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Società Italiana di Otorinolaringologia e Chirurgia Cervico-Facciale

Italian ORL SocietyPast and Present

Dino Felisati Giorgio Sperati

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Translation by Marian Shields

CONTENTS

• Presentation pag. 006• Introduction pag. 009

Chapther IThe origin of the Otorhinolaryngological Speciality in Italy

- The birth of Laryngology and Rhinology pag. 013- The idea of a unified speciality pag. 021- The Institutional Phase pag. 024- The Associative Phase pag. 033

Chapter IIThe Italian Society of Otorhinolaryngology - Head and Neck Surgery

- First Period (1892-1913) pag. 037- Second Period (1920-1938) pag. 039- Third Period (1946-1975) pag. 040- Fourth Period (1976-2005) pag. 044

Chapter IIIThe Headquarters of the Italian ORL Society

- The Headquarters pag. 051- The Library pag. 055- The Museum pag. 056

Chapter IVThemes on exhibition in the Museum

- Evaluation of Hearing Function in the Pre-Audiologocal Era pag. 063- The Golden Age of Tonsillectomy pag. 069- Adenoidectomy in the early 20th Century pag. 075- Origins of Laryngology pag. 079- Evolution of Mastoidectomy pag. 087- Birth of Broncho-Oesophagoscopy pag. 093- A forgotten Plague: Diphteria pag. 099- Outpatient Units one hundred years ago pag. 105

• References pag. 111• Index of personal names pag. 113

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PRESENTATION

It gives me great pleasure to present to the Delegates of the XVIII InternationalFederation of Otorhinolaryngological Societies Congress this Volume, edited by DinoFelisati and Giorgio Sperati.It describes the history of the ORL Specialty in Italy as well as the life of the ItalianOtorhinolaryngological Society; the Authors show, once again, their vast knowledge andcapability to correctly illustrate interesting and important moments of Society life, whichdeserve to be emphasized.My gratitude is also extended to these two friends for the valid support they have offeredme, in a moment that has totally engaged me, my family and my Collaborators in prepar -ing this Congress. For several months, we have been dedicated to organizing, in the bestway possible, this extraordinary event aiming to satisfy all the scientific and social needsof those who have enthusiastically accepted our invitation.In wishing you pleasant reading, I hope that our efforts will reinforce our friendship andscientific collaboration.

Prof. Desiderio PassaliPresident of IFOS XVIII International ORL Congress

In preparing this Volume, Dino Felisati and Giorgio Sperati, wanted to share their per -sonal experience and to offer our readers the opportunity to re-live the history of theENT Specialty in Italy and the history of the Italian Society of Otorhinolaryngology andHead and Neck Surgery (S.I.O. e Ch. C.-F.). Both Authors are well known to our manycolleagues, so who better than these two greatly esteemed colleagues, who have dedi -cated their professional activities to our Specialty, and have made no secret of their pas -sion for the history of medicine, could have achieved this goal.The aim not only of the Authors but also the Society is that this Volume and the contentsthereof become an instrument that, in reflecting on these events, will involve also ourcolleagues attending the International IFOS Congress in Rome. The Volume is dedicat -ed to all our guests, and the Italian Society (S.I.O. e Ch. C.-F.) hopes that it will bringgreat pleasure.

Prof. Pasquale Laudadio, President of the Italian Society of Otorhinolaryngology

and Head - Neck Surgery (S.I.O. e Ch. C.-F.)

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INTRODUCTION

In greeting Colleagues who have gathered from all over the world to be presenthere in Rome for the XVIII World Congress of the International Federation ofOtorhinolaryngological Societies (I.F.O.S), the Italian Society (S.I.O. e Ch. C.F.)wishes to welcome all participants with this token of friendship: an introductionto the history and birth of the specialty Otorhinolaryngology in Italy and the his-tory of the Italian Society of Otorhinolaryngology, one of the first born at the endof the 19th Century, when medical specializations appeared on the internationalscene. Prior to that time, the only specialties that existed were: Obstetrics,Odontoiatrics, Ophthalmology, Dermatology, Otology etc. These were mainlycultural manifestations with a modest scientific content. The first Specialtiesappeared in the mid 19th Century when scientific research methods, focusing ondetail, even the very smallest, led to the idea of separating knowledge, exactlyas in economics, in which the various aspects of work were being increasinglyseparated.The Specialty of ENT stemmed from a complex process with a long and diffi-cult gestation. Factors of a cultural, institutional and associative nature becameinvolved. The fundamental and qualifying moments in this fascinating story thatwitnessed the growth of our Specialization, finally becoming the Speciality ofHead and Neck Surgery were:- the birth of Laryngology and Rhinology, approached by exploration of the lar-

ynx and rhinopharynx, which had never been carried out before that time;- the involvement of the University and Hospitals in the teaching and practical

use of these new disciplines; - the foundation by a handful of pioneers, of the Società Italiana di Laringolo -

gia, Otologia e Rinologia (S.I.L.O.R), in 1892.The history of S.I.L.O.R. is a story spanning more than a Century, which step bystep, has followed the evolution of the Specialty, both from a cultural and asocial point of view. Clinical practice, in fact, has to bear in mind the develop-ment of scientific and technical knowledge, on the one hand, and, on the other,the problems related to patient-care which in every developed country hasreached such proportions that the activity, not only of the family doctor but alsothe specialist, are conditioned by them. Throughout these long years, facts hav-

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ing an impact on the role of the Specialists have been taken into account,attempting always to keep the specialty united but above all to increase theadded value of healthcare, paying attention to quality and observation of ethicalregulations.Many events have left their mark on the various phases of the Society’s history:there can be no doubt that the most important was the “rifondazione”, - the newfoundation - which occurred in 1976 that, by way of a process of integrationbetween the two fundamental components, University and Hospital, gave notonly new lymph and closer solidarity but also a more modern Society: SocietàItaliana di Otorinolaringoiatria e Chirurgia Cervico-Facciale (S.I.O. e Ch. C.-F.). This important step was followed by the creation of a scientific journal ActaOtorhinolaryngologica Italica that now publishes articles in English. From a historical viewpoint, a few special events occurring in Italy over the lastquarter of a century are worthy of mention: - the 10t h International ORL Congress organized by Michele Arslan, in Venice, in 1973;- the 2n d European ORL Congress organized by Giovanni Motta, in Sorrento, in 1992;- the present 13t h International ORL Congress prepared by Desiderio Passali, in Rome. The European Congress in 1992 provided the opportunity to celebrate, togetherwith our foreign Colleagues, the Centenary of our Society.S.I.O. e Ch. C.-F. has its Headquarters in Rome, the premises of which belong tothe Society and house the Archives, Library and Museum. These Headquartersare used for Board meetings, cultural events, Continuing Medical EducationProgrammes (E.C.M.). Representatives from the affiliated and joint specialitiesalso have the use of these premises. The Library contains the Society publica-tions, the official journal Acta Otorhinolaryngologica Italica, as well as journalsreceived on an exchange basis. There is also a valuable collection of volumesrelated to ORL and many books that have been left by Society members whohave passed away. The Museum contains a variety of historical instruments, bothof diagnostic and therapeutic interest; these have been classified according to thetype of disease and have been used to set up displays in several Congresses.

Dino Felisati Giorgio Sperati

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The origin of the ORLSpeciality in Italy

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The Specialty Otorhinolaryngology was born in the second half of the 19th

Century. Until then, diseases of the ears, nose and throat had been treatedseparately, as if the three organs were independent one from the other. Itwas in the 19th Century that, for a series of reasons which we will discusslater, the idea spread that, from a physio-pathological point of view, closecorrelations existed between the nose, ears and throat and that many dis-orders of these three districts influenced one another, therefore, the physi-cian’s studies and professional practice should focus on all three organstogether.Let us see how doctrine and practice actually came together leading to theformation of Otorhinolaryngology.From a philosophical viewpoint, the 19th Century is that in which twoschools of thought which had characterized the previous centuries, cometo a crisis: the rationalist thought, the origins of which came fromCartesian cogito, ergo sum, degenerating into idealism, vitalism, brown-ism; the empiric thought evolving into positivism, with the philosophy ofComte, which finally degenerated into experimentalism. We owe toImmanuel Kant (1724-1804) the merit of having taught us not to abusespeculation and to Claude Bernard (1813-1878), the idea that the “Man ofScience” should endeavour to achieve a synthesis between rationalismand experimentalism. Therefore, it is not difficult to understand why the19th Century was the century characterized by great scientific discoverieswhich led to the birth of new specialties, such as Microbiology, Immuno-logy, Histology, Experimental Physiology, Experimental Pharmacologyand new techniques, such as asepsis, antisepsis, local and general anaes-thesia which greatly contributed to the development of surgery.From ancient times and until then, studies had focused primarily onAnatomy. Starting with Alcmeone (6th-5th Century B.C.), who appears to

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have been the first to performanatomical dissections, then Gale-no, and, thereafter, the famousSchool of Padua in the 16th Century,gradually the anatomical secrets ofthe human body were revealed andgreat interest was taken in the studyof sense organs, which are so close-ly related to our own discipline.Antonio Maria Valsalva (1666-1723), in 1704, published De AureH u m a n a , Domenico Cotugno, in1761, described the labyrinthineliquids and the name of AntonioScarpa (1747-1832) became linkedto important discoveries regarding

the structure and function of the innerear: Anatomicae disquisitiones deauditu et olfactu (Pavia, 1789). In the17th and 18th Century, physiologicalresearch developed and with Giovan-ni Battista Morgagni (1682-1771), amedical giant of the 18th C e n t u r y,pathology took on a modern form. Atthe same time, endoscopy and use oflight sources were being improved.Of the three organs comprising ourspeciality, the ear was certainly the

2. - Antonio Scarpa, from the Athenaeum inPavia, published “De structura finestraerotundae auris et de tympano secundarioanatomicae observationes”, in Modena in1772, describing, for the first time, themembranous labyrinth.

1. - “De Aure Humana Tractatus” by AntonioMaria Valsalva, pupil of Malpighi andProfessor of Morgagni, published in Bolognain 1704. The volume contains a detaileddescription of the outer, middle and inner ear.

most studied and, from a clinicalpoint of view, the best known andtreated. The Otolologists were alsos u rgeons and this tradition willhave an effect, as we shall see,when fusion of the three ENT disci-plines actually becomes reality.The 19th Century is also the timewhen the work was further divided.This occurred in the industrial fieldwhich constantly required greaterspecialization in order to gain thebest advantages in production, butthis also took place in the scientif-ic field, in the conviction that thesearch for truth should be focusedon greater detail. As E. Isambertwrites in 1875: Les spécialités sont,en effet, un des besoins, et nouspourrons ajouter un des modes deprogrès les plus réels de la science

moderne. En médicine, comme partout ailleurs, la division du travail estdevenue une nécessité. Le temps de savant universel est passé. The evo-lution of the embryo and cell differentiation appear to be indisputableconfirmation of this new approach (Milne-Edwards, Spencer).The international panorama, in the early 19th Century, saw France in poleposition as far as concerns scientific and technical know-how. England,with the cultural tradition derived from Bacon, developed a practical clin-ical trend; with regard to care, Buchanan, in 1805, founded an Institute inLondon, for diseases of the ears and eyes, and still in London Curtis, in1816, created a hospital for ear disorders. Italy continues with anatomicalresearch studying embryology. Germany was still in the early stages, par-ticularly as far as concerns otology, but was destined to make up for losttime in the second half of the century. Together with Austria, Germanybecame the centre of major developments in our discipline. The Americanspecialistic culture limits itself to the translation of European books, with

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3. - Giovanni Battista Morgagni, Professor ofAnatomy in Padua, founder of modern patho-logical anatomy. His volume “De sedibus etcausis morborum per anatomen indagatis”,published in Venice, in 1761, was a milestonein the history of medicine.

a modest scientific production published in the journals dealing withGeneral Medicine; this was to become, in the 20th Century, the centre ofattraction for research workers in all fields of medicine. In the second half of the 19t h

Century, there was an explosion indiagnostic and therapeutic medi-cine - but particularly in surgicaltreatment. In the German-speakingcountries, the development ofresearch was so rapid that it evenexceeded that of other countries.This was the time of major expan-sion both in politics and in the mil-itary field. History has taught usthat the period of maximum splen-dour of the arts and sciences coin-cides with that of the greatest polit-ical and economic power of thecountry in which this is takingplace: this was seen in Athens at thetime of Pericles, in Imperial Rome,during the Italian Renaissance, in17th Century France, in 19th CenturyAustria and Germany, and in pre-sent-day America. The second half of the 19th Century was the time of the famous “all-in-one” Surgeons: Billroth (1829-1894) and Von Langenbeck (1869-1939) inAustria and in Germany, Cushing (1869-1939) in America; Bassini(1847-1924) and Bottini (1837-1903) in Italy; Paget (1814-1899) andHutchinson (1869-1939) in England.Heirlooms of the past left, to future generations, specialities in the embry-onal stage: Ophthalmology, Obstetrics, Urology, Paediatrics, Syphilo-graphy. They then became autonomous disciplines. Otology, in theGerman-speaking countries, developed very rapidly and, in Vienna,became the most important reference point for everyone. Research wascarried out on the anatomical and physiological aspects, especially of the

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4. - Theodor Billroth, one of the greatest sur-geons of the 19th Century was the first to per-form oesophageal resection in 1872, the firsttotal laryngectomy in 1873 and the first gas-troresection in 1881.

cochlear and vestibular areas; reflex light was used. The study and prac-tice of Otology then spread to other countries.

THE BIRTH OF LARYNGOLOGY AND RHINOLOGY

It was in this period that Laryngoscopy was born which led to Laryng -ology becoming of great importance. Anterior Rhinology was integrated,following the introduction of posterior rhinoscopy, thus offering the pos-sibility to explore the rhino-pharynx. As far as concerns the pathologicalaspects of this area, the aetiopathogenesis of many ear and throat disor-ders was recognized. From a cultural viewpoint, this was the most impor-tant aspect leading to the unification of the ENT specialization.Let us analyse these events step by step.Manuel Garcia, a singing teacherand a singer himself, was obsessedby the idea of being able to see hisown vocal chords. In 1854, using adentist’s mirror placed against thepalatine vault and sunlight, hemanaged to project on a mirror,placed in front of his eyes, theimage of his larynx. This discoverywas immediately used by L. Türck(1810-1868) and J.N. Czermack(1828-1873) to study laryngealdisorders. Thanks to Czermack,laryngoscopy became a populartechnique, combining illuminationwith light reflection and taking theadvantage of artificial light. Hetoured the most important capitalcities in Europe illustrating thetechnique and his own results. The first biopsies and topical treatmentswere carried out. Adoption of the technique encountered some difficultiessince local anaesthesia was not yet available, being introduced, in 1884,by E. Jelinek, an Assistant of Von Shroetter. This is how Carlo Labus

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5. - Manuel Rodriguez Garcia (1805-1906), in1854, used, for the first time, and with success,the laryngeal mirror.

(1847-1917), Ferdinando Massei(1847-1917), Adalbert To b o l d(1827-1907) and Jean Garel (1852-1930) invented the manikin whichenabled trainees to practise the useof this technique before actuallyhaving to carry out explorations onpatients. Laryngology develops as a branchof General Medicine and is prac-tised by Internists and Pneunomolo-gists, interested in better under-standing disorders of the lower res-piratory tract, and only later, thestudy of laryngeal diseases. Thosedevoted to this new doctrinal bodywere not interested in surgery and,indeed tracheotomy and the early

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6. - The L a ry n g o p h a n t h ô m e , created by CarloLabus, in 1883, to enable doctors-in-training topractise endolaryngeal manipulation manoeuvres.

7. - Allgemeine Krankenhaus, the large General Hospital in Vienna, which housed the Univer-sity Clinics where Türck and Czermak carried out their first experiments on indirect laryn-goscopy.

laryngectomies were carried out byGeneral Surgeons (Billroth 1873,Bottini 1875, Caselli 1879). Facedwith the problem of diphtheria, E.Bouchut (1818-1891), W. Mace-wen (1848-1924), but above all, J.O’Dwyer (1841-1898), developedlaryngeal intubation, thus avoidingthe trauma of tracheotomy. Fromthis time onwards, relationshipsbetween Laryngologists and Gene-ral Surgeons become more tensesince the former, who possessthese new techniques and compe-tence, want greater space for theirprofession, while the latter realizethat with the appearance of newfigures, with specialized qualifica-tions, there is a risk of losing fieldsof activity which hitherto had been theirs alone. Throughout Europe, pub-lic and private Institutions for Laryngology were set up. In about 1870, inVienna we would have found a Laryngology Service, Director of whichwas Schnitzler, a University Clinic, directed by Von Schroetter, and anOutpatient Unit specializing in Laryngology directed by Von Stoerk. I n1862, Merkel set up a Private Polyclinic for Laryngoscopy, in Leipzig. In1863, Mackenzie, in London, founded the Hospital Institution special-ized in laryngeal disorders. In 1870, Voltolini did exactly the same inB r e s l a w.In Italy, Labus, after having carried out further studies in the laryngolog-ical field in Berlin, accepted, in 1876, the proposal to open an OutpatientUnit for throat disorders at the Ospedale Maggiore in Milan which wasdestined to become the School of many Italian Specialists. In 1879, hewas nominated by the University of Pavia to introduce laryngoscopy aspart of the official teaching programme which he then continued until1883. Labus organized, in Milan, the First International Congress ofLaryngology and was elected President of the event. It was on that occa-

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8. - Leopold Schroetter von Kristelli (1837-1908), a pupil of Türck, was assigned, by theFaculty of Medicine in Vienna, theDirectorship of the first official LaryngologyClinic, in 1870.

sion that a proposal was made forLaryngology to become autonom-o u s. Massei became a privateteacher of Laryngology in Naplesfrom 1871 and Professore Straor -dinario in this field, in 1882.As far as concerns Rhinology,studies and professional practiceare still focused on anterior rhinol-ogy and on the paranasal sinuses.Nasal specula exist, which are illu-minated in various ways. Zuker-kandl in 1882, published a tomeNormale und patologische Anato -mie der Nasenhöle und ihrer pneu -matischen Anhange which becamea reference point for specialists inthis field of pathology. Cozzolino, in Naples, in 1889, developed a rhino-tubo-pharyngoscope which, for the first time, made use of electric light.

Albeit, the most outstanding newd i s c o v e r y, of those times, wasmade by Czermack, in 1868, whenturning upwards the small mirrorused for laryngoscopy, he actuallyperformed the very first rhino-p h a r y n g o s c o p y. Rhinology, con-sidered the all-round discipline ofnaso-sinusal and rhino-pharyngealdisorders, was born at this time. In1888, Voltolini and Cozzolinointroduced transillumination of thesinuses with electric light. Studieson the rhino-pharynx suggestedthat the disorders of this area werepathogenetic elements of manydiseases of the ear, hypopharynx

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9. - Carlo Labus organized the FirstInternational Laryngology Conference inMilan, in 1881, attended by 122 experts.

10. - Vincenzo Cozzolino (1853-1911), in1891, was appointed to teach Otology andRhinology at the University of Naples.

and larynx. The concept of the responsibility of the rhino-pharynx in thegenesis of auricular disease had already been expressed by Bonnet (1802-1858) and Pétrequin (1809-1876), but the time was not ripe for such state-ments. G. Killian (1860-1921), G. Caldwell (1834-1918), H. Luc (1855 -1925) A. Nelaton (1807-1873), E. Woakes (1837-1912) are, at this time,the prestigious practitioners of this discipline which developed both asmedicine and surgery thus becoming a trait-d’union between Otology andLaryngology.

THE IDEA OF A UNIFIED SPECIALITY

The idea of a unified speciality - Otorhinolaryngology - is the result of anevolutive process of ideas of a technical-scientific nature, but the birth ofthis new speciality had a difficult gestation. Above all, relationshipsbetween Otologists and Laryngologists were uneasy: the former have

behind them, a long-standing tradition and arefundamentally surgeons, while the latter aregeneric physicians. Therefore, they have no sur-gical background, and, moreover, with laryn-g o s c o p y, they believe they have, at hand, a meanswith which to obtain worthwhile results also forprivate professional purposes. In 1899, Massei, aLaryngologist from Naples, having read some ofthe works of Semon - an authoritative German-speaking Laryngologist who, together withWa l d e y e r, showed a tendency to be against anyfusion - agreed with and praised the opinion ofthis author in a long article published in theJournal A rchivi Italiani di Laringologia f o u n d e din 1881: The opinion of Semon appears to be thebest dam to build against a current that for sometime now has been pro g ressing in our part i c u l a rfield and which under the specious flag of thefusion of Laryngology with Otology wouldattempt, after a hard-fought and victorious battlethat we had endured to promote Laryngology to

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11. - Sir Felix Semon (1849-1921), of German origin,became one of the mostimportant laryngologists inthe United Kingdom. (Cari -c a t u re from Vanity Fair,1902).

an autonomous speciality, to then kill it, after the solemn baptism re c e i v e dby the scientific world, not only at International Medical Congresses butalso on other occasions, by uniting it with otology! One of the most terr i -

ble acts of autophagy. The attitude of mind of Massei was shared by a larg enumber of specialists who, for a long time thereafter, will continue to pro-fess medicine in a separate manner. It is worthwhile mentioning, moreover,that Massei, as we shall see later, becomes one of the founder members ofS.I.L.O.R., created in 1892, thus showing himself, in the end, to be some-what conciliating. Another interesting aspect to be taken into consideration concerns the rela-tionship with the newborn speciality and General Medicine. It gave theimpression of being the only font of medical knowledge and assumed anattitude which left no room for dialogue. Their real preoccupation, more-o v e r, appeared to be the loss of prestige and power. In his OpeningAddress, at the officially recognized course on Rhinolaryngology in 1887-88, Pietro Masucci, second in command at the Laryngology Clinic in

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12. - Ferdinando Massei (first on left) during a Congress, in Berlin, in 1868.(Photo by courtesy of Dr. Pietro Vitto-Massei).

Naples, states: … just listen to what Schleidinger has recently stated in apublic conference; I firmly believe (these are his own words) that there isnothing more dangerous for science, than the continuous analysing, con -tinuous dividing and subdividing, the incessant classifying and sub-classi -fying, because by so doing, you are going against the first fundamental ru l eof any discipline, which is never to lose site of “wholeness”. Every month,e v e ry week, every day, books are produced in which all the cells and cellnuclei are described in minute detail, both in normal and pathological con -ditions; but try asking these enthusiasts what an organism is, and you willsee that they remain completely stunned. The Rhinolaryngologists haveconcentrated all their intellectual activity on the first re s p i r a t o ry path -ways; beyond these, they see nothing, absolutely nothing … and mutatismutandis applies also to the other specialities. But Emilio De Rossi, fromhis Chair of Otology in Rome warns (1892): The scientist should not shrinkhis brain, by limiting it to a special study, but should continue to cultivateit, and not separate it from the rest of the scientific world which is the basisof medical and surgical culture . He who devotes his time to special branch -es of medicine, must then avoid that unhealthy pride (Selbstüberschatzung)described by Helmoltz and which is so easy to pick up unilateral intellec -tual activities.With the general surgeons, as already pointed out, the relationship was nob e t t e r. Billroth, in his writings of 1876, L e rh ren und Lernen, definedOtology as: that small discipline, however not without import a n c e.General Medicine complained of the surgical errors of some unqualifiedspecialists. To prevent quacks and imposters from discrediting the new dis-cipline, Vincenzo Cozzolino, wrote to Grazzi, Director of the B o l l e t t i n o, in1891: … well, to merit the title of Surgical Specialist you would have tou n d e rgo an examination, which is much more necessary to-day since theteaching of Otology and Laryngology are not compulsory, like Ophthalmo -logy and Obstetrics. Accept this concept of mine in honour of our pride, inthe interest that the practical exercise of our discipline will not be blem -ished by unskilled workers and in order that our literature is not despiseddue to publications reminiscent of the times of obscurantism.G r a d u a l l y, fields of activity were being defined for which the competenceof the ENT Specialist is mandatory: assistance for the deaf and dumb, con-sultancy in military medicine and in occupational medicine. Labus sets up

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the Istituto Ototerapico in Milan, stressing the need for the presence ofSpecialists in Institutes for the Deaf and Dumb and Tommaso Bobonefrom S. Remo expresses the hope that Institutes, similar to that in Milan,will be set up in other parts of Italy. The Railway and Marine A u t h o r i t i e stake into consideration the possibility of using oto-laryngologic expertiseto identify deaf subjects and patients with laryngeal disorders.

INSTITUTIONAL PHASE

The gestational phase of the Speciality involved two important phases:i n s t i t u t i o n a l and a s s o c i a t i o n a l. In order that a new medical discipline becomes stable, it is necessary,above all, that it enters the University and, if possible, recognized as partof the compulsory teaching programme. The University offers the possi-bility to carry out research, thus enhancing the cultural notions of the dis-cipline itself. At the same time, in the case of the clinical discipline, thisshould necessarily be practised in the hospital setting, where doctors with

proven experience offer the guaran-tee of correct use, not only of diag-nostic methods but also treatmentof the relevant pathological condi-t i o n s .Thus, teaching of the disciplinescomprising ORL first took place inthe private offices of the first pio-neers who very soon sought thepossibility to teach their disciplinein a University setting. Not an easytask, as the Professors, who werealready present in the Universities,were very much against introduc-ing new and competitive teachingcourses, which meant a challengeto their authority and prestige.Again, conflict was imminent, justas before when fierce competition

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13. - Emilio de Rossi (1844-1901) wasappointed to teach Otoiatrics in Rome, alreadyin 1871, and was one of the most famousOtologists in Europe.

had arisen between the new specialities and General Medicine and GeneralS u rg e r y. Emilio De Rossi was the first Italian to be nominated responsible, in 1871,for the Otology teaching programme in the University of Rome. In hisfavour was a volume entitled Diseases of the Ear for which he hadreceived the compliments of Schwartze. In 1881, he was nominatedP ro f e s s o re S t r a o rd i n a r i o of Clinical Otology and, in 1884, also L i b e ro Do -c e n t e of Laryngoscopy, which the following year became Laryngology.Both courses are complementary to fifth - and sixth-year studies. In 1881,the Clinic of which he was Director, at the Ospedale S. Giacomo, wasfinally renovated and a team was set up to meet the demands of teachingand patient assistance. In those years, despite many difficulties, De Rossifought to have the Chair of Otology brought into line with the others andto make Otology part of the compulsory teaching programme in all ItalianUniversities. On 14t h June, 1891, with the application of Art. 96 of theCasati Law, De Rossi is nominated Full Pro f e s s o r of Otology, an eventwhich was of great importance, also at international level, as this was the

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14. - Count Giuseppe Gradenigo (1859-1926) who was highly esteemed throughoutEurope for his important and meticulousscientific research in Otology.

15. - Giulio Masini (1853-1937), the first topractise Otorhinolaryngology in Genoa andone of the most successful research workersin the field concerning the physiology oflanguage and laryngeal nerve centres.

very first post of its kind in Europe. The Casati Law, of 15t h N o v e m b e r,1859, concerned the regulations of regarding State Education, and off e r e dthe possibility of including the Speciality within the UniversityProgramme. The figure of P ro f e s s o re Straord i n a r i o was foreseen, togeth-er with P ro f e s s o re Ord i n a r i o and D o t t o re A g g re g a t o, who would holdcourses and have Chairs in disciplines that had not previously been off i-cially recognized. With this Law, Libera Docenza (University teaching)came into force, with the faculty for private tutors to hold courses in com-p u l s o r y, complementary and similar topics. Libera Docenza meant recog-nition for those involved in Otology and Laryngology on account of thepossibility of a career both in the University and Hospital setting.In 1893, De Rossi together with Gradenigo launched the Journal A rc h i v i oItaliano di Otologia, Rinologia e Laringologia.In the last few decades of the 19t h C e n t u r y, we would have found on theItalian University scene:In Rome - Emilio De Rossi, as already mentioned; In Naples - Ferdinando Massei, Private Teacher of Laryngology from

1871 and P ro f e s s o re Straord i n a r i o of Laryngology from1882; Vincenzo Cozzolino in charge of Otology andP a re g g i a t o in Rhinolaryngology, from 1894, P ro f e s s o reS t r a o rd i n a r i o of Otorhinology;

In Florence - Vittorio Grazzi regular tutor for the Corso Libero i nOtorhinolaryngology from 1883 in the Medical School atthe Regio Istituto di Studi Superiori, at the Ospedale S.Maria Nuova in the University of Pisa;

In Pavia - Giovanni Longhi, who from 1880 to 1885 held a Course inO t o l o g y ;

In Genoa - Giulio Masini in charge of the teaching of Laryngo-rhino-o t o l o g y, from 1894, and P ro f e s s o re Straord i n a r i o , in thisteaching area, from 1896;

In Turin - Giuseppe Gradenigo P ro f e s s o re S t r a o rdinario of Otology,from 1896.

In 1905, the Clinical Otology and Rhinolaryngology Course becomes theOtorhinolaryngology Course and assigned as complementary to the Fifth-year programme of Medicine studies. The teaching of Otology, initiallyc o m p l e m e n t a r y, became compulsory, in 1920.

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Also in the Hospitals, the situation is in great fervour: a few ward, withbeds for hospitalisation, were set up in Milan, Naples, Padua and Turin. Inother Hospitals, in the large cities, Out-patient units, Dispensaries andConsultancies became available. At the Pamatone Hospital, in Genoa, Dr.Durand was put in charge of the Otologic Dispensary, while at theOspedale S. Saverio in Palermo, Dr. Giuseppe Ficano was put in charge asDirector of the Dispensary for ear, nose and throat diseases. In Ve n i c e ,Faustino Brunetti set up the first public Outpatient unit which was free ofc h a rge for disorders of the ears, nose and throat.

