ence with natural nasal breathing was one of the most important factors in the case.1

Surely that long list of pioneers and their discoveries in this specialty, comparatively limited, yet so important for health, makes it very clear that New York well deserves a place of high honor in the history of medicine for the work of the profession in this department. The whole specialty has practically been created here, and modes of treatment, unthought of in preceding generations, have been worked out and presented to the profession of the world. This would seem to be a great new development in surgery.

I think that there is nothing more interesting, certainly nothing more valuable, than to call attention to the fact that this is not a new chapter in the history of medicine, but a revival of an old one. It throws great light on the history of medicine to have our generation reminded that there was a preceding phase of laryngology and rhinology in which some excellent work was done, instruments invented, operations devised, technique elaborated and undoubtedly great good accomplished; and yet practically all of this progress was forgotten, not for a short time, but for centuries, and the whole work had to be done over again. It was done, not in the old world where medical and surgical traditions might have been expected to be revived, but in a new country practically without such traditions-here in America where the practical genius of the people prompted physicians to make their enterprising and progressive development of this subject.

It does not take away any of the credit for thorough originality and progressiveness from the New York founders of this specialty to tell the story of some of the details of an older phase of it, for it is most probable that they knew absolutely nothing about the historical anticipation of their

1 For other specific details see address of Dr. D. Bryson Delavan.

work and were intent only on solving, as well as possible, the problems which presented themselves to them. What is surprising, of course, is the fact that the medical profession should have made a magnificent development of laryngology and rhinology and then have forgotten about it or lost sight of it and ceased to practice it, until finally the older knowledge went into desuetude. The same thing happened, not alone with regard to this branch of medical and surgical knowledge, but also with regard to a great many other thoroughly practical and extremely valuable developments in professional work, and especially in surgical practice, made by the same generations which brought about the interesting oldtime evolution of the specialty of diseases of the nose and throat.

For there is no doubt now that the physicians and surgeons of the thirteenth and fourteenth centuries, some of whose work in laryngology and rhinology I wish to refer to, were using anesthetics and antiseptics, and some of them at least knew that pus, instead of being a necessary accompaniment of healing, is an undesirable complication. They developed, not only laryngology and rhinology, but plastic operations for the repair of mutilating wounds of the face, including the remaking of the nose, did trephining for various conditions within the skull, insisted on lifting up depressed bones in skull fractures, repaired wounds of the intestine, developing a whole interesting technique for this purpose. They fashioned various kinds of metal tubes to be inserted into the intestines in order to maintain the patulousness of the viscera during the process of repair, even suggesting the use of the trachea of an animal for this purpose, and made many other similar surprising anticipations of modern practice supposed to be entirely recent in origin. Little wonder, then, since all these things were also forgotten, that the advances in laryngology and rhinology were lost sight of, but the

question as to how such deterioration came is a fascinating history problem. Anyone who can answer that question in any adequate way knows a great deal about the history of medicine and surgery-ever so much more than I make any pretension to, for I must confess that I cannot answer it.

Surgery degenerated during the seventeenth, eighteenth, and early nineteenth centuries. That is the fact. At the same time hospitals degenerated, until in the early nineteenth century we had the worst hospitals in the world, though the mediæval hospitals had been beautiful in their exteriors and interiors, marvelously practical, well ventilated, with tiled floors that enabled them to be thoroughly cleansed, and many other features that make our modern hospital architects go back to them for suggestions. In the modern period nursing reached its lowest ebb in efficiency; the professional character of those occupied with it was less favorable. As a matter of fact always in the history of medicine those three coordinate factors-the minimization of any one of which at once is a source of serious deterioration of the power for good of all three-go together-good hospitals, good nursing, and good surgery. Whenever hospitals deteriorate, nursing does likewise, of course, and good surgery becomes impossible; whenever the surgeon does not keep the hospital up to its best possibilites surgery itself soon suffers.

It is this chapter of decline in surgery during several centuries before our time that has hidden from us the significance of the older history of medicine. We were inclined to think that if the eighteenth century had neither good surgery nor good hospitals and no development of the specialties, then surely the seventeenth must have had less, the sixteenth still less, and so on until the Middle Ages could have had almost nothing. As a matter of fact that idea of definite gradual progress by which mankind is supposed to have worked itself

up to its present stage of accomplishment finds no confirmation in history. The ups and downs of history are a commonplace to the serious historical student and he finds just as much of them in the history of medicine and surgery as elsewhere. Great advances are made and then forgotten and have to be made over again. That is what happened with regard to the specialty of throat and nose diseases, and it is that story that I want to tell, not in detail, but in a general way, for those who may be interested in this earlier chapter in the history of an extremely important specialty that we who have practiced in New York have a right to claim as our own.

