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Urology in a Changing World1
UROLOGY IN A CHANGING WORLD 1 OSWALD SWINNEY LOWSLEY
Gentlemen of the American Urological Association and guests: I wish to express my deepest gratitude to you for entrusting me with the high office of presiding officer of your Association, the largest and most important group of urologists in the world today. The American Urological Association started from a humble beginning. Led by that grand surgeon, internationalist and sportsman, the late Ramon Guiteras, a group of kindred souls met in a cafe called "Sieben Schwoben", on the upper West side of New York City, and, stimulated by a glass or two of ale, discussed the formation of a society for the purpose of reading and hearing papers on urological subjects. Of this group, Colin Luke Begg, the last of the original members of the American Urological Association, was still alive in 1941. Dr. Begg reported this historic meeting in Boston on May 21, 1936. Later, a more formal meeting was called, at which Ramon Guiteras, Follen Cabot, Ferdinand C. Valentine, Winfield Ayers, Terry M. Townsend, Colin Luke Begg, F. W. Levisseur, and M.A. Guillen attended and changed the name of our organization from the New York Genito-Urinary Society to the American Urological Association. The last of this group of pioneers, Dr. Terry M. Townsend, expired on Friday, May 15, 1942. On April 2, 1902, Dr. Bernhard Erdman, of Indianapolis, Indiana, was elected and is, therefore, the senior living member of the· organization. At the first annual meeting, held on June 13, 1902, the following members were elected and are still alive: Dr. Howard A. Kelly of Baltimore, Dr. Gustav Kolischer of Chicago, Dr. Louis E. Schmidt of Chicago, Dr. Hugh H. Young of Baltimore. The first annual meeting was held at Saratoga Springs on June 13, 1902, simultaneously with the meeting of the American Medical Association. The American Urological Association was, therefore, the second national urological association to be founded, the French Urological Association, organized in 1896, being the first. The Deutsche Gesellschaft fur Urologie, founded in 1907, was third. Now, 40 years later, our Association has grown from a membership of 8 to one of 1198, of whom 1161 are senior and active, 12 associate, 5 corresponding and 20 honorary. Every state in the union is represented except that of New Mexico. In addition, we have members of the following territories and foreign countries: Hawaii, Puerto Rico, Canada, Cuba, France and Panama. From its very beginning, the American Urological Association has held an important place among the scientific organizations of the world. At first, our society met at the same time and place as the American Medical Association, and much pressure was brought to bear to make it a section of the latter. In 1 Presidental address read on June 3, 1942, at the annual meeting of the American Urological Association, New York, N. Y.
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1909, after a prolonged discussion, it was definitely decided not to become a section of the American Medical Association; and since 1911 the annual meetings of the two societies have been held independently as to time and place. The first transactions of the Association to be published in book form-those of the sixth• annual meeting-appeared in 1907. The last set of transactions appeared in 1918. Since 1920, the papers read at our meetings have been published in the Journal of Urology, a decidedly forward step as the communications thus have a much wider distribution. The affairs of the Association have been controlled by a distinguished group of urologists, care being taken to make certain that no one section of the country is represented to the exclusion of others. One cannot discuss the recent affairs of the Society without paying tribute to that prince of good fellows, Dr. Clarence O'Crowley, whose influence for many years has been great and has always been exerted in the best interests of the Association as a whole. Doctor O'Crowley has not missed a single meeting of the Association in the thirty-five years of his membership. During the life of our organization we have seen many changes both in the type of men who become urologists and their training. It cannot be gainsaid that in the early days some of our members placed more stress on venereology than on urology, and the surgical ability of some of them was, to say the least, sketchy. At the present time, an applicant for membership must have graduated from an approved medical school five years before applying for membership; must have served an internship of one year in a recognized institution; must have limited 75 per cent of his practice to urology for two years before admission; must co-operate in organized medicine as a member of the American Urological Association; and must present twenty-five acceptable histories of major urological cases or an acceptable thesis. Indeed, the specialty of urology overlaps so many branches of surgery that many of us believe that the requirements for applicants to begin the study of urology should consist of a good academic degree, a certificate of graduation from a grade A medical college, and a two years' internship in medicine and surgery, during which period the applicant must personally have done one hundred operations in major general surgery. The period of special training in urology should last four years. Such a training, we believe, fits a young man to be a credit to the profession as a whole. Thanks to the superior preliminary training received by our young men, plus the development of new instruments of precision, the level of knowledge and ability of the applicants to membership in our association has steadily risen. This is evidenced by the present requirements for admission, which are rigid when compared with those of a decade ago, but not so rigid that any young doctor of intelligence and integrity cannot attain to membership. In this connection, I wish to emphasize that it is my understanding of the purpose of our Association to admit every urologist who is reputable and adequately trained. If that is so, it is my opinion that emphasis should be placed on the former, and that no increase in the scientific requirements should be enforced at the present time.
