SPECIALISM IN MEDICINE. BY W. K. SIMPSON, M. D., Fellow of the American Laryngological Association. REPRINTED FROM THE Weto York i&efctcal journal for June 8, 1895. Reprinted from the New York Medical Journal for June 8, 1895. SPECIALISM IN MEDICINE.* FELLOW OF THE AMERICAN LARYNGOLOGICAL ASSOCIATION. W. K. SIMPSON, M. D., The subject of the division of the practice of medicine into its various specialties is one that has claimed the at- tention of the profession for many years, having its long list of advocates and antagonists on either side, and it will, in all probability, remain a matter of argument for many years to come; but never before has the subject been so rife as at the present time, and never before has the pro- fession been as unanimous toward the solution of the prob- lem. As science and civilization advance, the matter of simplification becomes an all-important consideration, and we naturally see it creeping into every branch of human thought and labor, marking, as it were, the first great step toward true progress and advancement. Naturally, the first great law of simplification is a proper division into compo- nent parts, whereby minor details receive their due atten- tion and a permanent structure is at last perfected. Before entering upon the subject as it concerns our own, let us see how the principle applies to some of our kindred professions. Take that of the law, for example, * Read before the Hospital Graduates’ Club, January, 1895, Copyright, 1895, by D. Appleton and Company. 2 specialism in medicine. and at the outset we meet with the two great divisions into criminal and civil practice, the latter being still further sub- divided into numerous branches—for instance, patent, real estate, and railroad—each more or less separate from the other and requiring a different train of thought in its pur- suit, but still all being dependent on the same fundamental laws of reasoning. Again, here is still even a higher divi- sion into the various courts—oyer and terminer, supreme, superior, common pleas, surrogate’s, and the appellate court —each disposing of cases that come under its own especial jurisdiction. Perhaps there is no other profession where the line is so accurately drawn as in the law, and we can see at once what a simplifying effect these divisions possess, for without them litigation would be much more chaotic both for lawyers and clients. This same principle applies (though possibly not in so strict a sense) to the profession of engineering, the chief divisions being the civil, mining, and mechanical, there be- ing the same underlying principles in each, though the prac- tical application may differ very widely one from the other. Turning our attention to mercantile pursuits of any magnitude, we see this same law of division enacted. In manufacture, we see artisans spending their whole life of toil on some one special portion of work, being ignorant, perhaps, of the other branches. The various departments of the government, national and otherwise, show to a marked degree the efficacy and necessity of this same division. The minuteness of the postal service, for instance, is a most striking example. In the domain of art we notice the same principle. The artist and sculptor gain their reputation by confining their abilities to one special fancy. The perfect portrait painter and landscape painter are seldom combined in the one per- son ; the beautiful marines and interiors are by different SPECIALISM IN MEDICINE. 3 artists, and this concentration of ability is so often marked that it is often a matter of ease to detect at a glance the individuality of certain artists. In this instance the division into special work is, per- haps, more of a natural division, being a cultivation of a peculiar fitness or bent of mind. Still, it shows the point we are after, that perfection is more readily gained by pur- suing one definite line of action. The pursuit of the sciences in their varied and vast do- main is another instance of the value of special research. We have the astronomer, natuialist, chemist, physiologist, each in his own sphere, affording a grand opportunity for a life’s devotion. Education, in its numerous phases, shows the necessity for special training and application. And so we could go on multiplying examples to infinity, showing that whatever calling we may pursue in which a certain degree of perfec- tion is to be reached, a proper consideration of and devo- tion to its special branches is absolutely necessary. Having thus seen, to a certain extent, the application to and necessity of specialism in other branches of human endeavor, the question naturally arises, Does it not apply with equal or if not more force to the medical profession ?—. a question easily asked, but possibly not so easily answered When we come to compare our profession in this respect with other callings, we at once find many obstacles in the way which seemingly render such a comparison a matter of difficulty. Principal among these, and upon which all other objections more or less depend, is that the practice of medicine is not an exact science. We can not proceed with mathematical accuracy. There is no court of appeals, save the autopsy table—and how often that reveals the fallacy and error of previous theory ! No set of laws govern all cases; there are personal idiosyncrasies ; many phenomena 4 SPECIALISM IN MEDICINE. of disease are shrouded in mystery. The same disease attacks different persons in ditferent ways. Unforeseen complications are constantly arising; theory and specula- tion naturally form the basis of many of our conclusions, so that we often tlounder in a sea of uncertainty. Again, we must remember that we are dealing with the manifold changes of the human body—a complex organism, not made up of component parts that admit of entire isolation, but rather a structure, the various portions of which, nourished by the same medium, must act in perfect harmony with each other for the proper maintenance of life, the overthrow of one organ or function generally carrying disaster to some other on which it may depend, or perhaps throwing