It is assumed that the history of the specialties in medicine begins in comparatively recent times, and that indeed this specialization of attention and effort represents one of the Spenserian processes from homogeneity to heterogeneity which occur in the course of evolution. Men are supposed to have taken the whole body for their field in medicine at the beginning and then with the growth of scientific knowledge to have confined themselves to portions of it, presumably greatly to the benefit of their patients. This limitation of attention is thought to be a matter of the last generation or two and represents the great, absolutely new phase of the development of medical science which has occurred in our time. All of this feeling, though a commonplace in the reading world of our time, is entirely without foundation in any real knowledge of the past. For specialism is very old and the surgical specialties, though all of them redeveloped in our time, have a history well worth tracing in the older books on medicine and

surgery.

In this connection Herodotus has some interesting expressions with regard to medicine in Egypt. The great "father of history," though he wrote some 2500 years ago, had his attention particularly attracted to the highly developed specialism among the

Egyptians. He tells us in the quaint language of an old-fashioned English translation:

"Physicke is so studied and practiced with the Egyptians that every disease hath its several physician who striveth to excel in healing that one disease and not to be expert in curing many. Whereof it cometh that every corner of that country is full of physicians. Some for the eyes, others for the head, many for the teeth, not a few for the stomach and the inwards."

Now here is an historical description of a state of things that existed nearly one hundred generations ago; it makes one think of what has actually come to pass in our time, a condition which we were inclined to think of as eminently modern and, quite surely, a very recent development.

Of course it would be a simple matter to think that possibly Herodotus, in order to add to the interest of his history, had exaggerated somewhat the actual story of specialism as it existed among the Egyptians; but then we know better, in our time, than to accuse Herodotus of perverting the facts of history, for no one has ever been so thoroughly confirmed by all our modern documentary and archæological discoveries as the great "father of history." A century and a half ago it was the custom to make sport of his credulity, and Voltaire suggested that instead of the "father of history" he should be called the "father of lies." Voltaire, by the way, also thought Shakespeare an English barbarian, Dante a mediæval barbarian and Homer a wandering balladist the like of whom might be found on the streets of Paris in Voltaire's own day. He also made some slighting remarks about the Almighty. Voltaire found it very difficult to understand anyone above himself in intellectuality. We know now that Herodotus's story of the Egyptian spe

cialties was drawn very mildly, and that the human body was actually divided into some thirty-six regions with specialists for each of them; also that a good deal of jealousy existed between the specialists whenever they happened to invade one another's territory. All of which is not without practical interest, even in our enlightened time.

Probably the Middle Ages would be almost the last period in history where one would expect to find any particular development of the surgical specialties. The treatment, however, of the nose and throat and of the eyes received a good deal of attention at this time, and we have much documentary evidence of what was accomplished. The first modern medical school was established at salerno, not very far from Naples, in connection with the health resort which had been established there and which attracted patients and physicians, not only from southern Italy and from Greece, but also from the near East, from North Africa and from the West of Europe. We know that a son of William the Conqueror went down there to be cured of an ailment in the eleventh century, and that many bishops and other churchmen went there in the twelfth century. Salerno provided an excellent medical education in many ways; it placed the department of women's diseases in charge of women, admitted women medical students as a matter of course, and had very high standards of preliminary and actual medical education. Three years of preliminary study were required by law, four years at medicine, and then a year of practice with a physician before the young physician was permitted to practice. With that in mind it would not be surprising to find that even the surgical specialties developed down there.

The first great writer on surgery was Roger, sometimes called Roger of Parma, and sometimes Roger of Salerno, and he is the first independent writer on medicine in the Occident after the Arabian times. He

lived at the end of the twelfth and the beginning of the thirteenth century and probably wrote his "Practica Chirurgia" 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.2

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

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

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:

"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

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.

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."

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.

"If however, the uvula can not be made to shrink in this way then it should be grasped with a forceps made for this purpose near the palate where the uvula itself is sometimes of smaller diameter and snipped off. Care should be taken, however, not to touch the roots of the uvula."

Here evidently he was warning against the radical operation, though in the removal of the tonsils he encouraged thorough radicalness. What is constantly surprising in Roger's work is the mention of various special instruments for these purposes. Angina was described by Roger under the name squinancia, and evidently had

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."

"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.