IE NOSE AND THROAT
SDICAL HISTORY,
Jonathan Wright, LI. I
SURGEON GENERAL'S OFFICE
LIBRARY.
Section,.
JVo.
./■AA-7-P6-
/
THE
NOSE AND THROAT
IN
MEDICAL HISTORY.
" LI BttafcY ' 1
sjkiis on ecM.Mcsof PiCc
OUH. -16-190.3
Jonathan Wright, M. D.
Lewis S. Matthews & Co.
Medical Books,
2623 Olive St. ST. LOUIS.
W55U
I83&
THIS BOOK IS DEDICATED TO THE MEMORY
OF MY FATHER.
PREFACE.
A few words may not be amiss in the way of preface to this
history of the development of our knowledge of the nose and
throat. No one can have engaged in any such laborious task as
this without being painfully conscious at the last of the liability,
nay, the probability that many errors of omission and commission
will be noted by others in one's work. For these I can only
solicit the reader's charity.
An attempt has been made to link together the story of the
records of the nose and throat in medicine with the general drift
of medical history, with the salient features in the early history of
the civilization of mankind and with the general literature which
has a bearing upon the central subject of the work; for, as Hux-
ley has said: "Science and literature are not two things, but two
sides of one thing." This has been done in constant fear of ren-
dering my story too verbose and pedantic, but with the earnest
hope of riveting the attention of the reader in a way which can
not be attained in the routine preparation of an encyclopedia or
a dictionary. I have also ventured to hope that the information
thus laboriously offered will not, on account of its form, preve
less accurate or extended because an attempt has been made to
make it more attractive. If I have failed in realizing these ideals—
and who ever fully succeeds?—I may comfort myself with the reflec-
tion that the labor expended in an attempt to attain them has
been fully repaid by my pleasure in the work itself.
In the preparation of this work I have taken my notes chiefly
from the original sources. In addition I have made use of many
historical works both of medicine and of general literature.
Among the former those of Sprengel (the French edition of his
history), Baas (in English translation), Whittington, and espe-
cially Gordon Holmes' "History of the Progress of Laryngology,"
(Med. Press and Circular, July 15, seq. 1885), and Heyman's
"Geschichte der Laryngologie und Rhinologie" in his "Hand-
buch;" among the latter those of Buckle, Guizot, Freeman,
Draper, Lecky, Gibbon, Grote, Ranke, Prescott, Renan, and many
others have been systematically read during the course of my work.
The space of a preface would not suffice for acknowledgment
of indebtedness to all the works consulted.
*
INTRODUCTION.
In every age there have been attempts to draw from the appear-
ance of the countenance, especially from the shape and size of the
nose, prognostications as to the mental and physical attributes of
men; but although many are the rules laid down for the guidance
of observers, they are of little value; for while doubtless the features
tell their story to us occasionally, if we are close observers, in
spite even of the modern and scientific treatises of Bell and of
Darwin, the expressions are too fugacious and elusive to allow us to
gather from them any reliable data as to the characteristics of the
individual. i SeSaorai' fiirj? vovaov Ixao-To? Irjrpos e6aXp.wv IrjTpol KaTe.crTa.01, ol 8k Ke.a\r}<;,
ol 8k 686vt(dv, ol 8k twv koto. vr}8vv, ol 8k rutv aaveu>v vovo- y°u wiH find the word there used in describing how, after eating a
brace of Greeks and swilling barrels of wine, the bloody swinish
giant fell over in drunken stupor on his back in the cave while
wine and morsels of his cannibalistic feast regurgitated from his
capacious pharynx ("Odyssey," IX, 373).
dpvyo<*pv£ (throat) of Euryclea to prevent her crying out.
Even in the works of Hippocrates a similar looseness of meaning
is to be observed, as, for instance, in the Littre edition (Vol. VIII,
P. 565), where the translator renders the word as larynx. Galen, *
however, in his comments on Hippocrates, declared that by the
term pharynx the latter understood that region which is situated
in front of the gullet and wind-pipe and which may be inspected
by depressing the tongue.
The word larynx is, not found in Homer, but is first noted among
the dramatic poets; but here again quite indefinitely arousing our
suspicion that Xdpvi may have been at first a corruption and a
tautological use of the word cfrdpvi- This may be seen by a
reference to the plays of Aristophanes ("The Knights," I, 1363;
"The Frogs," I, 575). In the "Cyclops of Euripidies" (I, 157)
occurs the passage, /twy tov Xdpvyya SieKara|e crov, which the
dictionary translates, "Has aught run gurgling through thy
throat?" The thought arises from this quotation that the idea of
Drink in the the drink going into the larynx must have originally arisen from
the resonance of the larynx and trachea transmitting the sound of
the swallowed liquid from the esophagus. This might have been
still further strengthened by the sight of the movements of the
larynx in the act of deglutition. Hippocrates, however, will be
found to use the word more correctly when referring to results of
the division of the wind-pipe ("The Flesh," 18), and in the chapter
("Concerning the Nature of the Bones," 1) where he describes how
the larynx goes to the lungs and thence to the top of the bladder,
but even as late as Galen the two terms were occasionally used
interchangeably. Aristotle also uses the word in its present signi-
fication and only rarely speaks of the wind-pipe, i. e., the trachea,
* Ed. Kuehn, XVIII. B. P. 264.
28
as extending from the lungs to the mouth. Not until Galen, how-
ever, do we find the term definitely established by his anatomical
descriptions.
Homer uses the word Ao-dpayo<; once in the "Iliad" (XXII,
328), as a similar but more indefinite term. The god-like
Achilles, with the terrible spear, smote Hector in the throat, above
the clavicles, where the neck starts from the shoulder, in order that
there might be quick loss of life. "There the point went through
the tender neck," but the Ao-dpayo<; was not cut, in order that the
prostrate man might answer the victor's cruel taunts. It is clear,
therefore, that Homer recognizes, by this term, the organ from
which the voice issues. We may be allowed to conjecture, in the
absence of any information to the contrary, that this term Aacfrdpayos
arose from the contemplation of the wind-pipe as it sprouted from
the root of the lungs of the slaughtered sacrificial animals, whose
entrails were examined by the priests in their religious ceremonies
for prophetic indications. It must have appeared to them not
unlike a thick stalk of the vegetable for which the word, in one of
its two forms, was identical, according to the dictionary. From
this may have come (f>dpv$ and later Xapv$. This, however, is
entirely conjectural on my part.*
Daremberg is of the opinion that Homer, and, of course, by
Homer we mean the men of his day, knew that food and drink
passed down the gullet. He refers to the "Iliad" (XXIV, 641,
642), but I am not satisfied that XavKavirjs, the word employed,
meant the esophagus. It seems to have been applied almost as
loosely as the other Greek words for throat (Vid., etc., XXII, 325).
We will discuss later the interesting error of the ancients in
regard to the destination of liquids when swallowed. It is well
known, of course, that the word trachea arose from the subsequent
use by Erasistratus (Sprengel) of that Greek adjective, meaning
"rough," in connection with the artery (apT-qpia. i-pa^eia) to signify
that it belonged to the same class of structures as we now know
to carry blood and not air. The artery part of the name was
dropped when this error passed away and the trachea remained.
Bpdyxos was a word also frequently applied to the whole wind-
pipe, but later coming into use for the channels below the division
of the trachea.
* While the root of the word pharynx is said to be the same as in £pw— Latin fero—
we may imagine it is true, without any proof to the contrary, that the word aspharagos
arose as here stated.—Vid. Cent. Diet, and Greek Lexicon.
29
Finally, I quote from another brochure of Daremberg* the deri-
vation of another term rhinologists use every day:
"Euripides (Fragm. 1044) is, I believe, the first author where
one meets with MvktJp—the nostrils or the nose. It seems also
that Sophocles (Fragm. 58), and especially Aristophanes (Fragm.
650), calls the nose or the nostrils by the name Mv£a, which is
regularly applied to the mucus which escapes from them. ("The
Knights," 910; "The Wasps," 1488).
Scientific and philosophical records being so defective, and
purely medical treatises being entirely lost, if any existed before
. the Hippocratic era in Greece, we can not hope to glean much in
regard to our subject from this period. Nevertheless some faint
reflections may be found in the works of the later writers.
Early Greek Here is a fragment suggestive of the character of early Greek
Superstition. . . ,
medicine, showing that it differed little from that of other rude and
uncivilized races. The Dog and the Serpent were alike sacred to
^Esculapius, and on the second one of the columns, seen by
Pausanias at Epidaurus, this record has been found engraved
among others of medical interest, testifying to the efficacy of the
holy dogs kept at the shrines. A child of Egina, "affected with a
tumor of the neck, applied to the god. One of the sacred dogs
licked the affected part and cured it. "f
Philosophy has always at all epochs of Medicine dominated it.
Pythagoras established four elements: Earth, Fire, Air and Water
—Empedocles admits these, but adds to them their qualities: the
cold and hot, the wet and dry, which are found in medicine until
the Renaissance.
In Plutarch's "Morals"J there are to be found some curious chap-
ters on the senses, and he there quotes from many of the old Greek
philosophers who lived before the time of Hippocrates and whose
writings were apparently extant in the time of Plutarch (46 A. D).
The chapters on smell and taste are of interest to us here.
"Alcmaeon (B. 520 B. C.) believes that the principal part of
the soul, residing in the brain, draws to itself odors by respiration.
Empedocles (B. 490 B. C.), that scents insert themselves into the
* "L'Etat de la Medecine entre Homere et Hippocrate."
t Reinach: "Revue Archeologique," 1884, II, P. 129; 1885,1, P. 267. For a most interest-
ing account of the Temple of .Aesculapius at Epidaurus, see apaperby W. S. Coleman, M.D.
F.R.C.P., St. Thomas Hospital Reports, Vol. XXVII, 1898.
For a very readable account of the cult at Epidaurus, see "The Temples and Rituals of
Asklepios," by Richard Caton, M.D., etc., 1900.
X Translation. Ed. Goodwin, 1870, Vol. Ill, P. 170 (De Placitis Philos.).
30
breathing of the lung; for when there is great difficulty in breath-
ing, odors are not perceived by reason of the sharpness; and this
we experience in those who have the defluxion of Rheum."
