THE PRESIDENT’S ADDRESS DELIVERED BEFORE THE AMERICAN LARYNCOLOGrIOAL ASSOCIATION AT ITS TWENTIETH ANNUAL CONGRESS BY THOMAS R. FRENCH, M. D. BROOKLYN REPRINTED FROM THE NEWYORK MEDICAL JOURNAL FOR SEPTEMBER 10,-4898 NEWYORK £ D. APPLETON And COMPANY 1898 Reprinted from the New York Medical Journal for September 10, 1898. THE PRESIDENT’S ADDRESS DELIVERED BEFORE THE AMERICAN LARYNGOLOGICAL ASSOCIATION AT ITS TWENTIETH ANNUAL CONGRESS. THOMAS E. FRENCH, M. D., Fellows oe the American Lartngologioal Asso- ciation : In the name of Brooklyn, on behalf of its medical profession and personally as your presiding offi- cer, I extend to you a most cordial welcome, and at the same time I congratulate yon on the opening of this the twentieth annual meeting of the association. BROOKLYN. As I was not permitted to be. present at onr last meeting, I desire now to express to yon my deep appre- ciation of the high honor you paid me at that time, in selecting me to administer the affairs of the associa- tion for the year which has passed. Feeling as I do that there is no honor which can be conferred upon a laryngologist in America higher than to be made the chief executive officer of this body, my appreciation of your having selected me to act as your president must be understood. - Copyright, 1898, by D. Appleton and Company 2 THE PRESIDENT’S ADDRESS. The fact that we have met to-day to celebrate the twentieth annual meeting of this society gives ns food for thought, and calls to mind a long retrospect of achievements and successes which have placed this body on the highest plane of scientific activity. Though I was not a member at the time of the organization of this association, I am aware that some of those participating in it were of the opinion that the establishment of such a society was something of the nature of an experiment, and consequently especially earnest work was done in its early years, which placed it squarely on its feet, deter- mined its standard, and thus enabled it to continue through these twenty years in uninterrupted success. With the advance of years has come an advance in knowledge, and the association is as active and success- ful to-day as it has been at any stage in its existence. Our association was born at the daybreak of modern medicine. Though the part played by micro-organisms in disease was known in the laboratories to some extent several years before that time, the revelation of the new light to the profession at large was only just beginning to be made known through medical literature. Mainly as the result of the immortal work of Pasteur, Lister, and Koch, a new pathology has been made. The founda- tion of a medical education to-day is normal histology and pathology; but at the time that this association was formed, such knowledge was not easily obtained, and but comparatively few sought it, as it was only begin- ning to be required in the curricula of our best medical colleges. Since then the searchlights of biological and bacteriological research have revealed fields for study which are only now beginning to be fully cultivated, and in the twentieth century many of the truths which are THE PRESIDENT’S ADDRESS. 3 being so ardently sought after will doubtless be dis- closed. We are living in an age in which great advances are being made, and no earnest seeker after a field for fruit- ful effort need fail to find one. From biological re- searches must come the enlargement of our knowledge of the causes of disease, and from the further study of the life histories of bacteria must come a better under- standing of the means by which the destructive varieties may be controlled. While our dependence upon the microscope in diagnosticating disease is growing with each year, a proper conservatism in regard to its find- ings must be observed, for the useless loss of important structures may result from the not infrequent simula- tion of elements of simple inflammatory tissue for those of conditions requiring thorough eradication. We have all seen instances in which the diagnostic instinct ac- quired from clinical study outweighed the supposed revelations of the microscope. While a large physiologi- eo-pathological groundwork is essential for the attain- ment of the best results in the treatment of disease, it must not be forgotten that an acuteness of observation, derived from diligent study in clinical work, is of equal value. The history of the association, which corresponds to the largest part of the history of laryngology and almost all of rhinology, was presented in a masterly and exhaustive address by Dr. Delavan, the presiding officer, in 1894, to which it would seem that nothing particu- larly new could be added at this time. The thoughts that I would, therefore, express to you to-day are mainly in regard to specialism and the progress of laryngology and rhinology in the past twenty years. 4 THE PRESIDENT’S ADDRESS. The mind becomes confused in taking a retrospective glance through the past two decades, because of the improved conditions and the number of discoveries and distinct advances made in general medicine and surgery. It would seem almost as if in these years, to use a figure of fancy, the earnest seekers after the truth had bridled and seated themselves firmly upon the hack of their Pegasus, and from such vantage ground had dealt and were dealing more effective strokes upon the dragon of disease than in any corresponding number of years in history. Is it that we of this generation are endowed with a greater degree of intellectual activity than those who came before us? Emerson, in his essay on Circles, pictures intellectual progress as rhythmic. At a given moment knowledge is surrounded by a barrier which marks its limit. It gradually gathers clearness and strength until some thinker of exceptional power bursts the barrier and wins a wider circle within which thought once more intrenches itself. But the internal force again accumulates, the new barrier is in turn broken, and a wider horizon is presented. Tyndall, in one of his lectures on Light, says: “ People sometimes speak as if steam had not been studied before James Watt, or elec- tricity before Wheatstone and Morse; whereas, in point of fact. Watt and Wheatstone and Morse, with all their practicality, were the mere outcome of antecedent forces which acted without reference to practical ends/’ It is clearly manifest that we are to-day simply reaping the harvest which others have sown. During the past twenty years the means of communi- cation have grown prodigiously. The electric wire and the steel rail have belted the globe. The time of transit by land and by sea has been greatly reduced. Books THE PRESIDENT’S ADDRESS. 5 have multiplied. Magazines and journals have increased to such an extent that nearly every department of life, as well as medicine, has its exponent in the printed page. By these means the world has, in a sense, grown smaller. Cities have grown larger, while the population of most countries has not increased. If there have been fewer great men, compensation can be found in the fact that there have been more able men. If there have been fewer great orators there have been more speak- ers. Associations and societies have been greatly in- creased in numbers and men to be known must give expression to their thoughts and produce their results. In the days of our forefathers it took years to gather the same amount of information which can now be acquired in a corresponding number of days in one of the large, well-organized libraries. The genius of invention has simplified living. We are in close touch with the whole of the civilized world and are benefiting by the work of others to a greater extent than has ever before been possible. It is not alone that we have easier access to the work and the workshops of the scientists of the world, but the improved methods of promulgating knowledge bring a larger acquaintance with matters of detail, which are essential in order to put the facts to use. Science has expanded like the branches of a tree, and each branch is covered with its ever-increasing num- ber of workers who, centring their thoughts upon one particular branch, develop it until new shoots burst from its side, which are nurtured and still further developed by those who stand ready to cultivate them. Three classes of workers we know are needed in scientific work. The first is the original investigator who seeks the truth 6 THE PRESIDENT’S ADDRESS. for the truth’s own sake. The second is the teacher who diffuses the knowledge acquired by the original investi- gator, and the third is the applier of such knowledge to practical ends. Pasteur says: “We have science and the application of science, which are united as the tree and its fruits.” We may not all be able to win victories over reticent Nature, but we can, at least, apply as well as promulgate the knowledge of the truths discovered by others. In reflecting upon the great strides made in scien- tific medicine in this country during the past twenty years, it may be of interest to note the words of De Toequeville, written nearly fifty years ago: “It must be confessed that among the civilized peoples of our age there are few in which the highest sciences have made, so little progress as in the United States. . . . The future will prove whether the passion for pro- found knowledge, so rare and so fruitful, can be born and developed as readily in democratic societies as in aristocracies. As for me, I can hardly believe it.” Tyn- dall, in an address delivered in New York twenty-five years ago, said that in no other country would science in its highest forms exert a more benign and elevating influence than in ours. The willingness of American citizens to throw their fortunes into the cause of educa- tion was, he said, without a parallel in his experience, but hitherto their efforts had been directed to the prac- tical side of science. While his appeal for science on higher grounds is not as applicable to-day as when made a quarter of a century ago, it still suggests large possi- bilities for scientific research in this country, for the dependence of practice upon principles is as true to-day as it was then. THE PRESIDENT’S ADDRESS. 