Horace Green: The Father of American Laryngology and Tracheo-Bronchology
Steven M. Zeitels, MD, FACS
ABEA President 2004-2005
Horace Green (1802-1866) (figure 1) was the first specialized airway physician in the United States and endures as one of the greatest pioneers in American medical history. His life's work was committed to diseases of the pharynx, larynx, and trachea, which are key missions of the American Broncho-Esophagological Association. The founder of our society, Chevalier Jackson (1865-1958), was interested in similar subject matter, which is keenly illustrated by the authors' writing and research. [1-15] Additionally, both physicians were strong advocates of education. [16, 17] Among Green's monumental seminal contributions are that he was the first individual; 1. to directly treat diseased mucosa of the tracheo-bronchial tree , 2. to perform direct laryngoscopy , and 3. to endoscopically resect a laryngeal lesion with the visual control. 
Horace Green was born in Chittenden, Vermont on December 24, 1802. Green's grandfather was a Massachusetts physician, who had four sons that fought in the American Revolution. Green's father was the only son who survived while his three brothers all died in combat. Green was the youngest of four sons and graduated from Castleton Medical College in 1824. In 1830, he attended further lectures at the University of Pennsylvania. After practicing for a few years in Vermont, Green moved to New York City in 1835. He traveled to Europe in 1838 to advance his studies and initiated his investigations in throat diseases upon returning to New York, where he practiced most of his career.
Infectious Airway Obstruction in the Early 19th Century
Descriptions of infectious diseases of the airway date back thousands of years. There have been a wide variety of names including phthisis, cynanche laryngeal, quinsy, laryngeal and pharyngeal angina, diphtheria, tuberculosis, consumption, and croup. From ancient civilizations through the 19th century, tracheotomy, a primary treatment, was seldom done due to skepticism and limited understanding of human physiology and the biology of these diseases. However, in the earlier 1800s, there was a substantial expansion of investigations and reporting on these diseases. Bretonneau (1778-1862) [18, 19], Ryland (1806-1857) , Trousseau (1801-1867) [21-23], and Green [1-5, 7] led this effort. All were focused on surgical intervention of the larynx and trachea to avert the morbid and frequently fatal complications of these diseases, however, Green was substantially more focused on transoral instrumentation with topical administration of caustics to the diseased laryngo-tracheal mucous membranes. (Figure 2)
Possibly the earliest description of endolaryngeal intubation was by Avicenna (980-1037), who bent tubes of gold and silver to cannulate the larynx and trachea for patients with airway distress. In the late 18th century, Desault (1744-1795) [24-27], who was the Surgeon in Chief of the Great Hospital of the Humanity in Paris revived intubation and described passing a nasotracheal tube to secure the airway. He also was skilled in open transcervical operative techniques and is probably the first surgeon to stress the importance of surgeons retaining skill-sets in transoral and open surgical methods. Desault's technique was well known at the time and described in the famous surgical text by Malgaigne (1806-1865). [26, 27] A century later, this philosophy was more firmly established by Solis Cohen who was probably the first surgeon to specialize as a Laryngologist. 
There was a substantial need and interest for novel transoral management of infectious airway diseases in Green's era was due to potentially lethal consequences of these disorders as well as the procedure of tracheotomy. However, the emotions of patient's and clinicians were not surprisingly reflective of the severity of the problem and the frustration of inconsistent treatment outcomes. (see below)
Despite the expanding acceptance and performance of tracheotomy in the 19th century, the procedure continued to be appropriately perceived by most clinicians as a heroic intervention to be done in dire circumstances often when the patient was already in extremis. This was especially so for those attempting tracheotomy in children. Billroth (1829-1894), who successfully performed the first total laryngectomy for cancer , provides a compelling description of tracheotomy in a six year-old child. This individual was one of 12 laryngotomy/tracheotomy procedures that he reported for treating croup in children.  ìThis is the only case in which a patient has ever died immediately under the knife at my hands. It made a great and permanent impression on my mind, and has been to me a most decided warning against ever attempting tracheotomy again when single-handed.
Intraprocedural bleeding was commonplace during tracheotomy due to the thyroid gland and anterior jugular veins. If excessive blood was aspirated into the trachea and/or the patient was exhausted and unable to expectorate ominous circumstances ensued. The surgeon would frequently be required to place a catheter into the airway and clear the trachea by personally suctioning the blood and purulence with his/her own mouth. [23, 27, 30, 31] Even today, thoracic surgeons will similarly pass a flexible bronchoscope to aspirate blood and debris on surgical patients. The majority of patients who underwent tracheotomy died despite the airway procedure because the underlying systemic disease process had not been reversed. [19, 23, 32]
As to be expected, most aspects of this management were considerably more problematic in children. Indwelling tubes were not yet perfected and often became occluded and/or dislodged. Adequate lighting was frequently lacking and suction was not yet unavailable. In fact, casts of blood, and mucopurulent sloughing membrane had to be removed manually from the trachea by removing the tube.
Regardless of whether surgeons adopted a transoral/transnasal approach or tracheotomy to remedy airway obstruction, infectious membranous airway maladies created a medical and surgical imperative to access/treat the diseased mucosa. Profound medical or surgical needs typically catalyze paradigm-changing interventions.  Topical pharmacological agents such as silver nitrate or mercurial compounds were mainstays of treatment in the 19th century and the aforementioned airway interventions also provided a route of administration for delivering these agents. However, these topical agents did not treat the underlying disorder, which is why mortality rates remained high despite frequent successful airway palliation. Despite a range of systemic pharmacological treatment strategies leading to successful management of most infectious airway ailments in the 20th century, aggressive recurrent respiratory papillomatosis remains as a the 21st-century vestige of this era since systemic control remains disappointing.
