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Poland until 2000 Antoni Pruszewicz, Poznan Abstract The first medical doctor who entirely devoted his activity to phoniatrics was Dr. W. Oltuszewski (1855-1922), a pupil of A.Gutzmann. Between 1896-1922 together with his wife Zofia he founded a phoniatric unit in Warsaw for speech disturbances treatment and published 46 papers on phoniatrics among them in 1905 a handbook on “Speech and its deviations”. After the World War I at the following Universities phoniatrics units were established: Kraków (1925 prof. A.Mitrinowicz-Modrzejewska), Wilno (1926 Prof. B. Dylewski), Poznan (1932 Doc. M. Laczkowska), Warszawa (1935 Prof. A. Mitrinowicz Modrzejewska). After the World War II the first departments for phoniatrics were founded in Warsaw, Poznañ and Wroclaw (1950 Prof. L. Handzel). in 1954 Prof. A. Mitrinowicz-Modrzejewska was nominated as the first professor in Phoniatrics in Poland, this date is also accepted as the establishment of clinical phoniatrics in this country. Actually, at all University ENT departments there are phoniatric units. In Poznañ in 1982 was founded the first independent Department f or Phoniatrics and Audiology (head Prof. A. Pruszewicz) and in Lublin in 1995, Department for Children ENT and Phoniatrics /Audiology (head Prof. C.Niedzielska). Apart from above mentioned units in Poland we have polyclinics and outpatients departments for phoniatrics in the district cities and other public health institutions in the whole country. Here it should be mentioned that special phoniatric units are installed also at the University Schools of Music and different central institutions like for example Center for Medical Postgraduate Education. At the time we have in Poland 6 professors and 2 assistant professors in phoniatrics. In 1959 the Minister of Health and Welfare established phoniatrics as an independent medical specialization and founded Phoniatric Commission at the Center for Medical Education. Since then phoniatric in Poland has its own training program (3y curriculum) and about 120 ENT specialists graduated as the specialists in phoniatrics. In
1965 Phoniatric Section at the Polish ENT/HNS Society was established
and the number of its members amounts to 180. Every year 2 day
Phoniatric Symposia are organized; in the Journal of Polish
Otolaryngology a special division is devoted to Phoniatrics
and Audiology. The Phoniatrics Section is an affiliated member
to IALP, organized 2 Congress of UEP (1975 Wrozlaw, 1985 Poznañ)
and its members are represented in the different bodies of IFOS
and EUFOS. However, Phoniatrics in our country is an independent
medical specialization in last years a tendency to combine it
with audiology is presented by the authorities of Ministry of
Health and Welfare.
Jan
Siestrzynski (1788 –1824), who was a doctor as well as
a teacher working with deaf-mutes, is considered to be the precursor
of phoniatrics in Poland. In 1813 he graduated from the Department
of Medicine at the University of Vienna and started his work
under the supervision of famous Vienna professors Hildenbrandt
and Rust. Besides medicine he was also interested in deaf children
pedagogics. He became famous for working in the institutes for
hearing-impaired children in Prague, Berlin and Wroclaw, before
he took over a post as a teacher in the Deaf-Mute Institute
in Warsaw, where he popularized the audible, articulated speech
introducing it in place of the sign language or mechanical sign
and letter-form recognition methods, which had been used before.
Around 1821 he finished his lifetime work “Teoryja i mechanizm
mowy” (“The Theory and the Mechanism of Speech”,
which consists of two parts. The first one concerns the theory
of speech and reading and the other one includes the theory
of human speech mechanism as well as remarks on deaf children
education. The above work preceded other volumes in the same
domain published in England (Borthwick “Remarks on the
elements of language”) and Austria (Brücke “Grundzüge
der Physiologie und Systematik der Sprachlaute”) in 1856.