"Alcmaeon says that a moist warmth in the tongue, joined with
the softness of it, gives difference of taste. Diogenes,* that by the
softness and sponginess of the tongue, and because the veins of the
body are joined in it, tastes are diffused by the tongue; for they
are attracted from it to that sense and to the commanding part
of the soul, as from a sponge."
Alcmaeon is said to have been the first Greek anatomist and to The Eusta-
have dissected the eyes and ears of animals, discovering the optic
nerve and the Eustachian canal, thus antedating in the latter dis-
covery Eustachius by many centuries. Aristotle (Hist. Animal I,
IX, i) comments on a mistake of Alcmaeon in supposing that
goats breathed through their ears. It is singular that this error
should crop out so late as the seventeenth century A. D., but
Tulpius may be foundf asserting, in spite of Aristotle, that on
account of this anatomical configuration, as described by Alcmaeon,
it is possible in labored inspiration for air to find this auxiliary
passage to the lungs.
Alcmaeon explained hearing by the hollow bone behind the ear—
"for all hollow things are sonorous." (Plutarch 1. c.)|
Empedocles discovered the labyrinth of the ear and explained
sound by the impress of air upon it as upon a drum. In one of
the fragments preserved from the "Carmina of Empedocles,"§ we
read: "Thus they breathe out and in. Bloodless tubes extend
through all the flesh throughout the whole body, and the end of
these placed within the nostrils is perforated by large openings
leading to the cavities (cerebral?) so that they may hold back the
blood and open free passage for the air through the meatus." This
perhaps would suffice to illustrate the confusion in regard to
anatomy which existed among the best informed of those philoso-
phers older than Hippocrates, but I may perhaps be allowed to
add an embryological idea which Sprengel has found among the
fragments of verses of Empedocles: "He attributed the forma-
* I presume Plutarch here refers to Diogenes of Apollonia, born in the fifth century
B. C, who described the distribution of the blood vessels, which is to be found in the frag-
ment of his writings still preserved. "Fragm. Philosoph. Graec. Mullach," Vol. I, P. 254.
t Observat. Med., 1641, Lib. I, Cap. XXXV.
X See also Kuehn: "Opuscula Minora," I, P. 69.
I "Fragm. Philosoph. Graec." Mullach, 1875, 2d Vol. I, 343 f. f.
31
tion of the abdominal cavity and that of the intestines to the sud-
den and rapid passage of water through the body at the moment
of its formation, and the external openings of the nose to a current
of air which was established from the interior to the exterior."
Diogenes of Apollonia (500-400 B.C.) explained the superior
intelligence of men by supposing they breathed a purer air than the
beasts which carry their noses near the ground. (Draper.)
The Atomic Democritus is said to have been born at Abdera in the same year
(460 B.C.) and to have been greatly admired by Hippocrates, who
reproved the countrymen of Democritus for having supposed him
insane and for sending for him to cure him. He is said to have
derived his atomic theory from Leucippus (B. 500 B. C.) He is
quoted by Plutarch (1. c.) in regard to the voice as saying that
"the air is broken into bodies of similar configuration and these
are rolled up and down with the fragments of the voice." This
statement seems, of course, rather fantastical and we might suspect
Plutarch had confused a more intelligible passage from Democri-
tus did we not find in one of the fragments* remaining to us from
Democritus an analogous statement as to taste, the distinctions of
which he attributed to the different shapes of his atoms. Plutarch
continues: "The stoics say the air is not composed of small
fragments, but is a continued body and nowhere admits a
vacuum; and being struck with the breath, it is infinitely moved in
waves and in right circles until it fills that air which invests it, as
we see in a fish pool which we smite by a falling stone cast upon
it; yet the air is moved spherically, the water orbicularily.
Anaxagoras (B. 500 B.C.) says a voice is then formed, when
upon a solid air the breath is incident, which being repercussed is
carried to the ears; after' the same manner the echo is produced."
Out of much which is to us mere jargon, but which to them was per-
haps full of meaning, it may be seen that we may occasionally extract
passages which need little altering to conform with modern
doctrine.f
* "Fragm. Philosoph. Graec." Mullach, 1875, Vol. II, P. 362.
t It is absolutely necessary for any one desiring an intelligent knowledge of the med!
cal theories in the writings of Hippocrates and of all subsequent medical writers, that he
should acquaint himself thoroughly with the material and psychic philosophy of the
ancients. A very good re'sume' of the subject so far as it applies to medical doctrines may
be found in the Preliminary Discourses attached to Adams'Sydenham edition of "The
Genuine Works of Hippocrates," while Draper in his "Intellectual Development of Eu-
rope" gives a somewhat biased review of Greek philosophy in its broader ramifications.
In the "Proemium of Celsus," however, will be found the most succinct and the clearest
account of Medical Schools among the ancients.
32
THE HIPPOCRATIC TREATISES.
So completely have the records of Greek medicine before the time
of Hippocrates perished, that he seems himself to have created it.
It seems to have sprung from him and his associates, like Athene
from the head of Zeus, or like the sudden growth of the infant
Apollo after tasting of the ambrosial cup from the hand of Themis,
to have started at once into the full life of a vigorous and fruitful
manhood. We may be sure, however, from the cold analysis of
historical experience and of philosophical logic that there must have
been a long previous condition of growth and development, which
can not be traced in the scanty remnants of history left us.
On the authority of Celsus (Lib. I. Proemium) we must accept Hippocrates as
Hippocrates as really the first medical specialist in our civilization, a specia ist-
for he was the first to separate medicine from other sciences and
devote himself exclusively to that branch of knowledge, for which,
no doubt, as we may judge from reading Plato, he was regarded by
other philosophers as lamentably narrow and one-sided. Reasoning
from experiences of later ages, we may imagine that after a little
time some philosophers, who thirsted after the reputation of progres-
siveness, acknowledged that this specialization might possibly be ex-
cusable, provided the heretic had first spent all the productive years of
his youth in the pursuit of inquiry into the nature of the gods and
the occult properties of the four cardinal elements, fire, earth, air
and water. I can not forbear giving here Celsus' explanation of
how it happened that philosophers took up the study of medicine at
all, since it is somewhat amusing. He intimates that the old phil-
osophers spent so much of their time in sedentary contemplation and
nocturnal vigils that they fell sick, and were forced to resort to the
study of medicine to cure themselves.*
The civilization of the Chaldean and the Parsee, of the Egyptian
and even of the Hindu is strange and incomprehensible to us, but
we instinctively feel that the Isles of Greece, that Cos, over oppo-
site Abdera is a familiar land, and that there we will find a mental
* "Ergo etiam post eos, de quibus retuli, nulli clari viri medicinam exercuerunt; donee
tnajore studio literarum disciplina agitari coepit, quae, ut animo praecipue omnium neces.
saria.sic corpori inimica est. Primoque medendi scientiae sapientiae pars habebatur, ut et
morborum curatio, et rerum naturae contemplatio sub iisdem auctoribus nata sit: scilicet iis
hanc maxime requirentibus, qui corporum suorum robora quieta cogitatione, nocturnaque
vigilia minuerant. Ideoque multos ex sapientiae professoribus peritos ejus fuisse accep-
itnus; clarissmos vero ex iis Pythagoram, et Empedoclem, et Democritum. Hujus autem,
ut quidam crediderunt, dicupulus Hippocrates Cous. primus quidem ex omnibus memoria
diguus ,ab studio sapientiae disciplinam hanc separavit, vir et arte et facundia insignis."
It is needless to say that those acquainted with the writings of Celsus will recognize inthis
passage his bias towards the vital importance of bodily exercise in therapeutics.
33
activity into which we are able to enter. When we read in Xeno-
phon's Anabasis (III n 9) that the soldiers cried out when their
comrade sneezed, "Zcv aoxrov," "God save you," immediately comes
to our mind the Frenchman's ejaculation "Dieu vous benisse," and
the Germans' hail, "Gesundheit."* Turn to Hippocrates' account of
the case "In Thasus, the wife of Dealces who was lodged on the
plain"f and read there his account of a death from fever with cere-
bral symptoms. No such vivid impression is left on the mind by
any other portrayal of the fatal march of a mortal disorder until we
find Shakespeare describing in Dame Quickly's patois the death of
Falstaff, who was "so shak'd of a burning quotidian tertian that it is
most lamentable to behold," and how "at the turning o' the tide"
she saw him "fumble with the sheets and play with flowers and
smile on his fingers end," and noted that "his nose was sharp as a
pen," how "a' babbled of green fields," and cried out, "God, God,
God, three or four times," and "his feet were as cold as any stone."
The wife of Dealces fumbled with the bed clothes and picked at the
hairs on them and laughed and there was much talk and again she
was silent. Adams (1. c. p. 196) supposed Shakespeare to have
derived his description second hand from the celebrated passage in
HippocratesJ as to the facies of death, but it seems to me that
it bears a much closer resemblance to the description I have
alluded to. I do not believe Shakespeare ever had any knowl-
edge of either of these passages in the Hippocratic writ-
ings, either first hand or second hand. We are struck by the
resemblance of the impressions made on our minds by the words of
two masters in the description of similar objective phenomena. It is
the stroke of the master artist, the touch of immortal genius which
sprang as frequently from the soil of Greece in its Golden Age as
it did from that of Britain at the zenith of her literary glory. Such
objectivity is not to be found in the Orientals' dream of life. Do
we find here an explanation, or part of an explanation, of why the
civilization of the Orient, of the Ganges and of the Nile has stood
still for 3000 years and can not now be aroused from the slumber of
so many centuries? At least we can comprehend somewhat from
this objectivity how the virile fructifying aggressive mind of the
* This ancient custom, however, is older than the Greek civilization.
t Epidemics III Sec. 17, case XV. Adams Syd. Edition Genuine Works of Hippocrat
All reference to the Hippocratic treatises are to the Littre edition unless otherwise, as he
noted. <
X Prognostics 2, Adams.
34
Ancient Greek furnished a soil for the quick luxuriant growth of
seeds from a dying civilization, dying even then with its youth
stretching back into the inscrutable past of prehistoric times.
