Reprinted from the 
TRANSACTIONS OF THE PHILADELPHIA COUNTY 
MEDICAL SOCIETY. 
Vol. I.-1887. SPECIALISM IN MEDICINE. 
BY 
BOSS B. BUNTING, M.D., 
OF PHILADELPHIA. 
REPRINTED FROM THE 
TPJ H'TIOM-i OF THE PHILADELPHIA COUNTY MEDICAL SOCIETY, 
MARCH 9, 1887. 
PHILADELPHIA: 
WM. J. DORNAN, PRINTER. 
1887. SPECIALISM IN MEDICINE. 
ROSS R. BUNTING, M.D. 
[Read March 9, 1887.] 
The object in presenting this paper before the Society this evening 
is not with the idea of offering anything new, but rather with the 
hope that in discussing this rather hackneyed subject, something of 
advantage to our profession may be suggested. 
Specialism is a sign of progress. Herbert Spencer, in his Illustra- 
tions of Universal Progress, says, "From the earliest traceable cos- 
mical changes down' to the latest results of civilization, we shall find 
that the transformation of the homogeneous into the heterogeneous is 
that in which Progress essentially consists." In the development of 
the human organism the same law is followed from uniform to multi- 
form, from simple to complex, from the general to the special, produc- 
ing physiological division of labor or specialization of function. " It 
is always in the most advanced periods of civilization that division of 
labor is carried to its utmost limits. It is only the savage that com- 
bines in his own person in all their departments the character of phil- 
osopher, inventor, and operator." (Political Economy, Wayland.) 
" Medicine was practised primitively by the chiefs of families, of 
tribes, and of nations, and by generals and legislators. Afterward it 
was joined to the sacerdotal office for a very long time. At last it 
constituted a distinct profession which was at a later period subdivided 
even into several departments." (Renouard's History of Medicine.} 
Medicine, surgery, and midwifery (the latter practised mostly by 
women, as it now is in some parts of Europe), appear to have been 
the earliest divisions. Some writers consider specialism to have existed 
long before the Christian era, but we think it is only within the last 
twenty-five years that real, true specialism may be said to have existed. 
During this period there has arisen in our midst a practitioner 
known as the specialist. His advent was regarded with suspicion by 
the doctor. " He is like the locust plague of Egypt, devouring all be- 4 
BUNTING, 
fore him ; he has mapped out all the organs of the body as his especial 
property, leaving nothing for us," exclaimed the general practitioner. 
A writer in the Pacific Medical and Surgical Journal has become so 
alarmed at some one signing himself " Neurologist," that ironically he 
says, "Why not have a pneumatologist to attend to the lungs, a ther- 
matologist to observe the temperature, a narcotizer to see that the 
patients sleep well, a defecator to attend to their bowels, and so 
forth?" He was considered a quack, and many instances were 
related of his want of principle in appropriating the patients of his 
brother physicians. Although such cases occur at the present day 
not only among specialists, but in the profession at large, we think 
there are very few whose sense of honor is no better than that of 
Artemus Ward, who says, " You ask me about my principles? I ain't 
got no principles, I'm in the show business." It is not surprising that 
the family physician was astonished and alarmed when he found the 
inroads this special practice made upon his daily living. But the 
specialist has come to stay, like the female physician, and no amount 
of professional opposition will drive him from our midst. Lord Bacon 
says, " Surely every medicine is an innovation, and he that will not 
apply new remedies must expect new evils." It were good, therefore, 
that men in their innovations would follow the example of time itself, 
which, "indeed, innovated greatly, but quietly, and by degrees scarce 
to be perceived." These innovations would certainly have been more 
agreeable, especially to the older physicians, had they come more 
gradually ; but they were necessary for two reasons : 1st. The public 
wanted them, and were not slow in finding out that in many cases 
they were cured or relieved sooner than by the family doctor. The 
author of Lacon shrewdly remarks, " It is better to have recourse to 
a quack, if he can cure us, although he cannot explain it, than to a 
physician, if he can explain one disease but cannot cure it." It is the 
fashion now to go to a specialist, for fashion reigns in medicine as in 
society. During the last twenty-five years how many methods of 
treatment have we seen, " that, like empires, have had their rise, cul- 
mination, and decay"? People with the most trifling ailments seek 
special advice, in many cases that could as well be attended by their 
family physician. Some time since we were called to attend a baby, 
about ten months old, for an attack of diarrhoea; noticing a slight 
eruption on the face, the mother remarked " that the baby had been 
much worse, but having consulted a skin doctor, under his treatment 
it soon got better." If there be one class of cases which the family 
physician regards as his especial practice, it is that to which infantile SPECIALISM IN MEDICINE. 
5 
ailments belong. Having anxiously watched the advent of the little 
ones, often through sleepless nights, it is but fair he should attend 
them for the many diseases of babyhood. 
2d. The accumulation of medical knowledge has become so great 
that one mind cannot master, much less employ, this knowdedge in 
the practice of medicine. There are no " Admirable Crichtons " in 
our art. The genius of a Sydenham would shrink in despair before 
the immense masses of medical lore accumulated since his day. We 
read with astonishment of the acquirements of Dr. John Mason 
Good, who, to the reputation of a polyglot added that of one of the 
foremost practitioners of his age. It is universally acknowledged 
that the men of one idea, those who confine their attention to one 
thing, be it a business or a science, are the men who succeed, who 
represent the progress of the age, and whose names "posterity will 
not willingly let die." " There was once a boy put under the care of 
the Jesuits, who was noted for nothing but his stupidity. The teachers 
tried him abundantly, but could make nothing of him. At length 
one of the Fathers tried geometry, which so suited his genius that he 
became one of the first mathematicians of his age." We hear occa- 
sionally of physicians distinguished in the walks of literature, but it 
is extremely rare for them to be known to the public in this dual 
capacity-certainly posterity never remembers them as such. Oliver 
Wendell Holmes is but little known to the world as the professor of 
anatomy, but as the genial Autocrat of the Breakfast-table, and the 
author of that charming novel, Elsie Venner. We know but little of 
Dr. John Brown, of Edinburgh, as a physician, but as the essayist. 
