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 SPECIALTIES  IN  MEDICINE,

       By HENRY D.  NOYES,  M.D.,  [y^
         Surgeon to New York Eve and Eab Infibmaby.


READ BEFOEE THE AMEEIOAN OPHTHALMOLOGIOAL SOCIETY,
            JUNE, 186 5.
John MEDOLE^rtoteHJtJhSnieB Street, N Y
 
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SPECIALTIES  IN  MEDICINE.
  In every subject of scientific study the progress of investi-
gation and the accumulation of knowledge must reach a point
where it becomes a serious task to master all its facts, or to be
acquainted with all that has been written about it.  When a
great number of zealous observers are bending their energies
in a common  pursuit, it  happens  after a time that not the
oldest and most eminent  among them  can possibly attain to
a perfect acquaintance with all that is known about it.  For
example, the ardor of geologists during  fifty years  has ampli-
fied the science until it can hardly be expected of any that he
shall be conversant with all the details of the earth's mass and
structure.   Among botanists, no one can enumerate the entire
flora of the world and their minute peculiarities.  What chem-
ist can exhaust all the facts of his great study in a statement
perfectly comprehensive, and without omission of details ?
  From the  extension of knowledge, as well as from the
brevity of life, and the limited capacities of the mind, investi-
o-ators have been compelled to limit their researches to small
portions of their chosen field if they would  contribute  any-
thing valuable to  the  stock of facts.  In short, not only is it
impossible for  one mind  to  gather to itself the universum of
knowledge within the usual  period of a lifetime, but even in
particular branches of study the task has become so heavy as
to be beyond  human attainment.  The well-known anecdote
of Newton need not  be  quoted.   It is  not to be  denied
that  some men obtain extraordinary success  in grasping  a
multitude  of facts, and in reducing  them to systematic and
logical order.  They are the master  minds of their age, and 
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their names will be enduring as human  memory.   But gifted
men, like Erasmus, Bacon and Humboldt, are the astonishment
of mankind, and were we obliged  to wait for their advent in
the cause of science, the accumulation of knowledge would be
at the rate of progression in geologic eras, while the mode of
progress, instead of being by gradual accretion, would be an
alternation of  long and dreary ages of stagnation  with brief
times of dazzling splendor.  Such, however, is not the order
of things.  The processes  of nature and the growth of human
knowledge are alike.
  Increase is by slow additions, by patient and pains-taking
observation.  A multitude of workers, each bearing the little
burden  which  he  has gathered from the path where he has
wandered, cast in their contributions, and as the decades pass
the stately pile of human knowledge creeps upwards; it slowly
assumes harmonious proportion, broadens  its base, and lifts
its  soaring height.   The rising of an  ant-hill, the building of
Cheops, in one sense  arc typical of the increase of science; but
these limited  and finite  models  are far from  being perfect
representatives, for  science is the  gleaning  of gems from  the
exhaustless mines of knowledge, whose storehouses are  the
recesses of the infinite mind; to neither may we venture to set
bounds.
  If, now, this be the way in which science advances, how is it
in the applications of science to useful art ?  By useful  art I
mean the  adaptation of scientific facts and deductions to  the
u^cs of mankind.  Can practical application go on in advance
of the discovery of data?   Can implements be  made without
material?  Can fabrics be woven without both  material and
implements?   Useful arts can, therefore, make no more rapid
development than science.  In  fact, art is usually behind  sci-
ence by long stretches of distance, and these  sometimes so great
that the popular voice, not discerning their mutual dependence,
sometimes clamors against science  as dreamy and unworthy,
because it seems useless.  Science  is  its own justification- it
needs no defence any more than truth; the  one is synonymous
with the other.  But the mass of mankind are most concerned
to secure the comforts and benefits of  useful arts.   The  needs
of the body, the happiness of society, must be  provided  for. 
