Mudry, Albert
Institute for History of Medicine University Lausanne, Lausanne, Switzerland
Address correspondence and reprint requests to Albert Mudry, M.D., ENT & HNS Specialist, Private Practice, Avenue de la Gare 6, CH-1003 Lausanne, Switzerland; E-mail: amudry@worldcom.ch
In 1893, Adam Politzer was the first to describe otosclerosis as a specific disease fixating the stapes. The aim of this study is to follow Politzer's research to understand how he finally explained the mechanism responsible for the fixation of the stapes. Politzer conducted his preliminary research from 1862 to 1893. From the concept of a dry catarrh of the middle ear, the fixation of the stapes became progressively associated with a specific ossification in and around the footplate. Politzer presented his first results in 1893. He completed his research by concluding in 1901 that otosclerosis had become an independent disease and should have the right to its own chapter in otologic books. He selected the word otosclerosis to describe this new pathologic entity.
Despite the fact that the first description of an ankylosis of the stapes was already reported by Valsalva in 1704 (1), it was only in 1893 that this medical entity became associated with otosclerosis, a specific disease of the ear, described for the first time by Adam Politzer (2). The aim of this study is to follow Politzer's research to understand how he eventually explained the specific pathologic mechanism responsible for the fixation of the stapes (Table 1). This article is divided into three parts: the preliminary studies, the first description of the disease, and the complementary research. This study was possible because the author was provided with access to all known original texts written by Politzer. In one of his publications, Politzer began the description of otosclerosis with this statement, which can be taken as the beginning of his interest in this pathology: Long before the anatomic conditions of this special form of disease were known, various authorities raised the question whether the so-called middle-ear catarrhs running their course with progressive deafness should be classed among the true catarrhal processes of the middle ear. V. Trltsch was the first, from his clinical observations, to express the opinion that this form of disease could, through a broadening of our anatomic knowledge, be given a separate place in the category of diseases of the ear (3). This completed the first pathologic studies of Toynbee on this subject that demonstrate, because of their symptoms, that those disturbances of hearing, which formerly were classed under the name of nervous deafness, are caused in the majority of cases by ankylosis of the stapes with the oval window (4). After achieving his medical degree, Politzer visited von Tröltsch in 1860 and Toynbee in 1861 and followed-up their lessons in otology. Through these otologists, Politzer probably became aware of this unexplained abnormality and began his interest in researching its origin. In 1862, Politzer began his activity as an otologist in the Viennese general hospital and in the same year published his first account concerning the fixation of the stapes after an extensive study of all data available on this subject.
TABLE 1. Chronologic Table of Politzer's Studies Concerning Otosclerosis
| Year | Subject of study |
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1862 1882 1887 1893 1901 1908
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description of one case with new white bony formation at the place of the stapes two pathologic explanations : calcification and ossification of the ligamentous ring of the stapes - new formed osseous substance upon the inner surface of the footplate two different histologic forms of stapes ankylosis : anchylosis of the footplate ? anchylosis of the branches of the stapes primary disease of the capsule of the labyrinth with new bone formation proposal to name this disease otosclerosis description of the different histologic stages of the disease |
In 1862, Politzer published his first report concerning a case presenting a bilateral fixation of the stapes (5). He began his report mentioning that the ankylosis of the stapes is one of the most sadly lacking chapters of otology. He continued with the problem of a lack of pathologic knowledge concerning this affection: before Toynbee, the lack of research in anatomo-pathology made that the group of ankylosis was considered being part of the neuronal hearing loss. These two statements largely encouraged the young Politzer to give special attention to this disease. He focused on pathologic studies of the stapediovestibular joint to try to understand the reason for this affection. He described the case of a 56-year-old woman suffering from deafness for 14 years, probably of sudden onset. The clinical examination demonstrated normal otoscopy with a normal Valsalva maneuver. The acoumetric test with the clock and voice gave a diminution of hearing on the right side and no hearing response on the left side. Furthermore, in examining the temporal bone removed directly after the death of the patient, Politzer discovered a fixation of the stapes on the left and a reduction of movement of the stapes on the right side using his manometric method of measuring the movement of inner ear liquid after stimulation of the tympanic membrane (6). The middle ear was free of abnormality. In the aforementioned case, Politzer put forward, on the left ear, that as a substrate of the ankylosis of the stapes we found after removal of the antral wall at the place of the stapes footplate an elliptic white bony bulge, 1/2' high, corresponding to the circumference of the oval window, which became thinner towards the center and was completely fused with the stapes footplate. On the right side, Politzer also described the same fact: at a closer investigation of the vestibular surface of the stapes one could see a bulgy vascularized, even bony proliferation emanating from the superior, inferior and posterior surroundings of the oval window which was not joined with bone with the stapes footplate. It grew over the posterior half of the stapes footplate whereas the anterior half was freely visible. But Politzer did not understand the pathologic process to explain this new bone formation: The etiology of the process leading to new bone formation is not clear. We prefer to conclude only after a series of observations and not to speculate after a single observation. The door was open for future research.
