The History of Otolaryngology From Ancient to Modern Times

EMMANUEL S. HELIDONIS, MD, FACS

The history of medicine is the history of and (7) the modern period (19th and 20th cen- man himself. Prehistoric man was prone to turies) . regard disease as an evil spirit or the work of such a spirit. It is impossible to know how the THE FOLKLORE OF OTOLARYNGOLOGY man of the Neolithic period (10,000to 4000 A great number of fascinating references BC) faced different diseases. However by with regard to ear, nose, and throat diseases studying discovered bones, it was found that are found among different people. Folklore he knew how to immobilize fractured bones. remedies which have been used since ancient In all primitive societies priest, magician, times are in use even today. Vegetables, fruits, and physician were one and the same, and the juices of plants and snails, and the urine of medicine was practiced in a way we call today bulls and humans have been used for treating folk medicine.’ Scientific medicine devel- numerous disorders of the head and neck oped from this folk and magic medicine. area. In northern Greece in remote villages, Medicine as a scientific system began as a acute otitis media is still treated by dropping Mediterranean phenomenon, whereas the de- human urine into the ear canal, and in west- velopment of a rational, scientific concept of ern Bohemia nasal catarrh is treated by having disease not as a demon or something inside the patient inhale a child’s warm urine. For the body, but as altered physiology, is essen- treating diseases of the throat, folklore reme- tially modern. This turn of mind is believed to dies include the use of the juice of crabs, the date from the middle of the 16th century with ashes of a burnt swallow, cabbage, nettles, gar- Claude Bernard. lic, sorrel, and injection of butter boiled with Otolaryngology followed closely the path of honey. In Morocco on the 25th of March rain medicine. The oldest traces of information re- water is collected to be used for curing dis- garding ear, nose, and throat diseases are to be eases of the ear and nose. For treating epistax- found in folk medicine, which is probably the is several remedies have been also used oldest form of medical practice and was per- among different people, including cold water petuated by speech rather than by writing.’ and vinegar or salt applied to the forehead of The history of otolaryngology can be classi- hands and feet,’ various prayers, the use of fied into the following periods: (1) what has the patient’s own blood to write the words come down to us through the ages by way of “consummatum est” on his forehead,3 frying legends and folk medicine; (2) information one’s own blood and applying it a snuff ,4 and from the prehistoric age (before 4000 BC); (3) various plant and animal products. the Egyptian, Minoan, and Chinese periods; The ear as an organ of reproduction is found (4) the Greek and Hindu periods; (51 the Ro- in Indian, Mongolian, and Persian legends man, Byzantine, and Arabic periods; (6) the and also in the writings of Rabelais and Mo- Middle Ages and the Renaissance periods; liere.’ The size and shape of the ear was sup- posed to determine the character of the indi- viduals Small ears denoted high mental abil- From the Department of Otolaryngology, University of Crete, Heraklion, Crete, Greece. ity and large ears indicated dullness. Also, Address reprint requests to Emmanual S. Helidonis, large noses were connected with the sexual MD, FACS, Department of Otolaryngology, University of organs and there was thought to be a relation- Crete, PO Box 1218, Heraklion 71110, Crete, Greece. Copyright 0 1993 by W.B. Saunders Company ship between the size of the nose and the size 0198-0709193/1408-0002$5.00/O of the penis.5

382 American Journal of Otolaryngology, Vol 14, No 8 (November-December), 1993: pp 382-393 HISTORY OF OTOLARYNGOLOGY FROM ANCIENT TIMES 383

