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in surgery

ence with natural nasal breathing was one

work and were intent only on solving, as of the most important factors in the case. well as possible, the problems which pre

Surely that long list of pioneers and their sented themselves to them. What is surdiscoveries in this specialty, comparatively prising, of course, is the fact that the medical limited, yet so important for health, makes profession should have made a magnificent it very clear that New York well deserves development of laryngology and rhinology a place of high honor in the history of med- and then have forgotten about it or lost icine for the work of the profession in this sight of it and ceased to practice it, until department. The whole specialty has prac- finally the older knowledge went into desuetically been created here, and modes of tude. The same thing happened, not alone treatment, unthought of in preceding gen- with regard to this branch of medical and erations, have been worked out and pre- surgical knowledge, but also with regard to sented to the profession of the world. This a great many other thoroughly practical would seem to be a great new development and extremely valuable developments in

professional work, and especially in surgical I think that there is nothing more in- practice, made by the same generations teresting, certainly nothing more valu- which brought about the interesting oldable, than to call attention to the fact time evolution of the specialty of diseases that this is not a new chapter in the history of the nose and throat. of medicine, but a revival of an old one. It For there is no doubt now that the physithrows great light on the history of medi- cians and surgeons of the thirteenth and cine to have our generation reminded that fourteenth centuries, some of whose work in there was a preceding phase of laryngology laryngology and rhinology I wish to refer and rhinology in which some excellent work to, were using anesthetics and antiseptics, was done, instruments invented, opera- and some of them at least knew that pus, intions devised, technique elaborated and stead of being a necessary accompaniment undoubtedly great good accomplished; and of healing, is an undesirable complication, yet practically all of this progress was for- They developed, not only laryngology and gotten, not for a short time, but for cen- rhinology, but plastic operations for the turies, and the whole work had to be done repair of mutilating wounds of the face, over again. It was done, not in the old including the remaking of the nose, did world where medical and surgical traditions trephining for various conditions within the might have been expected to be revived, skull, insisted on lifting up depressed bones but in a new country practically without in skull fractures, repaired wounds of the such traditions-here in America where the intestine, developing a whole interesting practical genius of the people prompted technique for this purpose. They fashioned physicians to make their enterprising and various kinds of metal tubes to be inserted progressive development of this subject. into the intestines in order to maintain the

It does not take away any of the credit patulousness of the viscera during the procfor thorough originality and progressive- ess of repair, even suggesting the use of the ness from the New York founders of this trachea of an animal for this purpose, and specialty to tell the story of some of the made many other similar surprising anticidetails of an older phase of it, for it is most pations of modern practice supposed to be probable that they knew absolutely nothing entirely recent in origin. Little wonder, about the historical anticipation of their then, since all these things were also for

1 For other specific details see address of Dr. D. gotten, that the advances in laryngology Bryson Delavan.

and rhinology were lost sight of, but the

question as to how such deterioration came up to its present stage of accomplishment is a fascinating history problem. Any- finds no confirmation in history. The ups one who can answer that question in any and downs of history are a commonplace adequate way knows a great deal about the to the serious historical student and he history of medicine and surgery—ever so

finds just as much of them in the history of much more than I make any pretension to, medicine and surgery as elsewhere. Great for I must confess that I cannot answer it. advances are made and then forgotten and

Surgery degenerated during the seven- have to be made over again. That is what teenth, eighteenth, and early nineteenth happened with regard to the specialty of centuries. That is the fact. At the same throat and nose diseases, and it is that story time hospitals degenerated, until in the early that I want to tell, not in detail, but in a nineteenth century we had the worst hos- general way, for those who may be interested pitals in the world, though the medieval in this earlier chapter in the history of an hospitals had been beautiful in their ex- extremely important specialty that we who teriors and interiors, marvelously practical, have practiced in New York have a right well ventilated, with tiled floors that en- to claim as our own. abled them to be thoroughly cleansed, and It is assumed that the history of the spemany other features that make our modern cialties in medicine begins in comparatively hospital architects go back to them for recent times, and that indeed this specialisuggestions. In the modern period nursing zation of attention and effort represents one reached its lowest ebb in efficiency; the of the Spenserian processes from homoprofessional character of those occupied geneity to heterogeneity which occur in the with it was less favorable. As a matter of course of evolution. Men are supposed to fact always in the history of medicine those have taken the whole body for their field in three coordinate factors—the minimization medicine at the beginning and then with the of any one of which at once is a source of growth of scientific knowledge to have conserious deterioration of the power for good fined themselves to portions of it, presumaof all three-go together-good hospitals, bly greatly to the benefit of their patients. good nursing, and good surgery. Whenever This limitation of attention is thought to be a hospitals deteriorate, nursing does likewise, matter of the last generation or two and repof course, and good surgery becomes im- resents the great, absolutely new phase of the possible; whenever the surgeon does not development of medical science which has keep the hospital up to its best possibilites occurred in our time. All of this feeling, surgery itself soon suffers.

though a commonplace in the reading world It is this chapter of decline in surgery of our time, is entirely without foundation during several centuries before our time in any real knowledge of the past. For

spethat has hidden from us the significance of cialism is very old and the surgical spethe older history of medicine. We were in- cialties, though all of them redeveloped clined to think that if the eighteenth cen- in our time, have a history well worth tractury had neither good surgery nor good ing in the older books on medicine and hospitals and no development of the spe- surgery. cialties, then surely the seventeenth must In this connection Herodotus has some have had less, the sixteenth still less, and so interesting expressions with regard to medion until the Middle Ages could have had cine in Egypt. The great “father of history," almost nothing. As a matter of fact that though he wrote some 2500 years ago, had idea of definite gradual progress by which his attention particularly attracted to the mankind is supposed to have worked itself highly developed specialism among the Egyptians. He tells us in the quaint lan- cialties was drawn very mildly, and that guage of an old-fashioned English transla- the human body was actually divided into tion:

some thirty-six regions with specialists for

each of them; also that a good deal of jeal“Physicke is so studied and prac- ousy existed between the specialists whenticed with the Egyptians that every ever they happened to invade one another's disease hath its several physician who territory. All of which is not without pracstriveth to excel in healing that tical interest, even in our enlightened time. one disease and not to be expert in Probably the Middle Ages would be alcuring many. Whereof it cometh that most the last period in history where one every corner of that country is full of

would expect to find any particular develphysicians. Some for the eyes, others opment of the surgical specialties. The treatfor the head, many for the teeth, not a ment, however, of the nose and throat and few for the stomach and the inwards." of the eyes received a good deal of attention

at this time, and we have much documenNow here is an historical description of a tary evidence of what was accomplished. state of things that existed nearly one hun- The first modern medical school was estabdred generations ago; it makes one think of lished at salerno, not very far from Naples, what has actually come to pass in our time, in connection with the health resort which a condition which we were inclined to think had been established there and which atof as eminently modern and, quite surely, tracted patients and physicians, not only a very recent development.

from southern Italy and from Greece, but Of course it would be a simple matter to also from the near East, from North Africa think that possibly Herodotus, in order to add and from the West of Europe. We know to the interest of his history, had exaggerated that a son of William the Conqueror went somewhat the actual story of specialism down there to be cured of an ailment in as it existed among the Egyptians; but the eleventh century, and that many bishthen we know better, in our time, than to ops and other churchmen went there in accuse Herodotus of perverting the facts the twelfth century. Salerno provided an of history, for no one has ever been so thor- excellent medical education in many ways; oughly confirmed by all our modern docu- it placed the department of women's dismentary and archæological discoveries as eases in charge of women, admitted women the great “father of history.” A century

medical students as a matter of course, and and a half ago it was the custom to make had very high standards of preliminary and sport of his credulity, and Voltaire sug- actual medical education. Three years of gested that instead of the “father of his- preliminary study were required by law, tory” he should be called the “father of four years at medicine, and then a year of lies.” Voltaire, by the way, also thought practice with a physician before the young Shakespeare an English barbarian, Dante a physician was permitted to practice. With mediæval barbarian and Homer a wander- that in mind it would not be surprising to ing balladist the like of whom might be find that even the surgical specialties defound on the streets of Paris in Voltaire's veloped down there. own day. He also made some slighting re- The first great writer on surgery was marks about the Almighty. Voltaire found Roger, sometimes called Roger of Parma, it very difficult to understand anyone above and sometimes Roger of Salerno, and he is himself in intellectuality. We know now the first independent writer on medicine in that Herodotus's story of the Egyptian spe- the Occident after the Arabian times. He

branchi, or branci, and says that they swell interiorly and create, as it were, two almond-like bodies in the throat. As a consequence of this swelling, expectoration is difficult and breathing is conducted with anxiety. For this, gargling should first be used, and if the patient is not relieved recourse should be had to surgery. Then he describes how an operation should be done on them:

lived at the end of the twelfth and the beginning of the thirteenth century and probably wrote his “Practica Chirurgiæ” about the beginning of the thirteenth century. It is usually presumed that these Salernitan physicians living in the Mediterranean region were deeply influenced by the Arabs, above all since, according to a very old tradition, the founders of Salerno were four physicians of very

different origin—a Latin, a Greek, a Jew, and an Arab. Much was made of this supposed dependence on the Arabs in the older days, but Gurlt points out, after careful study of Roger's work, that it abounds in Græcisms, not Arabisms, and that evidently Roger was following the old Greek tradition of surgery. This is not surprising when we remember that the southern part of Italy in the neighborhood of Naples had been a Greek colony from very early times and indeed had been known as Magna Græcia.?

