The President's Address, DELIVERED BEFORE THE AMERICAN LARYNGOLOGICAL ASSOCIATION AT ITS NINETEENTH ANNUAL CONGRESS. BT CHARLES H. KNIGHT, M. D. RBFRIKTBD FROM THB Neto ¥orfc jf&rtitcal journal for August 28, 1897. Reprinted from, the New York Medical Journal for August 28, 1897. THE PRESIDENTS ADDRESS, DELIVERED BEFORE THE AMERICAN LARYNGOLOGICAL ASSOCIATION AT ITS NINETEENTH ANNUAL CONGRESS. By CHARLES H. KNIGHT, M. D. In accordance with custom, it becomes my agreeable duty to extend a cordial greeting to you all, and espe- cially to our guests, both from this country and from abroad, who honor us by their presence. I trust that this occasion may be rendered memorable, not only by the warmth of our welcome, but by the zeal and earnest- ness of our scientific labors. As your presiding officer, it is my privilege to occu- py a few moments in reviewing the affairs of the asso- ciation, and in referring to various matters of possible interest or importance. I wish to take advantage of my position to say a word or two upon a subject which has been recently forced upon my attention by several cir- cumstances. When we become absorbed in professional work, especially in clinics, and are thrown into familiar contact with infectious disease, we are apt to become careless as to certain safeguards which involve both Copyright, 1897, by D. Applbton and Company. 2 THE PRESIDENT'S ADDRESS. ourselves and others. A series of cases has impressed upon my mind with startling reality the lamentable con- sequences of neglect of those precautions as to instru- ments and manipulations which we are all supposed to observe. In view of the possibilities of infection thus acquired and perhaps for a long time unrecognized, it has seemed to me worth while to call your attention to the subject. In our special work there is particular liabil- ity to mishaps of this kind, since specific lesions of the mouth and fauces are extremely common, and are among the most contagious of morbid phenomena. It is unne- cessary to detain you by going into details as to meth- ods, well known to all of you, by which such accidents may be avoided. Closely allied to this subject is that of septic in- fection in general. In the growth of our specialty sur- gical procedures in the upper air-passages have assumed important proportions.. Absolute asepsis in the wounds we are in the habit of inflicting may be impossible and, in view of the satisfactory drainage usually insured, unnecessary. In this connection it is a pleasure to refer to another circumstance which has doubtless already at- tracted your notice, as a revelation of what may be ac- complished by earnest, intelligent study of scientific prob- lems. At the last meeting of the British Association for the Advancement of Science the story of the birth of antisepticism was told in an unassuming way by that distinguished surgeon who more than any one now liv- ing has contributed to the advance of surgical science. We shall begin to appreciate the importance of that epoch which he describes when we hear that in a sin- gle day hospital gangrene was banished from the All- gemeines Krankenhaus, of Munich, by the adoption of THE PRESIDENT'S ADDRESS. 3 Professor Lister's principles. We are told that pyaemia and erysipelas also soon disappeared, and that the trans- formation in his own wards in the Glasgow Royal In- firmary was almost equally marvelous. In reading Lister's masterful address, one sentence in particular caught my eye. He has been reviewing the question of putrefaction in wounds, and to illustrate the desperate state of affairs at the time he began his researches, he mentions that Syme, to whom he refers as " the safest surgeon of his time," was inclined to believe that am- putation, rather than any attempt to save the limb, was the proper course to pursue in all compound fractures of the leg. In his search for some way of preventing putrefaction, he remarks: "I had done my best to miti- gate it by scrupulous ordinary cleanliness and the use of various deodorants." No positive results were ob- tained until he began the use of carbolic acid, to which he still adheres as the safest and most effective anti- septic. Whether we accept with Lister the germ theory of disease and the principles of antisepticism, or discard with derision every antiseptic detail; whether we pin our faith to germicidal agents known to be fatal to bacterial organ- isms, or endeavor to combat " certain specific poisons of unknown nature " in accordance with rules of simple cleanliness, it is obvious that there are degrees of clean- liness, and that the more rigid our observance of care- ful methods of practice, the greater will be the reduc- tion in the chances of infection from whatever source. It may be difficult, and perhaps unnecessary, to shut out every septic germ from the upper air-passages, but we may readily exclude the commoner and coarser forms of wound infection. 