After Siestrzynski’s death in 1824 articles on the pathophysiology
of voice, hearing and speech, written by famous Polish physicians,
appeared in a number of Polish and foreign journals. Many important
papers in the area of phoniatrics were prepared on the turn
of the XIX century, when otolaryngology started to become independent
of surgery, constituting a separate branch of science. I would
like to mention here the works on the pathology and therapy
of stammering (1847) by Józef Dietl (1804-1878), professor
at the Universities of Vienna and Cracow, the works on the recognition
of the “phonic” laryngoparalysis (1878) and on the
phonatory activity of Mm. cricoarytaenoidei posteriores (1900)
by Antoni Jurasz (1847-1923), a paediatrist and laryngologist,
professor at the Universities of Heidelberg, Poznañ and
Lwów (Fig.6), as well as the works on the surgical treatment
of disturbances in a singer’s voice (1898) by professor
Teodor Heryng, a laryngologist from Warsaw.
The
professorship-qualifying thesis by Przemyslaw Pieniazek (1850-1916),
the founder of clinical otolaryngology in Poland, entitled “The
Mechanism of the Glottal Closure” also refers, to some
extent, to the problems of phoniatrics. However, neither in
the above works nor in many others, which we cannot mention
here, were phoniatric issues presented as the main problems.
First
phoniatrics centers were established after World War II, especially
at numerous university otolaryngology clinics. The first institution
of this type was organized in 1925 by professor A. Mitrinowicz-Modrzejewska
at the Neurology and Psychiatry Clinic of the Cracow Jagielonian
University (supervised by professor Jan Pilz) (Fig.7) and was
the first clinic for people with speech deviations. At the same
time (1925 - 1926) Benedykt Dylewski, subsequently professor
at the High School of Medicine in Lublin, established the first
phoniatrics center at the Otolaryngology Clinic of Stefan Batory
University in Wilno, supervised by prof. Jan Szmurlo. For many
years professor Dylewski dealt with the problems of voice and
speech disturbances in schoolchildren and he published a number
of works in this domain. Another two phoniatrics institutes
were established at university otolaryngology clinics in the
1930’s. In 1932 assistant professor M. Laczkowska, supported
by the head of the Otolaryngology Clinic professor A. Laskiewicz,
organized an advice center for speech deviations in Poznan (Fig.
1 and 2). A clinical phoniatrics ward with an advice center
for voice and speech disturbances was founded in Warsaw in 1935,
with the help of professor A. Mitrinowicz Modrzejewska and great
engagement on the part of the head of the Otolaryngology Clinic
professor F. Erbrich.
The phoniatric ward of the Otolaryngology Clinic in Warsaw was the first one to start working after the end of the Second World War. In 1950 the advice center of the Otolaryngology Clinic in Poznañ resumed its activity and in 1951, on the initiative of assistant professor L. Handzel, a new phoniatric institute was founded at the Mental Health Clinic in Wroclaw. Many phoniatrics institutes have appeared since that time which can be divided as follows: 1.
Institutions at the otolaryngology clinics of high schools of
medicine. Phoniatrists work basically in each university otolaryngology
clinic but laboratories or advice centers have been created
only at the clinics in Warsaw, Wroclaw, Poznañ, Cracow
and Lódz. Now in each University ENT Department (11 in
Poland) phoniatric units are established. In 1972 the Phoniatric
Unit was separated from the Otolaryngology Clinic in Wroclaw
and it became the first independent phoniatric laboratory in
Poland, being the first autonomous unit at a university school
of medicine. In 1982 the first independent Department for Phoniatrics
and Audiology (bed station and outpatients polyclinic) was established
at the University School of Medical Sciences in Poznan (head:
Prof. A. Pruszewicz). Similar Department for Child ENT and Phoniatrics/Audiology
was founded in 1995 in Lublin (head Prof. G.Niedzielska) and
in 1998 Lódz (head Prof.D.Gryczycska). Phoniatric laboratories
have beds in otolaryngology clinics, which enables them to admit
patients for diagnosis as well as conduct surgeries or rehabilitation
activities. Individual regional hospitals with polyclinics (Toruñ,
Poznañ) and sanatoria (Garwolin near Warsaw, Zagórze,
Zaskoczyñ near Gdañsk) have beds for patients
with voice and speech disturbances as well. Advice centers and
laboratories are venues for phoniatric courses prepared for
students and physicians specializing in otolaryngology, phoniatrics
and dentistry. The advice centers are also a place where most
scientific papers in the area of the pathophysiology of the
