134 IRISH JOURNAL OF MEDICAL SCIENCE

Dr. KENNEDY : L i ke Dr. H i c k e y , I h a d t h o u g h t of t empora l a r t e r i t i s , b u t h a d ru led i t out . The re were no al lergic m a n i f e s t a t i o n s . T h e t u b e r c u l i n t e s t h a d been done twice a n d on each occas ion i t was n e g a t i v e 1/100. P os s i b l y t he c o n d i t i o n was s o m e fo rm of p r i m a r y in fec t ion a n d I i n t e n d do i ng t he t ube rcu l i n t e s t aga in . If , however , i t is st i l l n e g a t i v e I t h i n k t h a t t u b e r c u l o s i s could be ru l ed o u t as i t i s n o w ove r th ree m o n t h s s ince t he onse t o f t h e cond i t i on . T h e p a t i e n t h a s neve r deve loped swel l ing in h i s legs a l t h o u g h he h a d c o m p l a i n e d o f p a i n in h i s calves . There was no ev idence o f a b d o m i n a l o r thorac ic i n v o l v e m e n t .

THE FUTURE OF OTO-RHINO-LARYNGOLOGY IN DUBLIN

By B R IAN 0 ' B R I E N .

T HE subject of my address has been chosen because I feel that the future of otolaryngolog)" in Dublin is at a critical stage of develop- ment at the moment. ~Ve are in a period of great change and it is

doubtful if any specialisation, any aspect of medicine, has been so pro- roundly affected as that to which we are committed. Because of this, and because I have witnessed the great changes brought about by the arrival of chemotherapy and antibiotics and the tremendous social changes in our medical way of life in the past twenty years, I feel that I may be able to bring before you the results of my anxious efforts to peer into the future.

Before taking such a step, however, let us briefly look back over some fifteen years and recall some of the medical problems then of everyday occurrence, now no longer with us.

Acute tonsillitis with its complications was still a matter on which the services of one or more consultants might be sought, and the differential diagnosis between a streptococcal throat and diphtheria was of vital importance. A high degree of clinical ability was often required to differentiate when the penalty of failure to recognise diphtheria was fraught with such grave consequences and when twelve hours' delay might mean the difference between life and death. I recall the terrible anxiety of t rying to decide whether one was looking at an acute ful- minating diphtheria or, to the patient, the equally distressing but much less serious tonsillitis with peritonsillar involvement. I had the great good fortune to work under the late Dr. C. J. McSweeney in Cork Street Hospital, and I have seen only too often the fr ightful consequences of incision into the pharynges of patients believed to have bilateral quinsy when their subsequent courses proved that, once again, diphtheria in its most dreadful form was the assailant.

There was another form of diphtheria, more insidious, but equally grave which attacked the larynx and rapidly progressed to complete respiratory obstruction, especially in the very young. Here, we could be life-savers performing emergency tracheotomies to re-establish an air- way, and have the wonderful satisfaction of seeing a small child in an agony of dyspnoea suddenly breathe again, and see the terror disappear from its face while we watched it slip almost immediately into a peaceful slumber. Thank God, today diphtheria is a thing of the past, but in

P r e s i d e n t i a l A d d r e s s to the Sec t ion o f o to l a ryngo logy , de l i ve r ed on N o v e m b e r 12~h, 1954.

F U T U R E OF OTORHINOI~ARYNGOLOGY 135

combating it we have lost one of the most powerful claims which th¢, community made on us.

Which of us is, today, ever urgent ly called to see an acute oti~i~ media or acute mastoiditis and yet, even in my time, I can recall when one never knew when one could spend an unin te r rupted evening by the fireside. In pre-antibiotic days an acute otitis media was a first-class emergency indeed, and the decision of whether or not to perfol-m a paracentesis called for the exercise of very careful judgment. An appal'- ently mild at tack of otitis media might rapidly progress to involvement of the mastoid an t rum and air cells and an operation of considerable ~.avity, with the ever-present possibility of intracranial complications which were likely to be fatal and, at best, of a s tay of front six weeks to three months in hospital, of ten only to leave with an ear not yet d ry and the likelihood of a fu r the r radical operation at a la ter date. The acute mastoid operation in its fu l ly developed form called for operative skill of the highest degree. I t is no more. Acute otitis media is diag- nosed and efficiently t reated by the family doctor, who indeed dis- covered the adequacy of antibiotics in spite of the most gloomy warnings of our specialty who saw yet another mainstay to their livelihood dis- appearing.