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Men have a right to demand  of science that  she  do not shut
up her treasures as ore in the bowels of the  earth, but freely
yield them up to be fashioned into implements for useful labor
and to minister to the welfare of the race.  Humanity  and be-
nevolence enter with authority to compel the assent of science
to their mandates.  The air, the earth, the sea, must contribute
to soften the hardships of social condition, to cure the sicknesses
of men, to soothe the pains of dissolution.
  This brings us to the subject of medicine.  It is both a sci-
ence  and an  art.  As a science, far in advance of its early
beginnings, yet mayhap as far yet from its  ultimate perfection
as from its primeval state.  As an  art its efficiency and suc-
cess depend  upon  the  fullness  and  clearness with which its
facts  are learned and  logically systematized; upon the mem-
ory and  readiness of the practitioner; upon the skill of his
manipulations; upon the fertility of his inventive and adaptive
power; and upon the keenness of his senses, touch, sight, hear-
ing, &c.   To  successfully practice  an  art, demands first the
careful study of science and also the education of the individ-
ual; or, as I  may express it, taking the practitioner in  the
sense of an instrument, he must be  fashioned into shape and
fitness in both mental and physical qualities, before he can
deal with the facts of science in their application.  To make
a fabric  for wearing apparel, science must discover the crude
cotton, silk, or wool, and prepare it for use; while art must
invent the weaving machine and bring it to  perfection.  The
physician possesses himself of facts furnished by science, which
are his raw material, and then proceeds to qualify himself to
apply them to his healing art.
  In  the  economic  arts  it may matter little if there be  a
wide  discrepancy  between the advanced state of science and
the clumsy appliances which utilize it.   Convenience and
luxury may be lacking, but perhaps  nothing more.   In the art
of medicine there must be no such  discrepancy.   Human woe
and bodily privation, the loss of health, the loss of the senses,
and the loss of life are the subject  matter of this art.  Here
there  may be  no lagging behind the front  line  of scientific
attainment; the very fore front is where the disciple of the ars
medendi must place himself and remain.  He has no business
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in the rear;  he is recreant to himself, recreant to humanity,
recreant to duty and to religion, if he voluntarily stay behiud
in the onward march of medical science.
  There frequently occurs among noble minds a sore conflict
between the demands of pressing  labor and the  monitions of
conscience and of the sense  of duty.  As such an one, to the
best of  his skill, administers to the distresses of men, he fears
that his mind may not possess all the facts which late investi-
gation has afforded upon this or that case; or that his hand
may not wield  the knife with the  correctness  and skill which
other men have acquired.  What practitioner of twenty years'
standing has not felt this burden ?  What young physician in
his first years  has not been  harrassed by the fear that he is
not doing justice to his patient, because he may not be fully
competent in the knowledge  of the case?  To what purpose
is our medical  journalism, but to furnish to the anxious, wait-
ing practitioner the latest facts, discoveries and appliances, to
be at once seized for the good of our patients.
  But is any medical man bold enough to  say that he has suffi-
ciently explored the records of the past; has stored  his  mind
with all  the wisdom of recent years, and  is every year up to
the level of modern science, so that he comprehends within his
grasp all of science, and can apply his art with  the highest
human skill ?  That no case can be presented to him in which he
cannot offer  the best  and soundest advice possible among the
medical  profession ?   Can settle a diagnosis with a precision
which no other can excel?  Can do an operation with a  dex-
terity inferior  to  no  other?  Such perfection of skill  and
knowledge no  man will venture to affirm for himself.   The
assumption would  to his fellows be the strongest evidence of
his imperfections.
  As decades pass and science and art attain greater com-
pleteness, the labor of the physician in fitting himself for his
profession becomes more  and more heavy.  As life  advances
and business multiplies, his disposable time for study of both
his own and of other men's labors  becomes less  and  less,
until it may be reduced  to  the merest fraction  of the  day.