If we could imagine a physician thrown into a Rip Van Winkle sleep 
of, say, but ten years, and then recommence the practice of medicine, 
he would be astonished at his own ignorance, so great would he find 
the progress in all branches of our art. He would feel " like the 
mouse which thought his chest was all the world, and was astonished 
when he stood upon the till and looked out to see what a great world 
lay beyond him." Having admitted the necessity of the specialist, we 
will now consider him in his relations to the medical profession. He 
ought to be regarded as the consultant of the general practitioner, 
and, when possible, to act and advise with him. An oculist once 
observed (with apparent satisfaction) that many people no longer con- 
sulted the family doctor about their eyes, but went at once to the 
oculist, as they would to a dentist for their teeth. With all due 
respect to the many honorable gentlemen in this line of practice, 
this is belittling the family physician, and the tendency will be to 6 
BUNTING, 
throw the general profession into disrespect. Why should not a 
physician, who is worthy the name, be asked an opinion whether his 
patient should consult a specialist ? Encourage the public to act in 
this manner, and the result will be to create an antagonism between 
the two classes of practitioners. Regarding the specialist as a con- 
sultant, would place the latter in the same position as the general con- 
sulting physician, who is supposed to comprehend and follow the Code 
of Medical Ethics. There has been a great change within the last 
few years in the attitude of the public toward the family doctor. 
Change of physicians seems to be the order of the day. Formerly 
they have been known to attend a family for two generations. Now 
many people change their doctor with every new illness. That 
specialism is partly responsible for this we have no doubt, but we 
think the desire for something new, and the want of faith in every- 
thing which characterizes our age, are also causes. 
Duncan Gray, the village doctor, whose character is so beautifully 
portrayed in Scott's Surgeon s Daughter, belongs to a class of 
physicians which is fast disappearing, although to be regretted; this 
is but one of the old landmarks swept away by the flood of scientific 
progress. The limitations of specialism include the diseases which 
properly belong to it, and the number of specialists. The majority of 
diseases should be treated by the general practitioner. Take two 
instances from two different specialties. Why should not the average 
doctor be able to prescribe the proper glasses for simple hypermetropia, 
and apply the uterine dilator in cases where it is indicated ? These 
methods of treatment are supposed to belong especially to the oculist 
and gynecologist. On the other hand, the busy practitioner would 
not have time (admitting that he has the knowledge) to attend to cases 
of mixed astigmatism, operations in laryngeal surgery, and the appli- 
cation of electricity, which necessitate the continued presence of the 
physician in his office, and require expensive instruments, for the out- 
lay of which there would not be sufficient remuneration, so compara- 
tively few would be his patients. We deem it obligatory on him, 
however, to have a working knowledge of the laryngoscope and the 
ophthalmoscope, which is just as necessary as an acquaintance with 
the microscope. Every year, as the physician becomes better edu- 
cated, is his field of labor enlarged. Some years since, the application 
of the obstetrical forceps was regarded as an operation requiring a 
consultation ; now every recent graduate considers himself capable of 
performing it. There are operations in general surgery, as lithotomy 
and ovariotomy, which will still be restricted to a few having special SPECIALISM IN MEDICINE. 
7 
skill and experience. The great dramatist's description of sorrows 
■which " come not single spies but in battalions," we think would be 
applicable to the number of specialists. 
Dr. Morell Mackenzie remarks, as one point of favor in specialism, 
that "in one city of the United States, of 130,000 inhabitants, he found 
thirteen specialists in throat diseases," We can well imagine the poor 
doctors in this city of many specialists, gazing around, and exclaiming 
with the bewildered Macbeth, " Can such things be and overcome us 
like a summer's cloud without our special wonder?" 
To the ignorance of the general practitioner may be ascribed, in a 
great measure, the large number of specialists. With the increased 
facilities for study, extension of the curriculum in our medical colleges, 
and post-graduate courses, the young physician will enter upon the 
practice of his profession much better qualified than his predecessor of 
a quarter of a century ago. The simple cases he will always treat, 
and some of the more difficult ones. The general increase of medical 
knowledge will also operate favorably on the specialist, obliging him 
to possess a fair knowledge of general medicine, which is impossible 
forthose uwho take up specialties" without ever having had a general 
practice, a state of things much to be deplored, for, as has been ably 
remarked, "the body is an organism, not a mechanism, and he who 
has the widest knowledge of that body, its disorders and diseases, is 
best able to find out the matter with his patients." There will always 
be a field, an inexhaustible one, for special research, for from the latter 
must emanate most of our scientific progress. A wise author has truly 
said: " He that shortens the road to knowledge lengthens human life." 
And a well-known political economist furnishes another tribute to the 
usefulness of the specialist when he says: The advantage of the many 
is best consulted by each individual looking after his own good in the 
most intelligent manner. There should be no jealousy between the 
general and special practitioner, for both belong to that honored pro- 
fession to one of whose members was applied by our Lord the title of 
"the beloved physician."