INTRODUCTION

In order to explain how such an interesting and innovative diagnostic and therapeutic system as that involving the outer ear remained unknown until about 50 years ago, we need to take a few steps back through the history of medicine, first to ancient times when a wide variety of animal and human ailments were cured using iron and fire. Cauterization was well known to Hippocrates (460–380 bc), who wrote in his last aphorism (section VII, no. 87), ‘quaecunque medicamentis non curantur, ferrum curat, quae ferro non curantur, ignis curat, quae igne non curantur, ea incurabilia sunt’ (‘those diseases which are not cured by medicines are cured by the scalpel; those which are not cured by the scalpel are cured by fire; those which are not cured by fire can be considered incurable’).

The great surgeons Avicenna (980–1037) and Abū al-Qāsim, also known as Albucasis (d. c.1013), were particularly skilled in cauterization, and in selecting the appropriate instruments and techniques. Albucasis stated in the first book of his work,¹ dedicated entirely to cauterization: ‘the cautery excels the drug by the rapidity of its success, the strength of its action, and the potency of its powers’. However, he admonished his pupils:

He removed some prejudices which still existed in this period:

His opinion was that:

In the centuries to follow, the methods used were termed ‘actual cautery’ and ‘potential cautery’. These indicated, respectively, treatment with red-hot iron and local application of caustics.

In Albucasis’s time many parts of the body and several diseases were treated with cauterization, for example pleurisy, chest complaints, liver abscesses, diseases of the spleen, dropsy, piles and anal fistula, painful menstruation and infertility, toothache, migraine, sciatic pain, etc. In Chapter 5 of his book Albucasis described the following treatment for earache:

Albucasis at work is depicted in a series of miniatures accompanying the Latin translation of his text (Fig. 1.1).

Fig. 1.1 Albucasis applying the cautery in a case of earache. Miniature from Abu’l Qasim Halaf Ibn Abbas al-Zahrawi, Chirurgia, second half of 14th century.

(Reproduced with the permission of the Wellcome Institute for the History of Medicine, London.)

The method of cauterization spread throughout Europe, and many physicians applied the actual cautery until well into the 19th century. In France, the country in which the practice of cauterization had most support and was most widespread, it was used in the hospitals of all the principal towns, and the person who in 1811 best summarized the history of the actual cautery and best described the technique was a Frenchman, Pierre-François Percy (1754–1825), a surgeon at the court of Napoleon, who had had considerable experience on the battlefield. Percy² ordered at least 10 instruments of different dimensions and shapes to be forged for various uses. The heated instruments were inserted into a special wooden handle (Fig. 1.2).

Fig. 1.2 Percy’s ten cauteries with handle on the left.

(Reproduced with the permission of the Wellcome Institute for the History of Medicine, London.)

The instruments were classified into three groups:

In England the practice of ironing the painful part with a laundress’s iron (the skin being protected by being covered with a piece of thin flannel or brown paper) had long been in vogue for various types of pain. However, it was only after 1830 that physicians such as Henry William Fuller³ and James Syme⁴ proposed the use of the actual cautery for lumbago, stiff neck and other forms of ‘muscular rheumatism’, which at that time included sciatica.

An exceptional case report comes from one of the great surgeons of the history of medicine, Joseph Lister. Having qualified in London, Lister went to Scotland, where in 1854 he became Syme’s house-surgeon at the Edinburgh hospital. During his stay he probably witnessed patients being treated with the actual cautery, as in the following case:⁵

Case IV. – Disease between the Atlas and Axis:

Actual Cautery applied with great benefit.

CAUTERIZATION OF THE EAR

It is not easy, even approximately, to identify exactly when cautery was first applied to the external parts of the ear (auricle) for therapeutic purposes.

If we limit our research to ancient Europe, there are traces in folk medicine which indicate that the external ear also had some significance in the prevention of disease. One noteworthy folk tradition is the custom of wearing earrings to improve sight or to prevent eye disease. Sailors of the European coasts and mountaineers of the central Alps shared this tradition, even though contact between these two populations was exceedingly rare in previous centuries. The custom, passing from one generation to the next, was popular in the valleys of Switzerland, Austria and northern Italy, and a common saying there, even in recent times, was ‘gold fits good sight’, referring of course to the wearing of a gold earring.

Among the more reliable pieces of information on cauterization of the ear in ancient literature, the quotations from the work of Johannes Scultetus or Schultheiss (1595–1645) reported in Percy’s book² are remarkable. The physician was the pupil of the famous anatomist Adrian van der Spieghel of Brussels (1578–1625), also known as Spigel. The pupil observed the teacher cauterizing the antitragus of patients with toothache on the same side as the pain. This was a technique which he had applied also on himself: ‘hac nova chirurgia dolor non amplius revertitur…ejusque virtutem in se primum expertus est auctor; post modum, me praesente, in non paucis aliis’ (‘with this new surgery the pain does not relapse so intensely…the value of which the author appreciated first on himself; afterwards, in my presence, also on not a small number of other patients’).

Another excellent witness, not so many decades later, was the anatomist Antonio Valsalva (1666–1723), who performed the first rigorous and documented differentiation between outer, middle and inner ear. In his book,⁶ based, according to his biographers, on 16 years of tireless work dissecting more than 1000 human skulls, particular mention is made of cauterizations carried out by healers on the posterior part of the lobe with the aim of treating toothache. Valsalva wrote:

Figure 1.3 shows the location of the site which was most frequently cauterized.

Fig. 1.3 The site (arrow) of cauterization for toothache according to Valsalva.⁶ ‘H = Locus, ubi ramus cujus ustio à quibusdam practicis ad tollendam odontalgiam proponitur, certius uretur’ (‘H = The site where the branch was more certainly burned by some healers for treating toothache’).

The experiences from the 17th century reported above hold particular significance for practitioners in the 21st century and the following remarks may be made: