Sketches Of Otohistory
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5.2.2004
Audiol Neurootol 2004;9:66–71
DOI: 10.1159/000075997
Sketches of Otohistory
Part 1: Otoprehistory: How It All Began
Joseph E. Hawkins
Kresge Hearing Research Institute, University of Michigan, Ann Arbor, Mich., USA
Medical knowledge of the ears and insight into their
that same Greek colony, who was the earliest neuroanat-
diseases came late in history, and clinical progress was
omist, carried out dissections that revealed the cranial
painfully slow. From the earliest times there were folk
nerves. Some have suggested that he may have discovered
remedies for earache and related ailments, but profound
the Eustachian tube, but Politzer in his Geschichte der
deafness was long regarded as a sign of feeble intelligence,
Ohrenheilkunde assures us that he must have been dissect-
and the deaf were thought to be both unteachable and
ing the external ear canal and not the tube when he got the
untreatable. In later years there were ‘aurists’, both ethical
notion that goats breathe through their ears. Alcmaeon
and otherwise, who attempted – or pretended – to treat
believed that hearing occurs when movements of the air
ear diseases, including deafness. It was not until after the
strike the void within the ear, and that deafness is the
middle years of the 19th century that otology became an
result of concussion that shifts the brain and prevents
essential and respected medical specialty.
auditory signals from reaching it.
The inner ear’s small size and surgical inaccessibility
The cochlea was probably discovered by the Sicilian
must have been primarily responsible for medical igno-
philosopher Empedocles, patron of the four elements. At
rance and long neglect, as well as for the lack of fruitful
least he must have been impressed by its form, for he
philosophical interest in hearing and deafness. Even so,
named it after the sea snail, ÎÔ´¯ÏÔ@, the prized source of
the few Egyptian medical papyri that have survived the
the Tyrian purple dye. (He would have known from his
ages suggest that there may have been some physicians of
native Greek that the omicrons in that word were pro-
that era who dealt only with the ears, just as others had
nounced as short o. This knowledge seems lost on the edi-
limited their practice to the eyes. The earliest known
tors of certain modern dictionaries that countenance the
scientific document, the Edwin Smith Surgical Papyrus of
sorely frequent US pronunciation with a long o.) Later
3,000–2,500 BC, includes descriptions of battle injuries to
Greek philosophers, including Diogenes, Plato and Aris-
temporal bones, and how they affected the hearing and
totle, may have thought more deeply, but they had no
speech of the wounded. In the sacred Egyptian pharmaco-
knowledge of ear anatomy. They believed that a resonant
poeia from about 1,500 BC that is known as the Ebers
space in the ear or head was filled with highly purified air.
Papyrus, there is a chapter on ‘Medicines for the Ear with
When it vibrated in response to sound, it gave rise to hear-
Weak Hearing’.
ing, which they regarded as the ‘air sense’. Aristotle’s illu-
Among the Greeks, the first to write of acoustics was
sion of that special air, implanted in the fetus or at birth,
the mathematician Pythagoras, of Croton in southern Ita-
persisted unchallenged until the 18th century, when Co-
ly’s Magna Graecia, who discovered the inverse relation-
tugno demonstrated to the world that the inner ear was
ship between the length of a monochord string and the
entirely filled with a watery fluid.
pitch of the note it produced. The physician Alcmaeon, of
© 2004 S. Karger AG, Basel
Joseph E. Hawkins
ABC
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Kresge Hearing Research Institute
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Tel. +1 734 764 0215, Fax +1 734 764 0014, E-Mail josehawk@umich.edu
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In sickness the Romans depended upon their Greek
He discovered and explored the facial canal or Fallopian
physicians. The acute observations of Hippocrates of the
aqueduct, and, likening the middle ear cavity to a drum,
Aegean island of Cos (450–377 BC) about the symptoms,
he named it the tympanum. In his De morbo gallico he
diagnosis, course and treatment of diseases, including
wrote of the unbearably loud tinnitus that can occur in the
those of the ear, had been faithfully recorded by his disci-
late stage of lues (fig. 1).