It must be borne in mind that Hippocrates lived in that glorious The Era of
time of Greek civilization and culture, the golden age of Pericles, Hippocra
that his life overlapped that of Phidias and Praxiteles, of Anaxa-
goras, Socrates and Democritius, of yEschylus, Euripides, Sopho-
cles and Aristophanes, of Herodotus, Thucydides and Xenophon,
of Plato, Aristotle and Demosthenes. Never since, in the history
of the world, have there existed in the span of one man's life so
many men whose fame still shines in mortal records and whose
words still influence the thoughts of men. Such a throng was not
to be gathered from all the broad empire of Augustus, nor to be
found in the brilliant court of the Grand Monarque, nor among
those who flourished in the days of England's Virgin Queen. None
can say that the great name of Hippocrates stands less illustrious on
the role of medical science than does that of Socrates in philosophy,
of Phidias in sculpture, of Demosthenes in oratory, of Thucydides
in history, or of Aristotle in science. It is the evidence of the
knowledge of the upper air passages and their diseases possessed
by this great primeval figure in medicine with which we are now
concerned. Among the large number of writings ascribed to Hip-
pocrates, there are only a few which have been acknowledged by
all authorities to have been really written by him. Some have been
■proven, many have been surmised, to have been written by his pre-
decessors and successors. It seems probable that some were written
by others during his life time who had the benefit of his guidance
and of his instruction. However this may be it is not my aim to
enter into a general discussion of such matters, but rather to bring
into prominence those gleams of light thrown upon our subject
which have come to us across twenty-five centuries. A reference
to the editions of Adams and of Littre and to the works of Galen,
will enlighten the reader as to the books which are accredited to
Hippocrates himself and as to those which are supposed to have
been written by others of his time or school. Some of the pas-
sages in the writings of these .Esclepiadae seem ridiculous to us,
but we should keep constantly in mind the charity which our suc-
cessors in their histories will have to extend to the productions of
our own times. Indeed, in looking over the various commentaries
on Hippocrates from Galen's time to our own, it is curious and not
a little amusing to observe how careful each critic is to point out the
errors Hippocrates committed in not being in accord with the doc-
35
trines of the critic's own time, which are now as obsolete as those
of Hippocrates. So little does Hippocrates have to say of the
cure of diseases that Asclepiades, an early type of the genus char-
latan, subsequently ridiculed his system by saying it was the con-
templation of death. It is perfectly evident that he recognized the
futility of drugs as curative agents, and all his works, especially
those which are supposed to be genuine, testify to the persistence
with which he studied the symptomatology rather than the phar-
macology of disease.
Innumerable facts have been discovered since these early times,
and the wonder chiefly is that they should have then been able to
reason as acutely as they did from the little actual knowledge they
had of normal anatomy or of pathological processes. We have
seen from the few extracts I have been able to gather how primi-
tive knowledge of the anatomy and physiology of the upper air
passages was. In the Hippocratic treatises themselves we find it
little more advanced.
In fact, until the writings of Galen, the knowledge of anatomy
seems to have been almost nil from a modern standpoint.
"Drink through the pharynx and oesophagus. Larynx to the
lungs and trachea. From these to the top of the bladder." This
is the literal translation of the Greek text as given in Kiihn's edition,
but Kiihn himself translates it "Potus per fauces et gulam, arteriae
summum, quod larynx dicitur, in pulmonem et arteriam ex quibus in
summan vesicam." This latter passage occurs in the book on the
"Nature of the Bones (I) which is apparently a collection of notes.
In the fragment of the book on "Anatomy" we find it stated that
the bronchi terminate at the top of the lungs, being composed of
curved rings. Then follows a description of the lungs and of other
organs detailed in such a manner that no room is left for the sup-
position that the writer had any idea that fluids passed through the
lungs to the bladder. Again, elsewhere,* we find, "If any one will
give water tinctured with a blue color or with vermillion to a thirsty
beast to drink, preferably to a swine, for this beast is not fastidious
but dirty, and will then cut the beast's throat after the drinking, he
will find it colored with the fluid." Nevertheless he says the greater
part of it goes to the stomach. At the end of the Fourth Book on
Diseases the author distinctly combats the idea that drink passes
through the larynx. It is evident, therefore, from these quotations
that no one man, but several, wrote the so-called Hippocratic
* Liber de Corde. Edit. Kiihn I, p. 485.
36
treatises. History tells of the great rewards offered by the Ptolemies
for manuscripts of well-known authors for their great library, and
nothing seems more certain than that enterprising, and of course
highly-respectable "rare-book" dealers, found it more convenient
to write than to find hitherto unknown treatises of Hippocrates. The
author of the Fourth Book on Diseases says, referring to the epi-
glottis, that the presence of a process in the form of an ivy leaf
prevents liquid from entering the larynx and keeps it in the pharynx.
He declared that the sounds emitted on expiration were multiplied
by the resonance of the head. The tongue articulates as the air is
driven out striking against the palate and the teeth. "All of which
shows that it is the air which makes the noise." In the book on the
"Flesh" (19) it is recognized that severance of the larynx stops
the voice, which is regained when it is reunited.
On the subject of the destination of liquids when swallowed, there
is a very curious chapter among Plutarch's "Symposiacs (Book
VII). When a line from the poet Alcaeus(6ii, 580 B.C.) was
quoted, "Now drench thy lungs with wine, the dog appears"*
(Dog Star), Nicias of Nicopolis, a physician, is made to say that
Plato should be reproved for the passage in the Timaeusf where he
adopts the same error. He enters into an argument in refutation of
the idea that the drink passes into the lungs, and he instances the epi-
glottis as an apparatus for preventing it. In the discussion which
followed Protogenes, the grammarian, claimed that Homer first spoke
of the stomach as the receptacle of the food, and of the breath and
windpipe as the instruments of the voice, but the discussion onthis pas-
sage in Homer hinged upon the meaning of the word dpv£ which
we have seen had a very indefinite meaning. Florus quoted many
poets, among them Euripides, who affirm with Plato that the drink
passes into the lungs and the conclusion of Plutarch's Symposium
seemed to be that Plato was right. Florus asserts that not only
Hippocrates, but his pupil, Dioxippus, (390 B.C. ?) and Philis-
tion, a very ancient physician of Locri, had no other thought.
Dioxippus supposed that the epiglottis served to divide the food and
drink into the coarser parts which passed into the stomach and the
* Vid. Gaisford: Poet. Min. Graec. Vol. HI, p. 321, XVIII.
t The passage referred to reads "the lung is a soft and bloodless organ, and moreover
is full of pores internally, like a sponge, in order that receiving air and drink it may refresh
the heart, quiet it and cool the heat which burns it. This is the reason why the channels
of the trachea are directed towards the lung, and the lung is placed near the heart." A
few lines further on it is evident, however, that Plato recognized that some of the liquids at
least go to the stomach, or rather "the region between the diaphragm and the navel."
37
finer parts which passed into the lungs. Aristotle* did not share
this error at all, but distinctly states that the larynx is only for the
passage of the air and the voice. From a passage in this symposium
Sprengel seems to draw the conclusion that Erasistratus taught that
the drink does not pass into the lungs. Now, Plutarch's writings
are of a date in the first century of the Christian era, 500 years after
the time of Hippocrates and 400 years after the time of Erasistratus.
One hundred years after Plutarch we will find even Galen in a
modified form entertaining this idea. He says, in reference to it:
"If Plato supposed that we take all our drink into our lungs, it is
proper to remark that he was ignorant of a very evident matter. If
he supposed, however, some part of the drink passing through
the trachea is carried to the lungs, he announces a thing possible
and like other matters concerning which physicians and philosophers
may disagree among themselves." He then proceeds to state that
it is quite possible for a small amount of fluid to steal down the
sides of the air tubes without producing irritation sufficient to cause
a cough.
We may, since we have already digressed somewhat, add here
another mention of Hippocrates by Plutarch, f He compliments
him as a man of wonderful skill in physic and fit to be imitated
by the greatest philosophers, especially as to his ingenuousness for
"he confessed publicly that he had mistaken the nature of the sutures
of the skull,| and has left an acknowledgement under his own hand ;
for he thought it very unworthy a man of his profession not to dis-
cover where he was in the wrong seeing that others might suffer and err
by his authority." Plutarch's comment on this is quite as applicable
to-day as in his own time. "And indeed it had been very un-
reasonable, if he whose business and concern it was to save others
and set them right should not have had the courage to cure himself
and to discover his own weakness and the imperfections in his own
faculty." Quintilian echoes Plutarch's eulogium.§
The origin of When we realize that the ancients, Hippocrates, Galen and their
Catarrhs. followers, knew nothing of the muciparous glands, and of course noth-
ingof thefunctionof these microscopic structures, it is easy to under-
standthe absolute mental necessity for them to find some explanation
* On the Parts and Gait of Animals. Ill, 111, 4.
t Man's Progress in Virtue.
X Vid. Hippocrates: Epid. V, I 27—ef. De Vuln. Cap. I 12.
i Celsus, from whom probably Plutarch and Quintilian drew their information, remarks
in regard to Hippocrates' superiority in this respect over lesser men. "Nam levia ingenia,
quia nihil habent, nihil sibi detrahunt." Lib. VIII, Cap. IV.
38
of the origin of the secretions which bathe not only the respiratory
tract, but the gastro-intestinal mucous membranes as well. As for
the moisture of the lungs, it is natural that they should look for
some explanation in the liquids swallowed. This lack of knowl-
edge, as well as a mistaken anatomical observation, led them into
another error which persisted still longer. The cribiform plate of
the ethmoid bone (the sieve like bone) at the top of the respira-
tory tract, was usually seen only in the dried specimen by the an-
cients unfamiliar with dissection of the human body. The idea
arose that the humors were distilled in the gland like contents of
the cerebral cavities and sifted through the cullender plate of the
ethmoid to parts below. If we can find no trace of this idea in
Hindu or Egyptian medicine, Herodotus* supplies us with in-
dubitable evidence that it existed among the Libyans. He says:
"The Libyans, when their children come to the age of four years,
burn the veins at the top of their heads. Others burn the veins
about the temples. This they do to prevent them from being
plagued in their after lives by a flow of rheum from the head and
such they declare is the reason they are so much more healthy
than other men. In all this I only repeat what is said by the
Libyans themselves." This burning, as we shall have occasion
hereafter to note, was the sovereign Arabian cure for all diseases.
