THE LARYNGOSCOPE.
(1854-1857.)
It was in 1854 (the year which saw the ultimatum of England and France
presented to St Petersburg, the prelude to the Crimean War) that the
important invention was made--or, as the maestro with characteristic
modesty described it, "the idea dawned on him"--of the laryngoscope.
As to its lasting value to the world at large, it will be sufficient to
point out that since that year, according to reliable estimates, 3 per
cent of the entire human race have been benefited by the invention.
With regard to the history of the discovery, an account of the earlier
attempts which had been made has been set down in the number of the
'British Medical Journal' published at the time of the Garcia Centenary.
Before proceeding further, it may be well to warn the reader that the
next few pages are bound to deal with a certain amount of technical
detail which it is impossible to avoid in relating this portion of the
maestro's career.
Although the dentist's mirror was in use among the ancient Romans, the
first trace of an attempt to examine the throat by means of reflected
light is found about the middle of the eighteenth century.
In 1734 Levret, whose name is still held in honour among obstetricians,
described a speculum, consisting of a plate of polished metal, which
"reflected the luminous rays in the direction of the tumour," and
received the image of the tumour on its reflecting surface. Levret seems
to have used the mirror, not as a means of diagnosis, but as a guide in
the application of ligatures to tumours in the throat. At any rate, his
invention bore no fruit.
Half a century later Bozzini, of Frankfort-on-the-Main, devoted much
attention to devising means of illuminating the main canals of the human
body. In 1807 he published a description of an apparatus by which the
throat and the posterior nares could be examined by reflected light. The
official heads of the profession laughed away his invention, which,
though cumbrous, deserved a better fate.
In 1825 Cagniard de Latour introduced a little mirror into the back of
the throat, hoping with the aid of the sun's rays and a second mirror to
be able to see the epiglottis, and even the glottis, but failed. In 1827
another unsuccessful attempt was made by Senn of Geneva; and two years
later Benjamin Guy Babington exhibited at the Hunterian Society of
London an instrument very like the laryngoscope now in use: he employed
it in many cases, but for some reason seems to have left no record of
them.
In 1832 Bennati of Paris stated that he could see the vocal cords by
means of a double-tubed speculum, invented by a patient suffering from
laryngeal phthisis. Trouseau, however, proved to his own satisfaction
that the epiglottis must always make it impossible to see the inside of
the larynx.
In 1838 Baumès of Lyons showed a mirror with which he said the larynx
could be examined.
In 1844 Warden of Edinburgh reported two cases in which he said he had
been able to make "satisfactory ocular inspection of diseases affecting
the glottis," by using two prisms of flint glass. In the same year Avery
of London devised a laryngoscope in which a laryngeal mirror was
combined with a lamp and reflector: the apparatus embodied the essential
features of the modern laryngoscope, but its clumsiness made its
practical application difficult, and in many cases impossible.
Up to 1850, then, the different attempts had met with failure in varying
degrees. When Garcia attacked the problem he was quite ignorant of the
fact that others had been at work, and his reason for wishing to
overcome the difficulty and catch a glimpse of the glottis was perfectly
different from theirs. His was one connected entirely with his work as a
teacher of singing. Ever since he had given attention to the scientific
aspects of voice-emission, he had longed to see a healthy glottis in the
very act of singing. The idea of employing mirrors for the purpose of
studying the interior of the larynx came to him in 1854. The following
is the story of the discovery as he related it one day:--
"During all the years of study and investigation of the problems of the
voice-emission," he said, "one wish was ever uppermost in my mind--'if
only I could see the glottis!'"
One day in the September of 1854, when on a visit to Paris, he was
standing in the Palais Royal. Suddenly there came to him an idea. "Why
should I not _try_ to see it?" How must this be done? Why, obviously by
some means of reflection. Then, like a flash, he seemed to see the two
mirrors of the laryngoscope in their respective positions as though
actually before his eyes. He went straight to Charrière, the surgical
instrument maker, asked whether they happened to possess a small mirror
with a long handle, and was at once supplied with a dentist's mirror,
which had been one of the failures of the London Exhibition of 1851. He
bought it for six francs.
Returning home, he placed against the uvula this little piece of glass,
which he had heated with warm water and carefully dried. Then with a
hand-mirror he flashed on to its surface a ray of sunlight. By good
fortune he hit upon the proper angle at the very first attempt. There
before his eyes appeared the glottis, wide open and so fully exposed
that he could see a portion of the trachea. So dumfounded was he that he
sat down aghast for several minutes. On recovering from his amazement he
gazed intently for some time at the changes which were presented to his
vision while the various tones were being emitted. From what he
witnessed it was easy to conclude that his theory, attributing to the
glottis alone the power of engendering sound, was confirmed, and thence
it followed that the different positions taken by the larynx in the
front of the throat had no action whatever in the formation of the
sound. At last he tore himself away, and wrote a description of what he
had seen.
Six months later, on March 22, 1855, his paper, "Physiological
Observations on the Human Voice," was submitted to the Royal Society of
London. In it was set down the scientific thesis of his discovery in
language which would have done credit to expert anatomists and
physiologists.