7 Since this association was founded a great change has been wrought in the character of medical practice. Though specialism was recognized and largely practised in Europe, it was comparatively new in this country, and those who confined their work to one department were relatively few. Now their number is legion, and the tendency toward the selection of a special field for practice is growing stronger each year. The widening of the field for study in every department of medicine has brought about this change. In no department, how- ever, have the workers increased so rapidly as in ours. When we consider the intimacy of the relationship which diseases of the nose and throat hear to diseases in remote portions of the body, and how many diseases of other organs, or symptoms referred to other organs, may be caused by diseases of the upper air-tract, it is hardly to be wondered at that so many workers have been at- tracted to this field of study. The laryngoscope and the rhinoscope are only twice the age of our association, but the pioneers in this department have made such good use of the instruments, and laid so strong and broad a foundation for the study of the diseases of the parts which they reveal, that it is now relatively easy to ac- quire the manipulative skill necessary to become a spe- cialist in rhinology. Years of practice, together with a natural aptitude, are absolutely necessary in order to acquire skill in the surgical treatment of diseases of the larynx; but much less practice is required to per- mit intranasal surgical work to be done, and this fact is unquestionably accountable for the large amount of indifferent or mischievous surgery which is yearly grow- ing more noticeable. The ability to adapt many of the modern appliances to the treatment of disease requires 8 THE PRESIDENT'S ADDRESS. only such training as will make a man a skilled me- chanic, hut to apply such measures with the best results and adapt them with intelligence requires a knowledge of the fundamental laws which are known to govern the human body. Pathology is the foundation of scien- tific medicine, but a knowledge of general pathology and the diseases which affect the whole economy can not be sufficiently acquired in a college and hospital course of study; and yet the disposition to consider such a training sufficient to permit a man to devote himself exclusively to the practice of a special department of medicine is growing to an alarming degree, and is bringing into the various fields a large number of men who can hardly be regarded as competent. The advice given by Sir Morell Mackenzie ten years ago, and in- dorsed by Dr. Asch in his presidential address before this body five years ago, that medical men should prac- tise general medicine and surgery during the first ten years of their professional careers, should be considered of greater value to-day than ever before; and in view of the rapidly increasing number of men who are flocking into the various special departments immediately after graduation, those of us who have the opportunity to speak to medical students should not fail to make it clear to them that success by honest efforts in these days can only be attained by those who have acquired a compre- hensive knowledge of disease by years of general prac- tice. It would, perhaps, be wise to remind them of the advice given by Dr. William Osier to the young medical graduate that “ as he values his future life let him not get early entangled in the meshes of specialism.” That specialism should continue and increase is, however, in- evitable and desirable. Is it not because men have made THE PRESIDENT’S ADDRESS. 9 special branches their life work that so much of value has been learned in the past fifteen or twenty years? Earnest workers, devoting most, if not all, of their time to one branch of medicine, have evolved many of the scientific truths on which the practice of to-day is based. The charge is made that the workers in the various departments of medicine are becoming too narrow in their studies, devoting themselves to the acquisition of knowledge of a limited field at the expense of general medical and surgical information. To a certain extent that, no doubt, is true, but as it has already become at least difficult to digest the rapidly increasing literature in any one department of the healing art, which is neces- sary in order to keep the methods of treatment abreast of the times, this condition is scarcely to be wondered at. As knowledge increases there will, of course, be less opportunity for general studies, and therefore the need of a higher school and college education as a foundation for the practice of medicine is becoming more apparent. When the means of acquiring information were not as large as they are to-day, great earnestness as well as ability were needed to overcome the difficulties in the path of the student, and are we not facing the danger that, as the acquisition of knowledge is made easier, the information will be accepted passively rather than ac- tively ? When, some years before the origin of this asso- ciation, Dr. Barnard said, “ ISToav we have made the task so easy, we have built so many royal roads to learning, in all its departments, that it may well be doubted if the young men of our day, with all their