This idea of the cerebral origin of catarrhs once fixed in the
conception of medical men was not detected as an error even by
Galen himself, whose anatomical knowledge was so extensive, f
They supposed that the airs and vapors, as they called them, were
inspired through the cribiform plate by the brain acting like a live
sponge, drawing up into itself not only the moisture but the air of
the nasal cavities and then redistilling them. Hippocrates says
olfaction takes places through the cribiform plate. The latter he
describes as being made of cartilage, soft like a sponge, and is
neither flesh nor bone. J So entirely had this conception of the
anatomy and physiology of the cribiform plate taken possession
not only of the medical mind, but so completely had it passed into
the popular mind, that it was supposed that the mental processes
were sluggish in those in whom the faulty excretion led to a clog-
ging of the brain with mucus. Hence, we find in Greek that not
only Coryza stands for a cold in the head, but it was the name ap-
plied to a fool, a driveller. Still more was this evident in the
* Liber IV, Cap. 187.
t Vid. Galen: "De Iustrumento Odoratus." Cap. iv.
X "The Flesh," No. 16.
39
Latin tongue. "Emunctae naris" refers to the mental acuteness
of the individual because he was supposed to keep his nostrils,
the cloaca of the brain, 'well cleaned out. This is found chiefly in
the satirists.
"Hinc omnis pendet Lucilius, hosce secutus
Mutatis tantum pedibus numerisque, facetus,
Emttnctce naris, durus componere versus."
Horatii Satira IV, 6.
"Obesae Naris," fatty or obstructed nose, in distinction to
"emunctae naris" referred to mental dullness. Many similar pas-
sages may be found in Martial. Hippocrates believed that in
order to smell well the nose must be dry, and probably this arose
from the observation of obtunded olfaction during a cold. He
supposed that the vaporous parts of the inspired air escaped
through the sutures of the skull.
Hence we may understand why Hippocrates looked upon the
brain, which he described as a gland, as the origin of all catarrhal
troubles, naming seven, of the eyes,* of the nose, of the ears, of
the stomach, of the throat and lungs, of the spinal cord and of
the hips. The acrid humors were distilled to these parts by
various routes—to the respiratory and digestive tracts through
the cribiform plate—but all starting from the brain.
In his book on "Ancient Medicine," where he protests against
the entertainment of hypotheses as to etiology, Hippocrates de-
scribes the symptoms of a coryza. "This discharge is much more
acrid than that which is usually found in and runs from the nostrils
daily ; and it occasions swellings of the nose and it inflames, being
of a hot and extremely ardent nature, as you many know if you
apply your hand to the place; and if the disease remains long, the
part becomes ulcerated, although destitute of flesh, and hard, and
the heat in the nose ceases, not when the defluxion takes place, and
the inflammation is present, but when the running becomes thicker
and less acrid and more mixed with the former secretion ; then it is
that the heat ceases." One of the Aphorisms (II. 40) reminds us
that catarrhs and coryzas are not severe in old people. It is
clear from a passage in the "Airs, Waters and Places" that
Hippocrates believed that not only do stomach catarrhs have their
origin in the head, but that nasal catarrh produces gastric symptoms.
"Their bellies are subject to frequent disorders, owing to the phlegm
* The Glands 10.
40
running down from the head." Another modern idea we are re-
minded of in the relation of a case* of habitual catarrh which was
cured in three days by coitus.
Cynanche, which English translators usually render as quinzy, is Acute Throat
a term Hippocrates applied to nearly all the acute inflammations of mflamma-
the throat. Littre (V. p. 579) discusses the question as to whether
Hippocrates was familiar with diphtheria. Croup, Littre calls it.
It is doubtful whether the cases are sufficiently differentiated in the
Hippocratic writings to make them intelligible to modern readers.
Even in the time of Littre's edition (1846) they would seem more
intelligible than in these bacteriological days. They were of a very
severe type, apparently, whatever the .nature of them. We may con-
jecture that the peculiar and striking features of Ludwig's Angina or
erysipelatous pharyngitis and laryngitis arrested Hippocrates' atten-
tion and caused him to record the casef of "the woman affected
with quinzy who lodged in the house of Ariston." Pro-
found constitutional symptoms, severe external swellings, and
evidently internal stenosis, causing dyspnea and the return
of fluids by the nose, rapidly brought the case to a fatal term-
ination. The etiology of cynanche was supposed by Hippocrates to
be the coagulation of the blood in the vessels of the neck. One
cannot imagine what sort of an angina could be the cause of opis-
thotonosj lasting forty days and getting well. One has only
to refer to "Diseases II," 26, 27, 28, 29, 30, 31, 32,
to perceive how severe was the type of throat inflammation
with which the Hippocratic writers were familiar and yet how im-
possible it is from the description to more than guess at thaxlass we
would now put them in ; as, for instance, No. 26 seems to have been
diphtheria, while accounts of the others indicate, some of them a
milder type of disease, and some ending fatally, but apparently not
diphtheria. In the "Coan Prognostics" is a paragraph (II 14)
which deals entirely with the prognostics of acute throat inflamma-
tions, but it is of little modern interest. In the "Aphorisms" (IV
34, 35) Hippocrates declares that "if a person laboring under a
fever, without any swelling of the fauces, be seized with a sense of
suffocation suddenly, it is a mortal symptom." Moreover, "if, in
a person affected with a fever, the neck become suddenly distorted
and he cannot swallow, except with great difficulty, although no
* Epidemics: V. 72, and VII. 69.
t Epidemics, III-VII.
t Internal Affections, 53.
41
swelling be present, it is a mortal symptom." Antitoxin, tracheot-
omy and intubation have of late years somewhat impaired the force
of this prognosis, but we still recognize the gravity of the condition.
intubation. Since the following passage contains an indication that the idea
at least of intubation existed in Hippocratic times, and because also
it is a striking bit of objective description, I will translate it as liter-
ally as possible from Kuhn's text (Vol. II, p. 300):
'■'■Cynanche.—From cynanche, so-called, a man chokes, and itseems
to be especially in the pharynx, and he is unable to swallow his
spittle or anything else, and his eyes are affected and start forth as
in those strangling, and he stares with them straight ahead, and he
is not able to turn them, and he hiccups and starts suddenly up, and
the countenance and the pharynx are burning, and even the neck.
To those looking on there seems nothing the matter. He sees and
hears dully, and from the dyspnea he knows not what he says, nor
hears, nor does, but lies there with open mouth drooling and acting
thus. He dies on the fifth or the seventh or the ninth day.
'■'■Para-Cynanche.—When some of these symptoms are absent, it
appears the disease is not so severe and they call it para-cynanche.
It is necessary to bleed, especially from the vein beneath the nipple
of the breast, for this naturally follows from the hot breath, pneuma*
of the lung, and it is necessary to purge by drugs or move the
bowels by enemata, and to pass tubes into the pharynx along the
jaws, so that the breath may be drawn into the lungs, and to make
them as quickly as possible to spit and thin the lungs (clear them
out?) and to fumigate with Cicilian hyssop, and with sulphur, and
with bitumen, and to breathe these in through the tubes and through
the nostrils so that the phlegm may be cleared out, and the pharynx
and the tongue may be cleaned in those having phlegm, and the
veins under the tongue should be cut; and blood should be drawn
from the elbows if the strength is sufficient. Abstention from wine
should be enjoined and thin barley water should be taken. After
the disease has subsided and the appetite returns, purging with
fresh elaterium should be employed so that he may not fall into
another illness." The appearance of an external rash in all these
cases of severe, possibly scarlatinal and diphtheritic pharyngitis and
laryngitis, was thought by Hippocrates and Galen, and reasserted by
Avicenna, to be a good sign.
In "Diseases II," 30 and 31, he recommends hot fomentations for
what is apparently peritonsillitis, and scarification of the tonsils, but
* For accounts of the pneumatic dogma and the pneumatists see any of the histories of
ancient medicine.
42
this latter not with sufficient clearness to make us sure of the recom-
mendation. He also speaks of treating external fistulae, resulting
from this affection, with the cautery. Evidently we have here a
confusion of diseases according to modern classification.
The nature of the tonsils is explained (Glands 7) as round bodies Uvuiotomy
placed on each side of the throat to absorb the secretions from the "ftaTxin.
head and send them back there again, and to do likewise for the siis.
vapors. From acute and chronic inflammations they mav become
greatly swollen. For enlarged tonsils he advised evulsion with the
fingers. Although we find in Hippocrates no mention of tonsillot-
omy, it is evident, from what is thought to be a genuine book of
Hippocrates, viz: (The Prognostics, No. 23) that he was familiar
with uvuiotomy. In a book of less assured authenticity we read his
description of the operation. "When the uvula alone is inflamed
seize it with the finger and press it up against the palate and cut off
the end."*
As has been intimated the Greek physician had every opportunity Fractures of
of familiarizing himself with fractures of the nose. The Hippo- theNose-
cratic writers devote much attention to it. In k-Mochlicus" 2,
Articulations 35, 36, 37, 38, 39, we find minute and practical direc-
tions for its treatment. Indeed, comparatively little advance has ever
been made over their methods. Great stress is laid upon the neces-
sity of replacement within the first twenty-four or thirty-six hours
after the injury. Satisfactory adaptation of the parts must be
attained notwithstanding the patient's suffering, if a good result is
to be reached. Hippocrates complains bitterly that the patient
strongly desires the latter without being willing to submit to the
former. For lifting the fragments of bone into place he preferred
the fingers, making use of those of some boy or women assistant, if
possible, because of their small size and their softness. Internal
splints from "Carthaginian leather" or other suitable substances
were used. He condemns the use of sponges for the purpose
because they soon become foul with the discharges. He relates how
in one case he made use of a piece of the lung of a sheep, probably
as a temporary expedient. Sacrificial altars to the gods were
always near the fields where the games were held in which many
of these accidents occurred, and we may imagine the resourceful
surgeon quickly cutting a piece of the soft elastic tissues from the
open chest of the slaughtered victim and inserting it into the nostril
of some vanquished athlete. While perhaps it is not so curious, a
"De Morbis" II, 29 and 49.
43
more valuable suggestion is contained in his description of the
method of treating lateral displacements of the nose, of course when
recent. An internal splint was inserted as usual and then a long
leather thong was glued at one end to the point of the nose which
was pulled beyond the median line to the opposite side, and the
thong wound around the head and fastened by gluing to the temples
or in some other convenient fashion. This could then be pulled more
taut or loosened as occasion required.
