RHINOLOGY IN THE PAST AND OF THE FUTURE. An Address Delivered before the American Rhino log- ical Association, on October 5, 1886, at St. Louis, Mo. BY CARL H. VON KLEIN, A.M., M.D., OF DAYTON, OHIO. Re printed front the Journal of the A m e teal Association, December IS, i886~ CHICAGO: Printed at the Office of the Association. 1886. RHINOLOGY IN THE PAST AND OF THE FUTURE. An Address Delivered before the American Rhinolog- ical Association, 011 October 5, 1886, at St. Louis, Mo. BY CARL H. VON KLEIN, A.M., M.D., OF DAYTON, OHIO. Reprinted from the Journal of the American Medical Association, December iS, 1886. CHICAGO: Printed at the Office of the Association. 1886. RHINOLOGY IN THE PAST AND OF THE FUTURE. No subject can present a higher interest than an inquiry into the past and future of rhinology. What- ever tends to correct error or introduce improvement into science must affect the comfort of the profession. No research on such a subject can be accounted too minute, no labor too long. Progressive as we have been in the past few years, we cannot boast of having revealed the last trace of civilization. When we look back to the history of rhinology, we find that as a specialty it is not of modern invention, as many sup- pose it to be. Egypt was the earliest home of medi- cal skill, and every mummy of the more expensive and elaborate sort involved a process of anatomy, particularly as to its pathological condition, and these interesting pathological specimens were more numer- ous by reason of the profession being divided into specialties. Herodotus says :* Egypt claims the in- vention of healing art. The medical practice among the Egyptians is divided, and each physician is for one kind of sickness and no more, and all places are crowded with physicians, for there are physicians for the eye, physicians for the head, physicians for the nose, physicians for the teeth, physicians for the stomach, and for internal diseases. It is claimed that the best anatomists among those specialists were those who practiced on diseases of the nose and stomach; they were the embalmers.2 Em- balming was first done by the rhinologist, removing a part of the brain through the nostrils by means of a crooked iron, and destroying the rest by injecting caustic drugs; and by the practitioners of the stom- ach, who made an incision along the flank with a sharp Ethiopian stone, and the whole of the intestines 1 111. in loco. 8 Herod., ii, 86-89. 4 removed. The cavity was rinsed out by palm wine, and afterwards scoured with powrdered perfumes. It was then filled with pure myrrh, pounded cassia and other aromatics, except frankincense. This done, the body was sewn up, and steeped in natron for seventy days. When the seventy days were accomplished, the embalmers washed the corpse and swathed it in band- ages of linen cut in strips and smeared with gum. They then gave it up to the relatives of the deceased, who provided for it a wooden case, made in the shape of a man, in which the dead was placed. Besides embalming, the rhinologists were also as- signed as executioners in punishment of adultery, which was inflicted upon adulterers by amputation of the nose. Strabo says :3 Rhinocolura is so called from the colonists whose noses had been mutilated. Some Ethiopians invaded Egypt, and instead of put- ting the malefactors to death, having cut off their noses they settled them at Rhinocolura, supposing that they would not return to their own country, on account of the disgraceful state of their faces. This gave those specialists opportunities for inspecting a vast amount of material, varying in every possible pathological condition. Such opportunities were sure to be turned into account by the more diligent among the faculty. Their reputation was so widely estab- lished that4 Cyrus and Darius, kings of Persia, sent to Egypt for physicians. The former was afflicted with nasal polypi, the latter with ophthalmia. From all historical accounts it is demonstrated that rhinology was one of the most cultivated specialties in the art of medicine. I have no doubt that rhino- scopic examinations were made by the Egyptians as well as they are made to-day. The use of mirrors among them was so common that they not only used them in their residences, but even as ornaments on their garments, and arranged them in their hair. And 3 Strab., xvi, 2. 