On the eve of the 17th ENT World Congress,
HOMAGE TO THE PIONEERS
François Legent & André Chays
Members of the French National Academy of Medicine
Here is the perfect opportunity to look back on the high points of our discipline. Seen from the vantage point of cyberspace, the early days of ENT look medieval. And yet the history is not just of anecdotal interest. It reveals just how fragile was the alliance between physicians of the ear, airway and head and neck. During the 19th century, ENT was often administratively assimilated to ophthalmology, and lacked the integrated unity that characterizes a well-delineated organ. For more than half a century, otology tagged along, ears pricked under the languorous gaze of ophthalmology. In France, the Paris Faculty of Medicine actually had plans in 1875 to set up a Chair of Otology-Ophthalmology! For decades, some of our colleagues were doing a bit of both – and this went on into the first half of the 20th century. In medical journals, the coupling was clear, as in the Archives of Ophthalmology and Otology, launched in 1869 in English and in German.
- The beginnings of otology and laryngology
Otology was well-differentiated ever since Jean-Marc-Gaspard Itard, in the early 19th century, first performed a systematic study of the ear. On the strength of his surgical training at the Val de Grâce military hospital In Paris and his medical post in the Institution for the Deaf and Dumb, he published his "Treatise on the Maladies of the Ear and of Hearing" in 1821. One of Itard's great contributions was to describe ear pathologies not just as symptoms but as disease entities. Thus, for example, he replaced the idea of otalgia by that of otitis, designating the inflammation underlying the pain in the ear, going beyond the anecdotal approach to medicine that characterized the 18th century. Trying to distinguish between maladies of the ear and maladies of hearing was no doubt artificial; but Itard's Treatise can nevertheless be considered as the first stone in the edifice of modern otology.
His successor at the Paris Institution for the Deaf and Dumb, Prosper Menière consolidated this attitude. Like Itard before him, Menière at first knew nothing about diseases of the ear when a combination of circumstances conspired to oust him from his comfortable university career and he set off to seek his fortune among the Deaf and the Dumb. He came to the Institution free of any preconceived ideas about the ear and taught himself the subject by reading the few books available – notably Itard's and that by Wilhelm Kramer, published in Berlin in 1836, which became the reference book in the field. Kramer was the first otologist to make the distinction, in pathology, between the outer, middle and inner ear. Menière translated him into French, based on the English edition, under the title Traité des maladies de l’oreille , published in 1848. In 1861, Menière created a sensation at the Academy of Medicine when he challenged the received wisdom about "cerebral congestion" as the cause of vertigo, incriminating rather the ear, with a wealth of clinical evidence, and thereby established the discipline of labyrinthology.
Modern otology had thus won its spurs by the mid-19th century and was in a position to team up with laryngology to lay the foundations of the future specialty of ORL. The study of sinonasal diseases went on to join them in this in the last decades of the century.
Diseases of the larynx and voice had been the object of study long before the advent of laryngoscopy. Armand Trousseau had himself experienced the severity of croup and the difficulty of treating it. In the face of the incompetence of the surgeons of the time, despite being a medical doctor he had been led to perform his own tracheotomies. The success of his surgeries was unprecedented for a procedure with a somber reputation and very little methodology. He brought order to the indications, execution and surveillance of the operation, and this encouraged him to move on to other laryngeal pathologies. His "Practical Treatise on Laryngeal Phthisis, Chronic Laryngitis, and Diseases of the Voice", published in 1837, was the first to cover the whole of chronic laryngeal pathology. By "phthisis" he meant a "chronic disease leading to consumption", and not necessarily a disease involving tubercles. It required the development of laryngeal examination by mirror for a true discipline of laryngology to be able to emerge, where clinical examination had hitherto been restricted to digital palpation; but Armand Trousseau played a key role among the precursors.
B- The illumination of the cavities: the tie that binds otology and laryngology
Illumination has been a constant concern for physicians wishing to examine cavities such as the external auditory canal, mouth, laryngopharynx or nasal cavities. Sunlight was replaced as soon as possible by artificial lighting, but this was still by no means up to the job, even when reflected off a speculum. The development of the perforated concave mirror enabled the beam of light to be superimposed on the line of sight, revolutionizing cavity exploration. For this, we have to thank a German ophthalmologist with an interest in otology, Anton von Tröltsch . When he was in London, he came to realize what a difference there was in scientific quality between the study of diseases of the eye and of the ear, and in particular how rudimentary were the current generation of otoscopes, depending as they did on direct daylight illumination. He was inspired to apply a brand new technique developed by Hermann von Helmholtz in 1851 to examine the fundus of the eye by means of his ophthalmoscope , using a perforated concave mirror. Marcel Lermoyez tells the story of how, in Paris in December 1855, during a banquet given in his honor by the German Medical Society of Paris, Tröltsch "announced his intention of henceforth examining the ear like an ophthalmologist". When he got back to Würzburg the following year, he put his idea into practice.
Lermoyez concluded his article by saying that "Von Tröltsch became the creator of contemporary otology". Above all, he signaled the forthcoming union of otology and laryngology, which for decades to come would enjoy the benefits of this lighting system borrowed from ophthalmology.
The combination of this new lighting system and the endoscopic mirror enabled laryngology to develop. Who exactly can claim priority here is hard to tell . As early as 1836, a surgeon in Lyon, France, Prosper Baumès, had used a laryngeal mirror, thanks to which he was able "to easily recognize suspected inflammation, obstruction or ulceration in the posterior end of the nasal cavities, larynx and some parts of the pharynx" . In 1840, Robert Liston of London announced he had observed the larynx by means of "the speculum that dentists use, fixed to a long stem and introduced into the throat mirror side down, after plunging it in hot water". But these pioneers lacked good lighting. In 1854, the singer Manuel Garcia attempted to see his own vocal folds using a dental mirror in daylight . Later, two German-speaking doctors, Ludwig Türck of Vienna, and Johan Czermak of Pest, launched the new mirror-based laryngoscope in 1858-60, associating posterior rhinoscopy .
Rhinology did not really get started before the last third of the 19th century. In 1882, Emil Zuckerkandl of Graz published his anatomic studies in rhinology under the title Normale und Pathologische Anatomie der Nasenhöhle und Ihrer Pneumatischen Anhänge . This textbook of normal and pathologic anatomy of the nasal cavities and sinuses served as a basis for subsequent studies in rhinology. Even before it came out in French in 1895 http://www.biusante.parisdescartes.fr/histoire/medica/resultats/?sous_groupe=orla&statut=charge&fille=o&cotemere=49447, many other studies of diseases of the nasal cavities and sinuses were published by clinicians such as Simon Duplay and Henri Luc in Paris, or George Walter Caldwell in New York.
Surgical magnification using an illuminating binocular lens, known as the operative microscope, was obviously another major step in the history of lighting.
In 1922 in Paris, at the 10th International Congress of Otology, Gunnar Hölmgren made a presentation on "Operations on the Temporal Bone using a Magnifying Glass and Microscope". This Swedish otologist and his assistant, Olaf Nylen, testified to the usefulness in ear surgery of the means of magnification used in ophthalmology: magnifying spectacles and a "corneal microscope". Maurice Sourdille was so intrigued that he made the trip to Stockholm to see for himself this new conception of ear surgery, and came back with the instruments in question. The microscope was the binocular lens used by ophthalmologists; the Swedish otologists fixed it onto their operating table, but its short frontal distance allowed only occasional observation. Back in Nantes, where he had his practice, Sourdille designed a new apparatus, adapting the "Zeiss n°12 binocular lens", with a frontal distance ranging from 15 cm for 10-fold magnification to 25 cm for 40-fold, an articulated support to enable movement, powerful convergent lighting, and a sterilizable casing allowing surgery under optimal conditions. This was thus the first true operative microscope, and could be used throughout most of the procedure. It featured in the report of the 1935 Congress of the French Society of ORL on "Surgical treatment of otospongiosis", which was made available only to Society members before being published in 1949. Subsequent studies of the history of the microscope generally mention only the 1949 publication, and seem not to be aware of the 1935 Report.
Esophageal and tracheal endoscopy
A third hero in the saga of endoscopic lighting should not be overlooked and deserves his place in the pantheon of otology: Jean-Pierre Bonnafont. It is to him that we owe, among other things, the principle of endoscopy. In 1834, Bonnafont commissioned an otoscope with a lateral light source and a mirror to reflect the beam into the ear, with a hole in the middle for observation (p.45). He sought in vain to establish priority after a urologist presented an instrument based on the same principle, in 1853. Once Thomas Edison had invented the electric light-bulb in 1879, all these aggressive specula and foreign-body hooks could safely be kept out of the esophagus and trachea. Dedicated rigid tubes with an electric light source gave rise to a new specialty within the sphere of ORL. Endoscopy transformed the dark prognosis associated with esophageal and tracheobronchial foreign bodies. For several decades, it was a skill reserved to otorhinolaryngologists, until flexible endoscopy opened up the field to specialists of other organs.