communication process are prepared. 3. Institutions at high schools of music, where phoniatrists do not only prepare lectures and seminars for students but also look after them and carry out scientific research on the physiopathology of vocal and respiratory organs. Phoniatrics laboratories of this type already exist in Warsaw, Wroclaw, Gdañsk and Poznañ and the establishment at the High School of Music in Warsaw became an independent chair of voice physiopathology in 1971. In 1959 the minister of health and social welfare signed a decree recognizing phoniatrics as an independent medical specialization. He also created a phoniatrics committee working at the center of medical education. The aim of the committee is to determine specialization and training norms in phoniatrics as well as to give specialization examinations in this domain. Till 1998 a position of state consultant for phoniatrics existed, since 1999 it is combined with audiology. Guidelines of the Polish specialization program for phoniatrics in Poland. His specialization in phoniatrics is a second-degree specialization available exclusively to medical doctors with the first-degree specialization in otolaryngology, neurology or psychiatry. It has been recently decided that phoniatrics education must be preceded by a the specialization in otolaryngology. Another prerequisite is a three-year phoniatric practice in centers with appropriate resources in terms of staff and equipment. At the moment this type of education takes place in Warsaw, Wroclaw, Poznan and Lublin but it can also be available in other centers appointed by the phoniatric committee. In Poland clinical phoniatrics is generally recognized as an independent scientific discipline and a medical specialization, dealing with the pathophysiology of voice and speech organs as well as with audiology (esp. children audiology) as far as it is related to the process of communication. The processes of voice and speech pathophysiology are very complicated and they require extensive knowledge of other medical disciplines as well as non-medical subjects, which makes the specialization period relatively long. As far as the specialization is concerned, phoniatrics collaborates with otolaryngology, neurology, psychiatry, physiological acoustics, clinical psychology, endocrinology, allergology, logopedics, psycholinguistics etc.. Phoniatric is most closely related to otolaryngology, which is its base specialization. The mutual activity of organs responsible for the production and perception of voice and speech sounds, the common basic research methods, the necessary knowledge of the rudiments of laryngological oncology, laryngological allergology etc. require considerable preparation. This why it is possible to start phoniatric education only after the first-degree specialization in laryngology and a three-month practice in neurology and child psychiatry. Full command of the theory and practice in the whole domain as well as extensive knowledge in the area of epidemiology, radiology and the organization and administration of phoniatric institutions are the necessary conditions for the recognition of the phoniatric specialization. The specialization examination, consisting of a theoretical and a practical part, takes place twice a year - in the spring and in the autumn semesters. In 1973 the ministry of health and social welfare decided to modify the examination regulations. As a result phoniatrics became a so-called subspecialization, which means that the intending phoniatrist has to obtain the second-degree specialization in otolaryngology first. In this situation the number of candidates for this specialization has fallen so the proper authorities appeal for the reintroduction of the previous regulations, according to which the first-degree specialization in laryngology was sufficient to start the specialization in phoniatrics. Since 1987 till now the phoniatric specialization was realized after the I degree of ENT. Due to this fact the number of specialists in phoniatrics amounts to about 120. During last two years a tendency to combine phoniatrics with audiology after ENT complete training is proposed by the Ministry of Health and Welfare. Actually we have in the country 4 full professors and 4 assistant professors in phoniatrics. The UEP has determined an index according to which one phoniatrist must be available to 200 - 250 000 citizens. In this situation Poland lacks about 50 phoniatrists. Specialized courses organized by university phoniatric centers in Wroclaw, Warsaw and Poznañ are another form of educating phoniatrists. On average there are 6 -7 courses a year, which last from one to three weeks and are compulsory for those specializing in phoniatrics. On 25 June 1965 The Phoniatric Section, one of four sections working within the Polish Otorhinolaryngologic and Head/Neck Surgery Society, was established in Wroclaw. It unites phoniatrists and laryngologists specializing in phoniatrics. The Phoniatric Section has 160 members now and its aim is to