In recent years science has added greatly to the knowledge of disease and means of combating it. The wealth of information available to physicians has become so tremendous that for any one doctor to be completely informed of all aspects of all branches of medicine is impossible. Thus, there have necessarily evolved both specialties in the field of medicine and physicians who specialize only in one phase of their profession. This limitation of practice enables the physician to stay abreast of all the latest developments in his specialty, and he therefore can provide the best treatment for those patients who fall into his branch of the medical field.
In order to outline the field of surgery, it seems necessary to start with the entire medical field and then break it down into the specialties and subspecialties.
This classification is almost universal. Various hospital staffs may vary slightly in their service divisions, but in general they follow this plan. (This is the professional section of a hospital staff and does not include the administration.) A patient’s symptoms or diagnosis automatically place him in one of these categories in the eyes of his physician.
Note that there are actually only two main divisions. The medical group of specialties is composed of those diseases in which the therapy (treatment) rests almost entirely with the use of drugs. The surgical specialties are those where the therapeutic measures are frequently by operations, and drugs are secondary or supportive to the main therapy.
Naturally there is considerable overlap in these specialties. Some patients with medical illnesses may undergo a minor operation for diagnostic aids or even a part of their treatment; on the other hand, many patients with surgical diseases will be treated entirely with drugs and never undergo an operation. Numerous examples of either could be given. To be sure, each specialist must be well informed of the phases of the other specialties which apply to his own. The cardiologist must be able to fully interpret chest x-ray pictures; the neurosurgeon must be entirely aware of all the medical diseases which cause headache, and all must recognize symptoms of mental disease. That all specialties overlap into all others becomes quite apparent. Yet to provide the best in treatment, a classification is necessary.
The list of specialties seems long, and actually they are still continually dividing. There are subspecialties in each specialty. As more information is acquired about a certain phase of disease and treatment, this necessitates a new subspecialty in order to best utilize that information. At the larger medical centers will be found many other subspecialties. There is no reason why a physician cannot confine his practice to any one organ or system of the body.
It must be emphasized that this is not an artificial classification of disease and patients, but rather one which developed in the field of medicine automatically. Through the evolution of the healing arts, diseases have fallen into certain classes by their own nature.
When you are sick, your symptoms will place you in one of these categories. In brief, it is the patient’s diagnosis which classifies him.
Of all the practitioners of the healing arts, none is held in higher esteem among his colleagues than the general practitioner. His practice is not limited to one certain phase of the medical field; rather, he must have a general knowledge of each specialty in the profession. He must keep abreast of all the latest developments in each branch of the medical field. This is not an easy matter with the rapid changes and many improvements that constantly arc taking place today in the science of medicine.
The general practitioner does not claim to be able to provide the best diagnostic and therapeutic measures for every type of disease. In many instances he will refer cases to a specialist, who devotes his time entirely to a certain class of diseases and thus has a greater understanding of that type of case.
However, it is not the general practitioner’s lot merely to classify patients and send them on to specialists. Most cases he will be as competent to handle as the specialist. He will just refer complicated, rare, and problem cases to the specialist. To be sure, he is well qualified to handle most of the commoner diseases and injuries.
Every person should have a family doctor, who, of course, should be a general practitioner. He will treat you for most of your illnesses, and if you should develop a rare or complicated disablement, he will suggest a specialist to you. To have a specialist for your family physician is unwise indeed, for you cannot predict what illnesses the future holds for you and your family.
When you are ill, report to your family doctor, the general practitioner. Do not ask him whether he thinks a specialist is needed for your case—he is well aware of the specialists available in your community, and he will send you to another doctor if he thinks that someone else can treat your case better. For most of the commoner diseases the general practitioner is very competent.