EGYPTIAN, CHINESE, AND crushing injuries of the neck, deafness and the MINOAN OTOLARYNGOLOGY loss of speech is mentioned. Hyperacusis also is described, which accompanies fractures of The oldest historic phase of medicine the temporal bone. In Smith’s papyrus frac- known to us is that of ancient Egypt. Egypt ture of the nasal septum is presented as the came second only to Mesopotamia in achiev- cause of disfigurement and epistaxis, which is ing civilization, around 2700 BC.~ Our main prevented by nasal packing. Besides trauma, sources of knowledge of Egyptian otolaryngol- infections are also discussed along with their ogy are the medical papyri, the well-splinted treatment. fractures of the Fifth Dynasty (2750-2625 BC), Emery described two tablets dating from the and certain pictures engraved on the door- beginning of the dynastic period, one belong- posts of a tomb in the burial ground near ing to Aha and the other to Djer.’ They show Memphis (2500 BC).~ Egyptian medicine is re- a person sitting and directing a sharp instru- flected in the papyri of Ebers, Kahoun, Hearst, ment towards the neck of a kneeling person. and others, and it is a mixture of magic and Vikentieff believes that this was a magical cer- important elements of pharmacology and emony tracheotomy meant to insufflate life anatomy. into the aged king9 (Fig 1). Egyptian medicine A considerable number of names and biog- also developed fields of specialization. Hero- raphies of ancient Egyptian physicians are dotus, in regard to the practice of medicine in known. The earliest physician was Sekhet’ Egypt, writes, “Each physician is a (specialist) enanch who lived about 3500 BC and of whom in one illness and in no more . . . some are set it is said that “he healed the king’s nos- as Ophthalmologists other as (physicians) of trils.“‘v3 The most famous is Imhotep who the middle body cavities, and other of Internal lived around 2800 BC. He was the prime min- illnesses.“” ister of the Pharaoh Djeser of the Third Mem- Egyptians seemed to understand well the phite Dynasty (before the ancient empire). He anatomy of the nose and its relationship to the was later adored and believed to be a descen- bases of the skull and brain. Herodotus de- dant of the god Ptah himself. scribes in detail the technique for mummifi- In Eb (854~) it is written that the deaf man cation practiced by the Egyptians: “As much cannot open his mouth, and in Eb (418) nasal as possible of the brain is extracted through cattarh is mentioned. For its treatment, the the nostrils with an iron hook, and what the milk of a woman who has a male child is hook cannot reach is rinsed out with drugs. mixed with an odiferous glue and this mixture The drawback lays in the fact, that the nasal is then inserted into the nose for the treatment septum, was destroyed which resulted in a of rhinorrhea. Surgery of the ears is also dis- slight flattening of the nose.“” cussed and several recipes are described During almost the same period as ancient many times in other undeciphered languages. Egypt the island of Crete made more rapid One of them, Eb (422), is a magig formula progress towards civilization. It is through the which is pronounced in the ancient language well-documented contacts with Egyptian his- of Kjtj, spoken by the people from the island of Crete. The Ebers papyrus, with extensive sections on the ear,7 was obtained by George Ebers at Thebes in 1872, and is dated to about 1550 BC. However the most valuable medical papyrus is that acquired by Edwin Smith (1722-1906) at Thebes in 1862. rm In Edwin Smith’s papyrus (1600 BC) are written 48 cases of clinical surgery covering, among others, injuries to the head, nose, and 7-mI temporal bone. Deafness is mentioned as re- Fig 1. Plaque illustrating a tracheotomy? (Courtesy of Cairo lated to fracture of the temporal bone. In Museum.) ?T 384 EMMANUEL S. HELIDONIS

tory that the cultural sequence of Crete can be so closely dated. Crete is indeed first men- tioned in records of the middle kingdom un- der the name of Keftiu, biblical Caphtor.’ Egyptian and Cretan culture no doubt evolved at approximately the same time and attained great heights. But their ideas did not cross- fertilize. Both countries were completely sep- arated and only in later times were some trade relations established.ll The 300 years preceding 1450 BC marked the zenith of Minoan civilization. Crete was densely populated. It was Homer’s rich and Fig 2. Kidney-shaped ceramic resembling an emesis basin of lovely land, boasting ninety cities.” The unknown use. (Courtesy of Heraklion Museum.) records of the Minoan civilization show that health matters were of the utmost importance. Minoans believed in two goddesses who were her attention to the healing of the particular directly related to medicine: the curing god- anatomic structure or to express gratitude for dess or “Poppy Goddess” (Sakelarakis),13 and her help in hea1ing.l” the fertility goddess who was worshiped in The following interesting items relating to the caves of Lithia and Inattos. Knowledge of otolaryngologic diseases are found in the Her- Minoan medicine comes mainly from study- aklion Museum (Crete]: an ivory idol sugges- ing frescoes, idols, sculpture, instruments, tive of hemilateral facial paralysis (2500-2000 and various written documents. Doro Levi, an BC; Fig 31, an idol showing a left lateral neck Italian archeologist, says the following about the anatomic details of Minoan sculpture. “On the harvester’s vase the profile of the fig- ures is pictured. The faces are clear. . . . The nose the nostrils and the mastoid processes behind the ears are well shown. At the neck the sternocleidomastoid muscles are shown, as well as, the depression between these and the projection of the larynx.“l* Instruments such as forceps, scalpels, big lacy forcep dilators, etc, believed to be used for medical purposes, were found in tomb K in Nafplia. Also a kidney-shaped ceramic re- sembling an emesis basin has been found by Sakelarakis (Fig 2). Egyptians held Cretan doctors in high esteem, and in written Egyp- tian documents there are references to Minoan exorcisms for medical prescriptions.15 By studying the grounds where the Minoans used to practice their religious rites one gath- ers that aside from the caves, the altars, the private sanctuaries, and the places of worship in palaces, the faithful used to climb on the tops of mountains to invoke the great god- desses’ help. Usual excavation finds on all peak sanctuaries are clay figurines portraying human structures deformed by disease. The Fig 3. Ivory idol showing an assymetry of the left side of the figurines were offered to the goddess to attract face. ICourtesy of Hersklion Museum.) HISTORY OF OTOLARYNGOLOGY FROM ANCIENT TIMES 387

the next written information about medicine comes from a Roman nobleman, Aulus Cor- nelius Celsus. He wrote an eight-book medical encyclopedia, the “De Medicina,” in which he refers to diseases of the ear, he recognizes the anatomy of the nose, and he gives the ear- liest description of a tonsillectomy. He also gives a practical description of how to remove a foreign body from the ear. One of the best-known ancient physicians was Aretaeus from Cappadocia, who lived about ALI80 to 160. He is perhaps the one who Fig 6. Plaque illustrating an eye and a pair of ears. (Courtesy made the earliest allusion to tracheotomy. of Corinth Museum.) The next thousand years in medicine were dria; thus the center of medical progress dominated by Galen who was born at Perga- shifted from Greece to Egypt again. Alexan- mos in Asia Minor (ca AD 131-201). He lived dria remained the medical center of the Med- most of his professional life in Rome and he itteranean world until the Arabic conquest in was the chief physician of the Emperor Mar- AD 641-642. cus Aurelius who had said, “we have but one The Ptolemies supported medicine and physician, Galen.” helped its further progress. The most famous Galen noted that the auditory nerve con- Alexandrian physicians were Herophilus and nected the ear with the brain, that the outer Erasistratus (300 BC). Herophilus described ear collected the sound, and he was the first to the salivary gland and he called the hyoid apply the term “labyrinth” to the inner ear. He bone the “parastate, ” because it was situated was perhaps one of the first to perform mas- near the nostrils. Erasistratus is believed to toid surgery. His surgical advise is astonishing have combine the words “trachea” and “arte- when he states that carious bone should be ria” to distinguish the windpipe from the ar- removed after making an incision behind the teries. It is a disaster that all the writings of ear. He treated deafness by diet and purga- those two great men and possibly of many oth- tives, an uncanny resemblance to the diuretics ers were lost when the library of Alexandria used today in cochlear