SPECIALTIES, 
And their Relation to the 
MEDICAL PROFESSION. 
By L. DUNCAN BULKLEY, a.m., m.d. 
Attending Physician for Skin and Venereal Diseases at the New 
York Hospital, Out-Patient Department, etc. 
Read before the American Academy of Medicine, at its Annual Meeting at 
Baltimore, Md., Oct. 29, 1884; approved for publication 
by the Council. 
Reprinted from the Journal of the American Medical Association, 
December 13, 1884. 
CHICAGO: 
Review Printing Co. 
1885. SPECIALTIES, AND THEIR RELATION TO THE 
MEDICAL PROFESSION.1 
The title chosen for this paper is 
ambiguous and possibly a trifle ungrammaticITf but 
it was desired to express by means of the title certain 
aspects of the subject of specialism in medicine which 
are worthy of consideration, and which are better 
indicated by this title than by one worded differently. 
The topic is not “ specialists, and their relation to the 
members of the medical profession,” but the broader 
one of specialism, or the concentration of thought and 
work in one direction, however it is accomplished. 
Nor is the topic “ specialties, and their relation to the 
science of medicinebut is broader even than this, 
and looks toward the relations which those who are 
practicing and advancing medicine should bear 
toward the development of its science and art, by 
developing the separate or special portions of that 
science and art. 
The thoughts to be presented in regard to special- 
ties in medicine may be grouped under several quite 
distinct heads : 
1. Specialties—what they are. 
2. Why they exist. 
3. The relations they bear to the progress of 
medicine. 
4. The relations they bear to general medical 
practice. 
5. Specialists, or those limiting their practice to 
a single branch of medicine, or class of diseases. 
'Read before the American Academy of Medicine, Baltimore, Octo- 
ber 29, 1884, and ordered to be printed by the Council. 2 
6. The education necessary for the proper practice 
of a specialty. 
7. The future of medical specialism. 
First, as to what medical specialties really are. 
A specialty is defined by Webster to be “ that which 
is the special or particular mark of any person or busi- 
ness : that for which a person is distinguished, or 
which he makes an object of special attention.” A 
specialty in medicine is some particular branch of 
the science or art, or even some individual disease, to 
which especial attention has been given, or with 
which, from any circumstance, a medical man is ex- 
ceptionally well acquainted. In the broadest sense, 
every one practicing medicine is more or less of a 
specialist, for it is impossible to have knowledge and 
experience so evenly acquired that they should not 
be relatively greater in one or more directions. This 
is certainly so in every other branch of science. 
Now, the step from having special knowledge and 
experience in any one direction to making advances in 
this line, is not, or should not be, very great, and with 
this increased interest in and study of a branch, the 
further step into concentrating more and more of 
energy and thought upon the special ‘subject which 
has become of interest, is most natural and fitting. 
Thus it is that specialties have grown in medicine in 
earlier times; thus it is that out of the general mass 
of those engaged in the study and practice of medi- 
cine, one and another has in times past emphasized 
and developed one portion and another of the vast 
field in which all have labored. Thus, from the con- 
glomerate mass of diseases, individual ones have been 
carefully differentiated, groups and classes have been 
established, and the field of general medicine and 
surgery has been greatly cleared, and much light has 
shone through what was almost impenetrable dark- 
ness two hundred years ago. 3 
This development of the science and art of medi- 
cine gives in part the answer to our second question : 
