THE VALUE OF SPECIALTIES IN MEDICINE


THE VALUE OF SPECIALTIES IN MEDICINE. WHILE we are gathered together from widely separated parts of the world in this fair city where so much that is of interest is now centered, I am not insensible to the honor you do me in pausing even for a few moments to listen to the thoughts I have to offer upon the general subject of “Specialties in Medicine.” Though the occasion is not one to warrant us in entering largely into details, both the time and subject are too important to permit superficial consideration.


WHILE we are gathered together from widely separated parts of the world in this fair city where so much that is of interest is now centered, I am not insensible to the honor you do me in pausing even for a few moments to listen to the thoughts I have to offer upon the general subject of “Specialties in Medicine.” Though the occasion is not one to warrant us in entering largely into details, both the time and subject are too important to permit superficial consideration.

Let us therefore, first inquire briefly how the thing which we now know as specialization was evolved. When we resolve all the multiform effort of the world into elementals, we find that the one thing in the world is life. The one thing we are trying to do is live. All the issue and ologies are only a part of it, or helps to it. The effort of all who think and work truly is to increase the value of life, not to make life, that were impossible, but to render life more complete, more perfect.

Broadly considered, human life can be perfect only when a power and faculty is fully developed in absolute harmony with every other. But, as it would be impossible to entrust to any one man or set women, the guidance of the race in all of its wonderful and bewildering individual capacities, man early came to be regarded as divided into three distinct entities, physical, intellectual and moral (or spiritual), and we have as a result three classes of men to when the world looks for its uplifting.

To physicians has been given the task of broadening and perfecting the physical life of the race. To the clergy the hardly more sacred work of enlarging the moral life and perfecting spiritual vision, and to the great army of teachers in every branch of science and art comes the glorious possibility of developing the intellect of man into something yet more godlike.

Medicine, theology, and philosophy, the first three specialities. .

But so complex and all comprehending a thing as intellectual life could never be brought within the bounds of one man’s power and knowledge, and so the educators have almost infinitely divided their work. Those to whom the care of souls was given soon discovered that no one expression of belief could be broad enough to provide scope for the infinitely out-stretching, constantly expanding individual spiritual life, and theology consequently divided and subdivided, and took to itself creeds.

While it is obvious how powerless my one man must be and must have been to cover with ever so great industry and genius the whole vast field of human possibilities, and while a division of labor was and is imperative, the greatest possible value can never be obtained by such division in any field without a right understanding on the part of those who undertake any branch of work of the economic reasons governing its divisions, and the great natural laws under which each man must work within his own lines.

The more deeply we think and study into the things of nature and of life, the more we become aware of a central unity running through all things; a fundamental law with which all other laws must co-operate, with which all truth falls in line, to which all logic finally points as the needle to the pole.

We are closely pressed in our industrial life in these days by failing to appreciate or to apply this law. The underlying principle of unity, in man as in nature, implies the most perfect harmony, the fullest co-operation, and at the same time, and only in consequence of this, the most perfect expression of individual life and liberty.

As the plant is dependent upon the sun and dew; as the tree is saved from death by the bird that lives upon the insect which would destroy it; as the tide answers to the noon and the world itself to the motion of the spheres, so must man recognize his unity with man and nature, acknowledge his constant mutual interdependence, must severe and be served, or lose his highest and most harmonious development.

The freest and most perfect expression of human power and life is possible, then, not by more and more separation, but by more and more unification; by a deeper and surer perception of the laws of the world, and a living in harmony with them. This does not preclude special work. It does not deny to any man the right to work out the best that is in him in his own way, to choose his work within very narrow lines if he will. But that he may attempt something like perfection in one direction, he must lay down as well as take up. Specialization means concentration. Emerson has somewhere said; “You must elect your work; you shall do what your brain can and drop all the rest. Concentration is the secret of strength.”