hydrops, and for tin- was burned. nitus he recommended opium of mandragora. About the same period as Greek medicine, He described the cartilages of the larynx and Hindu medicine showed great progress. The the anatomy of the trachea, and he divided most famous Hindu surgeon was Susruta diseases of the nose into polypi and ozaena around the fifth century BC. It has been pro- and classified inflammations of the throat into posed that Hindu medicine was influenced by five groupsz4 Hippocratic medicine, and even that the name After the fall of the Roman Empire in AD “Susruta” may be a Hindu corruption of Hip- 476, medical knowledge was kept alive by a pocrates. In the classic Sanskrit Atharva-veda group of men: the Byzantine Compilers. Paul documents of the ancient civilization of Hin- of Aegina (Paulus Aegineta) was the last of the dus (700 BC) there is much medical informa- Byzantine Compilers. He practiced at Alexan- tion on diseases of the ear, nose, and throat. dria, and died there about AD 690.25 We are The greatest achievement of Hindu otorhino- indebted to him for our knowledge of Antyl- laryngologic surgery was the reconstruction of lus, another Byzantine Compiler who recog- new noses by the use of flaps obtained from nized the value of laryngotomy in cases of air- the cheek or the forehead.’ way obstruction. Paul of Aegine described the removal of tonsils by hook and scalpel, differ- ROMAN, ARABIC, AND ent ways to treat ear discharge, earache, and BYZANTINE OTOLARYNGOLOGY tinnitus, and he noted that congenital deaf- After the decline of the empire of the Alex- ness is incurable. ander the Great and the School of Alexandria, Aetius of Amida, from the region of the Ti- 388 EMMANUEL S. HELIDONIS

gris (ca AD 500-550) has written the best de- Salerno was the first organized medical scription of diseases of the ear, nose, and school in Europe and flourished during the throat found in ancient literature. However, era of the Crusades (1096-1270).By the 13th his methods of removing foreign bodies in the century new schools emerged, the most fa- throat were not always successful and he of- mous being the school of Naples and the Uni- ten used Christian-flavored incantations on versities of Montpellier and Bologna, at which his patients. For example after taking his pa- human cadaver dissection was extensively tient by the neck he says, “As Lazarus came practiced. forth from the grave, and Jonah out of the One of the well-known anatomists and sur- whale, bone come up or go down.“5 geons of this period was the French surgeon Until the Renaissance little progress in Guy de Chauliac (1300-1367) who believed medical knowledge was made, and it is fortu- that the basis of surgery was anatomy. He was nate that medical learning was kept alive by perhaps the first to use an ear speculum, to the Christian church and Arabic physicians. facilitate the entrance of sunlight into the ex- The study of human anatomy was discour- ternal auditory meatus in an attempt to re- aged by both the above. However there were move foreign bodies, and to treat quinsy by some great Arabic physicians, such as Rhazes, incision. Avicenna, Abulcasis, and Maimonide, who As we have seen, Mediterranean medicine had a profound effect upon later European originated in Egypt and Crete, it was devel- medicine. Arabic physicians embraced Greek oped in Greece and Rome, and was transmit- and Roman medical science and made their ted by the Arabians to western Europe in the own contributions. The caliph al-Mamun en- Middle Ages. The Renaissance began about couraged Syrian scholars and physicians to the end of the 14th century and reached its collect the Greek manuscripts, translate them, zenith 200 years later. Great progress was study them and make them known to the Ca- made in this period in almost all aspects of liph and his circle. x In addition, Galen’s texts human cultural and scientific activities. En- became available to all those Arabians who lightened artists did not hesitate to exchange could not read Greek. Far behind Galen in brush for scalpel to better understand the hu- popularity were the texts of the Hippocratic man body and to be able to better express Corpus. themselves. Albucasis (AD 936-1013)practiced in Cor- The greatest among all artists in this period dova and in his work called the Collection of was Leonardo da Vinci (1452-1519) whose ge- Tasrif the use of tonsil guillotine is de- nius made great contributions in aviation, scribed.” warfare, art, and anatomy. In the ear, nose, Whereas Hippocratic and Galenian medical and throat area he is noted for his description knowledge was kept alive in Byzantium and of maxillary and frontal sinuses.30 Following the Islamic world, the knowledge of medicine da Vinci came Andreas Vesalius (1514-1564). drastically declined in the medieval Western He was the first to give an accurate descrip- Europe. 