In the  laborious rounds of practice among  thinly peopled
districts, in the hurry and press  of  large practice in cities,
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medical men strive manfully to keep  up their knowledge
of how the world of medicine moves on; but too  often they
are the first to  accuse themselves of being unable to meet the
duties of their  daily calling, and keep au niveau with' modern
improvement.  And it will be observed  that the men ready to
make this confession are or have been  the most studious, the
best qualified,  the most  conscientious  practitioners  among
the community.
   In  actual fact, regarding the practitioners of medicine as
we find them, does not every one know that but very few ot
them possess the highest fitness which medical knowledge and
skill  can reach?   This is largely due to defects of education,
both  of  an academic  kind and  in  the schools of medicine.
Men  are often  compelled, by the need of getting a livelihood,
to  enter  practice,  feeling themselves yet  very inadequately
prepared.
   Want of fitness at the outset of medical life must to a greater
or less degree  be affirmed of every one. Youth cannot claim
the attributes  of age and experience.  If  in this regard the
young doctor is at a disadvantage, neither on the other hand
ought the standard of medical attainment to be purely theo-
retical and transcendental.   It must be such as the wisdom of
experienced  and practical men deems needful.   It must fairly
represent the present; it  were folly in imposing medical qual-
ifications to seek to discount the future.
   All medical  men agree  in seeking the growth and improve-
ment of their art.   All admit that its science should  steadily
 and unfalteringly  move forward.  All will admit that the art
 cannot in any  large sense move onward faster than the science,
 and that the true way to better the art is to enlarge the science.
   Do all medical men, or many medical men, bestir themselves
 to add to the science ? Do they keep notes of facts ?  Do they
 inquire into remote causes ?  Do  they investigate collateral
 branches of knowledge ?  Do they publish to the world all their
 valuable observations  and deductions?   Every one knows the
 answer.   And why?  Mainly, want of  time; perhaps want  of
 inclination.  Wide diffusion  of their explorations frequently
 prevents  them from following out any one  line of  investi-
 gation to complete and  valuable results.  Herein is the un- 
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doubted  disadvantage of being  what  is called a  "general
practitioner."   He is busy  in laboring  at medicine  as  an
art, and  cannot readily pursue those investigations with the
microscope and the test tube, and in the laboratory, to which
the phenomena he observes invite him; nor can he keep proper
record of the facts which come before him.   This is no dispar-
agement  to general practitioners;  it is the unbending necessity
of their  lot, and  the  misfortune  of  science.  Many a man, a
willing votary of science, deplores that so swallowed up is he
in the cares, the labors and the hurry of practice, that neither
energy nor time remain  for the quiet  pursuits to which he
would gladly turn.  Could the human frame endure heavy en-
croachments on the hours of sleep, and this for long periods or
a long life, what rich contributions would multitudes of general
practitioners bring to their science.   This unhappily is impos-
sible, as many an  overwrought brain  discovers.
  The hard labors of medical  life, urged with an imprudent
zeal, are  too often stopped  by death; the man fitted mentally
to do most and best, feels keenly the brevity of  every earthly
career, and strives, by  diligence too great for human endurance,
to make  life most fruitful; but often his harvest is blighted,
because the great reaper puts'his sickle into the laborer's field.
  To sum up what has thus far been  said—the development of
medical science and the improvement of medical art are hindered
by the magnitude to which the science has attained, by the in-
ability of practical physicians to  bestow on  scientific research
the time  and labor which are indispensable to the best results.
The preparatory work in the study of medicine is so great, if
adequately done, that but few can spare time for its thorough
performance, and men must become practising  physicians to
support themselves.
  Disadvantages of early professional education of course be-
come a clog upon a man's usefulness in his art, and they almost
preclude  him from doing  anything valuable in scientific labor.
In early life, inadequate qualification; in later life, the want of
time to be spared from pressing duties, and the waste of energy
in their performance, result in disqualifying physicians from
aiding in the  rapid advance of their chosen science and the
perfection of their art. 
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   The man of ripe experience, who all his life has been a keen
and exact observer,  who  has  made  himself a judicious and
skillful practitioner, is sought for by the whole  community to
heal their infirmities—but full  of labors, he  can communicate
Ms results and opinions only to the patients whom he advises,
and to the physicians with whom he comes in  personal con-
tact.   He  dies, and the  world loses  forever -knowledge and
practical wisdom, which, stored in books, might for ages bless
mankind.  He has had no time to write.  He served well his
day and generation, but the future will owe nothing to him;
after  his  immediate friends  and beneficiaries have ceased
to utter his name, and are  in turn removed  from time, society
becomes oblivious of him.    The tombstone only  reminds
of a lost treasure, and turning  its back on what it  cannot re-
call, the world pushes on  to achieve  its allotted tasks.   Sci-
ence observes and records  as before, but has not written this
man's name among the honorable roll of her laborers.
   It may be remarked, that medical science  differs from most
sciences, in that those who  investigate and promote it are, with
rare exceptions, the very persons who apply it.   Chemistry
pursues the labors of the  scales  and  the  retort, paying  little
heed to the  practical arts.  The science of medicine  deals
with living organisms, and in  their investigation requires
the aid of  many  correlative sciences, but  its facts and deduc-
tions must  be put into immediate  practice.   Hence, in almost
all cases, the investigator in medicine is also a practitioner of
the art.
   Can anything be done to render the practice of medicine
more strictly in accord with the state of medical science, and
to render the progress of medical science more rapid ?
   Two  answers may be made to this question.  First, medical
science, it may be said, should be in the hands of those who may
give themselves exclusively to its  investigation, and leave the
art to practising  physicians.  To some extent this  has been
done.   A few names can be given of men who have dealt little
with medical practice, and devoted their lives almost entirely
to the scientific side of medicine.   These men have been teach-
ers in universities and professors  in medical  schools; they may- 
8
have been supported by governmental patronage, or, possessing
wealth, have had rare enthusiasm in medical study.
  But very few men can hold such  places, and were the ad-
vancement of  science to be given over to them, most of dis-
ease outride of hospitals would be lost  to  scientific study.
This notion is on  its  face chimerical.   Let me not, however,
fail here  to note'the name of one now living, who occupies very
much  this unique position, and whose unwearied labors  have
already done so much and been so generally acknowledged in
the world of medicine.  I allude to Prof. Rudolph Virchow. of
Berlin.
  But a second solution of the difficulty presents  itself.   It is
not of recent suggestion, while it might be. urged that it com-
mends itself to the good opinion of medical men, because it is
being every year more and more generally adopted.  This so-
lution is the subdivision of the field of labor.  This proposition,
which has universally been accepted in almost all the affairs of
life, in  the economic arts,  in manufactures,  and,  moreover,
in other  natural sciences, finds some difficulties in its applica-
tion to medicine.  These difficulties depend on the fact  that,
while medicine as a science, and considered abstractly, may be
subdivided, like any other natural science—as, for example, into
anatomy, physiology, pathology, and the functions individual-
ized to any extent, when it is brought into use—these distinctions
must,  to  a great degree, be ignored.  The  medical scientist is
at the same time art-ist (if I may apply to the word a somewhat
unusual sense.)  The  patient is a man;  his whole organism is
before us; it may be only partially diseased, but that  part bears
intimate  relations to all other parts; and sometimes  is insepar-
able from the whole.  From this circumstance some infer  that
a subdivision of medicine is, in practice, impossible.  The point
of inquiry is, whether, under some conditions, a  subdivision of
medical science  and art is not only possible, but whether it
is not attended by  extraordinary advantages.
