[From Schenckius: Observationinn Medicarum, Francofurti, 1609.] ANNALS OF MEDICAL HISTORY New Seri es , Volume VIII January , 1936 Number 1 DOMENICO COTUGNO

By ABRAHAM LEVINSON, M.D.

CHICAGO

EW indeed are the ology. Above all. he was the first to de- persons blessed scribe the existence of cerebrospinal with the ability to fluid in living animals. rise above the ordi- Just as great as his individual discov- nary level of life to eries was his understanding of some of make some discov- the principles of medical research ery of importance. which at times assumed the proportions Even rarer are those who bestow more of philosophic concepts. Similarly out- than one discovery upon mankind. To standing was his interpretation of facts. this select latter group belongs Domen- He was the first to realize that in order ico Cotugno, the great Italian anatomist to understand what is happening in the of the eighteenth century (Fig. 1) . • human body, dissection of the body Had Cotugno discovered only the must be done soon after death, else the aqueducts of the ear. his name would body fluids will be absorbed or altered. have gone down in history as a great He was one of the first, if not the first, anatomist; however, he made a number to formulate a theory on the physiology of other discoveries, each of which is of hearing. In this respect he was more monumental. In conjunction with his than an anatomist; he was a physiologist discovery of the aural aqueducts, he as well. found that the labyrinth is filled with In addition to his medical discover- fluid, and not with air. Simultaneously ies, Cotugno was interested in the socio- with Scarpa, he discovered the nasopal- logic phase of medicine and advocated atine nerve. His description of sciatica measures for the prevention of con- is classic. He was the first to describe tagion in tuberculosis which later re- intestinal ulcers in typhoid fever and sulted in the passage of a law to that pustules in smallpox. He was one of the effect in Italy. first to describe acute nephritis with His conception of electricity is said urine that precipitated on boiling. He to have been of great assistance in the contributed to our knowledge of cardi- discovery of galvanism. Biograp hic Data Cotugno was a practicing physician and Domenico Cotugno was born at was also royal physician. Ruvo, in the province of Bari, near the Cotugno died October 6, 1822. He bequeathed about 100,000 ducats to the poor of the Hospital for Incurables at Naples.

Predeces sors and Contemporarie s Cotugno was fortunate in having been preceded by men who laid the foundation for pathologic anatomy in general and for the study of the ear in particular. At the time of Cotugno’s birth, Giovanni Battista Morgagni (1682-1771) was establishing the study of pathologic anatomy at Padua and Cotugno later studied under this great master. Cotugno also benefited from the work of Joseph Duverney (1648- 1730) and of Antonio Valsalva (1666- 1723), both of whom did a great deal of original work on the anatomy of the ear. Cotugno also learned from Gerhard van Swieten (1700-72), the disciple of Palatinate, on January 29 (December Boerhaave and the founder of the Vien- 3, according to one historian), 1736. nese school of medicine. Although van One biographer writes that Cotugno’s Swieten made no fundamental discov- father spared nothing in order that his eries, he was a great clinician and or- son might be given a good education; ganizer and served as inspiration to another commentator states that his many men, among whom was Cotugno. father was so miserably poor, that Co- Cotugno’s admiration for van Swieten tugno was known as the Neapolitan was based mainly on the latter’s knowl- beggar. edge of, and high regard for, anatomy. Cotugno was a diligent student. It was It was this latter fact that moved Co- said that he could speak Latin fluently tugno to dedicate his “De ischiade when he was only nine years old. He nervosa commentarius” to van Swieten, studied medicine at Naples, and when as is seen in the following excerpt from but eighteen years of age became phy- the dedication1: sician to the Hospital for Incurables at 1 The quotations from “De ischiade ner- Naples. At the age of twenty (twenty- vosa commentarius” are taken from a copy of three, according to some accounts), he the English translation of the book, owned was appointed to the chair of surgery at by the Surgeon General’s Library, Washing- the hospital, and at the age of thirty ton, D. C. Thanks are due the Librarian, was chosen professor of surgery and Mr. Toepper, for permission to make a photostatic copy of the book, whose English anatomy at the University of Naples, a title is “A Treatise on the Nervous Sciatica position he held until his death. In ad- of Nervous Hip Gout”; it was translated by dition to his professorial appointments. Henry Crantz, London, 1775. . . . that, whilst I am encouraging ologist who came very near being a young men, by no trilling examples, to rival of Cotugno in the discovery of pursue the study of Anatomy, and promis- cerebrospinal fluid. Haller describes ing them that no small advantages may be reaped from it in the practice of Physic, they should look up to you as a Medical Luminary, in which they may see a nota- ble example of that most consummate knowledge in art, accumulated chiefly from a perfect acquaintance with the con- stitution of the human frame.

