HN0-Praxis, Leipzig 6, 175-178 (1981)

From the University of Southern California and the Institute of Laryngology and Voice Disorders Los Angeles, California, USA


Abstract

In a historical review outstanding attainments in the fields of anatomy and physiology of the larynx as well as pathology of the voice are keynoted.

Who deserves the accolade of the world’s first voice scientist? None other than Claudius Galenus who was known among his contemporaries as “Clarissimus” – the greatest. Born at Pergamos in Asia Minor in A. D. 131, this towering intellectual enlightened the history of medicine for 1,500 years. He practiced in Rome and served as physician to the Emperor Marcus Aurelius. When he returned to Pergamos about 168, the Emperor pleaded for his return to Rome where Galen eventually died about the end of the second century. Galen’s distinguished predecessors, such as Hippocrates and Aristotle, thought of themselves as philosophers and based their knowledge largely on speculation. Galen was the first to derive his knowledge of anatomy and physiology from the dissection of animals, and to base his judgment on these personal observations.

In his book DE USU PARTIUM CORPORIS HUMANI Galen described the most important cartilages and muscles of the vocal system and compared the production of the voice to a flute. He correctly identified the larynx as the instrument of voice or “principalissimum organum vocis”. He detailed the adductor and abductor muscles of the vocal cords as well as the extrinsic muscles of phonation. He noted the presence of the ventricles; he stressed the importance of the soft, flexible, mucosal lining for phonation. He recognized the brain as the center of phonation and described the motor pathways via the laryngeal nerves to the larynx. He separated speech from voice. He differentiated physiologic and pathologic dysphonias, and ascribed different types of hoarseness to various diseases and disorders of the vocal system.

During his brilliant career Galen compiled more than 300 books, of which some 120 are still available for our study. It is small wonder that this medical colossus reigned like a dictator over the world of medical science for almost 1,500 years. Subsequent authors were content to copy Galen’s teachings as gospel truth, regardless of their own observations. A typical example of this slavish devotion is shown in Mondino de Luzzi’s ANOTHOMIA, the first anatomical textbook which was written in the year 1316. This dominance extended throughout Europe and far into the 16th century. Even in 1559 the College of Physicians in London ordered one of its members, Dr. John Geynes, to retract his statement that Galen’s work contained errors. Dr. Geynes dutifully submitted his apology, for the great Galen could not be wrong.

After the decline of the Creek and Roman civilizations, the control of intellectual pursuits by the Church and the unstable conditions in Europe discouraged scientific programs; Arab physicians came to dominate medical science during the Middle Ages, and their voluminous writings serve as a repository for the traditional knowledge of the ancient world. In his nine-volume encyclopedia of medicine and surgery AL HAWI FIL TIBB the 9th century physician Abu Bakir Mohamed Ibn Zakeriya Arrazi (850-926) known to the Western world as “Rhazes”, referred to affections of the voice and hoarseness. He related the changes in voice to the laryngeal lining, to the recurrent nerve, the laryngeal muscles, the respiratory system, or to the brain. It is of interest, that this single work comprised the entire library of the medical faculty of Paris in 1395.

In the 10th century Ali Ibn Abass El Majusi or “Halt’ Abass” (994) published a concise account of the anatomy and physiology of the larynx, which may be summarized as follows: The larynx consists of cartilages which are held together by ligaments and joints. The lining membrane is continuous with that of the nose, mouth, trachea and hangs below. It has a dual function: respiration and phonation. Voice is produced by blowing air from the chest through a closed larynx. The larynx is closed during swallowing.

The most famous of the Arabic physicians Ali Ibn Hussyn Ibn Abdulla Ibn Sina is known to the Latin world as Avicenna the Persian (980-1037). In addition to his fame as a physician and scientist Avicenna was also an eminent philosopher, statesman and poet. Among some 100 books, he authored the QANUN which many authorities consider the roost famous textbook ever written, for after 500 years it was still a required textbook at the University of Vienna and other major universities. This book includes pertinent data on laryngeal anatomy and physiology, as well as a chapter on voice production and voice disturbances. Despite their voluminous publications, the Arab era added no significant discoveries to our knowledge of the larynx and voice. This major development was to collie during the Renaissance.