helps, acquire as much as those of the earlier period acquired without them,” did not his words imply the truth that conquest 10 THE PRESIDENT’S ADDRESS. means a spirit of augmented strength, and should we not, therefore, elevate the standard of requirement in proportion as the opportunities to meet it are increased ? Another potent reason for the belief that the specialist is occupied with too limited a sphere of thought and action, and is disposed to magnify the ailments in the department of the body to which he confines his practice, is an outcome of the opposition which he has met in extending his field of study. Many of his critics have shown the greatest unwillingness to his having investiga- tions made of other portions of the body than that with which he is identified; and yet the growth of knowledge has made it clear that the correlation of the various parts of the body is so intimate that it is impossible to determine the cause of many of the affections of a given part without a knowledge of the conditions which may exist elsewhere. The feeling is still strong that the specialist must limit his observations to his own field. To do so, the symptoms which he is asked to relieve would in some cases continue in spite of his best-di- rected efforts, while a happy outcome might be obtained if the physician who has the case in charge would heart- ily cooperate with him. To a large extent the absence of cooperation is to blame for not only many unsatisfac- tory results, hut for hedging in the specialist to a lim- ited sphere of action. The charge is also made that specialism is doing great harm because of the charlatans who live and thrive under its cloak. While the profession of medi- cine has never been without its charlatans, it is probably a fact that there are fewer of them to-day than ever before, and let this condition, therefore, be set down to its proper account—to the weakness or, if you will, the THE PRESIDENT’S ADDRESS. 11 selfishness of man, bnt not to specialism. In propor- tion as the standard of medicine is raised and the peo- ple are educated, so will the pretender and those mem- bers of the medical profession who are “ over the bor- der ” of reputable practice be discounted. So long as there is a demand for such men they will be supplied. It is unquestionably true that there are too many men in the special fields who have an eye alone for the main chance; but it is equally true that the earnest, upright specialist has as strong a desire to elevate the standard of medicine, and has as great a power as any to do so. Despite the evils which are growing out of special- ism, the fact that men are centring their thoughts upon special lines of work more than ever will ultimately re- sult in the largest good to mankind, for we are begin- ning to learn that concentration is the price we must pay for efficiency. The advance of civilization is, in a large degree, dependent upon a subdivision of labor. The advance in the knowledge of the human body in health and disease will depend upon an even greater subdivision of labor than now. The evils resulting from such subdivision of work and practice must be met and controlled as best they may, but the hope that has been recently expressed, that specialism will soon wane, is, in the nature of things, not likely ever to be realized. It therefore behooves us, individually and collectively, to think well on these things, that we may the sooner deter- mine how best to secure for specialism the minimum amount of harm and the maximum amount of good. The particular achievements which have been made during the life of this association, which have enabled laryngology and rhinology to occupy such conspicuous places among the specialties in medicine, have been 12 THE PRESIDENT’S ADDRESS. many. The dawn of the most brilliant era in these de- partments began when Koller made known the local an- aesthetic properties of cocaine fourteen years ago. The vast strides made in our knowledge of the pathology and treatment of diseases of the nasal passages and naso- pharynx would not have been possible without the assist- ance of this agent. The ease with which diseases of the upper air-passages can be revealed, the presence of in- struments tolerated, and the destruction and eradication of diseased tissue permitted by the application of this drug has revolutionized our knowledge and practice. While the discovery of lymphoid growths in the pharyngeal vault antedates the foundation of this asso- ciation by seven years, it is nevertheless true that the importance and frequency of occurrence of these growths were not fully appreciated in this country, at least, until 1884. To our deeply lamented and talented fellow, Dr. Hooper, must be given the credit for first awakening a lively interest in this affection in America. Countless thousands of lives during all the ages were rendered feeble and shortened by this heretofore un- recognized cause. To-day the operation for removal of these growths is performed by surgeons in every part of the civilized world. To have bestowed a boon of such magnitude upon posterity has made the distinguished discoverer of “ adenoid vegetations,” the late Professor Wilhelm Meyer, the greatest possible benefactor to man- kind. Antitoxine therapy, serum therapy, and organothera- py are methods of treatment which have arisen since the inception of this association. If antitoxine had accom- plished no more than the diminution in the number of cases of laryngeal invasion in diphtheria, it would have THE PRESIDENT’S ADDRESS. 