At the beginning of the 1860s, stapes ankylosis was considered as a kind of complication of catarrhal inflammation of the middle ear. The clinical diagnosis was very difficult. This entity was generally regarded as a nervous deafness because the tympanic membrane was normal and the eustachian tube permeable (7). Politzer conducted different studies with the tuning fork, published between 1864 and 1870. He clearly demonstrated the utility of Weber's test to localize, in front of a normal tympanic membrane, whether the lesion had its seat in the middle ear or in the labyrinth (8-10). During the 1870s, the situation had not evolved a lot. Different otologists described clinical situations of normal tympanic membrane associated with an impairment of the hearing and a lateralization of the tuning fork on the affected ear. They were usually classified as chronic nonsuppurative disease of the middle ear (11). In 1878, Johannes Kessel proposed to render the stapes movable or even more to extract it in this situation (12). This proposal was not accepted by many otologists such as Politzer, who wrote: rendering the stapes movable, like its extraction, is of no real value? the success?seems to me very doubtful (4).
In 1882, in the second volume of the first edition of his Textbook of the Diseases of the Ear (4), in three pages of the chapter concerning adhesive processes in the middle ear, Politzer wrote again on the ankylosis of the stapes. He explained that the origin of the ankylosis of the stapes was related to an inflammation of the mucosa of the middle ear: This anchylosis of the stapes is generally the result of a diffused inflammation of the mucous membrane of the tympanic cavity, and is often complicated with anchylosis of the malleus and the incus, with adhesions between the membrana tympani, the ossicula, and the inner wall of the tympanic cavity. He also described a second localized form in the region of the oval window: Often, however, it follows from circumscribed interstitial inflammation of the mucous membrane, when the pathologic changes are principally confined to the neighborhood of the fenestra ovalis, no signs of disease being visible in the other portions of the middle ear. Politzer enlarged his pathologic explanation: anchylosis of the footplate of the stapes with the circumference of the fenestra ovalis, is caused either by calcification and ossification of the ligamentous ring of the stapes, by a growth of cartilage from the circumference of the fenestra ovalis, or by deposit of new-formed osseous substance upon the inner surface of the footplate, and in the neighborhood of the fenestra ovalis. Politzer continued that in the case of deposit of new bone the anchylosis of the stapes cannot be regarded as the result of an affection of the middle ear lending support to the fact that Politzer was trying to find a new entity to explain the anchylosis of the stapes. He used this hypothesis as background for his future studies. Politzer presented various treatments used such as injection of air or vapors into the middle ear, treatment of stricture of the eustachian tube, or artificial perforation of the tympanic membrane without conviction concerning their efficacy.
In 1887, in the second edition of his Textbook of the Diseases of the Ear (13), still in the chapter concerning the catarrhal adhesive processes in the middle ear, Politzer went further with pathologic knowledge, dividing the anchylosis of the stapes into two different forms: the origin of the stapes anchylosis is either the growth of the border of the footplate with the circumference of the oval window (anchylosis of the footplate) or the anchylosis of the branches of the stapes with the inferior wall of the recess of the oval window (anchylosis of the branches of the stapes). He joined two photographs of a new case of a 48-year-old woman suffering from progressive hearing loss for 20 years on the left side and 10 years on the right side to demonstrate his affirmations (Figs. 1 and 2). These photographs are the first actually known photographs of otosclerosis. From a clinical point of view, Politzer demonstrated the importance of tuning-fork tests. For the first time, he also used the Rinne's test to complete his examination. Again, Politzer did not agree with mobilization or extraction of the stapes. Even more, he wrote that the tenotomy of the stapedius tendon had no indication.
