'-;«:<:•>;■•:< C«i<',<''--'.-'.'.S''.".'. u A HISTORY OF LARYNGOLOaY AND EHINOLOGT T BY JONATHAN WRIGHT, jVI.D. DIRECTOR OF THE DEPARTMENT OP LABORATORIES, NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL SECOND EDITION, REVISED AND ENLARGED LKA & FEBIGK R PHILADELPHIA AND NEW YOUK 1914 Entered according to the Act of Congress, in tlic j'car 1914, by LEA & FEBIGER in the Odice of the Librarian of Congress. All rights reserved. THIS BOOK IS DEDICATED TO THE MEMORY OF ]\IY FATHER. PREFACE TO SECOND EDITION. 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. 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 Huxley has said: "Science and literature are not two things, but two sides of one thing." This has been done in constant fear of rendering the 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. The author has also ventured to hope that the informa- tion thus laboriously offered will not, on account of its form, prove less accurate or extended because an attempt has been made to make it more attractive. If he has failed in realizing these ideals — and who ever fully succeeds? — he may comfort himself with the reflection that the labor expended in an attempt to attain them has been fully repaid by his pleasure in the work itself. In the preparation of this work the author has taken his notes chiefly from the original sources. In addition he has made use of many historical works both of medicine and of general literature. Among the former those of Sprengel (the Frencli edition of his history). Baas (in English translation), Whittington, and especially Gordon Holmes' "History of the Progress of Laryngology,"^ and Heyman's "Geschichte der Laryngologie und Rhinologie" in his "Handbuch;" among the latter those of Buckle, Ciuizot, Freeman, Draper, Lecky, Gibbon, Grote, Ranke, Prescott, Kenan, and many others have been systematically read during the course of the work. * Med. Press and Circular, London, 188.5, xci (n. s. XL), p. 49, spq. vi PREFACE rO SECOND EDITION In revising his book for a second edition the author cannot tail to acknowledge his indebtedness to The Laryngoscope and to its editor, Dr. Max A. Goldstein, for publishing the text of the first edition in their columns. Through an oversight this was not explicitly stated when it was first published in book form. As it was not a part of the author's ambition in preparing the first draft of the work that it should eventually appear in })ermanent form, and inasmuch as the text was furnished from the columns of that journal without emendation, naturally that care was not given to various matters in its preparation which is essential to its existence as a book. There is in press at this time a valuable and exhaustive history of laryngology in Germany. Its author, Dr. Karl Ivassel, of Posen, has with the greatest courtesy furnished advance proof-sheets, which show that it enters more into detail than this work, but differs somewhat from it as to references to contemporaneous events in the general history of civilization. The author desires to acknowledge his indebtedness to Semon's Centralblatt fur Laryngologie und Rhinologie. Without it the task of collecting such data as have been added would have been too great. He desires also to acknowledge a personal debt of long standing to Sir Felix Semon, who urged him years ago to under- take the present task and whose appreciative words in regard to the first edition are still gratefully remembered. The author desires to express his appreciation of the work of Mr. Frank Place, of the librarv staff of the New York Academ\' of Medicine, who has undertaken to confirm and revise the references. J. W. New York City, 1914. CONTENTS. Introduction 17 Physiognomy of the No«e. Etymology of the Nose. Egyptian Medicine 21 Specialists in Egypt. Herodotus' Account of Them. The Breath of Life. The Papyros Ebers. The Exodus of the Jews. Penalties for Malpractice. Chaldean Medicine 24 The Records of Magic. Their Introduction in Rome. The Medicine of the Market Place. Stercoraceous Drugs. ^Yitch Medicine. Pliny and the Therapy of the Magi. Its Contact with Greek Medicine. The Zend Avesta and the Medicine of the Parsees. The Medicine of the Talmud 27 Diphtheria Among the Babylonian Jews. The Relation to the Zend Avesta. Tracheotomy. Nasal Polyp and Ozjena. Hindu Medicine 28 Its Puzzling Chronology. Its Relation to Greek Medicine. Susruta and Hippocrates. Reference in the Rig Veda to Tracheotomy. Charaka Samhita. The Trace of Humoral Pathology. Uvulotomy and Tonsillotomy. Rhinoplasty. Vaporizations and Fumigations and the Intranasal Use of Oil. Sternutatories. Foreign Bodies in the Throat. Fracture of the Nose. The Physiognomy of Death. Pre-Hippocratic Medicine in Greece 35 Its Oriental Derivation. Its Occidental Transformation. Civilization in Greece. Ancestry of Hippocrates. Greek Medicine at the Siege of Troy. The Nose and Throat in Homer. Etymology of Greek Words for Throat. Pharynx, Larynx. Drink in the Larynx. Early Greek Superstition. The Early Philosophers and Their Ideas of Anatomy of the Xo.se and Throat and tlie Eustachian Tube. Goats Breathing through their Ears. The Atomic Theory and its Relation to Voice Production and Hearing. viii CONTENTS The HippocRATir Treatises 43 Hippocrates as a Specialist Among Philosophers. Oriental and Occidental Mentality. The Era of Hipijocrates. The Jilsclepiadae. The Destination of Fluids. The Origin of Catarrhs. "Cor.\za" in a Double Meaning. Coryza in Old People. Acute Throat Inflammation. Diphtheria. Intubation. Cynanche and Parac^'iianchc. Uvulotomy and Evulsion of the Tonsils. Fractures of the Nose. Shceps' Lung as an Intranasal Splint. Bandages on the Nose. Syphilis. Nasal Polypi and the Methods of Their Removal. Ejjistaxis. Vicarious Menstruation. Sinusitis. From Hippocrates to Celsus 59 Tlie Schools and Libraries of Pergamos and Alexandria. Anatomy of Aristotle, Praxagoras, Herophilus, Eudemis. Roman Medicine 64 Cato, the Censor, and Nasal Polypus. The Introduction of Greek Learning into Rome. Anatomy and Physiology in the Time of Cicero. Asclepiades. His Opinion of Synanche and of Laryngotomy. Celsus and the Pre-galenic Writers 66 Celsus on Coryza, Angina, Diphtheria, Oza;na, Nasal Polypi, the Tonsils, and the Uvula. The Therapy of Plin\-. Aretaeus on the Uvula, Syphilis. Cynanche, Laryngotomy, Syriac Ulcer or Diijhtheria, and the Manner of Death from It. Rufus of Ephesus and the Tonsils. The Tracheotomy' of Aiityllus. Coelius Aurelianus on Synanche and its Treatment. His Reference to tlie Intubation of Hippocrates. Galen 76 His Era. His Anatomy. The Intermaxillary Bone. The Internal Nose and its Functions. The Voice. The Larj'nx as the Instrument of the Voice: Its Structure. The Origin of the Voice. Drink to the Larynx. Hoarseness. The Glands. The Recurrent Nerves. Hmnoral Pathology. Anosmia. P(jlypi, Ozu'iia and its Therapy. \'arieties of Cynanche. Diphtheria. "latros." The Tonsils, the Uvula, and Their Amputation. The Greek Writers ok the Eastern Empire 87 Incantations, .Vmulets, and Charms. Constantinople and its Warring Sects. Cassius Felix and Dijjhtheria. CONTENTS IX The Greek Writers of the Eastern Empire: Nemesius and the Circulation of the Blood. Marcellus Empiricus. The Swallow Prescription. Amputation of the Tongue. Aetius, His Invocation to Jesus Christ. Alexander Trallianus. Theophilus on the Olfactory Nerves and the Cribriform Plate of the Ethmoid. Paulus Aegineta on the Operations of Tonsillotomy and Laryngotomy and His Use of the Knotted String for Nasal Polypi. The Arabians 96 The Transfer of Civilization to Them and Their Cultivation of It. Their Conquests. Destructions of the Alexandrian Libraries. The Arabian Renaissance of Learning. The Inferior Maxilla. Tracheotomy. The Cautery. Tonsillotomy. Nasal Speculimi. Stercoraceous Therapy. A Postnasal Tumor. A Relaxed Palate. Haly Abbas. Albucasis. Avenzoar. Mesua. Averrhoes. The Pre-Renaissance Period 104 Learning in the Middle Ages. Gregory the Great. The Schools. Ignorance and its Beginning Modifications by the Influence of Arabian Science, of the Church, of the Crusades, of the Fall of Constantinople. Italian Science. The School of Salerno. Hoarseness. "Squinantia." Operation for Nasal Polypi. Tonsillotomy. Uvulotomy. Tracheotomy. Constantine, the African. Arnold di Villanova. Henry of Amondeville. Gui di Cauliac. Their Dependence on Arabian Science. The Renaissance 115 The Influence of Maritime Commerce. Petrarch. The Gothic Cathedrals. The Hospitals of Saint Louis. The School of Bologna. Revival of the Study of Anatomy. Mondino di Luzzi. Subservience to Galen. Berengar del Carpi. The Cartilages of the Larynx. The Sphenoidal Sinus. Vesalius and the Revolt from the Authority of Galen. His Anatomical Plates. Human Dissection. The Olfactory Nerves. The Iiiterniaxillar\- Bone. X CONTENTS The Renaissance: "Glands" of the Throat. The Puhnonary Circulation. The Turhiiuitcd Bones. Anatomy of the Larj-nx. The Works of Fabricius ab Acquapendente and Casscrius on the Struc- ture and Function of the Larynx. The Reformation anu the Diffusiom of Knowledge 126 The InciuisitioM and tlio Index Expurgatorius. The Aid of the Church in the Acciuisition of Knowledge and its Later Restraint of its Spread. Decline of Commerce, Arts, and Sciences in Italy. The Diffusion of Knowledge through Wars and the Founding of Uni- versities and Learned Societies. The Beginnings of Physiology. The Circulation of the Blood. The Olfactory Nerves and the Theory of Willis. The Vascular Theory of the Nasal Glands and Other pre-Schneiderian Theories. The "de Catarrhis" of Schneider. The Correction of Errors as to Catarrhs and the Evolution of the Knowledge of Mucous Glands. The Chyliferous and Lymphatic Systems. The Microscope. The Pharyngeal Tonsil. The latrophysical and latrochemical and other Seventeenth Century Theories. The Disappearance of Chaldean Therapy. The Results of the Renaissance 141 Sixteenth Century Views as to Diseases of the Nose and Throat. The Treatment of Oza^na and Tonsillar Hypertroi)hy. Instruments for Operations on the Uvula. Tobacco and Tea Therapy. Syphilis. Prostheses. Rhinoplasty of Tagliacozzi. Epidemics of Influenza, Pertussis, Diphtheria, Scarlet Fever, and their Differentiation. The Tracheotomy of Fabricius and the Tubes of Guido-Guidi. Laryngocentesis and its Application in Cases of Drowning. The Modern 0])eration of Tracheotomy and Laryngotomy. Their Em()loyni('nt in Diphtheria. Intranasal Sukgery and Pathology of the Seventeenth and Eighteenth Centuries 161 Operations for Nasal Polypi. The Forceps of Aranzi and Fabricius ab Acquapendente and the Harpsi- chord Wire Snare of Fallopius. The Instruments of Levret and of Benjamin Bell and Belloc's Sound. The Pathogenesis of Nasal Polypi. The Anatomy of the Accessory Nasal Sinuses and Speculations as to their P^unctions. Wounds of the Frontal Sinus. Worms in the Sinuses. Description of the Maxillary Sinus by Highmore ami the Operation ot Cowper, his Predecessors and Followers on It. Normal and Pathological Anatomy of the Nose and Throat. Deviations and Sjjurs of the Nasal Septum. The Ccrebrosiiinal Fluid. Diphtheria. The Prelaryngoscopic Era 178 The Intermaxillary Bone. Bichat and the DifTerentiation of the Tissues. Special Treatises. Olfaction. Jacobson's Organ. CONTENTS XI The Prelaryngoscopic Era: The First Separate Treatises on the Diseases of the Nasal Fossae and their Sinuses. The Sj'stems of Medicine. Bretonneau and Diphtheria. The Epiglottis. Innervation of the Larynx. Modern Theories of Voice Production. Photography of the Larynx. Laryngeal Phthisis 193 Morgagni, Lieutaud, Petit, Portal, Sauve, Saignelet. Tubercle as Named by Baillie. Laryngeal Tubercle as seen by Broussais. Lack of Differentiation. Catarrhal, Syphilitic, Cancerous, and Tubercular Laryngeal Phthisis. Catarrhal L^lcers. Louis, Trousseau, and Belloc. Rokitansky. Histology and Pathology of the Mucous Membranes 199 The Cell. The Epithelium. The Tonsils. Schleiden, Schwann, Yirchow, Henle, Bowman, KoUiker, Sappey, His, Waldeyer. Prelaryngoscopic Ther.'VPy 201 Tonsillotomes. Galvanocautery Snare. Horace Green and His Intralaryngeal Applications. The Attempts of Bretonneau, Trousseau, and Belloc. The Intubation of Desault, Loiseau, and Bouchut. The Lary'ngoscope 203 Bozzini, Babington, Cagniard de la Tour, Senn, Liston, Baumes, Selligue, Warden, Avery, Manuel Garcia. The Difficulties of Techniciue. The Introduction of it in Clinical Work by Turck and Czermak. Their Rivalry. Rhinopharyngoscopy. Artificial Illumination by Czermak. The Spread of the Art of Laryngoscopy to other Countries. The Beginning of Special Clinics, Teaching, Societies, Journals, Text- books of Laryngology, and the Enormous Growth of its Current Literature. The Sequel of Laryngoscopy. Laryngeal Tumors. Intralarj-ngeal Operations Before and After the Invention of Laryngo- scopy. The Tonsils 217 The Pharyngeal Bursa and Tonsil. Tornwaldt's Disease. Embryology and Histology of the Pharynx. Leukocyte Emigration. Their Origin and the Controversy in Regard to It. Their Relation to the Epithelium. The Accessory Tonsil. The Lymphoid Cells. Wilhelm Meyer and the Discovery of "Adenoids." The Physiology of the Tonsils. Their Absorptive Power. The Fat Contents. Their Relation to Dust. Internal Secretion. Bacteriology of the Tonsil. Diphtheria. Intul)ation. Follicular Tonsillitis. xii CONTENTS The Tonsils: Vincent's Angina. Tuberculosis of the Tonsil. Their Relation to Systemic Infection. Tonsillar Syphilis. Operations on Tonsils and Adenoids. Indications for it. Anesthesia and Position in It. Hemorrhage and Other Sequoke after It. Ignipuncture and Galvanocautery Snare. Bone and Cartilage in the Tonsils. Nasal Anatomy, Physiology, and Pathology 238 Nasal Specula. Neglect of Nasal Disease after the Introduction of Laryngoscopy. Reflex Neuroses. Gross Anatomy. Relation of Nasal to Cranial INIorphology. The Erectile Tissue. The Glands. Intra-epithelial Glands. Smooth Muscle Cells. Vascular Mechanism and Sexual Development. Elastic Fibers. Olfactory Epithelium. Nasal Embryology. Nasal Lymphatics. Pathogenesis of (Edematous Nasal Polypi, Papillomata, Adenomata, and Papillarj- Hypertrophies. Bleeding Septal Polypi. Kiesselbach's Area. Cysts. Osteoma. Tuberculoma. Syphilis. Protozoal CJranuloma. Malignant Neoplasms. Nasal Bougies. Cautery. Dental Engine. Chronic Intranasal Diseask and its Modern Treatment .... 259 Reflex Neuroses. Septal Spurs and Deviations. Their Etiology and Operations for Their Relief. Submucous Septal Operation. Nasal Snares. Cocaine. Adrenalin. Thrombokinase. Inhalations and Detergents. The Compressed Air Spray. Improved Illumination. The Accessory Nasal Sinuses -69 The Beginnings of Interest in Disease of Them. Transillumination. Latent Suppuration. Necrosing ]']thni()iditis. Postmortem Examinations. Bacteriology. Histology. Cysts. Teeth in the Nose. Mucocele. Malignant Tumors. Choanal Polypi. Sinus Tuberculosis. CONTENTS xiil The Accessory Nasal Sinuses: Rhinitis Caseosa. Sinus Ozsena. Embryogeny and Anatomy of the Sinuses. Rontgenology, Transillumination, Irrigation, the Endoscope, and Negative Pressure in Diagnosis. Development of Operative Technique on the Different Sinuses and the Hypophysis. Complications of Sinus Disease. Sequelse of Operations and Trend to Conservatism. Local Anesthesia. Vaccines. Bacteriology of the Nose and Throat 296 Mycosis Pharyngis or Leptothrix Buccalis. Actinomycosis. Nasal Bacteria. Atrophic Rhinitis 300 Etiology. Histology. Treatment. Literature. Tuberculosis of the Upper Air Passages 308 Infection, its Portals and Paths. Primary Laryngeal Tuberculosis. Treatment of Laryngeal Tuberculosis. Rhinoscleroma 317 Recognition. Distribution. The Bacillus of Frisch. Contagion. Treatment. AuToscoPY 319 Lary'Ngeal Paraly'sis 320 First Reports. Differentiation. "Cadaveric Position" of the Cords. Rosenbach-Semon "Law" or the Greater Proclivity of Abductors to Paralysis. The Contracture Theory. Central Innervation and Cerebral Localization. Toxic Paralysis. Double Posticus Paralysis. Laryngeal Cancer and its Extirpation 327 Laryngotomy. Thyrotomy. Laryngectomy. Intralaryngeal Operation. The Emperor Frederick. Microscope in Diagnosis. Supposed Transformations of Benign into Malignant Growths. Semon's Statistics. Prosthesis. Pachydermia Laryngis. Epilogue 333 Index of Personal Names 335 Index of Subjects 3-15 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. The extensive disquisitions on character drawn from the aspect of the features are largely flights of a foolish and puerile fancy. Physiognomy of the Nose. — Xo longer ago than 1820 we find it stated in a scientific work^ that "a long and pointed nose passes for a sign of sagacity. A short and blunt nose marks a simplicity of mind, easy to deceive and with very little foresight. A little nose, thin and movable, denotes a natural mocker. Large noses are an indication of heaviness, for they bespeak the lymphatic nature of the complexion. Twisted noses, they say, are a sign of an obliquit}' of mind; but an aquiline nose, large and muscular, announces force and courage; a flattened nose an inclination to luxury; in fact, it is thought there is a correspondence between the sexual organs and that part of the countenance." "Noscitur ex labiis quantum sit virginis antrum Noscitur ex naso quanta sit hasta viri." This is a quotation drawn from a literature stimulated by the recent excursions of Lavater into the realms of uncontrolled and uncritical observation. On the testimony of Plutarch we learn that the Persians most admired the hawk-nosed type of man as resembling Cyrus, their best beloved king. This saying we find echoed in the sixteenth century by Riolan- and Laurentius,^ the latter declaring, with how 1 Diet, des Sciences Medicales, Paris, 1820, Vol. XXXXII, p. 220. - Opera Omnia, Paris, IGIO, Anatome, Cap., LIII, De Naso. ^ L'Historie Anatomique traduit par Size, Paris, 1610, p. 1374. 2 18 INTRODUCTION much truth I do not know, that the Egyptians in tlieir liieroulyphs use the figure of a nose to designate a man. We may plainl\' see the tyi)e of Cyrus in Bellini's jiortrait of the Sultan ]\Iohammed.* We learn from the Old Testament (Levit. XXI, IS) that there was a prejudice among the Patriarchs against flat-nosed people. But in spite of these predilections of the Caucasian race we find among the native negroes and the Chinese dift'erent ideals as to the beautv of the nose. "The ancient Huns during; the age of Attila were accustomed to flatten the noses of their infants with bandages for the sake of exaggerating a natural conformation. With the Tahitians to be called long-nosed is an insult and they compress the noses and foreheads of their children for the sake of beauty. So it is with the ^Malays of Sumatra, the Hottentots, certain negroes, and the natives of Brazil."- In attempting to present an outline of the growth of our knowl- edge of the nose and throat and of their diseases, it must be remem- bered that a complete and intelligent review of the subject can- not be obtained by beginning our study with the discovery or rather with tlie introduction of the use of the laryngoscope. That would be a consideration of the history of laryngoscopy and its sequelse in the history of the diseases of the upper air tract, and of the growth and development of technical skill. However great may have been the revolution wrought by Tiirck and Czermak in tliis field, the history of rhinology and laryngology begins not with the invention of the speculum and the laryngeal mirror, but with the earliest records of the civilization of man. In fact, it is reason- able to conjecture that it is only the lack of records which prcAcnts us from tracing knowledge of the diseases of the nose and throat still farther back into prehistoric times. It must necessarily be that any disease of the respiratory system causing obstructive dyspnoea, or any affections causing deformity and discharge from the nose, would have attracted the attention of the medicine men of our primeval ancestors. Injuries to the head must, as freciuently then as now, have involved the nasal organ. Indeed, we shall find in the very earliest Hindu and Greek records evidences of the care and attention devoted to the study of this branch of the medical art. We shall also find that to some extent the nose and nasal disease in the earliest times possessed proportionately a larger interest for medical men than it did in more recent and more enlightened times, until the beginning of the growth of what we are pleased to call ^lodern lihinology. Exposed to accidental and intentional injury in the sports and wars of the ancients, mutilated bj^ the deliberate acts of a cruel justice before the days of jails, or in the fierce outbursts of passion and revenge, traumatic ' Thi.s rimy be conveniontly rofcrrcd to in Mrs. Oliphant's Makers of Venice. - Darwin's Descent of Man, Part III, Chap. XIX. ETYMOLOGY OF NOSE 19 conditions of the nose have occupied necessarily not only a very large place in the medical literature, but in the secular writings of former civilizations: "Atque hie Priamiden laniatum corpore toto Deiphobum vidit, lacerum crudeliter ora, Ora manusque ambas, populataqiie tempora raptis Auribus et truncas inhonesto volnere naris." — Virgil, Aeneis VI, 494. Innumerable colloquial phrases in all known tongues still testify to its importance as a symbolical figure of speech. Etymology of Nose. — It would seem that the remarkable coinci- dence, pointed out by Hvorka,^ that the word "nose" has the same stem in all known European languages, might be explained, as he suggests, on phonetic principles, and it is very likely that the nasal resonance of the " n" followed by a vowel has had an influence in preserving the stem from radical changes; but it is difficult to see why, on this ground, the sibilant "s" should enter almost universally into the word. The following is the list of languages quoted by Hvorka in a little different sequence, with the accom- panying word for nose: Sanskrit . Old Indian Old Persian Zendic . Hebraic Greek Latin Italian . Spanish French . Gothic . Old Norse Old German Middle German Anglo-Saxon English . Nas Danish Noesen Nasa Netherland .... Neeus Nana Modern German . . Nase Naonha Old Slavonic .... Nosz Nohar Old Bulgaric .... Nosii /p'-r Old Prussian .... Nozy \p/vo- Lithuanian .... Nosis Nasus Lettic Nasis Naso Bohemian Nos Nariz Polish Nos Nez Polabian Nus Nasa Upper and Lower Sorbian Nos Nos Russian Nos Nasa Servian Nos Nase Croatian Nos Nose Slovenic Nos Nose Swedish Niisan It thus seems evident that there has been a direct transmission from the ancient Sanskrit of the word nose to the modern languages of Europe, one of the innumerable etymological evidences of the origin of our branch of the human race. If we look at a photograph of a miscellaneous group of natives of Calcutta or Bombay, and then glance out of the window at the pedestrians along Broadway or the Strand, we will note that not only the word has been trans- mitted, but the characteristics of the feature for which it stands. It may not be without interest in this connection to supplement 1 Hvorka: Die Aeussere Nase, 1893. 20 INTRODUCTION Hvorka's investigations by examining other languages ha\ iug no known affiliation with the so-called Arvan stock: Chinese Pe Japanese Hana Congolese (Africa) Djolo Mexican (Nahaute) Yacatl South American Indians. Aymara Nasa Moxas Nusiri Incas (Quichua) Seneca North American Indians. Cree Miskiwan Lenape (Delaware) Wikiwan Onondaga Onionchia Chinook Bekats Clallam (Washington Territory) Nuk'su A number of vocabularies of other North American languages show no such conformity as the European languages. There is, however, as will be seen, a suggestion of a common derivation of the word even as between the tongues of the three continents (Europe, Asia, America), but it would lead us too far astray to pursue the question further. It will be noted that the persistence of the nasal "n" and the sibilant "s" is not so marked in the languages of the non-Aryan races of the world. THE NOSE AND THROAT IN MEDICAL HISTORY. EGYPTIAN MEDICINE. N a volume published from the unfinished manu- script of A. ]\Iariette Bey, entitled "Les Mas- tabas de I'Ancienne Empire,"^ among many others is a fac-simile of a drawing on a slab found in the tombs of one of the old Egyptian kings. The grave in which the slab was found is said to date back to the fifth dynasty, a matter of .3500 years before the birth of Christ. On the slab is the delineation of a physician and his wife with her hand resting aftectionately on his shoulder. He was the medical attendant of King Sahura and his name was Sekhet'enanch, but what the name of his wife was does not appear. It is said to have been everywhere erased from the tablets. What subsequent domestic infelicity this may hint at does not appear. Edward ^leyer, in his " Geschichte des Alten .Egyptens" (II, p. 95), translates some of the inscription relating to the physician in such a manner that it appears the king had ordered it to be engraved as a testimony of gratitude to his doctor because he had "made his nostrils well." He wishes him, therefore, long life and happiness. This tablet had formerly been set up in the king's palace in an ante-room where all might see and read. ^Ye see hereby not only the antiquity of medicine, but also the antiquity of certain propensities which have not yet disappeared, so the uncharitable say, from the activities of its devotees; for we read further in Meyer's text that this method of recompense was suggested to the king by Sekhet'enanch himself. Truly "Vita brevis, ars longa." However, it does not appear that this early practitioner of medicine and violator of medical ethics was neces- sarily a rhinologist, for the word "nose" in this place, according to the translator, seems to have signified "breath of life." This, of course, makes the meaning of the passage very indefinite. It is an indication, howe\-er, that five thousand years ago they recog- nized the nose as belonging to the respiratory system, a fact to which it has frequently been necessary to draw attention in later, and we are fain to believe, more enlightened times. Voltolini- has 1 On Plate D 12. - Die Krankheiten der Nase, Breslau, 1888, p. 16. 22 EGYPTIAN MEDICINE quoted ]\Ioses for authority (Genesis II, 7), that the nose was recognized as an orjian of the respiratory apparatus when the "Lord God formed man of the chist of the ground and l)reathed into his nostrils the breath of life." According to Kautzsch this utterance was recorded only about 400 years before Christ or about the end of the life of Hippocrates as it is usually reckoned (Kassel). This reference and several others in the Sacred Writings point directly to the nostrils as emblematical of life and of the soul. It is not at all improbable that this figure of speech had its origin in Eg}'pt where the nostrils were the route by which the contents of the cerebral cavity were extracted in the more expensive methods of the uni^'ersal practice of embalming the dead. The exodus of the people of Israel from Egypt is said to have taken place at a date subsequent to that ascribed to the compilation of the " Papyros Ebers" (1550 B.C.). Specialists in Egypt. — As to the possibility of Sekhet'enanch having really been a rhinologist, we are supported only by a single historical reference. Herodotus (II, 84) makes a very positive statement as to specialization in Egyptian medicine, but makes no reference to rhinology, unless we suppose reference to the head to include affections of the nose and throat. The passage reads in Iiawlinson's translation (vol. ii, p. 136) thus: "Medicine is practised among them on a plan of separation; each physician treats a single disease and no more; thus the country swarms with medical practitioners, some undertaking to cure diseases of the eye, others of the head, others again of the teeth, others of the intestines, and some those which are not local." 'v^ ok cr^Tfnxrj xaza rath Oifc nko(i.(Jzar iiap vo'joo') ixaazo^ ir^T[>6^ iazc '/.at oh iz/MrJoy^. /Tdcvra o tr^zoCo'j lazt -rJ.ia: ol itkv yao ocpdoliuTw Ir^znoi y.azzazu.ot, ol ok /.z(fa/:/j:;, ol ok doot^Ziov, ol oi zuju xaza uv^d'Ji^, o: ok zcov d vo'jacov.^^ Maspero^ and P>man- are both inclined to believe that Herodotus somewhat exaggerated the extent to which the specialization of medicine was carried in ancient Egypt, but Montaigne, that garrulous and delightful old Erench classic, not only credited the statement of Herodotus but approved of it, for he says:^ "The Egyptians were right in neglecting the general calling of physician and of dividing the profession; for each illness, for each part of the body, there was an attendant, and therefore each part was more skilfully and less blindly treated, because they studied each one specially." It has been conjectured tliat this specialization of medicine in Egypt, when at the height of her civilization, was due to the same causes which have produced it today. The teeming population 1 Maspero: Dawn of Civilization. ^ Ernian: Life in Ancient Epiypt. ^ Montaigne: Essais, Livre II, Cap. XXXVII. THE PAPYROS EBERS 23 in the fertile, irrigated valley of the Nile dwelt largely in cities'- and these enormous aggregations of population, which is the striking phenomenon of modern civilization, furnish the only con- ditions under which such subdivisions of the arts and sciences are possible. The whole matter, however, resting as it does upon this passage in Herodotus, is involved in much doubt and uncertainty .