4 Smith’s Diet., p 1 q6q. 5 in the Egyptian temples, it was the custom for women to worship in linen garments, holding a mirror in the left hand and a sistrum in the right. Sir G. Wilkin- son says5 that the mirrors were susceptible of a lustre which has only been partly revived at the present day. The treatment in rhinology we may imagine was absurd; yet Hippocrates described the same treat- ment Of inhalation, fumigation and inspiration of es- sential oils, just as it is used at the present day. In the treatment of syphilis, fumigations were ex- tensively applied in clearing away the incrustations which generally exist in syphilis of the nose. Injec- tion of lotions have been used from time immemorial. As to the success, whatever it might have been, we are unable to find any records thereof. Various com- pilations are in existence of the relative sum of the disease of the various organs, but none pertaining to rhinocal. If there is such in existence, we can only expect an approximation to accuracy. Rhinology, like many other specialties of this century, began by men incompetent for the task. Any data, therefore, from this source, are too uncertain for philosophical deduction. Medicine is no doubt one among the many lost ancient sciences. From the period of the cultivated Egyptians to about the fifteenth century, very little was known of the science of medicine. From Hip- pocrates to the days of Galen, a period of about six hundred years, and from the time of Galen to Fra- castora, a period of about thirteen centuries, the sci- ence of medicine was like a barren desert. At the beginning of the sixteenth century she began to break the clouds which overspread the skies of blue, and the cultivation of medicine made its progress from day to day; though in the rear of other sciences, yet she is amid civilization. It was not until the beginning of the present cen- tury, when the scopic method was thought of, that 5 Ancient Egypt, iii, 384. 6 physicians became able to make a correct diagnosis of diseases. Great has been the usefulness of the urethroscope, rectoscope, stethoscope, ophthalmo- scope, otoscope, microscope, laryngoscope, and only within the last few years the rhinoscope. Consider- ing the numerous difficulties, and the multitude of conflicting theories which had from time to time been promulgated, on account of the parts and by reason of their being hidden from view, the pathological theories of nasal diseases were absurd and unphilo- sophical. Yet, with all its antagonism, it has in a great measure unveiled itself before the light of mod- ern investigation, and become reduced to a more scientific basis, though we cannot boast, however, we opened a new road to medical science. Our first acquaintance with some sort of an illu- minator of the upper respiratory tract is mentioned by Levret, of Paris,6 in 1743. In 1803, Bozzini7 in- vented a kind of hand mirror for the purpose of ex- amining all sorts of obscured cavities in the human body. In 182 7,8 Senn, of Geneva, proposed to ex- amine the larynx by a small mirror, by introduction into the mouth. In 1829, Dr. Babbington,2 of Lon- don, invented an instrument which he termed glotti- scope, and also some sort of a tongue depressor of polished steel combined with a mirror. In 1832,10 Kaslinsky, of Warsaw, invented a combined mouth speculum and gag. In 1835," Plate, of Amsterdam, describes a double mirror for the examination of the larynx and pharynx. In 1837,12 Selligue, a very in- telligent machinist of Paris, who himself was subject to laryngeal phthisis, invented a laryngeal speculum consisting of two tubes, through which light was thrown into the glottis, and by a counter glass, which 0 Phthisic Paris, 1837, S. 177. 7 Hufeland’s Archiv der Heilkunde. Neue Folger, 17 Band. 8 Gazette de Medecine et de Chirurgie. Ptaris, 1863, p. 263 9 Phthisie Paris, 1837, S. 177. 10 Woyenie Medicinsky Shornall. St. Petersburg part., L. xii. 11 Plate’s Voordragt over des Keelknobbel onderzoeking. Amsterdam, 1836. p. 13. by Morell Mackenzie. Third Ed., Lond., 1871. 7 he placed in his guttural extremities, he was able thereby to view his own disease. In 1838,13 Baumes, of Lyons, demonstrated a laryngeal speculum which cannot be found anywhere described. In 1840,14 Liston, of London, applied in the examination of the larynx a dental mirror with a long handle, similar to that of Babbington. In 1844,15 Dr. Warden, of Edin- burgh, introduced a contrivance made of an argand burner lamp, for the examination of the glottis. In the same year Avery, of London, is said to have in- vented a successful instrument, for the purpose of examining the dark parts of the upper respiratory organs. In 1855,16 Garcia, a Spanish vocalist and teacher in the City of London, wrote a paper enti- tled “Physiological Observations on the Human Voice,” which he read before the Royal Society, wherein he explains in what manner a large reflecting mirror, with a small dental mirror in the mouth, can be made to exhibit the anatomy and the physiological actions of the laryngeal and pharyngeal organs. At this time a period of half a century has elapsed, with discoveries from year to year to open a path to rhinology, yet not until 184717 the illustrious Dr. Tiirck, of Vienna, perfected a laryngoscope upon the same order as that invented by Garcia, of which he claimed to know nothing; it was much superior but of great resemblance to Garcia’s. In 1859,'® Dr. Czermak, of Pesth, and Dr. Gruber, of Krakau, with the assistance of Dr. Tiirck, experimented with the latter’s instrument, until they had opened a broad road to the obscure places which we are here to discuss. The system of rhinology has made a rich harvest of natural discovery which benefited mankind more 13 Trousseau et Belloc. Paris, p. 180. 