ASSOCIATIVE PHASE

The associative phase was equally as complex and interesting as thatexamined so far: the idea of a unified Speciality gains credit and import-ance as the significance and value become evident. The concept of theembryological, anatomical, physiological and clinical unity of the oto-rhino-laryngological districts and the relationships that these districts

have with the adjacentorgans (eyes, brain andlungs) and with theorganism, as a whole,are the most convinc-ing elements.As Grazzi pointed outin the B o l l e t t i n o: I norder for medical ands u rgical teaching tomerit the name of“special”, the part ofthe human organism towhich it refers must beof great importance. Itis necessary that diag -nosis of the variouspathological condi -tions that may develop

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16. - An otoscopic examination illustrated in the Otologyhandbook Manuale di Otologia by Vittorio Grazzi, publishedin Florence in 1866. Grazzi was the first President ofS.I.L.O.R.

in that part or organ may be difficult and give rise to mistaking the con -dition for another disease, on account of the nature and site, thus result -ing in the doctor being dubious concerning the possibility of making aclear diagnosis. In Specialty teaching, equipment and instruments shouldbe different from those ordinarily available, and the persons using thesemust be adequately trained. Finally, both medical and surgical tre a t m e n t ,if they are to be effective in curing the disease of the particular org a n ,re q u i re an extraord i n a ry theoretical and practical preparation. These arethe fundamental points which should form the basis of a Specialty teach -ing programme and Otology and Laryngology duly possess all these re q -u i s i t e s .And Trifiletti continues: Since rhinoscopy was derived from laryn -goscopy, it would appear rational not to separate the former from the lat -ter: but rhinoscopy is useful in solving problems related to disorders bothof a laryngeal and auricular nature, especially as far as concerns thera -peutic applications, by way of the Eustachian tube. Therefore, it wouldappear to be advantageous not to separate Rhinology from the othertwospecial branches. The first skill that the ENT specialist must displayis that of a competent endoscopist; he must be able to handle equipmentwith expertise, proven with thorough training.The need to unite ENT specialists into a single Society stems, in turn,from the need to obtain official recognition of the Specialty, to promotescientific and cultural activities, to qualify the Italian Speciality withinEurope. Cozzolino, in a letter entitled: Concerning an Italian Society ofOtology, Laryngology and Rhinology, sent to Grazzi, in 1891, for publi-cation in the Bollettino, wrote: I do not think, by any means, that theSociety should serve as a climbing frame for those aiming to become spe -cialized surgeons merely for enchantment, and not by way of virtue ofstudies performed with diligence and good results… and nor should aSociety exist to serve as a position of authority for anyone, whoever shemay be, but should become a scientific arena, to safeguard the interest ofall those who work seriously, and who, baptized in a clear fountain, pro -ceed tirelessly along their way, to be up to par and to contribute, as some -times happens, to practical scientific progress.The first proposal to create an ENT Society which appeared in theBollettino in July 1887 was launched by the Milanese Otologists Longhi

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and Sapolini who had been cultivating this idea, for many years, but bothwere aware of the difficulties involved in realizing the project. TheLaryngologists, in fact, are in a position of uncompromising indepen-dence. Nonetheless, the strength of the ideas prevailed and, in 1891, at theCongress of the Italian Association of Medicine, in Siena, whereOtologists and Laryngologists had their own separate Sessions, theArticles of the Statutes and Regulations of the impending constitution ofS.I.L.O.R., which had been prepared by Grazzi, were discussed andapproved. There is every reason to believe that the mention ofLaryngology first, of the various components of the unified Speciality, isa concession to Laryngologists in order to obtain their consensus. Indeed,Massei who, as a Laryngologist, had opposed this constitution, was thenamongst those signing the constitutional documents. There were 21founder members, representing Italy from North to South. On that occa-sion, it was decided that the first meeting of the new Society would takeplace in Rome the following year and, indeed, was duly held, 26-28th

October 1892. S.I.L.O.R, the Society of the unified specialities, was one of the first toappear on the international scene, the Sociedad Espagnola deLaryngologia, Otologia y Rinologia following in 1886; Société deLaryngologie, d’Otologie et de Rhinologie de Paris in 1891; SociétéBelge d’Otologie, de Laryngologie et de Rhinologie in 1895. However,the various Societies of Otology, or Laryngology, or Rhinolaryngology,which sprung up here and there did not have the characteristics of a uni-fied society.

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30

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The Italian Society of O.R.L.Head and Neck Surgery

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II

In Italy of the R i s o rg i m e n t o, in 1862, doctors had joined the A s s o c i a z i o n eMedica Italiana (A.M.I.) which held its Congress every two years. On thatoccasion, autonomous sections were created to discuss problems of inter-est to specialists, thus in the Congress of 1866, 50 Committees and 4000Society members took part. In thefollowing years, these numbersrapidly decreased, until, in 1887,there were only 4 Committees. It sohappened that the various Speci-alization sectors had started to gath-er together on their own, graduallybreaking away from GeneralMedicine. At the A.M.I. Congressin Turin, in 1886, the first meetingwas held of the LaryngologySection, President Carlo Labus,while, in 1889, in Padua, theSection of Otolaryngology, Presid-ent - Giuseppe Gradenigo, assem-bled. On that occasion, the desire tocreate an autonomous specialisticE N T Society was expressed. A l s oborn, at that time, were theSocieties of Dermatology (1885), Internal Medicine (1887), the ItalianOphthalmology Association (1890), transformed in 1924 into a Society,Society of Obstetrics (1892) and that of Paediatrics (1899). The Società Italiana di Laringologia, Rinologia e Otologia (S.I.L.O.R.)

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17. - Many Italian Otologists trained in Viennaat the School directed by Adam Politzer (1835-1920).

was founded in 1892.The 21 founder members were: Carmelo A b a t e from Catania, Tommaso Bobone from S. Remo, F a u s t i n oB ru n e t t i from Venice, Antonio Damieno from Naples, Ignazio Dionisiofrom Turin, Francesco Egidi from Rome, Alfonso Fasano from Naples,Giuseppe Ficano from Palermo, Vincenzo Garzia from Naples, G i u s e p p e

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18. - Letter from Sir Felix Semon to CarloLabus regarding polycentric research thatthe English Laryngologist had started inorder to evaluate the possible malignantevolution of benign laryngeal lesions.

G r a d e n i g o from Turin, Vittorio Grazzi from Florence, Carlo Labus f r o mMilan, S a l v a t o re Marano from Salerno, Giulio Masini from Genoa,F e rdinando Massei from Naples, P i e t ro Masucci from Naples, Vi t t o r i oN i c o l a i from Milan, Camillo Poli from Genoa, Carlo Secchi from Bologna,Giuseppe Strazza from Genoa, A l e s s a n d ro Tr i f i l e t t i from Naples.The 1s t Congress was held in Rome, 26-28t h O c t o b e r, 1892. Grazzi, thePresident, in his opening speech stressed the importance of Universityteaching in the new discipline: Only in three Universities (Rome, Naples

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19. - Letter from D.B. Delavan, Secretary of the American Laryngological Association, to CarloLabus, one of the Members.

and Turin) are our studies taught by official Professors. Only in the RomeMedical School has a proper clinical teaching been set up, which is author -itatively directed by the famous Professor Emilio De Rossi. In all othernational scientific centres, all that has been done and is being done, isthanks to the pure and simple initiative of the individuals, not always andw h e re v e r, encouraged by the respective Medical Faculty and HospitalAdministration… The main aim of our Association, besides gathering indi -vidual work together… consists, indeed, in popularising - allow me the useof this expression - our Specialty.What does he mean by “popularising?” He explains immediately: TheSociety of Laryngology, of Otology and Rhinology, following the exampleof what has already been done in America, Germany, England andFrance, will show, by means of scientific production and the practicalapplications thereof, how useful these studies are, not only for thoseinvolved in health-care, but also for mankind in need of care. Studies, theimportance of which, many still refuse to recognize.

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20. - 5th Congress of SILOR in Naples, April, 1900. (front row, from the left: Masucci, Grazzi,……, Fasano, Masini, Massei, Gradenigo, Cozzolino).

FIRST PERIOD (1892-1913)

The founder members are internationally esteemed scientists. All hadtrained in clinics in Austria, Germany, France and England, and, withtheir foreign professors, had established relationships promoting culturalexchange, reciprocal appreciation and friendship. For over 20 years,Zuckerkandl and Gradenigo, as well as Semon and Labus, had constantlymaintained correspondence. S.I.L.O.R. was invited to take part in theJubilee celebrations in honour of the teaching of Gellé and Politzer. In1910, the 50th Anniversary of the teaching of Politzer had been celebratedin Vienna, and on that occasion, the Italian President of S.I.L.O.R.,Gherardo Ferreri, in honour of the Austrian Otologist, presented a mes-sage, written in Latin on behalf of Guido Baccelli, a famous clinician inInternal Medicine and ex-Minister.In that period, the Society had several times, during the off i c i a lCongresses, expressed the need to strengthen University teaching and theMinistry of Education was informed in this respect. Gradenigo, in 1908,writes: Diseases of organs as important as ears, nose and throat are stillnot included in the compulsory teaching programme… continuing to con -

sider the study of a Speci -ality as an optional, is theequivalent of re c o g n i z i n gthat it is of limited value.On the other hand, in 1907,the School of MilitaryHealth, in Florence, tookthe initiative to recognizethe importance of the ENTdiscipline and includes it inits Statutes.Society Congresses wereinitially held every twoyears, later becoming anannual event. In order tomake the Society culturebetter known, these topics

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21. - Gherardo Ferreri (1856-1929) successor to DeRossi of the Chair of Otoiatrics at the Rome University.

were included in the presentation and discussion of the Official Lectures;to stimulate research in the younger generations, scholarships are award-ed. The Headquarters of the Society were, at the ORL Clinic, in Rome,which housed the official documents and publications. In 1911, theSociety and the Provincial Education Office for studies in Milan, set up acollaborative relationship in order to elaborate a programme for diagnos-tic purposes, in Otorhinolaryngology, in the teaching schools in that area.

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22. - 24th S.I.L.O.R. Congress in Catania (29th October - 1st November 1928).

SECOND PERIOD (1920-1938)

The XVII Congress takes place in Trieste, which has just been returnedto Italy, after the First World War (1915-18). From a debate during theAssembly, the need emerges not only to re-organize the administrativeand financial aspects of the Society, but also to seek new members. In this and subsequent congresses, the Society assumes the responsibilityof putting pressure on the Ministry of Education in order that the ORLexamination becomes a compulsory subject in the University teachingprogramme. Since the characteristics of the title of Specialist have not yetbeen defined, the Assembly at the 18th Congress held in Ravenna unani-mously agreed that … Member of the Society was not the equivalent ofbeing a Specialist. This point was, in part, resolved in 1923 with theGentile Law which set up Scuole di Perfezionamento for doctors with amedical degree (the equivalent of the Post-graduate Courses that we nowknow) and finally resolved, in 1933, by the Minister Bottai who, besidesthe Scuole di Perfezionamento, created the Scuole di Specializzazione.In 1931, the Congress was held in Messina, together with the SocietasLatina di ORL which brought many foreign colleagues to Sicily. In 1932,the Society officially takes part in the International Congress held inMadrid. At the National Congress, that same year, the Presidentannounces to the General Assembly that the Society will be taking part ina campaign again adenoidism, promoted by the Opera NazionaleMaternità e Infanzia (a national body involved in maternity and infantcare) together with organizations in this field. The aim is to set up aHospital ENT Unit in the major city of each Province throughout Italy.In 1934, S.I.L.O.R. is officially invited to the XXX National Congress ofthe Hungarian Society, an excellent occasion to set up relationships withcolleagues from that country. The Italian delegation, returning from thatMeeting, stopped in Vienna, an old prestigious home to ENT culture, witha view to re-establishing the friendly relationship with their Austrian col-leagues which had been interrupted by the war. The Society rejoined theCollegium ORL Amicitiae Sacrum, from which it had chosen to dissoci-ate, in 1923, since Italian, unlike English, French and German, had notbeen recognised as one of the official languages. In the NationalCongress, in 1938, it was found that the number of communications from

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members was excessive, a few proposals were made but several yearswere to go by before any restrictive measures were adopted. In this second period, the Society opens its doors to the so-called relateddisciplines, in particular, Phoniatrics.

THIRD PERIOD (1946-1975)

The XXXV National Congress was held in Venice, 24-29th September1946, after an interval of 8 years due to World War II. The war had dev-astated Europe, a new political situation had emerged in many countriesand new ways of life, due to well-being, created by the development ofindustry, began to upturn the old rules while the peasant society faces aninexhaustible decline, after a history lasting thousands of years.The industrial era develops further which is followed by that of informat-ics. As far as concerns health and medicine, this is the beginning of a peri-od of discoveries and structural reforms preceding a great revolution.

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23. - The two National Congresses in 1976 and 1977 witnessed the refoundation of the Societywhich changed its name from S.I.L.O.R. to S.I.O.

New Specialities are born, oftenwith the characteristics of “super-specialties”. The introduction ofantibiotics, led to the disappear-ance of many important diseasesencountered in Otorhinolaryngol-ogy which contributed to betterdefine its surgical vocation andthus become the first Specialty totake the sophisticated route offunctional surg e ry. G r a d u a l l y,functional surg e ry will imposeitself at an otological level, then atcervical level and, last of all, atnasal-sinus level. Step by step,A u d i o l o g y, Phoniatrics, PaediatricsO t o r h i n o l a r y n g o l o g y, Maxillo-fac-ial Surg e r y, become autonomous,while tracheo-bronco-oesophago-scopy passes into the field of anoth-er new discipline, E n d o s c o p y, and

O R L broadens its own competence to neck disorders, to great oncologicals u rg e r y, surgery of the skull base and cervico-mediastinic junctions, becom-ing a Head and Neck Surg e ry Speciality.S.I.L.O.R. has difficulty in following the new course in which the scien-tific Societies are no longer involved only from a scientific and clinicalpoint of view, but also taking into consideration the trade union aspects, aswell as maintaining relationships with the institutions. Furthermore, signsof disintegration begin to appear. The Society is faced, for the first time,with a real split when, in 1947, a group of Hospital Otorhinolaryngologistsgather around Giorgio Ferreri, P r i m a r i o at the ENT Department of theOspedale S. Camillo in Rome, and set up the G ruppo Otologi OspedalieriItaliani (G.O.O.I.) (Italian Group of Hospital Otologists). If, initially, theHospital group felt part of the mother society, they immediately afterwardsdeclared that they wanted to be autonomous and then set up their ownindependent social structure with its own National Congress.

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24. - Enrico De Amicis (1914-1983) whoplayed the major role in the refoundation of theItalian ORL Society.

In 1962, G.O.O.I. is transformed into Associazione Otologica Ospeda -liera Italiana (A.O.O.I.) and gains greater contractual importance com-pared to S.I.L.O.R. Reforms in the health field, resulting from theprogress made in medicine itself and the transformations that society wasnow facing, greatly increased the hospital structures and enlarged themedical teams in the spe c i a l i s t i cdepartments. Hospital Otorhino-laryngologists feel the strongerand more numerous force of theS e rvizio Sanitario Nazionale -SNN (National Health Service)and, therefore, have difficulty inaccepting that within S.I.L.O.R.,the minority University compo-nent has a greater influence thanthat of the Hospital contingent.The next few years are years ofconflict. At this point, comingonto the scene is a great person ofextraordinary intelligence andwisdom, Enrico De Amicis, ENTP r i m a r i o, at the Ospedale Fate -benefratelli in Milan. De A m i c i swants to put an end to the dis-agreements between S.I.L.O.R.and A.O.O.I. and proposes to theUniversity contingent to re-foundthe Society on an equality basis between the Hospital and University com-ponents in the Society Offices, in cultural manifestations and in otherforms in which Society life is expressed. A Commission is set up withUniversity and Hospital representatives including: Enrico De A m i c i s ,Alfonso D’Avino (Hospital), Italo De Vincentiis (University), DomenicoFilipo (University) and others who, after initial difficulties, converge onthe proposals of De Amicis. The University doctors found their Society,Associazione Universitari Otorinolaringoiatri (A.U.O.R.L.). De A m i c i sprepares the new Statutes which he reads at the Assembly of the National

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25. - Michele Arslan (1904-1988) brought hisbrilliant professional carreer to a close organiz-ing the 10th World Congress of IFOS in Venice in1973.