integrate, stimulate, and supervise the scientific, organizational and educational activities of Polish phoniatrists. This section is managed by the board and it organizes one scientific symposium every year. Since 1972 the section has also been a member of the International Association of Logopedics and Phoniatrics (IALP) and it participated in organization of the IVth Congress the Union of European Phoniatriciants (UEP) in 1974 in Wroclaw and The XIIthe one in Poznan in 1985.Mambers of the Phoniatric Section have been involved in different bodies of international organizations such as IALP, IFOS, EUFOS, World Voice Consortium etc. As far as the publishing activity of Polish phoniatrists is concerned there are a few works which should be mentioned: The chapter on voice and speech disturbances in children by B. Dylewski in the handbook “School Hygiene” (1958); the handbooks by A. Mitrynowicz-Modrzejewska “The Physiology and Pathology of Voice, Speech and Hearing” (1963) and “Infancy Deafness” (1974) as well as her materials for University School of Music students and educationalists and for philological sections; S. Klajmann (1975) “An Outline of Voice Hygiene”; M. Laczkowska (1976) “The Principles of the Anatomy and Physiology of Hearing and Speech Organs”. Besides A. Pruszewicz prepared the chapters on voice and speech disturbances in two editions of the handbook for otolaryngology specialists “Clinical Otolaryngology” (1972-1980), edited by A. Zakrzewski, and in the book for Child Laryngologists “Developmental Laryngology” (1979), edited by E. Kossowska. He also published and was the editor of two hand books: Clinical Phoniatrics (1992), Outlines of Clinical Audiology (1994) and the Proceedings of the XXth UEP Congress in Poznan (1985). L. Handzel prepared the chapter entitled “The Physiology and Pathology of Voice as Essential Problems of Phoniatrics” in the handbook “ Otolaryngology for Students of Medicine”, edited by St. Iwankiewicz (1973), and J. Tronczynska wrote a chapter on the phoniatric treatment of cleft palate for the handbook by J. Bardach (1974) entitled “Upper Lip and Palate Cleavage”. In
1966, on the suggestion of L. Handzel, the Phoniatric Section
started to issue “Phoniatric News”, edited by A. Pruszewicz.
This journal appeared 2-3 times a year with a circulation of
around 400 and was printed in the rotaprint technique. Altogether
there have appeared 24 editions, which included not only reports
on scientific meetings of the Phoniatric Section and on its
activity but also information about the history, scientific
achievements and organization of phoniatric centers as well
as historical data on Polish phoniatrists. The first thing to
be published was the Polish phoniatric bibliography before 1965
as well as works which appeared after this date and were considered
to be novelties in the Polish and foreign phoniatric bibliography.
Individual editions included communiqués on specialized
training, reports on the ongoing courses as well as original
scientific works concerning the pathophysiology of the communication
process, theoretical foundations of phoniatrics as a scientific
discipline and the problems of phoniatrist education. The publishing
of the Phoniatric News was suspended in 1970 . Now Polish phoniatrists
publish their scientific papers in the bimonthly “Polish
Otolaryngology”, which is an organ of the Polish Society
of Otorhinolaryngologists and H/N Surgeons. Division of the
journal called “Phoniatrics” changed its name to “Phoniatrics
and Audiology” in 1979. Polish phoniatrics has a representative
in the State Otolaryngology Board, which consists of five people.
The aim of the board is to control and program the development
of individual specializations. Scientific activity within Polish phoniatrics Phoniatrics as a scientific discipline has been developing in Poland in close relation with the trends, tendencies and scientific achievements of the European phoniatrics. All famous Polish phoniatrists of the old generation were trained along with Austrian (E. Froeschels, D. Weiss) or German (Flatau, Lange, Nadoleczny) phoniatrists and held close relations with them. Many phoniatrists of the younger generation were in a close scientific and friendly contact with professor M. Seeman and his successors Eva and Karel Sedlacek, who organized the first independent phoniatrics clinic. We also feel associated with the school of H. Gutzman, due to professor Seeman, who was a famous student of this great phoniatrician. Polish phoniatrists are also in the close and friendly relations with their colleagues from other European countries like Russia, France, Switzerland, Yugoslavia, Spain, Holland or the Scandinavian countries. As a result main trends in the scientific activity of Polish phoniatrists also reflect, besides some peculiarities characteristic of the given language and country, the problems of phoniatrics in Europe.
