocesses. Pathologists in the 1920s were begin-ning to show how laboratory tests could be usedto demonstrate minor changes attributable tothe effects of early lesions and how these could beused for diagnostic purposes. These trends werecertainly most noticeable in Great Britain andNorth America but in Europe and South Americapathologists lagged behind. Perhaps this was dueto the fact that in this country there would usuallybe only a single 'department' of pathology, andfrequently there was one head of departmenteven in a teaching hospital, and certainly in anon-teaching hospital. In Europe the Germanictradition of separating morbid anatomy and

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histopathology was rigidly maintained and clin-ical pathology was, and has remained, an entirelyseparate discipline. These laboratory doctorswere generally regarded as renegades from truepathology. However, departments of bacteriologywith university chairs were already becomingrespectable, and eminent scientists saw in thisnew subject opportunities both for research andfor the application of these sciences to theclinical fields. Such then was the situation in the1920s when Dyke and others, trained as doctorsand pathologists, felt the need to maintain aninterest in the patient as a whole and not only inhis secretions, excretions, and severed parts.They started this society deliberately in 1927 as apositive manifestation of the new trend forpathologists. Clinical chemistry, which had itsbirth amongst the physiologists of the day, wasemerging with great rapidity and promise, albeitwith very limited effectiveness because techniqueswere slow and cumbersome, using great volumesof blood, and not rapid enough to produce resultswhich could be of immediate value in therapy,although already useful in diagnosis. Someteachers of physiology began to use their depart-ments not only to teach clinical chemistry as asubject applied to clinical medicine, usingpatients on whom to demonstrate the effects ofthe changes caused by disease even before thestudents had been attached to a medical unit, butalso as diagnostic departments; today we wouldcall this a new integrated method of teaching!Haematology had not yet emerged as a separatesubject for study and practice. The few bloodcounts which were done were mostly performedby medical students straight from their physio-logical laboratories. Sir Arthur Hurst, a man ofno mean repute as a haematologist, was excep-tional in that he would only allow two selectedsenior students to perform his haematologicalinvestigations. Perhaps this was because thedifferentiation between primary and secondaryanaemia depended almost entirely on the colourindex, and it was astonishing how often all theother students contrived to make this come out toexactly 1, so that the onus of diagnosis was putback to the physician and not to the student whodid the count. The horizons in haematology wereon the whole limited to these primary and secon-dary anaemias and the leukaemias, and theirdiagnosis was entirely in the hands of physiciansand their students who used side room labora-tories.The purely morphological aspects of the blood

disorders, which had begun to show diminishingreturns, led to a shift to other aspects and todramatic advances in the subject. The discoveryof the blood groups and the immediate applicationto safe blood transfusions started the great ad-vances in immunohaematology, a subject now ofsuch depth and ofenormous interest to haematol-ogists, geneticists, immunologists, anthropol-ogists, and forensic scientists.