Congress in Capri (27t h S e p t e m b e r, 1975) and which the A s s e m b l yapproves. It is decided that it will be ratified by the Notary during theSociety Meeting at the next Congress to be held in Bologna at the end ofSeptember 1976. This will be the 1s t Unified Congre s s. Another will followat the end of September 1977, in S. Margherita Ligure, with the character-istics of the 2n d unified Congre s s. Finally, from 1978, the Congress willbecome a single event, with the two fundamental components united in asingle body, which will take the official name of Società di Otorinolarin -goiatria e Chiru rgia Cervico-Facciale (S.I.O. e Ch. C.-F. ) .De Amicis has in mind a programme to develop the Society, for the real-ization of which he associates two friends: Ettore Clerici and Dino Felisati.Together they prepare detailed regulations which outline the various phas-es of the Society’s life. The official Journal of A.O.O.I Annali di Laringo -logia, Otologia e Rinologia, which with the re-foundation has been trans-ferred to S.I.O. e Ch. C.-F. is considered inadequate for the new culturalrequirements. It is, therefore, decided to set up a new journal, to be knownas Acta Otorh i n o l a ryngologica Italica. Publishing begins in 1981, withissues appearing every two months, Editor-in-Chief Carlo Calearo.To say that the re-foundation of the Society, on the new basis of parity,has been a success would be an understatement: since the re-foundationthe Society has enjoyed years of absolute tranquillity, friendly collabora-tion between the two components, intense productivity both from a sci-entific point of view, as well as that regarding relationships with the insti-tutions.During this period, other events worthy of mention are: - the constitution, in 1971, of Sindacato Unitario Otorinolaringoiatri

Italiani (S.U.O.I.) which becomes part of the Union Européenne desMédecins Spécialistes (U.E.M.S.) union founded in Bruxelles, in 1958.Upon foundation of S.U.O.I., it is officially decided that a journal belaunched L’Otorinolaringoiatra of which Giuseppe Borasi is officiallynominated Editor-in-Chief. The organization, in Venice, in 1973, of the 10th International ORLCongress, which Michele Arslan had very much wanted. Arslan was aProfessor at the University of Padua, working in the ENT Clinic wherehe had focused attention on experimental Otoneurology, a research fieldin which he had been involved when he trained in Vienna as a young

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doctor. Arslan was a scientist with a vast culture, being well known andadmired abroad. The Opening Ceremony of the Congress was held atthe Palazzo del Cinema at the Lido in Venice with the Main Lecturebeing given by William House who presented the preliminary results ofhis experience on cochlear implants.

FOURTH PERIOD (1976-2005)

After the two unified congresses in Bologna (1976) and S. MargheritaLigure (1977), the Society enjoys a quiet period. In 1977, S.I.O. e Ch.C . F. joined the International Federation of OtorhinolaryngologicalSocieties (I.F.O.S.) and, in 1985, also the European Federation ofOtorhinolaryngological Societies (E.U.F.O.S.). In 1981, there werealready 1400 members. The number was destined to increase rapidlywithin the next few years, a consequence of the medical plethora result-ing from demagogic laws which had been come into force in the sixtiesand had not taken into consideration the peculiarity of medical studies, thepropedaeutics to a profession which does not offer alternatives. Manyyears will elapse before any action is taken, to adopt the rules of a closedentry number.In 1982, the Society is engaged in dealing with the Society of A u d i o l o g yconcerning the matter of p r i m a r i a t i (Heads of Unit) that this disciplinewants to introduce in the Hospital setting. The impending risk was the pos-sible transformation of Audiology into Otology, as an autonomous disci-pline with respect to ORL, with a return to the 19t h Century situation priorto unification of the Specialty. A joint Committeis held which discussesand approves a document stating that the ORL Speciality cannot be sepa-rated and the possibility of creating Audiological Centres, aimed at theprevention of hearing disorders in areas with over 5 million inhabitants.In that same year, the Ospedale Fatebenefratelli group in Milan decides too rganise an annual meeting dealing with: n y s t a g m o g r a p h y; proposed byAldo Dufour. Three years later, the University group proposes holding ajoint event A.O.O.I.-A.U.O.R.L.; this took the name of Giornate Otoneuro -logiche (Otoneurological Days), and, for many years, was the much a-waited Spring Meeting of the Society.In 1985, the Society becomes part of the Federazione Italiana delle Società

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Mediche (F. I. S. M.). In 1986,Italo De Vincentiis who thatyear organised the Congress inRome, made a gift to all partic-ipants of an anastatic copy ofDe aure humana by A n t o n i oMaria Valsalva, the original ofwhich is preserved in the ENTClinic of the University ofRome. In 1988, at the First E.U.F. O . S .Congress in Paris, the ItalianSociety was assigned a RoundTable and a Guest Lecture. Onthat occasion, Giovanni Mottaproposed Italy as candidate forthe 2n d E . U . F.O.S. Congress in1992, and the proposal wasaccepted. At the 2n d E . U . F. O . S .Congress held in Sorrento, in1992, all the participantsreceived a copy of I Cento A n -ni della OtorinolaringoiatriaItaliana, the volume prepared

by Dino Felisati for the Society’s Centenary.Between 1992 and the present day, little more than 12 years have elapsedbut the Italian Health panorama has changed completely. The ItalianNational Health Service is no longer able to guarantee free services,which are increasingly sophisticated and costly, to a population which isliving longer and has in ever-increasing need of health-care. Thus theprocess of hospitals becoming a business concern, is followed by re-engi -neering and the application of criteria of generic and specific appropri -ateness in carrying out routine duties on the wards. Progress in bio-med-ical research has been such that the Ministry of Health has introduced for -mation credits and approved the rules governing Continuing MedicalEducation. University and Hospital doctors are faced with the same diffi-

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26. - The volume edited, in 1992, by Dino Felisati tocommemorate the Centenary of the Society.

culties, since the Hospitals in which they work are financed by the Nati-onal Health Service. The doctor-patient relationship has lost its originalfeatures, the criterion of authority no longer exists and often the results ofthe doctor’s efforts are the object of legal disputes. The Hospital Doctorhas to endure difficulties which may arise when the patient contests him,society makes him out to be a criminal, accusing him not only of mal-practice. Furthermore, the responsibility of the organizational, and, some-times, also the technical choices has been transferred to the administrativebodies. The evident uneasiness is clearly shown not only by the decreasein the number of students entering the Medical University (the situation iscritical also in England: it has been estimated that a further 10,000 doc-tors are needed to meet the requirements of the National Health Service),but also by the fact that the profession is becoming increasingly female,as revealed by statistics that show a prevalence of the female sex in theUniversity lecture rooms. Within the clinical governance extraneous fig-ures have appeared, who, aware of their financial importance have a greatinfluence on the doctor’s work and on patient’s well-being. We cherish thehope that even though we live in a technologically and informatics-orien-tated society, we will still be able to maintain our clinical interest in thepatient, as has been the case for thousands of years in a purely humanworld. This is what the medical profession is all about.

S.I.O. e Ch. C.-F has very carefully monitored these transformations andoperated looking to the future, but, at the same time, continuing to remainfirmly anchored to its traditions.

The latest event, of special importance, which has marked the pace of theSociety’s life over the last few years has been the preparation of the 18th

International Congress of IFOS, which thanks to the dedication and prest-ige of Desiderio Passali, was assigned to be held in Rome, 25-30th June,2005. The President of S.I.O. e Ch. C.-F., Pasquale Laudadio, theExecutive Committee and the Society take this opportunity to expresstheir appreciation and heartfelt gratitude.

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PRESIDENTS (1892-2005)

S.I.L.O.R.

Vittorio Grazzi, Florence (1892-1895)Ferdinando Massei, Naples (1895-1897)Giuseppe Gradenigo, Turin (1897-1900)Giulio Masini, Genoa (1900-1903)Ferdinando Massei, Naples (1903-1905)Vittorio Grazzi, Florence (1905-1907)Vittorio Nicolai, Milan (1907-1909)Gherardo Ferreri, Rome (1909-1911)Camillo Poli, Genoa (1911-1913)Ferruccio Putelli, Venice (1913-1921)Carlo Biaggi, Milan (1921-1923)Giulio Masini, Genoa (1923-1925)Giuseppe Gradenigo, Turin (1925-1926)Federico Brunetti, Venice (1926-1928)Salvatore Citelli, Catania (1928-1930)Umberto Calamida, Milan (1930-1932)Guglielmo Bilancioni, Rome (1932-1934)Arnaldo Malan, Turin (1934-1936)Pietro Caliceti, Bologna (1936-1938)Luigi Umberto Torrini, Florence (1938-1940)Federico Brunetti, Venice (1946-1949)Giuseppe Vidau, Rome (1949-1951)Bruno Bruzzi, Naples (1951-1953)Giorgio Ferreri, Rome (1953-1955)Paolo Carcò, Bologna (1955-1957)Emilio Liveriero, Turin (1957-1959)Ernesto Pallestrini, Genoa (1959-1961)Franco Carnevale Ricci, Milan (1961-1963)Michele Arslan, Padova (1963-1965)Alfonso D’Avino, Naples (1965-1967)Carlo Felice Porta, Parma (1967-1969)Ettore Tavani, Lucca (1969-1970)Vincenzo Fortunato, Catania (1970-1971)Giuseppe Scalori, Pisa (1971-1972)Enrico De Amicis, Milan (1972-1973)Domenico Filipo, Rome (1973-1974)Giuseppe Bellussi, Rome (1974-1975)Mario Cherubino, Pavia (1975-1976)

S.I.O. e Ch. C.-F.

Giuseppe Borasi, Genoa (1976-1977)Pier Luigi Remaggi, Modena (1977-1978)Gianni De Vido, Treviso (1978-1979)Ettore Bocca, Milan (1979-1980)Ettore Clerici, Milan (1980-1981)Leopoldo Fiori Ratti, Rome (1981-1982)Dino Canciullo, Bologna (1982-1983)Ettore Pirodda, Bologna (1983-1984)Andrea Sellari Franceschini, Grosseto (1984-1985)Italo De Vincentiis, Rome (1985-1986)Dino Felisati, Milan (1986-1987)Carlo Calearo, Ferrara (1987-1988)Lucio Coppo, Rieti (1988-1989)Paolo Menzio, Turin (1989-1990)Gian Carlo Zaoli, Rimini (1990-1991)Giovanni Battista Catalano, Catania (1991-1992)Piero Miani, Udine (1992-1993) Giovanni Motta, Naples (1993-1994)Lorenzo Marcucci, Viterbo (1994-1995)Antonio Ottaviani, Milan (1995-1996)Giuliano Perfumo, Aosta (1996-1997)Paolo Puxeddu, Cagliari (1997-1998)Italo Serafini, Vittorio Veneto (1998-1999)Maurizio Maurizi, Rome (1999-2000)Giorgio Sperati, Genoa (2000-2001)Desiderio Passali, Siena (2001-2002)Enrico De Campora, Rome (2002-2003)Alberto Sartoris, Turin (2003-2004)Pasquale Laudadio, Bologna (2004-2005)

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49

The Headquartersof the Italian ORL Society

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III

THE HEADQUARTERS

The new Headquarters of the Italian ORL Society (SIO), situated in viaPigorini 6, Rome, were inaugurated on 30t h November 1991, the premiseshaving been bought with funds that the Society had destined for this pur-pose, over the years.This was an event of fundamental importance, a historical moment forSIO, since, finally, a long-standing dream of our predecessors had cometrue. This phase brought to an end a long period of a provisional characterand uncertainty.

The problem had, for a few years,been brought to the attention of theBoard but, despite awareness of theflorid economic conditions of theS o c i e t y, the fear of embarking upona financial operation which wouldnot be substantially remunerativehad always impeded its realisation.With time, however, any remainingdoubts were put aside and thanks,above all, to the enthusiastic eff o r t sof promotion on the part of Italo DeVincentiis, this programme metwith the full and unanimousapproval of the Society Members,at the General A s s e m b l y.These new premises, having beencompletely restored and adapted toSociety needs, were immediatelyprepared to permanently house the

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27. - Official Standard of the Italian Society ofOtorhinolaryngology-Head and Neck Surgery.

S o c i e t y ’s Secretarial and Treasury Bureaux, both of which operating withthe appropriate informatics equipment since 1986. A l a rge room is avail-able for periodic meetings of the Board of SIO as well as of the aff i l i a t e dSocieties. The Rome Headquarters have since been equipped to house also theLibrary and Historical Museum.The SIO has always had as a “top priority” duty, the promotion and diff u-sion of studies in the field of Otorhinolaryngology and the protection of theprofessional interests of its Members. A duty that has been carried out withdetermination and eff i c a c y, in over one century of the Society’s existence,in order to guarantee as far as possible the cultural updating of theMembers. In the realisation of this objective, a considerable contributionhas come from the Lectures, Round Tables and Main Lectures presentedeach year during the National Congress of the Society, the scientific pro-jects of the affiliated Societies, as well as of each member of the Societyand the publications in the journal Acta Otorh i n o l a ryngologica Italica –o fficial organ of the Society.Cultural updating of specialists, which was once left to one’s own initia-

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28. - Meeting Room.

tive, is now compulsory by law. SIO has, therefore, in respect of thesenew regulations, taken the necessary steps by appointing a Committee forContinuing Medical Education (Comitato per l’Educazione Medica Con -tinua) whose duty it is to ensure that the cultural manifestations of SIOand the Members have the qualitative requisites to be accredited accord-ing to the present law.

It is also the duty of this Committee to propose study and research pro-grammes aimed at the continuing formation of the specialist, such as, forexample, Up-dating Courses, Theoretical and Practical Courses,Congresses, Publications etc. to be prepared strictly adhering to the needsof the Members.The possibility of holding Theoretical and Practical Courses in our ownHeadquarters is currently under evaluation with a view to reducing to aminimum the expenses incured by members wishing to attend updatingcourses.

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29. - Inauguration of the new Headquarters in Via Pigorini, Rome.From the left: First row - Felisati, Calearo,Pezzarossa; Second row - Ottaviani, Miani, Perfumo,Zaoli, Catalano, Di Fede, Serra, Celestino, Laurini; Third row - De Campora, Arch. Ruspoli,Sperati, Coppo, Piemonte. (Photo by courtesy of Giovanni Ralli)

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31. - The Library.

30. - The Physiology Treatise of Albrecht von Haller (1769).

THE LIBRARY

In November 1991, at the Inauguration of the new Headquarters, theBoard assigned Domenico Celestino the task of organizing the Librarydestined to accommodate and preserve books, journals and documentswhich would witness the development of the Society.

To d a y, the Library, thanks alsoto the generous donations ofnumerous Members is endo-wed with hundreds of volumesof specialistic interest, some ofwhich, dating back to the 18t h

and 19t h Centuries, are of greathistorical interest. These incl-ude the works of M a e s t r i s u c has Haller, Cotugno, De Rossi,Mackenzie, Troesltsch, Nico-lai, Brunings, Gradenigo,Grazzi, etc., who have playeda determinant role in thedevelopment of our discipline.The Library also houses theProceedings of all the NationalCongresses of the Society, theProceedings of the Inter-national Specialistic Congresses as well as the completeseries of Acta Otorh i n o l a ry n -

gologica Italica, the official journal of the Society, since 1981, and otherimportant national periodicals of historical importance such as A rc h i v iItaliani di Laringologia, founded by Massei in 1881, Bollettino delleMalattie dell’Orecchio, della Gola e del Naso, founded by Grazzi in 1883,A rchivio Italiano di Otologia, Rinologia e Lary n g o l o g y, founded by DeRossi and Gradenigo in 1893 and Annali di Laringologia, O t o l o g i a ,Rinologia e Faringologia, founded by Masini in 1901.

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32. - The Italian Edition (1869) of the volume onOtology by Anton von Tröltsch.

THE MUSEUM

In 1998, the Board voted to set up a Historical Museum within theHeadquarters to house the collection of objects and instruments of thepast, witnessing the evolution of Otorino-Laryngology. The task of settingup and organizing the Museum was assigned to Giorgio Sperati.Within a few years, the Museum was considerably enriched thanks, aboveall, to the generous donations, by many colleagues, of objects from vari-ous periods.In coincidence with the 90th National Congress held in Rome, in May2003, Dino Felisati and Giorgio Sperati set up an exhibition, at theCongress venue, of antique instruments and volumes of particular signif-icance, belonging to the Society collections, which were arranged accord-ing to the specific topics.