2. Why do medical specialties exist ? 
The answer to this is comparatively simple : First, 
It is because the entire field of medical knowledge has 
become so vast, and the advances in it so great, that it 
is an absolute impossibility for any one mind to per- 
fectly grasp the former, or to follow and comprehend 
the latter ; and unconsciously the choice is made by 
every one, whereby certain things are specially consid- 
ered and certain others are slighted. It is with difficulty 
now that even a specialist can keep thoroughly posted 
in all that is accomplished in his own line of prac- 
tice, and it is utterly out of the question, even if it 
were desirable, for him to read all that is written in 
his branch alone. Second, Medical specialties but 
follow the lead of other branches of science, which 
are all divided and subdivided so that no scientist 
pretends to grasp the whole perfectly. In the other 
professions the same has taken place; in the law the 
lines of knowledge and practice are distinct between 
civil and criminal law, real estate, patent-office, in- 
ternational, and other departments of the legal pro- 
fession ; in mechanics, naval, mining, mechanical, 
and civil engineering are all quite separate depart- 
ments of work ; and so on of many other professions 
and occupations. Third, Medical specialties exist 
because there is a public demand for them, and the 
supply follows accordingly. The public wish, and are 
willing to pay for, the highest attainable knowledge 
and skill in regard to each and everything relating to 
the practice of medicine, and successful dealing 
with diseases which have previously proved obstinate 
or distressing under treatment, will inevitably lead to 
increased confidence in the individual who gives re- 
lief, and invariably tend to enlarged opportunities in 
the same direction. Thus, were the entire profession 
at any one time to be placed on a perfect equality of 4 
knowledge in a community, a greater or less degree 
of special practice would unconsciously develop, and 
certain members would, before long, stand more 
prominent than others in particular lines of work. 
This leads us naturally to the consideration of our 
third topic : 
3. The relation which medical specialties bear to 
the progress of medicine. 
As we have seen, specialties are the natural and 
necessary outgrowth from the progress of medi- 
cine. They have not arisen from any premedi- 
tation or desire to split up the subject of medicine 
into many disjointed parts, but they are only the 
long, far-reaching roots which the parent tree of 
medicine has sent out to draw sustenance from the 
deep and hidden springs of wisdom and knowl- 
edge, in order to minister to the growth and devel- 
opment of the trunk and branches, which in turn 
bear the leaves and fruit of healing. To oppose 
specialties is to sap the life of the entire science and 
art of medicine. Who can deny the gain which has 
resulted from the first great specialty, namely, sur- 
gery, or who can compute the lives and suffering 
which have been saved by those who have devoted 
special attention to this branch, even to the exclu- 
sion of ordinary medical practice? Subdividing 
this branch again, who can estimate the value of the 
lives which have been spared through the exertions 
of those who have given great attention to a single 
operation, ovariotomy? Who can be blind to the 
progress in the science and art of medicine made 
through the labors of those who have confined their 
energies to gynaecology, ophthalmology, laryngol- 
ogy, dermatology, neurology, and other special lines 
of work, and who can claim that the same advances 
could have been made by those whose thought and 
practice extended over the entire, rapidly enlarging 
circle of medical knowledge ? 5 
It is undoubtedly true that many valuable additions 
to special lines of practice have been made by those 
engaged in general medicine, of which ovariotomy, 
perhaps, is the most striking example ; but, on the 
other hand, the mass of knowledge in general regard- 
ing particular diseases has been contributed mainly 
by those whose opportunities gave unusual acquaint- 
ance with them. 
It must never be forgotten that the existence of 
specialties renders it possible to give to the medical 
profession a large amount of enlightenment and ex- 
perience in particular directions which could not 
otherwise be obtained. Thus, the gathering together 
of patients afflicted with diseases of a particular class, 
and the experience gained therefrom, enables the 
teacher to tell in a moment that which another might 
take a lifetime to acquire, and by the exhibition of 
cases, to demonstrate features of disease and methods 
and procedures of practice which another could learn 
only with the greatest difficulty, if at all, from per- 
sonal experience. 
We come now to consider our fourth topic: 
4. The relations which medical specialties bear to 
general medical practice. 
From what has preceded it is evident that as 
specialism is the outgrowth of general medicine, the 
connection between the two is very intimate; they 
can no more live apart than can the tree and its root 
live and thrive when torn asunder; the life of the 
one is the life of the other. 