However, if your doctor should send you to a specialist, recognize the fact that he is trying to provide the best for you and that your case is a special one. Do not think that he is incompetent because he did not treat you; he only wants you to have the best possible care. When the specialist has finished treating you, he will dismiss you and tell you to report back to your family doctor for any other illnesses. He will provide your doctor with a full report of your case, so that your family doctor may treat you for subsequent illnesses more wisely by knowing the complete facts of the illness you have had. Your family physician will know you well, and he can correlate all your past and present complaints into intelligent management.
If you are certain what branch of the medical field your present illness falls into, you may seek that specialist on your own. But it is best to visit your family doctor and let him decide. In any case, the specialist will want to know who your regular physician is, so that he may report the details of your illness to your doctor for future reference.
If your family doctor refers you to a surgical specialist and an operation is necessary, he may assist the surgeon at the operation. Often your doctor and the surgeon work hand in hand on special cases. Your doctor may want consultation while you are in the hospital. The consultant will review your symptomatology (set of symptoms) with you, make an examination, and then make suggestions to your doctor by formal hospital correspondence. In other instances your physician may ask the specialist to take over your case for your present illness, and when treatment is completed you will be referred back to your own family doctor for subsequent illnesses.
The usual general practitioner practices all of the medical specialties. Many do all types of minor surgery, and some perform certain major operations. Most practice obstetrics.
INTERNAL MEDICINE SPECIALISTS
The internal medicine specialist, or internist, is the practitioner who limits his practice to that field of medicine in which treatment is primarily by the use of drugs. He is highly skilled in the diagnosis and treatment of the diseases which fall into all of the medical specialties. He is the physician to whom most patients who are “diagnostic problems” are sent. The internist is very highly skilled in the subspecialties of cardiology, gastroenterology, allergy, geriatrics, and endocrinology, as well as the specialties of neurology and psychiatry. He is well versed in dermatology since many cases of dermatitis are a reflection of internal disease. He is aware of all surgical indications and knows when to refer a patient to a surgeon. Indeed, the internist’s understanding of pathology (the process of disease) is not minimal. The internal medicine specialist is well qualified in all the medical specialties, but most exclude pediatrics from their practice. (The term internist must not be confused with intern, which is a title applied to a hospital house officer, to be described later.)
The medical subspecialty which deals exclusively with diseases of the heart is called cardiology, and the physician who specializes in this division of the medical field is called a cardiologist. Actually there are few physicians in the country who practice cardiology only;
the specialty is usually covered by the internal medicine specialist. The cardiologist treats all conditions related to heart disease, including high blood pressure, but he does no surgery. Cardiac (heart) surgery is performed by the thoracic (chest) surgeon.
Gastroenterology is that medical subspecialty which deals with diseases of the digestive system. Although the term implies treatment of diseases of only the stomach (gastro) and the intestines (entero), the field covers the entire digestive system—namely, the mouth, salivary glands, esophagus, stomach, liver, gallbladder, pancreas, small and large intestines, and rectum. Again, this is a medical subspecialty and falls mostly to the lot of the internal medicine specialist, since there are relatively few physicians who limit their practice to just this phase of the medical field. Surgical conditions of the digestive system are treated by the general surgeon.
The field of allergy is one of the more recent subspecialties in the medical field, even though the condition has been recognized for well over 50 years. Allergy is the body’s response to a substance in the body to which a person is oversensitive. Allergic reactions may affect any part of the body, and the allergist is well informed of all the medical specialties since allergy may mimic almost any disease. His main treatment is directed at desensitizing the patient, minimizing the body’s reaction, and removing the source of the foreign substance, which may be eaten, inhaled, injected, or merely touched. The allergist does no surgery. Needless to say, all practitioners have some dealings with allergy.
With the prolongation of the life expectancy of man there are more and more aged people, and certain conditions are peculiar to old age. In recent years a new subspecialty has developed in medicine for the treatment of diseases of older people. This is called geriatrics. At present there are very few geriatrists (or geriatricians), and this subspecialty usually is included in the specialty of internal medicine. Geriatric surgery is carricd out by the various surgical specialists in whose field the particular case may be.