^ The "Papyros Ebers." — Whether these old Egyptians had special- ists or not, it is evident from the "Papyros Ebers" that they had physicians who observed and knew how to treat diseases of the nose and throat after a fashion. This "Papyros" is the earliest of all books on medicine and is said to have been compiled about 1550 years before Christ,^ but even the date of its compilation is somewhat conjectural, while that of its origin is wholly so. It is supposed by some to be merely a book on pharmacology, but as its learned translator^ has stated, it is more than that, for near the end it deals with anatomy, physiology, pathology, and surgery. In spite of the practice of embalming, anatomy was evidently largely a matter of fancy with these early doctors, and gave no promise of the great development which the Greeks under the Ptolemies, in the future city of Alexandria, a thousand years later, were to bring about in it. We read, page 181, "There are four vessels in both nostrils of which two carry blood and two carry mucus." In physiology they were scarcely less at sea, for when the air once entered the nose they lost track of it. " It goes to the heart and the rectum," says the author of the "Papyros," a few lines farther on. It is evident that tumors of the neck, both tuber- cular glands and goitre, were well known and as little understood. It must be remembered, however, that the translation is often uncertain and that it is impossible for us to comprehend exactly what they meant even when the equivalents of their hieroglyphics are selected in the modern languages. "If thou findest in his throat a fatty tumor (?) and it appears like an abscess of the flesh, which can be reached by the fingers, thou must say thereto, 'he has a fattv tumor in his throat; I will treat the disease with a ' Egypt in the time of Herodotus contained from eighteen to twenty thousand cities. Under the successors of Alexander it is said to have contained thirty thousand towns. (Baas.) There were so manj^ ph3'sicians in Egypt that Homer declared, perhaps as an early instance of poetic license, they were all physicians. -Cyrus sent for an eye doctor out of Egypt (Herod. IH, 1) and Darius (Ibid. Ill, 129) made use of one of his captives, the Greek physician Demo- cedes, to cure him of a sprain, but there is no mention of a nose doctor which I can find. Democedes, by the way, was the first physician of whose life and adventures we have a trustworthy record, and his romantic and interesting story is graphically told by the Father of History. He lived 490-430 years before Christ, and was paid fabulous prices for his services not only b}' the Persian King but by his countrymen. ' Moses brought Israel out of Egypt 1300 years before; Christ, and hence, according to these computations, 250 years after the compilation of the Papyi-os Ebers. ^ Papyros Ebers, iibersetzt von Dr. Med. H. Joachim, Berlin, 1S90. 24 CHALDEAN MEDICINE knife, taking care of the (blood) vessels.' " They were apparently very chary of snrgical procedures, and ('^•(•Il in this place it is uncertain from the translation whether the author does not really give preference to ointments and cataplasms, for whicli he gives a number of scarcely recognizable prescriptions. We will find in the "Zend Avesta" that the surgeon must first thrice essay his skill upon a slave or a lower caste man before operating on their betters. Let us think of our hospitals and dispensaries and refrain from unkind criticism. If they neglected to do this the}' operated at the peril of their lives on the high caste man. Such a penalty was calculated to encourage conservatism if it obtained in old Egypt as well as in Chaldea. CHALDEAN MEDICINE. Closely allied with Egyptian civilization was that of the Chal- deans and the Assvrians, but scarcelv anv notice has come down to us of their medical attainments beyond the records of magic. ^ the incantations and the invocations of good and evil spirits, which would indicate that our art among them was about on a level with that of the American Indians. In the satires of Juvenal we find Chaldean magic much cultivated by the decadent social world of Rome against which he aimed his shafts. "Chaldcis sed major erit fiducia; quicquid Dixerat astrologus, credent a fonte relatum Hammonis." (VI. 552.) In the popularity of theosophy and the mind cure and the faith cure we have in our day a parallel to the condition at Rome so far as the mystic influences of the Far East are concerned. It is impossible for us to stretch our credulity to the point of believing Herodotus when he asserts that the Babylonians had no physicians, but depended on the wisdom of the market-place, where the patients were exposed for the benefit of the comments of pas.ser.sby. Familiarity with human nature compels us to believe that even if they possessed no medical knowledge they must have possessed men who pretended to it, and others who believed in their assertions, for as Celsus remarked, "JMedicina nu.squam non est." According to Sayce- dog's flesh and the ordure of animals were among Chaldean medicaments, and such things we find in abun- dance in the "PapjTos Ebers." These disgusting drugs we will 'Some one paraphrasing Pliny has said: "Magic was the offspring of medicine, and after liaving fortified itself with the shield of Astrology it borrowed all its splendor and authority from religion." See Pliny: Hist. Nat. Lib., XXX. Cap. 1-2. 2 Hibbert Lectures, 1887, p. 84. THE THERAPY OF THE MAGI 25 again find recommended in the works of Galen, ^Etius and Oribasiiis, among those prescribed internally and even for internal local appli- cations in throat disease. We can perhaps therefore understand Juvenal's objections to the Chaldeans, and we may see from his mention how these articles crept into the later medical writings of the Roman Empire and subsequently appeared among the drugs of the jNIiddle Ages, thus transferred from the plains of Mesopo- tamia to the banks' of the Rhine and the Thames. The belief in the efficacy of precious stones as medicaments is first found in the accounts of Babylonian medicine and existed far into the Renaissance as costly articles of the Pharmacopoeia. Witch Medicine. — ^Mysterious invocations, gruesome and disgust- ing prescriptions occupy a prominent place in all records of primitive medicine, but apparently these with the cabalistic use of figures and signs have long lingered in the records of medicine and in literature as the heirlooms of Chaldean sorcerv. The Faust legend^ is full of them. The Walpurgisnacht in Goethe's "Faust" has a distinctly Chaldean flavor, not pleasant but weird. We recall the dark cave in "Macbeth," where the witches' prescription is compounded : "Fillet of a fenny snake In the cauldron boil and bake; Eye of newt and toe of frog, Wool of bat and tongue of dog, Adder's fork and blind worm's sting, Lizard's leg and owlet's wing." The same Chaldean prescription is found in Horace, where the foul witch Canidea orders: "Et uncta turpis ova ranae sanguine Plumamque nocturna; strigis, Herbasque quas lolcos atque Hiberia Alittit venenorum ferax, Et ossa ab ore rapta jejuna? canis Flammis aduri Colchicis." — HoRATii Fl.^cci Epodon, Liber 5, V, 19 Seq. These are merely Babylonian or Egyptian prescriptions in meter. The Therapy of the Magi. — Pliny,- who believed that he would be able to include all the wisdom of the world in his histories, has left behind him some curious information as to therapeutics derived from Chaldean or Oriental sources. He may be held up as a terrible example to the gentlemen who still believe that even now the whole field of medical science does not oft'er too wide a scope for their mental powers. "I find," says he, "that a cold is checked if any one will kiss the nostrils of a mule." "Inflammation of the fauces and the pain will be (aired by the dung of kids l^efore they have tasted grass, if it is dried in the shade." "Gargling with the ' Faust in der Geschichte und Tradition, Kiesewetter, Leipsic, 1893. 2 Hist. Nat., Lib. XXX. 26 THE MEDICINE OF THE PA USEES milk of a sheep helps the tonsils and fauces." "Anginas are helped by a goose's gall mixed with elaterium and honey — by the brain of an owl, by the ashes of a swallow soaked in hot water. Ovid is the author of this medicament." These suggestions arc taken at random and do not exhaust the supply of therapeutical measures for nose and throat diseases, which were derived from the IMagi by Pliny, to whom I would respectfully refer those curious in regard to or desirous of profiting by such garnered wisdom. Such things still are to be found in the folk-medicine of rural communities to a surprising extent. These relics of this peculiar phase of medical history are still w ith us, but we have but little direct knowledge of Chaldean medicine, although Sayce has lately partly deciphered "An Ancient Babylonian Work of Medicine."^ For some mysterious reason Egyptian civilization, and with it Egyptian medicine, was at a standstill for many centuries before the downfall of the Oriental dynasties. At a later period we see the same phenomenon among the Hindus. Although the Greeks apparently derived at least the foundation of their learning from these sources, they were far in ad\'ance of them when the generals of Alexander (330 B.C.) established his empire over Asia. Even in the time of Xenophon (401 B.C.), two generations earlier, the Persian monarchs were surrounded by Greek physicians whom they brought to their courts, usually by profuse pecuniary induce- ments, but not infrequently by force and by kidnapping. It was Ctesias, a Greek physician and historian, who treated the wound, and is said to have sa\'ed the life of Artaxerxes when he was left for dead by many of his native followers on the battlefield of Cunaxa, where he so nearly lost his crown to his brother, Cyrus the Younger, who was subsequently himself killed in this battle. - Now, more than a hundred years before this, we have seen that Cyrus the Great (559-529 B.C.) sent to Egypt for a physician for the eyes, while Darius (521-486 B.C.), one of his immediate succes- sors, made use of Democedes, the Greek, in preference to native and Egyptian court physicians. I do not know whether this sequence of historical events in medicine has any great value, but, in connection with other facts, it is perhaps significant of the shifting of medical knowledge. THE MEDICINE OF THE PARSEES. If we have not already had sufficient glimpses of Chaldean and Assyrian medicine we have only to glance through the "Zend- Avesta,"^ the sacred book of the Parsees, to understand the reluct- ance of their monarchs to avail themselves of home talent. The 1 Zeitschrift fiir Kcilschriftforschung, II, 1-3. 2 Xenophon: Anabasis 1, VIII, 27. Plutarch: Life of Artaxerxes. ^ Darnistetter: Sacred Books of the East, Vol. IV, Part 1. THE MEDICINE OF THE TALMUD 27 remedies of the ancient Parsees consisted chiefly of charms and spells. They divided medical practitioners into three groups: Those who healed with the knife, those who used herbs, and those who practised spells and incantations, and the "Zend-Avesta" recommends the latter class, not an anomalous proceeding in ecclesiastical advice of later time as well, but it gives, perhaps, a very good reason, viz.: They were apparently the least to be feared. ^Ye learn that one of their evil deities created 99,999 diseases with which to plague mankind. Out of this large number we find no mention of those of the upper air passages, nor of any other dift'erentiation that is intelligible to us. THE MEDICINE OF THE "TALMUD." There are a number of modern treatises upon the medical knowl- edge of the "Talmud," but a perusal of them, while it reveals a perhaps interesting state of early Hebrew sanitary science, does not give us much insight into their knowledge of diseases of the nose and throat. There are several references^ to acute inflamma- tions of the throat which seem to bespeak the existence among the Babylonian Jews of diphtheria, or of that disease described later by Aretaeus as Syriac ulcer, from which "they died the most terrible death of all" the 903 deaths possible. This passage reminds one of the mention of the number of diseases in the " Zend-Avesta." We are still further reminded of Chaldean medicine by the incanta- tions spoken of as therapeutic measures, of demons as etiological factors in fatal throat inflammations, and of the dung of a white dog mixed with myrrh as a local throat application in cases of coryza. Cynanche and "tumor of the palate" (apparently quinsy) are also mentioned. In the ]Mischna- (Fol. 42) we learn that transverse division of the trachea is fatal, Init (Holin, Fol. 45) that longitudinal section is not, if there remains an unsevered portion at the top and bottom. In the "Ghemara" (Holin, Fol. 57) it is stated that a hole in the trachea may be stopped by an artificial contrivance. It appears that they learned these facts from their sacrificial practice on animals. In the " Kethubot" treatise occurs this passage : " Samuel says that the polyp shows itself by a bad smell of the nose. A 'beraitha' says the odor comes from the mouth." Evidently Samuel and the "beraitha" meant ozsena, although in a footnote the translator seems to think otherwise.^ 1 Bergel: Die Medizin der Talmudistoii, Leipzig, 1885, pp. 33, 37, 42, 5L 2 La Aledizin du Talmud. Rabliinowitz. 3 Being entirely ignorant of Hebrew and Sanskrit, I have had to relj- on the authority of translations which have been sharply criticised, but I have taken some pains to verify the above extracts from the Talmud. The Jews are said, I know not on what authority, to have been ignorant of medicine until their introduction into Egypt. 28 HINDU MEDICINE HINDU MEDICINE. ^Yhen we begin to search the writhigs of the ancient Hinchis we enter a mysterious reahn full of surprises, finding therein many medical facts which seem to belong to a later period of the evolu- tion of the art. Finding these at a date many centuries liefore the beginning of the records of the Greeks, vouches by itself for the remoteness of the beginning of Hindu civilization. That their writings are, some of them, of immense antiquity seems evident, and that they are the origin of much which is to be found in the later scientific literature of the Greeks, seems very probable, for it is unreasonable to suppose that Greek civilization was as indigenous as they claimed both for it and for their race. Whatever was the origin of the Hellenic tribes, it is becoming yearly more evident with the advance in archaeological knowledge that their learning was transplanted at a comparatively high state of development from the land of the lotus flower, and in all probability from that mysterious table-land of Central Asia, the roof of the world, through the people which dwelt along the Ganges and the Eui)hrates to the shores of the Aegean; but while at its source scientific knowl- edge seems to have stood still in historical times, it has blossomed in other soil to the fruition we now enjoy. It may be conjectured that the reason for this non-progressive character of the knowledge of the Oriental lies in racial characteristics, and yet it is difficult from our ignorance of their historv to understand whv this halt in the evolution of their knowledge should have occurred after it had grown to the proportions we recognize in the Susruta.' The contention of Haas,- a German critic, that the writings of the Hindus show that they have never been a progressive race, but that they had borrowed their knowledge from the Greeks without developing it, is plausible when we consider how eagerly the Persian monarchs sought medical aid from that source rather than from the East. The Hindus, however, were further removed from the Persian monarchs than were the Greek cities of Asia Minor, which indeed formed a part of their cm])ire. Perhaps the strongest argument against this assum])tion is the fact that the same non-progressiveness is seen in Egyptian civilization, and yet the "Papyros Ebers" and other evidences prove that a comparatively high state of medical knowledge existed in Egypt at a i)eriod even anterior to the date assigned by the Greeks to the Trojan war, and at least many hundred years before the birth of Plippocrates. ' Guizot and Freeman both ascribe the stationary condition of Eastern civili- zation to the unison of the temporal and spiritual powers, but this scarcely satisfies us, and while admitting the strong ])robability of the efficiency of this factor, we instinctively look for other causes concomitant and anterior to it. ' Haas: Zeitschrift der Deutschen Morgenliindischcn Gesellschaft, Vol. XXX, p. 017: Vol. XXXI, p. 647. SUSRUTA AND HIPPOCRATES 29 " Herodotus' Histories" are sufficient evidence on this score. Never- theless Haas attempts to show that the medical writings of the Hindus are of recent origin : in fact, that they were composed at a period subsequent to that in which the various Hippocratic treatises were given to the world. Susruta and Hippocrates. — Haas goes still further and asserts that in all probability the Susruta is really a derivative of the Hippocratic system, and even that the name "Susruta" is a Hindu corruption of Hippocrates. It is supposed b}' him that the Hippocratic writings were rapidly disseminated through Asia and India by the Greek physicians, who were in such demand at the courts of the Eastern kings, but in the accounts of i\.lexander's campaigns will be found notices of Oriental physicians who possessed such knowledge of various parts of physic as were unknown to the army doctors, especially in regard to the cures for the bites of venomous serpents, which is perhaps not very conclusive evidence of a more extensive knowledge. Nevertheless in reading the Susruta and the Charaka one will be much impressed by some striking analogies to passages in some of the Hippocratic books which seem not to have been transmitted through generations, but to have been directly transferred from one treatise with very little modification to the other. Which was the original in nowise appears. It is scarcely necessary to say that Haas' arguments have not been generally accepted as convincing. At any rate, since the dawn of history, western medical knowledge blown on the wings of the wind from European lands has scarcely produced a ripple on the stagnant pool of Hindu medicine, and today the two systems in India are practised side by side. In the Talmud we have seen a reference to wounds of the car- tilages of the larynx and we again meet it in the Hig Veda and the Susruta. India is referred to in the Rig ^ eda as the Bountiful One who without a ligature can cause the wind-pipe to reunite when the "cervical cartilages" are cut across, provided they are not entirely severed.^ Thus early do we find a statement which refers to a point discussed for more than 1500 years after the beginning of the Christian era in the history of tracheotomy. The Hindu "Ayurvedas," just as the medical knowledge of all ancient peoples, were supposed to be of divine origin. Even in modern times the Christian Scientists and their ilk remind us of this tendency. The "Ayurveda of Susruta" was revealed by D'hanvantare, the i)hysician of the gods, out of compassion for the suffering of mortal men. These medical vedas or axioms were 1 Hornle: Studies in Ancient Indian Medicine. The Journal of the Royal Asiatic Society of Great Britain and Ireland, London, 190(5-09, \^ol. II, ]i. 922. See also Julius Jolly: Zur Quellenkunde der Indischen Medizin, Zcitschrift der deutschen Alorgenliindischen Gesellschaft, Leipzig, 19UU, Vol. LIV-L\'. 30 HINDU MEDICINE collected and transcribed by his disciple Susruta. The "Ayurveda of Susruta" is said b}- the wise men of the East to be at least of a date 1000 years B.C., and it contains scraps of medical lore which bear every evidence of being still more ancient. Time being of little value to the dreamy Hindu, his chronology is a source of inexhaustible irritation to the uneasy Western savage. Althougli we of another civilization have good reason for tracing our philologi- cal, our scientific and philosophical, even our ethnical origin, back to this cradle of antiquity, we have traveled a long distance since then on all these highways, and not only is the language obscure, but the ideas are many of them unintelligible to us in their old books. Therefore, althoush the "Susruta" is admirably arranged in captions much in accord with modern medical ideas, the Latin translation of Hessler (1844) is in many places confusing, and it is perfectly evident that the translator is often himself groping in the dark. There are to be found in the "Susruta," and easily referred to in Hessler's rendering, many references to the diseases of the nose and throat, some of them recognizable by our barbaric ^Yestern intellect, but many of them to us quite vague. Charaka Samhita. — The Charaka Samhita is being translated from Sanskrit into English by Avinash Chandra Kaviratna, a learned pundit of Calcutta. This work is said by the Hindus to be a revelation of Indra, the god of the middle air, through Charaka the sage, and is said to be of much more ancient origin than the compilation of "Susruta." At least it is more unintelligible to the modern student of medical history. To the student of philology it is said by Wise and Miiller, and Eastern scholars generally, to be of greater value than the "Susruta," and the learned and enthusiastic translator, a patriotic Hindu, indulges in the fond hope that by the diffusion of the wisdom of Charaka a profound impression may be made upon the practice of the medical art as pursued by the energetic sons of the West, the physicians of Europe and America. I am afraid our Hindu confrere does not realize the obduracy of the seed of Japhet. Both in the "Susruta" and in the "Charaka" the declaration is made, and this is found very little modified in the medical works of the Greeks, that "Whid, bile, phlegm have been said to be the cause of all bodily disease." What follows, however, I have not noted among the writings of the Greeks. It is a little too mystic for them, apparently. "The qualities of passion and darkness have again been indicated to be the causes of mental diseases." — ("Charaka.") In "Susruta" we learn' that there are sixty-four diseases of the mouth in seven situations. The seats of morbid action are the 1 Susrutas: Ex Sanskrita in Latinum: F. Hessler. Erlangae, 1844-55, Tom. I, p. 202. UVULOTOMY AND TONSILLOTOMY 31 lips (8 diseases), roots of the teeth (15), the teeth (8), the palate (9), the fauces (17) and all of them together (3).^ As one of the diseases of the palate we recognize quinsy in Hess- ler's Latin: "Tumor rigidus, in palati regione a sanguine ortus existit. Cognoscendus est hie morbus angina, febre dives." There are various passages translated by Hessler which Morell ^Mackenzie supposes to refer to diphtheria, but I doubt if we can differentiate the different forms of acute throat inflammation, accounts of which are found here, as elsewhere, in all extensive treatises of the ancients on disease, it matters not to what age or people they belong. One cannot but be struck by the early tendency of the medical man to lay great stress and emphasis on a name. We ha\'e seen how the physician of Egypt was to announce the presence of a "fatty tumor in the neck," and here in the "Susruta" the rendering is: "Qui tumor in linguae dorso magnus est, is intumescentia vocatur." We may readily imagine that these venerable doctors of the hoary past made use of some recondite word of a language still older than their own, if any such there were, to express in suitably dignified terms for the edification of the laity a diagnosis w^hich was really only a definition, " Un specieux babil, qui vous donne des mots pour des raisons," as Moliere' puts it 2500 years later. Uvulotomy and Tonsillotomy. — Here and there we can recognize familiar surgical operations. "By means of forceps between thumb and finger, drawing the u\'ula forward, the physician may cut it with a sickle-shaped knife above the top of the tongue." "Gilagum (quinsy?), so-called, may be cured by the knife." Firm, hard, and filling the fauces, extraordinarily swollen with sprouting flesh, giving rise to much pain, caused by the evil inflammation of the humors, killing almost a hundred men, it is recognized that (this?) swelling of the tonsils is incurable; but a tumor seen in the 1 The statement is made by Galen — "Galeni in Hippocratis Librum de Alimento Commentarius," III, XXVI (Opera omnia [Klihn] Lipsia?, 1821-33; XV, p. 363) — that the school of Cnidos, the rival of that of Cos, divided diseases into a great number of different kinds: "Seven diseases of the bile, twelve diseases of the bladder, four diseases of the kidneys," etc. If we consult the ideas and the philosophy of Pythagoras (500 B.C.), which had a profound effect upon Greek civilization and had a great influence at the school of Cnidos, we will find in them traces of much which he derived, evidently from liis long travels and his dihgont studies pursued among the Oriental nations with which Greek tradition crecHts him. Now this reverence for num- bers we find in the Charaka and Susruta, and we have ah'cady noted it in the Zend-Avesta and in the Talmud in connection with diseases. It is by many little hints such as this that we are able to trace the connection of Greek med- icine with that of the Orientals, and we may also note how the latter have purified and exalted it, not only by their initative, but bj- the dropi)ing of the superstitions with which it was overgrown. There is very little of spells and incantations, and reverence for numbers and malignant demons, to be found in the Hippocratic writings. 2 Malade Imaginaire. 32 HINDU MEDICINE throat about the size of the seed of the Phylhinthus Emblica, stationary, a Httle painful, made up of phlegm and blood, adherent like the fruit of the Terminalia Alata, this, curable by the knife, is called Gilagu." Are we here to recognize a differentiation of malignant and benign swelling of the tonsils and the prevalence of the practice of tonsillotomy? Wise,^ in his "Hindu System of jNIedicine," describes a method of abscission of the tonsils which aimed at removing a third part only with the knife. " If all is cut the patient will die of hemor- rhage." As he does not give his reference I am uncertain if this is contained in the more ancient books or not. ]\Iany more recent writers have insisted that a partial excision only is ever indicated, and is sufficient. We may be sure from these passages that they knew what secondary tonsillar hemorrhage meant as well as some of the rest of us. Rhinoplasty. — It is especially in the Hindu writings that we find such complete and minute accounts of the various plastic operations about the nose. This was due, doubtless, to the practice of the wrathful Oriental potentates who amputated the nose out of revenge or in the exercise of judicial penalties. This art was almost entirely forgotten by the Greeks, because they shrank in horror from the mutilation of the human form, and had little opportunity to practise plastic operations for its correction. In a more savage age and country, many centuries later, it was revived by Taglia- cozzi, but we shall easily trace it back to its Oriental source. ^'aporization and fumigation through a tube were frequently emj)loyed in the diseases of the nose and throat. Stimulating and acrid vapors seem to have been recommentled in what we may conjecture was oza?na.'' It was also prescribed for coughs, asthma, hoarseness, mucous discharges and enlargement of the tonsils, but as it was also advised for "mor})id baldness and a reddish yellow- ness of the hair,"^ one is left in some doubt as to its modus operandi. These diseases were all due, according to the sage, to the same cause. Local applications of ointments were made to the nostrils and various sternutatories were used for cleansing the nasal chambers, after which, apparently in coryza, the following directions were explicit, and could be only slightly inii)roved by the modern rhinologist: The patient was to lie on his back, raise the tip of his nose with his index finger and allow his physician to drop in his nostrils warm oleaginous liquids. While this w^as being done he was not to become angry, nor speak, nor laugh, nor swallow the oil dripping from his nose, but s])it it out. The use of sternutatories or snuffs was also recommended for sleeplessness and clearing the ' Wise, T. A.: Commentary on the Hindu System of Medicine. Calcutta, 184.5. 2 Susruta (Hessler), Therapia, Cap. XXII-XL. ' Cliaraka. (Trans, by Kaviratna.) Calcutta. RHINOPLASTY 33 head in the morning — apparently prescribed for conditions in which we order douches and sprays. Gargles were also a part of their therapeutical resources. They very often used oil as a men- struum, and apparently had a more thorough way of using the gargle than we usually insist upon.^ It is evident that these old Hindus recognized the dependence of laryngeal or nasal diseases, as is apparent in this sentence in Hessler's translation: "Nasale remedium morbos hominum supra claviculam ortos refrenat et organa sensuum pura atque os suaveoleus efficere potest." In the light of recent sanitary doctrines and regulations the following quotation from Charaka (p. 74) may })e of interest: "One should not eject the mucus or phlegm of one's nose in a place that is crowded." This, however, may have been only a precept of social intercourse rather than having the additional sanitary weight it now possesses. At this place occurs rather frank advice as to the relations between man and wife. They are amusing, but perhaps a little out of place now in print when not attended by the strict scientific necessity for their publica- tion. The one precept which may be quoted here is as applicable to laryngologists and rhinologists as it is to the rest of mankind. It is to the effect that a man should make a confidante of his wife, but he should not tell her all his secrets. These little scraps from the dim and misty past of a forgotten civilization make one realize the universal brotherhood of man. In fact, one cannot even glance through the works of Charaka, and especially of Susruta, without having one's mind impressed with the antiquity of human knowl- edge and wisdom, and it is a vast education for any man when he can be brought to realize, in this egotistical epoch, how little of it after all has had its origin in his day and generation. We can only conjecture that the development of the arts and sciences of the ancient Oriental world must have occurred chiefly in some prehistoric cycle of human acti^'ity, when man's mind and body were as free along the Ganges as they were on the shore of the ^Egean when the Hellenic tribes took up the torch, in the blazing light of which we still live. This is what liberty means, and we can now see along the Ganges and on the ^Egean the results of the mental and political slavery not only of an Oriental, but of a once glorious Occidental race. Kassel- quotes from Susruta a passage, which apparently I have missed, in which, to judge from the description, there is very good evidence that syphilitic disease not only of the genitals but of the nose was well-known to the Hindus. In Wise's work on "Hindu Medicine,"^ from which I now quote, there are many accounts of nose and throat diseases which I 1 Susruta (Hessler): Tomus, III, p. 42. 