Roger has written a very interesting description of inflammation of the tonsils with its treatment. He calls these organs

“Seat the patient before you and press his tongue down in his open mouth with an instrument, so that you can see the tonsils well. Take hold of the affected one firmly with a bronze or iron hook and incise it with a properly sharpened instrument. Leave the coverings (the pillars of the fauces) which stand next to them uninjured however."

This is of course a description only of a simple opening of a tonsillar abscess. When the inflammation of the tonsils has proceeded so far, however, that simple incision will not cure them, he suggests that with instruments made for this purpose they should be completely removed. His Latin words for this, “et a radice funditus, evellantur,” which may be translated literally, "plucked away entirely by the roots,” probably is responsible for our use of the expression, “under similar circumstances radical operation.”

2 Probably the greatest influence at work in the organization of the university at Salerno and of the medical school around which the University mainly came into existence was the Benedictine School at Salerno which had been in existence for several centuries. St. Benedict's greatest foundation was at Monte Cassino, not far away, and the Benedictines had been very much interested in the school in Salerno. That their influence continued after the foundation of the medical school will be best understood from the fact that Salerno's greatest writer and teacher on medicine in the eleventh century was Constantine Africanus, the great African physician who had come to Salerno and to whom patients came from all over Europe; he wrote the first modern textbooks of medicine in existence. Constantine and Abbot Desiderius became great friends, and indeed, according to tradition, it was the worthy abbot who insisted upon the necessity of Constantine's writing on the subject of medicine. He finally succeeded in getting him to do this, by taking the time from a very busy professional life.

Constantine became so much interested in the purely intellectual life of medicine that after a time he gave up practice and retired to Monte Cassino

to be near his friend the Abbot Desiderius and to enjoy the quiet life of the monastery. Probably he looked forward to years of friendly companionship and the satisfaction of mutual intellectual influence. Only a few years later, however, the Abbot Desiderius, much against his will and in spite of his refusals, was chosen Pope, and so Constantine was left in the monastery without his friend, the Abbot. This seems to have spurred him on to renewed interest in the intellectual life, in order to fill up the void thus created; besides the Pope encouraged him in his writing. The result is that we have a number of works from Constantine.

The story is interesting to us here because it makes very clear the fact that Benedictine influence must have been strong at Salerno, and that the usual assumption that Salerno is an Arabian foundation or was largely influenced by the Arabs is only a part of that tradition which came to be so rife in the eighteenth century, namely, that it was the Arabs and not the Christians who were largely responsible for the revival of interest in the intellectual life after the coming of the barbarians had so thoroughly interfered with the culture of the Roman Empire.

Manifestly there were a number of observations made on diseases of the throat in Roger's time and so we are not surprised to find, a little farther on, a description of a serious condition near the epiglottis which impeded the voice and obstructed the trachea, and which can be cured only by surgical intervention. Gurlt does not hesitate to say that in this Roger was probably describing edema of the glottis. Apparently this condition had been recognized and some mode of treating it discussed, though in his book on surgery Roger only refers to it indirectly.

In elongation of the uvula Roger suggested first the use of medicaments in powder form and then the application of gargles.

been studied with a good deal of care. It was differentiated into three varieties with slightly different names: squinancia, a very severe form; scinancia, a milder form, and finally quinancia, of which the prognosis was always good. The symptoms were practically all the same-difficulty of inspiration and expiration as well as difficulty in swallowing both food and drink. Sometimes the voice was completely interfered with and the saliva could not be swallowed nor the sputum emitted. The first form of the disease, squinancia, was located between the trachea—which, because it carried air was called at that time trachea arteriaand the esophagus, at a place called the isthmus. Its prognosis was very fatal and its cure was to be left to God alone. The second form, scinancia, much less severe or malignant-Roland's exact word is “maliciosa”—had for its characteristic lesion the development of pus, partly deep in the tissues but partly on the surface. The description evidently refers to what we call retropharyngeal abscess, the severer form being retro-esophageal abscess. Roger suggests that the retropharyngeal abscess can be ruptured with the finger or with some instrument, and that it is always well to do this as soon as pus has formed. He said that he had cured some patients with his own hand in this way.

This form of the affection he suggested might be treated as follows: He confesses that it is something of an experiment and uses the word "experimentum.

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“Take of salt beef, half cooked, of the size and shape of a chestnut or a filbert, and having fastened it firmly by a long silken cord have the patient swallow it and then let the physician pull it out suddenly and violently (cum violentia) in order that the abscess may be ruptured.”

: Old-fashioned filberts were larger than ours.

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