In the human body there are several internal glands which manufacture a substance and secrete it directly into the blood stream. The product circulates to various organs, where it influences the functions of these parts. These glands are called endocrine glands, and the substance secreted is called a hormone. There are numerous hormones, each affecting specific organs and other glands. The entire system is quite complicated. The branch of medicine which deals with these complex processes and their disturbances is called endocrinology. To be sure, every physician must understand this system, but the endocrinologist is the master of it. There are actually few endocrinologists at the present time. The practice of this phase of medicine usually falls to each specialist as it affects the diseases of his field, but especially concerned are the internist, the general surgeon, the urologist, and the gynecologist.
NEUROLOGY AND PSYCHIATRY
Neurology is that medical specialty which is concerned with diseases of the nervous systems. Both the central nervous system (brain and spinal cord) and the peripheral nerves are included, for the former could hardly be affected without the latter. Psychiatry is the branch of medicine which deals with mental disease. Usually these two specialties are combined and are practiced by the neuropsychiatrist. This specialist is therefore the authority in both organic (when there is demonstrable damage) and functional (no tissue alteration) diseases of the entire nervous system. Surgery of this system is done by the neurosurgeon.
Dermatology is that branch of the medical field which deals with the primary diseases of the skin. Many such conditions are associated with internal diseases, so the dermatologist has good insight into all the medical specialties. Most of the problem cases of dermatitis of the general practitioner are referred to the dermatologist. His treatment rests primarily with drugs, but he may also perform certain minor surgical procedures on the skin.
Pediatrics is the specialty which deals with the diagnosis and treatment of diseases of children. This is an age limitation rather than a restriction to a certain group of diseases or organs, since there are many diseases peculiar to infants and children. The pediatrician is concerned with growth and development, establishing immunity to certain contagious diseases, and social and psychological problems, as well as treating the acute illnesses of children. The pediatrician usually limits his practice to children under 14 years of age. Pediatric surgery is performed by the surgical specialist in whose class the disease falls, just as in adults.
The x-ray, or roentgen ray (after Wilhelm Roentgen, who discovered it), is useful in the field of medicine both diagnostically and therapeutically. This specialty is called radiology, or roentgenology. The radiologist (roentgenologist) is an expert at making and interpreting x-ray films, which are also called radiographs or roentgenographs. He also does fluoroscopic procedures for diagnosis. All practitioners are versed in these uses of x-rays for diagnostic purposes.
Since x-ray radiation has been found to have the power to control the growth of human tissues, it is useful in the treatment of certain conditions, such as many sorts of skin diseases, certain cancers and other new growths, and some chronic infections. The x-ray used in these cases may be that emitted from an x-ray machine or that emitted from the rare metal, radium. This is a highly specialized field, as the uses and dosages must be well controlled. This phase of medicine is practiced only by the radiologist, or x-ray specialist. He is often a part of the hospital staff and carries out his practice within the hospital, or he may have a private office.
Your surgeon may utilize the radiologist in obtaining diagnostic x-ray and fluoroscopic procedures. You may also receive x-ray treatments before or after your operation, or, in certain cases, the surgeon may limit your treatment to x-ray alone instead of an operation. Radiology serves all specialties in a similar manner.
Pathology is that medical science which pertains to disease processes and the changes in body tissues and fluids which diseases produce. To be sure, anyone who would attempt to treat a disease must know the exact mechanism of that disease, and all practitioners have a clear understanding of pathology. But the pathologist is the expert in the processes of disease, and it is he who operates the analytical laboratories in the hospital. All specimens of body products and body fluids your doctor wants tested are analyzed under the pathologist’s supervision by his trained laboratory technicians. However, the pathologist himself examines all tissues and organs removed from the patient by surgery. This includes both gross and microscopic examinations of the specimens. Reports of the tissues and fluids submitted to the laboratories are then sent back to your doctor to aid him in your treatment. It is also the pathologist who performs postmortem examinations of deceased patients to ascertain the exact cause of death and to determine the efficacy of the treatment given. Pathology is a most important part of the field of medicine, and this specialty serves all others.