The Impact of World War H on Pathology

The impact of World War II on pathology wastremendous in many parts of the world. InBritain much could be attributed to a combin-ation of the statesmanship of Sir Philip Panton,who had so much to do with the design of thepathological services of the Emergency MedicalServices, the energy of Sir Graham Wilson, whobrought bacteriology to the masses under theguise of possible enemy bacteriological warfare,and the three heads of the separate armed forcespathological services which had to expand sovery rapidly. Suddenly an organization of path-ology and pathologists took shape. Not onlywere pathologists to become part of a country-wide national service in one form or another, butnow young doctors were being specifically recruitedfor training in the four branches of pathology.These trainees were given a two-year rotationaltraining in selected laboratories, their trainingperiod more or less evenly divided into the foursubjects, and were thus being prepared to take oversmall Service laboratories abroad or similar postsin the EMS at home. There was no way ofassessing the value of this training, but the calibreof the trainee and the sort of advancement he wasworthy of were quickly noted. Certainly thisscheme, together with the Services schemes, helpedto prepare for the explosion in pathology thatwas inevitably to follow the end of the war. Andpathologists, many of them perhaps only partlytrained or of only limited specialized experience,were nevertheless available to take over thenew laboratories which were now needed.Physicians and surgeons had become used tomany more investigations being done on theirpatients and were beginning to demand a varietyof tests. The final push came with the start ofthe National Health Service. The rate of growthwas startling, even phenomenal. Where facilitiesalready existed. increases of 15 to 40% in workload per annum were being recorded, and allsorts of buildings were being converted to labor-atory use. Biochemistry led, and haematologywith its serological impetus, and microbiologywith the introduction of antibiotics, virology, andelectron microscopy as the stimulus followingclosely behind, but histopathology lagged some-what and was only much later stimulated by theintroduction of the new techniques of fluorescentmicroscopy, electron microscopy, tissue culture,genetics, and exfoliative cytology. Because of thisgrowth the concept of a central laboratory wasan inevitable consequence. The London CountyCouncil, having taken over the old hospitals ofLondon in 1929, provided six laboratories to dothe work of all the hospitals, each central orgroup laboratory serving up to a dozen or morequite large hospital units. This was a remarkableachievement although it only scratched at thesurface of the appalling lack of facilities forpathology in London. At this time too pathol-

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ogists were feeling that some form of qualificationin pathology of a standard equal to those ofother royal colleges was needed to put the speci-alty on a proper senior footing. The final phaseof respectability was thus achieved by the move-ment initiated by this Association for the for-mation of our College. The impact this madeon pathology cannot even now be fully appre-ciated. but after such a short life the Collegeachieved its Royal Charter. We have arrived!

Halcyon Days

The last 10 years were halcyon days for thehospital pathologist. Now he and his disciplinehad reached a peak. He prospered and multiplied.His departments mushroomed and spreadthroughout every available corner of a hospital,including houses taken over in the immediatevicinity, and he accrued to himself an army ofhelpers who were put to work turning out theincreasing number of tests and examinationsthat, stimulated by the pathologist, the clinicianwas demanding. In some parts of our presentpractice we have achieved an ominous legalimplication. In the same way that you would nolonger choose to treat or dismiss a possiblefracture without an x-ray examination, it may gohard with a doctor who diagnoses or treats anumber of conditions without proper laboratoryinvestigation, confirmation. and control. Thepathologist's standing in the profession is now atits zenith. Amongst our colleagues we have had aPresident and Vice-President of the Royal Society,Fellows of the Royal Society, and even a Presidentof the Royal College of Physicians.

Paths to Disintegration ?

But pathologists, having at last achieved somesort of unity, provided an examination qualifi-cation of a good standard, are now about to de-stroy the concept of pathology as a scientificsubject by having our four limbs torn apart by thesame expansionist ideals that founded the Asso-ciation and the College. There are many seniorand very serious-minded colleagues who nolonger see any connexion between the fourbranches of pathology, and their reasoning hassome substance. They see no purpose whatsoeverin their juniors undergoing a training or beingexamined in anything but their own disciplines.They feel that early specialization is essentialnowadays, and budding biochemists, for example,would be wasting their time and talents doingnecropsies or emergency cross-matching duringtheir training. Many colleagues are even agreedin fact that a medical qualification is an unneces-sary luxury and that again more specific specialist