It was remarked that every practitioner of medi- 
cine was, to a greater or less extent, a specialist, and 
the converse is still more certainly true, namely, that 
every really good specialist must be acquainted with 
general medicine and be able to practice the same 
with success; he cannot rationally and properly treat 
any special disease without understanding and ap- 
preciating the relations which that disease may bear 6 
to the system at large. Other things being equal, 
the best specialist is undoubtedly he who has the 
best knowledge of and experience in general medi- 
cine, and who applies the same in connection with the 
line of practice in which he is specially engaged. 
The greatest errors and harm can come from the too 
exclusive concentration of thought upon a single 
branch of medicine without a proper appreciation of 
the relations which may and generally do exist be- 
tween the organ of disease under treatment and 
other organs of the body, or the general system. 
This leads us again, very naturally, to the con- 
sideration of our next subject : 
5. Specialists, or those limiting their practice to a 
single branch of medicine or class of diseases. 
A specialist is defined by Ogilvie to be “ a person 
who devotes himself to a particular branch of a profes- 
sion, art, or science; a person who has studied and 
acquired a special knowledge of some particular sub- 
ject.” If the foregoing argument and reasoning are 
correct, a true specialist in medicine may be defined 
to be “a physician or surgeon who is thoroughly 
acquainted with general medicine, theoretically and 
practically, but who has devoted particular attention 
to, and acquired peculiar knowledge and skill in 
some special branch or department of medicine, or 
class of diseases.” The proverb poeta nasci/ur, 
non fit—the poet is born, not made, applies equally 
to the specialist as to the poet: he should be born 
out of the womb of mother medicine, should feed 
on the rich milk which nourishes all her children, 
and should grow out of the necessities of the case, 
being nursed in the lap of experience, and in full 
process of time he may develop into something use- 
ful; but to jump into the practice of a specialty, like 
Minerva from the head of Jupiter, fully armored and 
ready for the fight, can seldom be accomplished with 
the highest success. And yet many attempt this 7 
yearly; the idea seems very prevalent that a young 
man has but to secure a diploma, spend a little time 
in the study of one special subject in one of the 
larger cities here or abroad, announce himself as a 
specialist, write an article or two, and,presto, change, 
he is a veritable specialist, only waiting for patients. 
This tendency to hasty and imperfect preparation 
in the matter of general medical study and general 
clinical experience has resulted in much harm to 
specialism, and much injury to the science and art of 
medicine, as well as to its reputation before the 
world. Want of proper knowledge and training leads 
to imperfect medical observation, undue or insufficient 
appreciation of concomitant or allied symptoms or 
features of disease, and too often to unsuccessful 
treatment, from a failure to judge wisely in many 
matters relating to the individual under treatment. 
While accurate diagnosis and correct pathology are 
most essential and vital elements in medical practice, 
the broad knowledge and experience belonging to 
the general practice of medicine best fits one to 
understand and treat individual cases of disease, and 
the specialist will have but little relative success who 
ignores systemic influences, and pays exclusive at- 
tention to local phenomena and local measures. 
The practice of a specialty is, therefore, beset with 
no little difficulty, for the tendency is very strong to 
concentrate thought and attention too exclusively on 
one idea, and to see and think of only one organ of 
the body or class of diseases, and thus to lapse into 
what Lord Lytton calls “the wretched narrow- 
mindedness of every one who cultivates his specialty 
alone.” Let no one, therefore, envy the specialist, 
for in addition to the immense drudgery and mono- 
tony of seeing and dealing with the same diseases 
over and over again, and the untold labor of treating 
the thousands of free patients in public institutions, 
which give him his knowledge and skill, he has a 8 
constant struggle, if he be a true specialist, to rise 
above his speciality, and to maintain his proper rela- 
tions to the science of medicine. Few but those 
who have undergone it can appreciate the labor in- 
volved in connection with these matters, to say noth- 
ing of literary work and teaching; so that no one 
should seriously contemplate special practice who is 
unprepared for long and arduous toil. It is, I think, 
a fact, that the health of the specialist breaks down 
more commonly than that of one engaged in the 
round of general practice; certain it is that the daily 
weariness and exhaustion of one who has spent a day 
in varied occupation, out in the world, from place 
to place, with, changing scenes every moment, can- 
not excel that of the busy specialist who, going 
round and round the treadmill, day by day, over the 
same ground again and again, never seems to ad- 
vance much beyond the point at which he started. 