28 Those centuries were rather sterile tion of the malleus and the incus and also de- for otolaryngology. scribed the oval and round windows, the ten- sor tympani muscle, the auditory nerve, and the maxillary frontal and sphenoid sinuses.31 THE MIDDLE AGES AND Another great anatomist of this period, Gio- THE RENAISSANCE vanni Philippi Ingrassia (1510-1580) de- scribed the stapes and observed that teeth The Galenic and Hippocratic medical tradi- could conduct sound. tion, in its Arabic form, returned to Europe in The great discoveries in the anatomy of the 11th century Italy and 12th century Spain. ear continued with Bartolomeus Eustachius Constantive Africanus, after having studied (1520-1574) who held the chair of anatomy at Arabic medicine in 1lth century Tunis, trans- Rome.32 He described the eustachian tube and lated Arabic medical texts, including the he noted that the chorda tympani was a nerve. Kitab al-Malaki of al-Majusi, into Latin.” Another name also very familiar to otolaryn- HISTORY OF OTOLARYNGOLOGY FROM ANCIENT TIMES 389

gologists is that of Gabriel Fallopius (1523- Although the Middle Ages is considered a 1562) who succeeded Vesalius at Padua. He period of stagnation, a number of important names the cochlea, labyrinth, velum palati, discoveries and observations were made. It and tympanum. He described and named the was however the 17th century when impor- trigeminal nerve, the chorda tympani, the au- tant progress in medicine was observed. It was ditory nerve, and the fallopian aqueduct. He the Renaissance period. was also a surgeon and he is known for his One of the great physicians of the time was method of removing nasal polyps with a wire Thomas Willis (1621-1675), who in his book snare. He treated aural polyps with sulphuric De Anima Brutorum described the well- acid poured down a lead tube which pro- known symptom the “parakusis of Willis” tected the external auditory cana1.33 (hearing better in a noisy environment) found The 16th century is also the period where in patients suffering from conductive hearing tracheotomy became a standard procedure. loss. The next major contribution to otology Fabricius considered tracheotomy a life- was made by Antonio Valsalva (1665-1723) saving procedure, although he never per- who succeeded Malpighi in the chair of anat- formed it. Antonio Musa Brasavola (1490- omy at Bologna in 1697. Valsalva divided the 1554) was actually the first to perform a laryn- ear into the outer, middle, and inner ear, and gotomy in 1546. Others known to have he applied the term “labyrinth” to the entire performed this procedure were Sanctorius inner ear. He introduced the terms Scala ves- (1561-1636) and Nicolas Habitat (1550-1624), tibuli and Scala tympani, he gave a detailed who had four successful cases. account of the muscles of the pharynx and The word “tracheotomy” appeared for the uvula, and, 100 years before Politzer, during first time in the Libri Chirurgiales XII by the course of a dissection, he found a case of Thomas Fienus (1567-1631).34 ankylosis of the stapes. The maneuver named Practitioners of the 16th century were adept after him was used by him to expel pus from in procedures such as uvulotomy, tonsillot- the ear in cases of otitis or to replenish air in omy, and the removal of nasal polyps. the middle ear cavity when the eustachian Syphilis, then a prevalent disease, was the tube was blocked. It was also Valsalva who cause of sunken noses and perforations of the applied the name “eustachian” to the pharyn- soft palate, and various prosthetic devices and gotympanic tube in honor of Eustachius. even plastic surgery were used to reconstruct Other anatomists were