PRESIDENT'S ADDRESS.

SPECIALISM IN MEDICINE.

Strictly speaking, the only man who may be regarded as a general practitioner in matters of every-day life is a solitary individual-Alexander Selkirk on his desert island. As soon as the second man appears, they instinctively divide the duties between them---one providing the food, the other the shelter. A further increase of numbers develops the advantage of further specialization, and the carpenter, the blacksmith, the hunter and the agriculturist are evolved. Further growth brings the scientist and the professional men, the minister, lawyer and doctor. But the end is not yet, for the expansion of the fields of labor calls for a further differ entiation, and the various religious denominations, the different departments of legal practice, and the subdivisions of the practice of medicine spring up by a process of natural evolution. Thus we see that Specialties are a natural, nay, an inevitable result of the growth of communities and the question is not How may they be avoided or prevented? but, How may they be so guided and regulated as to make them of the greatest good to the community?

Some definitions of Specialism are of interest at the outset. Says Seguin "Specialism is the natural and necessary result of the growth of accurate knowledge inseparably connected with the multiplication and perfection of instruments of precision." Morton defines it as "the substitution of precision for vagueness, of a concrete differential diagnosis for an abstract supposition; it is the forced acknowledgment that the average

human mind cannot practically grasp all of medical science, in short, the protest of knowledge against ignorance."

Bulkeley says "The science and art of medicine has like the other sciences, become so vast that no one mind can fully grasp every portion. Every medical man is unconsciously more or less of a specialist, or more qualified in certain lines of knowledge and experience than in others. Specialism is therefore a natural, healthy outgrowth from general medicine." Many infer when you speak of a man having a specialty that you are necessarily speaking of a medical man. This is by no means the case for painters have subdivisions such as portrait, landscape, marine, animal, flower, etc. Engineers are military, civil, mining, electrical, mechanical and so on. Literature is classical, philosophical, historical, fiction, travel and many others. English legal practitioners are divided into Barristers and Attorneys, and Attorneys are subdivided into Attorney-at-Law, Solicitors in Chancery or equity, and proctors in admiralty and ecclesiastical courts. In this country there is but one legal grade, but virtually it is divided into civil, criminal, real estate, commercial, equity, patent, divorce, and many others.

Differentiation is the test of civilization. The farther the community is removed from the savage state, the more highly specialized is it-one man has physical and mental aptitudes different from other men and so special qualifications fitting him for certain work.

In the domain of pure Science the accumulation of scientific facts and the knowledge derived from a study of these facts must reach a point where it is impossible that any one mind can master it all. A very few men like Erasmus or Humboldt have attained extraordinary suecess in covering very large fields of work but they are the rare exception, and if advance was to depend solely on such exceptional men, progress would be by leaps

with long periods of quiescence between-we all know that it is different-that little by little, each worker contributing his mite-the structure grows, slowly it is true, but steadily.' (Noyes). In this department of Science one would scarcely venture to deny the necessity of Specialists. The accumulation of facts and the sifting and arrangement of those facts with the logical deductions therefrom could not conceivably be brought about save by a mind trained by years of practice. Hence specialism in the Science of Medicine, may be said to have an admitted status. needs no explanation and no apology. Our theme is with Specialism in Medicine as an Art in the application of the principles and facts handed down to us by Medicine as a Science. The very existence of Medicine as a Profession is a Specialty. Once the lawyer, minister and doctor were one person, and the striped barbers' pole reminds us that formerly the barbers were in a measure the Surgeons of the Community. Every practitioner is more or less of a specialist. Jackson says speaking of a specialist settling in a small town and finding numerous cases of neglected special trouble "the fact is not that the general practitioners are ignorant but that there are no general practitioners. Those calling themselves so have been practising specialism in its commonest form, i. e., the form in which the practitioner devotes his attention especially to acute inflammations-fevers and obstetrics, ignoring many very important branches of medicine." This comes, he says, from the inevitably defective medical education, arising from lack of time and means. Every successful man whether in science or art has been a specialist though not necessarily called so. Effort must be concentrated to be effective. Scattering energy weakens it. The true Special ist, however, is not a man of one idea but one with a dominant idea, carefully curbed and held in check, otherwise he becomes a crank and some one has said that the main use of a crank is to show specialists what they

may come to if they allow their specialties to master them.

Specialism is as old as History-Cambyses of Persia 525 B. C., sent to King Amasis of Egypt for an oculist to serve his mother. Herodotus says "The medical practice is divided among physicians as follows: each physician is for one kind of sickness and no more, and all places are crowded with physicians, for there are physicians for the eyes, for the head, for the teeth, for the stomach, and for intestinal diseases." It is said this came about because all sons had to take up the occupation of their fathers; hence physicians increased so as to compel partitioning off the fields for them to occupy. "In the celebrated Medical School of Alexandria and among Arab and Saracen physicians in the first six hondred years of our era we find mention of special practitioners-surgeons, Lithotomists-oculists and midwives (Seguin). The Priests of Esculapius took an oath, part of which was. "I will never cut for stone but will

leave this operation to those of that occupation."

The first mention I find of Specialists in this country is in the Medical Annals of Baltimore, June, 1805, as follows: "Medical & Chirurgical Faculty of Maryland meet. They endorse vaccination and offer to grant licenses to oculists if found competent." In 1884 the specialists were first recognized at a General Medical Congress (Copenhagen). Among early specialists are worthy of mention Laennec in physical diagnosis, Bright and Rayer in renal diseases, Bayle and Esquirol in mental disease. Abercrombie and Ollivier in diseases of the brain and spinal cord, Hope and Bouillaud in heart-diseases, Cruveilhier in pathological anatomy, Hunter, Magendie and Müller in anatomy and physiology, Trav ers, Daviel, Tyrrell and later von Graefe in the eye.

Certain specialties have long ago established themselves and have been universally accepted. Diseases of the brain, mind and nervous system form a striking

illustration, and the establishment of special hospitals and asylums for this class of cases serves to mark the acceptance of this specialty by the Profession and the Public.

Diseases of the Eyes, one of the oldest, dating back to at least 500 B. C., probably was set aside for special care on account of the especial skill demanded in operative work. Diseases of the Ear; of the Teeth; of the Throat; of the Skin; of the Genito-urinary organs; Diseases peculiar to Women, and Obstetrics, are generally recognized as specialties. In Great Britain, Surgeons have long formed a class by themselves and this department is becoming generally acknowledged as a Specialty.

This list might probably be extended to a much greater length. I well recall how, some thirty-five years ago my old preceptor, Dr. Willard Parker of New York, himself an unconscious Specialist in Surgery, was one day declaiming against the number of new specialties and exclaimed impatiently--I expect some one will soon be making Diseases of the Umbilicus a specialty and howheartily he laughed when I reminded him that that field was already occupied by our Naval Surgeons.

Fifty years ago specialists had no warm welcome from many of the profession. Sir Morell MacKenzie writing in 1885, says, "In 1860 the very name of specialist was a bar-sinister excluding a man from the more highly coveted hospital appointments and from admission to some of the principal professional Societies. The medical press lost no chance of abusing him, his brethren sneered at him in public and slandered him in private. This treatment caused a reaction on the specialists leading them into errors of taste or judgment. It is a significant fact that the hostility to specialism not only originated with the medical profession, but has been all along confined almost entirely to them.

What are some of the objections to Specialism? It is claimed first, that the development of special practice