Abstract
Introduction
Sir Charles Bell is renowned and revered as an outstanding surgeon, anatomist, clinician and teacher and his many contributions to various medical fields have been amply described. What are less well-known are his contributions to the field of laryngology.
Methods
Selected clinical and physiological publications by Bell were examined that addressed issues related specifically to the airway or pharynx. These included both case reports and case series.
Results
Bell was keenly interested in the physiology of voice production, disorders of the airways and deglutition. Despite a busy clinical and teaching practice, he took careful notice of individual cases that highlighted important generalizations regarding care for upper aerodigestive tract disorders that are relevant today. He was also the first to recognize the anatomy and physiology of pharyngoesophageal diverticula that Zenker later made more famous.
Conclusions
In addition to his many contributions to neurology, facial nerve anatomy and physiology, Sir Charles Bell was also a keen Laryngologist before the era of subspecialization. Rediscovery and study of his work should make us more appreciative of past clinician-investigators who cast a wide net to advance knowledge rather than burrow into a narrow tunnel of vision.
1
Introduction
British writer and philosopher Isaiah Berlin famously resurrected an ancient Greek adage that is useful in classifying thinkers: “The fox knows many things, but the hedgehog knows one big thing” . Neither is better than the other; rather, each serves an important purpose and when integrated, advances knowledge. In some ways, this dichotomy also reflects how Otolaryngology has evolved as a specialty.
Whereas current advances in Otolaryngology are driven by superbly trained subspecialists (hedgehogs), in the past, Oto-rhino-laryngology was advanced by practitioners well versed in all aspects of ear, nose and throat diseases (foxes). Of the many “fox” types, Sir Charles Bell’s reputation deservedly ranks high. His name is enshrined in many familiar eponymic structures, phenomena or conditions. Less well-known are Bell’s work pertaining to disorders of the upper aerodigestive tract.
This communication discusses some of Bell’s contributions to the study of airway form, function and disease. My goal is not to thoroughly catalogue or describe this work; rather, it is to direct the interested reader back to Bell’s own writings, which are often highly original and potentially dramatic in nature ( Fig. 1 ).
2
Brief life
Ch a rles Bell was born in November 1774 and attended the University of Edinburgh. As a result of innate talent and strong maternal influence, he had thoughts of becoming an artist. However, with his love of dissection and under the tutelage of his older brother John, himself an accomplished surgeon, Charles gravitated to surgery and became a staff member of the Royal Infirmary in 1799. It was not until 1813, when he was 39 years old, that he was admitted to the Royal College of Surgeons and embarked on a busy surgical practice .
Bell was not only a skilled surgeon, but also a compassionate one. In 1815, twelve days after Napoleon’s defeat at the battle of Waterloo, Bell joined the British surgeon John Shaw to operate on French casualties, since wounded British soldiers were already being treated. Upon returning to his practice in London, he won several awards and medals, was granted knighthood in 1830 and took an active role in founding the medical school of Middlesex Hospital in 1835. Bell then moved back to Edinburgh in 1836 at 62 years of age to become Professor of Surgery at the University of Edinburgh, and died suddenly in harness at age 68 on April 29, 1842. During his brief life, Bell worked assiduously to advance many fields of medicine and surgery and authored or co-authored dozens of papers and books (which went through many editions) all of which were widely translated and covered various aspects of neurology, surgery, hand surgery, urology and neurosurgery. His name is affixed to 5 eponyms or clinical signs
Bell was avidly interested in structural relationships and assisted his brother John in performing anatomic studies and dissections. This led to co-authorship with John of a well illustrated four volume Anatomy of the Human Body . This interest in anatomy was strongly complemented by a devotion to understanding function and physiology as well. However, form and function were not studied in isolation. Bell was also strongly devoted to both practical and classroom teaching as a way of advancing medical knowledge ( Fig. 2 ).