the whole system into a state of disease and ultimately causing death. Our daily practice is full of such illustrations; sufficient for the purpose may be found in the relations which the circulatory and nervous systems bear to each other and to the whole economy—e. y., a piece of vegeta- tion leaving the heart produces death by cerebral embo- lism ; interference with return circulation produces distant oedema; arrest of arterial circulation produces gangrene; reflex disturbances are so abundant that at times it is hard to know where to seek the source of trouble; and how much is included in that great term hysteria! A due con- sideration of these facts in all their bearings will present some of the difficulties to be encountered in reducing our profession to a system of exact specialties. Seemingly strong, however, as these objections may at first appear, there is, no doubt, a very positive affirmative side of the question. Medicine, as a science pure and simple, naturally divides itself into specialties; but it is in their application to our daily practice that we as physicians have to consider them. The rapid advances that have been made and are still SPECIALISM IN MEDICINE. 5 being made in our profession have caused it to assume such gigantic proportions that one can not expect to be master of the whole science, and any attempt or boast to that effect meets with just ridicule by more modest men. We are all daily meeting with cases which, owing to our lack of special knowledge, the possession of proper apparatus, or the time and facilities for proper treatment, we are unable to justly care for, and there remains no other alternative than to seek the aid of some one who is better fitted to treat the case. The patient’s welfare should claim our first- attention, and no one knows better than the physician him- self whether or not he is doing his duty to his patient. Far better for a practitioner to send a patient for additional advice of his own accord than to have a patient seek the specialist himself after a term of misguided treatment; the first creates a mutual holding of confidence between physi- cian and patient, and I might add, in passing, that the refer- ence of a patient to a specialist entails on the latter a trust of honor that can not be too strongly guarded. It is, per- haps, this breach of confidence that in some instances has brought odium on the practice of specialties. It is often the experience of specialists to correct the errors and oversights of the general practitioner. The en- deavor to do all we can for our patients is commendable, but to keep them out of the hands of specialists on the score of prejudice savors somewhat of deception. That one can arrive at a greater degree of perfection in the con- centration of his medical knowledge than in trying to ab- sorb the whole subject no one will deny ; that reputations may be made quicker is also an equally undeniable fact. The chances for brilliant successes are much greater in specialties, and the wear and tear attending a physician’s life is certainly lessened. The practice of medicine is fast losing its sentimentalism, and the public at large is becom- 6 SPECIALISM IN MEDICINE. ing a potent factor in its influence on the profession— their demands can not be ignored. People of the present time, in many instances, determine themselves as to about what their ailments are, and look about them to find out who is best fitted for their individual case, and naturally go to a specialist. We can not deny them their right of choice, and I am sure we can not stop them. This in a measure regulates the supply and demand, and as long as the laity clamor for specialists they are sure to exist. The present drift of medical research tends to special ism ; we see this strongly instanced in the division of so- cieties, academies, and congresses into separate sections. Medical journalism abounds in publications devoted to special subjects. Health boards demand specialists. Mat- ters requiring expert testimony surely call for specialists, and the medical educator must needs be a specialist. Tn return, it is needless to say that the specialist himself should be a man of broad medical views and thorough training in general medicine, for in the pursuit of no one specialty can we lay aside the laws of differentiation and the relation that one morbid action bears to another. True specialism is a limitation of work rather than a limi- tation of knowledge, and any one entering it without proper preparation will soon find the limitations of his action. Routinism is an objection raised against specialism, but I think we find just as much of it in the humdrum and weariness of general practice. The careful specialist is ever on the alert for new ideas and methods, and there yet remains to be found the specialty which has been mastered. The eagerness to bring all cases of disease under the specialty in which the physician is interested is another objection offered ; this will only happen to the blind and narrow enthusiast, who is a danger to be feared in any sphere. SPECIALISM IN MEDICINE. 7 After having considered the evident present tendency toward specialism, it might be well to consider the debt that the profession owes it. The relief from former igno- rance and chaos has been the result of men devoting them- selves to special work. The microscope and pathology are brilliant examples. Special surgery has allowed the ex- ploration of regions of the body with impunity which in former times were closed to all knowledge, yielding results which seem but little removed from the miraculous. Look at it as we may, specialism is a natural culmination of the advancements made in the science and practice of medi- cine, and, as a result, gyna3Cology, ophthalmology, neu- rology, orthopaedics, laryngology, otology, dermatology, and many others have reared domains of their own which are far from being circumscribed ; and it has not been the work of narrow-minded men, but men of broad minds and actions that have put specialism on a sure foundation and doubtless have made it the practice of the future. 952 Lexington Avenue.