2 Die Nasenheilkunde des Altertums, p. 20. ' Loc. cit. 3 34 HINDU MEDICINE cannot find or have inadvertently passed over in the translations of the "Charaka" and of the "Susruta" at my disposal. As he states that his work is taken exclusively from the ancient Hindu writings, althoiiii'h in the passages cited he does not indicate the sources from which he draws his information, it mav be inferred that thev are of equal antiquity with those I have drawn directly from the translations of Hessler and Kaviratna. ^Moreover, I recognize in Wise's book many passages identical witli those in the "Charaka" and "Susruta." ^ledicines administered by fumigation through the nostrils were used not only for local nasal diseases, but for some general affections, and particular directions are given for using them. Among the errhines or sternutatories to clear the head may be noted pepper, mustard, orris, ginger, asafoetida. One might think they would be efficient. One of the methods recommended for causing sneezing was to look at the sun so that its rays would fall on the mucous membrane of the nostrils. We recognize here an error in mistaking a reflex phenomenon of the retina for a direct action. Among the gargles, besides the more agreeable ones of oil, vinegar, honey, and the juices of fruits, the urine of cows finds a place. Stimidating and irritating substances (pepper) were also prescribed as gargles. There is an instrument spoken of (p. 169) for "eradicating nasal polypi; a frequent and troublesome disease in many parts of Hindustan." It seems to have been some sort of a curette. Foreign Bodies. — (p. 186.) If a foreign body is "in the throat, the extraneous matter may be discharged by thrusting down a hot iron to dissolve it, or soften it, and so remove it. In such case the hot iron is passed through a metallic tube. A probang for removing fish bones is usual; by drinking fluids and emetics it is also dis- lodged; this may also be done by beating the patient upon the back of the neck." Among the fifteen modes of removing extra- neous substances, Bidmapana is "by blowing, as a substance intro- duced into the larynx, which produces great irritation and strong efforts at coughing," etc. Pramarsa: "If in the nostrils, errhines are to be used." It must be confessed that the art of removing foreign bodies from the upper air passages does not seem to have been very highly developed, and the above described use of the hot iron seems strange and hardly credible. Is it possible that we have here a confused Hindu rendering of the recommendation by Hippocrates for the use of the hot iron in the nose?^ Fracture of the Nose. — We are reminded of Hippocrates in the passage (Wise, j). 192) : "When the bones of the nose are depressed they are to be raised into their natural position by means of an ^ Diseases II, where much else resembles the Susruta. PRE~HIPPOCRATIC MEDICINE IN GREECE 35 instrument called Shalaka: a hollow wooden tube is kept in the nostrils so as to retain the bones in their natural position."^ We may note another passage, and this is especially dwelt on by Haas (/. c.) as indicative of the corrupt and degenerate derivation of Hindu medicine from the Greeks. There is probably no quotation from Hippocrates so well known as that in which he describes the facies of approaching death (Prognostics 2):'- "A sharp nose, hollow eyes, collapsed temples; the ears cold, contracted, and their lobes turned out; the skin about the forehead being rough, distended and parched; the color of the whole face being green, black, livid, or lead-colored." Now compare this with Wise's translation from the " Susruta" : " When it [the nose] becomes pale, dry, and shining, and is turned to one side; the nostrils extended, dry, and dirty, and the passage of the air produces a noise; or when the point of the nose retracts and is flattened with weakness and depression, the person will soon die." We note how distinctly inferior this is to the graphic description of the Greek sage. I doubt very much the conclusiveness or even the suggestiveness of the passage in the "Susruta" as an argument for the derivation of Hindu from Greek medicine. Similar phenomena were observed by men of dissimilar mental powers. There are thirty-one diseases of the nose. Simple catarrh, acute and chronic, was called Pinasa. Ozsena is Putinaska. Nasal polypi were termed Nasarsah and there were four kinds. Tumors of the nostrils are of five kinds and were called Nasarbuda, but it does not appear how they were distinguished from the nasal polypi (Wise, p. 289). Goitre, tumors of the neck, scrofulous swellings, hoarseness, asthma, cough are all described, but there is little in the passages which is either interesting or instructive. We may pass lightly over the Hindu conception of anatomy and physiology. As an indication of its limitations, Wise,^ among other examples of their ignorance, declares that the Hindus had but one name for throat, "Khunt," including in its signification not only the air-way but the gullet. PRE-HIPPOCRATIC MEDICINE IN GREECE. Whatever may have been the truth as to the derivation of Hindu medicine, we have little actual means of knowing whence the Greeks drew the germs of their medical knowledge. We may conjecture that it came with the Phoenician trading vessels from the shores of Asia, or the Hellenic tribes may have brought it from 1 Vid. Susruta (Hessler), Tomus, II, p. 67. - Genuine works (Adams), 1, p. 195. ^ Review of the History of Medicine (among the Asiatics), London, 1867, I, p. 135. 3G PRE-HIPPOCRATIC MEDICINE IN GREECE the Asiatic tal)le-lantls with tlicin, but more prol)al)ly much the larjjcr portion of it came directly from the \ailey of tlie Nile when in (iTO B.C. the land of the lotus fiower was thrown open to Greek commerce and Greek curiosity. Thales and Pythagoras are significant personages in the early history of Greek science. In the fragments of their philosophy as well as in the legends of their lives we find unmistakal)le evidences of their sojourn among the Orientals and of their absor})tion of Oriental civilization and philosophy. The same may be said of Solon. Perhaps it may be of some value to note tliat therai)eutics in Greek medicine include none of the disgusting substances and scarcely any of the charms and invocations which mark so strongly that division of medicine among the Egyptians, Chaldeans, Hindus, and Eastern races generally, and which we have seen later was introduced into the Greek medical writings of the Roman Empire and upon which I have already commented. The period of four hundred or fi\e hundred years which stretches from the supposed age of Homer to the birtli of Hippocrates (4(10 B.C.) is one of which we know but little in the history of medicine. It is entirely devoid of medical works which ha^'e come down to us. In philosophy, Thales, Xenophanes, and Pythagoras greatly influenced the minds of men in weaning them from the superstitions recorded in the "Theogony" of Hesiod. They winnowed out from them idealistic portions which could be made to stand as symbolical of their own ideas of cosmogony.^ Coming down to the time of Socrates, we find him recognizing things divine and things material, while Hip])ocrates, but little his junior, brings all phenomena under one head and calls them all divine, one not more than the other. (Airs, Places, and \Yaters.) Whatever may have been the channels by which were carried the seeds of knowledge, the mar^■elous growth which sprang up on the soil of Greece has not ceased and will never cease to excite the wondering admiration of mankind. Civilization in Greece. — It is significant perhaps that the opening of Egypt to Greek coimnerce took place at about the time of the beginning of written records in Greece ((300 b.c.),^ and two hundred years after writing was first introduced and the epic ballads of the wandering bards and rhapsodists became perpetuated in written records we have the birth of the "P^ather of YIedicine." It needs only a cursory perusal of the Ilippocratic writings to realize how intense the mental activity of nascent Greek ci^■ilization must have been to have i)roduced in the short period of two hundred years a condition which made possible the comj)ilation of these masterpieces of medicine in whose inspiration we still live. After the excursions we ha^'e made into the more stagnant civilizations ' Grotc: History of Greece, \o\. I, p. 3GS f. f. = Ibid., Vol. II, p. 149. THE NOSE AND THROAT IN HOMER 37 in the search for the origin of medical knowledge we feel that we are nearing home, or at least on more familiar ground, when we begin the study of Greek medical history. At the port of entry looms up, obscuring all others, the great name of Hippocrates. There was medical knowledge in Greece before the birth of Hip- pocrates, of course, but the records of it have perished and so have the works of those who followed him. It is only by scanning secular literature and by noting references in later medical writings that we are able to obtain some glimpses of the state of the knowl- edge of the anatomy and the functions, but scarcely of the diseases of the upper air passages. In the legends of the Hellenic races are to be found traces of familiarity with a medical art which existed long before the rise of the school w^hich clustered around the altars of Aesculapius in the Isle of Cos. Ancestry of Hippocrates. — Hippocrates^ traced his lineage in the seventeenth generation through a medical ancestry to that demigod who according to Cicero (De Natura Deorum, III, 22) was the son of Apollo or of Hermes, or of Arsippus and Arsinoe. He w^as the first to discover the probe, according to Greek legends, the first to bandage a wound, the first to teach men to draw teeth and to purge their bowels. For these and other services he was deified, but because he raised the dead and attempted to exercise his power of making men immortal, he was struck into Tartarus by the forked thunderbolt of the jealous Olympian Zeus. His two sons, Podaleirus and Machaon, led the thirty Thessalian ships to the siege of Troy (Iliad, II, 731), where they exercised their father's art as well as that of Mars. Machaon was said- to be skilled in the arts of the surgeon, while Podaleirus had "skill over things invisible," and to the latter was given precedence, a custom still pre^'ailing in medicine to-day. It is to ]\Iachaon, who knew how to draw out darts, to make incisions, and to treat wounds and ulcers, that the present generation of rhinologists owe homage rather than to Podaleirus, who diagnosed madness in the blazing eyes of Ajax. We can do little more in this period of medical history than seek out the origin of the nomenclature of the parts of the human anatomy with which we are concerned. We have seen that the word nose is apparently contemporaneous in origin with that of the Aryan languages. While we have the authority of Darcmberg^ for the statement that there are only five instances mentioned in Homer's Iliad of wounds of the throat, there are a large number of lines in which the nose is mentioned. The Nose and Throat in "Homer." — We read (v. 291) how Athene directed the lance of Diomede so that it jiierced the nose of Pandarus 1 Grotc: History of Greece, Vol. I, p. 182. - Arktinus: (770 b.c.) Epicc. Grace. Fragm., II, p. 22. ^ La Mcdecine dans Hoinere. 38 PRE-HIPPOCRATIC MEDICINE IN GREECE near the eyes, crashed past the white teeth and, cutting the tongue, api)oared under the chin, and how the mortally wounded chieftain pitched headlong from his chariot. There is a line in the Iliad which gives evidence that embalming was understood bv Homer's Greeks (XIX, 39). The goddess Thetis dropped nectar and ambrosia into the nos- trils of the dead Patroclus to keep the skin hard and firm and thus preserve the body. This she does to allay the grief of her son Achilles at the death of his friend. As we know that embalm- ing was foreign to later Greek customs, we may perceive here a familiarity at least with Egyptian practices, if not an influence of Egyptian ideas, and to some extent the prevalence of oriental customs. Etymology of Greek Words for "Throat." — We have seen how indefinite was the Hindu Mord for throat. Although the Greeks, unlike the Hindus, had many words for this part of the anatomy, thev used them at first very indefiniteh' and interchangeablv. The word pharynx in early Greek literature was about as indefinite as our word throat. It occurs in Homer's Odyssey first. If you will turn to the graphic description of that horrible man-eating Cyclops, Polyphemus, in the ninth book, at line 373, you will 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 ca^'e while wine and morsels of his cannibalistic feast regurgitated from his capacious pharynx (Odyssey, IX, 373). (f)do'jyo~ (Js^saauTO oiuo^ (^>coiw( zaijophnzot. Whether this is the first written us(> of the word or not, it certainly occurs here in a most vividly striking passage of the greatest of poems by the first of poets. It will be seen that Homer has used the word here in accordance with its present significance, but in the Odyssey again (XIX, 480), Ulysses grasps with his right hand the 4>dyj^ (throat) of Euryclea to prevent her crying out. Even in the works of IIipi)ocrates a similar looseness of meaning is to be observed, as, for instance, in the Littre edition,^ 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 win(l-i)ipe and which may be inspected by dc])ressing the tongue. The word larynx is not found in Homer, l)ut is first noted among the dramatic poets; but here again quite indefinitely arousing our suspicion that /dnu^ may have been at first a corruption and ' Oouvrcs completes d'Hippocrate, Trad. i)ar. E. Littre', Paris, 1839-1)1, \"11I, p. 505. 2 Opera Omnia (Kuhn, XVIII, pars II, ]). 264). DRINK IN THE LARYNX 39 a tautological use of the word (f^dou^. This may be seen by a reference to the plays of Aristophanes (The Knights, I, 1363; The Frogs, I, 575). In the Cyclops of Euripides (I, 157) occurs the passage, fi(ou too Aafniyya osexaua^i aou, which the dictionary trans- lates, "Has aught run gurgling through thy throat?" Drink in the Larynx, — The thought arises from this quotation that the idea of 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 oesophagus. 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 refer- ring to results of the division of the wind-pipe (Des Chairs, IS),^ and in the chapter (De la Nature des Os, 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 occasionallv used interchangeably. Aristotle also uses the word in its present signification and only rarely speaks of the wind-pipe, i. e., the trachea, as extending from the lungs to the mouth. Not until Galen, however, do we find the term definitely established by his anatomical descriptions. Homer uses the word Aa4)an(lyo:: 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 Aacpapdyo:: 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 Aac^ajxlyoz 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 c/)do'jf and later ^-aou^. This, however, is entirely conjectural on my part.'^ 1 (Littre) VIII, p. 607. ^ i^id., IX, p. 169. ' While the root of the word pharynx is said to be the same as in aysia) 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, lioayyo' 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. Finally, I quote from another brochure of Daremberg^ the derivation of another term rhinologists use every day: Euripides (Fragm. 1044) is, I believe, the first author where one meets with MoxTrnj — the nostrils or the nose. It seems also that Sophocles (Fragm. 581), and especially Aristophanes (Fragm. 650), calls the nose or the nostrils by the name Mu^a, which is regularlv applied to the mucus which escapes from them. (The Knights, 910; The Wasps, 1488.) Scientific and i)hilosophical records being so defective, and purely medical treatises being entirely lost, if any existed before the Hippocratic era in Greece, we cannot 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 Superstition. — Here is a fragment suggestive of the character of early (ireek medicine, showing that it differed little from that of other rude and uncivilized races. The Dog and the Serpent were alike sacred to .F]scula])ius, and on the second one of the columns, seen by Pausanias at Ei)idaurus, 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 Aegina, "affected with a tumor of th<> neck, ap]ilied to the god. One of the sacred dogs licked the affected part and cured it.'"^ Philosophy has always at all epochs of Medicine dominated it. Pythagoras established four elements: Earth, Fire, Air, and Water 1 L'Etat dc la Mi'decino entrc Homore et liippocratc, Pari.s, 1SG9, p. 14. 2Roinac-h: Revue Arclieologique, 1884, II, p. 129; 1885, I, p. 267. For a most interesting aeeount of the Temple of Aeseulapius at K]n(laurus, see a paper by W. S. Coleman, M.D., F.R.C.P., St. Thomas' Hospital Reports, Vol. XXVII, 1898, p. 397. For a very readable aeeount of the cult at Epidaurus, see The temples and Rituals of Asklepios, by Richard Caton, M.D., etc., 1900. THE EUSTACHIAN TUBE 41 — Empedocles admits these, but adds to them their quaHties: the cold and hot, the wet and dry, which are found in medicine until the Renaissance. In Plutarch's "Morals"^ there are to be found some curious chapters 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 (520 B.C.) believes that the principal part of the soul, residing in the brain, draws to itself odors by respiration. Empedocles (490 B.C.), that scents insert themselves into the 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." The Eustachian Tube. — Alcmaeon is said to have been the first Greek anatomist and to have dissectedthe eyes and ears of animals, discovering the optic ner\'e and the Eustachian canal, thus antedat- ing in the latter discovery Eustachius by many centuries. Aristotle (Hist. Animal I, IX, 1) 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 found^ 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. Kassel has drawn attention to a passage in a papyrus No. 1558 from the Egyptian Museum dating back 1400 years before Christ in which it is said, "There belong two vessels to his left ear through which the breath of life goes; there belong two vessels to his right ear through which the breath does." We may conjecture from this that the source of Alcmaeon's knowledge as that of most of the knowledge of his day was p]gyptian. Whether any of this error may have arisen from observations of pathological perforations of the drum membrane is a permissible conjecture only. 1 Translation. Ed. Goodwin, 1870, Vol. Ill, p. 170 (De Placitis Philos.). - I presume Plutarch hero refers to Diogenes of Apollonia, born in the fifth century B.C., who described the distribution of the bloodvessels, which is to be found in the fragment of his writings still preserved. Fragm. Philosoph. Graec. MuUach, Vol. I, p. 254. ' Observat. Med. Amst., 1641, Lib. I, Cap. XXXV. 42 PRE-HIPPOCRATIC MEDICINE IN GREECE Ak'inaeon explained hearing by the hollow bone behind the ear — "for all hollow things are sonorous." (Plutarch, 1. c.)^ Emj^edocles 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 ()i)enings 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 phil- osophers 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- 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 Theory. — 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 (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 Democritus did we not find in one of the fragments-' remaining to us from Democritus an analogous statement as to taste, the dis- tinctions 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 })ody and nowhere admits a vacuum; and l)eing struck with the lircath, it is infinitely moved in waves and in right circles until it fills that air which invests it, as Ave see in a fish pool which we smite by a falling stone cast upon it; yet the air is moved spherically, the water orbicularly. Anaxa- goras (500 B.C.) says a voice is then formed, when upon a solid 1 See also Kuehn: Opusoula Minora, I, p. 09. ^Fragm. Philosoph. Grace, MuUacli, 1875, 2(1 Vol. I, 34)3 ff. => Ibid., Vol. II, p. 362. HIPPOCRATES AS A SPECIALIST 43 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 perhaps full of meaning, it may be seen that w^e may occasionally extract passages which need little altering to conform with modern doctrine.^ 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 A^gorous and fruitful manhood. We mav be sure, however, from the cold analvsis of historical experience and of philosophical logic that there must have been a long previous condition of growth and develop- ment, which cannot be traced in the scantv remnants of historv left us. Hippocrates as a Speciahst. — On the authority of Celsus- we must accept Hippocrates as really the first medical specialist in our civilization, 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 progressiveness, acknowledged that this specialization might possibly be excusable, 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 cannot 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 philosophers spent so much of their time in sedentary contemplation and nocturnal vigils that they fell ^ It is absolutely necessary for any one desiring an intelligent knowledge of the medical 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 resume 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 Europe gives a somewhat biased review of Greek philosophy in its broader ramifications. In the Pro- emium of Celsus, however, will be found the most succinct and the clearest account of Medical Schools among the ancients. 2 De Medicina, Lib. I, Praefatio. 44 THE IlIPPOCRATIC TREATISES sick, and were forced to resort to the study of medicine to cure themselves.' The ci\ihzati()n of the ("haldean and the Parsee, of the Egyptian, and even of the Ilinchi is strange and incomprehensible to us, but we instinctively feel that the Isles of Greece, that Cos, over opposite Abdera is a familiar land, and that there we will find a mental activity into which we are al)le to enter. When we read in Xenophon's Anabasis (III, 119) that the soldiers cried out when their comrade sneezed, "Zsu acoaov]" "God save you," immediately comes to our mind the Frenchman's ejaculation "Dieu vous benisse," and the Germans' hail, "Gesundheit."- Turn to Hip- pocrates' account of the case "in Thasus, the wife of Dealces who was lodged on the plain"^ and read there his account of a death from fever with cerebral 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 anv 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. 19()) supposed Shakespeare to have derived his description second hand from the celebrated passage in Hippocrates^ 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 knowledge of either of these passages in the Hippocratic writings, either first hand or second hand. We are struck by the resemblance of the impressions made on our ' Therefore, after those of wliom I liave spoken, no distinguished men prac- tised medicine until, by the more diligent study of letters, education began to be jiursued wliich, although indeed necessary of all things for the mind, is inimical to tlu; bod.y. Some have it that the science of medicine first began because the cure of diseases and the contemplation of nature were pursued by the same authors. This, moreover, was especially necessary to those who injured the strength of their bodies by sedentary thought and by late hours. Therefore, we believe that many of those who were (>xpert in the knowledge of things suffered in this way. ^J'he most distingui.shed of these were Pythagoras, Empedocles, and Democritus. T\w latter as some believe had llipijocrat.es of Cos for a disciple, the hrst and indeed the one of all most worthy to be held in memory, for he separated this science from other pursuits, a man distinguished in art and in natural attainments. - This ancient custom, however, is older than the Greek civiHzation. ^ Kj)idemics III, Sec. 17, case XV. (Adams) I, p. 349. ^Prognostics 2 (Adams) I, p. 285. Her(\'ifter, in the references to Hippo- crates' works, English terms refer to Sydenham (Aflams) edition, (N. Y.: Wm. Wood & Co., 1891, 2 vols, in one); French terms, the Littre edition; and Latin terms to the Kiihn edition. THE ERA OF HIPPOCRATES 45 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 explana- tion, 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 cannot now be aroused from the slumber of so manv centuries? At least we can comprehend somewhat from this objectivity how the virile fructifying aggressive mind of the Ancient Greek furnished a soil for the quick luxuriant growth of seeds from a dying civiliza- tion, dying even then with its youth stretching back into the inscrutable past of prehistoric times. The Era of Hippocrates. — It must be borne in mind that Hip- pocrates lived in that glorious time of Greek civilization and culture, the golden age of Pericles, that his life overlapped that of Phidias and Praxiteles, of Anaxagoras, Socrates and Democritus, of .Eschylus, Euripides, Sophocles 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 Mrgin 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 Hippocrates, there are only a few which have been acknowledged by all authorities to have been really written by him. Some have been pro\'ed, many have been surmised, to have been written by his predecessors and successors. It seems probable that some were written by others during his lifetime 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 dis- cussion of such matters, but rather to bring into prominence tliost-. 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 1 Littr6's Introduction to Ocuvres Completes d'Hippocrate. 46 THE IIIPPOCRATIC TREATISES as to those which are supposed to have been written by others of his time or school. Some of the passages in the writings of these .Esclepiadoe seem ridiculous to us, but we should keep constantly in mind the charity which our successors 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 otit the errors Hippocrates committed in not being in accord with the doctrines 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 charlatan, subsequently ridiculed his system by saying it was the contemplation of death. It is perfectly evident that he recognized the futility of drugs as ctirative 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 pharmacology 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 acttial knowledge they had of normal anatomy or of pathological processes. ^Ye have seen from the few extracts I have been able to gather how primitive 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 ahuost nil from a modern standpoint. The Destination of Fluids. — "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, arteri;e stimmum, quod larynx dicitur, in ptilmonem et arteriam ex quibus in summam 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 supposition 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 vermilion to a thirsty l)east to drink, preferably to a swine, for this beast is not fastidious but ' De Corde Liber. Magni Hippocratis Opera Omnia, edit. Kuhn. Lipsiae, 182.5-27, I, p. 485. THE DESTINATION OF FLUIDS 47 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 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 enterpris- ing, 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 epiglottis, 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 Alcseus (611, 580 B.C.) was quoted, "Now drench they lungs Avith 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 Timsesus- 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 epiglottis 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 dis- cussion on this passage in Homer hinged upon the meaning of the word 4>o-y'J^, 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 pu])il, Dioxip])us, (390 B.C.?) and Philistion, a very ancient physician of Locri, had iVid. Gaisford: Poet. Min. Giaec, Vol. Ill, p. 321, XVIII. ^ The passage referred to reads "the hing 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 toward the lung, and the lung is placed near the heart. A few lines farther on it is evident, however, that Plato recognized that some of the licjuids at least go to the stomach, or rather "the region between the diaplu-agm and the navel." 48 THE niPPOCRATIC TREATISES no other thought. Dioxippiis supi)osed that the epiglottis served to di\ide the food and drink into the coarser parts which passed into the stomach and the finer parts which passed into the hnigs. 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 find even Galen in a modified form entertaining this idea. lie 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. ^ He compliments him as a man of wonderful skill in physic and fit to be imitated by the greatest philosoi)hers, especially as to his ingenuousness, for "he confessed publicly that he had mistaken the nature of the sutures cf the skull,^ and has left an acknowledgment under his own hand ; for he thought it very unworthy a man of his profession not to discover where he was in the wrong seeing that others might sufter and err by his authority." Plutarch's comment on this is quite as ap])licable today as in his own time. "And indeed it had been very unreasonable, 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." Quint ilian echoes Plutarch's eulogium.' The Origin of Catarrhs. — When we realize that the ani'ients, IIipj)ocrates, Galen, and their followers, knew nothing of the muciparous glands, and of course nothing of the function of these microscopic structures, it is easy to understand the absolute mental necessity for them to find some ex])lanati()n of the origin of the secretions which bathe not only the respiratory tract, but the ' On the Parts and Gait of Animals, III, 111, 4. 