13 been a priceless boon; but, according to Richet, the lives of about fifty thousand infants are now saved annually by this agent alone. O’Dwyer began his experiments with intubation of the larynx two years after this association was organ- ized, but it is unnecessary for me to dwell upon the vast value of this distinctly American contribution to the relief of suffering humanity. It has to a very large extent driven tracheotomy from the field, but when a better adjustment of these two operations for the re- lief of laryngeal stenosis shall have been found the percentage of cures will doubtless be increased. There have been but few greater monuments reared in the sci- ence of medicine than that which will perpetuate the fame and the name of Dr. Joseph O’Dwyer. We are probably standing to-day at the threshold of our knowledge of tuberculosis. Koch found the bacillus sixteen years ago, and how best to destroy it in the living tissues is a problem to the solution of which many scientists in this country and Europe are devoting the best parts of their lives. While the meth- ods of treatment for laryngeal tuberculosis employed to-day give better results than heretofore, we can scarcely look for signal success in dealing with this disease until the nature of tuberculosis is better under- stood. Whether highly beneficial results from the use of the Krause-Heryng method are to be obtained in this country or not is yet to be demonstrated. The outlook is, however, encouraging. While but little knowledge has been acquired dur- ing the past twenty years in regard to the nature, causes, and medicinal treatment of cancer, we are certainly in a better position to contend successfully with the 14 THE PRESIDENT’S ADDRESS. disease in its early stages than heretofore. The note- worthy operative work in cases of cancer of the larynx of one of our corresponding fellows, Sir Felix Semen, and of Professor B. Frankel, brings the encouragement that even better results may be expected when the means of making early diagnoses with greater ease and certainty shall have been acquired. Semon reported in 1894 fifty-eight per cent, of cures of selected cases in his private practice, after removing the diseased parts through an opening made by dividing the thyreoid carti- lage. Further reports of eases operated upon by him since then, and presented in the Archiv fur Laryn- gologie, do not materially change the percentage of cures. The gratifying statement made by Semon is that in only one of his cases had recurrence possibly taken place. In a letter to me dated December 39, 1897, Semon stated that all of the patients who had recovered from the op- erations were doing well. Surely such results can not but encourage us to believe that even this dire disease, if dealt with in its early stages, may be permanently eradicated in a much larger percentage of cases than has heretofore been believed to be susceptible of cure, and that, too, with a minimum amount of disfigurement or loss of function. Almost all of our knowledge of diseases of the ac- cessory sinuses has been acquired in the past twenty years. Prior to the eighties the sinuses were opened only to relieve the symptoms occasioned by acute sup- puration. How, thanks largely to the brilliant original work done by a number of the fellows of this associa- tion, we are in a position not only to relieve the symp- toms produced by acute suppuration but, in a measure, to prevent its occurrence, and also to remove by rational THE PRESIDENT’S ADDRESS. 15 means the conditions resulting from long-standing dis- ease. In the early years of this society the study of vaso- motor reflex phenomena from structural diseases in the nose was begun by members of this body, and has been actively continued until the present time. While, perhaps, more was hoped from it than has been real- ized, nevertheless brilliant results have been obtained, and the investigators who have elucidated the subject have contributed facts of the utmost importance to rhinology. Mainly through the researches of a number of the corresponding and active fellows of this association, a large addition to our knowledge of the innervation of the larynx has been acquired. The discovery of the X rays in 1895 will perhaps mark an epoch of the utmost importance in medicine and surgery. Through the application of the rays to the portions of the body in which we are especially in- terested, excellent results have been obtained by our corresponding fellow in Glasgow, Dr. John Mackintyre. He has been experimenting with the cinematograph in conjunction with the X rays, and has been so far suc- cessful that he was able to show, at the Royal Society of Edinburgh last June, the movements of the’bones in the legs of a frog on the screen. In our special de- partment future