Morgagni (1682- the defects. The Branka family in Sicily in the 17711, Cotugno (1736-1822), and Antonio 15th century already used cheek, forehead, Scarpa (1747-1832). Morgagni, who was pro- and arm skin flaps to reconstruct the nose; fessor anatomy at Padua, described in detail their method was considered a family secret. the ventricles of the larynx, and he was the Gaspar Tagliacozzi (1546-1599), professor of first to prove that brain abscesses might occur anatomy and surgery at Bologna, specialized as a complication of otitis. Cotugno, professor in reconstructive surgery of the face. He pub- in anatomy and surgery in Naples (1760), was lished the book De Curtorum chirurgia per In- the first to show that the labyrinth was en- stionem in 1597, where he presented his tirely filled with fluid. Scarpa demonstrated method later to become known as the “Italian that the configuration of the membranous lab- method” of reconstructing the nose. Ambroise yrinth is similar to that of the bony labyrinth. Pare (1510-1590) the father of French surgery, The invention of the eustachian catheter recommended instead the use of artificial was fascinating form the point of view that, noses, held in place with strings.35 like the laryngoscope which was invented a Ozena, diphtheria, scarlet fever, and inflam- century later, both were developed by non- mations of the throat described under the term medical persons in Paris. Edme-Gilles Guyot, cynanchae and paracynanchae were treated at a postmaster at Versailles in 1724, succeeded that time with the old traditional remedies in treating his own deafness by passing a such as copius douching with perfumed white curved tube into the mouth behind the soft wine, ashes of a nesting swallow, the drinking palade and into the pharyngeal opening of the of urine and, of course, bleeding and cupping. eustachian tube. 390 EMMANUEL S. HELIDONIS

Myringotomy as a method for treating deaf- other things diphtheria or “white sore” in ness was recommended by Sir Astley Paston Chinese.” Cooper (1768-1841) of Guy’s Hospital in Lon- In 1765 the book Bencao gangmu shiyi was don. Cooper said that the operation was not a published, where 921 drugs were described. panacea for all kinds of deafness and he in- Two of them were the “Cinchona ledgeriana,” sisted on performing bone conduction tests the famous quinine for the treatment of ma- before performing a myringotomy with “a tro- laria, and the Sterculia scaphigera used for the car and canula, of the size of a common treatment of pharyngitis.l’ probe.“36 In 1649 Johannes Riolanus The Younger MODERN TIMES (1577-1657) suggested trephining the mastoid for treating tinnitus. It was not until the 18th The number of people who have contrib- century, however, that Jean Louis Petit (1674- uted to the study of otolaryngology in the 19th 1750) of Paris performed the first successful and the 20th centuries is quite impressive. operation of the mastoid in a case of mastoid Prosper M&i&e (1799-1862) reported the fa- abscess. The operation fell into disrepute, mous case history of a girl suffering from ver- however, because it was used indiscrimi- tigo which led to the recognition of the dis- nately with very bad results. Such an example ease bearing his name. Sir Charles Wheatstone was the Danish court physician, Baron Jahann (1802-1875) used the tuning fork, which was von Berger, who died in 1791 of meningitis invented by John Shore in the 17th century, a following a mastoid operation.37 sergeant trumpeter to James II, to test the hear- In 1750, Quelmaltz was the first to discuss ing. Ernst Heinrich Weber (1795-1878), pro- deformities of the nasal septum. He believed fessor of anatomy and physiology in Leipzig, that the cause of obstruction was pressure put Germany, described the tuning fork test which upon the nose during difficult labor, falls in bears his name. Adolf Rinne (1819-1868) of infancy, continually pushing the finger into Gottingen (Germany), Dagoberg Schwabach the nose in childhood, and inflammatory con- (1846-1920) of Berlin (Germany), and Bing ditions. (1891) also described tuning fork tests which The nature of nasal polyps was poorly un- now bear their names. Thomas Buchanan derstood and efforts to explain their origin (1782-1853) of Hull (England) was one of the were made by St Hilaire (1698), Pierre Dionis first to advise the use of artificial light as a (1650-1718), and others. As Jean Juncker means of inspecting the tympanic membrane; (1679-1759) said, “According as the moon he called the instrument used by him “Inspec- fills or wanes, the polypi of the nose increase tor Auris.” or decrease in size. Hence it may be con- Joseph Toynbee (1815-1866) in 1860 pub- cluded, it is best to attack the polyp in the lished the textbook Diseases of the Ear which waning of the moon.