The Renaissance began its work of enlightenment in the field of art and some of the bolder artists did not hesitate to exchange brush for scalpel in order to explore the human body. Among theirs was Leonardo da Vinci (1452-1519), a versatile genius who contributed major discoveries to the anatomy of the larynx and the physiology and pathology of the voice. His major anatomical study QUADERNI D’ANATOMIA that was completed about the year 1500 includes several rather lifelike drawings of the larynx. Unfortunately this priceless volume mysteriously disappeared; it was rediscovered almost 300 years later in an old chest, which was the property of the English Royal House.

Leonardo’s scientific experiments proved him centuries in advance of his time: his physiologic demonstration of producing tones from the larynx of a goose by squeezing its lungs was not repeated until 250 years later - by Ferrein in 1741; his physical studies of the difference between waves and vibrations were not confirmed for 400 years - by Giesswein in 1911; and his observations on the wave form of a string were reaffirmed by Melde in 1860 - 350 years later. Other similar examples of his genius abound. Leonardo da Vinci also described the parts played by the structures of the mouth, lips and teeth for articulation, and assigned phonetic terms to the acoustic signals.

The new spirit of freedom for scientific exploration found its zenith at the Italian universities. In Padua, the Belgian Andreas Vesalius (1514—1564) was appointed Professor of Anatomy while still in his 20’x. The publication of his great work DE HUMANT CORPORIS FABRTCA reformed the knowledge of anatomy; some of the magnificent woodcuts in this volume have been attributed to Titian. While Vesalius’ drawings of the larynx present a good image of the framework, the interior of the larynx is still influenced by Galen. For instance, the arytenoid cartilages still figure as one piece and the cricothyroid muscles as two pairs. It is of interest that Vesalius later served as court physician to the Emperor Charles V and died in shipwreck during a pilgrimage to the Holy Sepulchre.

While Vesalius taught at Padua his contemporary, Bartolomeus Eustachius (1520 to 1574), held the Chair of Anatomy in Rome. His opus magnum, the TABULAE ANATOMICAE, was completed in 1552, but was secreted away in the Vatican Library until 1714. A review of the laryngeal illustrations engraved by the famous artist Giulio de Musi heralds a new era, for these drawings were prepared completely according to nature.

One of the successors of Vesalius as Professor of Anatomy at Padua was Hieronymus Fabricius of Aquapendente (1537-1619). A diligent student of comparative anatomy, Fabricius published three books on the organs of vision, voice and hearing DE VISIONE, VOCE ET AUDITU. These books present anatomically correct pictures of the vocal organ and the author states categorically that “the vocal cords and gap between cause the voice”.

His pupil and successor as Professor of Anatomy in Padua, Julius Casserius of Placentia (1545-1616), authored a comprehensive textbook on the anatomy and physiology of the larynx which was published in Ferrara in the year 1600. This scholarly work DE VOCIS AUDITUSQUE ORGANIS HISTORIA ANATOMICA exposes the larynx and all of its parts in men and in animals and correctly includes all of the laryngeal muscles with the names, as we know them today; yet in his theories of voice production Casserius was still influenced by Galen.

With Gian Domenico Santorini, Professor of Anatomy in Venice (1681-1737), the scene shifts to the University of Venice and his OBSERVATIONES ANATOMICAE, published in 1724. In this volume Santorini first depicts an illustration of the larynx in situ.
We now return once again to Padua where Giovanni Baptista Morgagni (1682-1771) was the last and the greatest of the celebrated professors who made Padua the leading medical school of Europe. This remarkable investigator may be regarded as the second founder of laryngology, so completely did he initiate and pursue the study of the subject. Morgagni was the first to notice the posterior or oblique fibers of the arytenoid muscles: he also described the cuneiform cartilages, the epiglottic glands, the pharyngo-epiglottic ligament, the ventricular bands, the ventricles and other laryngeal structures. He correctly pointed out that the ventricles of the larynx probably acted as a reservoir of mucus to lubricate the vocal cords. His painstaking observations called attention to the larynx as the primary site of disease and formed the basis of laryngeal pathology.