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33. - Showcase in the SIO Museum in Rome.

Following the success of this exhibition, the two organizers decided todisplay the objects in the Museum, according to various themes. Whilstawaiting for all the objects to be set out according to these criteria the

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34. - Showcase in the SIO Museum in Rome.

antique instruments are currently displayed according to the followingtopics:• Evaluation of hearing function in the pre-audiological era• The Golden Age of tonsillectomy • Adenoidectomy in the early 20th Century• The origins of Laryngology • Evolution of mastoidectomy.• The first broncho-oesophagoscopies• A forgotten plague: diphtheria• Outpatient Units one hundred years ago.

For each of the cabinets containing volumes and intruments related tothese topics, cards have been prepared with a short historical note, pro-viding both general and specific information, to better understand the sig-nificance of the objects on display.The contents of these cards will be found in the following pages.

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35. - Brunton’s otoscope (SIO Museum - Rome)

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37. - Hélot photophore (SIO Museum - Rome).

36. - ORL instruments used by U.S. Army doctors during First World War. (SIO Museum -Rome).

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61

Themes on Exhibition in the Museum

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IV

EVALUATION OF HEARING FUNCTION IN THE PRE-AUDIOLOGICAL ERA

Hearing defects in the pre-audiological era were evaluated by estimatingthe subject’s ability to hear, at various distances and of varying intensity,a human voice, or other sounds, of predetermined frequency, emitted by

specific mechanical devices. Itwas an empirical and inaccurateevaluation, from a quantitativepoint of view, but, nonetheless,offered the possibility to performs u fficiently reliable diagnosticinvestigations throughout all the19th Century and the beginning ofthe 20th. The first tests were car-ried out with either a speaking or awhispering voice and with the useof a watch. Already in 1801, SirAstley Cooper (1768-1841), useda pocket watch, held at variousdistances from the ear beingexamined, to establish the entityof hearing loss and to decidewhether or not myringotomyshould be performed. The pocketwatch test was not standardized,

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38. - Sir Astley Paston Cooper (1768-1841)one of the first to promote paracentesis of thetympanum in tube obstructions (fromStevenson and Guthrie).

but each physician used his ownand compared the hearing levelof the patient with his own hear-ing. Various attempts were madeto propose particular instrumentssuch as Polansky’s watch (1842)with which the Viennese physi-ologist compared aerial andosseous perception, precedingR i n n e ’s test by 13 years, or theclocks of Schmalz (1846) or Rau(1856) which, moreover, werenot very successful. Tests, usingthe human voice gradually impr-oved with the improvement instudies on the various compo-nents of words carried out byPfingsten (1804), Itard (1821),but above all by Donders (1857)and by Helmholtz (1863). T h e s estudies led Oskar Wolf, fromFrankfurt, not only to propose adetailed classification of words,

in 1871, which was based on their frequency, but also to establish thresh-old values, which offered the use, for clinical purposes, of a sufficientlyreliable, but above all standardized, method, with which to carry out sta-tistical comparisons. The acoumetric examination used devices whichmechanically emitted sounds, at a given frequency. The most important ofthese instruments were the tuning forks which, for over a century, werethose most used by otologists throughout the world. The tuning fork wasinvented in 1711 by the English musician, John Shore (1662-1752), toobtain sounds with a constant high pitched tone which were easily repro-ducible. Its use, for clinical purposes, came about much later. The first touse it, in 1834, were the Weber brothers, Ernst (1795-1878) and Eduard(1806-1887), physiologists from Leipzig, demonstrating, with a low fre-quency tuning fork placed on the top of the head, the phenomenon of lat-

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39. - Albrecht von Haller (1708-1777), the greatestphysiologist of his time. His resonance theory wassimilar to that propounded by Helmholtz, morethan 100 years later.

otologist, promoted the use of the Weber test for clinical purposes and in1845 began to measure hearing acuteness with a tuning fork. Also EduardSchmalz (1801-1871), from Dresden, a student of Weber, was responsi-ble, between 1845 and 1850, for promoting the use, in otology, of theseinstruments which very soon became widespread.Other tests, besides that of Weber, were developed to determine whetherthe site of the hearing disorder was at transmission or perception level. Tothis end, Friedrich Heinrich Rinne (1819-1868), from Göttingen, set up atest, in 1855, focusing on the comparison between air and bone percep-tion, whilst Dagobert Schwabach (1846-1920), a student of Troeltsch andWurzburg and of Lucae in Berlin,proposed, in 1885, a test based uponthe duration of tuning fork percep-tion placed on the mastoid. Fromthe end of the 19th Century onwards,the tuning fork became an irreplace-able diagnostic tool used world-wide.In 1899, Giuseppe Gradenigo (1859-1926), in Turin, presented an inter-esting device to vary the oscillationsof the tuning fork, composed of twograduated metal bands inserted inthe tips of the prongs of the instru-ment: the invention was an immedi-ate success.At the beginning of the 20th Century,various research workers proposed aseries of tuning forks, each differingfrom the other. Those most usedwere the series proposed by Bezold-Edelmann which comprised 10 ele-ments calibrated on a frequency field ranging between 150 and 8700 Hz,and the series of Hartmann and Gradenigo, composed of 7 elements witha frequency ranging from 64 to 4096 Hz.As far as concerns hearing tests in the 19th Century, special instruments

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40. - Ernst Weber, Professor of Anatomy andPhysiology in Leipzig, in 1834, with hisbrother Eduard, demonstrated the phenome-non of lateralization of sound through thebone. This phenomenon had already beendescribed by Wheatstone in 1827 ( f ro mFeldmann).

were used, known as acoume-ters, which mechanically pro-duced sounds of calibratedintensity.The first apparatus of this typewas developed by ChristianWolke (1741-1825), in 1802,and consisted of a small oakhammer which, from a vari-able height and angle, hit ablock of pinewood. The mini-mum elevation necessary forthe sound produced to beheard was thus measured.Another similar acoumeterwas produced by Jean MarieItard (1775-1838) in 1821.This device comprised a pen-dulum with a swinging staff which produced a sound when it hit a copperring and, here again, the minimum change in the angle of the pendulum

required for the sound to be heardwas measured. Albeit, since thesepieces of equipment were cum-bersome and not very suitable forroutine diagnostic use, they weresoon abandoned. Adam Politzer(1836-1920) was responsible forthe development, in 1877, of asmall portable instrument whichsince it was extremely practicalwas highly successful for over 40years. It was held between thethumb and index finger of onehand whilst the small hammer hitthe small tube which produced acalibrated click.

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41. - Acoumeter of Adam Politzer which was heldbetween the thumb and index finger (b,b1) emitting acalibrated click when the small hammer (h) hit thesmall tube (c) (from Politzer, 1877).

42. - Galton’s whistle was used to evaluate theperception of acute frequencies (SIO Museum -Rome).

To evaluate severe hearing defects, in the high frequency fields, instru-ments emitting sounds higher than 4000 Hz were used, such as theKoenig sticks and especially the whistle of Galton and monochord ofStruycken. Sir Francis Galton (1822-1920), Charles Darwin’s cousin, had studiedmedicine but he dedicated his life to anthropology. In 1883, he had writ-ten an essay, Inquiries into Human Faculty, an area in which he hadthrown further light on the studies commenced, in 1820, by WilliamWollaston concerning the limits of the tone field.

In order to establish the upper limits of detectable frequencies, both inman and animals, he had a whistle made that would emit high frequencysounds. This instrument, on account of the simple design and smalldimensions, immediately became part of the diagnostic armamentariumof otologists, which later included the monochord, used for the same pur-pose.This device was developed, in 1910, by the Dutch Otologist, from Breda,H.J.L. Struycken and consisted, primarily, in a steel wire, with variabletension, able to produce a sound of approximately 5000 Hz.Following the modifications in the instrument, in 1911, by Schaeffer,physiologist from the Charitè Hospital in Berlin, it was possible to reacheven 25000 Hz.During the Otology Congress, in 1904, Politzer, Gradenigo and Deleauxclassified the acoumetric tests including them in the so-called AcousticSchema which should have led to uniform diagnostic criteria related tohypoacusia. This was based primarily on the vocal tests according toWolf, on attempts to establish the hearing threshold with the clock, theacoumeter of Politzer and the tuning fork and on the tests of Weber, Rinneand Schwabach which remained in use during the early decades of the 20th

Century and until the introduction of audiometrics.

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68

THE GOLDEN AGE OF TONSILLECTOMY

Hippocrates (5th Century BC) defined tonsils as “antiades” on account ofthe symmetrical oro-pharyngeal site and had already described this patho-logical condition, but had limited surgical treatment only to incision ofabscesses. For information concerning tonsillectomy, we must refer backto Celsus (First Century) who in theVII book of the De Medicina descr-ibed removal of the tearing away ofthe pedunculated tonsils with the fin-gers (digito circumradere et evel -lere) and for other cases, removalwith bistoury following anchoragewith a hook (hamulo excipere etscalpello excidere).Bleeding was treated by means ofrinsing with astringent solutions and,in the more severe cases, with caus-tic agents or with local cauterization.Intra- and post-operative haemor-rhage, at times even fatal, were typi-cal complications that for centuriesconditioned tonsillectomy. Aetius ofAmida (502-575) had, for this reasonadvised only partial removal of thetonsils and some Arab authors, suchas Alì Abbas (10t h Century) andAlbucasis (10-11th Century), despite

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43. - Aulus Cornelius Celsus (First CenturyAD) in the 7th Tome of “De Medicina”described, for what is believed to be the veryfirst time, tonsillectomy.

complete excision, cauterized the wound. Several famous leaders inRennaisance surgery, such as Ambroise Paré (1510-1590) and GirolamoFabrizi di Acquapendente (1533-1619) were, on the other hand, com-pletely against tonsillectomy which, in their opinion, gave rise to greater

risks than usefulness.Nonetheless, recurrence of inflam-matory suppurative episodes of thetonsils or peri-tonsil areas requiredthis treatment. To reduce the possi-ble risk of bleeding, use was madeof the snare which strangled thevessels of the peduncle whichenabled closure to be carried outmore rapidly than when a clean cutwas made with the bistoury. T h efirst to used ligature was a studentof Paré, Jacques Guillemau (1550-1613), followed, within a shortwhile, by many others. In the 18t h

Century the procedure of ligation ofthe peduncle was improved to per-fection primarily by Wi l l i a mCheselden (1688 -1752) who used aproper suture with the needle andthread passing first through one half

of the peduncle then the other. The Italian, Pietro Moscati (1739-1824),further improved this technique in 1759 employing four stitches ratherthan two. However, these steps, whilst guaranteeing better prevention ofhaemorrhage, gave rise, on the other hand, to other problems caused bythe cumbersome method and the habit of some to leave the tonsil to dropspontaneously due to necrosis. Thus the technique was used by very fewwhilst the majority remained faithful to dissection with bistoury and scis-sors and to cauterization of the wound.In the 19th Century, an important revolution took place with the advent ofguillotine tonsillotomy. This type of instrument, comprising two overlap-ping blades which ran one on the other and with a round or oval opening

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44. - Ambroise Paré, the famous CourtPhysician in France had always been againsttonsillectomy which he considered a uselessand risky operation.

at the tip, was derived from an identical instrument, the so-called kiotome,which in previous centuries had been used to amputate uvolas that weretoo long. It was to be a doctor in Philadelphia, with a degree fromEdinburgh, Philip Syng Physick (1768-1837), who, in 1828, presented atonsillotome which he had developed by modifying the kiotome of theScotsman Benjamin Bell (1749-1806). The tonsil which became impris-oned in the double ring was severed from the front to the back by the slid-ing blade, a rapid and relatively painful procedure. In 1832, William B.Fahnestock again modified the instrument inserting a two-pronged fork inorder to block the tonsil and inverted the sectioning movement which thusbecame from the back to the front and Albert Mathieu (1855-1917), thewell-known Parisian maker of surgical equipment, further improved thetonsillotome to the extent that it was used throughout Europe.Also Morell Mackenzie (1837-1892), with his indisputable authority inGreat Britain, used the tonsil guillotine and, in 1882, produced a simple

tonsillotome and a sec-ond one based uponthat of Physick.A further step forward,in this category ofinstruments, was madeat the beginning of the20th Century by a sur-geon from Chicago,William Ballenger,who, in 1909, devel-oped a new type ofguillotine. The follow-ing year, Greenfield

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45. - The kiotome, an instrument developed to amputate the uvola, from which all tonsillotomesand guillotines were derived (from L. Heister Chirurgie, Nuremberg 1763).

46. - The tonsillotome realized, in 1828, by Philip SyngPhysick (from Feldmann).

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47. - Tonsillotomes developed by Fahnestock, in 1832, and later modified by Velpeau and byMathieu (SIO Museum - Rome).

48. - The tonsil compressors devised by Mickulicz (above) and by Marshik (1914) used toarrest haemorrhage (SIO Museum - Rome).

Sluder from St. Louis, added a strong universal grasp which made it pos-sible to hold the instrument in one hand. The instrument produced bySluder-Ballenger associated the principle of the guillotine with that oftearing using a blunt sliding blade and digital disengagement, whichimmediately met with the approval of specialists throughout the world, afavour that remained unchallenged until recently. Use of this techniquewas destined primarily for use in paediatric patients, whilst in adults, dis-section with bistoury, scissors and snare with a Vacher-like metallic loopremained the procedure of choiceOther specialists such as the German Moritz Schmidt, Botey the Spaniardand the Pole Szendiak used, in the last decade of the 19th Century, dissec-tion with a galvanic loop, a technique proposed, in 1854, by AlbrechtMiddeldorpf from Breslau.A fundamental contribution to tonsillectomy was made with the introduc-tion not only of general anaesthesia with inhaling of ethyl chloride, a gaso ffering a very rapid induction effect and, likewise, rapid elimination, butalso of local anaesthesia by means of infiltration. These rather empiricalmethods which allowed only partial and temporary analgesia remained inuse for the first half of the 20t h C e n t u r y. After the Sixties, use of generalanaesthesia with gas and oro-tracheal or rhino-tracheal intubation,relieved surgery from the need to complete the operation too rapidly.