“’ was the most advanced and detailed work of Nathaniel Highmore (1613-1685) who prac- its kind. Toynbee described ankylosis of the ticed in Sherborne in Dorset (England) de- stapes, cholosteatoma, and he practiced my- scribed the maxillary autrum in 1651 in his ringotomy and mastoid surgery. The maneu- book Corporis Humani Disquisito Anatomica. ver of opening the eustachian tube while the He recorded a case of purulent sinusitis of patient swallows holding his nose is associ- dental origin which was relieved by pulling ated with Toynbee. He died at the age of 51 the tooth.38 after trying to inhale the vapors of hydrocya- In China in the 17th century, the beginning nit acid and chloroform while doing the Val- of the new dynasty, according to the memo- salva insufflation in an effort to relieve his ries of Lu Zhigi the “fieniie lunshu” there tinnitus. were already specialists for ophthalmology Sir William Robert Wills Wilde (1815-1876) and laryngology. A well-known laryngologist father of Oscar Wilde, practiced in Dublin, Ire- of the time was the Zheng Han or Zheng Me- land, and was recognized as a great otologist. ijian (1721-1787) who in his book the Chon- He designed an aural snare and he is known glon yuyao, which was published for the first for the Wilde’s incision used in mastoiditis. time in the 19th century, described among Hermann Schwartze (1837-1900) improved HISTORY OF OTOLARYNGOLOGY FROM ANCIENT TIMES 391

the technique of mastoid surgery, and later he George Walter Caldwell (1866-1918) from extended simple mastoidectomy to include the United States and Henri Paul Luc (1855) removal of the posterior meatal wall and mid- from Paris separately described the operation dle ear contents. He, together with Ludwig now known as the Caldwell-Luc method for Stacke (1859-1918)and Emmanuel Zaufal treating problems of the maxillary sinus.40 (1837-1910),expounded the indications of The 19th century is also rich with many mastoid surgery and stressed the value of other gifted persons who contributed to the meatoplasty for the inspection of the middle advancement of otolaryngology and paved the ear and mastoid cavities. Herman von Helm- way for the great discoveries of the 20th cen- holtz (1821-1894)wrote the book On the Sen- tury. sations of Tone, in which he proposed the pi- The 20th century can be described as the ano or resonance theory of hearing. Marquis golden age of otolaryngology. Great research- Alfonso Corfi (1822-1888) described the co- ers, advances in anesthesia and chemother- chlea, the organ associated with his name. apy, and the explosion of technology helped Adam Politzer (1835-1920),known as the to give the specialty its present status. father of modern otology, taught otology in Vi- Gluck (1912), Alonso (1947),41 Ogura enna to a score of students from Europe and (1948), and Som (1953) described conserva- all over the world. His teachers were Claude- tive surgical techniques for the management Bernard, Prosper Mbniere, Joseph Toynbee, of cancer of the larynx. Kleinsasser (1960) rev- Helmoltz, and other great names of his time. olutionized the diagnostic and therapeutic ap- He is best known for his contributions to the proach to treatment of cancer of the larynx by knowledge of ear anatomy, otitis media with applying microdiagnostic and microsurgical fluid, cholosteatoma, labyrinthitis, otosclero- techniques. An important step in cancer sur- sis, and more. He is also well known for his gery was the radical neck dissection. The technique of inflation of the eustachian tube, method was first described by Crile in 1906, it the politzerization. was later improved by Hayes Martin in 1941, Robert Barany (1876-1936) was the most and in 1967 Bocca described the modified eminent of Politzer’s students. In 1915 he re- neck dissection. ceived the Nobel Prize for his work on the Other important landmarks are the descrip- physiology and pathology of the vestibular or- tion of the maxilla-premaxilla approach to the gan. He described the Barany noise box, the nasal septum by Cottle and Loring in 194642; Barany rotating chair, and the caloric test of endonasal rhinoplasty described by Joseph in vestibular function. 