developments will depend upon how far it will be possible to photograph the soft tissues. By placing a fluoroscope in the mouth Dr. Mackintyre has succeeded in obtaining an image of the saeptum, the roots of the teeth, and other hard structures in that neighborhood. He has also been able to demonstrate the process of ossification in the thyreoid cartilage. In 16 THE PRESIDENT’!? ADDRESS. a letter to me dated January 6, 1898, Dr. Mackintyre, in writing of the X rays, says, in substance, that it is possible to get shadows of the larynx, but that their definition is not as sharp as those obtained in photo- graphs of hard structures or foreign bodies. Never- theless, he has great hopes for the future, as the subject of skiagraphy is but two years old. If Lister’s work has been of less value in our field of practice than in others, it has, at least, taught us the value of cleanliness. It has taught us the necessity of subjecting our instruments, whether used for examina- tion or for operative or non-operative treatment, to the germ-destroying action of heat. If we can not make very free use of antiseptics, we can, at least, give our patients the benefit of thorough asepsis. This brings with it the comforting assurance that if we are not always successful in contributing the largest amount of good, we have rendered it impossible to do harm by the conveyance of infectious germs. Through asepsis, antisepsis, and local and general ansesthesia, the fear of the knife is being rapidly banished, and, while this carries with it a certain degree of danger at the hands of the overzealous operator, it makes possible the eradi- cation of disease to a degree never before known in history. Although Valsalva demonstrated nearly two centu- ries ago that deafness was often due to the closure of the Eustachian tubes, the conditions in the nasal pas- sages and nasopharyngeal cavity which are now known to be frequently accountable for the imperfect ventila- tion or closure of the Eustachian tubes were not fully appreciated until within the past fifteen years. In one of the standard American treatises on diseases THE PRESIDENT’S ADDRESS. 17 of the ear published less than fifteen years ago, the author states that very few otologists made much use of the rhinoscope, as it was only in exceptional cases that it was found that the revelations compensated for the time employed. There is surely much yet to learn of the relation of diseases of the ear to diseases of the throat and nose, but the degree in which diseases of the ear may be prevented, or, when they exist, may be suc- cessfully controlled through the care of the nose and throat, is yearly growing greater. The most successful otologists to-day are necessarily competent rhinologists, and it is quite certain that the most successful text- books on diseases of the ear, which will be written in the future, will be those in which a large part of the contents will be devoted to the consideration of catarrhal affections of the upper air-passages. By comparison with the treatment of catarrhal affec- tions by applications of alterative and astringent reme- dies, which were employed almost exclusively in the early years of this association, how brilliant seems the surgical work now performed for the radical relief of catarrh of the upper air-passages! The recognition of the physiology of the nasal passages, the recognition of the pathological importance of hypertrophied turbi- nated tissue, saeptal spurs, and deflected nasal saspta, in- deed, the recognition of nasal diseases themselves— virtually the inception of rhinology—are a part of the history of our special department of medicine since the association first saw the light. Much of the work which has revolutionized our methods of treatment has been done in this country, much of it in this association, and to-day we can claim distinctive places for American laryngology and rhinology which could not have been accorded to them twenty years ago. 18 THE PRESIDENT’S ADDRESS. The utilization of the incandescent electric-light cur- rent, which can usually be found wherever specialists are in demand, for galvanism, faradaism, electrolysis, galvano-cautery, and small-lamp work for transillumi- nation, has greatly facilitated special work and saves much time. In the early days of the association these aids could only he obtained from cumbersome appara- tuses. It is my sad duty to chronicle the death of our lamented ex-president, Dr. Harrison Allen. By his per- sonal charms he endeared himself to every member of the association, as well as to all those who had the privilege of an acquaintance with him. He represented the best type of the dualist in medical studies, dividing most of his time, in pursuit of knowledge, between comparative anatomy and laryngology. To a very large extent he filled the place left by the late Dr. Joseph Leidy, but at present it is felt that there is no one to take the place of Dr. Allen, in that particular field of study, in the city of his birth. He was the author of a large number of contributions to the study of anatomy and laryngology, but his superb System of Human Anatomy will live as his greatest memorial. We will miss his presence at our annual gatherings, but we will feel the inspiration of his character and work and be prompted by the lesson of his life to do the utmost that is in us for the betterment of mankind. In the selection of a subject to. be brought before a scientific body many, no doubt, are often deterred from reading at all because they are unable to find an origi- nal field for discussion, or some novelty which will in- terest. But I take it that such is far from the meaning of the annual gatherings of this society when we meet, THE PRESIDENT’S ADDRESS. 