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There is a tendency on the part of some of our older members to keep their younger competitors out of the American Urological Association. In this critical time in our professional and economic status, when the medical profession is under fire and when we are being assailed on all sides by governmental interference, by quacks and by charlatans, we must not make the mistake of looking at the rock and miss seeing the mountain. Therefore, it is well for us to welcome our younger confreres, and not seek to prevent their membership in our important organization unless they are truly lacking in those qualities which make a professional gentleman, or are deficient in their urological training. I think the spirit of too quick criticism of each other should be discouraged. The fact that a prominent citizen chooses the younger urologist to do his operation, instead of the old professor, should not disqualify the former from membership in the American Urological Association. In these days of approaching and arrived state medicine, it is well to take stock of ourselves as specialists. In this regard, I think we may consider ourselves fortunate, because in those countries where some form of state medicine has been in force for any length of time, the specialist is the only type of doctor who has survived with the same degree of independence that marked the practice of medicine in this country a decade ago. So we may consider the approach of state medicine with regret, but so far as our personal affairs are concerned, with a certain amount of equanimity. The world is in a very hectic state. Every so often in the world's history, the current civilization seems impelled to commit suicide by countless wars. Just when we reach the point where it seems possible to settle differences by brains instead of bullets, by explanations instead of explosives, by integrity instead of invasion, along comes some gunman who disregards all the rules and institutes an international merger for murder, and then every one has to devote himself, and his country, to intensive preparation for war. The current war, with its worldwide repercussions, has stifled all hope of advance in medicine and the allied sciences in so far as the Old World is concerned. Only here in the Western Hemisphere is there hope for the preservation of our hard-won scientific civilization, and for real progress in the immediate and the more distant future in the fields of medicine, the other sciences, and letters. It seems to me that, as medical men, it is the duty of all of us-whether South, Central or North American-to promote Pan Americanism, to learn our neighbor's language, and to welcome each other to our shores, our clinics, and our homes. I therefore suggest that, individually and as an association, we promote friendly relations with our neighbors to the south by every means at our disposal. This is not hard to do. We have become acquainted with urologists in every country in Central and South America, and have found them to be splendid fellows as well as scientific urologists. In every land, we have found our scientific brethren only too glad to extend every hospitality if we only make ourselves known. We have with us here as visitors and members: Senor Dr. Don Alfredo Mena Garcia, official delegate from San Salvador; Senor Dr. Manuel E. Pesqueira,
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official delegate from Mexico; Senor Dr. Roberto Franco, counselor for the Colombian Embassy, Washington, D. C.; Senor Dr. Miguel Antonio Rueda, official delegate from Bogota, Colombia; Senor Dr. Desiderio Roman, official delegate from Nicaragua; Senor Dr. Jorge E. Cavalier, Bogota, Colombia; Senor Dr. F. C. Gonzales-Iman, Yucatan, Mexico; Senor Dr. Hector Davalos, Ecuador; Senor Dr. Louis E. Pagliere, Buenos Aires, Argentina; Senor Dr. Daniel E. Chanis, Jr., Panama, Panama. Some of these men are candidates for corresponding membership in the Association, and I know that every one favors their inclusion in our roster and will welcome them as members and friends. I am proud to be an American urologist. Urology is the youngest of the specialties, but urological operations are among the oldest in surgical history. In the pre-Listerian era, exploration of the urethra and bladder was possible without causing death, and cutting for bladder stone was the only major operation that could be done with any degree of success. With the invention of the practical cystoscope by Leiter and Nitze in 1887, urology as a specialty was born. This instrument, like so many inventions, represented a culmination of inventive effort. It was really made possible by the invention, in 1800, of the Edison incandescent lamp, which was first applied to the cystoscope by David Newman, in 1883. In 1885, Boisseau du Rocher invented the indirect-view instrument and a megaloscopic optical arrangement. In 1886, Dittel placed the platinum wire, formerly used by Brucks, on the beak of an endoscope; in 1887, Nitze and Leiter presented a really practical lens instrument with a suitable incandescent lamp; and in 1889, Brenner put in an irrigating tube, and Boisseau du Rocher added to this complicated instrument facilities for double catheterization of tqe ureters. The discovery of the x-ray by Roentgen, in 1895, coupled with the practical cystoscope, opened up an entirely new specialty concerned with the diagnosis of formerly hidden lesions of the urinary tract. New diagnostic methods were added rapidly, the most important of which was pyelography, accomplished by Voelcker and von Lichtenberg in 1905. The precision with which diagnoses could be made attracted more and better trained surgeons to the urological field, so that it was not long before our predecessors were referred to as the "peacocks" of the medical profession. One cannot mention the invention of instruments without thinking of our own country. In 1878, Bigelow, in Boston, invented the lithotrite, modifications of which we are still using, with cystoscope attached. A most important role in the advance of urology was played by the late Reinold Wappler, who not only took our vaguely conceived ideas and converted them into practical instruments, but insisted on keeping the record straight. An example is the Brown-Buerger cystoscope, produced some time after Brown's death; but a modification, still retaining Brown's name and still one of the most useful instruments ever devised, is in almost daily use. It is rare that such a distinguished father is followed by an even more distinguished son. Such, however, is the case in our own Frederick C. W~ppler. We would be seriously handicapped were he not at our disposal to make concrete our visions and produce instruments to do our bidding.