4 THE PRESIDENT'S ADDRESS. Ill looking over the eighteen volumes containing the record of our labors, we shall find cause to congratulate ourselves upon the spirit of wise conservatism which has characterized our work. We may flatter ourselves that we have not been carried away by fads of the moment. In the wild haste to gain fame and fortune from a new idea, the temptation is strong to present crude and un- tried theories as established facts. The premature an- nouncement of new cures for tuberculosis, which experi- ence has proved to be inert or injurious, has taught us a healthy skepticism. It is well, however, to cultivate a judicial temper of mind and not reject everything new, because of its novelty, without thorough trial. Sta- tistics are, no doubt, misleading; but every allowance being made for variation in severity of epidemics and for other modifying conditions, there is reason to hope that in diphtheria antitoxine we have an agent capable of, at least, restraining the ravages of that terrible scourge. The spirit in which the question is still being investi- gated, especially by the American Pasdiatric Society, can not be too highly commended. With the marvelous growth of specialism in medicine laryngology has more than held its own. Nevertheless, we not infrequently hear the question asked, After all, what has the laryngoscope accomplished, especially with relation to the development of the singing voice? I fear that we shall be compelled to admit that it has done little or nothing more than corroborate theories and knowl- edge acquired in other ways. Vocalization is a very com- plicated process. On the one hand, we know that a nor- mal larynx is essential to a perfect voice; on the other hand, we know that one may learn to speak intelligibly without a larynx, by means of the aid provided by the THE PRESIDENT'S ADDRESS, 5 accessory organs. These accessory structures-the lips, the teeth, the tongue, the palate, the pharyngeal wall, the nasal chambers, and the bones of the skull-all con- tribute their part to vocal function. An imperfection, a deviation from normal conformation or proportions in any one of these, must inevitably modify the quality of the voice to a degree more or less perceptible. While we are by no means agreed as to all the elements con- cerned in the correct production of the singing voice, it may be said that nearly all the information given by the laryngoscope as to the movements and position of the vocal bands during tone formation had been already furnished by dissection of the larynx. We knew before- hand, from the attachment of the intrinsic muscles of the larynx, what must be the action of individual fibres in ac- cordance with well-known mechanical laws. The laryn- goscope does not tell us why, of two individuals, with apparently identical vocal apparatus, one is a great vocal- ist and the other can not sing a note. Nor does it tell us why a singer with a voice of fine quality and perfect intonation, and used in accordance with a so-called good method, fails to thrill us. In other words, no scientific theory and no instruments of precision will discover that musical instinct, that artistic temperament, which inspires the voice of every great singer. No more trying ordeal confronts the medical practitioner than the at- tempt to manage the case of a youthful aspirant for lyric honors to whom Nature has denied those gifts es- sential to success. On the other hand, he experiences no more intense satisfaction than in proving his ability to restore a lost voice or in giving such advice as will assist in its recovery. Here, then, is the chosen and suc- cessful field of our art. An individual comes to the 6 THE PRESIDENT'S ADDRESS. physician with hoarse, husky, or whispering voice. No one can deny the importance and feasibility of deter- mining with accuracy, in most cases, the site of the diffi- culty-whether it be a fault of innervation, a defect of muscular action, a neoplasm or overgrowth of tissue, or a simple inflammatory condition. In the detection and relief of disease, and in thus protecting and preserving the singing voice, the laryngoscope will continue to be of inestimable value. We are compelled with regret to chronicle the oc- currence of two breaks in our ranks since we last met- one owing to the resignation of Dr. Clinton Wagner, of New York, and the other to the death of Dr. Charles M. Shields, of Richmond, Virginia. Dr. Wagner was one of the original members of the association and has added not a little to the fame of our organization. In the death of Dr. Shields we have lost a most genial and accomplished gentleman. During the few years