training should start as early as possible and sobring increasing benefit to their particular branchof pathology. Sectional interests within patho-logy are already served by their own societies.TheAssociation of Clinical Biochemists, the Patho-logical Society, the Society of Medical Microbio-logy, the Society for Haematology, and theCytology Society, all contain ACP members, andmost of their members could qualify for member-ship of the College. If any such pathologist feelsthat he is adequately represented scientifically andpolitically by his specialized association or society,this will be the death knell of the ACP and, I fear,eventually perhaps of the College. We are theonly two bodies in which all branches of pathologyhave an equal representation and in which thebranch of biochemistry, for example, can havedirect influence on another branch, for instance,on the practice of histopathology. I have usuallyfound that biochemists do not mind wielding thisinfluence, but resent being influenced in return.This common ground is the basis of the unitythat has provided us with the powerful voice withwhich the profession speaks most effectively tothe Department of Health. If the Department hasto deal with each separate society, we will haveachieved a 'divide and rule' situation which Idoubt would benefit the progress of pathology inthis country. After all, the College as an organiz-ation only reflects the conditions of our betterorganized laboratories where members of eachsection have an opportunity to discuss mattersamongst colleagues before the laboratory as aunit, speaking with one powerful voice, cansubmit proposals more effectively to its authority.If feeling in the ACP and/or College is strongenough then perhaps the difficulties could beimproved by forming sections with their ownofficers, who could make up the main body of theCouncil, with a smaller number of directlyelected members.

It is not at all surprising that the demand fortrained pathologists has overtaken the supply,and we are now facing a shortage of trainedpathologists. The attractions at the top of theclinical branches of medicine are very great andthe reasons for a young man entering pathologyare often obscure, even to himself. The vastexpansions in laboratory medicine have createdanembarrassing situation for laboratories whichcannot attract enough doctors. We are not clearhow many pathologists are practising and howmany are in training but the ACP has producedevidence which suggests that the number ofpathologists in training is falling far short ofnational requirements. The increasing load oflaboratory work is therefore falling more andmore on graduates and technical staff aided bymechanization and automation. The wholeapparatus of clinical pathology will have to bestudied afresh and eventually the position of thepathologist may be called into question. After all,if laboratory examinations can be performed and

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the answers produced by graduates, technologicalpersonnel, or even by unskilled labour attendingand feeding machines, what is the function of thepathologist, that expensively trained doctor, inthe laboratory? Will pathologists really have tocompete for the same opportunities as theircolleagues in the laboratories? Shall we be ableto afford trained doctors, who will inevitablydemand a higher status and salary compared withcolleagues in the laboratory because of theincreased length of training, with the corollarythat clinical salaries must be higher than otherseven in the universities? How does this trendaffect the present and immediate future ofpathologists? Our chemical colleagues, whoinevitably lead in this matter, have themselvesbeen divided, and do not speak with one voice.A past President of the Association stoutlymaintains that the functions of the chemicalpathologist and the biochemist are quite different,though overlapping and complementary. Othersof equal distinction see little or no difference,and hospital and university posts are beingadvertised as being available equally to a medicalor non-medical graduate. This, to me, is anobjectionable compromise as it means that theauthorities do not know what they want and thatprofessional men in charge of similar departmentswill be paid at different rates for the same job.This is untenable. The Zuckerman CommitteeReport does nothing to clarify the situation, and Ibelieve that if the trend continues the chemicalpathologist will quickly disappear-after all, whyindeed have a medical qualification which takesall of seven years when the same level in a pro-fession can be reached without? It may even be adisadvantage in the long run because of the age atwhich seniority is reached. The Royal College ofPathologists, by a considerable majority, at itsfoundation agreed to non-medical membershipand has facilitated the entry by examination ofscientists in various fields of pathology. Again,naturally, the options have been taken up first bychemists and the College has many non-medicalbiochemical members. The ACP has alwaysrecognized the situation by inviting senior scien-tists to extraordinary membership. We shouldremember that the open-ended structure oftraining for technologists, which many of us havestrongly supported, will shortly enable them toadvance their status by means of a graduatefellowship, which will mean that the giftedtechnician will be given the opportunity later tosit for the MCB and then to become a Member byExamination of the Royal College. I am certainlyin favour of this, and in our membership of theAssociation we have many very distinguishedpathologists who started their careers as youngmen working as technicians in laboratories. Whatis now a rarity might become a positive trend inthe future.What I regard as imminent in chemical