The location now shifts to Paris, where the scientist and physician Denis Dodart (1634-1707) presented a series of observations on laryngeal physiology to 1’Academie Royale de Science over a seven years period (1700-1707). In these reports he stressed that the glottis was the organ of voice, that the character of the tone depended on the tension of the vocal lips and that the concavities of the mouth and nose only modified the production of the voice.

Forty years later, the French physician Antoine Ferrein (1693-1769), Professor of Anatomy at the Jardin du Roi in Paris, presented his experimental results to the same body of scientists. Ferrein was the first scholar to conduct acoustic experiments on the isolated cadaver larynx. He discovered: 1) that a close reproduction of the voice could be obtained in a cadaver by bringing the vocal bands together and blowing through the trachea from below; 2) that the vibration of the vocal bands was the essential factor in the generation of sound and that the sound ceased on touching the vocal folds; 3) that the intensity of the voice depended on the force of the air pressure; 4) that the pitch was related to the action of the cricothyroid muscles; 5) that, the vocal bands followed the laws of the vibrating strings in their relation between pitch and length. Hence, he regarded the edges of the glottis as strings and called them. the “vocal cords”.

By 1761 sufficient knowledge had accumulated so that the Swiss scientist Albrecht von Haller (1708-1777), Professor of Anatomy in Göttingen and a humanist of many talents, devoted the third volume of his ELEMENTA PHYSIOLOGIAE to respiration, voice and speech including their discrepancies. In this compendium he postulated that the structures of the nose and sinuses enhanced the resonance of the voice.

Another giant step brings us to the research of the German physiologist Johannes Müller (1801-1858), who served as Professor of Physiology at the University of Berlin. Müller was another genius who enriched virtually all areas of his profession. Based on a series of painstaking experiments on the isolated human larynx, he confirmed the discoveries of Ferrein and developed fundamental data about the pitch, intensity and quality of voice production. In 1839 Müller correlated these studies in his work ÜBER DIE COMPENSATION DER PHYSISCHEN KRÄFTE AM MENSCHLICHEN STIMMORGAN that was followed by his comprehensive textbook on human physiology. Müller’s works were translated into the major scientific languages and his postulates were so persuasive that the myoelastic theory of phonation was accepted without question for over 100 years. Further clarification had to await the opportunity of visualizing the human larynx in a living subject.

This step was not long in coming. On March 13, 1855, Professor Manuel Garcia (1805-1906), a prominent Spanish singing teacher in London, presented his revolutionary “Physiological Observations on the Human Voice” to the Royal Society of Medicine. In this treatise he reported the first successful autolaryngoscopies during which he reflected the light of the sun with a small dental mirror on his own larynx and visualized the phonating organ on a hand mirror. The British physicians were not impressed but two years later the Viennese neurologist Ludwig Türck (1810-1868) reinvented mirror laryngoscopy and the Budapest physiologist Johann Nepomuk Czermak (1828-1873) modified the technique for clinical use. This development set the stage for worldwide interest in the visualization of the larynx and the establishment of laryngology as a specialty of medicine.

Hermann Gutzmann was born in 1865, during this exciting period. As a youth he must have learned from his father, the well-known teacher of the deaf, Albert Gutzmann, about his contemporaries: the great Manual Garcia, the distinguished Ludwig Türck and the famous Johann Nepomuk Czermak. Herman. Gutzmann was 40 years old when the legendary Manuel Garcia celebrated his 100th birthday, with honors from Emperors, universities and individual scientists, physicians and singers throughout the world. It is no wonder that Gutzmann selected the field of speech and voice disorders as his life’s work, but this has been our good fortune.

It was Herman. Gutzmann’s contribution to open the first clinic for speech and voice disorders in 1891; it was his distinction to introduce phoniatry as an academic subject at the University of Berlin (1905); it was his privilege to become the first Professor of Phoniatrics in the world. His research, his teachings and his clinical prowess were founded on a thorough knowledge of the basic sciences and of general medicine, and this is the orientation, which he bequeathed to his student. Several of his students like Max Nadoleczny, Rudolf Schilling, Miloslav Seeman, Rudolf Luchsinger, Paul Moses and Friedrich Brodnitz received renown in their own right; Luchsinger and Brodnitz are still among us. As laryngologists and phoniatrists we are proud of this heritage - from Galen to Gutzmann.