C- Teaching, scientific societies and international congresses
The time it took to get teaching in ENT organized varied greatly from country to country. For decades, it went no further than exchanges between colleagues during scientific meetings and congresses. In some countries, ENT was very slow to make it into the universities.
In the later 19th century, Austria set up the first university courses in the new specialty of ORL, in what was considered by many to be a model for good teaching. In France, Marcel Lermoyez was commissioned by the Ministry of Education to study the Austrian system, and wrote a long report on it which was published in 1874. The report began, "The teaching of laryngology and otology as it is done in the Vienna Faculty of Medicine is unique in the world". Adam Politzer dominated the scene, with his formidable reputation; in Lermoyez's opinion, he was "the most famous living otologist".
Alongside this official teaching, medical journals, scientific societies and congresses had been playing a major role since the mid-19th century. International meetings were the perfect breeding ground for the spread of knowledge. For example, the German Medical Society of Paris (Société Médicale Allemande de Paris),set up in 1844 and dissolved in 1871 Les medecins de langue allemande à Paris au XIX eme siecle promoted good Franco-German medical relations. It also attracted many foreign otologists and laryngologists, both students and confirmed practitioners, from Kramer to Politzer. The idea was for "each newly elected member to pay for the privilege by making an original presentation to the Society, thus sharing the ideas, doctrines and research of the university where he had studied or those he had visited. He was assisted in his work during his stay in Paris".
In our own time, this same tradition of international meetings based on a common language has led to the setting up of the International French-Speaking Society of ENT and Head and Neck Surgery (Société Internationale Francophone d’ORL et de Chirurgie Cervico-Faciale: SIFORL), which meets biennially.
The concept of a World Congress is not a recent one: as early as 1876, otologists from all over the world met in Philadelphia, in the otology section of the International Medical Congress held there to mark a century of American independence. It was decided that the second otology congress should be held where the International Congress of Ophthalmology was scheduled to meet, and thus the second International Congress of Otology took place in Milan, just after the First International Congress of Ophthalmology. The Milan congress had a special focus on "improving the fate of the deaf and dumb", providing a platform for many speakers from the world of deaf education. It was decided that "the pure method should be preferred"; sign language, promoted by Charles-Michel de l'Epée (best known as the Abbé de l’Épée) in the previous century, thus came to banished from many institutions for a large number of years, with fateful consequences for the education of many children suffering from severe hearing loss. The "Congress of Milan" is often remembered with bitter regret to this day.
While rhinology joined forces with laryngology in the late 19th century, it was not until 1928 that the fundamental triad was officially united. The "international congresses" of the 19th and early 20th centuries were essential to this process, and were the forerunners of the present-day World Congress. The 10th and last International Congress of Otology was held in Paris in 1922, and the first "World Congress" in Copenhagen in 1928 formally associated otology, laryngology and rhinology. It was such a success that the Danish organizers were obliged to enforce hitherto unheard-of strictness, withdrawing some communications by Danish members and limiting everyone to just one presentation each of not more than 7 minutes. This was surely testimony to the success of the proclaimed union of all of the branches of the discipline.
The present 17th meeting is not the first World Congress for Paris, which was already the host in 1961. Among the forerunners, there was also the 4th International Congress of Otology, held there in 1889; the chairman, M-E Gellé , had the distinction of being chosen by the foreign congress members to replace the organizers' candidate. Gellé was well-known for his physiological approach to otology, notably with the use of graphic recording. The 4th Congress in Paris was followed by another French venue with the 7th International Congress of Otology in Bordeaux in 1904, chaired by Pr. Moure, founder of the SFORL and the first professor of ORL in France.
This glance at the past reveals the long road traveled toward the splendid specialty of ORL and its great richness..
These meetings at world congresses afford a unique opportunity for specialists to get a panoramic overview of the discipline.
Headlong digitization is having a considerable impact on certain areas of medicine. It is time to take stock and work out just where the big changes are going to happen.
Special thanks to :
Estelle Lambert - Conservatrice, Service d’histoire de la santé de la Bibliothèque Interuniversitaire de Santé Paris
Jérôme van Wijland - Directeur de la Bibliothèque de l'Académie nationale de médecine Paris
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