ples and reverently handed down. His methods of treat-
Of the followers of Fallopius, the best known is Girola-
ment were almost entirely empirical, and he had scant
mo Fabrizi (Fabricius ab Aquapendente), who gained
knowledge of anatomy of the ear. He was mainly con-
fame and wealth as a surgeon. He published a theory of
cerned with its infections and with their relations to other
hearing that involved the mixing of animal spirits from
organs, including the tonsils and the brain.
the auditory nerve with Aristotle’s implanted air. He
It was only in the first century AD that a Roman medi-
insisted that ear surgery required adequate lighting, with
cal writer, Celsus, described treatments for tinnitus, otitis,
either focused sunlight or candlelight. Fabrizi’s chosen
deafness and foreign bodies in the ear, as well as surgery
successor, Casseri, an early comparative anatomist, re-
for atresia of the external meatus and injuries to the pin-
coded the forms of the auditory ossicles in various animal
na. The Empire’s most famous physician-anatomist and
species. He was also concerned with the human voice, and
most prolific medical author was Galen, a native of Perga-
with tracheotomy as a surgical procedure. Among the
mon, who spent some of his years in Rome caring for the
16th-century Italians there was also Varoli, a neuroana-
health of the philosopher-emperor, Marcus Aurelius. In
tomist of Bologna, whose name is linked with the pons. In
the course of his many dissections of dogs and monkeys,
his brief career he accurately described the stapedius mus-
Galen seems to have taken a cursory look at the inner ear.
cle and likened its action and that of the tensor tympani to
He named it for the Cretan labyrinth, thus admitting his
the role of the iris in protecting the retina against over-
wonder and ignorance of its intricate structure. In fact, his
stimulation.
notions of otoanatomy seem to have been little better than
Anatomical studies of the ear continued in the 17th
those of Hippocrates. Nevertheless, the arbitrary rules he
century, but in the light of new knowledge of its inner
laid down for the treatment of signs and symptoms of dis-
structure there was a growing tendency, especially among
eases, including those of the ear, such as otitis, tinnitus
the French, to speculate about its physiology. Laurant
and hearing loss, were followed religiously for the next 14
denied the importance of the implanted air and empha-
centuries.
sized the role of the ‘fifth’ (i.e. the eighth) cranial nerve in
Little if anything of value or significance was added to
hearing. The architect and physicist Perrault, in his essay
medical knowledge after the fall of Rome. In that sterile
on noise (Du bruit), regarded the ‘spiral membrane’ of the
period, Byzantine physicians upheld, but did not expand,
cochlea as the true organ of audition. It could be shattered
traditional Greek medical knowledge, and much the same
by the strong vibrations of loud noise, and in old age it
can be said for the Arabs and the Jews. It was only in the
could become too dried out to respond to sound. Mery
16th century, after the Renaissance in painting and sculp-
rediscovered Eustachi’s membranous spiral lamina that
ture, that human anatomy came into its own, with such
divided the spiral canal into two scalae and pointed out
dominant figures as Leonardo, Michelangelo, Eustachi,
‘un petit trou’ (a little hole) the cochlear apex, to which
Vesalius, Fallopio and Fabrizi. The ear was by no means
Breschet later gave the name helicotrema.
neglected. Its malleus and incus were discovered by sever-
The most celebrated anatomist during the reign of
al anatomists independently, but Berengario da Carpi was
Louis XIV was Duverney, who was appointed to instruct
apparently the first to note those ossicles. Credit for dis-
the royal family and courtiers in his fashionable science.
