Portuguese Version

Year:  2002  Vol. 68   Ed. 2 - (1º)

Editorial

Pages: 150 to 151

PDF PT  

Deepness and comprehensiveness

Author(s): Henrique Olival Costa

Keywords: -

In certain occasions, the editor of a scientific journal feels like a football coach that has more than one good player for the same position. The Brazilian Journal of Otorhinolaryngology has been faced with such dilemma: how can we take the best of the whole team? Our editorial policy is based on continuous improvement of the appraisal process, enhancing selection criteria. We thought that by doing so we would have a reduced number of submissions to the journal. Conversely, the input has increased and the level of scientific studies has improved a lot. Therefore, our problem became a solution, because we finally had a greater number of articles about the various areas of Otorhinolaryngology and we could group them in informal sections that favored the reading of interested readers.

We have been naturally doing it for three issues and we were considering the idea of formalizing the sections in the index. However, we wondered which sections should be included. It would understandably be Otology, Rhinology and Laryngology, since there are societies that congregate these areas. But what about Head and Neck Surgery, Pediatrics, Face Esthetic and Reconstructive Surgery, Occupational Medicine, etc, etc, etc...?

The dilemma has made us reflect about the route the specialty has taken from an academic perspective and it has led us to the beginning of our profession.

Taking for granted that no one knows precisely when Medicine actually started and considering that pre-historical drawings that survived the times represent a relatively late stage of stone age men, we concluded that it is extremely difficult to define the basic premises that determined man's inclination to practicing medicine. We know that magicians and medical men are the oldest professionals that we have heard of. In the Trois Frères Cavern, in the Pyrenees Mountains in France, there is a drawing of the so-called oldest physician of humanity, whose drawing dates from 15,000 AC.

The evidence of curative practice is preserved in pre-historical skulls in which there are clear signs of trepanation. Evidence is scarce, but it can still tell us about motivations and believes that drove our antecessors to practice medicine in its first times.

A number of authors studied the subject and the synthesis of their investigations may be described in two topics: 1 - the attempt to remove some morbid material or harmful influence from the victim, and 2 - the restoration of the soul, abstracted from the body of the sick.

Trepanation seemed to have attended to both purposes, since through the cranial orifice there could be the output of the evil spirits afflicting the victim, at the same time it favored the cure of traumatic lesions by draining the region.

The first reason is probably the most indicated one, since pre-historical medicine had an animistic-based perspective towards diseases. They used to believe that the disease was caused by influence of the evil, enemy, a god, or even an animal and it should be cured by removing this harmful cause from the body of the patient. In writings throughout the whole history of medicine, there are reports about the importance of having medication of unpleasant taste or repellent nature so that they could be effective. According to scholars, the purpose was to displace evil forces by repugnant artifacts. In the city of Cheshire, England, there was a medicine for ulcerated mouth aphthas that consisted of keeping a frog alive inside the mouth for some minutes, before setting it free. With such a maneuver, the disease would be transferred from the patient to the frog. In 430 AC, Heredotus retold us that each Babylonian was an amateur physician, because the habit at the time was to lay the sick on the streets so that those who passed by could help with their knowledge about the disease. He said: "If he has suffered from the same disease, or has known someone who had, he may give the sick some piece of advice... and no one was allowed to pass by a sick person in silence.".

The medical literature started then to be composed and many other cases were fantastically reported, together with the prescription to their cure. The description of a patient with displaced mandible is surprisingly modern "If you find a man with displaced mandible, you should find him with the mouth opened, incapable of closing it. You should put your two thumbs over the end of each mandible ramus inside the mouth and your fingers over the chin and you should force it backwards so that the mandible can restore its normal position" (2,000 AC).

Medical papyri are abundant and a special group had great influence on the professionals of the Old Egypt. This collection of medical information was called "The Hermetic Books" and they were so dear to the pharaohs that a medical practitioner was not found guilt of the death of a patient had he followed their teachings. However, if the physician had not practiced the methods described by the books and his patient progressed to death, he would have to pay with his own life.

We can clearly see the intensive search for systematic patient approach and the great responsibility supported by the practitioner of the art of cure.

The systematic approach stemmed from unknown believes, but they had an internal logic that determined the format of medical practice. One of the paths of systematization was the specialization of the art of cure. This process started in the 19th century. Both areas of clinical and surgical care started the process at the same time, but surgery had a more quick and significant definition. By the end of the 19th century, abdominal surgery and neurosurgery already existed. Orthopedics had already been practiced since the 18th century, but was called so only after the First World War. Otorhinolaryngology surged as a specialty a bit later than the other surgical specialties and much time after the clinical specialties of pediatrics, cardiology and endocrinology. However, the topic attracted attention since the 16th century, time in which ear anatomy had already been studied. From then on, there was a movement towards having ear disease treatments based on scientific support. One of the milestones of this journey was the foundation in 1805 of the London Dispensary for the cure of ear and eye diseases. Somewhat later, in 1838, the Metropolitan Hospital for ear and throat, called Otolaryngology, was opened. Rhinology was incorporated to the specialty a bit later, probably circa 1860, since in 1880 the periodical Revue de Laryngologie-Otologie-Rhinologie, in Bordeaux, was launched.

We noticed as a result of the facts, that ENT has aggregated special knowledge and built brick by brick the pillars of the specialty. Over one hundred years after our institution, we can see the modus operandi and the modus pensanti of subjects trained in the curative arts of Otorhinolaryngology. This attitude is the result of a gradual development of men for over a century, providing a comprehensive view of ENT but never refraining from studying deeply the complex topics of the specialty. Deepness and comprehensiveness: this binomial is not easy to get. In general, the more we are engrossed in a topic, the fewer horizons we can reach with our look, and the other way round. This is probably the dilemma faced by the journal right now: shall we specialize, deepen or embark everything? This quandary may be shared by our supra-specialty societies. They could be the academic support of the mother society, whereas the latter is concerned about fighting for better conditions of ethical and competent practice of Otorhinolaryngology. However, if they operated apart from the SBORL, would that not be a chance for restoring the old days, when Otology was not Laryngoly and Rhinology was nothing?

Competence and training are essential and expected attributes of all physicians. One of the healthiest ways to reach medical competence is by using critically the information produced by research. The ability to convey value to concepts defined based on scientific activity is closely related with ethical aptitude and the capacity to learn from lived and reflected previous experiences.

To practice medicine, we choose one specialty and we have to take it on as a whole, having at the same time a comprehensive perspective and narrowing it according to the need.

I believe it is high time we decided.

Let us not have the sections of supra-specialties and find another safer way to deepen our knowledge in this huge specialty.

Best wishes to all my OTORHINOLARYNGOLOGIST colleagues!

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