Let me briefly mention one more group of our lost operations: I will include in i t the whole surgery of suppurat ive sinusitis. How often do we see today the acute suppurat ive sinusitis calling for immediate operative intervention, the acute f ronta l sinusitis with f ronta l bone osteomyelitis requir ing the most radical resection of the affected areas. Many of you remember the suppura t ive ethmoiditis with orbital exten- sion demanding radical surgery i f the dreaded cavernous sinus throm- bosis was to be escaped. I could go on wearyingly, but it is unnecessary - -y ou all know that these are aspects of our professional life which are gone.

Wha t of the fu tu re ? I t seems to me we are going through a phase of ceadjustment. As suppurat ive nasal sinus surgery is disappearing, we are becoming more conscious of deficiencies which were overlooked when the saving of life was the fundamental reason for surgery. Today we are more critical of our results, especially where facial disfigurement is at .~take. i t has always seemed wrong to me that we should deal with surgery of the nasal cavity and sinuses while overlooking external deformity or, at best, feeling that here the plastic sm'geon should take over our uncompleted work. The internal and external s tructures of the nose are so int imately related and so in terdependent tha t the surgery of the one must involve the other and the dual responsibility is ours. We must never forget that the object of all real surgery is the restora- tion of a pa r t to normal, or as near normal as possible, and the "normal " includes not only funct ion but also appearance. Obviously, of the two the restorat ion of function receives priori ty, but when deal- ing with exposed parts as we do we must ful ly appreciate that the ~uture mental well-being and success in life of a pa t ient will be materi- ally influenced by his or her facial appearance. Here is a f ru i t fu l field of werk to which we are beginning to give our attention and one which will, I hope, become a recognised par t of our work. Again, as I see it, head injuries involving f ractures of maxillae cannot properly be t reated

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without the surgical co-operation of not alone our specialty, but also that of the skilled dental surgeon. I know that today many of these eases are dealt with by surgeons whose special skill lies elsewhere, but who from custom and tradition still feel that they alone and single- handed should undertake the solution of problems which require the co~operation of more than one expert. Today we are not alone in recog- nising limitations to the range of our surgical competence. Wiser judg- ment is encouraging the general surgeon to work hand in hand with his specialist colleagues in many more eases than he has done in the past. I t is up to us to show that such co-operation will be worth while.

We shall have to prove our worth to our colleagues and to the public, and we shall have to overcome the mistakes of the past. There are still too many in the profession and amongst the public who regard any nasal surgery as a prelude to a train of supplementary operations and pro- gressively increasing discomfort. Such an attitude is no longer justified. We have learned from experience the penalties imposed by destructive surgery of other days and we are gaining the increasing confidence of the public. We must also convince our surgical colleagues that palatal maldevelopment, abnormalities of the salivary glands and neoplasms of the mouth and maxillae come within our special competence. Elsewhere, the~e are accepted facts; here in Dublin we still have to establish them. Let no one doubt we shall do so. I have often wondered why we have laboured under so many restrictions, and I fear much of the fault lies with ourselves to have accepted such limitations as we have done.

Today immense strides have been, and are being, made in the surgery of the temporal bone where such procedures as the fenestration opera- tion, surgery of the facial nerve and surgery of non-suppurative dis- eases of the labyrinth have amply demonstrated the completeness of our technique. Indeed, the fenestration operation, which for refinement of surgical technique is perhaps unequalled, would have justified our recognition as a specialty. I t has and will continue to restore a nol~mal way of life to so many who, before its advent, were cut off from all social intercouL~e and were forced to see life as a mime in which they were unable to take part. No one who has not suffered from deafness can appreciate the extent of the affliction, the ut ter isolation which it im- poses. Indeed, those who have suffered the double affliction of loss of sight and hearing have, almost without exception, professed that given the choice of restoration of one sense only, they would unhesitatingly seek 1he return of hearing. Today the fenestration operation is firmly established and makes possible that restoration in a high percentage of deaf persons.