2 Man's Progress in \'irtue. 3 Vid. Hippocrates: Epid. V, § 27— cf. Dc Vuln. Cap. § 12. ■* Celsus, from whom probably Plutarch and (^iiinf ilian drew their informa- tion, remarks in regard to Hippocrates' superiority in this resjx'ct over lesser men. Nam levia ingenia, quia nihil habent, nihil sibi detrahunt. Lib. VIII, Cap. IV. THE ORIGIN OF CATARRHS 49 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 knowledge, as well as a mistaken anatomical observation, led them into another error which persisted still longer. The cribriform plate of the ethmoid bone (the sieve-like bone) at the top of the respiratory tract was usually seen only in the dried specimen by the ancients 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 indubitable 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. Li 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.^ 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 cribriform plate. The latter he describes as being made of cartilage, soft like a sponge, and is neither flesh nor bone.^ So entirely had this conception of the anatomy and physiology of the cribriform 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 clogging 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 applied to a fool, a driveler. Still more was this evident in the Latin tongue. "Emunctse 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 tantiun pedibus numerisque, facetus, EmunctxB naris, dui-us componere versus." Horatii Satira, IV, 6. 1 Liber IV, Cap. 187. 2 Vid. Galen: De Instrumento Odoratus. Cap. IV (Kuhii), II, p. 867. •^ Des Chairs (Littre), VIII, p. 605. 4 50 THE HIPPOCRATIC TREATISES "Obesae Xaris," fatty or obstructed nose, in distinction to "emiincti? naris," referred to mental dulness. ]\Jany similar passages 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 uj)on 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 cribri- form plate — but all starting from the brain. Coryza. — In his book on "Ancient JNIedicine," where he protests against the entertainment of hypotheses as to etiology, Hippocrates describes 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 (H, 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 running down from the head." Another modern idea we are reminded of in the relation of a case"^ of habitual catarrh which was cured in three days by coitus. Acute Throat Inflammations. — Cynanche, which English trans- lators usually render as quinzy, is a term Hippocrates applied to nearly all the acute inflammations of the throat. Littre (V, p. 579) discusses the cjuestion as to whether Hippocrates was familiar with diphtheria. Croup, Littre calls it. It is doubtful whether the cases are sufficiently difl'erentiated in the Hippocratic writings to make them intelligible to modern readers. Even in the time of Littre's edition (1loponcssus was Archagathus, the son of Lysania, in the year of the City, 535. — (Plinii Naturahs Hist., Lib. XXIX, Cap. 1-6.) 64 ROMAN MEDICINE rude old patricians of ancient Rome viewed the introduction of Greek civilization. It has always been noted in tlie history of the world that the first advances which have tended to ameliorate the asperities, to increase the amenities, and to introduce 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 toward effeminacy and degeneration. Cicero's Anatomy and Physiology. — 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, tum eloquentia vincebat ceteros medicos"^ 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 anatomy. " It will be more easily appreciated what has been done for man by the immortal gods, if the whole fabric of man is exam- 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 because it is reinforced by the air from the adjoined nostrils. The food is masticated by the teeth arranged in the mouth, and by them di\ided 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 oesophagus, adherent to the tongue as its root, receives from it that which has been received by the mouth. This, touching the tonsils on each side, is continuous with the end of the palate and this it is Avhich receives the food after it has been pushed along by the movements of the tongue, and passes it downward. Those parts which are lower down than that which swallows (the food) are dilated, while those parts above are contracted. 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 oesophagus 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 l)y 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 (i. e., the gastro-intestinal tract) is, however, multiple and tortuous, and it encloses and holds that 1 De Oratore, I Cap. 14. ^ Dq Natura Deorum, II, 54. ASCLEPIADES 65 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, pre- pared 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 lungs, however, there is a certain looseness of texture and a softness, 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 cannot 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. Asclepiades. — As to Asclepiades, that eloquent rhetorician of Bithynia, the friend of Cicero and Crassus, the great advocate of diet, exercise, and massage, and enemy of bitter doses and radical treatment generally, 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.^ Synanche- he said was "a flow of the humors 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 scarified the tonsils and the fauces around them. ]Moreo^'er, he approved of the practice of incision of the trachea as recommended by the ancients, which they called lar^'ngotomy,' 1 Pliny: Hist. Natur., Lib. VII, Cap. 37. 2 Coelius Aurel. de Morb. Acut. Ill, 1 (Amman), Amst., 1709, p. 181. ^ Coelius Am-elianus (de Morb. Acut.), Lib. Ill, Cap. IV, Edit, .\mman, p. 193 — Asclepiades — At si major (inquit) passio fuerit, dividendai sunt fauces, hoc est tonsillae et partes supra uvam constitutse, etenim summa est in his sequalis sive par incisura, quam appelavit homatomia. Dehinc a veteribus probatum approbat arterise divi.suram, ob rcspirationom faciendam, quam laryngotomiam vocant, varie ao multiplicitcr pcccans. 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. Coelius expresses the belief that the account of the ancients doing it was not true but an invention of Asclepiades. 5 66 CELSUS AND THE PRE-GALENIC WRITERS to relieve the respiration. Themison, the founder of the school of Methodists and a follower and disei])leof Asclepiades, also approved of this surgical operation. Celsus (Lib. 1\ , Cap. IX), quotes him approvingly and recommends his prescription of swallowing strong vinegar in ulceration of the fauces, and says that he condemned the practice of Erasistratus ligating the extremities for hemoptysis. AYith this condemnation Celsus does not agree. So far as the throat is concerned, therefore, his practice to-day would not be called very mild or conservative. CELSUS AND THE PRE-GALENIC WRITERS. In the eight books of the "De jNIedicina," which remain to us from the writings of Aulus Cornelius Celsus, who was probably born in the last da^'s 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 bv 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 W'Orks still contain much of value to the surgeon. Coryza.— In his chapter on coryza,^ he repeats the conviction 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 cribriform 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 abstention ^ The following lines have been held by some medical historians to refer to the physician Celsus, but there seems every reason to believe it was the some- what earlier poet Celsus to whom Horace here, as several times elsewhere, alludes : "Quid mihi Celsus agit? monitus multumque monendus Privatus ut querat opes, et tangere vitet Scripta Palatinus quecumque recepit Apollo, Ne si forte suas repetitum venerit olim Grex aviimi 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 Augustus, was already in reciuisition bj- writers, and already the charge of plagiarism was much indulged in by the literati. 2 Lib. IV, Cap. II. ANGINA, KYNANCHE, SYNANCHE 67 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. Angina, Kynanche, Synanche. — ^In regard to throat inflammations,^ those which are confined to the fauces, he said, the Romans called angina, while the Greeks gave the name synanche to that form in which there was dyspnoea 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 w^ere the highly agreeable gargles he used, though all his prescriptions were not so mild. Vinegar, powdered pe])per, and oxgall also formed part of his pharmacopoeia. In certain cases he made deep incisions exter- nally 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 quinsy. ^Yithout the necessary differentiation of diphtheria from quinsy or other inflammatory 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 centuries, saying that it w^as 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, ha\'ing 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 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. H, Gap. 1 Lib. IV, Cap. IV. 2 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 Hippocrates, Opera Omnia (Ktihn), XVIII, Pars. 2, p. 2()7, intimates that the two terms arose out of a different reading of the initial letter in the word, as uscfl bj' Hippocrates, by different writers, and that Hippocrates made no distinction. This is probably the correct explanation. We will find Areteus making elaborate distinctions in the use of the terms. ^ Hist. Animal, XXX, 4, 12. 68 CELSUS AND THE PRE-GALENIC WRITERS XXII)^ will be found the prototype of this prescription. "In affections [of the throat] arisinji; 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 dyspnoea he recom- mends a paste made of dried fox liver powdered. lie also advises it should be roasted and eaten. Even for dyspnoea 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 '\/0^«c, chieHy in children, for in men and women there is not the same peril. "^ Evidently this is diphtheria. He remarks that ulceration of the fauces is frequently followed by a cough, for which, of every description, he recommended long sea voyages, sea-side resorts, and sea bathing.^ He devotes a chapter^ to the spitting of blood and recognizes vicarious menstruation among other more frequent causes. Ozsena. — For ulcerated nares he recommended^ N'apor of hot w^ater from a narrow-necked vessel, and mineral astringents were applied to the ulcer. " But if these ulcers are around the openings and the^' have manv crusts and a foul odor, which \'arietv the Greeks call " Oyjcva, it should be recognized that it is hardly possible 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 mav then be removed bv the use of sternutatories." 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 leaving pledgets of lint saturated with some medication in the nostrils, this to l)e done twice a day in winter and spring and thrice a day in summer and autumn." 1 Susruta (Hessler), II, p. 133. 2 Celsus: De Mcdicina, Lib. VI, Cap. XI. ^ Ibi>^), fleshy and gland-like. We note thus early the occurrence of the word "adenoid" applied to the structure of this tissue. Again, in the "Anatomy of the Parts of the Body," ascribed to the same author, occurs the following: "At the deepest portion of the tongue and at each side of this organ are arranged at its base excrescences called lateral glands of the isthmus to the number of six; they have a gland-like structure. The form is rounded. They are movable and easy to excise; they are attached by means of small membranes which hold them at the base. Four are to be seen at each side of the l)ottom of the mouth — two are less visible." We may conjecture there lias here been some mutilation of the text. He noted they are more promi- nent when inflamed. He recognizes that the uvula is of little use and its amputation produces no alteration of function. As we shall see, in the descrij)ti()n of the tonsils he is less accurate than Galen, but more in accord with modern teaching as to the uvula. Rhazes, an Arabian writer, quotes Rufus as saying: "In fracture of the nose it is well to fill the nostril completely with cotton (or silk) stuff, and not extract it until the nose has taken its shape. "^ Tracheotomy of Antyllus. — Here is, perhaps, the place to introduce a quotation l)y i'aulus Aegineta from the lost works of Antyllus, a surgeon of much note, who is said to have lived during the reign of Hadrian (117-138 a.d.). It is the first specific description of ' I have hou-e used the excellent translation of Adams, p. 255. 2(Euvi-es de Rufus d'Ephese, Paris, 1879, p. 141. ' Ibid., p. 471. COELIUS AURELIANUS 75 the technique of the operation of tracheotomy. I avail myself of the Sydenham translation of Adams. ^ " The most famous surgeons have also described this operation (laryngotomy) . Antyllus, therefore, says, 'In cases of cynanche (as we will explain under the head of Dietetics) we entirely disapprove of this operation, because the incision is wholly unavailing when all the arteries (the whole of the trachea and bronchi) and the lungs are affected; but in inflammations about the mouth and palate and in cases of indurated tonsils, which obstruct the mouth of the wind-pipe as the trachea is unafl'ected, it will be proper to have recourse to pharyngotomy, in order to avoid the risk of suffocation. When, therefore, we engage in the operation we slit open a part of the arteria aspera (for it is dangerous to divide the whole) below the top of the wind-pipe, about the third or fourth ring. For this is a convenient situation, as being free of flesh, and because the vessels are placed at a distance from the part which is divided. Where- fore bending the patient's head backward, so as to bring the wind- pipe better into view, we are to make a transverse incision between two of the rings, so that it may not be the cartilage which is divided, but the membrane connecting the cartilages. If one be more timid in operating, one may first stretch the skin with a hook and divide it, and then removing the vessels aside, if they come in the way, make the incision.' These are the words of Antyllus." Xow, by the phrase in parentheses, "for it is dangerous to divide the whole," we are reminded of the passages I have cited from the Talmud and the Rig Veda. We may, therefore, entertain some conception of the antiquity of the operation of tracheotoni}-, though it is not mentioned in Pliny. Coelius Aurelianus. — Coelius Aurelianus is another of the many medical writers whose epoch we cannot definitely ascertain, though it is supposed he was a contemporary of Aretaeus and of Galen. His barbarous Latin and his ignorance of Greek show that his knowledge of polite literature was limited, but his accurate descrip- tion of disease, and especially his copious citations of earlier writers whose books have perished, make his works important in the history of medicine. He describes very vi^•idly the symptoms of acute throat inflammation,- which he calls synanche, and he includes under this head everything of the kind. His treatment does not differ materially from that of Aretaeus. He was very fond of the use of oil both as a menstruum for gargles and for the inunc- tion of the whole body, when he used it warm in se\'ere cases. He disapproved of the practice recommended by Hippocrates and his followers, of bleeding from the veins beneath the tongue in synanche, saying it did harm rather than good. He notes Hippoc- rates' suggestion of passing a tube along the tongue into the pharynx 1 The Seven Books of Paiihis Aejiineta (Adams), LoikIoii, 1S4G-47, II, p. 301 - De Morbis Acutis, Lib. Ill, Cap. I, II, III, IV (Aiiunan ed.), p. 179-198. 76 GALEN (or larynx?) for the relief of dyspnoea. He strongly condemned the practice which he says Asclepiades falsely ascribed to the older writers of opening the trachea. He says the report is an invention of Asclepiades, that it is rash and dangerous, and it would be a crime to perform it.^ Nevertheless, we have seen that Antyllus, who must have lived about the same time, carefully describing it, according to Paulus Aegineta. Aurelianus has a chapter on hoarseness- arising from colds and shouting, and notices the diseased uvula as the cause of chronic coughs; he has also a chapter on coryza.^ GALEN. Gibbon begins his immortal work, "The Decline and Fall of the Roman Empire," with the sentence: "In the second century of the Christian era the Empire of Rome comprehended the fairest part of the earth and the most civilized portion of mankind. . . . If a man w^ere called to fix the period in the history of the world during which the condition of the human race was most happy and prosperous, he would, without hesitation, name that which elapsed from the death of Domitian (96 a.d.) to the accession of Commodus" (180 a.d.). It was in this epoch, at the culmination of the mightiest empire that the world has ever seen, that Claudius Galen lived. It was under Trajan (98-117 a.d.) the empire reached its greatest territorial extent,^ and in the following reign of Hadrian (131 A.D.) Galen was born. With many vicissitudes of favor and exile he practised at Rome and elsewhere. His early life was passed under the beneficent reign of Antoninus Pius, and that of the great jNIarcus Aurelius, whose friendship he is said to have enjoyed; but in his last days he must have witnessed the disgraceful scenes which marked the reign of the brutal and licentious gladiator Commodus, to whom he was physician in ordinary, and those of his impotent and infamous successors, when mighty Rome had already begun to totter toward the long-delayed collapse of its widespread power. Hence it is that after Galen we are to meet no great work in medicine, which marks its material progress, for more than a thousand years. So intimately are all the forces of civilization interrelated and interdejjendent that the history of no one division can be intelligently followed without the side-light which other parts throw upon it. We see in Galen the culmination of the medical progress of the ancient world, and in the light he transmitted the new world, when 1 Dc Morbis Acutis, Lib. Ill, Cap. IV. • * De Morbis Chronicis, Lib. II, Cap. VI (Amman ed.), P- 378. 3 De IMorbis Chronicis. Lib. 11, Cap. VII, VIII, p. ;i79-388 For a more complete review of the work of CocUus Aurehanus, especially in regard to diph- theria and angina, vid. Mlinch. med. Woch., 1899, XLVI, p. 1382. .^Freeman: Chief Periods of European History. THE ANATOMY OF GALEN 77 it first began to emerge from the chaos of Rome's destruction, made its first feeble move toward a renewed growth in the develop- ment of medical knowledge.^ I have several times had occasion to anticipate in this history the account of some of Galen's views, and it is not necessary here to review these. I have also had occasion to animadvert upon the great advance of the anatomical knowledge of the upper air passages displayed in the works of Galen, beyond that to be found in the works of his predecessors. It needs very little perusal of them to convince one of the enormous strides made in the anatomy of the human body since the days of Hippocrates, five or six hundred years earlier. From Celsus, one hundred years his senior, and from Aretaeus, perhaps his con- temporary, we can derive only slight information as to the ana- tomical and physiological knowledge they possessed. They were evidently men of commanding talent, but their works which have been preserved are too meager for us to form much of an idea of their fundamental knowledge of the human body and its functions. The An'atomy of Galen. — It is in Galen's writings, therefore, that we first gain an idea of the advance made in those departments of medicine by the Alexandrian School of Anatomists. It is signi- ficant of the influence exerted by the great libraries of Pergamos and Alexandria that the birth and early education of Galen are accredited to the former city, and that he acquired at least some of his knowledge in the latter.- It would have been manifestly impossible for any one man to have himself originated the discovery of one-tenth part of the new anatomical facts we meet with in Galen for the first time, although he doubtless is the real author of some of them, especially of those in regard to the larynx. Far inferior to the author of the best of the Hippocratic treatises in talent and in genius, but greatly surpassing him in accurate knowl- edge, Galen is contentious, prosaic, and tiresome to the last degree. I would recommend that those who love to indulge in medical polemics should, as a punishment to fit the crime, be compelled to read seriatim the extant works of Claudius Galen. It is, however, to these very personal qualities we are indebted apparently, not only for all the medical learning of his o^^'n times, but for very 1 It is true that for seven hundred j-cars his works were not read in Eiu'ope, but after Gregory destroyed the hbrary on tlie Cai)itohne, that might be said of every other medical writer of merit. Under the Eastern Empire, during this time he was confessedly or secretly, with Pliny, the origin of all medical knowledge, but the first translations of Galen from Greek into Arabic, and hence into Latin, are in the eleventh and twelfth centiu-ies, while direct trans- lations from Greek to Latin did not take ])lace imtil the fourteenth centur.y. 2 If , as it appears probable, Galen was not acquainted with the dissection of the human b(^y, it would seem to follow that the jjractice of the Alexandrian School in the time of Erasistratus and Horophilus had not persisted to the time of (jalen. This cessation, if it really took place, we maj' conjecture to have been due to the prevalence of indigenous I'-gyptian prejudice over the tendencies of Greek science. 78 GALEN much Avliich we possess of that which existed before his ])irth in the works of eariier writers. This it is which has raised tlic medical works of Galen above all others in importance to medical science, greater even than those of the school of Cos. Had the latter not come down to us in their own form, we would still have most of them reproduced either literally or in substance by (lalen. The Intermaxillary. — (lalen described an intermaxillary bone^ in man. This a{)parent mistake was probably due to his observa- tions on the skeletons of animals which he seems to have dissected much more frequently than man. It led many hundreds of years afterward to a warm discussion between anatomists. Finally, in the last century, Vicq D'Azir and Goethe definitely settled the matter by showino; that traces of this intermaxillary bone are found in the skulls of children and in the fetus. This was one of the forerunners of Darwinism, a discovery of one of the suggestive facts which, with Goethe's INIetamorphosis of Plants, formed the germ of tlie doctrine of Evolution in the animal and vegetable world, and of the Spencerian philosophy. It is a striking instance of the Spencerian philosophy. It is a striking instance of the necessity of a proper soil for the germination of any observation of nature. Had the old Greek and Roman civilization persisted a few centuries more who can doubt that the circulation of the blood- would have been known a thousand years earlier, or that the enlightenment which has followed the promulgation of the doctrine of Evolution would have been similarly antedated. Galen fully recognizes the nose as the beginning of the respiratory tract.^ He describes the muscles* of the external nose as two in number, one on each side, for the dilatation of the nostrils, and he understood the distribution of the facial or hard part of the seventh pair of nerves to them.'^ Nasal Anatomy. — Galen's description of the internal nose in the "De Instrumento Odoratus""^ reads as follows: "The nose having a median dividing wall has two conspicuous openings, one for each nostril, and each one of them is divided in the upper part into two portions. One of these divisions leads to the mouth and the other one upward so that it starts from the entrance and ascends to the brain itself. There are two hollow oblong ofl'shoots of these (it?) toward it (these ?),^ having their beginning from the 1 De Usu Partium, XI, Cap. XX. 2 After a careful perusal of much of the writings of Galen 1 am unable to grasp thoroughly the idea he had of the circulation. ' De Usu Partium, Xl-II. I make use chiefly of Ki'ilm's edition. ^ De Dissect ione Musculorum. 5 De Usu Partium, Lib. XVI, .3. ' Kuhn, II, p. 858. ' Kiihn's Greek text, from which I translate, docs not seem to me to warrant the Latin construction which accomiianies it. Neither the text nor the trans- lation of Kiihn are here felicitous. We must imagine that the text itself has been mutilated by ignorant and careless copyists, but Kiihn's translation in making use of an unwairanted construction docs not thereby elucidate the anatomical description. THE FUNCTIONS OF THE NOSE 79 anterior ca\'ities, reaching to that part of the skull where the nose has its origin. At this point is the situation of the sieve-like bones (ethmoid), the function of which the name indicates, and the thick membrane (the dura mater) with which that of the bones is continuous, is pierced by fine openings. Through these first the thicker parts of the excretions from the brain are transmitted (the custom was started by Aristotle of calling such things excre- tions), for things more vaporous mount to the sutures and escape from it. The thick part of these, such as phlegm in coryza, is carried downward, having first passed through the dura mater. After having been strained through the sie^'e-like bones, it thus passes into the channels of the nose. There is a part runs into the openings of those channels heretofore mentioned which lead into the mouth itself; and the mucus, especially such as is viscid, part of it falling at one end into the channels leading into the mouth, the other part into the passages on both sides which lead outwardly, is blown forcibly from the nostrils and is hawked out through the mouth. A bloodless (sic) membrane, thicker than the skin, lines those straight passages of the nose leading up to the sieve-like bones, and likewise those other oblique channels which I have said end in the mouth. This membrane is continuous with that lining the circumference of the whole mouth, and covering the tongue, and in addition to these the pharynx, the larynx, the trachea, and the esophagus. To this membrane, which is one from the beginning and continuous, and in all the parts mentioned, has the appearance of the same substance, but has not the same thickness in all parts, certain small nerves are distributed, springing from the brain, except those to the tongue." This idea of the brain as the origin of the secretions of the mucous membranes of the respiratory and digestive tracts, as has been said, was due to the ignorance of the existence of the muciparous glands and to the absolute mental necessity of finding some explanation for the presence of the mucus. As we have seen, the idea is found in the Hippocratic writings, and it persisted for two thousand years in medical belief. The eyes and ears were also supposed to void their secretions through the lacrimal sac and the Eustachian tubes into the nose. He describes the trigeminus nerve^ as sending filaments to the mucous membrane of the nose and palate. The Functions of the Nose. — In order to show how closely, in spite of the gross errors as to the internal anatomy of the nose, Galen's physiology corresponded with what is orthodox doctrine in laryngology to-day, I quote from another work of (ialen.- Although the first sentence or two has now become obsolete, the rest seems as though it might have been taken from a modern 1 De Usu Partium, IX, 15. Lib. IX, Cap. XV, (Klihn) III, p. 743. 2 Ibid. Lib. XI, Cap. XL (Kiihn) III, p. 886. 80 GALEN text-book of the nose and throat: " It has been said conrernino; the uvula, in the commentary concerning the voice, that it contributes to the strength and beauty of the hitter, and both in an admirable manner, since the entering air first is divided by it and the force of its current is broken, and thereby that of its frigidity, so that some of those who amputate it at its base not only clearly injure the voice, but the increased coldness of the inspiration is felt, and many breathing this into the lungs and the thorax are thereby killed, so that it is not right to cut it off rashly, nor as chance would have it, but to leave some part of it at the base." " It has been stated before in regard to the perforations within the nostrils, how wonderfully the ])one situated in front of the ventricles of the brain receives them, being similar to a sponge, and in regard to the passage of these into the mouth, which is in the palate, how it is arranged that the beginning of the inspiration is not directly into the trachea, but there is a certain deflection of it, as a curve, before the breath arrives in the trachea, which arrangement it seems to me has a twofold advantage : first, because the air surrounding us is at times quite cold and the lungs then would be chilled; and, secondly, because small particles of dust or of ashes or anything of this kind may not fall into the trachea. In this bend, indeed, the breath may be carried further, but small particles of this kind are arrested so that they first, at this turn, fall upon soft and wet surfaces which are somewhat mucilaginous and are thus able to retain those which fall. If any get as far as the mouth, they stick to the palate and uvula. An exemplification of this is what daily happens to those who wrestle in much dust, as well as to those who are on a dustv lournev. In a little while they blow dust from their nostrils or si)it it out; but unless the channels of the nostrils were first directed straight up in the head, and thence obliquely backward to the palate, and unless the uvula were there, it is evident that nothing would prevent everything falling into the trachea, for this sometimes happens when one breathes by the mouth. I have even seen many athletes beaten in this very way, because the dust being breathed in by the mouth, they are nearly suffocated. When, indeed, any inflammation or tumor is present or any other affection obstructing the nose, then they are compelled to breathe through the mouth; from which thing it is possible to know that the nose is first in order as an organ of respiration, while the mouth, if nothing affects the animal, is in no way the organ of resj)iration, but in certain cases mentioned is an aid to respiration, which all directly points to the fact, which I have urged at the beginning of every disciuisition, that our INIaker formed all these things with one end of Ilis work in view." The Voice. — Galen's book upon "The Formation of the Voice" has been lost. Doubtless, had this been preserved, we would ha\'e been al)le to find much of interest in it. As it is, we read THE VOICE 81 much concerning the external muscles of the neck,'^ and we learn that he distinguished twelve intralaryngeal muscles, i. e., six pairs.^ He described the cartilages of the larynx as three in number, the thyroid, the cricoid, and the arytenoid. He supposed the latter was a single cartilage. We have seen how Aristotle described the anatomy of the trachea. For him it was made up of entire cartilaginous rings superimposed one on the other; but Galen knew better, describing the membranous portion behind and recognizing its function^ of facilitating deglutition.^ He is somewhat confused in his description of the production of the voice, at least in the books which have remained to us; but it seems as near as possible to the proper explanation in an age when the vibratory movements of the air as well as its other physical properties were so imperfectly understood. He claims to have been the first to discover and describe the ventricles of the larvnx, and he well imderstood that the glottis was the point at which the voice was produced, likening it to an ancient flute. He describes the vocal cords as a membranous substance so constituted as to resist the impact of the air and lubricated by mucus to prevent injury from the vibrations of a dry surface.^ "For it is pointed out there ("The Formation of the Voice") both that the trachea prepares and prearranges the voice for the larynx, and it being arrived there, the}' (the cartilages) increase it, and it is still further augmented by the vault of the throat which acts like a sounding board, the palate like a plectrum." '^ He reproves those who think the voice is sent forth by the heart, but declares that the larynx is the instrument of the voice.^ He corrects Erasistratus^ for saying that the pulmonary vein, like the bronchi, is free of blood; the latter, he says, contains blood only when there is a tear, or an anastomosis with a bloodvessel, when it mounts to the pharynx and is voided. We have seen that Galen, in a very qualified manner, was inclined to share the belief of his predecessors that fluids when swallowed passed at least to some extent into the lungs, and he seems to have believed that it is possible, by allowing medicaments to slowly melt in the mouth and by restraining the inclination to cough, for some of the material to find its wav into the lar\'nx and thus benefit those suffering from affections of that organ, which he often noted in actors, singers, etc.'^ The drugs he commended for 1 De Usu Partium. Lib. VII, Cap. XVII et seq., (Kiihn) III, p. 588. 2 De Musculorum Dissectione, XMII, pars 2, p. 92G. ' De Usu Partium, XII, 3, (Kiihii) IV, p. 6. ^ De Musculorum Dissectione, (Kiihn) XVIII, pars 2, p. 926. 5De Usu Partium. VII, 13, (Kiihn) III, p. oGO. « Ibid. Lib. VII, Cap. V, (Kiihn) III, p. 525. " Placitis Platon. et Hippocratis. Lib. II, Cap. V, (Kiihn) V, p. 240. 8De Usu Partium. Lib. VII, Cap. Ill, (Kiihn) III, p. 518. 'De Compositione Medicament, (Kiihn) XIII. 6 82 GALEN these troches are miuli the same as we use today. This was a favorite method of medication with Asclepiades. Perhaps it was for this reason that Galen declared that ulcers of the wind-pipe are easily cured. His explanation of speech was couched in almost the same words as that of Aristotle, saying that the voice produces vowels and the tongue, nares, lips and teeth form the consonants.^ The Glands. — He seems to have appreciated the identity of the lymph glands in the neck with those of other localities, for he says: "There are around the pharynx and larynx certain glands similar to those in the mesentery, but these latter are small, and on this account are not commonly recognized, but those around the fauces and larynx arc large and prominent."- This, of course, could only have been learned by careful dissection, and from the context we may imagine that he confused pathological with physiological conditions. Galen^ quotes INIarinus as saying: "The use of all the glands is twofold; (1) for they either support the deep vessels which are accustomed to be suddenly swelled (?) and undergo the dangers of divulsion on account of more rapid movements; (2) or they are able to moisten by the generation of humors the parts which are in need of viscid and widespread lubrication, lest easily becoming dry they may be unfit for motion. (And as for the other kind of glands which reinforce the vessels whose function it is to open (?), we will leave that for the time, as we have no use for it in this place.)" Elsewhere Galen'* explains "that since the glands, which fill what space there is in the midst of vessels distributed to various parts, act as a foundation or support for this distrilnition, they are of no very great use to living beings, but nature out of its abound- ing provision has formed these glands as it has many other things." Galen's^ reference to glands around the larynx and pharynx similar to those of the mesentery, may mean the thyroid and the tonsils. He refers in the same manner here to glands as elsewhere. This, quoted by jNIorgagni,*^ I am unable to find in Kiihn's Galen. Galen, or whoever is the author of the book, " De Voce et Anhelitu," says: "The neck, however, has two glands in which humidity is generated. But from these two glands which are in the neck veins are not given off in which the humor runs as in those which come from the glands of the tongue." Evidently the thyroid gland. The Recurrent Nerves. — He vaunts his discoveries in the larynx thus: "Attend, therefore, especially to this exposition which I 1 De Locis Affectis. Lib. IV, Cap. IX, (Kfihn) VIII, p. 2(56. 2 De Aliment Facultat. Lib. Ill, Cap. VI, (Kiihn) VI, p. 673. 3 De Semine. Lib. II, (Kuhn) II, p. 594. * De Methodo Medcndi. Lib. XIV, Cap. XI, (Kiihn) X, p. 982. ^ De Aliment orum Facultatibus. Lib. Ill, Cap. VI, (Kiihn) VI, p. 673. ' Morgagni: Adversaria Anatom, I, 26. THE RECURRENT NERVES 83 have in hand, because I was the first to discover it. None of the anatomists have hitherto known anything of these nerves (the recurrents), nor of those things hitherto mentioned concerning the structure of the larynx. Therefore, having turned your attention to that which is most to be respected, and having become a pupil worthy of the instruction about to be imparted, listen to the exposition setting forth a most wonderful phenomenon of nature."^ This wonderful arrangement was the reflection of the recurrent laryngeal nerves around the vessels of the thorax; but when he proceeds to explain it on the principle of the pulley, so that they may approach the laryngeal muscles from below, his solemnity and impressiveness in preparing the wondering pupils for the great secret seems a trifle ludicrous to modern readers. However, no one has really ever succeeded any better in attempting to explain this anatomical phenomenon, though there have been many theories advanced since "the days of Galen. Elsewhere^ he again claims that he was the first to discover and give a name to the recurrent nerves, those only being known to his preceptors which were near the arteries (pneumogastrics). In several places he makes the statement that chilling of the recurrent nerves during operations damages the voice, and he, therefore, advised against operations in this region during cold weather. He relates the case of a boy who was operated on for a struma, which was removed by evulsion, causing aphonia, due to injury of the recurrent nerves. In this connection it may be well to mention a belief of the old Greek philosophers, the origin of which Galen, in confuting with much prolixity, ascribes to Zeno the Stoic, it having been transmitted by Diogenes Babylonius and subsequently taught by Chrysippus.^ Cicero^ expresses it thus: "The trachea reaches from the lungs to the back part of the mouth through which the voice, taking its beginning from the mind, is perceived and has its origin." Galen savs the Stoics reasoned thus : " It is evident the voice cometh from the mind. It is also evident it cometh from the larynx. Hence the mind is not in the brain." Galen demolished this sophism thus: "They will wonder when they hear the voice is produced from the brain, and much more after having heard that all voluntary motion is performed by the muscles. . . . For the muscles move certain parts upon which the breathing and the 1 De Usu Partium. Lib. VII, Cap. 14, (Kiihn) III, p. 567. For a discussion of this subject, witli an interesting account of a modern theory, see The Lancet, 1893, I, p. 128. 2 De Locis Affectis. Lib. I. Cap. VI, (Klihnj VIII, p. 48. According to Baas, Marinus (100 a.d.) discovered the inferior larj-ngeal nerves. He gives no reference. » Vid. Galen: De Placitis Platon. ct Hippocrat., Lib. II, Cap. II, (Kiihn) V, p. 215. •• De Natura Dcorum, II, 59: Primum enim a puhiionibus arteria usque ad OS intimum perlinet, per quam vox principium a nientc ducens percipitur et funditur. 84 GALEN voice depend, and they themselves in their turn are dependent on the nerves from the brain. If you surround any one of these with a hcature, or if you cut it, you will render the muscle to which it is distributed motionless, as well as the limb of the animal which has moved before the nerve was cut." Another evidence of Galen's familiarity with experimentation on animals in elucidating the function of the laryngeal nerves is to be found further on in the same chapter: "The bones being removed from the brain, or its ventricles in some manner compressed, immediately there is not only no voice or breathing, but the animal is at once deprived of all sensation and of all motion during the compression." Humoral Pathology. — Galen adopted Hippocrates' idea, and thought health resulted from the proper equilibrium of the four humors, the temperaments, so called, resulting from the preponder- ance of one or more humors. He applied the four qualities to the four elements thus: Water Cold and wet. Earth Cold and dry. Air ^^"arm and wet. Fire Warm and dry. He applied to the humors the theory of the elements. Every disease is engendered by one of the humors or several combined. "The phlegm is an imperfect blood which may become true blood by the action of the natural heat of the body. In the phlegm water is abundant. It is cold and wet like w^ater. It nourishes the brain and all cold and wet parts. It tempers the blood and aids the movements of the articulations." We thus see it has directly to do with the mucous and serous membranes. In its other rami- fications the description of the applications of this doctrine is prolix and fatiguing. Its adoption tended to suppress originality of thought, just as any system always does. I have detailed at considerable length the indications of the anatomical and physiological knowledge which Galen possessed of the upper air passages, not only because in his work we first meet with any considerable notice of such knowledge, but because this knowledge formed the basis upon which rested for more than a thousand years the superstructure of theory and practice, until, indeed, it received from Vesalius and his followers a rational criticism, and eventually a refutation of his doctrines of pathology. The abolition of the latter by the physicians of the Renaissance and later, was a boon to suffering humanity. It was one of the many fetters which bound the human intellect — may we never see its like. As to other passages of interest concerning the nose and throat in the works of Galen, those treating of their diseases need not detain us long. POLYPI AND OZ.ENA 85 Anosmia. — We have seen the defects in Galen's knowledge of the anatomy and physiology of the nose, and hence we need not be surprised that he instances obstructive anosmia as a condition in which the air may pass through the cribriform plate to the brain without the odor — the particles of the latter being too large to pass through the perforations in the membrane lining the cribriform plate. ^ As a further illustration of the supposed entrance of the air or rather of the "pneuma" into the brain, he instances the case of a man who after forcible inhalation of an irritating substance into the nose, suffered acutely with headache referred to the frontal region. - Polypi and Ozsena. — Galen seems to have divided diseases of the nose into two classes, polypi and ozaena — corresponding, perhaps, to the modern classification of hypertrophic rhinitis, including cedematous hypertrophy and polypi, and atrophic rhinitis including possibly syphilis, if it then existed. Elsewhere, however, among the Definitions^ (Xo. 371), he states that oza^na is a deep ulceration in the nostrils, emitting a breath of a bad odor, and says: "Sarcoma is the unnatural growth of flesh within the nostrils. Indeed, a polyp is a kind of sarcoma. ... A sarcoma differs from a polyp in size and structure." His differentiation of nasal disease was, of course, very faulty. He gives a very large number of prescrip- tions, both of his own and others, for the so-called ozsena and polypi, but his therapy for these affections is decidedly inferior to that of Celsus. In the treatment of ozsena many compounds of iron or copper salts with honey, myrrh and other sweet-smelling herbs were introduced into the nostrils through tubes. Archigenes Asclepiades, Antipater, Charixenes, and many others are referred to by Galen as recommending these mixtures both for "polypi" and for ozaena. Oily applications, goose fat, calf tallow, and irritating medicaments like turpentine were also employed. A fuller account of this therapy may be foinid culled from Galen in Kassel's book, but as the diff'erentiation of intranasal disease is entirely lacking in the modern sense, it would be a work of supererogation to repeat his extracts. There is no reference made to Hippocrates' method of removing nasal polypi. Considerable attention is given to epistaxis as a symptom of various general diseases, but not as much stress is laid upon this point as in the Hippocratic treatises. He, as did his predecessors, recognized the dependence of diseases of the larynx upon affections of the parts above, but they explained this by the assumption that the brain was the common origin of all catarrhs. We find in Gakni abundant evidence of the influence of what I have called Chaldean medicine, the excrement of men and animals being freel}^ used in throat inflammations. Bleeding 1 De Usu Partium, Lib. VIII, Cap. VI, (Kiihn) III, i). (W(5. ^ De Instrumentum Udoratus. ^ (Kiihn) XIX, p. 440. 86 GALEN from beneath the tongue was also a favorite remedy in all afi'ections of the pharynx and larynx. Varieties of Kynanche. — We have seen how Celsus and Aretaeus subdivided infiamiuations of the throat into kynanche and synanche. Galen refers' to the ])ook of Prognostics of IIip])ocrates to prove that all these inlianimations were at first called kynanche. Galen himself, while not disposed to increase the number of names, divides throat inflammations into five varieties. First, inflamma- tion of the fauces. Second, difficulty of breathing with no inflamma- tion of the fauces or swelling of the external parts. Third, when the region of the fauces externally is inflamed. Fourth, when the fauces internally and externally are inflamed. This all seems very nonsensical, but we must remember the influence of the school of pneumatists. Although Galen supplanted all schools, he was by no means himself free from the influence of many of their theories. Fifth, in both Galen and Hippocrates there is a description of a throat affection which Galen explained as a dislocation of the odon- toid process of the axis vertebra. I am entirely at a loss to identify this affection, unless it was a postpharyngeal abscess. They both speak of it as an affection more or less commonly met with, and Galen created a fifth class for it. Diphtheria. — If any doubts have arisen as to the correctness of the assumption that diphtheria was known to earlier writers, the following passage from Galen should set the matter at rest. It occurs incidentally in Galen's treatise on therapeutics.- "For thus the youth having an ulcer of the pestilential disease in the trachea regained his health, and others in the same manner after him. In another youth, about eighteen years old, a cold having gone on for many days, a little fluid blood came up after a cough — not much — but after this he coughed up some part of the membrane itself, which, having remained behind in the trachea, came up through the larynx into the j^harynx and mouth. It seemed to me from the apparent thickness of it and from the patient's sensa- tions, it came from the body of the larynx. Thenceforth the man's voice was injured, and this for some time, but he eventually recovered." latros.- — Thus far in making citations from the works of Galen I have refrained from quoting from "latros, or The Surgeon," a book usually included in the more authentic works of Galen. While the latter may have written the introductory parts, nothing can be more certain than that he is not responsible for the })ody of the work. Evidently it is the work of another and a much inferior hand. It is full of anatomical and physiological errors which Galen himself in his other works has refuted or shown tliat he did not share. Galen's great familiarity with Hippocrates would 1 De Locis Affect., Lib. IV, Cap. VI, (Ktihn) VIII, p. 237. 2 De Mcthodo Mcdondi, Lib. \, Cap. XII, (Kiilin) X, p. 360. lATROS 87 haA'e prevented him from making the statement we find in the "latros" that if the nasal bones are broken they cannot be straight- ened. Galen in his "Commentaries on the Hippocratic Treatises," dealing with this subject, shows his perfect familiarity with the treatment of such cases. ^ We find also that the author, whoever he was, made the same distinction between kvnanche and svnanche as did Celsus and Aretaeus, a distinction which Galen, as we have seen, distinctly repudiates. He agrees with Galen in attributing great importance to the epiglottis as a protection to the larynx, but he fails to add any precept of caution to his mention of the operation of amputation of the uvula to which Galen attached such necessary physiological functions. He speaks of the tonsils as four in number, one at each side of the fauces, and one at each side of the base of the tongue, this being the first mention of the lingual tonsil. He used a sharp, narrow spatula to separate nasal polypi from the bone, and afterward shaved off the roots with a sharp knife. It is in this book that the assertion is positively made that Asclepiades actually performed laryngotomy in extreme cases of dyspnoea, but there is no comment with the statement. THE GREEK WRITERS OF THE EASTERN EMPIRE. And now begins that long and dreadful epoch in the history of mankind when civilization was almost o^'erwhelmed in the slowly crumbling ruins of the Roman Empire. Julius and Augustus Caesar, in extinguishing the anarchy of the last days of the Republic, extinguished with it much of that burning fire, the love of human liberty, which has always blazed high in lighting the progress of civilization. Tiberius, Caligula, Claudius, Xero, Domitian spilled the best blood of patrician Rome and demonstrated the horrible evils of a despotism under weak and wicked men. Xerva, Trajan, Hadrian, the Antonines demonstrated the enormous but temporary advantages to mankind of a despotism under virtuous and capable rulers, but by the time they had passed away, the ^•irtue, and the sense of responsibility, the power of initiative, had long since perished. Anarchy and ruin began to spread over the world, and the powers of darkness, oriental sorcery, the incantations of ignorant priests, the vulgar fanaticism of a nascent religion with all its superstitious dross, unrefined and unrestrained, held high carni^•al in the temples of science and the advance in the art of medicine ceased, and for many hundreds of years the best we can say of medical writers such as Oribasius, Aetius, and Paulus Aegineta 1 Also in the De Fascibus: In the Basel Edition of Galen, 1586, VI, p. 299 et seq., may be found a number of wood-cuts illustrating in the most graphic manner the methods Galen describes for nasal bandaging, including those suggested by Hippocrates, Phalera, and Amj-ntas. 88 THE GREEK WRITERS OF THE EASTERN EMPIRE is that they copied with tolerable accuracy from the writings of others, intruded few of their own ideas, and the admission to their pages of incantations, the descriptions of amulets and cabalistic figures, the recommendations of Chaldean drugs are no more than the perusal of the history of their times should lead us to expect. Attempts were made to check this tendency toward magical therapy. Thus Serenus Sammonicus,^ the elder, was put to death by the orders of the savage Caracalla (211 a.d.) because he recom- mended amulets as remedies for intermittent fever (Sprengel). He or his son wrote a medical poem (Edit. Ackermann) in which, among numberless other remedies, he advised the application externallj' by friction of bull's grease or bear's grease to the neck in cases of sore throat, besides the popular prescription of vinegar as a gargle. Such remedies are still popular ones on every country hillside. Constantinople.- — Constantine founded his great city at Byzantium and moved thither the capitol of the world' (330 a.d.). Julian the Apostate, his grandson, in his attempt to revive the old pagan religion engaged also in the more laudable endeavor to resuscitate the learning of the ancients. Oribasius accompanied him in his campaigns in Gaul before his accession (361 a.d.) to the throne of Constantine, and to him was delegated the task of collecting and epitomizing the works of former masters in the art of medicine. The works of Galen are the chief sources from which he made his compilation, but unfortunately, unlike Caelius Aurelianus and Paulus Aegineta, and indeed Galen himself, Oribasius only reveals to us knowledge of the diseases of the upper air passages which is accessible to us at its source. There is scarcely a passage of any importance concerning the nose and throat which we have not already noted in the works from which this author drew his information. It was in vain that Julian in his short reign attempted to revive ancient learning. Succeeding rulers of a groveling despotism, although themselves occasionally enlightened and virtuous, were unable to bring back the old free spirit which produced the age of Pericles and the era of Augustus. 1 may again quote the remarks of the sententious Gibbon: "The subjects who had resigned their wills to the absolute commands of a master were equally inca])able of guarding their lives and fortunes against the assaults of the ' Serenus Sammonicus was a firm believer in the magical efficacj' of the triangular arrangement of the word Abracadabra written on a piece of paper folded into the form of a cross, tied up in a piece of linen cloth and placect over the pit of the stomach, to be worn nine days, and then before sunrise cast over the shoulder into running water. * Christianity began in Gaul in the middle of the second century, in the time of Galen, Lyons having the first clnu-ch, and so rapid was the spread of the new faith that two hundred years later Constantine the Great found it to his interest to embrace the forms of Christianity as his ostensible faith and to free the church from taxation. THE EASTERN EMPIRE 89 barbarians, or of defending their reason from the terrors of super- stition." The Roman world was divided at its hne of natural cleavage between the oriental and the occidental races of mankind. The Eastern Empire lived many centuries at Constantinople in the reflection of the light of the old world of Galen and Hippocrates, but it was around the western shores of the ]Mediterranean, as formerly along the coasts of the Aegean, that civilization was, after many hundretl years, again to assume a new life and a new vigor. On the death of Theodosius (395 a.d.), the last great Roman emperor, the mighty fabric fell apart forever, and under Honorius and his equally impotent successors, after the death (40S a.d.) of Stilicho, the great commander, the Western Empire was deluged by the hordes of Goths and Msigoths, by the Huns and Vandals, and anything like medical learning utterly perished with the other arts from that part of the face of the earth. The barbarians were converted to Christianity, and their monks, in the search for means of saving their souls from eternal torment, found it necessary to study the Holy vScriptures. Their rude chieftains in their search for methods of legal procedure and orderly administration found it necessary to study the codes of Roman law. These circumstances finally brought about their familiarity with Latin and Greek litera- ture. Virgil, Cicero, Livy, contributed to the amelioration of their manners and the expansion of their intellects, while Galen, Pliny, and Celsus eventually transmitted to them the seeds of medical science, which had matured in the old civilization, and had been almost lost in its annihilation. Cassius Felix was a medical writer who is supposed to have lived in the fifth century. His book,^ as he confessed, was mostly made up of extracts from the earlier Greek writers. He thus speaks of what is apparently diphtheria : Diphtheria. — " Ulceration of the fauces, if accompanied by acute fever in sickness, is found to be very bad and fatal, especially if it has begun with severity. There is moreover another inflammation besides the acute fever, which forms in the deep recesses of the mouth, white or black, or rather dusky gray patches, which they call tephros (ash colored). It is usually called by the Greeks, Aphtha, which we call 'coction' of the mouth. And it is worse, even deadly, in young nursing infants on account of the tender age." There is no mistaking this blending of aphthous sore mouth with true diphtheria. The Eastern Empire. — The Eastern Empire preserved the vestiges of Greek learning, all but suffocated by the sorcery and witchcraft which apparently have always found such a fertile soil beyond the Hellespont. Nemesius, a bishop of Emesa in Syria, lived during the reign of Theodosius (370-395 a.d.) and wrote a book on the 1 Cassii Felicis De Medicina (Edit. Val. Rose). Lipsiae, 1879. 90 THE GREEK WRITERS OF THE EASTERN EMPIRE "Nature of Man," in which the old critics, envious of the fame of Harvey, used to })retend to find the discovery of the circulation of the blood. In this book there is a chapter on the respiration, and in it we find the author describing tiie larynx under the name of the bronchus, and following Galen in saying it is made up of three cartilages. It is Marcellus, very aptly called "Empiricus," however, who best illustrates the condition of medical learning at this time. He was a Gaul, born at Bordeaux, and though a high officer of Theodosius and his son Arcadius, exhibits, as Sprengel remarks, the soul of a slave in his works, recommending certain remedies because they were used by the Diva Augusta or the Diva Livia. His work "De INIedicamentis" is said to have been much mutilated by later editors. Chapter X deals with the diseases of the nose, coryza, polypus, ozsena, nose-bleed, or rather with their treatment; for few writers after Galen devote much space to any- thing but the transcription of multitudinous formulte. V\e will not pretend to mention the innumerable drugs, but we note that he recommends the prescription of Pliny that a man whose nose stinks should kiss the nostrils of a he-mule, and if the patient is a woman she should kiss the nostrils of a she-mule. Besides drugs which are orthodox now% all kinds of stercoraceous applications are recommended. ^Yhen the nose is bleeding it is helpful to say three times in the ear of that side some unintelligible jargon. However much we may have to criticise in ]\larcellus, there is one axiom which he lays down which is not always found in preceding authors and is often disregarded by his successors. In his chapter on affections of the throat, he says: "For a swelling of the fauces and of the palate everything used in the prescription should have no irritating quality;" but the very efficacious prescription which follows contains the juice of sour grapes — Sprengel surmises, because the Latin word uva means both grape and uvulitis; but we have seen that the juice of unripe fruits was a favorite prescrip- tion for this affection among both the Hindus and the early Greeks. This, however, is his incantation for pain in the throat, which he who suffers should sing to himself: " Grissi crasi, cancrasi — put the hand on the throat and repeat it three times." Incantations and Amulets. — Besides the usual inevitable swallow prescription of the ancients w-e find also this remarkable modifica- tion of it: "This cure will help one suffering with chronic sore throat. You must shut up a live swallow in the cavity of an African shell and this being tied up in the linen cloth of Egypt, you shall hang it around the neck and on the ninth day you will be free of your trouble." And this is another elaboration of the swallow prescription a])parently derived from Dioscorides: "But especially against synanche it is useful if you will take young swallows alive in the nest, and will burn these alive so that a powder is made from them (their ashes) on the day of Jupiter INCANTATIONS AND AMULETS 91 in old moon, but look to it that you find unequal numbers^ in the nest and that you burn as many as there are, and you will give this powder mixed up with warm water as a drink, and with the finger covered with the powder you will touch the place of the synanche from the inside. You will greatly admire this prescrip- tion." And then come some more incantations, long and involved. As an amulet some Greek jargon was to be written on a paper which was to be wrapped in linen and hung around the neck for a sore throat. Another mysterious formula was to be used in the same way for a bone in the throat. While I have not exhausted Marcellus' savory pharmacopoeia in any of its branches it is under- stood, of course, that these selections are made from many others of a more rational nature which have not even the virtue of originality nor the interest which always attends the mysterious in thera- peutics. Indeed, to do him justice, he only speaks of the incanta- tions, as a rule, after mentioning many of the routine prescriptions which are found in the writings of an earlier and a happier age. As we have seen, there was an interval of two hundred years (660-460 B.C.) between the introduction of written records into Greece and the birth of Hippocrates. This doubtless included that period when the record was engraved on the column of the temple of Aesculapius at Epidaurus of a sacred dog curing a cervical tumor by licking it. From the birth of Hippocrates to that of Galen, six hundred glorious years of medical progress intervened. We have seen the high state of anatomical knowledge revealed in the works of Galen. From the death of Galen to the time of ]\Iarcellus approximately another two hundred years had elapsed. The holy dog of Epidaurus finds a mate in the live swallow of Marcellus. "Facilis descensus Averno." As illustrative of the times and as containing a matter of some interest to our subject, I again quote from a page of Gibbon (HI, Cap. XXXVH). A war had been raging in Africa between the Arians who denied and the Catholics who upheld the Trinity. It resulted in the discomfiture of the latter (530 a.d.).