covery of the stapes was claimed by several famous anato-
In his elegant small volume, Traité de l’organe de l’ouı¨e,
mists, included Eustachi, Vesalius and Fallopio, but it
he not only presented impressive drawings of his dissec-
seems rightfully to belong to his contemporary, the Sicil-
tions of the inner ear, but affirmed that sound is transmit-
ian Ingrassia. According to Politzer, Eustachi gave the
ted, not by air to the round window, but by the ossicular
first accurate description of the tensor tympani and recog-
chain to the oval window. In proposing a resonance theory
nized the chorda tympani as a nerve and not a blood ves-
of sound analysis by the cochlea, he anticipated Helm-
sel. Of his numerous anatomical discoveries, the only one
holtz. From the gradual narrowing of the osseous spiral
that bears his name is the tube. Fallopio, as surgeon and
lamina from base to apex, he inferred that the base
anatomist, was hailed as the ‘Aesculapius of his century’
responds to the lower frequencies and the apex to the
and brought renown to the Paduan school of medicine.
higher. He could not measure the tapered width of the
Otoprehistory
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Fig. 1. Sixteenth-century Italian anatomists.
Left: Gabriel Fallopius (1523–1562). Right:
Bartholomeo Eustachi (1510–1574). From
Politzer A: Geschichte der Ohrenheilkunde.
Stuttgart, Enke, 1907, vol 1, plates III and
IV.
Fig. 2. British scientists, Elizabethan and
Jacobean. Left: Francis Bacon (1561–1626).
From ‘Portrait of Sir Francis Bacon’, Holl F:
Works of Francis Bacon. London, Spedding,
Ellis, Heath, 1857, vol 1. Right: Thomas
Willis (1621–1675). Portrait by George Ver-
tue; in Birch T: Heads of Illustrious Persons
of Great Britain. London, Knapton, 1742.
basilar membrane, which shows the exact opposite to be
Bacon, and the Oxford physician and founder of neurolo-
true.
gy, Thomas Willis (fig. 2). Bacon wrote about hearing and
In Elizabethan and Stuart England there were two
speech, and numerous other acoustic phenomena, includ-
noteworthy contributors to auditory studies, the court
ing the injurious effect of intense sound. He mentioned a
philosopher and alleged author of Shakespeare, Francis
Spanish auditory instrument, perhaps the first hearing
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Hawkins
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Fig. 3. A tribute to Valsalva. Left: Engraving
from his posthumously published Tractatus
de aure humana, Bologna, 1740. Right: Put-
to with knife and well-dissected ear.
aid, ‘that helpeth somewhat those that are thick of hear-
Of Morgagni’s 20 Epistolae anatomicae, 7 were con-
ing’. Unfortunately, he never got around to writing the
cerned with the ear. One described the minor effect on
volume on audition and acoustics that he promised to his
hearing of experimental perforation of the tympanic
readers. Willis was the first to recognize that the cochlea
membrane in a dog. In his monumental work of patholo-
was the true organ of hearing. He pointed out that dipla-
gy, De causis et sedibus morborum, he considered the rela-
cusis was possible, and also wrote of the phenomenon of
tion between otitis media and brain abscess, concluding,
‘paracusis’, whereby some hard-of-hearing patients hear
in opposition to so many of his contemporaries, that the
better in noise than in quiet. Furthermore, he suggested a
otitis was primary, the brain abscess its secondary effect.
theoretical distribution of high and low frequencies in the
Credit for the discovery of the liquids filling the inner
cochlea, even before Duverney.
ear also belongs to the Italians, to Cotugno of Naples
Otological studies in the 18th century were dominated
(fig. 4) for the perilymph and to Scarpa of Modena and
by the Italians, primarily from Bologna. The first of them
Pavia (fig. 5) for the endolymph. At the age of 24, while
was Valsalva (fig. 3), a pupil of the histologist Malpighi.
still a student, Cotugno published his epoch-making De
Valsalva’s Tractatus de aure humana, published after his
acquaeductibus auris humanae... His impressive later
death by his follower and former prosector, the patholo-
contributions were made in other fields of medicine. Scar-
gist Morgagni, was based on 16 years of work, in dissect-
pa’s Disquisitiones anatomicae de auditu et olfactu tells of
ing more than a thousand human heads. One section of its
his discovery of the membranous labyrinth with its ‘spiral
text was anatomical, the other physiological. In one case
passage’ (the cochlear duct), containing a watery fluid, the
of deafness he demonstrated disarticulation of the incu-
endolymph. He also traced the course of the branches of
do-stapedial joint, and in another, ankylosis of the stapes.