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74

ADENOIDECTOMY IN THE EARLY 20th CENTURY

The clinical importance of the adenoids was demonstrated by WilhelmMeyer (1824-1895), the father of Danish Otology. He was the first in his-tory to perform adenoidectomy, thus paving the way that was soon to befollowed by otorhinolaryngologists all over the world. Mayer was a gen-eral physician who had dedicated his time to the study of ear disordersand had opened a private clinic in Copenhagen specializing in these dis-eases. On 22nd October, 1867, he examined a young peasant who, since

childhood, had complained of fair-ly severe hypoacusia and a nasalobstruction that could not, howev-er, be accounted for by rhinologi-cal disorders.Upon digital exploration of therhinopharynx, which, in thosedays, was not a common proce-dure, Meyer noticed that the areawas completely filled with tissueof a soft consistency, with an irreg-ular surface which appeared tooriginate from the superior and lat-eral walls. He, therefore, had aslim instrument made, with a cut-ting ring-like tip which he used inthe attempt to remove the neofor-mation. The adenotome, intro-duced through the nasal cavities

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49. - Wilhelm Meyer carried out the firstknown adenoidectomy in history, in 1867, inCopenhagen.

enabled him, with repeated movements to free the rhinopharyngealobstruction while the abundant bleeding was stopped by rinsing with coldwater and the use of caustic agents. The brilliant results obtained, with areturn to normal of breathing and improvement in hearing, led Meyer tosystematically proceed with digital exploration of the rhinopharynx in theattempt to find other analogous cases and, to his surprise, he realised thatthe presence of that hypertrophic tissue, which he defined as adenoid veg -etations, was not in the least a rare occurrence and within a few monthshe had already found as many as 48 cases.Meyer’s publications led to considerable enthusiasm amongst the Europ-ean Otologists and great interest was focused on the problem of adenoiddisorders not only on account of the repercussions on hearing and respi-ratory function but also upon psycho-physical development in the young.Meyer himself carried out numerous statistical studies, in this respect, onDanish, Swedish, German, Dutch and Italian school-age populations. Theinfluence of the adenoids on the psycho-physical development of adoles-cents was soon considered unquestionable (Guye from Amsterdam coinedthe term Aprosexia, especially as far as concerned the changes in the

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50. - Ethyl chloride, inhaled by means of the mask proposed by Esmarch, was very much usedin adenoidectomies since it induced a rapid, even if only brief, anaesthetic effect.(SIO Museum - Rome)

development and configuration of the upper maxillary bone, studied indepth by Michel in 1876, by Jarvis in 1885, by Delavan, in 1887, and byGleitsmann, in 1897).After the 1870’s, throughout Europe of the 19th Century, a crusade waslaunched against hyperplasia of the rhinopharyngeal lymphatic tissue,histologically described by Lusschka, in 1868, and adenoidectomies mul-tiplied enormously and, consequently, also the surgical techniques andinstruments. Via the nasal approach, Meyer’s curette was being used, thesnare of Chiari, that of Zaufal and the galvanocautery, but this type ofapproach was of little success and the oral route was preferred usingMotais’ surgical nail (a thimble-like cutting device fixed to the tip of theindex finger), the pincers of Loewenberg and, above all, the curvedcurettes which were the most used instrument. Of these, it is worthwhilementioning the adenotome designed by Moritz-Schmidt, the laterallycurved model of Hartmann, as well as that of Gottstein.To avoid fragments of tissue from slipping down during the operation, theso-called basket adenotomes were proposed (Gottstein, La Force) withwhich the part removed was trapped by the instrument.For several decades, adenoidectomy was the operation most carried out in

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51. - Adenotome of La Force (SIO Museum - Rome).

the otorhinolaryngology setting. Quite often, however, incorrect indica-tions led to this practice becoming overtreatment. Not everyone agreedwith the exaggerated use of these operations and, already in 1877, theViennese Clinician Leopold Schroetter stigmatized how excessive thiswild surgical enthusiasm had become towards a disorder, the importanceof which had, in his opinion, been overrated. Despite adverse opinions, which were rare, adenoidectomies continued tobe practised, on a large scale, for a long time, offering the specialists,moreover, substantial economic advantages. In this regard, a phrase fullof significance was written by Jonathan Wright, in 1914, in his History ofLaryngology and Rhinology referring to Wilhelm Meyer and his discov-ery: …he has furnished a subsequent generation of rhinologists with theirmost lucrative source of income.

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ORIGINS OF LARYNGOLOGY

Laryngology, as a medical discipline, originated in Vienna, between 1857and 1859, thanks to an Austrian neurologist, Ludwig Türck, and a Cze-choslovak physiologist, Johann Czermak, who introduced, to clinicalstudies, the most useful and efficacious means with which to carry outindirect laryngoscopies: the laryngeal mirror invented, three years earlier,by the Maestro of song, ManuelGarcia.E n d o s c o p y, the possibility toobserve in vivo the characteristicsof the hidden organ, was the indis-pensable condition with which todevelop new specialities such asrhinology, urology and also laryn-gology.Throughout the 19th Century, vari-ous attempts had been made torealize polyvalent endoscopes,from the l i c h t l e i t e r of Bozzini(1806) to the glottiscope ofBabington (1829), from the poly-scope of Avery (1844) to that ofWarden (1844), but none of thesehad led to satisfactory results forlaryngoscopy.Even the attempts of Cagniard DeLa Tour (1825), and of Liston

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52. - Ludwig Türck, in 1857, was the first toadopt the indirect laryngoscopy methodinvented by Manuel Garcia (from Reuter).

(1837), with the dentist’s mirror, led to negative results, since theyallowed visualization of only part of the epiglottis.The invention of Garcia, in 1854, was, instead, of fundamental impor-tance, even if, at the beginning, the possible clinical applications were notcompletely understood. It was Ludwig Türck (1810-1868), from the VIMedical Division of the Allgemeinen Krankenhaus in Vienna, who, in theSpring of 1857, began to experiment the use of the laryngeal mirror inneurological patients employing sunlight as the source of light. Once

Winter came, with fewer days ofsunshine, the clinical investiga-tions were temporarily abban-doned. Taking advantage of thisoccasion, Johann Nepomuk Czer-mak (1828-1873), who, in Vienna,worked with Brücke and Ludwigthe promoters of Neuephysiologie,asked to borrow the instrument forexperiments of a physiologicalnature.He immediately realized the greatpossibilities available with theapplication of the laryngeal mirrorand became an enthusiastic pro-moter. He immediately made use ofartificial light and already in March1858 published, in the Wi e n e rMedizinische Wöchenschrift, areport on the technical aspects of

this instrument. In 1859, he continued his propaganda work visiting themost important European Clinicics, arousing, everywhere, the enthusiasmof many colleagues, such as, Mackenzie, Ye a r s l e y, Lewin, Tobold, Moritz-Schmidt, Gerhardt, Voltolini, Fauvel, Moura-Bourillou, and others, wholaunched larygoscopy in their countries.The success of Czermak provoked, as might be expected, the resentmentof the very reserved Türck, who felt that he had been defrauded of the pri-ority in this field. Thus a dispute began between the two that lasted for

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53. - Johann Czermak who was responsible forhaving promoted the technique of laryn-goscopy throughout Europe.

many years and which was remembered with the name of Türckenkrieg(the Turkish war or the Türck war) to which each of them contributed,making, from time to time, important technical innovations as far as con-cerns both the examinationand the instruments. Thus itwas not a useless dispute,only for the sake of argu-ment, but, involving generalinterest, played a definiterole in the success of laryn-gology.There can be no doubt, onthe one hand, that the meritof having commenced exper-iments belonged to T ü r c k ,while, on the other, the roleof Czermak was equallyimportant for having pro-moted the method through-out Europe, and both gainedrecognition, in this respect,to the extent that during theFirst International Congressof Laryngo-Rhinology heldin Vienna, in 1908, a com-memorative medallion was prepared, dedicated to both, as promoters oflaryngology. In 1860, Czermak transferred to Pest, where he had beenassigned the Chair of Physiology, while Türck remained at the GeneralHospital of Vienna with the title of Lecturer of Laryngology from 1861and Associate Professor of this subject from 1864. Upon his death, fromtyphoid fever, in 1868, his work was continued by his students CarlStoerk (1832-1899) and Leopold Schrötter von Kristelli (1837-1908).The latter remained to direct the Unit of the General Hospital where, in1870, the first Laryngologic Clinic was officially inaugurated with 16beds, while Stoerk became the Director of another important institution,the Ambulatorium für Laryngologie. In 1872, Vienna had a third centre:

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54. - Carl Stoerk, with Schrötter and Schnitzler, con-tinued the work of Türck and Czermak, promoting theprestigious School of Laryngology in Vienna.

the Laryngological Service of the Allgemeinen PoliklinikK, Head ofwhich another illustrious person, Johann Schnitzler (1835-1893).Vienna was, therefore, unquestionably the world centre of this new disci-pline and students rushed there, from all over the world, not only to learn,but also for advanced training, as for example, the American Elsberg, theRussian Rauchfuss, the Spaniard Ariza, the Italians Labus, Gentile and

Massei who were then tobecome the first and mostimportant experts, in thisfield, in their own coun-tries.Schnitzler reported thatfrom 1872 to 1876, forhis courses, he had had,in his Institute, about 500students of whom 11 8from the United States,10 from Asia and 2 fromAustralia thus demon-strating the enormousand universal interest inthis new discipline inthose pioneering years.On the other hand, itshould not be forgottenthat Vienna, throughoutthe second half of the 19th

Century was the Worldcapital not only of thenew specialities but ofMedicine as a whole.As already pointed out,the evolution of Laryng-

ology depended mainly upon the progress of laryngoscopy and perfectionof the technical aspects was one of the primary aims of the specialists.The main problem was that of finding suitable sources of light as well as

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55. - The Clinical Atlas of Laryngologie appeared in 1895,two years after the death of Johann Schnitzler.

the means by which to converge thelight rays on the mirror. For over 20years, all kinds of proposals werecontinuously put forward by theexperts in this specialty. As sourcesof light, almost all types of inflam-mable means available, at that time,were used: passing from candles topetroleum or paraffin lamps, fromthe Argand gas lamps to those ofAuer which besides burning gas,burned a mixture of lanthanium andzinc oxide, from the Drummondburners providing oxy-hydrogenlight to those using acetylene ormagnesium. The inflammable sub-stance most used was, nonetheless,gas which was by then available, inall homes. After 1880, the advent ofthe small electric light bulbs resultedin considerable progress since it

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57. - The portable laryngoscope invented by Krishaber (SIO Museum - Rome).

56. - The “cobbler’s lens” comprised a glassjug full of water which was used to concen-trate light rays (from Stoerk).

enabled the use of direct (Hélot, Trouvé) or reflex (Roth, Clar) light pho-tophores and, furthermore, paved the way for the affirmation of broncho-oesophagoscopy (Killian, Brunings) and of direct laryngoscopy(Kirstein).To concentrate the light rays on the laryngeal mirror, convex lens or con-cave mirrors were used. From the simple lens of the cobbler, a glass jugfull of water, to the appliances with multiple lens of Fauvel or of Moura-Bourillou to the portatable laryngoscope of Krishaber, the converginglens, albeit, had short-lived success and, with time, reflex mirrors werepreferred. Some of these were held by fixed (Stoerk, Lleiter) or folding supports

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58. - Reflection mirrors: with straight handle (Hofmann, Troeltsch), angulated handle (Lucae),with a support for the teeth (Czermak), fixed to spectacles (Semeleder) or to a headband(Kramer).

(Türck), but quite soon preference was shown for those with a less accen-tuated concavity and bored through the centre in order to allow both thevisible and the luminous rays. These had a handle which could be heldwith one hand (Garcia) or between the teeth (Czermak), or could be fixedto the head by means of spectacle frames (Semeleder) or a band aroundthe forehead (Kramer, vonBruns) and, indeed, the latterwas to become the most suc-cessful type of reflection mirrorand was used for almost a cen-tury.Laryngology, at the beginningwas a medical, and not a surgi-cal, speciality like Otology, butthe first Laryngologists werenot contented with simpleobservation and began immedi-ately to dedicate their time toendoscopic manipulations. A tfirst, these were only instilla-tions, medications with causticsolutions using the appropriatetampoons and syringes, but asthey became more expert theysoon went on to perform smalloperations such as polypectomy. These manipulations becamemuch easier following theintroduction of local anaesthesia by contact with cocaine solutions intro-duced in Vienna, in 1884, by Edmund Jelinek (1852-1928). T h eSpeciality proceeded from that time onwards acquiring increasing auton-omy, leaving behind the initial empirism.

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59. - Edmund Jelinek, in 1884, experimented, forthe first time, with local anaesthesia by bringingcocaine solutions into contact with the pharyngealmucosa.

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EVOLUTION OF MASTOIDECTOMY

Mastoidectomy, practised for leaking disorders of the middle ear, was offundamental importance for Otologists, especially in the second half ofthe 19th Century and in the first half of the 20th. Albeit, the history of mas-toidectomy began much earlier: it is well known, in fact, that Jean Riolan(1580-1657) in Paris, was the first to propose drilling of the mastoid, in1649, who, nonetheless, prescribed it for the treatment of tinnitus anddeafness, but not for the leaking forms.

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60. - Traité de l’organe de l’ouie (from Jacques Duverney - Paris 1683).

At that time, otorrhea was considered a product of brain excretion untilJoseph Duvernay (1648-1730), author, in 1683, of the famous Traité del ’ o rgane de l’ouie containing splendid, detailed illustrations of the anatom-ical structures of the ear, showed that the purulent secretions wereautochthonous in these structures and not derived from the encephalus.Duvernay was also the first to describe cholesteatoma and, at that sametime, Marcello Malpighi (1628-1694) reported finding, in a patient who haddied from a brain abscess, the presence of caries in the bone in the homo-lateral middle ear. Surgeons then focused attention on otitic suppuration,attempting treatment to, at least, prevent complications, for the manage-ment of which, already since very early times, attempts had been made todrill the skull. Jean Louis Petit (1674-1750), in 1736, carried out the firstoperation on the mastoid for the presence of discharge. The outcome wassuccessful and this operation was followed by many others. In 1776, Jasser, a Swedish surgeon of Prussian origin, successfully oper-ated a young deaf otitic patient which not only cured the otitis but led torecovery, in part, of the hearing. This led Jasser to extend the indicationsof mastoidectomy to all cases of deafness. The theories and results of

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61. - A typical bone drill that would have been used at the end of the 18th Century.(SIO Museum - Rome).

Jasser spread rapidly and operations of mastoidectomy greatly increaseduntil a famous victim diminished the enthusiasms of many. Von Bergen,personal physician to King Christian VII of Denmark, who had, for sometime, suffered from progressive deafness, tinnitus and dizziness, inform-ed of the success obtained by Jasser, convinced his colleague, the CourtSurgeon, Koeplin, to perform drilling of the mastoid in 1792.Unfortunately, the patient died 12 days later, following surgery formeningo-encephalitis. The news spread throughout Europe on account ofthe famous people involved and this contributed greatly to drilling of themastoid being abandoned in the attempt to cure deafness.Therefore, this surgical proce-dure was, after the beginning of19th Century, destined only forthe treatment of discharge dis-orders even if criticism wasexpressed for its use, also inthese cases.Even Jean Marie Itard (1775-1838), in 1827, supported thosewho were contrary, on princi-ple, to this type of surg e r ywhich he considered totallysuperfluous. Studies on chronicotitis and related complica-tions, nonetheless, continuedand Jean Cruveilhier (1791-1874), in 1828, and JohannMuller (1801-1897), in 1830,defined the characteristics ofcholesteatoma or pearl-like tumour and, slowly, attempts were made toprogress also from the surgical viewpoint. William Wilde (1815-1876),who initiated Otology in Great Britain, in 1853, proposed cutting behindthe ear, a procedure that was named after him, to evacuate the surfacemastoid pus, and, at the same time, Alfred Velpeau (1795-1867) estab-lished the indications which justified opening the mastoid, but it was to beAntonin von Troeltsch (1829-1890) who carried out, in 1861, the first

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62. - Sir William Wilde who launched Otology inGreat Britain.

mastoidectomy in the way that it is known today, a surgical procedurecodified more precisely by Hermann Schwartze (1837-1910), in 1873,both as far as concerns the technique and the indications which until thenhad remained somewhat vague. Simple mastoidectomy was a kind ofextended anthrotomy, destined essentially for use in acute oto-mastoidi-tis, but not sufficient for the cholesteatomatous forms. For the latter, sur-geons from Berlin, namely, Ernst von Bergmann (1836-1907) and Ernstvon Kuster (1839-1930), in 1888, developed a radical operation which,with copious demolition, allowed eradication of the osteitic lesions and agood approach to treat eventual endocranial complications. To allow ade-quate viewing of this large cavity in the post-operative period, LudwigStacke (1859-1918), from Erfurt, and Schwartze himself began to carryout meatoplasty.