Some apprehension of this truth, however dimly conceived, lay at the foundation of the first conscious division of work into what we call specialties. But specialization means also renunciation. “Drop all the rest, lay down as well as take up.” Leave some work that one might do, that even might bring more generous results in its performance than the little bit that must be wrought at with such unflagging care to bring it to its fullest beauty and perfection.

One must leave to some one else the work that might have been his own; be must relinquish some part of his inheritance; and if he would secure a true value in his exchange, let him see to it that what he gets is something more than a mess of pottage. His work will be to him little more than this if it is undertaken from motives of self- aggrandizement. If his object is a mercenary one, he will doubtless make money, which means food and clothes, as a good as, or a little better than, his neighbor’s; a little power and splendor, and a residuum, after analysis, of dust and ashes.

His object has been separation, not unification; he has striven against, not with, his brothers; he has undertaken a special work, not that he might do a little more perfectly than he could do more and the thing that he has devoted his life to be, in consequence, on more value to the world, but that by doing some one thing better than any one else could do it, he might receive for himself more gain and glory. Both greatest good will, of a surely, be denied him if he is content to seize these apples of Sodom. His work, I do not hesitate to say it, will fall short of that which is best.

Therefore, the value, that is, the worth, the importance, the utility of specialities, in medicine as in anything else, depends less upon the thing specialized, or the necessity for its specialization, than upon the man who does it and the spirit he works in. In comparison with this, all other reasons and reasoning are vain.

It has been said, and not without reason, that narrowness is a result of specialization.

But a broad man, liberally educated, does not necessarily become narrow by devoting his best energies to some one thing that he feels he can develop more power in than he could attain in any other direction. He may give himself up so completely to his chosen work as to almost exclude the possibility of any extended reading, not to say research, in any other direction. His time may become so absorbed by the demand upon it in his limited field that he can rarely even meet with those whose work is carried on with larger lines. And yet, if he maintains his true relation to the world; if his mental attitude be a right one, I insist that he need not become narrow in the generally accepted sense of the term.

There will be much that he cannot know, that he must voluntarily relinquish the possibility of knowing, but he will be broadly interested in it all. He may renounce frequent fellowship, but if in his work and growth he is constantly and conscientiously one of the great human family, connected by the closest ties with every other, doing his part, however distinct it may be, not in isolation, not in the spirit of separation, but simply as his bit of the great whole, in all of which he has a personal interest, which is all his, and yet not his; which, but for the perfection of his, would be less perfect, which is never to be lost sight of in the exclusion of his own, -if, in a word, he need no lose materially, or beyond compensation, by his adoption of a specially.

He does not renounce the spirit of fellowship, he does not glorify his own work to the exclusion of any other, he does not fasten his eyes to exclusively upon that which is growing under his hand as to lose I power of seeing it in perspective.

For, to reiterate, the value of any special work depends, first and chiefly, upon the power of the man who does it, to look at it constantly in its relation to that whole of which it is a part. From a failure to do this arises all the question as to the value specialties.

Educators have recently been considering with much seriousness whether many of the most defective methods of our educational systems might not be directly traceable to the arbitrary division of that which was never intended to be divided-the life of man-into physical, mental, and spiritual, the result being unequal, and, consequently, unnatural development.

It would seem as if the division were an imperative antecedent on progress, the mistake being that in the division of work each worker should look upon his part as a whole in itself. he then might and did isolate it and himself from those to whom the work of perfecting the other parts had fallen, and the morbid conditions thus created have spread into every branch of study and of practice, and have worked endless disintegration where wholeness should have been.

You will bear with me if I seem to be dealing too long with abstractions. In the daily routine which absorbs our every faculty as physicians into one tremendous effort to restore and preserve such physical perfection as is possible to suffering humanity, we have little time or opportunity to think of that which it were worth our while not to forget, -which is not alien to the practical side of our work, but an integral part of it,- the fact that even before we are physicians we are men, and that the highest physical life is at its best but an expression of the intellectual and spiritual life.

