Horace Green

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 [1], 2. to perform direct laryngoscopy [3], and 3. to endoscopically resect a laryngeal lesion with the visual control. [3]

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.

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 [1] 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 [36], which was subsequent to Garcia’s presentation of indirect laryngoscopy. [37]

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. [38] 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. [3] 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 [38] 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”. [46]