On May 24 this was read before the Society by Professor Sharpey at a
meeting held under the presidency of Lord Wrottesley, and was duly
published in the 'Proceedings of the Royal Society,' vol. vii.
Investigation shows that primarily it is an account of the oral cavity
and of the physiology of the voice, exemplified by the mechanical
contrivance of the author's own thoughtful invention, actually used in
an autoscopic manner with the idea of elucidating the action of the
larynx during vocal effort.
As far as Garcia was concerned, the laryngoscope ceased to be of any
special use as soon as his first investigations were concluded. By his
examination of the glottis he had had the satisfaction of proving that
all his theories with regard to the emission of the voice were
absolutely correct. Beyond that, he did not see that anything further
was to be gained beyond satisfying the curiosity of those who might be
interested to see for themselves the forms and changes which the inside
of the larynx assumed during singing and speaking. The method of making
scientific use of the voice is due to his discovery and ocular
verification of the action of the vocal cords and of the glottis in the
emission of sound.
As to the subsequent use of the laryngoscope in another sphere of
investigation, and the far-reaching results which are due to it, it was
nearly two years before the possibility of making practical use was
seen. The medical profession was slow to realise what an invaluable
instrument of observation the musician had provided, and at first it was
treated by superior persons as nothing more than a physiological toy; in
fact, as so often happens when a discovery is made by some one not
belonging to the craft, Garcia's communication was originally received
by the doctors with indifference, if not with incredulity.
It might have been expected that the uses to which the instrument could
be put for diseases of the throat would forthwith have been perceived,
and its value as a means of diagnosis appreciated. Yet, but for an
accident, the paper might have lain buried in the dusty tomb of the
'Proceedings' of the Royal Society.
It is generally said that Türck of Vienna, coming by chance across it
two years after the date of its presentation, was inspired to apply the
invention to the examination of the upper air-passages. "This," says the
'British Medical Journal,' "is not accurate. Türck had been working
independently on much the same lines as Garcia, and had even devised a
laryngoscope. He showed the instrument to a friend, who at once informed
him that the invention was not new, and directed his attention to the
paper in question."
Türck continued his experiments for a time; and it was in this year,
1857, that the instrument was actually used for the first time for
diagnostic purposes. He seems, however, to have given up his experiments
later, owing to the want of sunlight in the winter.
Soon after this, Professor J. N. Czermak of Buda-Pesth, another great
physiologist, visited Vienna, and was shown the instrument, in which he
was keenly interested. With it he made the observations which he
published. This fact gave rise to one of those bitter controversies as
to priority, of which the history of science offers so many examples.
The famous dispute had the immediate effect of directing the attention
of the whole world to the laryngoscope. As to the rights of the matter,
it would appear that while there is no doubt that Czermak owed his
knowledge of the method to Türck and indirectly to Garcia, he made the
important modification of substituting artificial illumination for the
uncertain light of the sun.
One thing is certain, and that is that to Czermak belongs the credit of
making known to the world the laryngoscope, and to some extent the
possibilities lying hidden in the little mirror. He visited the
principal medical centres of Europe, and, luckily being gifted with a
capacious and exceptionally tolerant throat, he was able to give
convincing demonstrations of the value of the discovery, and its
scientific and practical possibilities. If Garcia was the founder,
Czermak was the apostle, of laryngology.
As to the demonstrations with the instrument, many amusing incidents
have taken place. Two in particular I remember hearing Garcia relate.
His pupil Charles Battaille, to whom reference has been already made in
an earlier chapter, was most enthusiastic over it, and, having been a
medical student at one time, considered himself well qualified to
demonstrate its virtues. Hearing that the Turkish Ambassador in Paris
was going to give a dinner to the most prominent French inventors of
that time, he obtained permission to show off the uses of the new
exhibit during the evening. After pointing out that it would
revolutionise the scientific study of the throat, he proceeded to force
the instrument down the gullet of an unfortunate Court official who had
barely finished dinner. The result was disastrous.
The other story was a comical experience of a well-known specialist.
Like all very sensitive areas of the human body, the organ of the voice
is sometimes invaded by special symptoms, notably in hysterical
patients.
When the laryngoscope became a speciality, a young lady who for two
whole years had lost all power of articulation was brought up to London
by her mother for advice and treatment. The experienced laryngologist to
whom she was introduced placed her in proper position before his lamp,
while the parent poured out the prolonged tale of affliction. Without
taking any apparent notice of the latter, he placed the mirror in the
girl's throat with the usual request, delivered in a cool and commanding
tone, "Say 'aw,' please"; when the young lady snappishly drew back her
head with, "How can I with that thing in my throat?"--followed by, "Oh,
dear, I've spoken!" The specialist turned at once to the anxious parent,
and told her she might take her daughter home cured,--as she proved to
be.