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In 1888, during the international congress of otology in Brussels (14), Politzer presented some new observations completing the case described in the second edition of his textbook, notably the case of a 77-year-old, nearly deaf man. The pathologic examination demonstrated adhesion of the posterior crura of the stapes with the corresponding wall of the niche (Fig. 3). He emphasized the importance and the orientation of his research: in this research, it was firstly for me an establishment of anatomo-pathologic details without an exact relation with the precise determination of the troubles of hearing caused by these changements. Furthermore, Politzer stated that more research was necessary to understand this important subject: nevertheless the histologic researches on this interesting point have been up to recent times less cultivated than demanded the importance of the subject.
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FIG. 3. Adhesion of the posterior crura of the stapes with the corresponding wall of the niche. |
In 1889, Politzer published the first treatise on the histology and pathology of the ear (15). It is interesting to note that Politzer did not mention specific pathologic modifications of the stapediovestibular joint, stated only in general terms such as ossification, thickening of the periosteum of the surface of the labyrinth, and hyperostosis.
In July 1893, in the third edition of his Textbook of the Diseases of the Ear (16), once again in the chapter concerning catarrhal adhesive processes of the middle ear, Politzer refined his knowledge of the subject, presenting the results of dissection of three cases and adding two new photographs already presented in Brussels: Within a short time I have dissected three cases of deafness in which the stapes was fastened to the pelvis ovalis by the growth of a bony tuberosity. Politzer also mentioned a relation of the anchylosis of the stapes and heredity: the anchylosis of the stapes is undoubtedly favored by congenital narrowing of the niche of the fenestra ovalis. The exact implication of heredity was not understood but empirically stated. Politzer was in possession of many elements to verify his hypothesis that a specific entity was responsible for the ankylosis of the stapes.
In December 1893, Politzer published, in German, in the Zeitschrift für Ohrenheilkunde, his description of the primary disease of the bony labyrinthine capsule supported by 16 anatomopathologic temporal bone dissections (17). This report was translated into English and published a few months later in the Archives of Otology, the English counterpart of the Zeitschrift (18). Politzer introduced his report with owing to its clinical course, this disease has previously been tabulated in the group of chronic dry catarrhs of the middle ear, the so-called sclerosis of the middle ear mucosa. A series of observations of a clinical nature, made in the late years, from cases that later came to the post-mortem table, show, without a shadow of doubt, that in a considerable number, which, from their clinical symptoms and their usual course, we are inclined to attribute to chronic middle-ear catarrhal disease, the anatomico-pathologic foundation for the loss of hearing is not to be sought for in a disease of the mucosa at all, but in a primary affection of the bony labyrinthine capsule. Politzer gave a clear description of the pathologic finding: according to the results of the histologic examination of these cases, it is a circumscribed disease of the bony labyrinth capsule, leading to new bone, overgrowing to the oval window and stapes, and finally leading to complete anchylosis of the stapes and to the closure of the oval window. He concluded his study with: These observations ought to suffice to show, that in a considerable number of cases which we generally call sclerosis of the middle ear mucosa, the pathologic alterations leading to anchylosis of the stapes do not lie in the mucous membrane at all, but in a primary disease of the capsule of the labyrinth.
In reality, Politzer had already presented his discovery in September 1893 during the first medical Pan-American Medical Congress held in Chicago. He showed 10 pathologic preparations to support his affirmations in a presentation entitled On a Peculiar Affection of the Labyrinthine Capsule as a Frequent Cause of Deafness. A short report was published only 2 years later (19). Then, Politzer traveled worldwide with his otosclerosis specimens. His works gained support and acceptance through the studies of several colleagues such as Siebenmann and Habermann. This topic was widely discussed in the otologic literature (20). Politzer was thanked for his new conquest in the field of otology in adding another gem to his crown. His research hypothesis was demonstrated and a new otologic entity was born: it offers proof that the affection arises from the capsule and that the bony new proliferation not only attacks the plates of the stapes but proliferates upon its outer surface (17). Politzer illustrated his affirmations with eight photographs, five of which were previously unpublished (Figs. 4-8).