19 partly to discuss again subjects which, by judicious pruning, may crystallize our knowledge in regard to them. Such discussions also assist in preventing us from forming habits of work or fixed beliefs in regard to sub- jects about which men hold different opinions. Let us remember that in scientific medicine the ideal is the truth, and the actual but that part of the truth which has been attained. As we are ever striving for the ideal and have but one desire, to know the truth, and thus but one fear, to believe an untruth, free and friendly discussion, entailing, as it does, the discipline of suspending judgment, is, I take it, one of the means of converting the actual into the ideal. It is for these reasons that I feel that a large part of the value of our meetings is derived from the discussions of papers. If the fellows could be made acquainted beforehand with the manner in which the subjects to be presented were to be treated, they would come better prepared to discuss them. If epitomes of papers to be read at each meeting could be sent to a committee whose duty it would be to print them and mail a copy to each member of the asso- ciation two weeks before the meeting, discussions of a most fruitful character would be the natural result. Such a course of proceeding would probably also result in the saving of time, as under those conditions the dis- cussions would tend toward crispness and brevity. To provide the best material for the growth of our as- sociation, in the future selection of applicants for fellow- ship we should take pains to acquire the largest possible knowledge of their mental habits and ideals, as well as their scientific attainments. In this age of rapid advance and sharp competition, the physician who is not a good student can not be a candidate for the honors which will 20 THE PRESIDENT’S ADDRESS. be awarded in the future of modern medicine. But there are things better even than science. Character is higher than intellect, and the highest mark in human nature is reached when high intellect and upright char- acter are found combined. We are all striving for the highest attainments in the work of the association, and we wish to feel assured that the coming men will be thoroughly competent and tilled with enthusiasm in their work. We want young spirit, vigorous spirit, and particularly men who are interested in, and in touch with, the advancing knowledge of biology, bacteriology, and pathology, for it is through these departments that medicine is being rapidly converted from an art into a science. At its last meeting the council thought it wise to call attention to article 14 of the by-laws of the association, which reads as follows; “ Any fellow who shall have failed to furnish a paper for three successive meetings, or who shall have absented himself from three successive meetings, may, on vote of the council, be dropped from the association.” At the same time the council recom- mended that the by-law should be amended by excluding fellows of twenty-years’ standing from its provisions— an amendment upon which you will be asked to vote at this meeting. The by-law is one which should be enforced in order to maintain the highest efficiency in the pro- ceedings of the association. The average attendance at the nineteen meetings of the society has been fifty-six per cent, of the total membership. Even though the fellows reside in all parts of the country, from Massa- chusetts to California, and from Canada to Louisiana, the members of the council are hopeful that the attend- ance at the meetings in the future will be even greater THE PRESIDENT’S ADDRESS. 21 than heretofore. A dearth of enthusiasm can not be complained of; but it seems desirable at this, the be- ginning of the third decade in the life of the association, to call attention to such measures as have been provided to insure an increase, or prevent a decline, in interest in the meetings of the association. Since Elsberg first presided in this place there have been printed in the archives of the association four hun- dred and eleven papers, many of them masterpieces, carved with infinite pains and great labor in enduring bronze, upon the contents of which much of our prac- tice of to-day is based, and which will, perhaps, be util- ized to an equal extent by posterity. The wide range of subjects which have been discussed has, among other things, demonstrated very conclusively the intimate re- lationship which diseases of the throat and nose bear to internal medicine. Many of the founders of the asso- ciation are among our most enthusiastic workers to-day and still