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Our scientific presentations would be drab indeed were it not for the illustrations that accompany them. We are fortunate to have in this country a group of artists especially trained in the drawing of urological pictures. This group, led by the internationally recognized William P. Didusch, has elevated the standard of urological presentations to a point where they are unexcelled in any land. So much for the past. What, now, of the future? I, for one, think that it is most important to encourage our young men not only in doing research work but in presenting it. For several years past, it has been our practice to have the junior member of a co-author paper present the work before this Society, and I think you will agree that they have excelled in such presentations and have profited by being allowed to make them. Our whole system of education is wrong if we do not develop men who, sooner or later, will outstrip us. The time inevitably arrives when the oldsters become static, and it is a sorry commentary on our methods of teaching if we fail to produce a group of youngsters who will progress farther than we have. In fact, most people judge the success of the head of a department of urology by the men he turns out rather than by his personal surgical ability and publications. As your President, I feel permitted to offer a word of advice to the younger men. Do research work. Organize your private life so that you set aside certain evenings each week for this purpose. If you do not read the work of others, write up your own experiences, develop new methods of diagnosis and operative technique, attend meetings, and hear and discuss papers, you will never be anything but a neighborhood urologist. Remember, if you read everything that has been written on a certain subject and then add an original point to the sum total of that knowledge, you will know more about that particular subject than any living person. In regard to original work, let me remind you that research is like poetry, it comes from within. Fancy laboratories and luxurious offices have nothing to do with the birth of ideas. It is a well recognized fact that almost every great advance in medicine and surgery has been made by men working under great difficulties and without adequate funds. The birth of a totally new and original idea is almost universally received with great opposition-particularly by the old, influential members of the medical fraternity, who should know better. In a recent survey of twenty-six of the more prominent Southern urologists, reported by Dr. Grayson Carroll last year, twenty-five of them had carried on their researches entirely at their own expense, without outside financial aid. It seems that the main function of endowed institutions such as I represent has become, with rare exceptions, to supply a place where original ideas can be modified and perfected. Take, for example, the history of the use of ribbon gut in surgery. The idea was a brain-child of our own beloved William P. Didusch, who presented it to us. Our only claim in connection with this important addition to our surgical armamentarium is that we received the idea with alacrity and were able, through our laboratory facilities, to do the necessary research work in proving it useful. Another bit of advice! Don't be dominated by your chief. Be guided by
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him, but do not hesitate to question him regarding his methods or theories. It is understood that this must be done in a thoroughly polite and diplomatic manner, and that care must be taken in choosing the time and place for such discussion. One of the most valuable men I have on my staff is a dear personal friend who differs with me on 49 per cent of all subjects. We have often agreed that when we disagree on 51 per cent of all subjects, we must then reluctantly sever our connection; but 49 per cent is well withiri the permitted limit. Do not be intolerant of your chief and the older urologists in your community. If you suffer an injury, real or fancied, take it, and above all hold your peace. My mother taught me, when I was a boy: "No one can hurt you if you are right in your heart." Any attempt to hold or push you down should serve merely to stimulate you to greater efforts; and when you think you are being abused, that is the time to "wake up," not "give up." Looking into the future, one cannot fail to be impressed with the fact that progress will probably not be along the line of great developments in surgical technique or even in diagnosis, but will,.in all likelihood, be influenced tremendously by the study of endocrinology, vitamins, and chemotherapy, and by the application of the knowledge of these subjects to the diagnosis and treatment of urological conditions. An important phase of our activities is the study of the cause and cure of urinary stone. Here the subjects of vitamins and endocrinology, and their relationship to the genito-urinary system, are vital and greatly concern us. The fact that urinary stones are very rare in the wet tropics, while the populace in dry tropical lands abounds with them, is of interest. Certain parts of the temperate zones, such as the Mediterranean countries, have many cases of urinary calculi, while other adjacent lands, with a similar climate, are almost free from this malady. This geographical distribution of urinary stone offers an opportunity for an important and interesting bit of research. Our ever-present problem of cancer is a black page in medical history._ Never has there been a subject upon which so much thought, time, and money have been expended; yet the surface is barely scratched. When the cause of cancer is discovered, it will probably be by men working along biological or endocrinological lines; by someone working independently, under great odds, and along some revolutionary line, and not by a worker in one of our highly endowed institutions. Such has been the history of most great discoveries in medicineand this one is overdue. Two of the most promising presentations on cancer research in our own field that we have thus far heard are the reports presented at the annual meeting of the Association last year by Charles Huggins and his associates, of Chicago, who obtained spectacular results of a favorable nature by castrating men suffering from discomfort due to advanced carcinoma of the prostate gland, and the report of almost identical results obtained independently by Arbor D. Munger, who irradiated the testicles in such cases. We have followed Huggins' and Munger's methods, and have found that they did not exaggerate but, rather, underestimated the beneficial results.