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FIG. 6. Sharply defined bony formation in the anterior portion of labyrinthine capsule near the oval window. Synostosis of the plate of stapes and window. New bone proliferative tissue in the posterior segment of the oval window, proliferating over the external surface of the plate of the stapes. |
FIG. 7. Osseous new formation near the margin and involving the base of the stapes |
FIG. 8. Bony new proliferation filling the oval window.
Concerning the treatment, Politzer stated that all treatment must be regarded as nearly hopeless (18). In 1899 (21) and again in 1900 (22), Politzer wrote: the simple mobilization of the stapes, had only a temporary effect on the hearing. Even more: the operative extraction of the stapes was of no use because the cause of the fixation of the stapes is a proliferation of bony tissue of the labyrinthine capsule, which, even after removal of the stapes, effectively closed the fenestra ovalis. This opinion was largely accepted by many of his colleagues. In 1901, Politzer went on, stating that the unfavorable opinion as to the value of extraction of stapes in non-suppurative middle-ear processes, and in otosclerosis, has been confirmed, in the last few years, by many authors (3).
Otosclerosis became an independent pathology and earned its own chapter in otological books such as in the fourth edition of Politzer's Textbook of the Diseases of the Ear in 1901 (3). Politzer probably introduced the term otosclerosis for this affection. He wrote in note that this affection has erroneously been called dry middle ear catarrh? Since specialists have already adopted the termination sclerosis for the progressive form of deafness, the author considered it advisable to select the term otosclerosis. It may also be called capsulitis labyrinthi. Politzer presented, in a structured chapter, all the data available concerning this new medical entity. He stated that: The pathologic investigations which have been carried out extensively within the last few years have, to a certain degree, given us a clearer idea of the nature of this disease. He was also interested in finding an etiological origin and wrote clinical observations have demonstrated that heredity plays a very important part in the etiology of otosclerosis. The same year, Politzer edited the Atlas and Epitome of Otology with Brühl in which three photographs of otosclerosis were presented, two of which were new and in color (23) (Figs. 9 and 10).
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FIG. 9. Bony new formation at the posterior margin of the fenestra vestibuli and union with the border of the base of stapes |
FIG. 10. Osseous new formation on both borders of the margin. Union with the borders of the base of the stapes and with the posterior limb |
In 1908, during the meeting of the German Otological Society in Heidelberg, Politzer presented many cases of otosclerosis (24), and particularly demonstrated the different histologic possibilities and stages encountered in otosclerosis and the reality of new bone production in this disease. In the fifth edition of his Textbook of the Diseases of the Ear published in 1908 (25), Politzer summarized the knowledge of his epoch in a 12-page chapter entitled, the typical otosclerosis. Politzer wrote a note that: as the name of otosclerosis had already found its way into otology, the author would therefore like to limit this term only to the clinical, sharply-defined, typical form of this disease about to be described. In his complementary research, Politzer reinforced his knowledge concerning otosclerosis; thus, this disease found its final place in otology.
Politzer played a central role in the history of otosclerosis, a condition in which there is an invasion of the footplate of the stapes by abnormal bone which interferes with the passage of sound from the middle to the inner ear (26). In a progressive way, he constructed his knowledge to be able to finally describe this new medical entity. This fact was certainly possible because Politzer had the opportunity to dissect many cadavers from the Asylum of the Viennese General Hospital. Politzer's own research allowed him to develop new methods to study temporal bones and over the years progressively demonstrate the pathologic basis of otosclerosis. Beneath this remains the question of whether another otologist would have had the opportunity to describe this entity before Politzer. The answer is debatable because different factors were necessary for this to happen, such as the possibility to perform autopsies on known patients, the sufficient knowledge in preparation of temporal bones, the access to works of other colleagues, and the perspicacity in pathologic research, demonstrated by the elapsed time between the first dissection in 1862 and the presentation of the entity in 1893. A period of 31 years was necessary from the first observation of new-bone formation in the oval fenestra to the demonstration that this was a specific entity giving an explanation to the dry middle ear catarrh found in many otologic books of the second part of the 19th century.
With this study, it is possible to demonstrate that Politzer was an excellent researcher. He was aware of the different steps of the hypothetico-deductive methodology that he largely used to explain the origin of otosclerosis. This can be used as an excellent example of how to conduct research for young ear, nose, and throat and ear specialists.