1. Hearing disturbances and children deafness. Works in this domain concern mainly audiological diagnosis methods (the examination of hearing with filtered noise bands, the examination of phoneme recognition and discrimination in word tests, objective topodiagnostics of hearing disorders, construction of new acoustically balanced speech audiometry tests. electrophysiological examination, ERA , otoacoustic emission), acoustical voice structure examination methods, the formation of musical speech factors, X-ray larynx examination and state-of-the-art in rehabilitation methods for children with hearing disturbances. The above methods are not limited to the rehabilitation of articulated speech only but they also include voice, hearing and the environment the child lives in (e.g. advice centers for mothers with deaf children). Recently were worked out the complex problems of diagnostics and rehabilitation in patients with cochlear implants together with evaluation of their influence on voice performance. New solutions in hearing screening in neonates and children were prepared as well as basic problems in prophylaxis and prevention of hearing disabilities. 2. Stammering examinations, performed mainly in the centers in Wroclaw, Warsaw, Gdañsk, and Poznañ. Their aim is to explain some problems in the area of etiopathogenesis (electrophysiological examination like ERA, EMG, EEG and those of the electrolyte volume in blood serum, usg, X-ray kinematographic examination of respiratory, articulatory and phonatory organs). The results of these examinations led up to the isolation of the tetany stammering and subsequently made it possible to suggest an appropriate therapy including the application of kinesiotherapy, musical motor exercise, pharmacological preparations or complex treatment in appropriate specialized institutions. Further investigation in this domain concerned the development of a cybernetic model for the disphatic stammering resulting from damage to the central nervous system, especially its integration and coordination centers. 3. The pathophysiology of substitute voice after total laryngectomy. Works in this domain concern the influence of various factors before, during and after the surgery on the results of voice and speech rehabilitation, the classification of the substitute voice and speech qualities and the comprehensibility examination for this speech together with acoustic analysis using MDVP and CSL methods. Especially should be emphasize the X-ray kinematographic examination of the pseudoglottis and oesophagus as well as the electroacoustical and aerodynamic examinations of the alaryngeal voice. There are also interesting findings related to the examination of the substitute voice after the surgical formation of a pseudoglottis in patients after laryngectomy or after the application of a neck vibration apparatus. Some works discuss the examination of voice after partial laryngectomies and after X-ray and CO60 radiation therapy. These examinations have shown the important role of phoniatrists in the rehabilitation of the communication process and in the resocialization of the growing number of patients after laryngectomy. 4.
The examination of the macrostructure and the microstructure
of the physiological and pathological speech and singing voice
(in the deaf, after partial laryngectomies as well as in cases
of different forms of laryngoparesis, of voice in virilization
and other endocrinological diseases, cleft palate, in noise
induced hypoacusis, after larynx papillomatosis extirpation
and posttraumatic larynx cicatrices, in profesional dysphonia).
The examinations of the macro- and microstructure of the singing
voice are also concentrated on University Schools of Music. 6. The examination of hearing voice and speech disturbances caused by changes in the central nervous system is concentrated basically on the symptomatology and rehabilitation of these disturbances in the case of different cerebral forms of infantile paralysis and in children with low birth weight (LBW).. Another group of works is constituted by publications on prophylaxis an prevention in the case of infantile voice disturbances and for people using their voice for professional purposes. This research is the first step towards testing a compulsory examination of suitability for voice-strained occupations in our country. Other scientific papers going beyond the scope of topics discussed before concern the pathophysiology of the communication process as a whole. They show the necessity for a comprehensive presentation of all disturbances in this domain by university phoniatrics centers. Most of the problems discussed in this paper have been presented in Polish literature; a great number of articles have been published in foreign journals and presented as lectures during international symposia, which is confirmed by the following bibliography.
Literature
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