The surgical specialty of general surgery is essentially just what the name implies. It includes in part the treatment of diseases of all other surgical specialties. This is modified, however, by the surgeon himself and the community in which he practices. The availability of other surgical specialists in the community automatically designates the scope of the general surgeon. If there is an orthopedic specialist in the area, for example, the general surgeon will do no major orthopedics, and if there is a urologist, the general surgeon will not practice urology; instead, he would prefer to refer to the respective specialists. This applies to all other surgical specialties as well. In brief, the scope of the general surgeon is determined in part by the availability of the other surgical specialists in the community.
There are, however, certain types of surgical cases which fall directly into the realm of general surgery. These include all abdominal surgery except gynecology and urology; surgery of the soft tissue parts of the arms and legs, the breasts, the neck structures and thyroid gland, blood vessels, muscles, lymph glands, fatty layers and skin, and all types of minor surgery. In these phases of the surgical field there are no definite specialties as yet. It is seen that general surgery is rather widespread, hence its name. The other surgical specialties are confined to one anatomic area or system of the body.
Anesthesiology is the specialty which deals with the rendering of all types of anesthesia. There are physicians who specialize in this field alone, and, of course, their practice is closely correlated with that of the surgeons. These specialists are called anesthesiologists. Some physicians render anesthesia as an adjunct to their practice. In some cases the family doctor will give the anesthetic for surgery of patients he has referred to a surgeon. In most hospitals, however, the anesthesia is rendered by a specially trained nurse under the direct supervision of the surgeon.
Such nurses are called nurse anesthetists. If an anesthesiologist is available in the community, he will be utilized by the surgeons for every type case, but especially for difficult, prolonged, and poor-risk cases. In cases where local anesthesia (just one area anesthetized) is used, the surgeon usually gives the anesthesia, but the anesthesiologist may be called. (A later chapter is devoted to the subject of your anesthesia, and the various types are discussed there.)
Thoracic surgery means chest surgery. This is just as the name implies, including all surgical conditions from the neck to the abdomen. In the chapters on thoracic surgery you will note the contents of the chest to include the heart, great vessels, lungs, trachea, esophagus, and the covering membranes of all these parts. Surgery of these structures, as well as the thoracic wall itself, is done by the thoracic surgeon. You will note that it is an anatomic area which confines this specialty.
Plastic surgery deals in the repair and replacement of surface defects of all parts of the body. Most of these defects concern cosmetics or appearance, and therefore are of the exposed parts, particularly the face. Bony defects of the face are also a concern of the plastic surgeon, in such cases as injuries, fractures, and congenital deformities. However, plastic surgery deals with all areas of the body, and is concerned with the improvement of function as well as appearance. Covering of defects after surgical procedures, such as the open area of skin after breast amputation or removal of skin tumors, covering areas of skin loss from burns, the treatment of scars and chronic skin ulcers—all are in the class of plastic surgery. Transferring tissue from one area to another, especially skin grafts, is the most often used procedure of the plastic surgeon. The other surgical specialties deal in part with plastic surgery, such as the oral surgeon in cases of harelip or cleft palate and the urologist in defects of the external genitalia.
Neurosurgery deals with diseases of the entire nervous system. Both the peripheral and the central nervous systems are in the realm of this surgical specialty; that is, any surgical lesion of the brain, spinal cord, or nerves is the concern of the neurosurgeon. The greater share of the surgery in this specialty is for injuries and tumors, but infection and birth defects are treated as well. Defects of both the motor nerves (those stimulating action) and the sensory nerves (those of sensations) are treated by this specialty. In some cases functional disorders are treated by “disconnecting” certain areas of the brain. This is a highly specialized field, and the operations are usually quite delicate. Every surgeon is concerned with the nerves in the area he is operating on, but operations for diseases of the nervous system per se fall to the lot of the neurosurgeon.