  What  principle  shall be adopted in drawing lines of demar-
cation and division across the field of medicine?  No a priori
consideration can be appealed to in such a matter.   The only
safe guide will be the teachings of experience.   It  might be
said that the several functions of the body would  be proper 
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subdivisions—for  example, digestion, respiration,  circulation,
excretion, generation, innervation, the special senses, &c.  To
be sure this has in part been adopted, but respiration  and cir-
culation are usually studied together; innervation and circula-
tion are both inseparably connected  with all other functions;
while excretion belongs both to the  digestive and to  the  res-
piratory apparatus, as well as to the  kidneys and skin.  Both
anatomy and physiology fail to  give  perfectly unobjectionable
divisions.
  The only guide will be to take those subdivisions which
have in actual trial been shown  to be practicable  and ad-
vantageous.    The  following  are some of the  subdivisions
or " specialties " which have been successfully made.  Diseases
of the brain, mind, and nervous system;  long have these been
isolated in  the establishment of hospitals  and  asylums for
the  insane.  Diseases of some  of  the special senses,  the  eye
and the ear, and it may be remarked  that there is no necessary
connection  between them, as many seem to think; the senses
of taste, smell and touch  have never been isolated in practice.
Diseases of the teeth, long ago  consigned to a special  class of
practitioners; diseases of the throat;  diseases of  the  skin, in
eluding its appendages,  the  hair  and nails; diseases of the
chest;  diseases of the genito-urinary  organs, both in the male
and in the  female—the latter have  been separated from the
former.  Midwifery has  by some been  exclusively practised,
while only venereal diseases have been attended to by others.
Furthermore, surgeons  have  in Great Britain  divided  them-
selves  from so-called  practitioners of medicine; this distinc-
tion is becoming universally acknowledged.
  Besides  all  this,  other subdivisions have been made,  and
which  have been vaunted in a pretentious and unworthy man-
ner, by persons claiming almost marvellous abilities, and guilty
of most unseemly conduct.   Such are  the  corn  doctors, the
bone setters, the electricians, the  pimple doctors, the hair re-
storers, the  pile doctors,  &c.   These  men having been styled
specialists, have caused a portion of the odium belonging to
their evil practices to fall upon those  who maintain an honora-
ble  position, while they cultivate only  a limited field of practice. 
10
This sentiment will  no longer continue  when special  depart-
ments of medicine fall into the hands of right-minded men.
  The object sought in specialties  is the attainment of more
perfect  skill in practice and  more rapid advance in science.
That a higher perfection in art is thus made possible, is apparent
form the great frequency with which cases of a similar kind are
treated.  The ear becomes sensitive to  nice distinctions of
sound; the eye instantly recognizes differences of  form and
color, and instinctively notes features  making up the  tout
ensemble of disease, which eyes  less familiar must  slowly
analyze and combine.  The accustomed phases of disease are
at once  anticipated, and departures from  their ordinary course
arrest immediate and  eager attention.   Wise  discrimination
in the choice of medicine follows, as the necessary result of
daily  familiarity with its  effects  in particular cases.    The
practiced hand has learned to do its delicate and momentous
work with unerring certainty, and with entire confidence  in its
own powers.   Success vindicates the homely adage that " prac-
tice makes perfect,"  in results so brilliant, so noble,  and so hu-
mane, that no one can gainsay its truth.
  In promoting the  growth of  science do specialties offer de-
cided  advantages?  The answer is, sound deductions maybe
drawn from the tabulation of  a great wealth of cases.   For
example, the  ratio of success  in extraction of  cataract  may
be taken from the results of more than a thousand ca>es  done
by one operator, Prof. Grade, of Berlin.  The  annotation of
cases  becomes easier, because  it can be  greatly systematized
and simplified.  General features  being thoroughly  under-
stood, data of  time and peculiar varieties only need  to be spe-
cially noted.   The mind of the observer  does not become dis-
tracted  by being called in many and  wTidely different direc-
tions;  he cannot only inform  himself of all the past of his
specialty, but can in  this limited field become perfectly  cogni-
zant of the present.  Earnestly and constantly bending his
thoughts on comparatively few problems, and  gaining  large
opportunities for observation, the specialist has  an advantage
for  making new discoveries and reliable conclusions far be-
yond one who sees fewer cases and can think less about them.