1931; external rhinoplasty by Rethi in 1929; Manuel Patricia Rodriquez Garcia (1805- fenestration of the lateral semicircular canal 1906) a professor of singing at the Paris Con- by Julius Lembert in 1943; and the stapedec- servatory and later at the Royal Academy of tomy technique by Shea in 1956 for the treat- Music in London, succeeded in observing his ment of otosclerosis43; the different tech- larynx with a dentist’s mirror, where before niques of tympanoplasty described by Zollner him many others with more medical and sci- and Wullstein44; and the translabyrinthine ap- entific training had failed.3Q Theodor Billroth proach to the acoustic neuroma described by (1829-1892) from Vienna, performed in 1873 William House.45 the first total laryngectomy for cancer, The 29th century also saw the emergence of whereas the first laryngectomy in the United the otolaryngic allergy treatment and of endo- States was performed by Solis Cohen in 1884. scopic surgery of the nose and paranasal si- One of the great laryngologists of the time nuses, the introduction of a number of inno- was Morel Mackenzie (1837-1892) from Lon- vative reconstruction techniques using del- don who is known as the father of British topectoral, myodermatic, and free vascular laryngology. He was involved in the medical flaps, the development of the skull base sur- management of Crown Prince Frederick who gery and laser surgery, and the application of suffered from laryngeal cancer. The Crown minute hearing aids and cochlear implants for Prince succeeded Emperor Frederick III of the restoration of hearing. Computer tomogra- Germany but only reigned for 99 days before phy and magnetic resonance imaging unrav- dying of cancer. eled many of the hidden secrets of the normal 392 EMMANUEL S. HELIDONIS

and pathologic anatomy of the head and neck 4. Moncrief J: The Poor Man’s Physician, 1716 area, and the otoneurologic laboratory exami- 5. Weir N: Otolaryngology. An Illustrated History. Lon- don, England, Butterworth, 1990 nation was greatly facilited by the introduc- 6. Trump I-ID: The Prehistory of the Mediterranean. tion of computers in audiology and speech Richard Clay (The Cancer Press), 1960 laboratories. It is also the century of the great 7. Garrison HF: History of Medicine led. 41. Philadel- phia, PA, Saunders, 192i ear, nose, and throat departments with the 6. Emerv WB: Preliminarv reoort on the excavation at various clinical, research, and educational ac- north Sakkara. J Exper Archeol52:3-6, 1966; 53:141-145, tivities, of the many scientific ear, nose, and 1967; 65:5-11, 1970 9. Vikentieff W: BIE 32. 1949-1950, p 171 throat societies and journals, and of the great 10. Herodotus. II 156 opportunities for training and education 11. Wunderlich GH: The Secret of Crete. 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Zu- blood vessels, where implants will administer rich, 1967, pp 20-22 drugs for destroying tumors. Other implanted 19. Littre E: Oeuvres Completes d’Hippocrate, vol l-10. Paris, 1839-1661 devices will restore the function of different 20. Kasas S: Important Centres Medicaux de l’Antiq- organs. At the same time imaging in the form uite. Epidaure et Corinthe. Quand la medecine etait en- of “virtual reality” will allow the surgeon to core divine. Mater Med Nordmark 30:9-10, 1978 21. Aristotle; Smith JA, Ross WD (trans-ed): Oxford, better perform different procedures, and the Clarendon, 1910-1913 same method will be also used for training 22. Sudhoff K: Aeg Mummienmacher Instr. Arch and rehearsal surgery. Gesch Med 5:161, 1912 23. Brock AJ: Translation and edition of works of Ga- In laser surgery the introduction of new la- len. Loeb Classical Library, London, 1916 ser systems will allow for more precise sur- 24. Galen: Brock AI ftrans-edl: Works of Galen. 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