In a brilliant new book Bell’s life is examined through the lens of nineteenth-century British medical culture. This monograph is a nuanced, extensively researched view of Bell in his world and no one who desires a deeper understanding of Sir Charles Bell can afford to miss reading it. In it, Berkowitz points out that Bell was instrumental in advancing and reforming British medicine by a unique approach to advanced pedagogical techniques with a strong emphasis on anatomy, anatomic preparation and contextualizing these in a clinical setting. Bell’s advances in physiology were always grounded in anatomic observation. Or, as Berkowitz observes he emphasized a system of education which artfully blended displays, objects and clinical teaching: “Pedagogy Inside and Outside the Medical Classroom: Training the Hand and Eye to Know” .
A careful study of Bell’s work rewards the reader with a deeper appreciation his great talents as artist and observant surgeon. Straying from the well-trodden books on nerve anatomy and function one also begins to appreciate his many unheralded contributions to the nascent field of laryngology.
As defined by the ALA:
Laryngology is a subspecialty within Otolaryngology – Head and Neck Surgery encompassing a field of knowledge that deals with disorders of voice, airway and swallowing. The laryngologist has special expertise in the diagnostic and therapeutic approaches to problems in these areas and participates in the advancement of knowledge through clinical and/or basic science research .
As a clinician and surgeon Bell had a long-term interest in airway function and dysfunction, and although he would blanch at the idea of such an arbitrary separation, these interests can be artificially subdivided into form plus function as well as clinical dysfunction.
2.1
Larynx, voice production
Bell’s interest in laryngeal physiology and the human voice were motivated by his desire to further understand the distinctive functions of many cervical nerves. His views on vocal production were partly derived from comparative anatomy studies and structural disorders, thereby leading to some biases and incorrect conclusions. Even so, these views are of interest.
Bell likened the trachea to an air tube with the overlying thyroid gland serving to dampen tracheal tubular vibrations. He believed that the glottis not only serves to regulate air passage to the trachea, but is vital in producing sound via motions of the membranous thyro-arytenoid ligaments. He also opined that, by analogy to the larynx of great apes, the laryngeal saccule had a major influence on sound production. Further, Bell described the influence of the pharynx and velum on articulation. He then presented several clinical cases of injuries or diseases in each of these sites which resulted in alterations in of sound and speech .
While Bell’s simplistic mechanistic views of the larynx and trachea are easily contradicted by modern physiology, the more salient issue is that he chose to couple anatomic information- using either primary human dissection or reasoning from comparative anatomy-with clinical observation to try and understand a highly complex function.
It is more in the clinical realm, where observation and anatomic preparation were linked, that Bell’s contributions to Laryngology excel.
2
Brief life
Ch a rles Bell was born in November 1774 and attended the University of Edinburgh. As a result of innate talent and strong maternal influence, he had thoughts of becoming an artist. However, with his love of dissection and under the tutelage of his older brother John, himself an accomplished surgeon, Charles gravitated to surgery and became a staff member of the Royal Infirmary in 1799. It was not until 1813, when he was 39 years old, that he was admitted to the Royal College of Surgeons and embarked on a busy surgical practice .
Bell was not only a skilled surgeon, but also a compassionate one. In 1815, twelve days after Napoleon’s defeat at the battle of Waterloo, Bell joined the British surgeon John Shaw to operate on French casualties, since wounded British soldiers were already being treated. Upon returning to his practice in London, he won several awards and medals, was granted knighthood in 1830 and took an active role in founding the medical school of Middlesex Hospital in 1835. Bell then moved back to Edinburgh in 1836 at 62 years of age to become Professor of Surgery at the University of Edinburgh, and died suddenly in harness at age 68 on April 29, 1842. During his brief life, Bell worked assiduously to advance many fields of medicine and surgery and authored or co-authored dozens of papers and books (which went through many editions) all of which were widely translated and covered various aspects of neurology, surgery, hand surgery, urology and neurosurgery. His name is affixed to 5 eponyms or clinical signs
Bell was avidly interested in structural relationships and assisted his brother John in performing anatomic studies and dissections. This led to co-authorship with John of a well illustrated four volume Anatomy of the Human Body . This interest in anatomy was strongly complemented by a devotion to understanding function and physiology as well. However, form and function were not studied in isolation. Bell was also strongly devoted to both practical and classroom teaching as a way of advancing medical knowledge ( Fig. 2 ).