It is useless for our subject to enter this matter 
more fully, but many specialists will be willing to 
agree that in many things they envy the general 
practitioners—in the largeness and variety presented 
by their field of operation, in the many warm and 
true friendships formed, and in their varied and 
healthful occupation ; which things the possibility of 
a larger pecuniary success in a few instances in a 
specialty by no means counterbalances. 
We come now to consider : 
6. The education necessary for the proper prac- 
tice of a specialty. 
As may be judged from what has preceded, a 
specialist’s education should be most thorough and 
complete. In the first place, the academic and col- 
legiate education is most necessary, both for the 
training of the mind to close study and observation, 
and for the knowledge of the languages, ancient and 
modern, which are continually required in the study 
and prosecution of any special branch. 9 
In beginning the study of medicine proper, the 
idea of a specialty should be kept entirely out of 
mind, and the most thorough course of general med- 
ical study possible should be followed, with especial 
attention to chemistry, histology and pathology. The 
practical portions of study should also be closely fol- 
lowed, and later in the course as much as possible 
should be learned from clinics. If the medical man 
is subsequently to give his attention to one branch 
more exclusively, it is all the more reason that he 
should have the foundation and groundwork thor- 
oughly and perfectly learned, for it is a constant 
lament of specialists that there is so much outside of 
their specialty which they would like to know, but 
which their subsequent press of work prevents their 
acquiring. It may be stated most positively that no 
portion of a thorough medical education is wasted in 
preparing one for the practice of a special branch, 
not even obstetrics for a laryngologist, or ophthalmol- 
ogy for a gynaecologist; sooner or later every particle 
of medical knowledge which can be acquired will be 
brought into requisition. Three years is all too short 
for laying a groundwork which may be called upon 
for use many years later, to solve some doubtful ques- 
tion in pathology or therapeutics. 
On graduation, it is exceedingly important to have 
a period of service in some general hospital as in- 
terne, for two years if possible ; this is preferably to 
be in a medical service, rather than in a surgical. If 
one is to deal with only one class of diseases in his 
future practice, it is all the more necessarv that he 
should have practical and personal acquaintance with 
general diseases beforehand, and this hospital service, 
if well employed in note-taking, will be to him after- 
ward a mine of wealth of experience from which he 
may draw with the greatest comfort and benefit. All 
who have served as internes in a hospital will appre- 
ciate this, and will recall how little they found that 10 
they knew practically on leaving the medical college 
and entering the hospital. It makes one shudder to 
think of those who have plunged into a specialty 
without having thus had their studies crystallize into 
practical shape under the fostering care of the experi- 
ence acquired in hospital life. This service in a gen- 
eral hospital is of far more value, practically, than a 
residence in a special hospital devoted to the branch 
which is to be followed. 
On leaving the general hospital a service in a spe- 
cial hospital is most desirable, and forms the best 
basis for acquiring the specialty. It is painful to an 
educated man visiting the centres of medical educa- 
tion abroad, to see how little the younger students 
there from other countries know of what is well 
known at home, and much reproach is thereby 
brought on our own land and institutions. 
The student of a specialty should learn all that is 
possible here before going abroad; otherwise his 
judgment is warped, and correct impressions and clear 
knowledge cannot be obtained. Many who have 
been special teachers here will verify the statement 
that those who return from studies abroad continually 
express surprise, on their return, that so much is 
known here, and the remark is often made that if 
they had appreciated the fact they would not have 
gone abroad for study. If two or three years are to 
be taken for the study of a specialty, a certain, if not 
considerable, portion of it can be far better spent 
here first, and then one is able to determine the true 
value of what may be seen and learned abroad. 
Space forbids entering further on this topic, on which 
much might be said, as it is a most important matter, 
bearing strongly on our subject. 