the auditory nerve to their various sites of ending in the
Unlike his predecessors, he located the terminations of
labyrinth, of course never suspecting that almost half of
the auditory nerve in the membranous portion of the laby-
them were concerned with a sense quite different from
rinth rather than in the osseous spiral lamina and referred
hearing.
to them as sound receptors, comparable with harps having
By the early years of the 19th century, knowledge of the
strings of different lengths. Thus, Valsalva may also be
gross anatomy of the inner ear was well established, and
said to have anticipated Helmholtz.
physiology was beginning to be based on experiment rath-
Otoprehistory
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Fig. 4. Italian finders of the inner ear flu-
ids. Left: Domenico Cotugno (1736–1822).
Right: Antonio Scarpa (1752–1832). From
Politzer A: Geschichte der Ohrenheilkunde.
Stuttgart, Enke, 1907, vol 1, plates XV and
XVI.
Fig. 5. Parisian otoanatomist and Viennese
otologist. Left: Gilbert Breschet (1784–
1845). Lithograph by Grégoir et Deneux af-
ter A. Maurir, edited by Rosselin, Paris.
Right: Adam Politzer (1835–1920). Undated
photo by Angerer. From Majer EH, Skopec
M: Zur Geschichte der Oto-Rhino-Laryngo-
logie in Österreich. Vienna, Brandstätter,
1985. Reproduced with permission by Insti-
tut für Geschichte der Medizin, Wien.
er than imagination. Breschet of Paris (fig. 5), with his
pils, including Helmholtz. Müller was interested in all
Recherches anatomiques et physiologiques sur l’organe de
aspects of sensation, including hearing, and he was the
l’ouı¨e, brought order into otoanatomical nomenclature, in
first to make an experimental study of the passage of
imitation of Carl von Linné’s monumental service to bio-
sound waves from air to water. Among contemporary
logical taxonomy. Breschet insisted upon precision in the
anatomists was Rosenthal of Greifswald, whose dissec-
definitions of older terms and coined welcome new
tions revealed the modiolar canal that contains the spiral
names, such as helicotrema, endolymph, perilymph, oto-
ganglion and still bears his name. Huschke of Jena discov-
lith and otoconia.
ered the zona dentata of the limbus when he examined the
In Germany the pioneer of experimental physiology
inner ears of birds. He thought that he had found the true
was Johannes Müller of Berlin, who attracted many pu-
endings of the auditory nerve fibers. That triumph was
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left for Corti, whose teacher, Hyrtl of Vienna, used the
public respect for their chosen medical field, were deter-
corrosion technique to study the blood vessels of the ear.
mined to rehabilitate it by the reforms that it so desperate-
Despite this upsurge of research activity, the practice
ly needed. Their devoted labors were soon to begin in the
of aural medicine and surgery languished for years, domi-
British Isles.
nated and misdirected by the edicts of a German autodi-
dact named Kramer, who insisted upon the rightness of
his not infrequently wrongheaded clinical convictions and
Acknowledgment
the futility of further anatomical and pathological investi-
The most thorough and reliable account of the origins of otology,
gation. Many aurists, both in Britain and on the Conti-
from its very beginnings until the early years of the 20th century, was
nent, were far worse: either unskilled incompetents with
offered by Politzer in figure 6 in the first volume of his Geschichte der
virtually no training or outright quacks and charlatans. In
Ohrenheilkunde (1907; an English translation was published in
a letter to Covington in 1859, Charles Darwin expresses
1981). His Geschichte was the major source used by this writer for the
regrets over his friend’s deafness, but advises him that
chapter, ‘Auditory Physiological History: A Surface View’, that
appeared in Jahn and Santos Sacchi’s Physiology of the Ear (1988,
aurists are humbugs. A few conscientious practitioners,
2001). The information presented here is based on those sources.
fully aware of the almost total absence of professional or
Otoprehistory
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