And, lest anyone should feel that we are obsessed with surgery, let me remind them that we have, in co-operation with the physicist, devel- oped a new science of audiology which is having and will have the most far-reaching influence on the work of otology; almost a specialty within a specialty, including yet other specialists, the experts in the education and rehabilitation of the deaf whose work co-ordinated with that of the otologists is achieving success beyond our early hopes.

When one turns to the consideration of laryngology the scene is dominated by the problems of malignant disease of the larynx and laryngopharynx and, while we must pay full tribute to the work of the

FUTURE OF OTORHINOLARYNGOLOGY 137

radiotherapists, the position of surgery in the battle against cancer o£ these regions is constantly becoming more dominant. Whatever happens we must not limit the scope of our neck surgery. We must be able to deal surgically with the lymph-nodes of the neck along with the area.~ which they drain.

Let me say that I am not making a clMm to monopolise the surgery of the neck. The neck is a corridor, an essential passage-way between the head above and the thorax and rest o£ the body below. Su,'gery of the corridor is commonly undertaken for the relief of conditions origin- ating beyond its borders and presupposes understanding of the path,)- logical and anatomical problems of the adjacent areas. I t is a meeting place of importance to many surgical specialities.

The neuro-surgeon is concerned with intracrmfial sepsis, vascular anomalies, cervical disc protrusions and peripheral pain pro/)lems. The endocrinologist surgeon presides over the field of thyroid and para- thyroid disorders. The thoracic surgeon has long considered the adjacem neck his own field from phrenic nerve avulsions to oesophageal and tracheal reconstructions. The specialist in sympathetic surgery will find many of his ganglionic interests here.

Our interest is a major one also, not only in dealing with malignant disease of the pharynx and larynx, but in dealing with metastases from these areas invading the cervical lymphatics. In this connection I must draw attention to the necessity for a change of outlook in Ireland on the surgical treatment of laryngeal carcinoma. Elsewhere, radical surgery of the larynx is firmly established, but it is disturbing to think of the number of sufferers in this country who are allowed to endure such distress for want of active treatment. I often wonder how many of these patients are slowly ending their lives in the chronic wards of our County Hospitals. Even in what appears to be the terminal stage of imminent asphyxiation, tracheotomy to restore the airway will often make possible a later radical operation with the prospect of an indefinite period of useful and contented life, especially now since we have at our disposal means of restoring the ability to speak by developing an oesophageal voice.

I have endeavoured to review as briefly as possible our work in the light of present-day requirements. I have, from time to time, mentioned the otolo~st, the rhinologist, and the laryngologist, and we include them all under the comprehensive grouping of skills designated in the term " 0torhinolaryngology ".

Are all these special skills to be combined in the one person ? I do not think so. I am inclined to believe that, already, our composite specialty is too big a field in which any one man can reasonably be expected to excel in each one of its parts. How then is this view to be reconciled with already expressed belief in the expansion of our sphere of action? Are we to plan for the future development of our specialty? I would like to dwell a little on this problem.

Two courses of action call for consideration. Are we to develop our work in a specialised hospital or, alternatively, are we to base ourselves and plan our future in conjunction with the great teaching hospitals ?

In theory the first course would seem to have many advantages. Assuming the possibility of adding yet another specialism hospital to

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the existing ones in Dublin, there would be the attraction of gathering there together the best brains of our specialty. There would be the possi- bility of grouping together cases of a similar nature, the advantages vf theatre staffs trained in special techniques, the opportunity of recording observations and producing reports with impressive numbers for statistics. These, and other attractions, will suggest themselves to you. I will not deny that they have their appeal for me also.