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Regarding our immediate future, I have certain specific recommendations to make: First: That we encourage our younger men to compete for the various prizes offered for scientific accomplishments. I would also urge that the Association offer more cash prizes, each to be accompanied by an appropriate medal. Second: That the urologist concern himself with all diseases of the kidney. There is no sharp line of demarcation between the so-called "medical kidney" and the surgical kidney. The urologist must necessarily concern himself with hypertension since, in certain cases, operation offers the only hope of relief for the patient. Third: That surgery of the adrenals should receive our utmost attention. Dysfunction of the adrenals is responsible for many abnormalities in humans. Research work by our members has shown that adrenal tumors may cause personality changes. Blood pressure is often disturbed by changes in the adrenals as well as alterations in kidney hormones, as shown by Page. Fourth: That the urologist pay more attention to female urology and to the urological ailments of children. The bladder, except for the vesical orifice, and the organs of the upper urinary tract present the same problems in the female as in the male, and they all fall within the realm of the urologist. Both male and female children present many developmental, infective, and other types of urological lesions. Due to the development of small instruments, by Butterfield and others, we are now able to investigate and treat any part of the urinary tract in a child of any age. Fifth: Upon the urologist devolves the duty of teaching the intricacies of his branch of medicine to nurses, both male and female. An intelligent and welltrained nurse can often be of the greatest assistance in the handling of a difficult urological case, and if we are to get the best results, we must teach our nurses the theory as well as the practice of urology. Sixth: A most important step forward has been taken by us this year. We have initiated a "refresher" course for the benefit, primarily, of those who are about to take the examinations for the American Board of Urology. I suggest that the Postgraduate Committee, headed by Dr. Hamilton McKay, be made a permanent standing committee. Seventh: It is impossible to place too much importance on the first official recognition of the scientific participation, in our meeting, of our neighbors of the Western Hemisphere. The success of this departure is almost entirely due to the energy and efficiency of Dr. Elmer Hess, and I recommend that the PanAmerican Committee be continued as a standing committee. In conclusion, may I emphasize two points. First, I believe that it is the duty of every one of us who can possibly arrange it to volunteer for duty in the armed forces of the United States. Upon induction into the Army or Navy, do not be impatient if you are assigned to some routine duty not in line with our specialty. After serving quietly and efficiently wherever assigned for several months, it is quite proper to request special duty in urology or general surgery through the appropriate channels. If such request is not granted after a reasonable
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length of time, an appeal to the special committee, composed of Dr. Hugh H. Young, Chairman, Dr. Hamilton McKay, and your President, will be followed by an attempt to get you properly located. Secondly, let us older men strive to the best of our abilities to keep science on the march. Scientific endeavor is reflected in meetings such as are held by this and other organizations. It is our duty to carry on. How fortunate we are not to have been invaded! If we continue in this happy state, we may be able to avoid another dark age in scientific medicine. I therefore urge that we continue to hold our meetings, regardless of the prospects of small attendance and other handicaps. Finally, may I again express my gratitude to all of you for having elevated me to the highest office in our specialty; to the officers, particularly our efficient secretary, Dr. Clyde Deming, who have been most co-operative in conducting the Association's affairs; to those who have presented, and will present, scientific papers making this one of the best programs we have ever had; and last, but not least, to Dr. John Taylor and the other members of the local committees, who have worked so hard and entertained us so royally.