Prom "Galeni Opera Omnia," Basel, 1561, Vol. 6, P. 593.
Hippocrates* indulges in some satirical and still instructive re-
marks concerning bandages for a fractured nose.
"Those who put great store by a senseless dexterity rejoice to
meet with a fracture of the nose in order to apply a bandage. For
a day or two the physician takes great pride in himself, and the
patient rejoices; but the latter soon tires of wearing the bandage,
which is annoying; as for the doctor, it is enough for him to have
shown that he understands how to put various bandages on the nose.
Such a bandage does, however, quite the contrary to what is desired ;
on the one hand, in those in whom the nose had been sunken, it
becomes markedly more sunken if pressure is exerted over it; on
the other hand, in those in whom the nose has been dislocated to the
right or to the left, either in the cartilaginous, or in the upper part,
these, evidently, far from deriving any advantage from a bandage
placed on it, suffer harm from it." We look in vain for any refer-
ence to operation for straightening a chronic deviation of the sep-
tum. It is a little surprising that with the experience derived from
the treatment of recent fractures and dislocations of the nose, they
should have f ailed.to remedy the chronic lesion which must have been
frequent enough. He insists that external wounds or comminution
of the fracture are not contra-indications to his plan of treatment.
He must have witnessed the results of tremendous blows, probably
* "Articulations," 35.
44
with the cruel cestus, the iron shod glove of the boxer, for he speaks
of the sinking in of the bridge of the nose when there is also exfolia-
tion of the bone of the hard palate. Evidently in these dangerous
encounters fracture at the base of the skull was an occasional result.
At least he was familiar with its characteristic symptom, for he says:
"A contusion of the head without an external wound, either by fall,
fracture or compression, produces in some cases the flow of acrid
humors which run from the head into the throat." Possibly, how-
ever he may here refer to suppuration as a result of intranasal
fracture.*
We have just seen that Hippocrates was familiar with depression syphilis (?)
of the nasal arch as the result of injury. That he was familiar with
it as the result of disease would appear fromf the relations
of the cases of two| childreu who from ulceration lost their
teeth and pieces of the bone of the palate. This caused a
sinking of the nose. They also had a bloody muco-purulent dis-
charge. This description sounds very much like that of syphilis,
either congenital or tertiary. This is thought by the majority of
writers to have appeared first in Europe two thousand years later,
brought from America by Columbus' sailors. This sinking of the
nose is again referred to in another place. §. It is to be
gathered from Galen's commentaryll that he also was familiar
with a sinking in of the bridge of the nose, due to
a loss of substance in the structures beneath. Darembergt
has suggested that syphilis is the disease referred to by
Hesiod (Fragm. 27, 28) who betrays a knowledge of some skin
diseases in aphrodisiac women. After a perusal of the text alluded
to, it seems to me very doubtful if this was the Corona Veneris as
Daremberg surmises, though crusts and blotches were found in the
scalps of these women. The passages here cited from the Hip-
pocratic writings and from Galen seem much better evidence of it.
We are unfamiliar to-day with any other disease of the palate and
gums of a chronic nature which is accompanied by exfoliation of
bone and the sinking in of the nasal arch. The nasal arch will not
* These excerpts from fractures of the nose I have taken from Adam's translation of
the "Genuine Works of Hippocrates."
t Epidemics, IV, 19.
X This is the reading of Littre's translation, and to my mind that of Kiihn's text, but
the latter's translation refers to but one child.
{• Epidemics, VI, 3.
I Edit. Kiihn: Vol. XVII A. p. 823.
1 Etat de la Medicine entre Homere et Hippocrate.
45
sink from the loss of the palate bone, except the nasal bones them-
selves are affected at their junction with the bony septum. Of course
it may possibly have been some severe case of scurvy or phosphor-
ous poisoning, but producing such results as these it seems very
unlikely.
Nasal Polypi. Probably there is nothing in the Hippocratic books so familiar to
the modern rhinologist as Hippocrates' sponge method of removing
From Baldwein.
nasal polypi.* Indeed this was a method practiced by Voltolini
and mentioned in his text book.f Until the comparatively recent
invention of the steel wire snare, it compared favorably
with other methods of ablation. An interesting paper
on the "Rhinology of Hippocrates," by Baldwein,\ is largely
♦Diseases II: This book, from which I have quoted so freely, is said to have been
written by Draco and Thessalus, sons of Hippocrates.
t "Die Krankheiten der Nase," 1890.
X "Zeitschrift fur Ohrenheilkunde," Bd. XXVIII, Hft. 2.
46
taken up with a discussion of the various methods recom-
mended by Hippocrates for the removal of nasal polypi,
and the accompanying illustrations elucidate the procedures
very much. There were several methods. The sponge method was
used for those soft pendent polypi which move out and in the nos-
tril on expiration and inspiration. It consisted of tying the ends of
three or four strings to a sponge cut to the proper size and shape. The
other ends knotted together were fastened to the eye of a soft slender
tin or leaden probe which was pushed through the nose into the
pharynx. The ends of the strings thus secured were passed over
the end of a forked probe held in the pharynx. By traction across
this, the sponge was dragged into the pharynx, if successful, bring-
ing the polyp with it. In another method for harder growths, per-
haps our fibrous hypertrophies, the principle of the snare was em-
ployed. The loop of a sinew was adjusted around the polyp, and
the end having been carried to the pharynx and traction made as
before, evulsion was attained. For still harder growths which Bald-
wein conjectured may have been bony cysts, he employed cauteriza-
tion with a hot iron through a hollow tube used as a speculum. I
do not see any reason for imagining this procedure was for this rare
form of intranasal growth. It may easily have been many other
pathological conditions, more likely to come frequently under the
observation of the physician, such as cartilaginous spurs and hyper-
trophies. He speaks of a fleshy growth in the nostrils which he
calls cancer, to be treated by the cautery, but as he says nothing
about the strikingly fatal symptoms which ensue from any form of
local treatment of malignant growth of the nose, it is doubtful if his
term is equivalent to the present acceptation of it. He doubtless
had encountered rhinoliths, for he speaks of something in the nose
which, when you touch it with a probe, sounds like a stone. For this
he recommended an external incision. After all these radical opera-
tions he advised the application of copperas powder and the inser-
tion of tents in the nostrils, smeared with oil and honey, no doubt to
prevent synechias and stenosis. I think that all rhinologists will
agree that these procedures, for the time, were not bad intranasal
surgery.
From the book on "Affections" we learn that all diseases come
from the phlegm and the bile. The Hindu idea was that all
bodily diseases come from Wind, Bile and Phlegm. Indeed, there
are many resemblances in this book, as well as the one I have just
quoted from, which remind us of the Susruta. Polypi were sup-
posed to be caused by the phlegm. It was derangement of these
47
elements which produced diseases according to the Hippo-
cratic authors. These books are not supposed to have been written
by Hippocrates himself. Indeed, he explicitly discourages all
theorizing as to etiology in his book on Ancient Medicine.
Epistaxis. In various places Hippocrates has much to say of nasal hem-
orrhage as a symptom in many diseases, and in Airs, Waters and
I Places remarks that persons under thirty years of age are liable
to severe bleeding at the nose in summer. In the Affections (No.
27) recommendations for stopping epistaxis include cold exter-
nally, a tent in the nostril, styptics and purging. One of the
Aphorisms shows that he was familiar with vicarious menstrua-
tion as a cause of the nose bleed. "In a woman when there is a
stoppage of the menses, a discharge of blood from the nose is
good." (V. 33).
sinusitis (?) Various other references to diseases of the upper air passages
may be found in the Aphorisms, and among them one (VI. 10)
referring evidently to the symptoms of aural or nasal sinus
disease:
"In a person having a painful spot in the head, with intense
cephalalgia, pus or water, running from the nose or by the mouth
or at the ears, removes the disease." It was supposed, as we have
seen, that the origin of this discharge was the brain.*
The last of the Aphorisms applies with especial force to the
nose and throat, though it is meant of course to be of general ap-
plication. (VII, 87). "Those diseases which medicines do not
cure, the knife cures; those which the knife cannot cure, fire
cures; those which fire cannot cure are to be reckoned wholly in-
curable." A similar apothegm is found in the Hindu Susruta.
In the clinical notes which go under the title of Coan Prog-
nostics we find an intimation that phthisis pulmonalis is a result
at times of nasal catarrh, cases thus arising being considered most
dangerous of all. (II, xxi, 430). This is a superstition which
still lingers in medicine and is continually reappearing in some
form or other.
There is a passage in this book which is of considerable value
in the differential diagnosis of hemoptysis, especially among a
people who drink directly from brooks and springs and pools in
the primitive fashion. (II, 17). "In those in whom the throat
becomes filled with blood several times, day and night, without
*Vid: Galen's Commentary. Edit. Kiihn: XVIII. A. 20.1
48
preceding pains in the head or cough or vomiting or fever or pain
in the chest and back, look in the nose and throat. You will find
there either a wound or a leech."
It must be borne in mind that there are many other passages in
the Hippocratic books of great interest to the laryngologist, but I
have already cited enough to convince the reader that a compila-
tion of them all would make a brochure, on the diseases of the
nose and throat, which no modern student of laryngology could
afford to despise.
FROM HIPPOCRATES TO CELSUS.
There now followed a period of more than four hundred years
before a medical work was given to the world which was destined
to survive the ravages of time, the vicissitudes of empire and the
vandalism of man, and to transmit to us at first hand the state of
medical knowledge in the Roman world at the zenith of its power
and vigor. From Hippocrates to Celsus is a long stretch in the
history of the world. It is crowded full of events of absorbing
interest and importance to our present civilization. It witnessed
the rise and glory of Grecian civilization and its absorption into
the world-wide domain of imperial Rome. In the Hippocratic era
tiny Greece was battling with that huge menacing bulk of Oriental
despotism, the enervating and soul-enslaving empire of the Persian
kings. In that death struggle for our civilization she rolled back
from Marathon (490 B. C.) Platea (479 B. C.) and Salamis (480
B. C.) that tide of stifling slavery and voluptuous sensuality, which
was threatening to engulf the garden she had planted and to extin-
guish the torch she had lighted at fires long since quenched by this
very Orientalism. From the rugged mountains and wind-swept
isles of Greece this eastern terror recoiled to the plains of Asia.