14 Liston’s Practical Surgery. London, 1841. 15 London Medical Gazette, 1844, vol. ii, p. 256. 16 Gazette de Med. et de Chir., 16 Nov., 1855. 17 Zeitschrift der Ges. der Aertze zu Wien., April, 1858. 13Czermak, Der Kehlkopfspiegel und seine Verwerthung fur Physi- ologic und Medicin, 2 Auflage. Leipzig, 1863. 8 than any progression in medical science made in this century, save anaesthetics. No organs within the human system can be so disclosed and show their pathological conditions, as those affected by the lar- yngoscope and rhinoscope. I speak of the laryngo- scope, because rhinology and laryngology work hand in hand, and the former developed itself through the latter; and through Tiirck’s invention of the laryngo- scope we are indebted to Czermak for the invention of the rhinoscope. Since he has demonstrated the pathological conditions of the upper respiratory tract by illumination, many have tried to improve upon the process of illuminating the nasal pharyngeal cav- ities, with many good and important results. The improved methods of Schroeder, Schnitzler, Senefelder, Cramer, Voltolini, Stoerk, Lewin, Traube, Fraenkel, Hirschberg, Ruete, Merkel, Waldenburg, Krishaber, Middeldorpf, Gerhard, Ziemssen and To- bald, of Germany; Rauchfuss, Poznisky, Ritter and Volltzior, of Russia; Mandl, Maura Bourouillon, Ba- trille, Cusco, Trauvel and Beverbire, of France; Mackenzie, Gib, Johnson and Boxt, of England, and so many others of this side of the Atlantic, that it would require an entire volume to name them all. Through their constant effort to improve the illu- minary apparatus they have made many valuable ob- servations within the nasal cavities, necessitating the invention of many other instruments, such as rhino- scopic mirrors, nasal speculums, tongue depressors, palate hooks, uvula holders, nasal douches, nasal syringes, nasal spouts, nasal sprays, nasal catheters, nasal inhalers, nasal sponge holders, nasal forceps, nasal probes, nasal respirators, nasal powder blowers, nasal tampons, nasal snares, nasal ecraseurs, nasal retractors, nasal cannals, nasal scissors, nasal brushes, nasal caustic holders, nasal evaporators, nasal dilat- ors, nasal camesoils, nasal plugs, nasal gauges, nasal drills, nasal blowers, nasal burs, nasal saws, nasal tro- cars, nasal spoons, nasal knives, nasal curettes, nasal 9 clamps, nasal applicators, nasal fumigators, nasal cauterizers, nasal cauterys, nasal electrodes, etc. The rhinoscope evidently brought to light the ne- cessity of inventing the appliances mentioned, and their inventors, in order to complete them, were forced to experiment with them, and by their exper- iments many observations were made, to such an extent, that it had made many deaf ears hear, and many blind eyes see, because many of those afflic- tions are caused by rhinocal disease, to say nothing of the numerous other kindred diseases, to which the upper respiratory tract is the sole cause. It has lately been discovered that many of the lower respir- atory organs cannot be healed until the disease of the nasal cavities is cured. The dreadful disease, asthma, which has always been considered a nervous disease, has recently been successfully treated by the removal of a large hypertrophy of the posterior nares.19 Others, as I, have cured cases of nervous prostration by healing the nasal pharyngeal cavities, and many other organs connected therewith. Such affections may frequently be observed in the bladder, liver, kid- ney, stomach and brain. In 1881 I succeeded in curing a case of epilepsy of two years standing by the removal of two large polypi of the posterior nares. The patient was a girl ii years old. In the same year I successfully treated a case of insomnia by the same operation as in the former case. Last year I cured a case of sup- posed insanity by extirpating a large turbinated pro- cess. Indeed, there is scarcely an organ or structure of the body in which they are not occasionally af- fected by nasal disease; it stands to reason; the nose is the gate to disease; in nine cases out of ten the causes of human ailments pass through the path- way of the nasal cavities. If an inhalation of ob- noxious gases can enter the lower intestines and produce a typhoid fever, why cannot it enter to the 19 Jour. Am. Med. Ass’n, vol. vi, 1886, p. 696. 