However he considered that every member of the surgical staff at this time suffered from some condition likely to shorten his life. Consequently Lane devoted himself to the study of surgery, determined to overcome his repugnance of it. How wrong Moxon’s forecast was is shown by the fact that owing to the deaths of Fagge, Wilks, Moxon and Pavy, Dr Hale White, who was a year younger than Lane, was appointed to the medical staff in 1886, two years earlier than Lane was appointed assistant surgeon!28 Of course, when it comes to climbing the rungs of any professional ladder, more is required than the convenient death of one’s superiors and rivals. There is that indefinable quality which in some allows a characteristic to be used to advantage, whilst others are damned by it. The diligent reader will find many examples of this in the ensuing pages.
(c) The Foundation of ENT Hospitals
From the last third of the eighteenth century there was a new development – the foundation of medical institutions by medical men. These special hospitals played a key role in confirming the position and power of specialists.29 In the words of an 1860 edition of the British Medical Journal they enabled medical men to “step to fame and fortune by means of bricks and mortar”.30 The fact that they could be a route to power, prestige and wealth is underlined by the vociferous opposition they encountered from much of the medical profession in the mid-nineteenth century. Despite this initial condemnation, by the end of the century, those aspiring to the top of their specialty were applying to join the staff. To set this in some sort of historical context one must remember that in the eighteenth and nineteenth centuries the middle and upper classes were usually treated at home, with hospitals generally being supposed only for the “deserving poor”. Senior doctors would give of their time free of charge in exchange for the prestige and contacts which accrued from such an association; junior medical men used hospitals in order to learn their craft.
Initially these were usually simply outpatient departments, based on that started by John Lettsom in 1770. He was also the founder of the Medical Society of London, from which the Royal Society of Medicine developed. What might be considered the first British hospital specialising in otology was set up in 1816 as a dispensary in Soho Square by John Harrison Curtis (1778-1860) who began his professional life as a dispenser in the Royal Navy. From these humble origins as the Dispensary for Diseases of the Ear arose the Royal Ear Hospital which is now part of University College Hospital, a humble teaching hospital in London.31 The specialist hospitals evolved from these outpatient dispensaries and, once in, the doctor had access not only to wealthy governors and patrons but the basis on which to establish a practice. As an indication of the value of such a position it should be noted that at John Lettsoms’s Aldergate Dispensary two competing applicants paid six hundred guineas between them to secure an entrance.32 The template for otolaryngology was Moorfield’s Hospital, founded in 1805 by John Cunningham Saunders (1773-1810).33 It was originally for both the eye and ear, but treatment of ear conditions ceased after two years.34 Saunders was born in Devon and, after being apprenticed to a barber surgeon, walked the wards in London and became house-pupil to Sir Astley Paston Cooper. Following this, he became a lecturer at St Thomas’ Hospital, no doubt paying for the privilege. However, when his mentor left for Guy’s Hospital in 1800, taking on Benjamin Travers as his apprentice, Saunders was left out in the cold. He departed for the provinces the following year. He was in luck, however, for having worked for Astley Cooper, he could draw on this connection by emphasising a degree of specialisation in otology by publishing a book.35 In 1804 he established his London Dispensary for the Relief of the Poor Afflicted with Ear and Eye Diseases. This was clearly the thing to do – a check of the Medical Directories of the period reveals that by the 1860s there were at least sixty six specialist institutions in London alone.
The loyalty extended to a hospital might reach almost ridiculous proportions. A patient was seen at the Manchester Ear Hospital complaining of a running ear, which was treated. When an attempt was made to examine her other ear, this was refused. This ear was under the care of another hospital, St John’s Dispensary just around the corner! The effort of attending for daily dressings at two different hospitals can be imagined and for those who cannot picture the chaos of the waiting room of such hospitals then Lowry’s Outpatients at Ancoat’s Hospital is an apt visual description. This picture used to hang in the hospital in Ancoats and was coveted by a well-known lady Minister of Health in the 1960s for her Whitehall office. For those of our readers who knew Manchester in the past but have not been back for some time, we have to relate that many of these neighbourhood areas have now changed quite a lot. This has not necessarily been for the better, not obviously for the worse – it all depends on one’s needs. The corner tobacconist is now in the hands of a chocolatier. This is an advantage for those requiring something more than a bar of Fry’s Five Boys Chocolate; it would prove difficult to get five Woodbines though. The new shop is clearly more profitable – “Art Deco” chocolate is sold at a vast sum per ounce – it is simply Toblerone with the wrapping taken off. The shop next door is for futons. This is fine if your idea of living is to eat/wear/drink/(or whatever one does) to a futong. The bolder of your authors enquired at a bespoke corsetry shop but remained unenlightened; at least we know it is nothing to do with that. Perhaps for once our American readers can turn the tables and enlighten us?