he had been with us his industry, his exceptional mental endowments, and his attractive personality had fully vindicated his title to membership. He joined the asso- ciation in 1893, and had been an active and efficient fel- low. The announcement of his death will be heard with sincere sorrow. A suggestion or two as to our management may be permitted. In the first place, let me ask you to consider the propriety of increasing our annual dues. You are made painfully aware about every three years of a de- ficiency in our revenues by a call from our worthy secre- tary for an extra assessment. It seems to me and to some other members of the council that a slight addition to our income would be desirable, not only to forestall our tri- ennial exigency, but to provide us with a fund for other THE PRESIDENT'S ADDRESS. 7 purposes. For example, it would be eminently proper for this association, as a body, to be represented on the subscription lists of memorials to distinguished members of our profession who have passed away. Individually our response to such calls is always liberal, but as an organization it seems to me we should recognize move- ments of this character. Another purpose to which a part of a surplus fund might be devoted is the collection and preservation of in- struments devised by members of the association. At our meeting in 1894 a committee was appointed to con- sider this matter. The plan they suggested of necessity involves more or less outlay. If suitably provided for, such a collection would be of interest and value. Still another project has long been in my mind, but may seem to you impracticable and utopian-namely, the establishment by this association of a bulletin, or peri- odical, which should be not only the official organ of this society, but the mouthpiece of all American laryngolo- gists. In view of the long list of names of those more or less identified with our specialty in this country and of the voluminous literature relating to diseases of the throat and nose, it seems not unreasonable to expect that such a publication would receive adequate support. The realization of this hope may not be impossible, and I ven- ture to commend the idea to your serious consideration. No reference to the events of the year which has elapsed since our last meeting would be complete which failed to mention the continued interest manifested in the new world opened to us by the Rontgen ray. We may take pride in the fact that one of our correspond- ing fellows, Dr. John Macintyre, of Glasgow, has been especially active and successful in experimenting with 8 THE PRESIDENT'S ADDRESS. this wonderful discovery. It remains to be seen whether it will be of any practical value to us in our special line of work. In locating foreign bodies and in determining the dimensions of tumors and the extent of infiltration in malignant disease, it may prove to be of service. At the meeting of our association a year ago a com- mittee was appointed to draft a memorial to Congress protesting against the adoption of a bill to restrict vivi- section. In our business meeting to-morrow we shall hear more in detail of this matter. Let me remind you, however, that it becomes us to approach this sub- ject with caution, and at the same time with candor. Such apparent brutalities are said to have been com- mitted in the name of science that we can hardly wonder at the earnestness of those who oppose vivisection. On the other hand, the extravagant and intemperate lan- guage of some fanatical antivivisectionists is most exas- perating. If scientists may be justly charged with mis- representation, surely the arguments of their opponents have, in many cases, descended to vituperation. While the question would seem not to concern us very closely as specialists, yet we find that one of our fellows, whose memory we cherish, was a particular object of attack by certain champions of the dumb animals. You have not forgotten the warm discussion which took place at our meeting in New York, in 1887, when our lamented friend, Hooper, read his paper on the Anatomy and Physiology of the Recurrent Laryngeal Nerves. With the excep- tion of that paper and others by him, and of contribu- tions in a similar line by Donaldson, the record of our work in our published Transactions contains little or nothing which may be fairly regarded as the product of that barbaric ferocity which is supposed to character- THE PRESIDENT'S ADDRESS. 