10 other organs or structures of the upper and lower ex- tremities? When a piece of heavy artillery passes along the highway it can be traced from the very spot the wheel commences to revolve; it leaves its impression from the starting point to its destination. All diseases caused by exposure, or inhalation, must evidently make their first impression within the gate, the nose. It would therefore be better in all cases that rhinoscopic examinations should be made what- ever the disease may be, the gate should be first ex- amined. The nose is the foundry of a large machine-shop, wherein disease appears in its rough casting. Other organs are finishing rooms, wherein they appear en- tirely developed. In fact, the whole human body is comparatively a machine, and such a machine should be handled by different machinists; as all the cogs are connected, therefore they ought to be understood by each mechanic the connection of the entire ma- chine; as a single cog, in a single wheel, is no doubt but a small part of its mechanism, and can contrib- ute but a small portion to the effect of the entire work; yet the want of its cooperative influence may, if not entirely stop, yet greatly impede its motion. It is ever so with the physician, though he ought to understand every physiological action, and its an- atomical connection with every part within the hu- man body, yet, I hold that he ought to practice only a specialty. If a mechanic, for example, a fabric, wood, or a metal worker, who requires simply physi- cal training, can produce better special work, why not a physician make better cures if he confines himself to a specialty? If a cabinet maker can make a better bureau than a bedstead, or a pants-maker can make a pair of pants better than a coat-maker, or a metal-worker can produce better filing than an anvil-worker, or vice versa, why not a cultivated phy- sician with an active brain and mind, who devotes himself to one special subject, make a better physi- 11 cian? A man who devotes his mind and trains his eye to microscopy, makes a competent microscopist; why not he who devotes his time and trains his mind to the ophthalmoscope, make a good ophthalmolo gist? or a laryngoscopist a laryngologist? and a rhi- noscopist a rhinologist? Above all, I believe that rhinoscopy is one of the hardest studies of all. It takes more perseverence, patience and assiduity to make a correct rhinoscopic diagnosis than in all other “scopics.” Only such persons who are con- stantly devoting their time to rhinocal pathology are qualified. Specialism is a discovery of lost thought in medi- cal art. Sooner or later we will all be specialists, but not until the common prejudice has vanished and the narrow-minded will cease to influence those who are eager to learn the truth. Dr. Crosby, of Manchester, President of the New Hampshire Med- ical Society, in his Annual Address says:20 “Shall the practice of medicine sink to the level of a trade, where every competitor supplements his skill as an artisan by all the tricks of cunning and diplomacy of which he is able? Shall the body of the profession be broken up into fragmentary joints, each little seg- ment calling itself a specialist, until the organs of the body are parcelled out as booty is divided among thieves? Shall the grand old column be broken up into detachments that shall ultimately destroy one another, because men honestly differ as to means employed to subdue disease?” Just think of such irreverent assertions by men who ought to seek the truth which is before them, and forsake the errors of the past. But, gentlemen, fear it not; such is like the wretched ghosts of the idle and the inglorious in the Inferno of Dante, who did neither good nor harm while on earth, and who are in consequence debarred all admission into 20 Boston Med. and Surg. Jour., vol. cxv, 1886, p. 13. 12 heaven and hell as having no direct character for either place: Cacciarlii Ciel per non essermen bello ; Ne lo profondo Inferno gli riceve. The remarks of Dr. Crosby are heretical to the sentiments daily advanced by great men of medicine. Our beloved lamented late Dr. Austin Flint gives the following to the world with the last stroke of his pen:21 “The unavoidable subdivision of medical literature and medical instruction into special de- partments makes necessary, to a certain extent, spe- cialism in the practice of medicine. It is certain that this will not lessen, but increase in the near fu- ture, and it is important to think of possible emer- gencies which are even now foreshadowed. Special- ism conduces to the advancement of knowledge. It behooves us, however, to consider, where the prac- tice of medicine is to be given up to specialists, what would become of the medical profession? With due appreciation of services devoted to special branches of medical knowledge, there are tendencies pertain- ing to the practice of a specialty that should not be overlooked.” Dr. Angell, of Rochester, President of the Medi- cal Society of Central New York, in his Annual Ad- dress, says:22 “It is an undeniable or selfevident fact, that at the present day medical science has ex- panded to such an extent that its intelligent cultiva- tion as a whole, by one person, has become im- possible.” The body of the medical profession should and must “be broken up” into “specialisms.” It should not remain as “a Jack of all trades and master of none.” “The grand old column” which has been standing for so many years, must be repaired and decorated with fine jewels to meet the present de- 51 Flint’s Medicine of the Future. The prepared Address for the Annual Meeting of the British Medical Association for 1886. 