Further proof of Cotugno’s admira- tion for van Swieten is contained in the closing paragraph of “De ischiade,” in which Cotugno says: Such are the observations, illustrious Swieten! on the Nervous Sciatica, which I have addressed to you: where, in respect to the greatness of the subject, I may, per- haps, appear to have been inelegantly and lamely concise; but in respect to the diffi- culty of treating a matter entirely new (which would not be an easy work for men of the brightest genius, much less so for me, who have no abilities to boast) I Cotugno as a “brilliant man, keen and may seem to have said more than enough. In this untrodden and unbeaten path, I shrewd in the most detailed investiga- have walked without a guide or compan- tion.” ion. At my own peril I was to penetrate these unknown regions, and travel boldly Discov ery of the Aqued uct s of the Ear to draw out truth from obscurity. I hope AND OF THE LABYRINTHINE FLUID these learned men, whose understandings When barely twenty-five years old are better supplied than mine, with assist- (1760), Cotugno published his work ance to undergo this toil, will make up entitled “l)e aqueductibus auris hu- the deficiencies of these remarks, which manae internae anatomica dissertation” are certainly not few; and will illustrate (Naples, 1760, 1761; Venice, 1764; such things as I have not sufficiently ex- plained. I shall look upon myself as amply Vienna, 17(14). (Fig. 2.) recompensed, if what I have here ottered In this book, the author describes the should incite men of abilities to give the cochlear and vestibular aqueducts, dis- public their own observations. This, il- cussing their importance in the trans- lustrious Swieten! I think, is chiefly to be mission and drainage of the labyrin- expected from you, when you finish what thine fluid, which, he found, filled the I impatiently expect, your immortal Com- entire labyrinthine cavity. mentaries on Boerhaave. Although Duverney, Valsalva, and Of Cotugno’s contemporaries, the Morgagni had previously spoken of the outstanding name is that of Albrecht moistness of the labyrinth, they did not von Haller (1707-//), the great physi- know that it was filled with fluid; Co- tugno was therefore the first to assert Discov ery of the Nasop alati ne Nerve that it was. According to him, the older Cotugno discovered the nasopalatine anatomists had failed to discover the nerve in 1761. Scarpa, however, had discovered this nerve at the same time as Cotugno, or perhaps even before him, so that the credit for this discovery is usually given to Scarpa. Cotugno’s investigations, however, were made without his being in the least ac- quainted with those of the Pavian pro- fessor.