- "A military count was dispatched from Carthage to Tipasa; he collected the Catholics in the Forum, and, in the presence of the whole province, deprived the guilty of their right hands and their tongues. But the holy confessors continued to speak without 1 Tema tibi haec priinum triplici diversa colore Lioia circumdo, terque haec altaria circum Effigiem duco; mtmero dens impnre gnndet. — \'irgil Kcloga) VIII, 73-75. "For there's luck in odd uuinlxM's, says Rory O'More." — Sam'l Lover. - The motto of the Church later, "Ecclesia abhorret a sanguine," was hardly appUcable to this period. Macchiavelli, referring to these African religious troubles in his Istorie Florentine, says: "Vivendo adunque gli uomini intra tantepersecuzioni portavano descritto negli occhi lo spavento dell' anime loro." The men living then amidst such persecutions carried written in their eyes the terror of their souls. 92 THE GREEK WRITERS OF THE EASTERN EMPIRE tongues; and this minicle is attested by Victor, an African bishop, who pubHshed a history of the persecution two years after the event. 'If any one,' says Victor, 'should doubt of the truth, let him repair to Constantinople, and listen to the clear and perfect language of Restitutus, the sub-deacon, one of these glorious sufferers, who is now lodged in the palace of the Emperor Zeno, and is respected by the devout Empress.' At Constantinople we are astonished to find a cool, a learned, an unexceptional witness, without interest, and without passion. Aeneas of Gaza, Platonic philosopher, has accurately described his own observations on these African sufferers; 'I saw them myself; I heard them speak; I diligently inquired l\v what means such an articulate voice could be formed without any organ of speech; I used my eyes to examine the report of my ears; 1 opened their mouth, and saw that the whole tongue had been completely torn away by the roots, an operation which physicians usually suppose to be mortal.' " The operations now done for the extirpation of the tongue have proved that the tongue is not the indispensable organ of speech, but what would Galen or Aeneas say if they should now be shown that the larynx is not the indispensable "instrument of the voice?" Aetius. — Aetius is said to have lived as a medical officer of the court at Constantinople about the middle of the sixth century. He was an Asiatic of Amida in Mesopotamia. After Oribasius, he was perhaps the best of those who transcribed the works of Galen and the older writers. There is a great deal in his works (The Tetrabiblion) concerning the nose and the throat, but very little w^e have not met with elsewhere. Uvulotomy and tonsillotomy and the incision of a quinsy are the surgical operations described. He warns against the dangers of secondary hemorrhage in ton- sillotomy and directs that only that part of the gland which projects shall be cut oft". If even a small portion of the normal underlying tissue is removed there is danger of hemorrhage. He was familiar with diphtheria and with adhesions in the larynx resulting therefrom, or possibly he refers only to the acute stenosis. Alum, nutgalls, mercury, besides bryonia, and many other vegetable and mineral astringents and emollient drugs are recommended by him. He fully equalled jMarcellus in stercoraceous pharma- cology. Incantations are less numerous perhaps, but not by any means absent from his writings. He recommends the use of forceps in extracting bones and foreign bodies from the tonsils. ^Yhen they were in the gullet, the patient swallowed a sponge with a string attached to it, by which it was then hauled up. For this trouble he also advises the repeated swallowing of bread boluses. It is said the following is the first mention of the Saviour in medical writings:^ "Moreover for the removal of those things which are ' Tcfrab. II Sormo IV, Cap. L. Galen is said to nu'iilion the Christians in a book extant in Arabic (Historia Antcisiam Abulteda>. Ed. Fleischer, p. 109). OLFACTORY NERVES 93 stuck in the tonsils, immediately take a seat in front of the patient and command him to harken to thee, and thou shalt say: 'Come out, bone' (if indeed it is a bone or a straw, or whatever it may be), 'in the same way as Jesus Christ raised Lazarus from the grave, and in the same manner as Jonah came from the whale.' Then seizing the patient by the throat, exclaim: 'Blasius, the martyr and servant of Christ, says come up or go down.' " This must have been excellent treatment for globus hystericus among the faithful. Shortly after Aetius, lived Alexander to whom the surname of Trallianus is given, he being one of the five talented sons of a citizen of Tralles. He was the brother of Metrodorus, the gram- marian, and of that Anthemius who was the architect of the great church, now the mosque of St. Sophia in Constantinople, which was built (532 a.d.) by Justinian and his consort, the fair Theo- dora, the licentious Cyprian prostitute who disgraced even the stage of Constantinople before she sullied the much-stained purple of the Caesars.^ Although there are many instances of thaumaturgy in his works, Alexander Trallianus practised at Rome with honor and profit, and was perhaps the most enlightened physician and the least tainted with superstition of any who had succeeded Galen, but while he has written chapters on the diseases of the nose and throat, there is nothing in them to especially arrest our attention. Of a very different character was Sextus Placitus Papiensis, who outstripped even Marcellus and Aetius in the use of the viscera of animals and equaled them in other departments of Chaldean pharmacology.- Olfactory Nerves. — Theophilus, a colonel of the guard under Heraclius (GIO a.d.), seems to have been one of the very few medical writers who, in copying^ from the Avorks of Galen and others, troubled themselves with transcribing any of the anatomy or physiology or semeiology, of which they were in such need. Even he is very inexact. The teleology so prominent in the work of Theophilus is by no means absent from that of his great predecessor, Galen, but the former wishes to explain every function in a manner tending to the glory of God, and he remarks upon the use of the epiglottis in protecting the larynx, that if a crumb fall in it, owing to the lack of proper action on the part of the epiglottis, the patient is suffocated, which is a gross exaggeration of even Galen's remarks in the same vein. His ideas of the purposes of the Almighty in perfor- ating the dura mater and the cribriform plate of the ethmoid would hardly be orthodox today, illustrating how dangerous are dogmatic statements outside of the domain of theology. The only advance over the ideas of Galen which 1 am able to note in Theophilus 1 Gibbon: The Decline and Fall of the Roman Empire, Vol. IV, Cap. XL. - De Mcdicamcntis ex Animalibus Liber. (Ackermann.) Norimberga>, 1788. 3 De Homin. Fabric., Lib. Ill, Paris, 1555. 94 THE GREEK WRITERS OF THE EASTERN EMPIRE is the point to which several historians liave drawn attention. He ac'('ei)ted the Galenic and llippocratic idea of air inspired and excretions drained through the perforations in the cribriform plate. He also supposed that through the perforations go the odorous particles. It is perfectly evident that he recognized^ "the first pair of nerves as starting from the anterior ventricles of the brain and going to the foramen of the nose on each side, on account of which the brain perceives odors," but as the presence of the nerve fibers in the perforations would be inconsistent with the idea of their patency, we must conclude that Theophilus knew nothing of the distribution of the olfactory twigs. As his was a text-book in the schools of the pre-Renaissance period, this inter- pretation would certainly have been recognized if justified by the text. Neither the Pandects or legal reforms of Justinian, nor the virtuous reigns of Tiberius H and Maurice (578-610 a.d.), were of avail in arresting the degredation of the Empire of the East. Justinian abolished the philosophical school of Athens and the consulship of the old Roman regime, but they were long since become mere shadows which were brushed away w^ithout harm and without profit to the world. What bar})arians had spared the suicidal fanaticism of the despicable Christian citizens of Con- stantinople, or their equally cowardly and incompetent rulers, destroyed. Even under the great Constantine, every manuscript that could be seized was forthwith destroyed if it contained any- thing of pagan learning. Paulus Aegineta. — Under Heraclius, whose victories shattered the resources not only of the hostile Persian Empire, but the already faltering forces of his own (610-641), we note the last of the Greek physicians whose works it is worth while for us to review in our search for knowledge of the diseases of the nose and throat. We are indebted to Paulus Aegineta for much which he has borrowed from sources inaccessible to us in the original. It is frequently impossible for us to know how much was original with him.^ At least, with the exception of Alexander Trallianus, he is almost the 1 See the 1555 Paris edition. The Greek text is so antiquated that I am compelled to judge from the Latin translation of the passage which occurs at page 67. Theophilus was one of the medical writers whom it was necessary to study and to teach at the Univerity of Paris when it took its rise in the thirteenth century. (Sprengel.) It may be surmised that this choice was due rather to the theology than the physiology of his works. 2 Dr. Francis Adams' Sydenham edition (London, 1844-47, 3 vols) of the translated works of Paulus Aegineta, which I follow, contains the translator's comments on the ditTcrcnt subjects treated, and these consist mainly of citations from all the ancient writers on medicine, including the Arabians. No better work can be consulted for a review of ancient medical knowledge, although rarely there seem to be grave errors, and the citations do not usually guide one to the quoted sources in the texts of the originals. Unfortunately the text of Paulus does not accompany the translation. THE KNOTTED STRING FOR NASAL POLYPI 95 only one after Galen whose works prove their author capable of any originality of his own. Living in the seventh century, he was probably contemporaneous with Theophilus. We still find aphtha^ in infants confused with the graver disorder of diphtheria. He says that the black variety of the ulcers is the most fatal. As in many of the older writers there is in Aegineta a chapter (1. c, sec. 19) on the exercise of the voice, not only for strengthening it but as a general exercise of the body. After mentioning the operations for nasal polypi^ which we have noted in Celsus and Galen, he remarks: "iVfter the operation, having sponged the parts carefully, we inject oxy crate of wine into the nose, and, if the fluid descend by the roof of the mouth to the pharynx, the operation will have been rightly done; but if it does not descend, it is clear that about the ethmoid bones, or the upper part of the nose, there are fleshy bodies which have not been reached with the polypus instruments." The Knotted String for Nasal Polypi. — Then follows the descrip- tion of a barbarous method which, it seems to me, Paulus must have derived from a faulty reading or a misunderstanding of the sponge method of Hippocrates. Certainly nothing of the kind can be found in the Hippocratic treatises, as Adams in his com- ments intimates, but we shall subsequently find the Arabians sedulously following this plan. They apparently derived much of their knowledge from Paulus. "Taking, then, a thread moderately thick, like a cord, and having tied knots upon it at the distance of two or three fingers' breadth, we introduce it into the opening of a double-headed specillum (probe), and we push the other extremity of the specillum upward to the ethmoid open- ings, passing it by the palate and mouth, and then drawing it by both hands, we saw away, as it were, with the knots the fleshy bodies. After the operation, we keep the opening separate by means of a tent resembling the wick of a lamp." As for tonsils^ he pulled them forward with a hook "and then we cut them out by the root with the scalpel suited to that hand, called ancylotomns, for there are two such instruments having opposite curvatures." He used a tongue depressor in this operation as well as in that of uvulotomy (1. c. sec. 31) but he adopts Galen's caution not to cut ofi' too much for fear of injuring the voice and making the patient liable to inflammation of the lungs. If the patient refuses a cutting operation the redundant portion may be removed by caustics applied by a special instrument, called " staphylocaustos." In his comments upon the operation of Antyllus for tracheotomy which I have quoted, Paulus makes it plain that he himself was 1 Book 1, Sec. 10, Vol. I, p. 14. ^ gook VI, Sec. 25, Vol. II, p. 289. ^ Book VI, Sec. 30, Vol. II, p. 297 96 THE ARABIANS familiar with the operation, for he says (1. c. see. 33): "We jiul^re the wind-pipe has been opened from the air rushing through it with a whizzing noise and from the voice having been lost." In closing the wound he freshened the edges of the transverse incision and sewed the skin, but not the cartilage, the latter not being divided. He follows Hippocrates in his treatment of fractures of the nose, (1. c. sec. 91). We miss all invocations, incantations, and amulets from the throat pharmacopoeia of iVegineta, and he does not lay much emphasis on the Chaldean prescriptions, though they are mentioned with approval,^ stercoraceous drugs and the swallow prescription being advised. THE ARABIANS. In pursuance of the plan of this book we must now devote an unusual amount of space to the rapid enumeration of the political events which shifted the leadership in science and medicine from the Greeks to the Arabians, events which are connecting links in the progress of civilization. Greek physicians existed at Constantinople as long as the Chris- tian religion flourished there, but while their works are of interest to the student of the phenomena presented by a dying civilization, they are of less interest to the historian of the progress of medical knowledge. Guizot,^ speaking of Roman Gaul in the last days of the Empire, asserted that "The Library at Constantinople had a librarian and seven scribes constantly occupied, four for Greek and three for Latin ; they copied the new works which appeared or the ancient ones which were degenerating. It is probable that the same institution existed at Treves, and in the larger cities of Gaul." Notwithstanding periods of vigor exhibited by the Eastern Empire, notwithstanding, as Freeman declares, many of th(> Emperors were great conquerors and rulers who beat back their enemies on every side, and made conquests in their turn, although the last Constantine died a death worthy of the first, h()])e]essly battling for his empire in the breach of the city wall, notwithstanding all these things, learning did not send forth any new shoots, and Gibbon sums the matter up thus: "They read, they praised, they compiled, but their languid souls seemed alike incapable of thought and action." Finally, their political existence sank to the level of their civilization. The walls of Constantinople protected its feeble inhabitants, except for its conquest by the crusaders, for more than a thousand years after its impregnable situation had 1 Book III, Sec. 27, Vol. I, p. 464. 2 Hist, de la Civilization en P>ance. THE ARABIAN CONQUEST 97 been selected and its defences constrncted by the foresight and energy of the great Constantine. At last it fell (1453) before the conquering Turk, as falls every work of man, however wisely built or however stupendous, vniless its bulwarks are the con- tinued energy, virtue, and intelligence of the people who enjoy its protection. We have seen how, five hundred years before the Christian era, the great kings of Persia drew their physicians from the Greek schools of medicine. The Alexandrian dynasties had long since passed away, and it is significant to note to how low a level Greek medicine had sunk among the bastard descendants of that noble race to find another line of Persian kings sending Arabian physicians to Constantinople to minister to the many bodily ills of some of the Greek emperors; but it was first through Greek physicians, through the exiles whom* the fanaticism of the theologians of Constantinople had driven into Persia, that the Arabs received the first inoculation of the virus of learning. It was through the exiles driven by anarchy and the forebodings of impending ruin, as well as by its culmination that Italy first received the direct impetus from Greek sources which resulted in the Renaissance. From the Nestorians the Arabians not only absorbed profane knowledge, but from them the youth ]\Iohammed on his caravan trips drew the inspiration of his religion. Not only the Nestorians, but still more perhaps the Jews, who taught their religion to both Christ and ]\Iohammed, aided in this transfer of learning to the Arabians. The Arabian Conquest. — Four years after the death of Justinian, ^Mahomet, the only son of Abdalla, was born at ]\Iecca in 569 A.D. Heraclius, after his great victories over the Persians, was weighted down by age and disease, and his empire was exhausted by years of destructive warfare. Therefore the feeble races imder the sway both of the Persian and of the Holy Roman Empire of the East were easy conquests for the sturdy Arab. The forces of nature are eternal, their laws immutable, and the results of their activity when surveyed over long periods of time and sufficient expanse of space, appear analogous even to the finite understand- ing of man. The expansion of the Mohametan crescent raj)idly grew until in a period of less than a century from the death of Mahomet in 632 a.d. one horn rested in the fertile valleys of Spain (710 A.D.) and the other menaced the walls of Constantinople itself. The fanaticism which is easily engendered in the populations of Asia has made it the cradle of religions. The poverty and hard- ships of the human beings who struggled among the burning sands of Arabia weeded out the weaklings of the race and trained the endurance of the survivors to resist the effects of thirst, hunger, and fatigue, and when fired by the visions of ^Mahomet with the prospects of glory and power and with the hope of the indulgence 7 98 THE ARABIANS of libidinous passions both in this world and the next, they swept away the feeble civil power, and with it the babblinc; theological dissensions of the Christians of Africa and Asia ^Minor. crossed the JNIediterranean and overwhelmed the Goths who had had time to be enervated by the luxury of the fertile plains of Andalusia and Granada. But from the northeastern confines of the temperate zone in Asia, the Turks, having previously accepted the religion and despised the civilization of the followers of the Prophet, checked the advance of his race. From the northwestern provinces of Europe the Germans and Franks, unsullied by a religion which inculcates the righteousness of polygamy and human slavery, checked the advance of the Saracens at the mountainous line which separates the Spanish peninsula from the rest of Europe. Charles Martel with his stout heart and iron mace annihilated their army before Tours in 732, and e\'entually they w^ere driven back beyond the Pyrenees to develop a wonderful civilization and to suffer from its luxury and the enervation of the climate, which after nearly eight hundred years made them a prey to the po\\ers of Fredinand and Isabella (1493) grown to an effecti^'e force amidst the more arid and mountainous regions of Aragon and Castile.^ We have cause to be grateful not only that the victories of Mahomet produced em])ires which protected science and letters at Bagdad, Alexandria, and Saragossa, but because they shattered the belief of large numbers of P^uropean mankind in the vain and presumptuous claims of the Christian ecclesiastics to a monopoly of the favor of heaven, and so perhaps did something to start the idea that the abodes of bliss are not exclusively a private park for the priests and their friends. At any rate they must have suggested the idea that images and relics were as little efficacious in ensuring victory as the gods of the pagans over whose destruction the early Christians gloated. The Destruction of the Alexandrian Libraries. — Julius Caesar had first, by the accident of war, caused the burning of the Alexandrian library in the ^luseum. This was later replenished by Anthony in his devotion to Cleopatra, at the expense of the library at Pergamos. Four hundred years later Theophilus, the Bishop of Alexandria, destroyed also the library in the Serapion. His nephew, the saintly Cyril, followed him in the bishopric and added further laurels to the family fame by killing the fair ITypatia with a club. She was a learned pagan lady, addicted apparently to lecturing on theosophy. Finally the remnants of the books in Alexandria, which had survived the vicissitudes of a thousand years, were burned by the Arabians, when they were fresh from the barbarism of the desert, Omar • The Arabs coiujuered Persia in the seventh, Spain in the eighth, and ti:e Punjaub in the ninth century, and finally all India. THE ARABIAN RENAISSANCE 99 sending word that what was not contained in the Koran was false and what was also to be found in the Koran was on that account superfluous. The great temple of the Serapion, the annex to the jNluseum, where science had flourished for centuries, with its splendid gardens of birds and beasts and its laboratories supplied with its instruments of precision, were destroyed by the fury, the folly, and the fanaticism of man. It has been denied that the Arabians found anything to destroy. However that may be, these fiery fanatics, intent on entering the gates of Heaven, filled with objects of sensual delight, suddenly developed such a love for material science as the world had never seen before and perhaps has not been familiar with since. The Arabian Renaissance. — As Draper says, the Byzantines obliterated science in theology and the Saracens illuminated it in medicine. Vast libraries again were collected at Bagdad and elsewhere in Asia, Africa, and Spain. The works of Ancient Greece were translated into Syriac by the Jews and the Nestorians, both of whom, the former for denying and the latter for modifying the Catholic acceptation of Christ, had been persecuted and expelled from the Byzantine and Roman dioceses. A good deal of Chaldean medicine was introduced by them to the Arabs who were at first apt scholars in these matters. We have seen how its amulets and incantations and its filthy drugs abounded in the later Greek writers. ^Yith these things, however, astrology and the germs of alchemy were brought from the plains of Asia, and out of these aided by the traditions, if not the records, of the school of Alex- andria the Arabs developed the great sciences of astronomy and chemistry. While they soon rejected with contempt the belief in incantations and amulets, they persisted in the use of stercor- aceous drugs. Unfortunately for medicine they neglected the study of anatomy through the dissection of the human body. In this fact we recognize the influence of their religious scruples in preventing any material advance of rational medicine over the teachings of Galen and Hippocrates; for without this underlying study, medical science comes to a standstill and will ultimately perish entirely, however enlightened its votaries may be in other directions. Indeed, whatever may have been their contributions to other sciences, I confess, after reading something of Arabian medicine, to have been neither edified nor impressed. It would seem that in six hundred vears thev miglit lla^■e done more when we consider the six hundred years which elapsed between Hip- pocrates and (ralen. We look in ^•ain for any material advance in the knowledge of the nose and throat and their diseases made by the Arabs. It is to them, however, we owe the introduction into our pharmacopeia of the syrups and elixirs, so useful in aft'ections of the throat as vehicles for drugs administered in them, which often derive from the vehicle an ephemeral reputation. 100 THE ARABIANS The Inferior Maxilla. — It will be remembered that Galen supposed the inferior maxillary bone was not a single bone, but composed of two hahes. This error, accordinfj; to Sprengel, was pointed out by AbdoUatif, who made the discovery ])y examining with care one of the many heaps of human bones which were so j)lentiful in tlie days when religion was propagated with sword and fire; and this was almost the extent of their contribution to the anatomy of the head and neck. They were familiar with uvulotomy and tonsillotomy and the removal of nasal polypi l)y the barbarous string method of Paulus Aegineta, ]\Iesua using horse hairs twisted into a knotted string for the purpose. Rhazes, also an early Arabian writer (died 923 a.d.), was familiar with these methods. Tracheotomy. — Tracheotomy was known to them only from Aegineta's description of Antyllus' o})eration. Even Albucasis, a late (died 1122) and perhaps the boldest, certainly the most brutal, of the Arabian operators, knew of no one in his time who had performed it. He had seen a nurse girl who had cut her wind- pipe and who had completely recovered when he sewed up the wound. iVvicenna (980-1036), the Prince of Physicians and the greatest, of the Arabian authors, simply describes the operation according to Paulus, while Avenzoar (died 1161) went so far as to try it on a goat. Avicenna, and many others of the Arabian writers, showed they w-ere practical observers in likening some of the nasal polypi to hemorrhoids and advising the ligature for them. In this they were followed by many of the writers of the Italian Renaissance and even of much later times. A\-icenna, whose work was a text-book of almost exclusive authority during the later ]\Iiddle Ages, describes the anatomy of the nose and throat in a very poor transcription of Galen. He gives, however, a very good description of the disturbances of olfaction, recognizing the two varities, viz., obstructive anosmia due to nasal stenosis and the essential form due to some central brain lesion.^ The Cautery. — The use of the cautery, carried to such great extremes by Albucasis, was a favorite remedy for all sorts of affections. Baas relates- how ]\Iahomet, instead of resorting to a more spiritual and miraculous method, advised a friend suffering from angina that he should have an application made of the actual cautery. Johannus Mesua Damascenus advised'' the use of forceps for the removal of ])olypi and afterward the cauterization of their roots, or else the use of hot forceps, but if this method was im])os- sible he used the horse-hair string. In this author we may find this remarkable reconnnendation for the cure of inflannnation of the palate.'* " The second method of cure is the diversion of the cause, 1 Edit: Venice, l.