22 Buffalo Med. and Surg. Jour., July, 1886, p. 567. 13 raand in medical science, that she may glitter in the midst of other sciences. Nor “ shall certain meth- ods be considered Catholic, and all else irregular and to be damned by bell, book and candle.” If rhinology had to depend on the treatment re- commended by writers of general medicine, she could not reach the bright future before her. We must take cognizance of the fact that her future is filled with admiration of the striking phenomena, having an inexhaustible mine of pathological devel- opments lying dormant within the reach of those who wish to adjure them. For there is no condition, no period of life that can claim immunity from disease within the nasal cavity. It is said that about nine-tenths of the human fam- ily are more or less# afflicted with rhinocal disease, and which were not observed on account of insuffi- ciency in rhinocal appliances. Here a wide and wonderful chasm occurs, which cannot be, as formerly, overlooked. The illumina- tion by the rhinoscope, the examination by the mi- croscope, the extirpation by electro-cautery, the inspiration by the spray, and by the true, honest and conscientious method of our friend Dr. Rumbold, will make rhinology fruitful and progressive. If we will not remain idle, many important facts will be unveiled and rhinology will be the greatest in the whole domain of medicine. The microscope will reveal new pathological organic disease of the ol- factory sense. The variety of nasal catarrh will be divided by each individual characteristic discharge, having its own nomenclature, according to their mor- bid condition. The various muco-purulent discharges which orig- inate in the different sinuses, will, as well, be recog- nized by microscopic examination. All the hyper- trophies within the nasal chambers will bear their own pathological name. The eruptions and ulcers in the nose will be regarded like the variety of ec- 14 zema. The abscesses, polypi, and all other foreign bodies within the nasal cavities will be assigned to their own nomenclature. By a combination of the rhinoscope and the microscope diagnosis will be made easy and certain. The treatment in nasal diseases might change in the use of drugs and remedies, but in the manner in which it is applied the spray and Rumbold’s method will remain certain and without end. The day is not far when all diagnosis of the respiratory and their kindred organs will first be looked after in the upper respiratory tiact. Hospitals and asylums will be well fitted out with rhinoscopic appliances for the purposes of examining all those who may become inmates of these institutions. The public will be- come acquainted with this specialty as well as they are with the dental profession, so that the rhinologist will not have to depend mainly on practice which is sent or recommended by the general practitioner. Gentlemen, from all the foregoing you will doubt- less place me as a specialist. I am sorry to state that I am not; nor will I be untill the profession has adopted “the best policy,” and that is, “honesty.” I mean honesty with their professional brethren. I know of a physician in good standing befriended by all the practitioners (about one hundred in number) within his city, who three years back commenced to practice, as a specialty, diseases of the nose and throat; though he was encouraged daily while in conversation, however, during said period but a sin- gle patient was recommended to him. I hold this dishonesty; for the simple emolument of a few shek- els they were but too whiling to undertake to treat disease for which they are neither competent nor prepared. There are theories which some men despise be- cause they will not consider them, and which they will not consider, because they despise them. They naturally despise specialties, because they think them 15 insufficient, and hate specialists, because they think them inferior; with such men, be cautious in your intercourse, as they always consider themselves greater; such men seldom confer obligations on their supposed inferiors but from interested motives. Friendly they appear, as long as it serves their own turn; but they will render no assistance in time of actual need. In conclusion to the foregoing I will say, all those obstacles are indeed great, but to determined and persevering exertion they are not insuperable; though we cannot conceal them from ourselves, we should not allow them to daunt our spirit; let us comfort ourselves by devoting our time and talents for the good, not only for the world of medicine, but the world of man.