When the future specialist has completed this por- 
tion of his preparation, what course should he pursue 
in regard to active practice ? For many reasons it is 
important that he should attend first to general med- 11 
ical practice. This should be the backbone of his 
life, both for the purpose of remuneration until he 
can secure adequate special practice, and more espe- 
cially in order to accustom himself to meet and treat 
patients, recognizing readily their various complaints 
and adapting himself to their different constitutions. 
He will soon enough get narrowed down to the little 
rut or track around which he must travel day after 
day, and this early experience in general practice will 
be looked back upon with pleasure and profit as he 
plods in his beaten circle in after years. 
For some reasons it is desirable for a young spe- 
cialist to secure a class of patients in a dispensary other 
than those presenting the complaints he is to treat. 
Indeed, the best is a general class of digestive dis- 
orders, including rheumatism and the various un- 
classified diseases which are often grouped together. 
This will enable him to get a wider and a firmer grasp 
on general medicine. Also, if it were possible, later, 
to secure an appointment as attending physician to a 
hospital, it is wise and beneficial to take one devoted 
to general diseases, and it would be well if all spe- 
cialists could have such appointments in general hos- 
pitals, as they would best serve them in keeping up 
their practical acquaintance with general me'dicine. 
In regard to the matter of a specialist practicing 
general medicine later, in connection with his spe- 
cialty, or confining his practice to the latter exclusive- 
ly, a few words may be said. Although theoretically, 
as has been shown, this is highly advantageous and 
proper, there are certain practical objections to it 
which render the latter course, now generally pur- 
sued, necessary if not desirable. First, in the large 
cities there is quite sufficient work for a specialist to 
do without going outside of his special line. Those 
who really get into a good practice have often all that 
they can do, and many are quite exhausted with this 
work alone. Second, the hours which the consultant 12 
is required to be in his office are such that he cannot 
well attend to outside patients, however much he may 
desire. In the cities it is necessary to have early 
hours for the business gentlemen, and morning and 
noon hours for ladies, so that with critical cases it 
would not be right or proper to delay the visit until 
after office hours, which are often prolonged, say, even 
until two o’clock or later. Third, there is always the 
danger lest a specialist, by his success in a single dis- 
ease, may make such an impression that the patient 
wishes his care on all occasions, and thus he may 
readily alienate from their regular attendants individ- 
uals who have, perhaps, been referred to him in his 
special branch. This is an experience which every 
specialist has had more than once, and one is urged 
continually to do this by enthusiastic patients. The 
only safe way, so as never to give offence to physicians 
or patients, is to avoid the acceptance of such pa- 
tients for other diseases on any account whatever; 
and this is made the easier if, after one has become 
established in special practice, he abandons all but 
such cases as legitimately come within his special 
province. 
Thus, we see, the specialist should properly grow 
out of the general practitioner, either following 
throughout some previously determined course, or 
shaping his practice as circumstances and experience 
seem to direct. 
We come now to our final topic, namely: 
7. The future of medical specialism. 
Many medical men view the comparatively recent 
growth of specialties with more or less alarm, and 
fear lest, with specialists for every organ of the body 
and class of disease, there will soon be nothing for the 
general practitioner to do, and on this ground some 
have opposed specialists and have failed to seek their 
aid, even in proper cases. This fear is quite natural, 13 
for, verily, if every case should be turned over to 
the various “ologists” who might possibly claim 
it, the family physician would indeed become but a 
distributer of patients without aiding his own pocket 
or reputation. 
But, like every other principle in political economy, 
this one will solve itself on the basis of supply and 
demand. If the public want better treatment in 
difficult cases than they have had, and if they are 
willing to pay for it, it will surely be forthcoming 
somewhere or in some way—so that the tendency to 
specialism in medicine cannot be arrested, even if it 
were so desired. In the law the patent office lawyer 
gets the difficult and doubtful cases, and the cele- 
brated criminal lawyer is retained where his services 
are most needed. 