%2, f. 581 et seq. 2 History of Medicine, N. Y., 1889, p. 219. ' Lib. II, De Aegritud. Nariuin, Cap. G, Opera, Venice, 1,589, p. 231. ^ Opera, Lib. II, p. 238. Lib. II, Sect. II— Summa 1, Cap. 2. NASAL SPECULUM 101 and this is performed in a manner which causes the trouble to shift its seat, in short rubbing of the ears and pulHng them forcibly upward, and the painful stretching of them, and the application of cups to the opposite part. For these things raise the inflammation and bear it upward; and among those things which are usefid in the elevation of it is that a handful of hair should be grasped in the hands and the patient told to keep silent. Then put thy feet on his shoulders and drag strongly on the handful of hair, until the skin is pulled up, for by such dislocation will the pharyngitis also be raised." These patients probably complained as do our own that their "palates were down." Some confusion exists among the Arabians as to whether the dung of a white dog or the white dung of a dog, to be ol)tained by feeding him on bones, was the proper medicament in angina. The swallow prescription is always mentioned in some form. In removing foreign bodies from the throat Janus Damascenus recommends, apparently as a variation of the sponge method we have noted in Aetius, the tying of a piece of half-cooked meat on a string and bringing it up after it is swallowed. Nearly all even of this sort of surgery may be found among the late Greek writers of the Eastern Empire. Nasal Speculum. — Guy de Cauliac^ refers to Haly Abbas using "un instrument appelle mirror an soleil" or in the Latin edition "speculum ad solem," for opening the nostrils in examining a nasal growth. On referring to the Latin translation of Haly Abbas by Michael de Capella in 1523,^ it may be seen that the passages to which Guy apparently refers hardly warrant this rendering. In the work of Constantine the African, "De Communibus Medico Cognitu," which is said to be an abridgement of Haly Abbas, nothing of the kind is to be found. We may conjecture that Cauliac read the text wrongly or that he had access to others which are not now accessible to us; Init at anv rate it is evident that Cauliac had some knowledge of such an instrument. Indeed, the use of the cautery in the nose from the time of Hippocrates to the present presupposes the use of a tubular speculum at least.^ From the fact that the processes are occasionally multiple with a common base of attachment and the Greek conception of them was eml)odied in the name polypus or many feet, we find the medieval translations from the Arabic converting the name into the word "Scorpio." How accurately this expresses the Arabic word for polypus, I do not know. Albucasis who used the cauterj' savagely for almost everything 1 Edit: Nicaise, Paris, 1890, p. 328. 2 Liber Totius Med., Lugduni, ir)2;5. Lilier IX, Cap. ;}2, f. 279, Col. C. ' According to Cloquet the speculum of Ciuy de Cauliac, or Haly Abbas, is figured in L'lntcrpretations des Dictions Chirurgicales which Laurent Joubert printed at the end of his edition of the (Irande Chinn-gie de Guy de Chauliac, printed at Rouen in Kilo. 102 THE ARABIANS and apparently often at random, recommends burning tlie skin beneath the eyebrows for a bad odor from the nostrils.^ We may conjectnre that this is related to the Libyan custom as related by Herodotus (1. c.)- Some of the remarks of Albucasis in regard to operations on the nose and throat may be inserted here as inter- esting and illustrating somewhat the figures of the instruments taken from Channing's Latin version of his Surgery. The existence of these figures in the original manuscript was one of the fore- runners of the introduction of wood-cuts,- which antedated the invention of Guttenberg. It mnst be confessed that Channing's Latin text of Albucasis does not clearly correspond with the figures which accompany it. Tonsillotomy. — "And when glands occur in the throat similar to the glands wliich occur externally, they are called the two tonsils. When thou hast treated them with those things which 1 have mentioned and they are not cured, look and if the tumor is hard and of a dark color, of slight sensibility, do not touch them with the knife. And if it is of a red color and the base is broad do not touch it with a knife for fear of hemorrhage, but delay until it has ripened, for then thou canst perforate it or it will break of itself. But if it is of white color, round and has a slender base, this is the kind Avhich is suitable and thou shouldst cut it. Thou shouldst examine before operation if the swelling has entirely disappeared or in what manner it has diminished. Then thou seatest the patient in the clear sunlight and takest his head in thy lap and openeth his mouth and taketh the instrument in thy hands which will depress his tongue, a concave instrument somewhat of this form Fig. 6 (Fig. 6); thou canst make it of silver or of brass; it should be thin like a knife; with this the tongue is depressed and the swelling will be ai)parent to thee, and let thy vision fall upon it. Then thou shalt take a hook and fix it in one tonsil, and with it thou shalt draw it out as far as possible; but of course thou shalt not draw out with it any of the membranes. Then thou shalt incise it with an instru- ment of this form (Fig. 7). It is similar to a forceps except that the ends are curved and the edge of each is opi)osite the other and is very sharp. It is made from Indian or fine Damascus iron. 1 Albucasis de Chiriirgia: cura J. Channing, Oxonii, 1778, I, p. 35, Sec. XIV. 2 The earliest wood-cut roinaininp; to us dates from 1423, but there is ample evidence of the existence of the art long before this, in Venice and elsewhere. A POSTNASAL TUMOR 103 But if this instrument is not at hand thou mayst cut it with a knife with this shape (Fig. 8) — sharp on one side, less so on the other. And sometimes other tumors than tonsils grow in the mouth. Thou wilt cut these out as thou doth the tonsils." (Liber II, sec. 36.) Fig. 7 Fig. S c i) A Postnasal Tumor. — In short, they were to be cut out with scissors or a sickle-shaped knife. Then follows the very interesting report of a postnasal growth. "Once I treated the tumor of a woman which had grown in her throat. It was of a dusky color and not very sensitive. The woman was almost strangled, and from the constriction of the passage breathed with difficulty, and she was prevented from drinking or eating anything, so that she was reduced almost to the point of death, and she had been in this condition a day or two. The tumor so projected forward that two branches of it protruded from the nostrils. Therefore W'ith the greatest promptitude I hastened to fix in one of these a hook and dragged on it, and that whole portion was pulled forward. Then I cut it off where I had pulled it out at the nostrils. Then I did the same for that which projected on the other side. Then I opened her mouth and depressed her tongue. Then I fixed a hook in the tumor itself and cut off a part of it and only a little blood came from it, and the throat of this woman was free and she immediately drank water. Then I offered her some food. I did not cease to cut pieces from this tumor for a long time, but the new growth filled the place of the excised pieces until her patience and my own were exhausted. Wisely then did I act, and I cauter- ized the tumor up in the back of her throat and thereupon it did not recur. Then the woman left me and I know not what God did with her after me." These quotations, as literal as possible, from Channing's deplorable Latin, will indicate the manner of man this modest Arab was, and better than words of mine will portray the state of laryngological practice among the Arabs, It may be profitably compared with the procedures of Hippocrates in cases of nasal polypi, in order to realize the backward steps taken in 1500 years. Albucasis describes about the same methods of treatment for uvulotomy, following the injimctions of Galen. His directions for removing foreign bodies are much the same as those of the later Greeks. His remarks on laryngotomy I have referred to above. Love of the hot iron and dread of the knife characterized Arabian surgery, and they seemed more afraid of drawing blood than of infiicting atrocious pain. In all this we behold the result of defective anatomical knowledge. 104 THE PRE -RENAISSANCE PERIOD And these were the votaries of science who guarded the portals of medicine for six hundred years. In other departments doulitless their achievements were great, but despite tlie great debt modern civiUzation owes to them, medical knowledge languished and we have only to be thankful that it did not entirely expire, that it was not wholly given up to amulets and charms and stercoraceous drugs, that mysticism and the occult, which we still ha\e with us in the Faith Cure and the ]Mind Cure and all that foul brood of Darkness, did not in this period of weakness, when anatomy had perished entirely, overwhelm the Art of ]\Iedicine as it did in India. The spectre Orientalism still haunts us. It is a vague disembodied spirit, but it is the ever-present foe of civilization. For several centuries it was through the Arabs only, or ])crhaps it is better to say, chiefly, that Europe knew anything of the medi- cine of Hippocrates and Galen, but when the better editions of the early Greek writers came into the possession of the Italians, it was soon perceived how gross had been their rendering of them. THE PRE-RENAISSANCE PERIOD. To the superficial reader of mediaeval history the causes of the Renaissance may seem mysterious and puzzling. It requires, how- ever, only a moderate amount of reflection and study to under- stand that the infusion of the vigorous new northern blood into that which flowed in the veins of the old races, dwelling around the Mediterranean, produced a new and, from the cross-breeding, a more vigorous race of men. Amid the ruins of Rome, ignorance, superstition, and fanaticism, the interminable wars, the terrible devastating plagues had induced a gro\'eling misery and a poverty, for many ages foreign to the sunny slopes of the Cis-Alpine hills and fertile valleys of Italy. The primeval forces of Nature thus working through evolutionary laws again produced in this garden spot of the world a race of men from which the weak in bod}' and mind had been weeded out. The soil was rij)e for the seeds wafted from other civilizations now rapidly approaching collapse. Learning in the Middle Ages. — Daremberg^ does not succeed in convincing us that much, if anything, that may be called medical learning really was to be found in Europe in that period which lies between the deluge of the barbarians from the north and the introduction of Arabian science. The ruthless hand of Gregory the Great (Pope 59(H54()) had long since demolished the library on the Capitoline Hill which the munificence of Augustus had founded. His motto: "Ignorance is the mother of devotion," supplied tlicn a sufficient defence as it now furnishes an ample 1 Hist, des Sciences Mtd., Paris, 1870, Vol. I, p. 277. INFLUENCE OF ARABIAN SCIENCE 105 explanation of the deed. He himself was one of the most learned men of his times, but the intellectual treasures of the Ancient World had been lavished on his barbarian soul in vain. Some manuscripts, it is true, with other weaklings had found a refuge in the hidden recesses of the cloisters of sordid monks, who sought as eagerly for safety in this world as for Paradise in the next, but these manuscripts escaped rather through the negligence than the respect of the priestly rabble.^ Famous schools, it is true, existed at Monte Cassino, Amalfi, Naples, and Salerno during the ^Middle Ages, but what their learning consisted of it is impossible to know. Professor Ordronaux's elegant edition of the Regimen Salernitanum gives a hint of it in many places. We may easily form a picture of a circle of lusty, merry, dirty monks sitting around a rough table, and with beer mugs and drinking horns held on high roaring forth the refrain: "Si tibi serotina noceat potatio vini Hora matutina rebibas, et erit medicina." Influence of Arabian Science. — The origin of the School of Salerno is unknown, but there is little doubt that such learning as there existed was derived through the Jews and possibly through other sources from the Arabians. It was there, or at Monte Cassino (1086), that Constantine, an African prelate, after a sojourn of thirty-nine years among the Arabians, where he is said to have been a pupil of Avicenna, wrote his plagiaristic works which he did not dare, and perhaps did not wish, to credit to the pagans, Hip- pocrates, Galen, Avicenna and Haly Abbas, from whom everything in them of value was miserably transcribed. By such means, at first secretely, then openly, the knowledge of the Arabs found its way into Europe through Italy and Spain, and this process was greatly facilitated by a few enlightened individuals, who, like Constantine, had spent their youth at the courts of the Arabian monarchs. Averrhoes introduced skepticism, "le flambeau de la science," as some Frenchman calls it, to the Arabians and was duly hated by the ^Mahometan and Christian dogmatist alike, })ut this was a mere undercurrent in Christian Europe for a long time, too feeble to be perceived amidst the robust but groveling superstition of the times. Pope Sylvester II had been educated at Cordova, spoke Arabic like a Saracen, and had been elevated (999 a.d.) by the politics of the time to the chair of St. Peter as a creature of the Emperor Otto HI. The influence of the Arabians on the ' Daremberg: Hist, dcs Sciences Med., Vol. I, p. 25G, quotes from a mediaeval author as follows: C'lerici nostri tciiiporis polius sequntur scholas Antc-Christi quam Christi, potius dediti gula; (|uain glossa;: potius coUiguiit libras quam leguiit librcs; libentius imitantur Martham quam Mariam. 106 THE PRE-RENAISSANCE PERIOD science of the ^Middle Ages may be strikingly witnessed in the Inferno of the pious Dante where Hippocrates and Galen are joined to the shades of Avicenna and even to that of the hated Averrhoes. (Canto IV L, 144.) There is a curious observation to be made casually in reading Kassel's excerpts from Averrhoes which gives one a hint of the mental vigor of the Arabian, who excited the execration of the churchman and earned a warm place in the Inferno of Dante for himself by his skepticism. Speaking of the five senses, he declares that animals diiler from men in the fact that some of them can smell without possessing the organ for that sense, this being the case with bloodless organisms. In other words, this free thinker, Averrhoes, accepted the testimony of observation even though it went against the (Talenic and Hip- pocratic acceptation that for voice production we must have an instrumentum vocis, for smelling an "instrumentum odoratum." This is the essence of scientific thought, this is the spark that made the conflagration in Christendom later. It has taken nearly a thousand years to make it a familiar thing to scientific men that bloodless things, like some spiders, can smell with their whole bodies even though they have no nose, but A\errhoes stands alone in the Arabian civilization. If it had lasted longer he might have had associates. It is gratifying to be able to pick out even in our subject this live thing in the dead mentality of mediaeval thought, one of the things that earned A\errhoes a place in Hell.i Influence of the Church. — Neverthless, as Guizot says, it is difficult to imagine what would have happened after the downfall of the Roman Empire in Europe if the Christian Church had not been organized. It stepped in first as the handmaid and then as the mistress of the civil power, and thus, by furnishing some sort of authority, having its real foundation deep in the souls and super- titions of men, brought order out of chaos. It was Gregory the Great who was active in the destruction of learning in Italy, but who nevertheless was a great power of cohesion where all things tended to disruption. Gregory VII was the great Ilildcbrand who, when elected pope, substituted ecclesiastical for imperial tyranny, and in 1077 King Henry of Germany waded barefooted through the snow of the Alps to humble himself at the feet of the pope at Canossa. Again, the civil power gained the ascendancy under that liberal man of genius, Frederick II (1194-1250), king of the two Sicilies, who had imbibed much learning and freedom from superstition by his Arabian education and affiliations. He rendered the greatest service possible to the art of medicine by his decree ordering the dissection of the human body. ' For an account of Averrliocs and his works by a synipatlictic critic, see R^nan; Averroes et TAverroismc. INFLUENCE OF THE CRUSADES 107 Influence of the Greeks. — As has been said, Greek men of learning, rats from a sinking ship, flocked into Italy with their precious manuscripts from Constantinople, many coming before the crisis and many escaping at the final shipwreck in 1453. They found for themselves and their learning an asylum in Italy, where the great families of the Medici, the Farnese, the Este, the Colonna, the Gonzaga, enriched and enlightened for the most part by mari- time trade, and urged by the influence of Petrarch, gave them a welcome and an enthusiastic reception which fanaticism had denied the Arabians. But Petrarch's welcome extended rather to other branches of letters than to medicine, whose practitioners he lashed with a fierce satire from which ^Nloliere later drew his inspiration. A hundred years before the fall of Constantinople, on hearing of the loss at sea of a vessel carrying a valued and a learned Greek friend, Petrarch's first thought was to inquire if perchance the surviving sailors had not saved some Greek or Latin manuscripts which might have been among his effects. It has been noted that from the time of our first knowledge of the School of Salerno to this epoch medical learning was derived almost wholly from Greek sources through the Arabians. This pre-Renaissance period of perhaps 300 or 400 years includes Henri di ]Mondeville, Mondino di Luzzi, Guy di Cauliac, Arnold di Villanova, Petrus d'Abano, Brunus, and others, the first fruits of the seeds of learning of modern Europe from the old stock of Hippocrates and Galen. Influence of the Crusades. — Even the most cursory review, such as this professes to be, of the salient influences in the spread of knowledge cannot ignore the crusades. As two thousand years previously the Grecian hosts are said to have attacked the walls of Troy, the holy city of Jerusalem was the scene of another furious onslaught of western brute strength on an eastern metropolis. Homer draws a more artistic and vivid but no more fearful picture of the sack of Troy than later historians drew of the capture of Jeru- salem by the crusaders. Returning, if his thirst for blood and holy relics was not satiated, the crusader at least brought with him, as doubtless did the ancient Greeks, more enlightenment than he set out with. The survivors of the mighty hosts brought with them back to their homes not only the bones of the saints and the splinters of the true cross, but a broadened knowledge of men and things. The aggregations of such large bodies of men, under the necessity of acting more or less harmoniously, laid the foundation for the spontaneity with which various movements of European social, political, and religious activity subsequentlj' occurred. Different nations and different conditions of men became, to some extent, mutually heli)ful in their \arious struggles toward liberty with that ecclesiasticism which had fattened on their estates and their temporal power during the absence, which the priests had urged upon them. 108 THE PRE-RENAISSANCE PERIOD Italian Science. — "The eagerness with which the Arabians had collected the medical works of the Ancients hardly surpassed the zeal with which the Italians of the Fifteenth Century pursued the same course, and Cosmo ^Medici may be compared in this respect with Khalif ^Mamun, but let us mark the difference. The Arabians translated, they often even destroyed the originals, and their own ideas so permeated the results that they theosophized Aristotle, turned astronomy into astrology and made use of tiiese in medicine. The Italians on the other hand read and learned. The true Aristotle eventually crowded out the Arabian/ out of the unaltered writings of the Ancients they learned their Science, Geography directly out of Ptolemy, liotany out of Dioscorides, the Science of ^Medicine out of Galen and Hippocrates."^ The Ancients not only supplied them with knowledge as they did the Arabians, but they inspired them with such a thirst for it that their own authority in science was soon destroyed, something which had never happened wath the Arabs. The popes and the clergy in fostering at first these beginnings of intellectual life were conjuring up genii which in a few centuries were to rob them of all but a vestige of their power, riches, and veneration. It is this progressiveness which in medicine distinguished the European from the Arabian civilization. Although the Greek physicians from Constantinople brought their language and their manuscripts, they themselves had perhaps directly little influence. Their scientific attainments were insig- nificant as compared to the Arabians. They were the unworthy custodians of the relics of a former civilization, the puny descend- ants of a once vigorous race. They were full of lies, superstition, and effrontery, and they imposed on the credulity of those still more benighted than themselves, if we are to believe what Petrarch says of them. "To lie like a doctor," he declares was a proverb in his day. This depravity is easily perceived in the counsels of worldly wisdom, which the pre-Renaissance medical writers scattered so plentifully through their works. Henri di jNIondeville or Her- mondeville in the frank discourse of his surgery is very amusing, but he, quite as much as Boccacio (b. 1313) and later Benvenuto Cellini (b. 1500), displays the general disregard of ethical or moral considerations in his relations to his patients and confreres. In the history of medicine, keeping step as it does with the history of civilization, it is a long, dreary stretch of a thousand years from the sack of Rome by the Vandals (455) to the fall of Constantinople by the Turks (1453), and even Sprengel, the most ' Guizot (Hist, de la Civilization en France. Edit. 16, T, 12, ]). 182) asserts positively that the knowledge of Aristotle was not, during the Middle Ages, derived exclusively from Arabian sources. Alcuin did much in the time of Charlemagne to keep alive the acquaintance of the learned with the works of the Ancients. 2 Ranke: Geschichtc dcr Piipste, Bd. I, Cap. 2. SQUINANTIA 109 phlegmatic of historians, breaks into paeans of rejoicing when he arrives at the Renaissance. In medicine this properly begins with Berengarius, or Berengar del Carpi, but there is a pre-Renaissance period, to which I have referred above, which it will be interest- ing to glance at for information as to the nose and throat. The School of Salerno. — Among the Salernitan verses from Prof. Ordronaiix's translation we may select "De Raucidine Vocis" or Hoarseness : "Oil and raw apples, nuts and eels, 'tis said With such catarrhs as settle in the head, And leading to a long intemperate course Of life, will render any person hoarse." And the cure for it is "Fast well and watch. Eat hot your daily fare. Work some and breathe a warm and humid air; Of drink be spare; your breath at times suspend, These things observe if you your cold would end." "Si fiuat ad pectus, dicatur rheuma catarrhus, Ad fauces bronchus; ad nares esto coryza." It is singular that, in quoting from the school of Salerno, we so frequently offer evidence of their convivial habits, snugly ensconced as thev were in their cloisters sheltered somewhat from the stormy experiences so abundantly detailed in mediteval history. Johannus Platearius^ (1225?) relates that his father cured a "certain Salerni- tan who was playing at dice, and suddenly felt that he was attacked by 'squinantia.' When he began to be suffocated and had showed the painful place with his finger, as he was unable to speak, my father, of blessed memory, a remedy having come to his mind, placed a wedge between the patient's teeth, and forced into his throat a piece of wood and the skin of the aposthume was ruptured, and thus, blood flowing in great quantity, he was relieved." "Squinantia." — Apropos of this word "squinantia," we may note an instance of transformation through the vicissitudes of time, language, and translation from the technical Greek to the English vernacular. We have seen how in the time of Aretaeus and Galen they were disputing as to the etymology and significance of the words kynanche and synanche (vid. pp. 07 and 86). How this word was translated into the Syriac and Arabic dialects I am not sufficiently versed in Oriental linguistics to know, but when it emerged into medieval Latin it was "squinantia," a term unknown to classical Latin. In the English of Iluxham,'- not a bad example of a classical p]nglisli medical writer of the eighteenth century, ^ Jo. Platearii. . . . Practica Brevis. De Squinantia. In Practica Jo. Serapionis Dicta Breviarium. \'cnctiis, 1497, f. 176, b. - An Essay on Fevers, to which is now added a Dissertation on Malignant Ulcerous Sore Throat. London, 177.5. no THE P RE-RENAISSANCE PERIOD we find the term changed into "squinzy," and from this to the famihar (jiiinsy is but a step. Giirlt (Gcschic'hte der Chirurgie) quotes from Brunus de Longo- bardus, who ended his work in 1252, a passage by which we may see the inane confusion into which this old dispute of the Greeks had thrown their witless heirs: " Xam hujus apostematis tres sunt species, quarum una dicitur quinantia — aha dicitur sinantia — aha dicitur squinantia." He tries to define the difference between these, but he leaves the modern reader in a fog, and there can be no better iUustration found of the paucity of original thought and observation, and even of feebleness of imitation which is so characteristic of pre-Renais- sance medicine. In the Glossulse Quatuor ^Nlagistrorum the same differentiation is adopted by Rolando. A still further example of obfuscation and pedantry may be obtained from the same source. Lanfranc was a surgeon who died in 1306, and this is his idea of the topography of the neck; it is untranslatable: "Quidam tamen faciunt differentiam inter collum et cervicem; gulam et guttur; quae tamen omnia sub colli nomine comprehen- duntur multotiens. Intra collum et gulam ab intra locatur meri sive ysophagus — ex parte vero interiori versus gulam locatur eanna pulmonis — super has duas vias et epiglotus ex tribus cartila- ginibus compositus. (The epiglottis was the usual mediaeval name for the larynx, 'canna pulmonis' for the trachea.) Guttur dicitur eminentia epigloti; latus gutturis dicitur gula." Arnoldo di Villanova^ (1285) speaks of "squinantia" as a throat inflamma- tion "inquodam folliculo quod est inter ysophagum et tracheam." Going back to the first of these writers, who drew their knowledge principally from Arabian sources, we look in vain through the ponderous tome of Constantine the African (1015-1087)- for any- thing \'arying from Hippocrates, Galen, and Avicenna except in the obscurity of diction and the misapprehension of its sense. It is largely a catalogue of drugs, including, for the throat, the swallow prescription and the usual line of stercoraceous remedies. The same may be said of Gariopontus (1040) . They were Salcrnitans and the school had then been in existence, for a time under the Saracens, for several centuries. It only formally went out of existence with many other old things in the time of the great Napoleon, but it had l)egun to decline even in the time of Roger of Rarma (12.")0), and his disciple Rolando, who were the first writers in whom there is any evidence of originality, and this is seldom apparent. Operation for Nasal Polypi. — From the text of Rolando^ we learn that for nasal polypi he at first purged the patient and then "Cum 1 Opera, Edit., Lugduni, 1509, f. 166. ^ De Morborum Cofiiiitione et Curationo. In his: Opera Basileac, 153(). ^ Glossulaj Quatuor Alagistroruin. Edit. Daremberg, Neapoli, 1854, p. 129. TONSILLOTOMY, UVULOTOMY, TRACHEOTOMY 111 spatiimine usque ad profundum evellatur et sagitella inscidatiir." The sharp spatula referred to is evidently from Galen. The recom- mendation for the use of a saw may have resulted from the descrip- tion of the use of the knotted string in the manner of a saw as described by Paulus Aegineta, just as the latter probably through imperfect manuscripts derived the string operation from the more rational and humane sponge method of Hippocrates. At least in some of the translations from the x\.rabian books reference to this "sagitella," usually in the way of comparative illustration of the knotted string method, may be found; but SprengeP says that Rhases recommends the saw as well as the ligature for the removal of nasal polypi. Rolando seems familiar with the knotted-string method also, but nevertheless I imagine there is confusion here arising from the transcription. Tonsillotomy, Uvulotomy, Tracheotomy. — Holmes refers to Roger and Rolando as having observed a neoplasm of the larynx. This, when we consider the general state of medical diagnosis in their day, seems very improbable. The passage in the "Glossulffi" to which he apparently refers does not seem to warrant that interpre- tation,^ but it seems clear to me that enlarged tonsils was the con- dition the writer had in mind. The last sentence doubtless refers to tonsillotomy. Immediately thereafter follows the reference to the treatment of elongated uvula. For this he had a good deal of faith in an ointment, doubtless carried in the boxes of the peri- patetic practitioners of the day, the quacksalbers. This salve was supposed to destroy proud flesh, and cause the growth of better. If no other remedv was efficacious the cauterv was to be used as recommended by the Arabians and "Ypocras." He quotes Avicenna in a warning to be observed after u^■ulotomy, clearly derived in exaggerated form from Galen. The patient should not lie on his back, lest epilepsy, apoplexy, and paralysis should be caused. He also had reason to recommend as a gargle the water in which a fat hen had been boiled, a prescription which may be found in the Arabian works. Petrus d'Abano' warns against incision of the trachea as dangerous and gives his puerile reasons for the opinion. Arnaldo di Villanova (1. c.) repeats the Arabian hair-pulling formula for relaxed palate, and the fat-hen prescription for sore throat. As for the ridiculous "Lilium Mediciiiii.'" of Bernard Gordon, a teacher at Montpellier from 1285 to 1307, the title reflecting the stilted style of chivalry with which Cervantes lEssai. . . . sur la Medccine. Paris, 1809-10, II, p. 337. - Est auleni quaedaiu passio quenascitur in gula juxta epiglotiiiu quod dicitur foUum (?) que quandoque est una et quandoque sunt due carunculse tenues et late et modus folii que tracheam arteriam et vocem impediunt; cum vero patiens aperit os ad loquclam, se elevant et