111 E. 71st St., New York, N. Y.
Gentlemen of the American Urological Association and guests: I wish to express my deepest gratitude to you for entrusting me with the high office of presiding officer of your Association, the largest and most important group of urologists in the world today. The American Urological Association started from a humble beginning. Led by that grand surgeon, internationalist and sportsman, the late Ramon Guiteras, a group of kindred souls met in a cafe called "Sieben Schwoben", on the upper West side of New York City, and, stimulated by a glass or two of ale, discussed the formation of a society for the purpose of reading and hearing papers on urological subjects. Of this group, Colin Luke Begg, the last of the original members of the American Urological Association, was still alive in 1941. Dr. Begg reported this historic meeting in Boston on May 21, 1936. Later, a more formal meeting was called, at which Ramon Guiteras, Follen Cabot, Ferdinand C. Valentine, Winfield Ayers, Terry M. Townsend, Colin Luke Begg, F. W. Levisseur, and M.A. Guillen attended and changed the name of our organization from the New York Genito-Urinary Society to the American Urological Association. The last of this group of pioneers, Dr. Terry M. Townsend, expired on Friday, May 15, 1942. On April 2, 1902, Dr. Bernhard Erdman, of Indianapolis, Indiana, was elected and is, therefore, the senior living member of the· organization. At the first annual meeting, held on June 13, 1902, the following members were elected and are still alive: Dr. Howard A. Kelly of Baltimore, Dr. Gustav Kolischer of Chicago, Dr. Louis E. Schmidt of Chicago, Dr. Hugh H. Young of Baltimore. The first annual meeting was held at Saratoga Springs on June 13, 1902, simultaneously with the meeting of the American Medical Association. The American Urological Association was, therefore, the second national urological association to be founded, the French Urological Association, organized in 1896, being the first. The Deutsche Gesellschaft fur Urologie, founded in 1907, was third. Now, 40 years later, our Association has grown from a membership of 8 to one of 1198, of whom 1161 are senior and active, 12 associate, 5 corresponding and 20 honorary. Every state in the union is represented except that of New Mexico. In addition, we have members of the following territories and foreign countries: Hawaii, Puerto Rico, Canada, Cuba, France and Panama. From its very beginning, the American Urological Association has held an important place among the scientific organizations of the world. At first, our society met at the same time and place as the American Medical Association, and much pressure was brought to bear to make it a section of the latter. In 1 Presidental address read on June 3, 1942, at the annual meeting of the American Urological Association, New York, N. Y.
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1909, after a prolonged discussion, it was definitely decided not to become a section of the American Medical Association; and since 1911 the annual meetings of the two societies have been held independently as to time and place. The first transactions of the Association to be published in book form-those of the sixth• annual meeting-appeared in 1907. The last set of transactions appeared in 1918. Since 1920, the papers read at our meetings have been published in the Journal of Urology, a decidedly forward step as the communications thus have a much wider distribution. The affairs of the Association have been controlled by a distinguished group of urologists, care being taken to make certain that no one section of the country is represented to the exclusion of others. One cannot discuss the recent affairs of the Society without paying tribute to that prince of good fellows, Dr. Clarence O'Crowley, whose influence for many years has been great and has always been exerted in the best interests of the Association as a whole. Doctor O'Crowley has not missed a single meeting of the Association in the thirty-five years of his membership. During the life of our organization we have seen many changes both in the type of men who become urologists and their training. It cannot be gainsaid that in the early days some of our members placed more stress on venereology than on urology, and the surgical ability of some of them was, to say the least, sketchy. At the present time, an applicant for membership must have graduated from an approved medical school five years before applying for membership; must have served an internship of one year in a recognized institution; must have limited 75 per cent of his practice to urology for two years before admission; must co-operate in organized medicine as a member of the American Urological Association; and must present twenty-five acceptable histories of major urological cases or an acceptable thesis. Indeed, the specialty of urology overlaps so many branches of surgery that many of us believe that the requirements for applicants to begin the study of urology should consist of a good academic degree, a certificate of graduation from a grade A medical college, and a two years' internship in medicine and surgery, during which period the applicant must personally have done one hundred operations in major general surgery. The period of special training in urology should last four years. Such a training, we believe, fits a young man to be a credit to the profession as a whole. Thanks to the superior preliminary training received by our young men, plus the development of new instruments of precision, the level of knowledge and ability of the applicants to membership in our association has steadily risen. This is evidenced by the present requirements for admission, which are rigid when compared with those of a decade ago, but not so rigid that any young doctor of intelligence and integrity cannot attain to membership. In this connection, I wish to emphasize that it is my understanding of the purpose of our Association to admit every urologist who is reputable and adequately trained. If that is so, it is my opinion that emphasis should be placed on the former, and that no increase in the scientific requirements should be enforced at the present time.