Ninety years later, ten thousand Greeks, a mere handful among
millions, marched fifteen hundred miles into the heart of the Persian
empire and after putting to flight an army of a million men turned
around and cut their way out again. When next they plunged into
Asia, seventy years later, it was with the youthful Alexander at their
head. They dismembered the lifeless body of Orientalism which
had been so long a menace to them, and for a thousand years it lay
prostrate before it again threatened the civilization of Europe.
When it was again about to inundate the budding civilization of the
west, Don John, of Austria, at Lepanto (1571), and John Sobieski,
with his Poles, at Vienna (1583), again stemmed the rising tide and
forced it back. In the century which now opens before us, the
49
drama of two civilizations played on the stage of the world for
twenty-five hundred years by the immortal gods is, let us hope,
drawing to a close. Although the ancient Greeks shattered the
cohesiveness of the mighty Persian empire they could not graft on
the barren limbs of Orientalism the buds of their own fructifying
activity. In vain did the generals of Alexander and their succes-
The schools of sors call around them the most brilliant minds of the age. The
Pergamos libraries of Pergamos and Alexandria, with their hundreds of thou-
and Alex- *» ' .
andria. sands of volumes, and the great schools which were founded with
lavish expenditure of Oriental treasure wrung from slavish races by
their Grecian rulers, advanced enormously the state of medical
knowledge, but these institutions with the records of their own and
of past scientific labor, planted in a land powerless to defend them,
perished utterly at the hands of a succession of ruthless Roman and
Saracen conquerors. The universal prevalence of the spirit which
creates such monuments is the only bulwark which can defend
them.* As Gibbon suggests! the loss to literature pure and simple
was probably not great, but to medicine and science it was irrepar-
able, for only in such a collection of books can we hope to find those
of ancient date which appeal to the understanding of man rather
than to his emotions. It is the historian of science alone who fully
realizes that the destruction of the great libraries accomplished
greater wrong to humanity a thousand times over than any event
history records. The great poets, historians, dramatists have many
of them been preserved to us, but not so the records of those parts
of civilization which administer directly to man's material comfort
and health, and thus indirectly to his happiness. J
We are reduced, therefore, again to the necessity of scanning
secular literature and of extracting second hand from the later
works of Galen, Pliny, Oribasius, Rufus, Aetius the scanty records
of the labors of more original workers than they. We have every
reason to believe that enormous strides were made in anatomy by
the schools of Alexandria where dissection of the human body was
first certainly regularly pursued. It is even said that the school of Alex-
andria indulged in the practice of human vivisection. § This is related
with a shudder by the historians who delight to report the innumer-
Anatomy. able tortures inflicted upon innocent men by their fellow-men from
* "II n 'y a pas de systeme qui puisse durer autrement que par des institutions."
(Guizot.)
t "The History of the Decline and Fall of the Roman Empire," Vol. V, P. 228.
X The School and the Library of Alexandria was founded 320 B. C. by the Ptolemies and
was finally destroyed 640 A. D.
I Celsus: "Lib. I., Proenmium."
50
motives of ambition, pride, lust and revenge. The statement is
received with horror by a cultured and refined public, who peruse
with pleasure and avidity the other pages of history reeking with
gore and replete with accounts of human misery. Erasistratus,
Herophilus and their confreres, if they did it at all, seemed to have
pursued their investigations on gentle murderers and other virtuous
criminals, out of the reprehensible motives of enlarging the bound-
aries of human knowledge and increasing the powers of man's
benevolence and humanity. This practice attributed to the Alex-
andrian school has been denied and certainly not satisfactorily
proven. Dissection of the dead human body as well as of animals,
however, did at this period, create the science of anatomy. The
records of this fruitful activity have, as has been said, utterly per-
ished, but we may see from the works of Hippocrates and of Aris-
totle how deficient was the knowledge of human anatomy before,
and from the works of Galen how enormously increased it was after
the foundation of the libraries and schools of Pergamos and
Alexandria.
Singular to say, Aristotle (384-322 B. C.), who dominated the
medicine and the philosophy of the dark ages, and who was said to
have long practiced physic before he devoted himself to pure science,
has left behind him very little pertaining directly to medicine, not-
withstanding his profuse contributions to nearly all other branches
of knowledge. Nevertheless we may find in his works a few indica-
tions of his conception of the anatomy of the upper air passages. He
placed at the top of the nostrils a kind of a lid which rises at the time of
inspiration to let in the odors. "There is no passage from
the ear to the brain, but there is to the roof of the mouth."
He described the larynx as the organ through which the voice and
the breath pass, and as situated in the front part of the neck. He
says the trachea is cartilaginous and surrounded by smooth rings and
contains but little blood. "It lies at the upper part toward the
mouth opposite the passage from the nostril to the mouth, wherefore
if any liquid is drawn into it in drinking it passes out of the mouth
* through the nostrils." "Between the passages is the epiglottis,
which can be folded over the passage which extends from the trachea
to the mouth ; by the epiglottis the passage of the tongue is closed ;
at the other extremity the trachea reaches to the middle of the
lungs." "The heart is connected with the trachea by fatty cartila-
ginous muscular bands." The uvula is described as a very vascular
organ. He speaks ot the epiglottis as part of the tongue. He
51
recognized* that the voice was produced within the trachea by the
impact of the air, inspired by the soul which he thought resided in
the heart and lungs, against it. "It is the voice and the larynx
which emits vowels; it is the tongue and the lips which form the
consonants, or the aphonic letters."f As we have seen (1. c),
Aristotle was free from the error of supposing that drink passes into
the lungs.
Praxagoras was the last of the yEsclepiadae of whom we have
record. We read in "Coelius AurelianusJ that he recommended
cutting off the end of the uvula or scarifying it deeply when it
was greatly inflamed. He transmitted the medicine of Hippo-
crates to his pupil Herophilus (300 B. C), the great anatomist
of the Alexandrian school. He is said to have instructed the
latter in the knowledge of the pulse, which he afterwards so greatly
developed. Pliny refers to Herophilus as the "vatis medincinae,"§
the oracle of medicine. He, in all probability, contributed greatly
to the anatomical knowledge of the upper air passages, but only the
merest hints of it remain to us. Thus we learn from Rufus Ephesius||
that he called the hyoid bone the parastate because it was situated
near the tonsils. According to Soranus, quoted by Oribasius
(XXIV, C 31), Herophilus likened the cervix uteri gravidi
to the larynx. Plutarch, from whom we have so often
to quote, after mentioning^ some incomprehensible theories
of Empedocles and of Asclepiades, says that Herophilus attributes
a moving faculty to the nerves, arteries and muscles, but be-
lieves that the lungs are affected only with a natural desire of
enlarging and contracting themselves. From the citation made by
Marx in his brochure on Herophilus (P. 34), I would infer
that the latter thought that the lung drove the air into the pleural
cavity, and then, receiving it back again, expelled it externally.
Erasistratus and Herophilus both knew that the arteries contained
blood and that the pulse was connected with the heart, and yet
apparently the circulation of the blood remained unknown for eight-
een centuries. We learn from Celsus (Lib. IV, Cap. 12) that the
former used ligation of the extremities as a remedy for hemoptysis.
* De Anima: II, VIII vid. Translation by St. Hilaire "Traits de l'Ame," p. 225.
t "Hist, of Animals," IV, Chap. IX.
X "De Morb. Acut.," Ill, C IV.
I "Hist. Nat.," II 37, 88 Sec. 219.
1 "Du Nom des Parties du Corps" (Edit. Daremberg), p. 155.
H "De Placit. Philosoph.," XXII.
52
Eudemis (279 B. C), we learn from Rufus (1. c), compared the
styloid process to the spur of a cock, but gave it no name. This is
a small gleaning from a period of several hundred years which
marked the beginnings of the study of anatomy, but as to the upper
air passages we look in vain for more, at least until the time of
Asclepiades.
ROMAN MEDICINE.
Pliny is often quoted as saying that Rome for 600 years was
without physicians but not without physic. Cato, the Censor, (b.
232 B. C.) we know had a very poor opinion of the doctors and
in fact of learning in general. He was instrumental in driving
Carneades and the other Greek savants from Rome in his day, but
it cannot be conjectured that this arose from any skeptical turn of
mind on his part, for in his book on Agriculture, amidst many
receipts, amulets, charms and invocations we find him prescribing
his favorite, almost his sole, drug for nasal polypus: "If there is
a polypus in the nose rub together some dry wild cabbage leaves
in the hand and place it at the nose and draw up the breath as
much as you can. In three days the polypus will fall away.
Nevertheless, for some days do the same; so that you may render
the roots of the polypi entirely healthy."
It was not until the year 219 B. C. that Greek medi-
cine found its way to Rome. Arcagathus was the first Greek
physician, who, about that time, came to Rome.* He was very
unsuccessful. We may read in Plutarch's Life of Cato, the Cen-
sor, how the Romans treated Carneades, the Athenian philosopher
and Ambassador, in order to appreciate the prejudice with which
the sturdy but rude old patricians of ancient Rome viewed the
introduction of Greek civilization. It has always been noted in
the history of the world that the first advances which have tended
to ameliorate the asperities, to increase the amenities, and to intro-
duce a wider knowledge among a rude and vigorous people have
met with the suspicion and contempt of the conservative majority,
who look upon the innovations as the first steps towards effem-
inacy and degeneration. It was not until the time of Asclepiades
(100 B. C.) the friend of Cicero (106-43 B. C.) "is quo nos medico
amicoque usi sumus, turn eloquentia vincebat ceteros medicos"!
* "Cassius Hemina, among the most ancient authors, is authority for the report that
the first of physicians to come to Rome from the Peloponessus was Archagathus, the
son of Lysania, in the year of the City, 535."—(Plinii Naturalis Hist. Lib. XXIX Cap.
1-6.)
t "De Oratore," I Cap. 14.