9 ize the bloodthirsty frequenters of the physiological laboratory. Yet the subject is one of vital interest to all scientific physicians. Who shall say that vivisection has accomplished nothing, has bestowed no boon upon hu- manity in view of the achievements of Harvey and of Magendie, of Claude Bernard, of Pasteur, and of our own investigators? The jubilee of anaesthesia might not have been celebrated last year had sympathy for the lower animals prevailed. Without preliminary tests even Morton, with all his courage, would hardly have dared to apply his beneficent discovery to human beings. Thus the race might have been long deprived of that blessed immunity from pain which it has enjoyed for the last fifty years. The lives and the sufferings of thousands of such animals as are used in experimentation are not to be considered if a single fact which may improve the health and increase the happiness of mankind may be established. More than that, we claim that vivisection is justifiable and should be permitted as a means of impressing certain important phenomena upon the minds of students in our schools, not indiscriminately to a gen- eral medical class, but to the more advanced and special students in pathology and biology. As a stimulus to in- terest, as an incentive to study, and as a means of perfect- ing technical skill, vivisection is a valuable educational resource. No reasonable man can object to restrictions which look to the prevention of wanton cruelty, but those contemplated by the bill and urged by ill-informed agi- tators of the question would practically prohibit ani- mal experimentation in the District of Columbia. The adoption of the proposed measure would be merely a step to the introduction of similar bills elsewhere, with the result of eventually closing all our schools for bio- 10 THE PRESIDENT'S ADDRESS. logical research. Erelong we should reach the condi- tion of our English cousin, a celebrated surgeon, who, bemoaning the difficulties of vivisection under the strin- gent law of Great Britain, remarked that he had filled many graveyards with human beings in learning intes- tinal surgery. Probably our friends are not aware that they are offering themselves as substitutes upon the sac- rificial altar of science. What shall we say of the sickly sentimentalism which evokes spasms of maudlin sympathy over the death of a worthless dog and sits with folded hands before the horrors of the unspeakable Turk, or denies to suffering humanity hope of exemption from disease, the study of which may be most readily conducted upon the lower animals? A distinguished Philadelphia physician is being extensively quoted as representing the more enlightened sentiment of the profession. One of his points which our " humane " friends have taken up with great alacrity refers to the ingenious con- trivances for confining animals in position for vivisec- tion. The necessity for such apparatus is thought to in- dicate that the anaesthesia employed " is frequently nom- inal rather than real," whereas the immobility of human beings in surgical operations is secured by profound an- aesthesia. I should hesitate to invite this tender-hearted gentleman to witness one of my own operations for ade- noids, in which the reflex, unconscious struggling of the patient under partial anaesthesia and while the operation is in progress would surely appall the souls of our gen- tle critics. The childlike reasoning which jumps at the conclusion that every movement of an animal or of a human subject under anaesthesia is an index of pain, is quite in keeping with most of the arguments against vivisection, and only merits attention because persistent THE PRESIDENT'S ADDRESS. 11 repetition of even the most baseless of statements finally gives it a certain authority. It is to be hoped that the good sense of our lawmakers will enable them to relieve the question of the plausible sophistries and silly calum- nies associated with it by ignorance and prejudice. Let it be our duty to show the world that we are not actu- ated by motives of frivolous curiosity. Let us endeavor to disabuse the public mind of the notion that we are a cruel and heartless band of inquisitors. Let us demon- strate the fact that many of the advances in surgery and therapeutics hitherto made have had their origin and confirmation in experiments upon the lower animals, and that one of our great hopes for future progress in these departments rests upon further intelligent and unhampered exploration. In conclusion, let me again express my keen apprecia- tion of the honor you have done me in choosing me to preside over your deliberations. May I, without im- propriety, express the hope that no shortcomings of mine may by contrast add brilliancy to the official career of my illustrious predecessors? To that end permit me to crave your forbearance. It now gives me pleasure to invite your attention to the programme which has been prepared for your consideration, and to declare the Nineteenth Annual Congress of the American Laryngo- logical Association open for business. 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