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There is a tendency on the part of some of our older members to keep their younger competitors out of the American Urological Association. In this critical time in our professional and economic status, when the medical profession is under fire and when we are being assailed on all sides by governmental interference, by quacks and by charlatans, we must not make the mistake of looking at the rock and miss seeing the mountain. Therefore, it is well for us to welcome our younger confreres, and not seek to prevent their membership in our important organization unless they are truly lacking in those qualities which make a professional gentleman, or are deficient in their urological training. I think the spirit of too quick criticism of each other should be discouraged. The fact that a prominent citizen chooses the younger urologist to do his operation, instead of the old professor, should not disqualify the former from membership in the American Urological Association. In these days of approaching and arrived state medicine, it is well to take stock of ourselves as specialists. In this regard, I think we may consider ourselves fortunate, because in those countries where some form of state medicine has been in force for any length of time, the specialist is the only type of doctor who has survived with the same degree of independence that marked the practice of medicine in this country a decade ago. So we may consider the approach of state medicine with regret, but so far as our personal affairs are concerned, with a certain amount of equanimity. The world is in a very hectic state. Every so often in the world's history, the current civilization seems impelled to commit suicide by countless wars. Just when we reach the point where it seems possible to settle differences by brains instead of bullets, by explanations instead of explosives, by integrity instead of invasion, along comes some gunman who disregards all the rules and institutes an international merger for murder, and then every one has to devote himself, and his country, to intensive preparation for war. The current war, with its worldwide repercussions, has stifled all hope of advance in medicine and the allied sciences in so far as the Old World is concerned. Only here in the Western Hemisphere is there hope for the preservation of our hard-won scientific civilization, and for real progress in the immediate and the more distant future in the fields of medicine, the other sciences, and letters. It seems to me that, as medical men, it is the duty of all of us-whether South, Central or North American-to promote Pan Americanism, to learn our neighbor's language, and to welcome each other to our shores, our clinics, and our homes. I therefore suggest that, individually and as an association, we promote friendly relations with our neighbors to the south by every means at our disposal. This is not hard to do. We have become acquainted with urologists in every country in Central and South America, and have found them to be splendid fellows as well as scientific urologists. In every land, we have found our scientific brethren only too glad to extend every hospitality if we only make ourselves known. We have with us here as visitors and members: Senor Dr. Don Alfredo Mena Garcia, official delegate from San Salvador; Senor Dr. Manuel E. Pesqueira,
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official delegate from Mexico; Senor Dr. Roberto Franco, counselor for the Colombian Embassy, Washington, D. C.; Senor Dr. Miguel Antonio Rueda, official delegate from Bogota, Colombia; Senor Dr. Desiderio Roman, official delegate from Nicaragua; Senor Dr. Jorge E. Cavalier, Bogota, Colombia; Senor Dr. F. C. Gonzales-Iman, Yucatan, Mexico; Senor Dr. Hector Davalos, Ecuador; Senor Dr. Louis E. Pagliere, Buenos Aires, Argentina; Senor Dr. Daniel E. Chanis, Jr., Panama, Panama. Some of these men are candidates for corresponding membership in the Association, and I know that every one favors their inclusion in our roster and will welcome them as members and friends. I am proud to be an American urologist. Urology is the youngest of the specialties, but urological operations are among the oldest in surgical history. In the pre-Listerian era, exploration of the urethra and bladder was possible without causing death, and cutting for bladder stone was the only major operation that could be done with any degree of success. With the invention of the practical cystoscope by Leiter and Nitze in 1887, urology as a specialty was born. This instrument, like so many inventions, represented a culmination of inventive effort. It was really made possible by the invention, in 1800, of the Edison incandescent lamp, which was first applied to the cystoscope by David Newman, in 1883. In 1885, Boisseau du Rocher invented the indirect-view instrument and a megaloscopic optical arrangement. In 1886, Dittel placed the platinum wire, formerly used by Brucks, on the beak of an endoscope; in 1887, Nitze and Leiter presented a really practical lens instrument with a suitable incandescent lamp; and in 1889, Brenner put in an irrigating tube, and Boisseau du Rocher added to this complicated instrument facilities for double catheterization of tqe ureters. The discovery of the x-ray by Roentgen, in 1895, coupled with the practical cystoscope, opened up an entirely new specialty concerned with the diagnosis of formerly hidden lesions of the urinary tract. New diagnostic methods were added rapidly, the most important of which was pyelography, accomplished by Voelcker and von Lichtenberg in 1905. The precision with which diagnoses could be made attracted more and better trained surgeons to the urological field, so that it was not long before our predecessors were referred to as the "peacocks" of the medical profession. One cannot mention the invention of instruments without thinking of our own country. In 1878, Bigelow, in Boston, invented the lithotrite, modifications of which we are still using, with cystoscope attached. A most important role in the advance of urology was played by the late Reinold Wappler, who not only took our vaguely conceived ideas and converted them into practical instruments, but insisted on keeping the record straight. An example is the Brown-Buerger cystoscope, produced some time after Brown's death; but a modification, still retaining Brown's name and still one of the most useful instruments ever devised, is in almost daily use. It is rare that such a distinguished father is followed by an even more distinguished son. Such, however, is the case in our own Frederick C. W~ppler. We would be seriously handicapped were he not at our disposal to make concrete our visions and produce instruments to do our bidding.