53
that the art of medicine really began to flourish in Rome, and we
soon find Cicero describing the wonders wrought by the immortal
gods,* not the least of which are the marvels of the human
Cicero's Anat- anatomy. "It will be more easily appreciated what has been done
omyandPhy- for man ^ t^e immortal gods, if the whole fabric of man is exam -
siology. .
ined, and the perfection and method of human structure is brought
to our comprehension. The life of living creatures is maintained
by three things, by food, by drink and by the breath (spiritus)
and for making use of these the mouth is especially adapted be-
cause it is reinforced by the air from the adjoined nostrils. The
food is masticated by the teeth arranged in the mouth, and by
them divided and softened. The sharp front teeth divide the food
when bitten, and the back ones, which are called the true teeth,
prepare it and this preparation seems to be aided even by the
tongue. The esophagus, adherent to the tongue at its root, receives
from it that which has been received by the mouth. This, touch-
ing the tonsils on each side, is continuous with the end of the
palate and this it is which receives the food after it has been
pushed along by the movements of the tongue, and passes it
downwards. Those parts which are lower down than that which
swallows (the food) are dilated, while those parts above are con-
tracted. But since the "Aspera Arteria," for thus it is called by
physicians, has an opening joined to the roots of the tongue,
a little above where the esophagus is joined to the tongue, and
since this reaches to the lungs and receives the air (or soul-anima)
that being received from the breath (spiritus) and this being inspired
and again returned, it is protected, as it were, by something like a
lid, which is provided for the reason that if by any chance food
should fall in it, the breath would be stopped. Since by its nature
the belly, attached below to the esophagus, is a receptacle for food
and drink, and the lungs and heart form an exit for the breath, in
the belly many things are admirably arranged, which it is about
agreed, are (controlled) from the nerves (nervis). It (J. e.,
the gastro-intestinal tract) is, however, multiple and tortuous, and
it encloses and holds that which it receives whether it is dry or wet,
so that it may be altered and digested; it is by turns contracted and
relaxed, and everything which it receives it compresses and mixes,
so that all things, prepared and digested by the heat, of which it
has much, and by the attrition of the food and especially by the
breath (spiritus), are distributed to the rest of the body. In the
* "De Natura Deorum," II, 54.
54
lungs, however, there is a certain looseness of texture and a soft-
ness, similar to the sponges, most carefully adapted for drawing in
the breath. They in turn contract on expiration and dilate on
inspiration, so that the nourishment by which breathing creatures
are principally supported may be frequently taken in."
In another passage (Ibid, Lib. II, Cap. 57) Cicero intimates the
existence of further knowledge of nasal physiology in his remark:
"Likewise the nares, which are always open on account of neces-
sary functions have narrower entrances lest anything which might
be injurious should enter them, and they always are supplied with a
moisture not useless for arresting dust and many other things."
Of course we can not suppose that Cicero included bacteria in his
"multaque alia depellenda."
After all, these passages from one of the greatest masters of human
speech who has ever lived, and a man profoundly imbued with all
the knowledge of his day, are perhaps not a bad index of the state of
knowledge of the anatomy and physiology of the air and food tracts.
It is a great advance over anything we can find in Hippocrates and
Aristotle.
As to Asclepiades, that eloquent rhetorician of Bithynia, the Asclepiades.
friend of Cicero and Crassus, the great advocate of diet, exercise
and massage, and enemy of bitter doses and radical treatment gen-
erally, we have only a few fragments, collected by Gumpert.
He made a great stir in his day; he declared that so perfect was his
regimen, disease had no terrors for him ; he was never sick and only
died because he fell from a ladder and broke his neck in extreme
old age.* Synanchef he said was "a flow of the humours or a
wetness of the fauces, or rather of the very top of them, coming
down from the head." Besides the purging and bleeding he scari-
fied the tonsils and the fauces around them. Moreover he approved
of the practice of incision of the trachea as recommended by the
ancients, which they called laryngotomy,t to relieve the respira-
tion. Themison, the founder of the school of Methodists and a fol-
lower and disciple of Asclepiades also approved of this surgical
* Pliny: Hist. Natur., VII, 37.
t Ccelius Aurel. de Morb. Acut. Ill, c. 1.
X Ccelius Aurelianus Cde Acut. Morb.) Lib. Ill, Cap. IV, Edit. Amman P, 193—Ascle-
piades—"At si major (inquit) passio fuerit, dividendae sunt fauces, hoc est tonsillar et
partes supra uvam constitutse; etenim summa est in his sequalis sive par incisura, quam
appelavit homatomia. Dehinc a veteribus probatum approbat arteriae divisuram, ob
respirationem faciendam, quam laryngotomiam vocant, varie ac multipliciter peccans."
This is the first mention we find of this operation unless it is referred to in the Talmud.
It is a good illustration of how much must have been lost from the old records. Ceelius ex-
presses the belief that the account of the ancients doing it was not true but an invention of
Asclepiades.
55
operation. Celsus (Lib. IV, Cap. IX), quotes him approvingly and
recommends his prescription of swallowing strong vinegar in ulcera-
tion of the fauces, and says that he condemned the practice of
Erasistratus ligating the extremities for hemoptysis. With this con-
demnation Celsus does not agree. So far as the throat is concerned,
therefore his practice to-day would not be called very mild or con-
servative.
CELSUS AND THE PR/E=QALENIC WRITERS.
In the eight books of the "De Medicina," which remain to us
from the writings of Aulus Cornelius Celsus, who was probably
born in the last days of the reign of Caesar Augustus, about
the beginning of the Christian era, are found several
chapters which deal with the diseases of the upper air passages.
Written by a Roman patrician, it is the first and almost the only
work of medicine which has come down to us written in the Latin
tongue as used by Virgil and Horace,* and all that brilliant coterie of
men who adorned the imperial courts of Augustus and Tiberius,
and sauntered through the gardens of Maecenas. As an interpreter
of Hippocrates he was profoundly influenced by the precepts of
Asclepiades, but he evidently was a man of virile understanding
and original powers, whose works still contain much of value to
the surgeon.
coryza. In his chapter on coryza (Lib. IV, Cap. V), he repeats the con-
viction of Hippocrates that some cases of phthisis owe their origin
to catarrh of the upper air passages. "Destillat autem humor de
capite interdum in nares, quod leve est; interdum in fauces, quod
pejus est; interdum etiam in pulmonen quod pessimum est." For
him, as for Hippocrates before him and Galen after him, the humor
dripped through the cribiform plate. So far as the coryza is con-
cerned, indeed, he says, there is nothing pestiferous about it
unless it ulcerates the lungs. He recommended as treatment
* The following lines have been held by some medical historian* to refer to the physi-
cian Celsus, but there seems every reason to believe it was the somewhat earlier poet
Celsus to whom Horace here, as several times elsewhere, alludes:
"Quidmihi Celsus agit? monitus multumque monendus
Privatus ut quaerat opes, et tangere vitet
Scripta Palatinus quaecumque recepit Apollo,
Ne si forte suas repetitum venerit olim
Grex avium plumas moveat cornicula risum
Furtivis nudata coloribus."—(Horat. Epist. I, 3, 15.).
We see by this extract that the library on the Palatine Hill, founded by Augustua was
already in requisition by writers, and already the charge of plagiarism was much indulged
in by the literati.
56
abstention from daily routine, and protection from the weather, as
well as abstention from the bath, wine and venery. He approved
of active exercise in the house and laid great stress upon massage.
He advised against overeating and recommended that only a half
pint of water a day be taken as drink. Warm vapors, the head
and neck wrapped in flannel, and especial care to be given to the
diet, were also urged. These prescriptions were varied somewhat
as the discharges became thicker, but at all stages massage and
exercise were to be employed.
In regard to throat inflammations (Liber IV, Cap. VII), those Angina,
which are confined to the fauces, he said, the Romans called Kynat
.. Synam
angina, while the Greeks gave the name synanche to that form in
which there was dyspnea without any appearance of inflammation
in the fauces, and cynanche to that form where the obstruction
could be made out in the fauces. The Greeks supposed the former
condition (i. e. the synanche) to be due to the disease of the
"pneuma" itself, and that this it was which caused a collapse of
all the parts of the chest and neck.*
With Celsus cupping, bleeding, purging were the remedies
employed, the cups to be applied around the fauces. Hyssop,
thyme, absinthe, bran or dried figs steeped in water were the
highly agreeable gargles he used, though all his prescriptions
were not so mild. Vinegar, powdered pepper and oxgall also
formed part of his pharmacopeia. In certain cases he made deep
incisions externally beneath the jaws and bled from the lingual
veins. His incision into the palate above the uvula (VI-X) was
more in accord with modern practice in quinzy. Without the
necessary differentiation of diphtheria from quinzy or other in-
flammatory processes, we can readily understand his remark that
' 'if the patient is not aided by these things, then we may know he is
a victim to this disease." He apologizes for mentioning a remedy,
which seems later to have been very popular in Rome for cen-
turies, saying that it was somewhat out of place in a scientific
work. Pliny and Galen mention the same and speak highly of
its efficiency. A swallow either fresh or salted, having been kept
thus in the house for the purpose, is to be burned to a cinder and
the ashes, moistened in water, are to be applied to the throat in a
* There seems to have been great confusion among the Greek medical writers at this
date in the use of the two terms. Galen in his "Commentaries on the Prognostics of Hip-
pocrates" (Edit. Kiihn XVIII, B. 267), intimates that the two terms arose out of a different
reading of the initial letter in the word, as used by Hippocrates, by different writers, and
that Hippocrates made no distinction. This is probably the correct explanation. We will
find Aretaeus making elaborate distinctions in the use of the terms.
57
threatened attack of angina. Pliny* dwells on the same remedy
at considerable length, and dilates on the difference in the efficacy
of the different kinds of swallows. On a reference to the Hindu
Susruta (Vol. II, Cap. XXII) will be found the prototype of this
prescription. "In affections (of the throat) arising from the
blood and bile, cure is obtained by the use of swallows." This is
one of the many instances of the Oriental origin of this sort of
therapy. Celsus thinks no apology necessary when in the next
chapter on dyspnea he recommends a paste made of dried fox
liver powdered. He also advises it should be roasted and eaten.
Even for dyspnea he recommends moderate exercise and does not
forget massage.
Diphtheria. "By far the most perilous of all ulcers (of the mouth) are those
which the Greeks call "A, chiefly in children, for in men and
women there is not the same peril." (VI-XI). Evidently this is
diphtheria. He remarks that ulceration of the fauces is frequently
followed by a cough, for which, of every description, he recom-
mended long sea voyages, sea-side resorts and sea bathing.
