June 2, 1922] 



SCIENCE 



the disease, but also its location, and the de- 

 grees of resultant structural functional impair- 

 ment. 



Confusion obviously exists, particularly 

 among general practitioners, as to the correct 

 use of many current laboratory procedures. 

 This must in some way be overcome if the 

 dangers arising from their improper utilization 

 are to be eliminated, chief among which is an 

 incorrect or incomplete diagnosis, and there- 

 fore inefficient service to the patient. Ways 

 must be found to control or to limit the wide- 

 spread application of tests that should be con- 

 fined to well organized medical clinics, until 

 the results there obtained have been subjected 

 to long and critical analysis. The same is true 

 of procedures requiring a degree of special 

 technical ability not possessed by the average 

 practitioner or technician employed by him. 

 Witness merely as one example the widespread 

 and misapplied study of basal metabolism, an 

 instance of the mischief that inevitably follows 

 the random use of mechanical methods. As Sir 

 James Mackenzie has well put it, "While it may 

 be claimed that we have one hundred new meth- 

 ods for investigating disease in the living, it 

 must also be recognized that we have one hun- 

 dred more ways for going astray. The benefit 

 to the patient is often doubtful, and the em- 

 ployment of many contemporary laboratory 

 methods in the- contemporary manner is often 

 harmful." The unintelligent use of laboratory 

 tests is one etiological factor for the contem- 

 porary fibrosis and atrophy of the emotion of 

 wonder and its associated instinct of curiosity: 

 together "they arouse the impulse to approach 

 and examine more closely the object or diffi- 

 culty which excites them. Demand for the 

 solution of a perplexity is the steadying and 

 guidiiig factor in the entire process of reflec- 

 tion. Laboratory tests have certainly encour- 

 aged the development of a certain "naivete of 

 diagnosis" which seriously threatens the culti- 

 vation of a healthy curiosity. 



(B) Specialism and Specialists 

 Contemporary specialism has been unavoid- 

 able. It has been pointed out that specialism 

 is calculated to increase productivity, to facili- 

 tate the acquisition of accuracy, speed and 



skill, to provide a better distribution of tasks, 

 to economize material equipment and mental 

 energy, and to accelerate discovery and inven- 

 tion. Barker refers to a "virtuous circle," "for 

 on the one hand specialism increases knowl- 

 edge, and on the other the growth of knowledge 

 and technique creates new specialties. Human 

 wants grow as knowledge and skill increase, 

 and ever new types of medical men must 

 emerge to supply the services that will ade- 

 quately satisfy these wants." Viewed from this 

 rather broad philosophic standpoint, as well as 

 from a purely practical one, it is probably 

 true that the "abolition of specialism would 

 compel a return to a darker age of medical 

 practice." 



But, whether specialism with its increasing 

 sub-division can be applied to clinical medicine 

 in the same way that it has been to commerce 

 and industry is a very debatable question. Cer- 

 tain dangerous aspects of specialism are 

 thought by many to be responsible for ad- 

 mitted deficiencies in the practice of medicine 

 of to-day. These dangers doubtless represent 

 not so much arguments against specialism as 

 against its indiscriminate or unwise use. In 

 specialism one easily recognizes the lure for 

 those whose ambitions are more for material 

 reward than for human uplift. To specialism 

 may be attributed the existing inequality of the 

 financial compensation of the specialist and of 

 the general practitioner, and hence the eco- 

 nomic situation that explains in part the pres- 

 ent inadequate supply of physicians in rural 

 communities. A contemporary anonymous 

 writer sees the origin of specialism in surgery. 

 The degree of specialism that has developed in 

 this one branch of medicine alone has been as 

 extraordinary as it has been absurd. It is 

 cheerful, therefore, to read from no less a pen 

 than that of William J. Mayo : "Surgery should 

 be put back where it belongs — a means of me- 

 chanical therapy in conjunction with medicine 

 which should not continue in competition with 

 the internist, as it has in the past." Specialism 

 has been responsible for the development of 

 what might be termed class discrimination in 

 the profession, by which the so-called general 

 practitioner has seemed to lose caste. Applied 

 to patients, it has also fostered a feeling of 



