Otolaryngology 1900–1999: A Century of Progress?

The year 2000 has arrived and we have survived Y2K! Looking back to 1900, dare we ask, Has this been a century of progress? Have we succeeded in our major tasks of improving patient welfare, curing diseases, relieving suffering, promoting rehabilitation, and realizing our professional roles? To tackle this problem, I have reviewed the journal of the American Laryngological, Rhinological and Otological Society, Inc., The Laryngoscope, for 1900 and for 1999, along with other materials from these 2 years, with several questions in mind: 1) What conditions from 1900 are still problems today? 2) What diseases have essentially been eradicated? 3) What diseases have been introduced? 4) What resources do we have, to address the problems of the future? Where was otolaryngology in 1900? Many pathological processes for neoplasia, infection, inflammation, and trauma had been elucidated. Surgery for cancer had been successfully, if only occasionally, performed, and infections were treated not by antibiotics but by drainage, chemicals, and supportive care. Medical education was evolving from preceptorship to formal residency programs with the focus shifting from travel to European training sites to development of programs within the United States. 1. In an attempt to bring practitioners together, the Society had its first meeting in 1894, and the American Academy of Ophthalmology and Otolaryngology was convened 2 years later. Many local medical organizations provided the locus and opportunity for exchange of clinical experiences. Importantly, medical care focused on the physician–patient interface without major external intervention. The 1900 Laryngoscope contained 63 original articles and 266 abstracts, mainly from the proceedings of local and regional societies. Each article had a single author, and 92% were from the United States (Table I). When categorized according to type of report, the original articles were distributed as shown in Table II. The distribution of both articles and abstracts according to subspecialty is shown in Table III. 2. *Canadian (2), German (1), Italian (1), British (1). Let's look at a few highlights from 1900: The principles espoused by Coen 3. for treatment of stuttering are basically unchanged today. Surgical cowardice in confronting sphenoid suppuration was derided by Lodge, 4. who wrote, “Much, if not everything, might have been accomplished by a careful but bold surgeon operating aggressively.” Lennox Brown remarked, regarding carcinoma of the larynx, 5. “Each case should be recorded … It is in keeping with true scientific progress to record failures as well as successes.” The frustration in treating atrophic rhinitis was appreciated by several authors 6.-11. in a special series on this topic. The lack of successful therapy for treatment of tonsillar tumors was summarized by Ingersoll, 12. whose patient asked him to promise a cure (and he refused). He wrote, “The last I heard of him, he was being treated by a ‘cancer specialist’ who had told him he would guarantee a cure for $300 or treat him without guarantee for $150. It is to be hoped that the patient accepted the latter generous offer and thereby saved enough money to pay for his own funeral expenses.” Importantly, telling comments on the state of the art of 1900 came from two leaders. D. Braden Kyle, 13. the 37-year-old president of the Society, stated in his presidential address, “A review of the literature of diseases of the nose, throat and ear shows that while not a great deal that is new has been brought forward much that is interesting has been published…. We are gathered together … to aid one another by a rehearsal of our failures and our successes; that is, our experiences. Let us do it in a liberal way and along liberal lines.” Later that summer, Scanes Spicer, 14. president of the British Medical Association, stated, “I would remind you that prevention is better than cure, and that if… we have knowledge of causative factors of disease, we can in many cases, eliminate and prevent them… The highest achievement is the prevention of disease and deformity… It behooves us to resolutely and firmly apply scientific facts, and to concern ourselves no less with the beginning of disease and its prevention than with the highest developments of special technique.” With regard to health care delivery in 1900, the three pervasive issues were cost, access, and quality. The ensuing 99 years brought an extraordinary series of developments that influenced medical practice. Wars occurred, interpersonal trauma increased, personal behavior changed, and technology developed. Within medicine, antibiotics were discovered and created, along with anti-inflammatory, antineoplastic, and other medications. Instruments for diagnosis, treatment, and rehabilitation were invented, including lasers, radiological