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Our scientific presentations would be drab indeed were it not for the illustrations that accompany them. We are fortunate to have in this country a group of artists especially trained in the drawing of urological pictures. This group, led by the internationally recognized William P. Didusch, has elevated the standard of urological presentations to a point where they are unexcelled in any land. So much for the past. What, now, of the future? I, for one, think that it is most important to encourage our young men not only in doing research work but in presenting it. For several years past, it has been our practice to have the junior member of a co-author paper present the work before this Society, and I think you will agree that they have excelled in such presentations and have profited by being allowed to make them. Our whole system of education is wrong if we do not develop men who, sooner or later, will outstrip us. The time inevitably arrives when the oldsters become static, and it is a sorry commentary on our methods of teaching if we fail to produce a group of youngsters who will progress farther than we have. In fact, most people judge the success of the head of a department of urology by the men he turns out rather than by his personal surgical ability and publications. As your President, I feel permitted to offer a word of advice to the younger men. Do research work. Organize your private life so that you set aside certain evenings each week for this purpose. If you do not read the work of others, write up your own experiences, develop new methods of diagnosis and operative technique, attend meetings, and hear and discuss papers, you will never be anything but a neighborhood urologist. Remember, if you read everything that has been written on a certain subject and then add an original point to the sum total of that knowledge, you will know more about that particular subject than any living person. In regard to original work, let me remind you that research is like poetry, it comes from within. Fancy laboratories and luxurious offices have nothing to do with the birth of ideas. It is a well recognized fact that almost every great advance in medicine and surgery has been made by men working under great difficulties and without adequate funds. The birth of a totally new and original idea is almost universally received with great opposition-particularly by the old, influential members of the medical fraternity, who should know better. In a recent survey of twenty-six of the more prominent Southern urologists, reported by Dr. Grayson Carroll last year, twenty-five of them had carried on their researches entirely at their own expense, without outside financial aid. It seems that the main function of endowed institutions such as I represent has become, with rare exceptions, to supply a place where original ideas can be modified and perfected. Take, for example, the history of the use of ribbon gut in surgery. The idea was a brain-child of our own beloved William P. Didusch, who presented it to us. Our only claim in connection with this important addition to our surgical armamentarium is that we received the idea with alacrity and were able, through our laboratory facilities, to do the necessary research work in proving it useful. Another bit of advice! Don't be dominated by your chief. Be guided by
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him, but do not hesitate to question him regarding his methods or theories. It is understood that this must be done in a thoroughly polite and diplomatic manner, and that care must be taken in choosing the time and place for such discussion. One of the most valuable men I have on my staff is a dear personal friend who differs with me on 49 per cent of all subjects. We have often agreed that when we disagree on 51 per cent of all subjects, we must then reluctantly sever our connection; but 49 per cent is well withiri the permitted limit. Do not be intolerant of your chief and the older urologists in your community. If you suffer an injury, real or fancied, take it, and above all hold your peace. My mother taught me, when I was a boy: "No one can hurt you if you are right in your heart." Any attempt to hold or push you down should serve merely to stimulate you to greater efforts; and when you think you are being abused, that is the time to "wake up," not "give up." Looking into the future, one cannot fail to be impressed with the fact that progress will probably not be along the line of great developments in surgical technique or even in diagnosis, but will,.in all likelihood, be influenced tremendously by the study of endocrinology, vitamins, and chemotherapy, and by the application of the knowledge of these subjects to the diagnosis and treatment of urological conditions. An important phase of our activities is the study of the cause and cure of urinary stone. Here the subjects of vitamins and endocrinology, and their relationship to the genito-urinary system, are vital and greatly concern us. The fact that urinary stones are very rare in the wet tropics, while the populace in dry tropical lands abounds with them, is of interest. Certain parts of the temperate zones, such as the Mediterranean countries, have many cases of urinary calculi, while other adjacent lands, with a similar climate, are almost free from this malady. This geographical distribution of urinary stone offers an opportunity for an important and interesting bit of research. Our ever-present problem of cancer is a black page in medical history._ Never has there been a subject upon which so much thought, time, and money have been expended; yet the surface is barely scratched. When the cause of cancer is discovered, it will probably be by men working along biological or endocrinological lines; by someone working independently, under great odds, and along some revolutionary line, and not by a worker in one of our highly endowed institutions. Such has been the history of most great discoveries in medicineand this one is overdue. Two of the most promising presentations on cancer research in our own field that we have thus far heard are the reports presented at the annual meeting of the Association last year by Charles Huggins and his associates, of Chicago, who obtained spectacular results of a favorable nature by castrating men suffering from discomfort due to advanced carcinoma of the prostate gland, and the report of almost identical results obtained independently by Arbor D. Munger, who irradiated the testicles in such cases. We have followed Huggins' and Munger's methods, and have found that they did not exaggerate but, rather, underestimated the beneficial results.