continue to contribute material of a character which has made the association famous. The inspira- tion of the work done for us by Elsberg and Hooper, who sought the truth in its wholeness, not diluting it or masking it, is still with us, and will remain with ns as long as the association exists. The heritage of the scientific spirit of Allen will add material strength to the foundation upon which we are to build in the future. The attendance of the members of the association’s council at its annual midwinter meetings during the past twenty years has been sixty-five per cent, of the total membership. Ho better demonstration could be had of the responsibility felt by that body in conducting the affairs of the association, for, in order to attend those meetings, it required, in some instances, the devotion 22 THE PRESIDENT’S ADDRESS. of the largest part of two days to travel and, in many instances, the absence of at least two days from home. In order to maintain the high order of excellence in the work of the association and the lofty standard which has resulted from its proceedings thus far, it is neces- sary to put forth extra efforts in the future so that the scientific spirit of the association may be seen to be growing ever finer, and as from the beginning reflecting the highest credit upon the department of medicine to which we are devoting our lives. The words of Elsberg, written when the laryngoscope was but five years old, that “ the realization of a glorious future for laryngology needs but resolution, labor, and perseverance,” are as applicable to-day as when written thirty-five years ago, and the high obligations imposed upon us by those who founded this association can only be met when we re- member that “ men walk as prophecies of the next age.” Though great advances have been made, greater advances are yet to be made, and with “ resolution, labor, and per- severance ” we may lift laryngology to a still higher plane of usefulness, and thus contribute to the elevation of scientific medicine. Again, gentlemen, I extend to you a cordial welcome to the borough of Brooklyn in the city of New York, and offer you my best wishes for a highly successful and most enjoyable meeting at this the twentieth annual congress of the American Laryngological Association. A TEXT-BOOK ON SURGERY: GENERAL, OPERATIVE\ AND MECHANICAL. Bt JOHN A. WYETH, M. D„ PROFESSOR OP SURGERY IN THE NEW YORK POLYCLINIC ; BURGEON TO THIRD EDITION,, REVISED AND ENLARGED. MOUNT SINAI HOSPITAL, ETC, 997 Pages, with 938 Illustrations. Buckram, uncut edges, $7.00; sheep, $8.00; half morocco, $8.50. SOLD ONLY BY SUBSCRIPTION. Froin the Author's Preface. The original edition of this work was published in 1886. It was revised and enlarged in a second edition in 1890. Within the period of seven years to this date (November, 1897) so many important advances have been made in surgical science and the operative technique that the author has found it necessary again to revise and practically rewrite this volume. To add all that was new and accept- able to that which experience had already demonstrated to be useful has of neces- sity increased the number of pages and size of the hook. By careful elimination of matter which could with least disadvantage be left out, this volume, however, only exceeds the former by one hundred and twelve pages. It has been the author’s aim to retain those features of the original work which made it available to the busy practitioner for quick and ready reference, and to add to this edition some elementary pages which may commend it to teachers for their undergraduate pupils. With this end in view the matter has in great part been rearranged. The introductory section is devoted to surgical pathology, subdivided into six chapters. These chapters treat of inflammation and the process of repair in the various tissues of the body, and the differences in repair in a tissue affected with simple or non-infective and infective (or suppurative) inflammation. Specific and non-specific urethritis, erysipelas, actinomycosis, glanders, tetanus, malignant oedema, hydrophobia, tuberculosis, syphilis, leprosy, diphtheria, and typhoid infec- tion are also embraced in this portion of the work. Chapters YII and YIII are devoted to surgical dressings, sterilization, asepsis and antisepsis, and anaesthesia. In Chapters IX and X are given haemorrhage, wounds, bums, skin grafting, frostbite, furuncle, carbuncle, ulcers, and gangrene. Bandaging is given in Chap- ter XI, and Chapter XII is devoted entirely to amputations. Chapters XIII, XIY, and XV deal with the lymphatic vessels and glands, veins, arteries, aneurism, and ligation of the vessels. In Chapters XYI and XVII are given the lesions of the bones and joints, and the various operative measures for their correction. The chapters from XVIII to XXIX inclusive are devoted to regional surgery, and in that portion of this section in which the abdomen is considered many im- portant changes have been made and much new matter added. Chapter XXX takes up deformities and their correction, while the final chapter (XXXI) is devoted to the subject of tumors. D. APPLETON AND COMPANY, NEW YOKE.