Radical mastoidectomy was the treatment of choice for almost 70 yearsleading to a successful outcome in the majority of the osteitic and chron-ic suppurative processes but resulted in sacrificing the middle ear whichconsequently meant permanent severe damage to hearing. Otologists,therefore, immediately faced solving the problem of preserving hearing;this led to the development of the so-called modified radicals which were

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63. - Mastoidectomy with gouges and hammer (from Laurens).

intended to safeguard the function of the transmission apparatus. The firstattempts go back to 1889 with Otto Koerner, in Wiesbaden, and to 1906with Charles Heath, in London, and William Bryant, in New York.By the beginning of the 20th Century, mastoidectomy was a well-codifiedoperation, in all the various forms, as well as in all the indications andnecessary surgical instruments.The manual drill had been abandoned already 20 years previously andosteotomies were carried out with scalpel and curettes of various shapesand sizes and with these apparently clumsy instruments Otologists gainedmanual expertise which enabled them to carry out even delicate proce-dures, in very little time, with the technique of a master. After the SecondWorld War, treatment with antibiotics, the use of the surgical microscopeand the development of increasingly sophisticated reconstructive tech-niques, paved the way to Otological Surgery which had become increas-ingly less invasive and more functional, finally closing the great demoli-tive operation of the mastoid period, forever.

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BIRTH OF BRONCHO-OESOPHAGOSCOPY

The practice of direct oesophagoscopy preceded, by about 20 years,the manoeuvres aimed at exploring the bronchial apparatus. In fact, theearly positive experiences of Adolf Kussmaul date back to 1868, when,modifying the endoscope of Desormeaux, he managed to diagnose a

carcinoma of the middle third ofthe oesophagus.Both before and after that date,many attempts had been made -with somewhat disappointingresults - to perform indirectoesophagoscopies, employingvarious instruments (Semeleder1866, Stoerk 1866, Bevan 1868,von Schrotter 1875, Nitze andLeiter 1879, Morell Mackenzie1879). In 1880, Johann vonMickulicz managed to performthe first gastroscopy, using as alight source the electric light ofLeiter, the essential componentsof which were a red hot platinumthread and water for cooling.The reason why exploration ofthe digestive tract preceded thatof the respiratory tract was due to

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64. - Adolf Kussmaul (1822-1902) wasDirector of the Medical Clinic in Erlangen andthen in Freiburg. He meticulously studiedpathophysiological problems related to gastro-oesophageal disorders, and for which, to betterhis understanding, he performed the very firstoesophagoscopy (1868).

the different tolerability to thetwo types of manoeuvre relat-ed to the different tolerabilityof the zones stimulated. Therespiratory mucosa obviouslyreleased much more vivaciousreflexes. Playing a determinant role inovercoming this impasse wasEdmund Jelinek who, in 1884,in Vienna, introduced, inE N T, local anaestheia bymeans of contact with solu-tions of cocaine, thus enablingendoscopic evaluation to be

extended to the aero-digestive tract in all patients. These investigationshad previously been limited to sub-jects with hyporeflexia.It was in a patient with severepharygo-laryngeal hypoextesia thatAlfred Kirstein, in 1895, per-formed the first direct laryn-goscopy which he called a u t o -s c o p y. The larynx was easy toexplore in the indirect fashion bymeans of a simple mirror; this wasnot the case for the trachea andbronchi. Doctors and Laryn-gologists, therefore, focused theirattention on inventing instruments,suitable for this purpose.The first medico-surgical act on thelower respiratory tract was carriedout, in 1897, by Gustav Killian in

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65. - Oesophagoscope of Morell Mackenzie.Indirect vision and poor dilatation of theoesophageal folds limited its use (from Willemot).

66. - Mickulicz-Leiter gastroscope (fromBrunings).

Freiburg. Using an oesophagoscopic tube, he managed to extract afragment of bone which had become embedded in the right bronchusand baptized the manoeuvre with the name that it was to keep forever:bronchoscopy.From then onwards, new horizons were available to medicine, partic-ularly Otorino-Laryngology which could thus considerably broaden itscompetence. The examinations carried out by Killian, in this new fieldof study, rapidly multiplied and hundreds of bronchoscopies were per-formed in his clinic, either under local anaesthesia with the patient ina sitting position, or under general anaesthesia, with the patient in thesupine position.Whilst recognizing the great authority of Killian in this field, thegreater merit for having spread the use of bronchoscopy throughout theworld goes to his best known pupil: Wilhelm Brunings (1876-1958).The instruments that heinvented and which were pro-duced by Pfau in Berlin have,for more than 50 years, beenpart of the armamentarium ofevery ENT Unit, the worldover.Brunings introduced the shortbronchoscopic tubes, with aninternal telescopic-type length-ening, and the oesophagealtubes with a blunt end, obliqueand cut in the form of the flutemouthpiece. The lighting sys-tem, using a bulb, was incor-porated in the handle of theinstrument and remained, wasstill, in the early 20t h C e n t u r y,considered as progress, withrespect to the frontal pho-

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67. - Title page of the famous text of Bruningswhich played a fundamental role in the widespreaduse of broncho-oesophagoscopy techniques.

tophore used by Killian, Guisez, Ledoux, von Schroetter and others.Nonetheless, this system represented an obstacle for the introductionof instruments for endoscopic manoeuvres, and, therefore, Hasslingermodified the original handle designed by Brunings, moving the lightsource to a slightly lateral position. Further progress was made in1899, thanks to Chevalier Jackson in Philadelphia. Jackson was the first to introduce distal illumination by inserting a

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68. - The Cauzard and Chevalier Jackson tube with distal lighting from a minute lamp insert-ed on a sliding rod. This was greatly appreciated on account of the excellent viewing conditionsit provided (from Laurens).

70. - Oesophagoscopy with the Guisez tubeand Clar mirror. There are clearly difficultiesto be overcome to achieve good distal illumi-nation with this technique (from Laurens).

69. - The universal handle invented byBrunings and produced by Pfau with theincorporated light source. (SIO Museum - Rome).

small lamp, mounted on a thin rod, which ran along a small canal inthe lateral wall of the endoscopic tube. This new modification left theproximal opening of the tube itself completely free and provided amuch better light. Jackson’s instrument was then further perfected inLondon, after the First World War by Sir Victor Negus. Thanks to theintuition of these great pioneers, the instrument and the bronchoscopytechnique were already codified in the early 20th Century and remainedalmost unchanged for more than half a century until the introduction ofthe modern optic fibres.

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72. - Oesophagoscopy in the Mouret posi-tion. Mouret invited his patients to pretendthey were leaning on the window sill talkingto their neighbour, opposite on a higher floor( f rom Laure n s ).

71. - Oesophagoscopy in the Bensaude posi-tion to improve viewing, completely disre-garding patient comfort (from Laurens).

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A FORGOTTEN PLAGUE: DIPHTHERIA

Diphtheria had, for centuries, appeared only as sporadic or endemic mani-festations, but at the end of the 16th Century, it devastated Europe (in par-ticular, France, Spain, Italy and Scandinavia) with periodic spreading of

very severe epidemics whichdecimated primarily the paedi-atric population.Laryngeal localization was thatmost dreaded and, unaware ofthe causes, it was considered asa disease in itself and called, inthe various countries, by differ-ent names (morbus strangula -torius, suffocatio stridula, maldi gola affogativo, suffocatinga n g i n a , mal del garro t i l l o,etc.), but all having one symp-tom in common: suffocation.The name croup was attributedto this morbid form only in1765, by Francis Home, havingderived the expression from aScottish verb to croop (stran-gle).The only treatment possiblewas tracheotomy, despite thehigh rate of intra-operative

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73. - Tracheotomy in the 18th Century. Illustrationfrom the Surgical Treatise by René C. de Garengeot(from Guerrier).

mortality (more than 80%) whichfor a long time limited its use.For more than two centuries, theperiodic epidemic exacerbationsof this morbid condition spreadterror amongst the populations,without any progress being madeas far as concerned the diagnosticand therapeutic aspects. In 1807,Napoleon Bonaparte launched aninternational award, with 12,000Francs in gold as the prize towhoever contributed to a betterunderstanding of croup.This project had been determinedby the death, at only 5 years old,of the Crown Prince of Holland,nephew of the Emperor.None of the 79 contributions pre-sented for the award led to anyreal progress in the understandingof the disease; a new phase com-menced in 1826, when Pierre

Fidèle Bretonneau published the results of his observations during the dis-astrous epidemics that struck Tour and the surrounding region between1815 and 1821.Finally, Bretonneau clarified that the pharyngeal form, which was lighter,and the laryngeal form, which was more severe, were not two indepen-dent morbid conditions, as had previously been held, but localizations ofa same disease that he called diphtheria (from the Greek diftera = mem-brane) due to the presence of the pseudomembrane characteristics.In this regard, it should not be forgotten that, already in 1749, the Italianfrom Cremona, Martino Ghisi, had drawn attention to the typical charac-teristics of the pseudomembranes.Bretonneau greatly stimulated the use of tracheotomy as the only meansby which to save patients from suffocation and, in this regard, also pro-

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74. - The famous writings of 1826 in whichBretonneau put forward his theories which wereto revolutionize the convictions of those times.

posed new instruments such as thecurved cannula with contra-cannula,the tracheal retractor, etc. It was tobe his pupil, the great A r m a n dTrousseau, who codified the tech-nique of the surgical procedure, as itis known today.Trousseau had the great merit ofestablishing that tracheotomy shouldbe carried out as soon as possible,and not at the last moment as hadbeen the case for centuries, thusachieving a considerable reductionin the intra-operative death rate.

Laryngeal intubation

In the mid 19th Century, tracheotomywas still the only form of effectivetreatment for the laryngeal localisa-tion of diphtheria, but it was associ-ated with severe risks of complica-tions and, therefore, less invasiveapproaches were sought in theattempt to maintain the larynxviable. The intubation era had thusbegun. The first attempt to adopt thismethod for croup was made by thefamous surgeon Friedrich Dieffen-bach, in Berlin, in 1839, but resultswere disappointing. Albeit, heraldedas the real inventor was the French

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76. - Joseph O’Dwyer (1841-1898) perfect-ed the laryngeal intubation technique incroup and was responsible for it becomingused throughout the world. He died afterbecoming infected by one of his smallpatients.

75. - Armand Trousseau (1801-1867), themost ardent sustainer of tracheotomy, defin-itively codified the technique.

paediatrician Eugène Bouchut who, on 18th September 1858, presented hisintubation method, at the Medical Academy in Paris, which consisted inthe introduction in the larynx, of a small metal tube.The method, unfortunately very traumatic, was met with great scepticismby the Members of the Academy (only Malgaigne defended him) but,above all, after the very harsh words of Trousseau, it was totally rejected.Disappointed, Bouchut went into retreat, giving up the idea to make thosetechnical changes which would have made laryngeal intubation easy toperform. Those modifications were, instead, realized years later, in 1885,by the paediatrician in New York, Joseph O’Dwyer.

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77. - The laryngeal intubation technique: the tube was made to slide along the index finger ofthe left hand which hooked and fixed the epiglottis (from Laurens).

78. - Intubation set of Egidi-Ferroud (SIO Museum - Rome).

The instruments designed by O’Dwyer, as well as the technique he pro-posed for intubation, were soon highly successful not only with paedia-tricians but also laryngologists, first in USA, then Europe where variouschanges were made (Egidi, Ferroud, Collin, Aviragnet, Weil, Perez,Valagussa, Citelli etc.), to the original instrument, none of which substan-tial.Use of this technique became very widespread, between 1890 and 1925,for the treatment of children with croup and, in the majority of cases, tookthe place of tracheotomy.From 1925 onwards, thanks to the progress made in bacteriology andimmunology, the incidence of diphtheria gradually dropped, until italmost completely disappeared, in the more developed countries.Following the discovery of the bacterium responsible (Klebs 1883,Loeffler 1884) and of the anti-toxin (Behring and Kitasato, 1890) whichtriggered serumtherapy, until the introduction of the anatoxin (Ramòn1923) which led to the possibility of mass vaccinations, the medical treat-ment for the infection of diphtheria had finally won, after centuries, ofthis severe plague.

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79. - Intubation of a small patient with diphtheria performed by Dr. Josias (Paiting by Chicotot,Paris, Musée de l’Assistance Publique).

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OUTPATIENT UNITS ONE HUNDRED YEARS AGO

Otorhinolaryngology was born, as is well known, in the second half of the19th Century from the union of Otology (a branch dealing primarily withsurgery) with Laryngology (medical speciality) to which Rhinology hadsome time later become associated.The anatomical relationship upon which this union was founded, wasalready evident when, in 1868, Czermack began to explore the rhinophar-ynx where the tubes converge, the nasal cavities and the pharynx. It wasat that time that our Speciality originated, even if several years were to goby before it became official.

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80. - Tobold apparatus (1887) comprised a petroleum lamp, the light of which was concentrat-ed, reaching, by a system of mirrors and lens, the reflecting mirror (from Reuter).

The practical activity of the new specialists, from 1880 to the beginningof the 20th Century was carried out mainly in the Outpatient Unit and onlyin a few cases in specific Hospital Divisions.The Outpatient Units, whether private or set up by public institutions,

were, for a long time, where Otorhino-larygology procedures, concerning diagnosisand treatment, were performed.How would a specialistic Outpatient Unithave been organized in the period betweenthe 19th and 20th Century and what structureswould have been available?Since a synthetic description is warranted, aschematic outline will be given which, whilstunacceptable from a literary viewpoint, is nec-essary in order to proceed chronologically andto provide as much data as possible.

Diagnostic activity

In order to explore the organs related to ENTcompetence, it was necessary to have not onlyadequate endoscopic equipment available,

but, above all, valid sources of light. The medical literature from the 19t h

Century refers to a vast number of instruments, of valves, specula andlights which used all kinds of inflammable substances: such as gas, acety-lene, petroleum, paraffin, magnesium, oxygen and hydrogen mixtures, etc.The main problem was availability of an adequate light source as well asto be able to concentrate the rays on the cavity to be examined by meansof lens and mirrors. Sunlight was the first to be used, but for obvious reasons, was not alwaysavailable and, therefore, it was necessary to use lamps. The first inflam-mable substance to be used for lighting was gas which, at the end of the19th Century, was available in almost all homes and was used in prefer-ence to others such as magnesium or acetylene, which gave a brighterlight, but ran the risk of deflagration. The explosion of one of these lamps,fortunately not involving any people, but which destroyed the surgery of

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81. - Transillumination of theparanasal sinuses (diaphano-scopy) introduced by Hering,Cozzolino and Voltolini in about1890 was for a long time a validdiagnostic tool.

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Fraenkel, in Berlin, caused agreat sensation. The gas wasused either alone or associat-ed with other inflammablesubstances, such as in theAuer lamp, which burnedcotton wool soaked in a solu-tion of zinc oxide and lantha-nium.The arrival of the electricbulb (Edison 1879) offeredthe OtorhinolaryngologicalOutpatient Unit a new impo-rtant means of illumination,even if should not be forgot-ten that, before it becamefully accepted, several yearswere to go by. Due to thehigh costs of electric light, itwas used by only a few, and,at least until the early part ofthe 20th Century, traditionalsources of light continued tobe used. Small bulbs (m i -gnon, 1880) led to the development of practical diagnostic instruments,such as photophores (Hélot-Trouvé, Killian), headband mirrors (Clar,Kirstein, Roth), equipment for transillumination (Héring, Vo l t o l i n i ,Cozzolino), endoscopes (Killian, Brunings, Mickulicz, Nitze-Leiter).