Orthopedics is that surgical specialty which deals with the restoration and preservation of function of the skeletal system, its joints, and its related structures. This includes fractures of bone, joint dislocations and diseases, and defects of muscles, tendons, and ligaments. Much of the therapy concerns recent injuries, but it also includes treatment and prevention of deformities of the skeletal system from any cause. The advent of industrial machinery and the automobile have made this branch of surgery a more important and prominent specialty. Also, more emphasis has been placed recently on the care and treatment of crippled children, and this is because improved orthopedic procedures have made it possible. Orthopedics is a rapidly advancing surgical specialty, essentially limited to the bones and their associated structures.
The surgical specialty of gynecology is a term usually used synonymously with diseases of women. However, this specialty is actually much more limited. It is concerned only with those diseases of the female genitalia, both internal and external. Essentially, then, it concerns diseases of the uterus (womb), ovaries, tubes, vagina, and vulva (external genital area). There are many associated structures with which the gynecologist must deal, but primarily he is concerned with the genitalia per se. This system presents a variety of pathologic conditions due to its perpetual hormonal changes, its complicated functions, its communication with the outside, and its psychological influences. Because of the close correlation of this system with childbirth, most gynecologists associate the practice of obstetrics.
Urology concerns conditions of the organs of urinary excretion and the male genitalia. The urologist treats diseases of the kidney, ureters, bladder, and urethra of both sexes, as well as diseases of the penis, testes, scrotum, and associated structures of the male. These internal organs are inaccessible for ready evaluation, and the procedures are complicated; it is a highly specialized field.
Treatment of diseases of the anus and the rectum makes up the specialty called proctology. This seems like a rather narrow limitation, but, like all other specialties confined to one anatomic region, proctology must deal in part with adjacent and associated structures. The complex anatomy and the variety of conditions affecting these parts make this specialty rather technical. Some authorities classify this phase of surgery as a subspecialty of general surgery rather than an isolated specialty.
Ophthalmology is the surgical specialty which concerns itself with all diseases and abnormalities of the eye. The ophthalmologist is an eye surgeon as well as one who fits glasses. For this reason, ophthalmology is classed as a surgical rather than a medical specialty. All eye operations are extremely delicate, and this specialty is handled almost exclusively by the ophthalmologist; it is related less distinctly to general surgery than are the other surgical specialties. A synonym for the term ophthalmologist is oculist. (Do not confuse this specialist with the optometrist)
Otorhinolaryngology means, literally, the study of ear, nose, and throat. These three organs are closely associated, and diseases of this system are common. Even though the majority of the cases are treated with medicines, this is classed as a surgical specialty because the otorhinolaryngologist, or ENT specialist, does the surgery of this system. Some ENT specialists also treat diseases of the eye, and in some hospitals these two specialties are combined so that Eye, Ear, Nose, and Throat make up one section of the surgical service. However, usually they are separate.
Oral surgery deals with all surgical conditions of the mouth and the jaws, including the lower half of the face. This specialty is unique from the rest of the surgical specialties in that it falls to the lot of the dental surgeon. The oral surgeon will perform many of his procedures in his office, but the major ones are done in the hospital. Such conditions as cleft palate, harelip, facial bone and jaw fractures, and root abscesses are treated by the oral surgeon. He usually does no fillings and is not to be confused with the orthodontist, whose concern is straightening teeth.
Obstetrics is that specialty which is concerned with pregnancy, childbirth, and the after-care of the mother. Many other allied subjects, such as heredity and the care of the newborn, are also a concern of the obstetrician, of course. The system of organs involved is the same as that of gynecology, and most obstetricians practice these specialties together. Childbirth actually is, in part, a surgical act but it is also closely related to the medical fields. Most hospital staffs class obstetrics as a surgical specialty, but many make a separate service of it and some even make a separate service for obstetrics-gynecology combined.