devices (computed tomography [CT], magnetic resonance imaging [MRI], positron emission tomography [PET]), endoscopes, hearing aids, and appliances for facial bone reconstruction. And most recently, the information revolution has occurred. Numerous sentinel events occurred in medical care delivery between 1900 and 1999, including the Flexner report of 1910 that prompted new initiatives into the scientific basis of medicine and the creation of third-party payer system in 1930 to pay both hospitals and physicians. In the period immediately following World War II, we saw a growth of clinical research, creation of the National Institutes of Health, and the development of employment-based medical insurance through the Kaiser system. Medicare and Medicaid appeared in 1965 in Lyndon Johnson's “social contract with the American people.” The period from 1970 to 1985 is characterized retrospectively as the “good old days” of medical practice. However, discontent within the government and employers brought about the Health Maintenance Organization (HMO) Act of 1973, the open market initiative of 1985, the concept of managed competition of 1993, and other programs (Health Insurance Portability and Accountability Act, Balanced Budget Amendment, patient protection initiative, and the Consumer Bill of Rights) in the waning years of the century. The pervasive issues in health care in 1999 were, again, cost, access, and quality. Let's look at how otolaryngology as depicted in The Laryngoscope in 1999 differs from 1900. The number of articles increased from 63 to 335 (not including “How I Do It” articles). The average number of authors per article increased from 1 to 4 (with a high of 17 authors on one article). The distribution of types of communications is shown in Table IV. Note that case reports have virtually disappeared, as have abstracts, while literature reviews have become an integral part of most articles. The distribution of communications according to subspecialty is shown in Table V, which also allows comparison with 1900. At the end of the century, in addition to reports of innovative surgical procedures, we see numerous contributions from outside fields including bioengineering, information technology, anesthesiology, radiology, immunology, pharmacology, genetics, and other basic sciences. 15. *Japanese (20), French (10), Swiss (8), Swedish (7), Australian (7), Canadian (7), Dutch (7), British (6), Korean (5), Danish (5), Taiwanese (4), Spanish (4), Finnish (4), Israeli (3), Brazilian (3), Belgian (3), Italian (3), Norwegian (2), Chinese (2), Austrian (2), Turkish (1), Croatian (1). Numbers are percentages. Of course, no single journal in a single year can summarize what has taken place in a century. Therefore I would offer a few thoughts for your consideration, including some of the ecstasies and ironies of the past century. Otology. Antibiotics have changed the management of otological infections from surgical to nonsurgical at the same time that advanced technology has modified much of the rehabilitation of hearing loss from nonsurgical to surgical (including tympanostomy tubes, stapedectomy, and cochlear implants). Head and neck surgery. Combat experience in major wars, the advent of new diagnostic modalities, and accumulation of large numbers of patient care encounters emboldened otolaryngologists to fight for dominance in surgical management of head and neck tumors. No sooner had dominance been apparently achieved than the focus on management has switched from surgical to nonsurgical techniques. Also, there is some evidence that cure rates for head and neck tumors reached a plateau around 1975, and further improvement remains to be seen. 16. Laryngology. Techniques for total and partial laryngectomy were available in 1900 and were enhanced in the past 100 years. However, the current focus appears to continue to be on appreciation and rehabilitation of the voice and the need for prevention, as pointed out by Spicer in 1900. Rhinology. One of the oldest of medical specialties, rhinology has received a tremendous amount of attention during the past 30 years with the arrival of new instrumentation for the treatment of a huge number of patients, in many of whom the diseases would have been prevented with better control of environment and personal habits. Bronchoesophagology. One of the highlights of our field in the earliest part of the century, bronchoesophagology has essentially been lost to other practitioners with other skills and tools. Facial plastic and reconstructive surgery. In 1900, no one could possibly have predicted that otolaryngologists would become respected facial plastic and reconstructive surgeons, thanks to the hard work of the pioneers who have developed the field, the innate and acquired skills of many practitioners, and the cultural emphasis on youth and beauty which provides so many