  I have spoken of  specialists, and have, perhaps,  been sup- 
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posed to mean only those physicians who announce themselves as
giving their attention to particular diseases, to the exclusion of
all others.  This is the generally understood sense of the term.
But we all know that men who for years have  followed gen-
eral practice, often acquire reputation for skill in certain  dis-
eases, and come to addict themselves more and more to treat-
ment of these, to the neglect of  others.
   Here  is the vindication of my plea  for specialties;  the or-
der of nature and of  events has proved that it is wise to group
diseases into classes,  and useful to refer the treatment of them
to hands which constant familiarity has rendered facile.  The
community  find this out, the profession admit it, and do  we not
know the men who, in a particular district, will be consulted
in diseases of women, of the joints, of the blood-vessels, of the
eye, to be those who,  if they repudiate the questionable honor of
the name " specialist," are to all intents and purposes occupying
the same position ?
   I come now to a vital point  in this discussion.   I have been
arguing in favor of those who  early in professional life set
themselves  apart from  other practice, to the pursuit of a par-
ticular  branch.  That  any man  has an abstract right to do
this none will question, nor does  anybody challenge so plain a
proposition.  But the question is vital  to the welfare and dig-
nity of  a noble and learned profession, Avhich must jealously
hold high its standard of intellectual attainment for those who
seek entrance  into  its ranks:—what  amount of  knowledge
should a specialist possess?  May he know only that depart-
ment which he calls his specialty ?   May he ignore all the rest
of medicine?   May he cultivate his specialty as a stone-cutter
chisels his own block, and knows  nothing of the grand edifice ?
May a man begin the practice of eye disease, of  skin disease,
of syphilis, without knowing anything, or only a mere smattering
of the principles of medicine, or the theory and practice of all
disease ?  Here will  be found the dividing line between those
who strive for  honorable position  among a noble profession,
and  those who seek only their selfish aggrandizement, and care
for nothing so much as for money.   Herein will  be found the
distiction sharply cut and cropping out between  the members
of a profession and the craftsmen of a trade. 
12
  With the latter, in the pursuit  of useful and honest voca-
tions, earning their daily bread, I have  no fault to find, but
render due praise and pay for work honestly done.   But when
I rise from the level of handicraft and mere manual labor, and
pass to the ranks of the  scholarly and learned, of the benefac-
tors of the race, of those in whom men confide at their times
of sorest need, I leave  behind the contracted, the sordid, the
selfish.  The true  physician seeks to enlarge his  knowledge
beyond the immediate confines of his profession—the specialist
can lay no claim to honor  and respect if he permit himself to
shrivel into the scanty limits of his little shell, and know noth-
ing outside its impenetrable crust.  The specialist has no claim
to be an honorable physician who has not first gained its de-
gree by study and fair examination. He must be well educated
in general medicine and surgery, and in all their departments;
he should not only know  them  after the manner of the fresh
graduate, but he ought to know  them practically.  He  should,
if practicable, seek this education in general hospitals.  When
thus made ready for the wide responsibilities of general prac-
tice, he  is  in position to choose a  specialty  if he list.   In  no
other way can he become a fit specialist; no otherwise can he
comprehend the dependencies and sympathies of the  human or-
ganism.  No part or organ can be isolated from the rest of the
body in health; nor can  it be  isolated in the phenomena of
disease,
   The syphilologist must know all of human structure.  The
uterine physician cannot  shut his  eyes to the complex sympa-
thies of the generative apparatus with all the rest of the female
economy.   The oculist must understand general pathology and
therapeutics, because  the  brain, the circulation, the digestive
functions, the kidneys, the uterine system, are all to be inter-
rogated if he would comprehend the diseases which  the eye
presents.   Nor may he forget  the poisons, both animal  and
vegetable, which vice and indulgence or accident may inflict
upon the  body—syphilis,  tobacco, &c.