Functional diagnosis

Whilst inspection of the areas of ENT interest represented the major partof the diagnostic workup in the Outpatient Unit setting, it should not beforgotten that, at the end of the 19th Century, this was integrated with func-tional evaluations which following the empirism of the initial phases,gradually acquired an increasingly safer reliability. Exploration of hearing

82. - Headband mirror of Clar with sagittal support andthat of Kirstein-Killian (from Citelli).

function, for example, was nolonger carried out only with awhispered or spoken voice orwatch tests, but with the useof instruments such as thetuning fork of Hartmann, theacoumeter of Politzer, thewhistle of Galton, the mono-chord of Struycken etc.At the end of the 19th Century,the acoumetry phase thusbegan; it was no longer suffi-cient to reveal the deficit, italso had to be measured.It was also during this period

that the first studies on smell (Zwaardemaker, Grazzi) and taste (Luciani,Biffi) were carried out.Activities were not related only to diagnosis, in the specialistic OutpatientUnits, but, between 1880 and 1920, medical and surgical treatment werealso carried out.

Medical treatment

Medical treatment was essen-tially focused on the localapplication of medications (pri-marily, antiseptics and causticagents, but also balsamic sub-stances, emollients, astringentsetc.) applied with a dropper,sponges mounted on smallsticks made of various materi-als (whalebone, wood, ebonite,volcanite, bakelite), metal cot-tonwool containers of variousdesigns, powder blowers.

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83. - Model of the inhaler introduced by Siegle in1880 (from Stoerck).

84. - Complicated equipment, introduced byStoerk, in about 1875, consisting in a sprayer ofRichardson applied to a pedal pump (from Stoerk).

Inhaling was one of the treat-ments very much in vogue atthat time. This was performedusing special equipment which,under pressure directly reducedthe pharmacological prepara-tions into fine spray (Richard-son, Stoerk, Lewin), or carriedthem with a water vapour(Siegle, Gradenigo-Stefanini).Electrotherapy was also verypopular between the end of the1 9t h Century and the first quarterof the 20t h C e n t u r y.Galvanic and faradic stimula-tions were used and small elec-tric motors were employed toe ffect a vibrating massage, par-ticularly of the nasal andpharyngo-oesophageal muscles.

Surgical treatment

Small operations were also car-ried out in the Outpatient Unit,such as incision of phlegmons,tympanic paracentesis, removalof small neoformations, biop-sies, laryngeal intubation,chemical and galvanic caustics,but even more important proce-dures such as tonsillectomy andadenoidectomy.Thus the Outpatient Unit wasequipped with many of the nec-essary instuments. During thatperiod, the production of these

109

85. - Inhalers in use in 1902 (from Castex).

86. - Galvanic cautery introduced by Schech and itsterminals still in use at the end of the 19th Century.(SIO Museum - Rome).

surgical instruments and equipment reached extraordinary numerical lev-els, since each specialist of importance usually used those which he him-self had devised or that he had modified to his own personal requirements.As far as concerns the practical realization, highly qualified artisans werecalled upon, who were well known for the professional quality of theirwork, such as Leiter, Pfau, Trouvé, Adams, Collin, Reiner, Charrière.Instruments prepared by any of these are, still today, a century later, inperfect working order.

110

REFERENCES

01. CASTEX A. Maladies de la voix. Paris: Naud; 1902.

02. CITELLI S. Malattie dell’orecchio, del naso e della gola. Turin: UTET; 1926.

03. CLODE J.E. Història de Otorrinolaringologia. Lisboa: - Soc. Portug. ORL; 2003.

04. FELDMANN H. Bilder aus der Geschichte der Hals-Nasen-Ohren-Heilkunde. Heidelberg:Median; 2003.

05. FELISATI D. I cento anni della ORL Italiana. Prato: Giunti; 1992.

06. GUERRIER Y, MOUNIER-KUHN P. Histoire des maladies de l’oreille, du nez et de lagorge. Paris: Dacosta; 1980.

07. ITARD J.M.G. Traité des maladies de l’oreille et de l’audition. Paris:1821.

08. LAURENS G. Chirurgie de l’oreille, du nez et du larynx. Paris: Masson; 1924.

09. PIRSIG W., WILLEMOT J. Ear, nose and throat in culture. Oostende: Schmidt; 2001.

10. POLITZER A. Ueber einen einheitlichen Hoermesser. Arch Ohrenheilk 1877; 5:104-9.

11. POLITZER A. Geschichte der Ohrenheikunde. Stuttgart: Enke; 1907.

12. POLITZER A., GRADENIGO G, DELSAUX V. The choice of a simple and practical acu -metric formula J. Laryng 1904;19:525-32.

13. REUTER M. A., REUTER H.J., ENGEL R.M. History of endoscopy. Stuttgart: Max NitzeMuseum; 1999.

14. SKOPEC M., MAJER E.H. History of ORL in Austria. Vienna: Brandstatter; 1998.

15. SPERATI G. Origine e sviluppo della chirurgia laringea nel 19° secolo. Genova: Mengotti;1998.

16. S P E R ATI G. Philipp Bozzini e il Lichtleiter. Le origini della endoscopia. A c t aOtorhinolaryngol. Ital 2000; 22:42-6.

17. STOERK K. Laryngoscopie und Rhinoscopie. In: Pitha V, Billroth T. Handbuch der allge -meinen und speziellen Chirurgie. Stuttgart: Enke; 1880.

18. STEVENSON R.S., GUTHRIE D.S. A history of otolaryngology. Edinburgh: Livingstone;1949.

19. WEIR N. Otolaryngology, an illustrated history. London: Butterworths; 1990.

20. WILLEMOT J. Naissance et développement de l’ORL dans l’histoire. Acta ORL Belg1981;Suppl. 35:

21. WRIGHT J. History of laryngology and rhinology. Philadelphia: Lea & Febiger; 1914.

111

112

113

INDEX OF PERSONAL NAMES

114

115

A

ABATE C. - 34ADAMS F. - 110AETIUS OF AMIDA - 69ALBUCASIS - 69ALÌ ABBAS - 69ARGAND A. - 83ARIZA R. - 82ARSLAND M. -10,42,43,44,47AUER W. - 83,107AVERY J. - 79AVIRAGNET J. - 103

B

BABINGTON B.G. - 79BACCELLI - 37BALLENGER W. - 71,73BASSINI E. - 16BEHRING E. VON - 103BELL B. - 71BELLUSSI G. - 47BENSAUDE R. - 97BERGMANN E. - 90BERNARD C. - 13BEVAN J. - 93BEZOLD F. - 65BIAGGI C. - 47BIFFI S. - 108BILANCIONO G. - 47BILLROTH T. - 16,19,23,111BOBONET T. - 24,34BOCCA E. - 48BONAPARTE N. - 100BONNAFONT P. - 65BONNET A. - 21BORASI G. - 43,48BOTEY R. - 73BOTTAI G. - 39BOTTINI E. - 16,19BOUCHUT E. - 19,102BOZZINI P. - 79,111BRETONNEAU P. - 100BRÜCKE E. - 80BRUNETTI F. - 27,34,47BRUNINGS W. - 55,84,94,95,97,107BRUNS V. von - 85BRUNTON J. - 58BRUZZI B. - 47BRYANT W. - 91

C

CAGNIARD DE LA TOUR R. - 79CALAMIDA V. - 47CALDWELL G. - 21CALEARO C. - 43,48,53CALICETI P. - 47CANCIULLO D. - 48CARCÒ P. - 47CARNEVALE RICCI F. - 47CASELLI A. - 19CATALANO G.B. - 48,53CAUZARD P. - 97CELESTINO D. - 53,55CELSUS A.C. - 69CHARRIERE J. - 110CHERUBINO M. - 47CHESELDEN W. - 70CHIARI O. - 77CITELLI S. - 47,103,111CLAR K. - 84,96,107CLERICI E. - 43,48COLLIN A. - 103,110COMTE A. - 13COOPER A.P. Sir - 63COPPO L. - 48,53COTUGNO D. - 14,55COZZOLINO V. - 20,23,26,28,36,106,107CRUVEILHIER J. - 89CUSHING H.W. - 16CZERMAK J.N. - 18,79,80,81,84,85,105

D

DAMIENO A. - 34DARWIN C. - 67D'AVINO A. - 42,47DE AMICIS E. - 41,42,43,47DE CAMPORA E. - 48,53DELAVAN D.B. - 35,77DE GARENGEOT R.C. - 99DELEAU N. - 67DE ROSSI E. - 23,24,25,26,36,37,55DESORMEAUX A.J. - 93DE VIDO G. - 48DE VINCENTIIS I.- 41,45,48,51DIEFFENBACH F. - 101DI FEDE S. - 53DIONISIO I. - 34DONDERS F.C. - 64DRUMMOND T. - 83

DUFOUR A. - 44DURAND D. 27DUVERNEY J. - 87,88

E - F

EDELMANN A. - 65EDISON T.A. - 107EGIDI F. - 34,102,103FABRIZI G. - 70FAHNESTOCK W.B. - 71,72FASANO A. - 34,36FAUVEL C.H. - 80,84FELISATI D. - 7,9,43,45,48,56,111FERRERI GH. - 37,47FERRERI G. - 41,47FERROUD J. - 102,103FICANO G. - 27,34FILIPO D. - 42,47FIORI-RATTI L. - 48FORTUNATO V. - 47FRAENKEL B. - 107

G

GALTON F. sir - 66,67,108GARCIA M. - 17,79,80,85GAREL J. - 18GARZIA V. - 34GELLÉ M. - 37GENTILE GIO. - 39GENTILE GIU. - 82GERHARDT C.A. - 80GHISI M. - 100GLEITSMANN J.W. - 77GOTTSTEIN G. - 77GRADENIGO G. - 25,26,33,35,37,47,55,65,67,109GRAZZI V. - 23,26,27,28,29,35,36,47,55,108GUILLEMAU J. - 70GUISEZ J. - 96GUYE H. - 76

H

HALLER A. von - 54,55,64HARTMANN A. - 65,77,108HASSLINGER F. - 96HEATH C. - 91HEISTER L. - 71HELMHOLTZ H.L. - 23,64HELOT P. - 59,84,107

HERYNG T. - 106HIPPOCRATES - 69HOFMANN F. - 84HOME F. - 99HOUSE W. - 44HUTCHINSON J. - 16

I

ITARD J.M. - 64,66,89,111

JJACKSON CHEV. - 96JARVIS W. - 77JASSER K. - 88,89JELINEK E. - 17,85,94

K

KANT I. - 13KILLIAN G. - 21,84,94,95,96,107KIRSTEIN A. - 84,94,107KITASATO S. - 103KLEBS T.A. - 103KOENIG F. - 67KOEPLIN H. - 89KOERNER O. - 91KRAMER W. - 84KUSSMAUL A. - 93KUSTER E. von - 90

L

LABUS C. - 18,19,20,23,33,34,35,37,82LAFORCE P. - 77LANGENBECK B. von - 16LAUDADIO P. - 7,46,48LAURINI F. - 53LEDOUX A. - 96LEITER J. - 79,84,93,107,110LEWIN G. - 80,109LISTON R. Sir - 79LIVERIERO E. - 47LOEFFLER F.A. - 103LOEWENBERG B.B. - 77LONGHI G. - 26,28LUC H. - 21LUCAE J.C. - 65,84LUCIANI L. - 108LUDWIG C.F. - 80LUSSCHKA H. von - 77

116

117

M

MACEWEN W. - 19MACKENZIE M. - 19,55,71,80,93,94MALAN A. - 47MALGAIGNE J.F. - 102MALPIGHI M. - 14,88MARANO S. - 35MARCUCCI L. - 48MARSHIK H. - 72MASINI G. - 25,26,35,36,47,55MASSEI F. - 18,20,21,22,26,29,35,36,47,55,82MASUCCI P. - 22,35,36MATHIEU A. - 71,72MAURIZI M. - 48MENZIO P. - 48MERKEL C.L. - 19MEYER W. - 75,76,77,78MIANI P. - 48,53MICHEL C. - 77MICKULICZ-RADECKI J. - 72,93,94,107MIDDELDORPF A. - 73MOSCATI P. - 70MOTAIS E.A. - 77MOURA-BOURILLOU B. - 80,84MOURET J.P. - 97MULLER J. - 89

N

NELATON A. - 21NEGUS V. - 97NICOLAI V. - 35,47,55NITZE M. - 93,107

O

O'DWYER J. - 19,101,102,103OTTAVIANI A. - 48,53

P

PAGET J. Sir - 16PALLESTRINI E. - 47PARÉ A. - 70PASSALI D. - 7,10,46,48PEREZ F. - 103PERFUMO G. - 48,53PERICLES - 16PETIT J.L. - 88PÉTREQUIN J.P. - 21

PEZZAROSSA G. - 53PFAU H. - 96,110PFINGSTEN J.P. - 64PHYSICK P.S. - 71PIEMONTE M. - 53PIRODDA E. 48POLANSKY V . - 64POLI C. -35,47POLITZER A. - 37,66,67,108,111PORTA C.F. - 47PUTELLI F. - 47

Q - R

RAMON G. - 103RAU W. - 64RAUCHFUSS C.A. -82REINER A. - 110REMAGGI P.L. - 48RICHARDSON J. - 108,109RINNE F.H. - 64,65,67RIOLAN J. - 88ROTH W. - 84,107RUSPOLI L. - 53

S

SAPOLINI G. - 29SARTORIS A. - 48SCALORI G. - 47SCHAEFFER K. - 67SCHECH A. - 109SCHMALZ E. - 64,65SCHMIDT M. - 73,77,81,111SCHNITZLER J. - 19,81,82SCHROETTER von KRISTELLI -18,19,78,81,93,95SCHWABACH D. - 65,67SCHWARTZE H. - 25,90SECCHI C. - 35SELLARI-FRANCESCHINI A. - 48SEMELEDER F. - 84,85,93SEMON F. Sir - 21,34,37SERAFINI I. - 48SERRA A. - 53SIEGLE E.A. - 108,109SLUDER G. - 73SPERATI G. - 7,10,48,53,56,111STEFANINI U. - 109STOERK C. -19,81,82,83,85,93,108,109,111

STRAZZA G. - 35STRUYCKEN H.G.L. - 67,107SZENDIAK H. - 73

T

TAVANI E. - 47TOBOLD A. - 18,80,105TORRINI L.U. - 47TRIFILETTI A. - 28,35TROELTSCH A. von - 55,65,84,89TROUSSEAU A. - 101,102TROUVÉ G. - 84,107,110TURCK L. -17,18,19,79,80,81,85

U - V

VACHER L. - 73VALAGUSSA G. - 103VALSALVA A.M. - 14,45VELPEAU A. - 72,89VIDAU G. - 47VOLTOLINI F. - 19,20,80,106,107

W - X

WALDEYER H.W. - 21WARDEN A. - 79WEBER E. - 64,65,67WEBER ED. - 64,65WEIL M.P. - 103WHEATSTONE C. - 65WILDE W. - 89WOAKES E. - 21WOLF O. - 64,66WOLKE C. - 66WOLLASTON W. - 67

Y - Z

YEARSLEY J. - 80

ZAOLI G.C. - 48,53ZAUFAL E. - 77ZUCKERKANDL E. - 20,37ZWAARDEMAKER H. - 108

118

119

ACKNOWLEDGMENTS

Autors are grateful to Collegues Giuliano Perfumo andGiovanni Ralli for their valid collaboration; to Mrs. TizianaDi Giacomo, responsible for S.I.O. Bureau, for her hardwork; to Mrs. Marian Shields for her meticulous translationof this Volume.

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Tipografia Mengotti Carlo & c. sncGenova