We who have chosen for our calling the physical redemption of man cannot look too broadly upon our work, and that will not be lost time which we spend in getting it so in focus that we can have indelibly printed upon our mental negative a picture of what we are doing, and the relation our work sustains to the moral and intellectual life of our race. Still more is this necessary if we have taken but a small part of the medical practice for our field. The same laws hold good here as those that work throughout the whole wide range of human experience. Unity is strength, life; division is disintegration, death.

No one part of the human economy can be disturbed without affecting in some degree every other part; and it would be at variance with every law that we know in nature or in life to believe that in studying thoroughly one branch of medicine, one might, without more than a very superficial knowledge of anything else, treat successfully the one part two which faithful attention has been given.

In the practice of a specialty one may not do any work outside of certain lines, but one must do a vast amount of study and investigation outside of those lines, and the work within must be constantly connected and fitted into that which lies without. One must work steadfastly in a restricted field, yet with constant reference to the whole; must be able to work alone, yet in a spirit of fellowship, to work in accordance with the great world-law of unification, and not against it.

When this become not only possible, but habitual, then and then only is one in a position to understand and to prove the great value of specialization, by the concentration of force in one direction.

The concentration of force develops power in two ways. It makes possible a more profound intellectual grasp of the subject specialized, and if it be in the line of technical work, it given tactile fineness and manual skill to a degree impossible to derive from general work.

The devoting of much time to one thing renders the research and the acquisition of facts in regard to it so complete as to often outrun all previous knowledge, and lead to discoveries and inventions, to new refinements of diagnosis, added instruments of precision, and to scientific methods of investigation and practice that seem little short of marvelous; and it is a wonderful power of eye and hand, a wonderful acuteness of sight and touch, that are developed by doing intelligently one thing over and over again.

The value of this knowledge and technique is three-fold. First, to the specialist himself, since knowledge is power, and “All power,” as Emerson says, “is a sharing of the nature of the world.” Second (second only in order of sequence, not in importance) is the value to the large number of those whose increased soundness, and therefore increased power, is the direct result of the physician’s dealing with the things that make strength. And third (in order of sequence) is the value to the world at large; for all increase of knowledge and power and strength becomes a part of the world’s inheritance, and this is perhaps the widest and most positive value of all.

We see, then, the specialist taking his little bit out of the work that lies waiting for who can and will do it, giving to it the best of his time, his strength, his intellect, perfecting it more and more until he returns it to the world again, as a sculptor might the stone into which he has wrought his brain, his heart, his life, and which has become, in the process, of a value immeasurable.

The practical proof of the value of specialization in medicine lies, of course, in what has been accomplished through specialties that would not have been possible under the time and opportunities afforded by general medicine.

This is somewhat difficult to specify with exactness; but it is safe to say that the enormous results that have recently been obtained in surgery, gynecology, obstetrics, neurology, and ophthalmology could not have been reached but by that deliberate concentration which is indeed the “secret of strength.” I need not dwell upon the work that has been done by the men in each of these different fields, although it would be pleasant to do so, for with much of it you are familiar, and to begin would make my task an endless one. But of the results of special work in bacteriology-a comparatively new field for specialization-I wish to speak a little more at length.

Whatever a man’s work may be, whether generalist or specialist, whether Old School or New, bond or free, if he is a physician at all, one thing he must be familiar with, so far as study and investigation can make him so, and that is the nature of disease. This, I think, will be admitted without question, and no further argument will be necessary when it is remembered that no less a subject than that-the nature of disease-has come to be entirely reconsidered in consequence of the light thrown upon it by the investigations and discoveries of bacteriologists during the last few years.

I have somewhere read that the “new” opinion which now obtains was held by some several centuries before Christ, and has found credence in every age since, but it eluded proof, and consequently could not gain general acceptance until the specialization of bacteriology has brought knowledge on these lines to such a point of perfection as to establish as a fact what more than eighteen previous countries filled to render more than “probable.”.