Descrip tion of Scia tic a In 1764 Cotugno published his “De ischiade nervosa commentarius,” which is to this day one of the most important contributions to our knowledge of the neuralgias. (Figs. 3 and 4.) Cotugno distinguishes two types of sciatica, one in which the pain is fixed in the hip and extends no farther, and the other in which the pain “runs along in a track, as it were, and is propagated even down the foot on the same side.’’ l he sciatica which is localized to the hip he terms arthritic sciatica, the other, nervous sciatica; it is nervous sci- atica to which his book is devoted. Cotugno divides nervous sciatica into two types, posterior and anterior, de- pending upon whether the pain is along the posterior or anterior portion of the leg. The pain accompanying the sciatica he characterizes as either continual or fluid because they had worked on old intermittent. He presents an accurate cadavers. The source of the labyrin- description of the symptomatology of thine fluid, according to Cotugno, was the disease. an exhalation from the blood vessels. The cause of sciatica he attributes to The function of the labyrinthine fluid, a distention of the “vaginae” of the he claimed, was to protect the nerves ischiadic nerves. It is in this connection that might become injured by constant that he presents a lengthy description contact with bony structures. of cerebrospinal fluid and its location. In addition to the aqueducts, Co- The remedies for sciatica given by tugno described many other structures Cotugno are as follows: of the ear. He also described the ear of Bloodletting, which always relieves the fetus and of the newborn infant. the patient and may cure him entirely. Emetics and purging, which may also betes. It is therefore, in the first place, relieve the sciatica completely. evident, that urine, which is never coagu- If the disease is of long standing, he lable in healthy people, in particular cases advises friction of the affected leg. Also recommended are electricity, and opium for pain. Finally, he uses perforation of the vaginae of the posterior ischiadic nerve in posterior nervous sciatica. This is done at the head of the fibula, the bot- tom of the tibia and the back of the foot, places deprived of muscles and covered only with tegument. This per- foration can be accomplished by pro- ducing a blister on the skin in these places (Fig. 5).

Descri pti on of Album inuri a Sixty-two years before Bright’s work on nephritis and long before Wells (1811) and Blackwall (1813) wrote on dropsy and albuminuria. Cotugno, in 1764. described a case of acute nephritis with a heat-coagulable substance in the urine. Only Frederik Dekker, in 1694, had preceded Cotugno in describing the effect of heat and acetic acid on cer- tain types of urine. Cotugno describes dropsy in a twenty-eight year old sol- dier, and then tells how he coagulates the urine: This was proved, experimentally, to be as I imagined; for, on placing two pints of the urine over the fire, when one half was evaporated, the other formed itself into a white mass, like the soft white of an egg may be proved to be so experimentally. when boiled. This experiment was re- Dis covery of Cerebro spina l Fluid peated until the flux of urine stopped; and my pupils, who were present at the The presence of cerebrospinal fluid first experiment, proved the same thing in hydrocephalus was known to the by repeated experiments. Nor have I early Greek and Roman physicians. found this matter, which coagulates at the The credit for the discovery of cere- fire, in the increased urine of dropsical brospinal fluid in normal animals persons alone; but (though not in so con- should, however, go to Cotugno. Some siderable a degree) even in the urine of authors credit Albrecht von Haller such as have been troubled with a Dia- with this discovery, but a study of Hal- ler’s writings shows that he considered absorbing water from the ventricles, they cerebrospinal fluid a vapor during life, are not supported by any anatomic dem- as is evident from the following excerpt onstration; which makes it probable that the vapor, which is secreted into the ven- tricles of a healthy person, is, in like pro- portion, absorbed again by the inhaling veins; and that if there be any excess, it descends through the bottom of the ven- tricles to the spinal marrow. That this is the case, appears from the palsies, which ensue after apoplexies and from the watery tumors in the lower part of the spinal marrow, in hydrocephalic patients. Cotugno’s description, on the other hand, shows that he knew that cerebro- spinal fluid is a liquid and not a vapor: But also, all that space which is between the Vagina of the Dura Mater, and the spinal marrow, is always found to be filled, not as some eminent men imagine (because the fact is as yet immersed in obscurity) by the marrow itself, which is more full in the living, than in dead sub- jects, nor by a thick vapour; but with water, like that which the Pericardium contains about the heart; or such as fills the hollows of the ventricles of the brain, the labyrinth of the ear, or other cavities of the body, which are impervious to the air. Cotugno ascribes the failure of ear- lier investigators to observe and study the cerebrospinal fluid to their faulty dissection technique: The reason that anatomists have never yet observed this collection of water about the brain, and in the spine, is owing to the common preposterous method of dis- secting; for, when they are about to exam- ine the brain, they commonly cut off the head from the neck; by this means the tube of the Dura Mater, which descends by the spine of the neck, being cut from his works: through, all the water that is collected As for the various accounts which are about the brain, and the spinal marrow, given of the pituitary glands, of the in- flows out, and is foolishly lost; so that, fundibulum and of the ducts which lead when the skull is opened, all the spaces from thence into the veins of the head, between the brain and the Dura Mater, which were before tilled with water, are immediately after death (and especially in now found empty; and deceive the anat- the sea-tortoise of about fifteen pounds omist with the appearance of empty cavi- weight) I have found the brain to be very ties, which, perhaps, some dissipable va- small, in proportion to the skull, and a pour filled. Here then, nothing scarce at considerable space remaining on the in- all is to be found, either in the cavities at side between them; and it appeared that the base of the skull, or in the chief vagi- all this space was filled with water all nal sinus’s of the Dura Mater, to prove around the Medulla Spinalis, which took that they were occupied before by some up the other part of space remaining. But fluid. So that, by this irrational method of 1 did not find it to be the same in living dissecting, all the Hu id collected around dogs, or flying fowls, as the brain and the marrow and brain being lost, air en- spinal marrow here were so large, whether ters in, and supplies its place. This is the the subjects were alive or dead, that the reason, that, in examining the brain, we cavity in which they were contained, was find a number of little bubbles of air, entirely filled up. But though these ani- under the Membrana Araclmoides, on the mals were not so proper to prove the ex- top of the Sulci or furrows of the brain. istence of the fluid, yet they exhibit a cleat- The number, indeed, is greater, or less, in proof that the brain and spinal marrow different subjects, according to the greater are not diminished in their size by death. or less distance or partition of the Pia, and Although there are some who imagine the Araclmoides membrane. To these par- that the spinal marrow is larger in life, titions there is an open passage, where the and that it is sufficient of itself to fill up Araclmoides, in its descent to the spine, all the surrounding space, they ought, makes its greatest recession from a contact however, to take notice, that the branches with the Pia Mater; through this passage, of the nerves, proceeding from the spinal on cutting off the head, as the fluid of the marrow, which in a dead body run along Sulci flows out, the air rushes in and oc- that space unfolded, wotdd, by their sup- cupies its room. Therefore, in those heads position, be entangled, and compressed in which I have carefully opened, without a living subject. All that space, therefore, separating them from the trunk, I never which is around the spinal marrow, is found these little bubbles of air under the filled with water naturally, and in this re- Arachnoides. spect, a dead body varies little, or nothing from a living one. Cotugno describes a method of dis- section by means of which he was able Of unusual interest is Cotugno’s to collect, in each of twenty cases, be- statement concerning the color of the tween 4 and 5 ounces of cerebrospinal cerebrospinal fluid in newborn infants fluid. who had been strangled during difficult To settle the question whether cere- labor. . but in foetus’s strangled brospinal fluid exists during life in ani- in difficult labor, little as it [the