pathology merelv points to the way which other

subjects may well follow. Certainly the trend isalready evident in microbiology and in haema-tology where science graduates have been en-couraged to take postgraduate training in thesesubjects and posts in routine and/or in researchdepartments, and no doubt in the future they willfully man these deparments too. In immunologyand in cytology the highest status has already beenachieved in these relatively newer spheres bydistinguished non-medical scientists, and in factit has probably been easier in these newerdisciplines to integrate the medical and non-medical scientists. This leaves, as far as I can see,untouched and I may say sometimes unmoved,the fairly entrenched histopathologist who seeslittle or no threat to his branch of pathology. Is itso unthinkable that necropsies could be done bynon-medical staff (I could quote in fact manyinstances of this in forensic pathology) or thatthe preparation of histological sections will befully automated and that machines will even beable to distinguish the main patterns of histology?Perhaps this trend is too far ahead to matter, butthe problem will, without doubt, emerge in oneform or another in histopathology. It will be nodefence to say that such positive diagnoses, asfor example in the malignant conditions, are soimportant that these must be made by a doctor.We already see in cytology malignancy and itsgrading being determined by highly skilledtechnologists, and the medical cytologist oftenacts only in confirmation and as the intermediarywith the clinical staff, but even that interventionmay be superfluous.

Forensic pathologists have improved theiracademic status by an increase in the number ofuniversity chairs in the subject. However, thebulk of the necropsies being routine work, arestill done by morbid anatomists (and sometimesother pathologists) who are primarily hospitalpathologists. Criticism of this state of affairs iscontinually heard, but mostly concerns theoccasional abuse by individuals and the failure tofulfil their commitments to their hospitals. Thetrends in this subject are no less confusing. Wenow have forensic scientists who specialize in awide range of detailed scientific investigationswhich will and must affect the status and auth-ority of the forensic pathologist. In a recent radiobroadcast Professor Camps was making the casefor the pathologist, who said 'Forensic path-ologists of the Spilsbury type are passing-thesetimes are finished-we must now work as a team.The forensic scientist will come up with the resultsof tests but a doctor must be the one to providethe materials for the scientist in the first place andwith his knowledge of medicine to interpret theresults'. I thought this sounded a rather weakreason for maintaining the status quo. I can seehere again only a short step to the scientist takingover all but what is regarded as the chore of thenecropsy itself.Do we see in all this rather confused and

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disturbing situation any real threat to the statusof the pathologist, a status so recently achieved inso many parts of this country and of the world,and to the ACP and the College, so newly formedand honoured?

Let me turn to a slightly different problem. Anincreasing number of doctors in the whole field ofmedicine are involved in some form of scientificresearch. This is being done in departments ofmedicine, surgery, and gynaecology, and hasmeant that these departments have had to beprovided with laboratories and graduate andtechnical help, and in fact such research hasturned them into specialized departments of path-ology and pathophysiology in the widest sense.They have, inevitably, been placed in an invidiousposition of competition for laboratory space,technical staff, and even money with the 'routine'laboratories, sometimes to the disadvantage ofthe latter. Some pathology laboratories have thusinevitably been slowly relegated solely to theprovision of a routine service, and they have metthis particular challenge by improved method-ology. Much energy has inevitably gone into themethods of performing accurately large numbersof tests with the maximum efficiency, speed, andaccuracy. Mechanization, automation, and dataprocessing with computer aid have producedwhole areas of new thinking in our laboratories.First having set up the machinery, we must feedit and it is then found to be easier to centralize theworkshop and so more effectively use the machine.Therefore the tendency is to have huge, accessiblelaboratories doing hundreds of tests a day,excellently controlled as to quality and, as is oftenquoted, it is then easier to do all the 12 or 15 or25 tests that the machine is capable of performing,Therefore we are now amassing a huge volume ofdata which may or may not ever be used. Thistendency must shift the accent away from thebedside, and chemical pathologists are alreadybecoming aware that they must at all cost main-tain contact with patients and their doctors, anda swing back to clinical chemistry and metabolicmedicine is urgent. In the United States the situ-ation is taking a curious direction where commer-cial firms are moving into the field which oncebelonged exclusively to pathologists. Not only arechemicals and reagents packaged and apparatusautomated and data processed, but in one part ofAmerica a commercial firm has a clinical lab-oratory staffed by four pathologists and servicing31 hospitals.On the other side of the coin, some clinical