   Let the specialist take this ground, that he has mastered all
the preliminary studies  which every physician pursues when he
sets forth in his career,  and then let him add to this prepara-
tion the further labors of his chosen department, cultivated with 
13
ardor, and to a degree which puts him in this particular quali-
fication visibly above the attainments of his fellows, and he
then need not fear a want of recognition and respect.   His fel-
lows in the profession must and will respect him.  He is one
of them; he never secedes from their ranks, nor will they have
the least disposition to cast him out.
   This  leads to the inquiry, what are the relations of the spe-
cialist to the profession? and what attitude should each hold
towards the other ?
   I have maintained that the specialist must be a well-edu-
cated physician, and I also maintain that he must not in any
way hold  himself aloof from  the  duties, the obligations, the
courtesies and the proprieties which belong to the medical pro-
fession.  He is jealous of professional honor—he is mindful of
professional courtesy.  He is none the less bound by ethical
rules than are his brethren.  His real position toward them is
that of a counsellor in difficult cases belonging to his sphere.  He
claims a peculiar skill on one subject; when other practitioners
 need counsel  in  these cases, they ask for his assistance.  They
may simply call him in consultation, or they may turn the pa-
tient over to his care.  In cither case the specialist must govern
himself by the rules which all medical men observe in holding
consultations with each other.
   Friction with his  brethren  may arise  on  two  points:
First, claiming to be a consulting physician or surgeon in his
peculiar province for the benefit of his professional brethren
and the community, the young specialist perhaps finds himself
in an anomalous position; a counsellor who has no clients; a per-
son claiming  to  be distinguished,  but whose claim has never
been  admitted.  Specialists have sometimes demanded, as their
right, that they may advertise  their pretensions in the public
prints or in the  medical journals.  The former kind of self-
proclamation is universally condemned by the profession, as an
unworthy attitude  for the member of a  liberal profession to
hold towards the community; none the less should it be con-
demned and abnegated by the specialist.   Advertising in med-
ical journals may be done as offensively as in any other prints;
but when it consists simply in the  announcement of name, ad-
dress and specialty, it is difficult to see the offensive quality of 
14
the act.  It is but the tender of services to the medical pro-
fession, which they may accept or decline:  they may or may
not admit the specialist's claims to  particular skill.   I cannot
conceive  the  impropriety of a specialist communicating  to his
'professional brethren the fact of his  practising in a special sub-
ject, and in that alone.
  The question, how he may do this, may be one of expediency.
If advertising in medical journals  be permitted by local  eti-
quette, none can find fault in it; if ic be disallowed, he were an
idiot to excite the disapproval of the profession.  He must get
at the  profession by inoffensive means;  he  may send  them his
card under cover; he may seek out their individual acquain-
tance.  If, by well-considered  contributions to current med-
ical literature, he display the reality of his  claims to special
regard, he will both make himself known to the profession and
offer the  best plea in his own favor.   I must, however, disclaim
advocating the insertion of crude or puerile papers, reports of
cases which  have  in themselves no interest, and no purpose
other than to serve the writer's personal emolument, under pre-
tence of contributing to the  welfare of medical science and the
interests of the profession.
  I hold the dignity of the profession to be as dear to the spe-
cialist  as to any physician.  I justify in him no loose morality,
professional or otherwise, any more than in any brother of the
order.  It seems to me, however, that a correct understanding
of mutual relationship shows that, to  the general physician, it
is a great help to be able to call in an emergency the services
of a highly accomplished and honorable fellow, who may solve
the  doubt, may rescue  the  patient, may successfully achieve
the difficult operation; and  that, for the case in hand, it mat-
ters not whether this aid  be rendered by one  who  is  not
ashamed  to be called a specialist.
  On the other hand, every specialist—and I speak emphatically
in behalf of young specialists—knows  full well  that his best
friends are brother  practitioners not of his peculiar branch.