However, it is my firm belief that any possible advantages are nega- tived by the great weakness of over-specialisation, the withdrawal away from the main body of the profession which cannot be counteracted by the appointment of consulting physicians, neurologists, endocrinologists, thoracic surgeons and other experts in their own field. The whole atmos- phere of a specialised hospital engenders an atmosphere of mental isola- tion which is inimical to progress and encourages the development of techniques rather than the broadening of knowledge. We must never forget that our vocation is to treat patients, not diseases, and it is here the specialised hospital is most vulnerable.

Every advance is demonstrating more clearly the absolute interdepen- dence of different aspects of medicine. Working, as I do, in a busy general hospital I am constantly struck by the high percentage of the patients I see who are referred suffering from diseases which a few years ago would have been considered solely of interest to the physician. We, in turn, recognise that many of our problems, once considered suit- able for surgery, are wrongly or incompletely treated without the aid of physicians skilled in knowledge of endocrinology or allergy. All of you can call to mind other examples calling for a combining of indivi- dual skills in different aspects of medicine.

Indeed, it is doubtful whether there is any real case for specialised hospitals today, unless it be to achieve the deliberate isolation of patients suffering from infectious diseases, and even these seem to have a dimin- ishing sphere of usefulness.

If, on the other hand, we throw in our lot with the teaching hospitals, what will be the outlook for the futuro? We shall play our part in pass- ing on our knowledge to future generations of doctors, surely scarcely less important than the treatment of disease. We can, if we use our influence wisely, play a much greater part than we now do in this respect, and is there any stimulus to compare with that of teaching? In addition, the teaching hospitals are constantly forging closer alliances to the Universities, associations which must become more and more a feature of our medical teaching. We cannot much longer continue our present inco-ordinated system, pressure of circumstances will see to that. We shall have a limited number of teaching hospitals closely tied to the Universities and it is in these hospitals that our specialty must find a responsible and respected place.

There will be, I hope, also a system of close association with County and Local Government Hospitals and there should be ample opportunity for grouping of cases of a similar nature under one roof. In this way we shall be able to achieve something we have not yet attempted, that is, to develop our own postgraduate training. I hope we shall attract those who have taken the time to acquire a comprehensive training in surgery.

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I should like to see an extension of the registrar system to our specialty in Dublin and to see reg i s t ra~ in their early postgraduate years combine their otolaryngological t ra ining with simultaneous experi- ence in pathology or, at least one other aspect of surgery, whether neurological, thoracic, abdominal or plastic. Then, when the time come~ to devote themselves solely to otorhinolaryngology each one will bring t~, the specialty a width of outlook and a balance of mind which will prevent the danger of mental isolation in ~t limited field. Throughout their lives they will realise tha t they a:re hut a par t of a whole in which all sub-divisions must co-ordinate their efforts to achieve worthwhih, results. F u t u r e recruits must be satisfied that in taking up our specialty they will not be restricted by a narrowing field of techniques, but thal they can look forward to a professional life full ,)f interest and one in which they will have ample oppor tuni ty to exercise the fruils of their wide training.

We must be pal~ and parcel of the progress of medicine as a whole, constantly adjust ing and modifying our ideas in keeping with ils chang- ing field.

Our fu tu re place in medicine is assured. We have a record of steady progress and achievement which compares favourably with other speciMties. We have not taken our responsibilities lightly. When our fight against disease has forced us to resort to destructive surgery (as in the operation of laryngectomy) we have not been satisfied to leave our pa t ien t - -we have taught him to limit his disability and to develop an oesophageal voice. We have t ra ined the deaf in l ip-reading and in the development of normal speech so that the term " deaf and dumb " ~s only a memory.

Dare I hope that, in the immediate future , our colleagues on the Medical Boards of our teaching hospitals will not be above including their specialist colleagues in their councils and so welding their interests into a common one for the welfare of our profession and removing the urge to seek improved conditions of work in new speeialised hospitals which, I hope you will agree with me, are harmful to the fu tu re teaching of our undergraduates , to our profession as a whole and, most of a l l to our specialty.