In the present state of our knowledge of such matters, it is rather
startling to remember that two and a half centuries ago the famous
physician of Norwich, Sir Thomas Brown, thought it a part of his duty,
as an advanced teacher of his contemporaries, to devote a chapter of one
of his books to stating and proving that food and drink did not descend
into the body by two separate tubes. It appears that at that date the
majority of the British public actually believed that, as Nature had
placed two pipes in the neck, solids were transmitted by one and fluids
by the other during the ordinary act of swallowing.
Most people nowadays are aware that the vibrations of the elastic bands,
of which there is one on each side beneath the membrane of the upper
part of the larynx, produce the sounds of the voice by their effect on
the air issuing from the lungs. Certain qualities of tone, and of course
the pitch of a note, are determined by their length and tension, while
the special characteristics which make the voice of each individual
definitely recognisable are due to the varied forms of the several parts
of the throat, nose, mouth, &c., above that level. Again, the "breaking"
of the voice of a boy on reaching the threshold of adolescence is due
to the mechanical effect of the elongation of the elastic bands above
referred to--so-called "vocal cords,"--produced by the forward growth of
the cartilages of the larynx which determine the formation of the
"Adam's apple." All these simple facts were absolute mysteries
previously to the enlightening device of Manuel Garcia.
Though Czermak took up the laryngoscope and added to its general
feasibility by the introduction of artificial light, it still had many
obstacles to overcome, but in this it only shared the common fate of all
innovations. A number of the men who bore the heat of the day in the
early time of storm and stress are still alive, and must rejoice in the
fulness of recognition which their speciality has gained.
Intralaryngeal medication and surgery soon followed the discovery of the
diagnostic properties, and its principles were extended to the
elucidation and treatment of diseases of the parts situated between the
nose and throat.
Professor Osler has told us that if we take the sum of human achievement
in science and the arts, and subtract the work of those above forty,
"while we should miss great treasures, even priceless treasures, we
should practically be where we are to-day." The achievement of Garcia
supplies a striking comment on these hasty words. He was ten years over
the limit fixed by the professor when by his invention he opened up a
new world to scientific exploration. Subtract the laryngoscope from
medicine, and what a gap is left in modern methods of diagnosis and
treatment! Before its invention threw light into places which had been
dark since the birth of the human race, the larynx was an undiscovered
country, and its diseases lay beyond the limits of medical art.
"Had Garcia's work ended when he was forty, we should still not
improbably be powerless to deal with functional aphonia, with laryngeal
growths, with tuberculosis of the larynx, and with many conditions in
the upper air-passages which can now be treated satisfactorily, because
they can be seen. What is more important, we should be without a means
of diagnosis which has proved invaluable in the detection of unsuspected
disease of the brain and in the elucidation of obscure mediastinal
affections. Abductor paralysis of a vocal cord is often the only
appreciable symptom in the early stage of tabes, and it may give the key
to the situation of a growth in the fourth ventricle, the medulla, or
the cerebellum. Faint appearances, discoverable only by laryngosocopy,
may furnish the first indication of pulmonary tuberculosis before any
physical signs are present. The state of the larynx, in fact, is often a
danger-signal to those who can read its meaning. The laryngoscope may
also reveal the presence of an aortic aneurism or a mediastinal tumour.
Its value in medicine is greater than that of the ophthalmoscope,
because its application is wider, and the indications which it supplies
are often more definite."
While touching general medicine at many points, laryngology is also to a
large extent an autonomous territory in the great federation of the
human organism. The extensions of Garcia's discovery which have been
made in so many directions, have given it a field of usefulness vaster
than was dreamt of by those who first applied the laryngoscope to
medicine.
As to the development of the instrument, Manuel Garcia, the discoverer
of the hidden land, attained his results by the most simple means. He
merely placed the little dentist's mirror (previously heated) with a
long handle against the uvula, holding it at an angle of 135 degrees,
and then, by means of an ordinary hand-mirror, flashed a ray of sunlight
upon its surface. Next Czermak and Türck took the matter up, and made
certain improvements in the instrument, substituting artificial light so
as to render it useful independently of the sun. The laryngoscope was
illumined by a concave mirror fastened to the forehead of the observer.
This mirror received the rays of a lamp situated close to the head of
the subject, and focussed their concentrated light on to the
laryngoscope. The position to be given to the patient was definitely
fixed by these workers.
With the advent of electric light fresh perfections were introduced;
while in 1896 Kirstein, of Berlin, discovered a novel method of
laryngeal investigation which led to the establishment by Killian, in
1902, of a new method of "bronchoscopy," which permits of the direct
exploration of the "bronchiæ."
But all these discoveries are only a continuation of that invention
which assures to Garcia a glorious name in the history of medicine.
With the advent of March 17, 1905, which saw not only Manuel Garcia's
hundredth birthday, but the fiftieth anniversary of this discovery, the
acorn which he had planted in the middle of the nineteenth century had
grown to a stately and wide-branching oak-tree. We shall see later, when
we come to the description of this event, how medical representatives
from every part of the world combined to do honour to him as the author
of a most fruitful addition to the resources of medical art and as the
initiator of a great advance in medical science. It must have brought
the centenarian a great and justifiable pride when on that day he looked
on the representatives of the Laryngological societies encircling the
world, who united to call him Father.