Of course the concentration of cases in such specialist hospitals led to a wealth of clinical experience for the otologists working there. Sometimes the unwitting testimony of the local inhabitants showed the extent of ear disease within the community. This was demonstrated to one of the authors when a Salford woman brought one of her many children complaining that “his left ear won’t run properly”. That ear was the only one in the whole extended family which had an intact tympanic membrane. Whilst demonstrating a new instrument he had devised for tonsillectomy Mr J F O’Malley told the audience that he was in the habit of operating on thirty cases in the morning at his hospital in two hours.36 Whilst the cases may have been concentrated together in specialist hospitals, the specialists may well have found themselves covering a very wide area indeed. George Archer was appointed in 1932 to be consultant to Manchester Northern Hospital and Stockport, Buxton and Warrington Infirmaries.37 Similarly, Lennox Browne (1841-1902) seemed to work in London, being aural surgeon to the Royal Society of Musicians and surgeon to the Royal Choral Society; he was in addition to this also consultant to Newcastle Throat and Ear Hospital.38 E D D Davis was appointed to the senior surgical staff of Charing Cross Hospital, London but was also on the staff of the Royal Dental Hospital, the Throat Hospital, Golden Square, the Hospital for Sick Children, Great Ormond Street, Mount Vernon Hospital and Queen Alexandra Military Hospital, Millbank. In between commuting he managed to find time to do some operating and also to be President of both Sections of Laryngology and Otology of the Royal Society of Medicine.39
The rationalisation of a multitude of small hospitals into fewer “more efficient” units is nothing new. Prior to the outbreak of war in 1939 the Central London Throat, Nose and Ear Hospital amalgamated with Golden Square Hospital to become the Royal National Throat, Nose and Ear Hospital. Chappie Gill-Carey (1896-1981), who had been appointed to the consultant staff of the Central in 1923 became the first Dean of Laryngology and Otology, a post which he held until 1960. Robert Scott Stevenson (1889-1967), a former Manchester registrar, ex Royal Army Medical Corps and writer, saved the independence of the Metropolitan ENT Hospital at the post-war inauguration of the NHS.40
(d) The Interface with Radiology
The close liaison which has developed between radiotherapy and ENT is, of course, a reflection of the fact that squamous cell carcinoma is the commonest nasty in the upper aero-digestive tract and on the whole is eminently radio-sensitive. Wally Jackson, a radiotherapist from Norwich tells the story of Professor Ralston Patterson, the first director of the Christie Hospital and Holt Radium Institute, Manchester on a ward round where one of his firmly held views was challenged. Ralston did not give much truck to the time-honoured idea that clay pipe smoking gave rise to cancer of the lip. (One of your authors who used to smoke a clay pipe as a schoolboy vividly remembers tearing the skin from his own lip after it had stuck like glue to the white stem of the pipe. A new pipe always had a red lacquer over the mouth piece but this became easily broken off). The director, firmly convinced of the error of this theory, was somewhat put out to learn, on enquiring of the smoking habits of a patient with a fungating lip cancer, that he did in fact smoke a pipe, and, even better, a clay pipe. However, not to be put out, Ralston asked him on which side he smoked it. The patient, who had a large tumour on the right side, looked puzzled but pointed to the left side.
“What did I tell you?”
announced the Professor, triumphantly.
“Here is a man who has smoked a clay pipe all his life on the right side of his mouth, and then goes and gets cancer of his lip on the other side!”
A discussion ensued as to how best transform the appearance of the man’s mouth to something resembling a kebab (or hedgehog) by the intelligent use of radium needles and then, before moving on, the Professor asked if any of the students would like to pose a question of their own. One lad, a little less overawed by the situation than many, asked the old Lancastrianh
“Have you always smoked your clay pipe on the left sir?”
The reply came:
“Oh no! I always used to smoke it on the right until this bloody thing came along”.
A dewlap is the hanging pouch of flesh found at the throat of oxen and dogs. It is present because the investing layer of cervical fascia in their necks is not attached to the Adam’s apple (so called because a piece of the forbidden fruit of the tree of knowledge of good and evil became stuck in his throat causing this swelling; this theory has been challenged recently) as it is in humans. A radiation dewlap is a sequel to late-stage tumours of the tongue, pharynx and supraglottis, well-known to ENT surgeons and radiotherapists alike. Nevertheless it had been described neither in standard texts nor journals until a bright spark seconded from ENT to radiotherapy collected a few cases. He found that if the dewlap was pressed with the thumb for a few minutes it behaved like pitting oedema. It was duly written up and one of your authors now has two academic prizes for describing in print what everybody already knew. We call it Riddington Young’s sign.41
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