opportunities on which to capitalize. Pediatric otolaryngology. Surely, one of the most gratifying developments has been the evolution of the field of pediatric otolaryngology with its special focus on one end of the age spectrum. Perhaps the next century will see increased focus on the other end of the age spectrum. As we look back over the past 100 years, let's examine three lists of conditions: those that have been eradicated (Table VI), those that are unchanged (Table VII), and those that have appeared during the past century—the diseases of progress (Table VIII). Although many might challenge these classifications, I will leave that for others to discuss. Have we seen progress? Have we focused on disorders most bothersome to patients? Perhaps the latter question is inappropriate, particularly in view of the fact that the World Health Organization has shown that less than 10% of the world's medical research financing is directed at the health problems that afflict 90% of the human population. 17. However, this is a specious argument, and the need to focus on genuine patient concerns is real. How might we address clinical problems in the future? Let's look at the resources available within the Society itself. In December 1999 the Society had 975 members distributed according to age as shown in Table IX. If we ignore residency and assume that patient practice experience begins at age 30, we have a total of 25,565 cumulative member years of experience. If we also assume that each practitioner has 75 patient contacts per week, our society has a total of 95,868,750 patient contacts in its membership. If we limit analysis to those 633 members under the age of 65, we see that we are accumulating 2,373,000 patient experiences each year. Of course, Society members represent only about 15% of American otolaryngologists. This means that our profession actually has 639,120,000 aggregate patient contacts and is accumulating 15,820,000 experiences each year. How soon can we have a system that will capture, catalogue, collate, and communicate those experiences and provide us with a clinical distillate that will enhance our patient care skills? The technology is available, if we have the motivation. The patients whom we treat will probably be happy to help us. Let's hope that the next century will be one of dealing with empowered patients in a productive way. In summary, the journey from 1900 to 1999 has been exciting, and it has, indeed, been a century of progress—but progress in small steps, an active process involving many people. As 2000 begins, we celebrate not so much the arrival at a destination but the actual process of traveling—traveling in a collegial, challenging, and serendipitous journey that gives us a sense of purpose and benefits those entrusted to our care. Looking toward the future, we might recall words from Kyle's presidential address 13. in 1900: “To bring about the highest perfection in medical sciences it requires individual efforts of individuals and the united efforts of all. He who thinks he can do without the world deceives himself; but he who thinks the world can do without him is still more in error.” Where might we go in the next century? Many years ago, Henry David Thoreau exhorted, “Go confidently in the direction of your dreams.”18. Let's allow ourselves to dream. I dream: Of a day in which a country that can clone a sheep can cure the common cold. Of a day in which the science that can control vestibular disorders in outer space can control them on the ground. Of a day when a society that can spend billions on perfumes can cure the loss of smell. Of a day when a government that can focus weapons of mass destruction on human populations who are different from us will instead focus its weapons on subhuman populations that destroy us. And of a day when our medical knowledge will be used to prevent disease and to make life even more pleasurable. Dare we dream? Robert Kennedy liked to paraphrase George Bernard Shaw 19. by saying, “Some men look at the way things are and ask why. I dream of things that have never been and ask why not.” As we enter 2000, I hope that we can each take time away to look away from the world of the way things are, the office, the operating room, the clinic, the laboratory, the pragmatic, and the mundane, and to entertain occasional excursions into that ineffable world of fantasy, of speculation, and of dreams. The author gratefully acknowledges the input of colleagues (Gady Har-El, MD, Richard M. Rosenfeld, MD, MPH, Ari J. Goldsmith, MD, Neil M. Sperling, MD, Jon B. Turk, MD, Nira A. Goldstein, MD, Jessica W. Lim, MD) and the assistance of the excellent staff of the New York Academy of Medicine Library and the American Academy of Otolaryngology—Head and Neck Surgery Foundation's Department of History and Archives.

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