departments with small technical staffs havesometimes produced results which do not standup to scrutiny because of lack of quality controlwhich would have been mandatory had the workbeen carried out in the adjacent department.Certainly in some surveys results from differentlaboratories, even in one hospital, seem to bearno relation to each other. The idea that alllaboratories in one hospital should be centrally

housed is a concept which we should encourageso that men and ideas should constantly beinterchanged. The old side room and smallisolated converted attic lab should disappear.There is also a growing movement towards theconcept of the 'common user' section in largelaboratories.Today we must accept the situation that path-

ology and pathologists are in a sense the meat ofa sandwich, which is being squeezed by the pres-sures on the one side by science graduates, whoare taking more and more responsibility first inareas of shortage but now in full competition, andon the other by clinicians who a few years agomight have had little or no training in scientificmethod, but are now in charge of growing depart-ments with more and more scientific output. Ourfounder and his contemporaries had little doubtwhere they stood and where they were going andfor 40 years made a huge impact on the practiceof medicine, particularly in Britain and the USAand the English-speaking countries. But I amconvinced that we cannot remain in this staticposition. I think that there are three choicesbefore us.

Three Choices Before Us

First, the move by the Royal College ofPhysicians in recognizing the specialty of clinicalhaematology has highlighted the problem in thisbranch of pathology. Many young, aspiringhaematologists have probably by now opted totake the MRCP and specialize in haematologythat way. According to an agreement betweenthe Colleges, they would not normally expect totake charge of the haematology laboratorywhich would be reserved for holders of the MRCPath. This agreement puts the question: Will ourfuture pathologists revert once more to beingphysicians who, not by accident of appoint-ment or later inclinations but by design andintention and training, will be physicians incharge of patients with blood diseases, metabolicdiseases, infectious diseases, and immunologicaldisorders, and will be associated with thelaboratory aspects of the work as were the earlyscientifically minded physicians. This pathologist-physician would have a place in the departmentin which to carry out any laboratory investigationshe might wish but would not be in charge of thelaboratory unless he qualified so to be by means ofthe MRCPath. Otherwise the laboratory wouldbe run by a non-medical scientist qualified to doso. This is quite a common pattern now in theUSA and in European countries.The second choice is to forget about a medical

heritage and join in the scientific service of theNHS and other medical services. We have out-standing scientists who are fulfilling just suchfunctions now and we could throw our lot in

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with them and make no pretence that we aredifferent.

Thirdly we can maintain the status quo, withsome modifications, and practise what we call'laboratory' medicine.

First we must decide whether we continue tostand together united in one common purpose(which is clear enough) as one profession, asspecialists in laboratory medicine (I hope we willdo this), and second, we must see exactly the roleof the pathologist and try to define it broadly.

In the USA non-medical scientists had begunto open and run their own clinical laboratories afew years ago, andtheAmerican Society of ClinicalPathologists took legal advice and action withequivocal results in different States. The matterwas later referred to the Monopolies Commissionwho ruled against the pathologists. The mattercame to a head with the advent of Medicare andMediaid, which provided an opportunity toobtain a Federal decision as to whether pathologywas a clinical and therefore medical discipline.The decision is a compromise one and non-medical scientists are now allowed to run theirown laboratories, to investigate patients, andreport upon certain clearly defined investigationalareas. The Past President of their College in arecent article told his members that they mustnow return (if they had ever left) to the clinicaland applied aspects of pathology. This I am sureis what we will do. It is at the bedside and withthe patient and physicians and surgeons that wecan be most effective. Advice on diagnosis andcontrol of therapy has always been the forte ofthe pathologist. In the past we had to mastertechniques too. Many will still with pride continueto use their hands to much advantage. But wenow have scientists and technologists whoundertake these duties more effectively and onlyrarely will pathologists be expected to carry thisheavy burden alone. Of course any pathologistwho is content to interpret without detailedknowledge and experience of techniques willinevitably fail in the sight of his colleagues, bothscientific and medical. The College examinations,I believe, take care of this aspect. The standard ofthe theoretical and practical examinations ishigh enough and should remain so to ensure thehighest level of competence in every aspect oflaboratory medicine.