If the general practitioner  find  advantage in using Ids skill,
the  specialist is indebted to him for the countenance he asks
to commend him to the community, for the most valuable por-
tion of his reputation, and for  the  direct patronage  which he 
15
bestows on him.  I do not mean by this word anything servile
on the  one hand, nor  offensively patronizing on the other.
All men are mutually dependent; all arts, all sciences  are kin-
dred; all professions  deal with the interests of humanity.   In
medicine all practitioners enter into noble competition for the
general weal.
  Acting  on these principles, mindful of each other's rights,
what jarring can mar  the  harmony  between specialists and
other physicians?  The specialist must be careful, not even in
his territory, to assume lordly airs; not to warn off all other
men from his boundaries as rude intruders.   General practi-
tioners  will and should treat all cases of disease which  fall
into their hands, for which they  feel fully competent, provided
that they do not permit ignorance of the current advancement
of medical knowledge to create in their minds an unwarranted
assumption of competence.
  Specialists naturally  belong to  densely populated districts,
to cities and large towns.  They rarely flourish in small places.
But they do not find a local practice; their name and influence
extend  over wide sections of country, and therefore they may
easily avoid all jealousy on the part of practitioners around
them, by the observance of the plainest dictates of fair dealing
and professional comity.
  This  introduces a second point, to which I must allude,
which has made unpleasant feeling against specialists.  They
have been sometimes accused of throwing out a specialty as a
bait to  allure  other and general practice.   In other words,
they impose on the confidence cf their brethren, and seek to
rob  them  of their just prerogatives.  But one word need be
said about such conduct; it is  utterly reprehensible.
  Specialties have in many instances  been to their  practicers
means of rapid professional advancement.  But the specialist
has no royal road to favor and position.  He may have keen
competitors; he may have  mistaken his vocation;  he has no
immunity from  hard and vigorous labor.  If  he claims much,
he must know much.  If he would know much he must work
zealously.   Above all, he must not set out leaping  in  a course
soon to  slacken his pace, to lag among  the  dullards, and be
consigned to the shelves of the yellow and the musty.  If for 
16
 any cause he cannot by honest endeavor and honorable efforts
 attain that success which he hoped, rather  than do wrong to
 his fellows in practice, let him lay aside all  pretences to  spe-
 cial practice, and, if need be, enter into general  practice, in
 another  place, where none  can charge him with using un-
 worthy arts to  dissemble  sinister  ends.   A  specialist who
 announces himself by approved  means as being such, must be
 that and  that  alone.  It may happen  to him that an emer-
 gency, a person in sudden  illness, a victim of an accident, a
 case of poisoning, may demand his immediate attention, be-
 cause no other help is near or could be timely.  Humanity for-
 bids him  to  refuse doing all that he can to give relief.  If
 he  be  qualified to come to  the  rescue of the sufferer, he has
 reason to glory that no  narrow  views of  what  a specialist
 should know and be able to do,  have prevented him from act-
 ing the part of benevolence in a  critical moment.   This crisis
 past, the specialist resigns the case.  It may sometimes  even
 be proper for him to continue his attendance, because of family
 relationship  or of other extraordinary  reasons.  These cases
 are, however, entirely exceptional, and  do  not weigh in the
 general argument.
  There need be no difficulties between specialists and general
 practitioners, any more than among gentlemen in  social rela-
 tions.  I doubt not the time will come when  no  one will dream
 of any necessary antagonism  among any classes  of  medical
 men who hold to the principles of honor and truth, to  the love
 of science, and to the welfare of humanity.
  Already an era of good feeling has begun between specialists
and general  physicians.   We  see  around us men in  special
practice on  terms of cordiality and confidence with all their
brethren—each conceding to the other his just  place—neither
intruding  upon the other offensive  assumptions.  So may it al-
ways  be wherever the art  of  healing  carries its beneficent
work.