The contest between the bacterium and the phagocyte has added a new factor to our study of disease, and has made necessary a statement of every pathological equation. It has robbed tuberculosis of half its terrors by localizing its origin and making large possible its prevention. It has lowered the mortality in surgery a phenomenal degree. It has demonstrated the source of typhoid fever and diphtheria, and it has proven the germicidal character of cholera and enabled us to keep it at bay. It has elevated sensation to a position of first rank, and makes it possible for us to deal more intelligently with matters of dietetics and hygiene.

Not all our problems are yet solved, but we may now deal with them in a more direct and scientific way, and are much further advanced toward their correct solution by reason of the data put into our hands through bacteriological research.

As brilliant and important as have been the additions to our medical equipment through the medium of specialism in the past, I cannot but believe that greater things are in store for us when we have learned more practically that specialization does not mean separation, and when specialists work more constantly in unison.

And now let us hear the conclusion of the whole matter, in words more strong and beautiful than I would hope to equal, words taken from the “Ethics of the Dust,” by John Ruskin:.

“The highest and first law of the Universe, and the other name of life, is ‘help.’ The other name of death is ‘separation.’ Government and co-operation are, in all things and eternally, the laws of life; anarchy and competition, eternally and in all things, the laws of death.

“Exclusive of animal decay, we can hardly arrive at a more absolute type of impurity than the mud or slime of a damp or overtrodden path in the outskirts of a manufacturing town. That slime we shall find in most cases composed of clay (or brick- dust, which is burnt day), mixed with soot, a little sand, and water.

“All these elements are at helpless war with each other, and destroy reciprocally each other’s nature and power; competing and fighting for place at every tread of your foot; sand squeezing out of clay, and clay squeezing out water, and soot meddling everywhere and defiling the whole. Let us suppose that this ounce of mud is left in perfect rest and that its elements gather together, like to like, so that their atoms may get into the closest relations possible.

“Let the clay begin. Ridding itself of all foreign substances, it gradually becomes a white earth, already very beautiful, and fit, with the help of congealing fire, to be made into finest porcelain, and, painted on, can be kept in king’s palaces. But such artificial consistence is not its best. Leave it still quiet, to follow its own instinct of unity, and it becomes not only white but clear; not only clear but hard, but so set that it can deal with light in a wonderful way, and gather out of it the blue rays only, refusing the rest. We call it then a sapphire.

“Such being the consummation of the clay, we give similar permission of quiet to the sand. It also becomes first a white earth; then proceeds to grow clear and hard, and at last arranges itself in mysterious, infinitely fine, parallel lines, which have the power of reflecting not only the blue rays, but the blue, green, purple, and red rays in the greatest beauty in which they can be seen through any material whatever. We call it then an opal.

“In next order the soot sets to work. It cannot make itself white at first, but it comes out clear at last, and the hardest thing in the world, and for the blackness that it contained obtains in exchange the power of reflecting all the rays of the sun at once, in the vividest rays that any solid thing can shoot. We call it then a diamond.

“Last of all, the water purifies itself, contented enough if it only reach the form of a dew-drop’ but, if we insist on its proceeding to a more perfect consistence, it crystallizes into the shape of a star. And for the ounce of slime which we had by the political economy of competition we have, by political economy of co-operation, a sapphire, an opal, and a diamond, set in the midst of a star of snow.”.

In this wonderful description we have seen the earth elements struggling in the mire of discord, until the law of unity came to work and created, out of apparently hopeless confusion, the most transcendent harmony and beauty.

You have noticed that all they require-these earth elements- that they may begin the work which is to lead them to the utmost perfection, is only that they shall be allowed absolute freedom of action, that no one should interfere with any other, and then they may work out their own salvation, each in his own way, not like any of the others, but each its best, and though separating itself, and accepting only what its own special developments require, still following the law of unity, and proving that not in concentration alone, but co-operation, there is strength.

F Parke Lewis