One Profession within Medicine

I think we are now bound to pose again thequestion as to whether we are in fact one profes-sion. If we are, and I think at this moment we arestill united enough and can all be called pathol-ogists, then ifwe are to stay thus we have to definecommon backgrounds of training and practice.Otherwise we must confess that we are a mixtureof four or six professions within medicine, linked

only by the accident that we work mainly inlaboratories which are usually, and certainly willbe in the future, housed within one complex.Whichever stand we take on this point, the

next question is how much are we and the medicalprofession as a whole willing to tolerate or encour-age dilution? I use the term 'dilution' deliberately,but I know you will understand that I do not useit provocatively. We are facing the dilemmaearlier than other sections of medicine, but I haveseen medicine broken down in an emergencysituation whereby young volunteers can be trainedto vaccinate, to deal with certain aspects ofhygiene, to become specialists in one narrowlydefined disease, for example, the treatment oftrachoma (and it can work), but this is surely aretrograde step only acceptable in situations ofextreme necessity.

I believe that if we accept this trend withoutcomment we will be the first to start the process ofthe disruption of the unity of medicine. We will nolonger produce men of sufficient breadth of visionable to view the whole vista of pathology, letalone the broad sweep of medicine. I believefirmly in a unifying concept of medicine and thefunctioning within medicine of teams of peoplewho must be able to see and understand andcontribute to the patient as a whole. I doubttherefore whether the 'single line' trained path-ologist will really provide the answer to ourproblems, although we may be driven to encourag-ing the technologist trained in a single subject.

If this unifying concept in pathology is toflourish, I would like to see the entry to allbranches of pathology through one primaryexamination which would cover all the scientificbases of our subject. Without going into greatdetail I should like to see our young traineesgiven a thorough grounding in cell biology, cellpathology, biochemistry, physiological measure-ments, isotope techniques, microscopic tech-niques, and so on, which would provide acommonbasic training and examination and enable thecandidate to proceed to the final of his choiceafter adequate laboratory experience coveringthe overlapping areas of four or five disciplines.I am not worried about the final examinationswhich, I believe, are excellent.

Finally, I would speak briefly on the ultra-specialist, that is, the man who eventually con-centrates on one organ or one disease. The day ofthe 'generalist' seems to be rapidly passing andnot only in pathology. The Times CricketCorrespondent, analysing the end of the season'sfigures, laments the passing of the great allrounders and points out that this year no onehad achieved the coveted double (for our Scotsfriends 1,000 runs and 100 wickets). More andmore pathologists are finding great academic andprofessional success and satisfaction in limitingtheir life's work to a narrower specializationwithin pathology. Great reputations have thusbeen made in neuropathology and neurochem-

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istry, bone pathology and bone chemistry,gynaecological pathology and related hormonechemistry, paediatric pathology and chemistry, ordisease of the thyroid, the adrenals, or withinhaematology in clotting disorders, immunohaema-tology, or haemolytic disorders, and it may wellbe that the pattern in pathology of the future willfollow, as medicine itself might do, the study ofan organ in depth, covering all aspects of labora-

tory medicine in relation to a specific organ.

If, as I hope, the future trends follow thedirections I have indicated, then I see a brightenough future (which will attract young men) forpathology and for pathologists who, having longago discarded their image as backroom boysand boffins, are now in a position once more tocement their efforts and continue to hold togetherthe scientific bases of medicine.

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