Green's Transoral Treatment Methods
Green's well understood the ravages of the diseases that he committed his career to treat. His novel approaches to the airway evolved from two clinical imperatives, infectious airway diseases were lethal and tracheotomy was problematic. The high-intensity controversy about transoral versus transcervical intervention for airway obstruction described herein would occur similarly with O'Dwyer [34, 35] 40 years later and remains today in selected clinical scenarios.
In 1840, Green initially presented (New York Medical and Surgical Society) his technique for transoral blind application of therapeutic caustic agents (i.e. silver nitrate) to the laryngeal mucosa. He further recounted in his comprehensive text  that he was reluctant to bring the matter to the society again for a number of years due to the skepticism with which it was received. Visualized mirror-guided applications would not be done for until almost 20 years later , which was subsequent to Garcia's presentation of indirect laryngoscopy. 
As Green pursued, perfected, and championed transoral endolaryngeal administration of topical mucosal treatment for infectious membranous airway diseases of the larynx and pharynx, he advanced the technique to administer the tracheo-bronchial tree. [1-8] He developed reliable methods for blindly instrumenting and cannulating the rima glottis. (figure 1) His approach depended on patient training and sensory accommodation to instrumenting the supraglottic and glottis, which was also typical in the first 25 years of mirror laryngoscopy prior to the introduction of topical cocaine anesthesia.  Two of Green's primary instruments were a whalebone probang with a cotton sponge on the end for direct administration of caustics and a hollow-lumen curved catheter to inject caustics into the airway. (figure 2) The sponge-probang was used to apply the caustic directly and to mechanically remove debris and exudate. The catheter was used to inject compounds directly into the airway, which was then diffused by expectoration.
The reaction to Green's diligent efforts is likely the most striking example of malicious reactions to a key innovation in Laryngological history. [39-41] The ensuing controversy was so dramatic that the New York Academy of Medicine convened a committee to investigate the Green's academic reports and contemporaries claims of incredulity. Remarkably, a detailed account of the affair was reported in the lay-press Harper's weekly in 1859. After methodically perfecting his technique and presenting his data, a number of contemporaries initiated viscous attacks besmirching Green's skill and integrity thereby forcing him to defend himself publicly. A complicated fierce academic battle ensued, which is well beyond the scope of this work. However, Green silenced his critics by demonstrating the technique in patients in whom the cannula could be visualized through a tracheotomy thereby being publicly vindicated.
Green's experience also illustrated selected colleagues' responses to his unique skill sets in performing a difficult technical task. In fact, blind awake laryngeal intubation would be considered extremely difficult maneuver today, even with the advantages of topical anesthesia. More remarkable was the fact that Green also performed the first direct laryngoscopy and visually-controlled endoscopic excision of a laryngeal neoplasm, which was done in a young girl, who had airway obstruction from a ball-valving polyp.  He initially removed her tonsils since she had intermittent cyanosis and obstructive sleep apnea. Green employed a bent-tongue spatula similar to a current-day intubating laryngoscope and likely succeeded due the favorable cephalad position of the child's larynx. This accomplishment would not be repeated for over 40 years until Kirstein [42, 43] utilized topical cocaine  and electricity instead of sunlight for endolaryngeal illumination.
Subsequent indirect and direct methods of endolaryngeal surgery over the past 150 years provided incontrovertible evidence of the authenticity of Green's remarkable skills, validated his claims, and established his contributions as being of the most important in annals of human airway management. Fortunately, Green died in 1866 and received broad acknowledgement of his accomplishments in the last years of his life subsequent to origin of laryngology in 1857. [44, 45] Louis Elsberg, as president at the inaugural meeting of the American Laryngological Association in 1879, recognized Green as the Father of American Laryngology and stated "his methods and his success will forever remain a brilliant monument of his intrepidity, perseverance and skill". 
The events of Horace Green's career illustrate creativity, unique skills, foresight, and perseverance. This story is one of the most remarkable in American medical history and serves as a literal and figural testament to Yankee ingenuity. Jackson, the father of the American Broncho-Esophagological Association, also acknowledged Green's work and was born in the year prior to Green's death.
1. Green, H., A Treatise on Diseases of the Air Passages. 1846, New York: Wiley and Putnam.
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4. Green, H., On the subject of the priority in the medication of the larynx and trachea. American Medical Monthly, 1854. 1: p. 241-257.
5. Green, H., Remarks on Croup and its Treatment. American Medical Monthly, 1854. 1: p. 401-421.
6. Green, H., Bronchial Injections: A Report With a Statistical Table, One Hundred and Six Cases of Pulmonary diseases Treated By Bronchial Injection. The American Medical Monthly, 1856: p. 40.
7. Green, H., Report on the use and effect of applications of nitrate silver to the throat, either in local or general disease. Transactions of the American Medical Association, 1856. 9: p. 493-530.
8. Green, H., On the Difficulties and Advantages of Catheterism of the Air Passages in Diseases of the Chest. The American Medical Monthly, 1860.
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