foramen trachee artei'ie; cum vero OS claudit, subsident, unde jjatiens vix |)otest formare alicjuod v(u-l)um intelli- gible. Que passio numquani curatur nisi beneficio cvrurgie. » Concil. Diff. Venetiis, 1522. He lived 12.50-1320 a.d. 112 THE PRE-RENAISSANCE PERIOD later played such havoc, this seems an utter annihilation of cere- bration. Dyspnoea was sui)pose(l to l)e (hie to "weakness as in chikhen on account of the (k'bihty of the nerves and paralysis, on account of spasm and many such things," he recognizes uvulotomv and hints at the advisabilitv of tracheotomv in verv desperate cases. The intractability of chronic hoarseness is expressed, however, in the tersest language, to which modern science could hardly add anything. " Haucedo post ununi annum non recepit curationem. liaucedo ex rheumate numquam- curatur, nisi prius rheuma curatur." Platearius (1. c.) gave expres- sion to the same opinion. All these authors shared the credulity of their age. In the records of sorcery, so abundant in the ]\Iiddle Ages, the accounts of cries and coughs and barkings, especially among the hysterical recluses of the convents, were the syni})toms of the convulsive spasms of the pharynx and larynx still occasionally seen, and perhaps, as Dupouy suggests,^ prodromata of the more general convulsive seizures. The ignorant credulity of the age was extremely likely to cause the burning of these poor wretches. But greater men had begun to appear and in Henri di Mondeville and Guy di Cauliac, his pupil at the University of ]\Ionti)ellier, we have evidence of advancing intelligence and knowledge, which manifests itself however chiefly by a better understanding and rendering of Galen and the Arabians. Their productions in their naivete are amusing, in their form approach somewhat to the standard of good literature, and in their substance are valuable as giving an insight not only into medical knowledge and ethics, but also to a considerable extent into the spirit and general con- ditions of the time. There is also to be noted some improvement in the latinity. Henry of Amondeville. — Henricus de Anionde\ ille,' as he styles himself, declares in his Proemium that he set out to write his Manual of Surgery in 1306. This is just ten years before ]\Iondino di Luzzi is said to have dissected in public the human body, and it will be interesting to note the advances, small but significant, in anatomical knowledge which are evident in the work of Ilermon- deville (for thus he is also called at times), over the state of it revealed in the citations I have made. He describes the olfactory lobes, not according to Theophilus, whose description was not noted until recent historians have brought it to light, but according to Galen as a i)art of the brain and the true organ of smell: "Just in front of these is a certain fossa which is between the two eyes under the upper extremity of the nose, where the said fossa begins." (He is describing the internal nose.) "The reason for the creation of this fossa is twofold: (1) That it may receive the superfluities of the brain, and that they may be expelled through it. (2) That in ' Lo Moycii Afro Mrdical. Pari.s, 1895. - Die Chirursic des lleinrich von Mondeville, edited by Pagel. Berlin, 1892. GUI DI CAULIAC 113 it the air, carrying a sort of odorous matter, may remain quiet until it is taken up by the organ of smell. From the said fossa spring two canals toward the mouth and the palate through the ethmoid bone. The use of the said canals are threefold : (1) That when the mouth is closed there may be an inspiration of air to the lungs. If this were not so it would always be necessary to keep the mouth open. (2) By blowing forcibly through these the said sieve-like bone (the ethmoid) may be purged of its filthy viscosities. (3) That they may aid in the enunciation of letters." The description of the external nose which follows is a little better, but while an improvement may be noted over his immediate predecessors, it may be easily seen how much inferior this is to the passage in Galen (vid. pp. 137 and 142), from which it has been taken, especially in the physiological part of it. The same remark applies to the anatomy of the throat. " From the stomach by way of the . . . oesophagus^ there goes a membrane, which surrounds the whole mouth on the inside, and the proof that it comes from the stomach is that when a man is touched under the mouth (in the back of the mouth?) he immediately has a tendency to vomit. Extending into the mouth is the upper end of the oesophagus and the air passage which is called the 'canna pulmonis et trachea arteria,' whose opening into the mouth the cymbalar cartilage covers which is the third part of the organ which is called the epiglottis, i. e., the nodule of the throat, which cymbalar cartilage rises up when a man talks and covers very loosely the food way, and when a man swallows food it is depressed and then loosely covers the tracheal artery and the food way remains open, wherefore unless at the time of swallowing it should co\'er the airway food would enter it, as often happens when, etc." We meet also with the queer remark of Hermondeville that the flesh of the tongue is white in order that it may change the watery saliva into a color similar to itself. He repeats the mistake of Galen that the lower jaw is made of two bones. Among his thera- peutics invocations are occasionally recommended. In all the writers before Vesalius epiglottis was a term applied to the whole larynx, and this and other anatomical terms, as among the early Greeks, were used in a bewildering way when they tried to describe the throat. Gui di Cauliac. — We now turn to the great surgeon of the pre- Renaissance period, Gui di Cauliac,- and so far as the nose and throat are concerned he does not differ materially from his preceptor, Hermondeville. He speaks of the ethmoid bone as belonging to ^ A stomachio mediante irieri vel via cibi, vel ysophago, quae sunt idem." Stomachus in cla.ssical latin usually meant the (Esophagus, but was frequently loosely applied to the stomach, while meri is apparently an Arabian word adopted into tlu; Mediaeval latin. - La Grande Chirurgie de Guy dc Cliauliac — Composee en I'an, 1303. Edit. of E. Nicaise, Paris, 1890. 8 114 THE P RE-RENAISSANCE PERIOD the frontal, which he calls the coronal. In it are the holes for the eyes and "les colatoires des narilles divisez par certaine addition ossue en forme d'une creste di geline a la quelle est plante le cartilas^e qui despart les narilles." (P. 41.) Although Gui has something to say of wounds of the nose and bandaging, he passes over its diseases very superficially, quoting Avicenna that the obstruction of the nose is "humoral, or fleshy, or crusty," the symptoms of which are the inclination to hawk, the impossibility of breathing with closed mouth, tinnitus aurium, nausea; in short, not a bad summary of lesions and symptoms, but not very specific. Plis treatment was the snuffing up of water impregnated with various mollifacient and astringent drugs. He recommends for this purpose also the urine of camels, having copied this, of course, from the Arabians, who, in their long and terrible journeys through the burning sands of the desert, not infrequently were compelled to quench their thirst with it and to perform their ablutions with sand. His account of the diseases of the mouth and pharynx are also merely repetitions of the medical writings of the Greeks and Ara])ians. He quotes from Mesua a description of a cannula for cauterizing the uvula, " in the head of which at one side is a fenes- trum in which the uvula is engaged; and then through the cannula is introduced a hot instrument like a knife, and it is incised h\ cauterizing." He also follows the procedures the Arabs had adopted from Paulus Aegineta, for the tonsils and for foreign bodies, quoting Haly Abbas, that if it is a leech in the throat, give onions with vinegar, or pull it off with the forceps. In quinsy the following treatment was used after pus was supposed to be present. Quoting from the practice of his predecessors, he says: "The abscess having matured, they first try to incise it with a lancet, if it is to be seen, and the mouth is rinsed out with parsley or with some other of the usual detergents. If, however, it is so far within as not to be seen, it should be broken with the finger nail or by rubbing with something if possible." We are reminded of the rough-and-ready operation of the old Salernitan on the dice player. He refers to this remarkable procedure of Roger, which we have noted elsewhere for another purpose. "A half-cooked piece of meat should be taken and tied to a long, strong cord, and the patient should be made to swallow it, and while he is swallowing it, it should suddenly be jerked out with violence by the cord, and the abscess thus ruptured. The same may be done with a sponge." This was the way Aetius and the Arabians removed foreign bodies, but certainly there is no lack of originality in this for a tonsillar abscess. Through Avicenna he quotes Hippocrates' intubation process by means of gold and silver tubes for the relief of dyspnoea, reproducing the Arabian remarks ujoon tracheotomy. The same may be said in regard to nasal ])oly})i and ozwna. "Of the ulcers which are in the nose, some are without superffuous flesh and others THE INFLUENCE OF MARITIME COMMERCE 115 with it. . . . One should not despise these ulcers of the nose, since as all say they lead to polypus, and polypus of every kind is pernicious." For them he recommends the process of Albucasis, the knotted cord, etc. "Split open the bone according to the four masters, and burn it." Botium was the name in the Middle Ages for goitre, and they knew nothing better, according to Gui, than the use of setons for the surgical treatment of it — quite a fall from Celsus.^ Goitre during these times, as is well known, w^as cured by the laying on of royal hands, and the patriotic partisans of the kings of England and France carried on an active and spirited warfare in quite orthodox fashion, as to the claims of priorit}^ of their respective monarchs. THE RENAISSANCE. The Influence of Maritime Commerce. — The removal of the papal court in 1305 to Avignon, where it remained for se^•enty years, gave Italy an opportunity to develop her own wonderful terrestrial and maritime resources and to lay a solid foundation for the develop- ment of civilization. For without wealth there can be no civiliza- tion, and wealth, as Spain gorged with the gold of the Xew World later demonstrated, does not consist of heaps of the yellow metal drained by conquest or superstition from other countries. In Italy the crusades and the religious devotion which made them possible had swelled the leaking coffers of the church in vain, but when the enterprise of commerce had made her merchants princes, the arts and sciences again blossomed along the shores of the ]Medi- terranean. When we remember the foundations laid in the lives of Darwin, Huxley and Hooker in our own day by the knowledge acquired on voyages in her Majesty's service, we may understand the influence such maritime development exercised on the budding civilization in Italy in the fourteenth and fifteenth centuries. The sails of Venice brought not only w^ealth l)ut enlightenment to her wharves. The Genoese sailor, the son of a wool comber, had learned indirectly from the Arabs, whom his sovereigns were just driving out of Spain, that the world was round and he was fitting out his three ships to prove it, less than forty years after the fall of Con- stantinople had extinguished science in the East. The church had denied it. In the process of the suppression of the Pelagian heresy and the establishment of the doctrines of St. Augustine, the book of Genesis had become the reference hand-book for the cosmography as well as the cosmogony of the church. Supported ^ It was not until 1443 that Thomas of Sarrano, afterwai'd Pope Nicholas V, discovered a manuscript of the De Medicina of Celsus. Hippocrates was translated from the original about the same time. IK) THE RENAISSANCE thereby, we find the infallible Roman pontifl' fixing the age of the world at 6000 years, while as he walked in the gardens of the Vatican, his sandals were grinding shells which the sea had left there a million years before. At first the hierarchy did noble work in fostering the feeble shoots of learning which began to appear, but later when the \-igorous plant began to overshadow them they strove to destroy it, or rather to train it to grow as they wished, but in vain. It had outgrown their powers. Petrarch. — Petrarch (1304-1374) ridiculed the ignorance of the physicians, and Boccaccio (1313-1375) exposed and laughed at the \-ices of the clergy long before anyone understood or attempted to invalidate the slavish compliance with authority which so degraded the human mind. Now, 500 years after Petrarch, we are only reminded that this mental slavery once existed by noting some remnants of it in the waste places of modern civilization, and these are the verv localities in which modern scientific and political achievement had their beginning in Europe under the Arabians and the early popes. The School of Salerno began as early as the time of Charlemagne and Haroun al Raschid during the Arabian lienaissance, and became the Civitas Hippocratis to which Richard of the Lion Heart and other great personages resorted in the search for health. By the end of the Crusades the Artisan Guilds began to be formed, family names were adopted, commerce and industry sprang up. The commons in the cities wrested their charters of freedom from their sovereigns in the twelfth century. The great Gothic cathe- drals arose at Paris, Rheims, Rhouen, Strasburg, Amiens. Saint Louis (1226-1270) founded hospitals in Paris, and his confessor thought he was doing more by establishing the theological school of the Sorbonne which took his name. The school of Bologna, where ^Nlondino taught, was started in 1119, and before the fifteenth century uni\ersities were fiourishing in nearly all the countries of Europe, and all under the jurisdiction of the church. Revival of the Study of Anatomy. — The Arabians, as we have seen, shrank in holy horror from the contamination of a dead human body, and the students of the School of Salerno, animated as it was l)v Arab influence as earlv as the eleventh centur\', studied the anatomy of the pig. Catholicism also proscribed the study of anatomy by dissection, and at that time the church represented all the public sentiment there was, but the enligiitened Erederick II, while successful in his warfare with the pope, connnanded (1224?) that a human body should be dissected at one of the schools at least once in five years, but after him the emperors kept no abiding power in Italy. The church in those stormy times could not be long kept from tem})oral power. Mondino di Luzzi. — An edict of Boniface \ II, ])ublished in 1300, again pr()liil)itc(l dissection not only in Italy l)ut in all the countries KEREN GAR DEL CARPI 117 under sacerdotal authority. Nevertheless only a little time after this, in 1308, the senate at Venice decreed a body should be dissected annually, and in 1316 ^Mundinus di Luzzi, called the restorer of anatomy, being the professor in the University of Bologna, had the audacity to dissect two cada\'ers in public. Besides the impor- tance of this record in the history of medicine it is also a suggestive indication of rising insubordination against papal authority, much weakened by the dissensions which, as we ha\'e noted, had removed the court to Avignon, and had resulted several times in the existence of more popes than one. It was also the servile beginning of freedom from the exclusive authority of the Ancients. Mondino did little more than open the thoracic abdominal and cerebral cavities and refuse to see anything not described by Galen. He says^ the functions of the tonsils are "to gather the humidity which they generate for the lubrifaction of the trachea, and to fill up the space so as to make it level between the 'gula' and the epiglottis, and to act as a shield to the apoplectic veins" (the carotids). He gives the name cooperatorium (a cover) to the epiglottis, the latter name as usual being applied to the larynx, which is described entirelv in the sense of Galen and with the same superficiality and lack of original observation we have already noted in other writers of this period. For nearly two hundred years apparently little advance was made in spite of the greater prevalence of the practice of dissection. Let us not be astonished at this, but reflect on the few men to-day who see at the autopsy table or under the microscope anything not set down in books. Achillini indeed made some important discoveries (1463-1512) in other regions of the body, but the editions of his work are so rare and so wretchedly executed, I have had to depend upon the citations of subsequent authors. It was not until the study of anatomy became a passion with the princes of Italy, as it had previously been with the Ptolemies in Egypt, that the great strides noted in Berengar began. Under their protection the arts and sciences flourished, and the study of the anatomy of the human body by dissection wrought great changes in the practice of the Medicai Art. Berengar del Carpi. — Mondino is called the Restorer of Anatomy, but it is to Berengar del Garpi, who taught surgery at Bologna from 1502-1527, that we owe the actual demoustratiou of any consideral)le number of new discoveries. Although he avowed himself to be only the commentator of Moudino, he used the work of the latter principally as a text from whic-h to elaborate his own more extensive and accurate observations. In Benvenuto Gellini's entertaining aut()biogra])hy we read his very uncom])limeiitary reference to Berengar as a charlatan and a ' Anatomia — Restituta per Joh. Dryandrum. Marburg, 1541. 116 THE RENAISSANCE mounteback, an impostor and a miser who made enormous sums of money out of his new mercurial cure for cases of the French disease, which acconhn^ to CelHni at Rome was "molto amici di preti." AVe receive a hint of his ex])erience with sypliihtic cases by the error he was led into through his defective acquaintance with its laryngeal manifestations. He notes^ the declaration of Zerhi that certain French singers have their uvulae cut off that they may acquire a "grossam vocem," but he does not believe it, because he has seen those having no uvula who were hoarse and had the worst kind of a voice. Following Galen he had great res])e('t for the physiological importance of the uvula. Notwithstanding that we ha^'e cause to remember, in reading the works of Carpi, the declaration of Aristotle that authority in science is the worst enemy of the advance of knowledge, and notwithstanding the bad stories related by the uncharitable Cellini, Berengar in his Commen- taries and especially in his Isagogae showed that he was an acute observer of anatomical facts. He thought when he noted the nasal muscles he had made a new discovery, but he was not bold enough to be sure of it in the absence, as he thought, of any knowl- edge of them by others. Cartilages of the Larynx. — He declared, at first with some hesita- tion in the Commentaries (1521) and later more positively in the Isagogse (1535) that the larynx is made up of five cartilages, the arytenoids or "cymbalar cartilage" being double, but like his predecessors he speaks of the larynx as the epiglottis, and uses the word cooperatorium as did ^Nlondino. He says that he had cured patients with perforation of the trachea, but clings to the old belief that cartilage will not heal, "because," he says," it is spermatic." He speaks of the substance of the "membranoso coopertorio" the epiglottis); "around this there is some fat, especially in the place where it is bound to the thyroid cartilage." Most writers referring to this passage agree with jNIorgagni in believing that Berengar observed the laryngeal glands abundant at this point, but after reading the text it seems to me more probable that he referred to the lymphoid material in the glosso-epiglottic fossa which we now call the lingual tonsil. He was the first to describe the thyro-epiglottic muscle. He was the first to describe the sphenoidal sinus, which he considered the source of catarrh, and he denied that the ethmoid plate Avas pervious to the passage of the cerebral fluids. Sphenoidal Sinus. — He supposed this to take place through the sphenoidal sinus, because he noticed that in one case the nutrient canal of the bone communicated with the sella turcica beneath the pituitary body, which was supposed to secrete the cerebral fluid. So far as I see this was the first departure from the idea of the ^ Carpi Comment ai'ii. Anat. Mmidini, 1521. VES ALIUS 119 ancients, and was an attempt to adjust physiological theories to new anatomical facts, which finally after more than a hundred vears ended in the demonstrations of Schneider. He not only noticed the sphenoidal sinus and conjectured that this was the route of catarrhal discharges, but he is said by Cloquet to have been the first to note the existence of the frontal sinuses. Berengar speaks of the lacrimal canal and of the passage of tears through it, explaining that this is the reason we are able to smell odoriferous collyria. Otherwise his anatomy of the internal nose is very super- ficial indeed. The Revolt from Galen. — Some of the pre-Vesalian writers on anatomy stroNe to explain the countless variations they observed from the anatomy of Galen by supposing that men in those glorious days were not made in the same mould as at present. They had degenerated and altered in their structure. This has always been a favorite idea with the poets from Ovid down. It is embodied in the very word (h'scenchnits, frequently lingers in the fond recollec- tions of age, and even haunts the title of Darwin's famous book, who indeed has demonstrated the mutability of anatomical struc- ture, but not in a manner to support the assumption of the anat- omists of the early Renaissance, who made timid excuses for the originality of their own observations. One may easily see by this ser^•ile acquiescence in authority that it was not only the temporal and spiritual tyranny of kings and priests which ensla\'ed the minds of men. It was the distrust of intellectual infancy, terror stricken at the thought of the loss of support, and guidance if they impugned the authority of their predecessors. No fear of papal excommunication and the burning fagots, no dread of being impaled and racked and hung and quartered was at the bottom of this faltering. How ineffectual these instruments of orthodoxy were when used may be comprehended by noting that this intellectual slavery, without the fear of fire here and hereafter, endured quite as long as did that spiritual and political subservience for the l)erpetuation of which they were employed. Vesalius. — A few years before the death of Berengar (1550) the open revolt against ancient authority in anatomy was to appear. Vesalius was born at Brussels about 1515, just one year before that mighty ruler, Charles V, who had inherited half of Europe from his various ancestors, ascended the throne of Spain and four years before he was crowned Emperor of the Holy Roman Empire. A great man is Charles V in political history, and not less great in medical history is his physician, \'esalius. He became pro- fessor of anatomy at Padua, and taught also at Bologna and Pisa, before the emperor called him to his court. He made many an anatomical blunder himself, but it is to Vesalius that this funda- mental branch of our art owes its modern development. He possessed that attribute of genius, which has been expressed by 120 THE RENAISSANCE Carlyle as the a})ility to sec with one's eyes, and the inal)ility not to beHeve what one sees. lie declared tliat Galen had never dis- sected the linman body, but had depended upon examinino; those of animals, lie ridiculed the excuses which had begun to be made for the discrepancies in Galen's anatomy when compared with the results of dissection. He was much readier to believe in the falli- bility of the ancients than that the structure of man had varied in a thousand years. It is very e\'ident that as to the anatomy of the nose and throat Vesalius committed more errors than he cor- rected, but his persistent refusal to accept either Galen or his preceptors' word for that which his eyes tautjht him was false, his uuAvearied diligence, and boundless energy ^^■rought great changes in anatomical research. He published his great work which would have been a worthy monument for the labors of a lifetime in 1.142, at the age of twenty-seven. He insisted upon the greater value to be derived from personal dissection of the human body, a matter left to barbers and underlings by his predecessors and by many of his contemporaries, than by the continued perusal of the ana- tomical descriptions of the old Greeks and Arabians, and we find him declaring in liitter scorn of one of his preceptors, who had turned against him, that he would be quite content that as many strokes of the knife should be inflicted on him as he had ever seen his master practise on man or beast. (De Radic. Chyn. Epistola.) For him, as for his predecessors, and for his successors for more than a hundred years, the secretions of the brain percolated through the base of the skull, but he denied that it found passage through the cribriform plate, following Berengar thus far; but he supposed that it went through the lacerated foramina. Nevertheless he ascribed to the perforations in the cribriform plate the function of transmitting air and odors to the brain,' urging the necessity' of coml)ating the idea of Galen as to the exit of fluids through them. His old teacher, Sylvius, whom he tried to treat with deference and respect, loaded him with opprobrious ejiithets and scurrilous abuse for impugning the authority of Galen in this and other par- ticulars. The Olfactory Nerves. — While \'esalius recognized the mammillary processes as the seat of olfaction he did not ascribe to them the functions of nerves, overlooking the filaments which pass from them and calling the optic nerves the first pair at the base of the skull (1. c. Lib. IV, cap. 3). We have seen that Theophilus had given a better account of them many centuries before, but his observation seems to have been entirely lost to view until revealed by the industry of comparatively recent historians. We may readily understand that the mind of man must necessarily find some * De Humani Corp. Fabrica, Veneti, 1.542, Lib. I, cap. 6 and 12. 2 Ad Joachinnim Roclarils Epistola. In Vesalius, Ojx'ra Omnia, Lu^'d. Batav., 1725, 11, p. ()21-()81. THE OLFACTORY NERVES 121 explanation for the cribrous condition of the bone here, and it was quite impossible to banish erroneous speculations until a correct understanding was ready to take their place. Zerbi, who lived at the end of the fifteenth century, and met a horrible death at the hands of the vengeful and suspicious Turks now in possession of Constantinople,^ described the filaments which the olfactory bulbs give off, but he regarded them as prolongations of the mam- millary processes through which the cerebral secretions find their way into the nose. Most of the anatomists of the sixteenth century regarded them as too soft to be really nerves, but Achillini, who died in 1512, described their distribution in the nose.- ]\lassa, who is said to have died in the same year as Vesalius (1504), wrote-'' this in regard to them: "Notwithstanding the learned and never-to-be-sufficiently- praised Galen, on an examination of the nerves springing from the brain, first at the anterior part where the substance of the brain is, which is called the mammillary caruncles, there are to be observed two soft substances, yet they are not so soft as is imagined, like to the form of other nerves, and they descend, without any doubt, to the nares, and are attached and distributed to the inner substance of the nostrils, for furnishing the sense of olfaction." Nevertheless he hesitates very much to give them the name of nerves, but is inclined to believe they shoidd be so regarded in spite of their soft consistence, and he wonders that the anatomists do not name them as the first pair. Thirty years subsecjuent to this Varolus,^ in 1572, described them as nerves, and in 1627 Spigelius added them definitely to the other cranial nerves. "Septem his paribus quae vulgo sic recenscentur octavum addimus, quod ner\'os olfactorios constitit,"-^ but even he did not follow the filaments through the cribriform plate. Indeed, even Schneider made the egregious blunder of not accepting them as nerves. Bauhinus,'^ in his com- mentaries on previous anatomical works, in 1()21, still followed Plato in the idea that odor is a vapor of the nature of fire, which 1 He had been sent for from Italy to treat a Turkisli Bashaw, who imi)roved so much under treatment that the busy practitioner did not think it necessary to remain lonjjer, but sailed away loaded with the gifts of the fjrateful j^atient. No sooner had he gone than the patient had a relapse and died. His relatives, believing Zerbi had poisoned him (or did they want his fees?), overtook the ship in which he had sailed away, brought him back to Constantinople, sawed his son in quarters before his eyes and then did likewise with him. This storj' explains in itstdf why the Turks had to send away for a doctor, as did the old Persians in earlier t imes. - 1 have derived from Sprengel, Metzger (Nervorum Primi Paris Ilistoria), Clotiuet and others this account of the work of Zerbi and Achillini, as the originals are, for me, illegible. ^Epist. Med. et Philosoph., Venetiis, l.'viO, Epist. VI, p. 58. * Cioquct (Osphresiologie, ]*]d. 2, Paris, 1821) gives a most exhaustive history of these nerves, as indeed do(>s Metzger (1. c). 5 De Coi'i). llumani I'abrica, Lib. VH, cap. 2 (Opera, Amst., 1645, I, p. 193). ^ Theatrum Anatomicum, I'Yancofurti, 1605, Lib. Ill, cap. 7, p. 543. 122 THE RENAISSANCE ascends throuo;h the cribriform plate. Fallopius accepted the old doctrine of Hippocrates that vapors ascend throii