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Regarding our immediate future, I have certain specific recommendations to make: First: That we encourage our younger men to compete for the various prizes offered for scientific accomplishments. I would also urge that the Association offer more cash prizes, each to be accompanied by an appropriate medal. Second: That the urologist concern himself with all diseases of the kidney. There is no sharp line of demarcation between the so-called "medical kidney" and the surgical kidney. The urologist must necessarily concern himself with hypertension since, in certain cases, operation offers the only hope of relief for the patient. Third: That surgery of the adrenals should receive our utmost attention. Dysfunction of the adrenals is responsible for many abnormalities in humans. Research work by our members has shown that adrenal tumors may cause personality changes. Blood pressure is often disturbed by changes in the adrenals as well as alterations in kidney hormones, as shown by Page. Fourth: That the urologist pay more attention to female urology and to the urological ailments of children. The bladder, except for the vesical orifice, and the organs of the upper urinary tract present the same problems in the female as in the male, and they all fall within the realm of the urologist. Both male and female children present many developmental, infective, and other types of urological lesions. Due to the development of small instruments, by Butterfield and others, we are now able to investigate and treat any part of the urinary tract in a child of any age. Fifth: Upon the urologist devolves the duty of teaching the intricacies of his branch of medicine to nurses, both male and female. An intelligent and welltrained nurse can often be of the greatest assistance in the handling of a difficult urological case, and if we are to get the best results, we must teach our nurses the theory as well as the practice of urology. Sixth: A most important step forward has been taken by us this year. We have initiated a "refresher" course for the benefit, primarily, of those who are about to take the examinations for the American Board of Urology. I suggest that the Postgraduate Committee, headed by Dr. Hamilton McKay, be made a permanent standing committee. Seventh: It is impossible to place too much importance on the first official recognition of the scientific participation, in our meeting, of our neighbors of the Western Hemisphere. The success of this departure is almost entirely due to the energy and efficiency of Dr. Elmer Hess, and I recommend that the PanAmerican Committee be continued as a standing committee. In conclusion, may I emphasize two points. First, I believe that it is the duty of every one of us who can possibly arrange it to volunteer for duty in the armed forces of the United States. Upon induction into the Army or Navy, do not be impatient if you are assigned to some routine duty not in line with our specialty. After serving quietly and efficiently wherever assigned for several months, it is quite proper to request special duty in urology or general surgery through the appropriate channels. If such request is not granted after a reasonable
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length of time, an appeal to the special committee, composed of Dr. Hugh H. Young, Chairman, Dr. Hamilton McKay, and your President, will be followed by an attempt to get you properly located. Secondly, let us older men strive to the best of our abilities to keep science on the march. Scientific endeavor is reflected in meetings such as are held by this and other organizations. It is our duty to carry on. How fortunate we are not to have been invaded! If we continue in this happy state, we may be able to avoid another dark age in scientific medicine. I therefore urge that we continue to hold our meetings, regardless of the prospects of small attendance and other handicaps. Finally, may I again express my gratitude to all of you for having elevated me to the highest office in our specialty; to the officers, particularly our efficient secretary, Dr. Clyde Deming, who have been most co-operative in conducting the Association's affairs; to those who have presented, and will present, scientific papers making this one of the best programs we have ever had; and last, but not least, to Dr. John Taylor and the other members of the local committees, who have worked so hard and entertained us so royally.
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