cere- mals, or whether it exists only post brospinal fluid] was, I observed it to be mortem, Cotugno performed a number always red, and opake.” The changes in of dissections, in which he found the the cerebrospinal fluid were un- former to be true: doubtedly due to cerebral hemorrhage. But besides, the dissection of some liv- Additional Contributio ns ing animals confirms me in my opinion, that this water which we doubt of, is also In addition to his numerous discov- to be found in a living man; for in those eries, Cotugno made many observations fishes which I have dissected when alive or that were verified by others. He saw in- testinal ulcers in typhoid fever, and life, he was probably the first to point pustules in smallpox. He also made out the changes that body fluids numerous observations in connection undergo after death, and to stress the necessity of examining the body im- mediately after death. He emphasized this fact particularly in connection with the labyrinthine fluid, explaining the failure of earlier investigators to find fluid in dead bodies as due to the fact that they worked on old cadavers. To prove his contention about the existence of cerebrospinal fluid, he worked on living animals, thus being one of the first experimental physiol- ogists. His physiologic conceptions not only led him to the discovery of cere- brospinal fluid, but also to the formula- tion of one of the first, if not the first, theory on the physiology of hearing. Cotugno’s chief contributions to medicine may be summarized as fol- lows:

Discovery of the cochlear and vestibular aqueducts of the ear Discovery of the presence of fluid in the labyrinth Discovery of the importance of the aqueducts for the drainage of the laby- rinthine fluid Formulation of the theory on the physi- ology of hearing with the human heart. In addition, he Description of sciatica made observations on animal electric- Research in animal electricity ity. Although he did not know the eti- Description of a case of nephritis and ology of tuberculosis, he claimed that it coagulation of the urine on boiling was contagious and advocated a law for Observation of intestinal ulcers in ty- the prevention of the spread of the phoid fever and pustules in smallpox disease. Contribution to cardiology Physiologi c Concep tions Finally, discovery of cerebrospinal fluid in living animals. With the development of physiology, it has become clear that post mortem Works of Domeni co Cotug no examination does not always reflect the De aqueductibus auris humanae internae. state of the human body during life, Naples, 1760, 1761; Venice, 1764; especially as far as the body fluids are Vienna, 1774. concerned. While Cotugno did not De ischiade nervosa commentarius. Naples, work with body fluids in man during 1764, 1779; Vienna, 1770. A Treatise of the Nervous Sciatica, or Nerv- Gradenigo , G. Domenico Cotugno e la teoria ous Hip Gout. Trans, by Henry Crantz, sulla audizione. Gior. d. r. Accad. di London, 1775. med. di Torino, 24:240, 1918. De sedibus variolarum. Naples, 1769; Vienna, Riforma med., Napoli, 24:671, 1918. 1771, 1786. I.ancet. Editorial. Ed. 3, 2:476, 1823-1824. Dello spirito della medicina, discorso. Major . R. Classic Descriptions in Medicine. Firenze, 1775. Springfield. Thomas, 1932. Alcuni scritti inediti. Pisa, 1890. Messe dagi .ia , L. “1/ Iter Italicum Pata- vinum” di D. Cotugno: G. B. Morgagni e l’Universita di Padova nel 1765. Atti r. Books and Article s on Domeni co Cotugno 1st. Veneto di sc., left, ed arti, 73:1691- 1803, 1913-1914. Barduzzi , D. Cotugno, non Helmholtz fu Mongardi , R. Da Cotugno a Helmholtz. l’ideatore della teoria sull’audizione. Arch. ital. di otol., Torino, 22:393-400, Riv. di storia crit. d. sc. med. e nat., 1 9 1 1. Siena, pp. 143-145. Pace , D. Cotugno’s contributions in the field Bianchi , L. Domenico Cotugno, 1736-1822. of cardiology: ancient and modern con- Riforma med., 39:1, 1923. ceptions on pathology of venous circula- Bilancioni , G. Lettere inedite di Domenico tion. Gazz. internaz. med.-chir., 41:204 Cotugno. Arch. ital. di otol. Torino. (April 15); 241 (April 30) 1933. 25:2s1; 5°8- '9'4; 26:47, 1915. Politzer , A. Geschichte der Ohrenheil- Capp aroni , P. Profili bio-bibliografici di kunde. Stuttgart, 1907-1913, Vol. 1. medici e naturalisti celebri italiani dal Vui .pe s , B. Per la solenne inaugurazione del sec. xv° al sec. xviii°. Roma, 1932, 1:97. busto in manno di Domenico Cotugno Dock , W. Some early observers of albumi- nell’ ospedale degl’ incurabili di Napoli. nuria. Ann . AIed . Hist ., 4:287, 1922. Napoli. 1824. Fig. 6.