But there is a solution of the difficulty which is 
rapidly working itself out, and which daily becomes 
more and more apparent. By the multiplication of 
colleges, post-graduate courses, and clinics, and by 
the great increase of periodical literature and of 
books, these very specialists are doing all in their 
power to enlighten the medical profession, present 
and future, not only as to what has been already 
learned, but also as to what they are daily learning 
from their extended experience. They are continu- 
ally, at great pains, giving to the medical profession 
the most careful and particular instruction, not only 
as to the grosser matters in their several branches, 
but also the more minute and special points in diag- 
nosis and practice; they are, in fact, giving away 
their most precious truths, points of practice, secrets 
even, and they are publishing widecast all that they 
use in their successful practice. An outsider would 
exclaim, “That seems incredible;” and yet it is a 
fact, and who can deny it? 
Now, what is the solution of the question ? Sim- 
ply this, the coming medical man will be educated 14 
not only in all that his predecessors knew, but he will 
acquire such an additional knowledge of the various 
special diseases to which the body is subject, that he 
will be able to treat successfully a large share of the 
ordinary cases. No specialist now claims that all 
cases belonging to his branch should come to him, 
but he seeks continually to enlighten others so that 
they can manage them, and he rather delights in the 
more difficult and obscure cases. And such cases must 
always exist, and the student of the special branch 
will come in to aid where the skill of the general 
practitioner naturally fails. 
Who then is to blame at the present time if the 
specialist succeeds in curing cases where others have 
failed to give relief? Who is to blame if other simi- 
lar cases come to him on the recommendation of 
those who are cured? Shall he refuse to give relief 
when asked ? 
The thoroughly educated and properly qualified 
specialist, then, has and will ever have his functions 
to perform in the great field of the science and 
practice of medicine, and his powers for good will 
increase, and his field of usefulness enlarge, with the 
advancing world of science, and the broadening and 
deepening of the stream of knowledge. What a 
necessity, therefore, that the formation of this class 
of practitioners should be most zealously guarded in 
the future ! what need is there that their general 
education by collegiate instruction should be strongly 
and well accomplished, and that their general medi- 
cal education and practical knowledge of the entire 
science and art of medicine should be most com- 
pletely and carefully planned and carried out to the 
letter 1 
It is recognized and acknowledged with regret 
that there are those who have entered special practice 
without the full and proper training here described, 
and that the tendency of imperfect specialism is to 15 
narrowness of mind and even to charlatanry. But 
is the evil much greater here than that which yearly 
takes place in the indecent thrusting forth ,bv the 
many medical colleges of the hosts of imperfectly 
prepared doctors of all sorts upon the community ? 
Surely the American Academy of Medicine has a 
great and noble work to perform in boldly attempt- 
ing to stem this tide of evil. 
There are certain questions of etiquette in connec- 
tion with the matter of the relations of specialties to 
the medical profession which it might be well to con- 
sider, did time permit; but this paper has already 
exceeded the limits intended, and their consideration 
must be deferred. 
In conclusion, the matters here presented may be 
briefly summed up as follows : 
1. The science and practice of medicine has, in 
company with other sciences, become so vast that no 
one mind is capable of fully grasping every portion 
of it. 
2. Unconsciously its various departments have be- 
come divided up, and from natural causes certain 
men have become prominent in various departments. 
3. These so-called specialties in medicine are so 
great and extensive each, that particular or exclusive 
attention is now devoted to them, the study and prac- 
tice in each branch being sufficient to fully occupy 
the time and thought of any one physician. 
4. The development of these branches has greatly 
increased the scope and extent of medical knowledge. 
5. Every medical practitioner should be more or 
lebS of a specialist, excelling in some particular di- 
rection. 
6. To properly follow and develop one of these 
specialties, the medical man should be particularly 
well educated, theoretically and practically, in gen- 
eral medicine as well as in his special branch. 16 
7. This tendency to specialism in medicine can- 
not be arrested ; but the difficulty tends to solve itself, 
by the education of practitioners and students in 
these specialties, so that the majority of simpler cases 
shall be treated by them, while the more difficult and 
obscure cases will naturally fall to the specialist who 
refuses to treat other diseases and confines himself to 
the practice of a single branch.