(IV-X). He devotes a chapter (IV-XI) to the spitting of blood
and recognizes vicarious menstruation among other more frequent
causes.
ozena. For ulcerated nares he recommended (VI-VIII) vapor of hot
water from a narrow-necked vessel, and mineral astringents were
applied to the ulcer. "But if these ulcers are around the open-
ings and they have many crusts and a foul odor, which variety the
Greeks call "O^aiva, it should be recognized that it is hardly pos-
sible to cure this disease. Nevertheless these things may be
tried; let the head be shaved to the skin, and persistently and
vigorously rubbed; let it be bathed with plenty of hot water; let
there be much walking; moderate food, nothing very sharp or very
strong; then in the nostrils let honey be applied with a small
amount of the resin of turpentine, which may be used on a probe
wrapped with wool; let this liquid be drawn in with the breath
until the taste of it is perceived in the mouth; by the use of this the
crusts are loosened, which may then be removed by the use of ster-
nutatories." How accurate this prognosis was we still have reason
to know; how excellent the local treatment was we still bear
testimony to in our present therapy of irritating applications to
the nostrils. We recognize here another method of treatment
which has been thought to be entirely modern. He advises
* Hist. Animal. XXX, 4, 12.
58
leaving pledgets of lint saturated with some medication in the
nostrils, this to be done twice a day in winter and spring and
thrice a day in summer and autumn.*
In another place (VII-XI) he describes a very radical surgical
operation for the cure of ozena, which has also been urged by at
least one modern author, t Celsus does not, however, himself
indorse the operation, which consisted in the use of the actual
cautery through an earthenware tube or the quill of a writer's pen,
and the affected parts thoroughly seared, and the wound dressed
with astringent and soothing applications. Nasal polypi, which Polypi.
he likened in appearance to the nipples of a female breast
(VI-VIII), he treated by caustics. He described them as show-
ing in front'on the lip and sometimes behind, "by that foramen
through which the breath descends to the fauces," hanging down
so that it may be seen behind the uvula, and in cold, damp days
it strangles a man. Some he calls KapKivw8rj,
<w 1 1 • <•-■-» Columbat.
croup as affecting children and the Diphtheria of Bretonneau as
affecting adults. He refers also to spasmodic croup and hys-
terical spasm of the glottis, cases having been reported by
Albers, Sir Charles Bell and Porter. Tumors of the larynx and
tracheotomy occupy considerable space in his book. Columbat in-
vented a clumsy instrument for opening the mouth and depressing
the tongue, which he called a stomatoscope, also some devices of
inferior interest for cutting the tonsils and the uvula.
A very much more interesting work, and one evincing more orig- Piorry.
inal though frequently erroneous ideas, is the one by Piorry pub-
lished in 1844.If He opens his work with the remark that the dis-
eases of the nose are unfortunately usually not considered in treatises
on diseases of the respiratory system, and he insists on the doctrine,
which received no help even from the advent of laryngoscopy, that
not only many diseases of the larynx but also of the lungs depend
upon morbid conditions of the nasal passages, nasal obstruction,
called by him rhinostenoma, one of the forms of which- we
* I am only familiar with the second edition published in 1837. Holmes speaks of the
first edition as too limited in scope to be compared with the treatise of Albers, whieh
appeared in 1829. However that may be, it is the first separate treatise on the larynx since
the little work of Codronicus two and a half centuries earlier.
t Die Pathologie und Therapie der Kehlkopfkrankheiten. Leipzig, 1829.
I Beobachtungen a. d. Gebiet. der Path. 1836. Atlas der Path. Anat. 2te Abth. 1842.
I A Treatise on the Diseases and Injuries of the Larynx and Trachea, by Frederick
Ryland.
I Trait6 des Maladies et de la Hygiene de la Voix.
H Ueber die Krankheiten der Luftwege, von A. Piorry. It seems to have been written
but never published in French, the German edition being the only one I have found noted.
181
recognize in a deviated septum, the other being alternating
vaso-motor stenosis. He proposed percussion, then a young
science, for investigating the accessory sinuses. He described
with considerable accuracy many of the sequelae of nasal obstruc-
tion and mouth breathing, including aural symptoms from closure
of the Eustachian tube, and pulmonary changes, such as chronic
Nasal Bougies, dyspnoea and asthmatic attacks. He referred the cause of nasal
disease to systemic affections. Crusts in the nose are to be removed
after soaking in oil. He advised the introduction of bougies even
in acute attacks. He described the dilatation of the alae nasi with
a forceps to allow the light to fall in, but admitted that it was im-
possible to see very far by this means. Stethescopy was also
recommended by him in the diagnosis of intranasal conditions. He
described rhinitis attending cases of the grip, which was prevalent
in the first half of the century. On the whole this book exhibits a
surprising amount of information in regard to intranasal conditions
at an epoch when anterior rhinoscopy was feebly developed, and
posterior rhinoscopy was unknown. Some of his ideas have not
received the sanction of modern rhinology, but may not on that
account be the less true. He declared that one of the causes of
Evil Effects of rhinitis was the cutting of the vibrissas in the vestibule of the nose
Nasal °mu^C wn*ch should filter the dust particle from the air. He asserted that
cosa. water was injurious to the whole upper respiratory tract with the
exception of the naso-pharynx, and syringing either the ear or the
nose, especially with cold water, resulted in inflammation. Rhinitis
thus frequently arose from bathing and diving. As treatment he
urged the injection of oily or fatty substances in the nose. To
such extremes did he go in this direction that he advised the an-
nointing of the nostrils with oil while shaving or washing the face.
The intranasal syringing of water he condemned very strongly ex-
cept for the purpose of removing foul, stinking secretions. Nitrate
of silver and various powders he recommended as medicaments for
internal applications. His other therapeutic measures were of a
general nature, in accordance with his views of etiology. Blisters,
bleeding, purging, sweating, were the vigorous measures which
were recommended for rhinitis, in keeping with the heroic treat-
ment of his times. He confused ozoena with purulent disease of
the accessory cavities. For intranasal operative procedures he
refers the reader to the general works on surgery. His remarks
upon affections of the larynx, trachea and bronchi, as one must
expect in prae-laryngoscopic times, are confusing and of little value.
182
In the first half of the 19th century, began again the custom of systems.
including in one work, or in a continuous series, all the medical lore
known to mankind, but instead of such a work being attempted by
one author it was divided among several. In these early Systems
and Handbuchs and Traites, the chapters on the nose and throat are
lacking, or treated in the most cursory and incomplete manner. As
an example of this sort of literature one may be cited wherein the
following was published, just three years before Garcia announced
the event, which at once shed a new light on diseases of the larynx.
Friedrich * says: "Unfortunately the methods of physical
diagnosis do not allow, in diseases of the larynx and trachea, that
extended application they do in diseases of the deeper parts of the
respiratory organ."
Laennec's "Traite de l'Auscultation Mediate" in 1819, his in-
vention of the stethescope, and the rapid development of the other
methods of the physical diagnosis of the diseases of the chest, doubt-
less did their part in stimulating interest and curiosity, which finally
culminated in the application of inspection to the diagnosis of in-
tralaryngeal lesions.
We have noted Piorry attempting to apply Laennec's methods to
diseases of the nose, and we find Friedrich attempting to explore
laryngeal phenomena by means of palpation, auscultation
and inspection of the epiglottis through the mouth. In Friedrich's
chapters we find intelligent attempts at differentiating tubercular
from syphilitic diseases of the larynx, but oedema of the glottis and
perichondritis laryngea are for him, as for many later writers, still
pathological entities. He speaks of paralysis of the glottis with
aphonia as paraplegias, but of couise he had no means of establish-
ing a diagnosis except from rational symptoms.
To return now to the individual topics of interest in the develop-
ment of our laryngological and rhinological knowledge, we may
begin again with Bichat.
In the few notes which remain to us from the works of Bichat
upon the histology of the diseases of the pituitary membranes, he
cast but little light upon the subject. We may note, however, that
he questioned whether ozoena was really an ulceration, but leaned
to the idea that it was a diffuse inflammation. He speaks! of the
liability of the mucous membrane of the larynx to become gorged
with serum during inflammation. He succeeded by traumatism in
* Die Krankheiten des Larynx und der Trachea; Virchow's Handbuch der Spec. Path.
und Therapie, 1854.
t Trait6 d'Anatomie Descriptive, 1802, T. II, p. 399.
183
producing this condition in dogs, but we look in vain for those
details of the study of the respiratory mucous membranes, which
later followed, from Bichat's initiative, in the works of Bretonneau
and others.
In 1791 Fourcroy and Vauquelin had* examined nasal secretions,
both in healthy subjects and in those suffering from coryza, and had
noted the salts of lime and soda. According to him, the mucus
was the same from all the mucous membranes, but Berzelius later,
on the contrary, believed it to vary according to the locality
from which it was taken. Majendie thought that the mucous glands
are not necessary for its formation, but that it is found where there
are none, and also after death.
These were some of the preliminary studies which, together with
the direction given to medical study by Bichat, lead toBretonneau's
Treatise on Diphtheria. In the works of Matthew Baillie, which,
though not collected until 1825, were of a considerably earlier date,
may be found several accurate accounts of the post-mortem appear-
ances in those dead of Croup.!
Anglada says: "It is known that Napoleon, in 1S07, on account
of a sorrowful event, put the question of Croup to the Assembly;
numerous and important works followed." He offered a prize for
the best essay on the disease, owing, it is said, to the death of a son!
from it. Not only in France, but elsewhere, as we have seen, the
disease was being more carefully studied. John Cheyne, in 1809,
wrote on "The Pathology of the Membrane of the Larynx, and
Bronchi," a treatise which is chiefly upon the lesions of Croup,
under which title he also published a work.
It was not, however, until Bretonneau's publication, in i826§, that
any very great advance is to be noted in the nineteenth century in
the study of Diphtheria. He recognized its specific character and
thus gave it its name (p. 41-43) : "From the impossibility of apply-
ing to a special inflammation, so well defined, a single one of the
names which have been given to its variations, allow me to desig-
nate this phlegmasia by the name Diphtheritis, derived from
AJ