The life and work of Antonio Maria Valsalva (1666–1723) – Popping ears and tingling tongues

Introduction

The Valsalva manoeuvre is the increase in intra-thoracic pressure achieved by attempted expiration against a closed upper airway. Valsalva described it as ‘air is forced inwards with occluded nostrils and mouth’ and described its use as ‘a remedial exercise, to be repeated, and will lead to extrusion of praetor-natural cerebral matter either via the wound, via the nostrils, via the mouth or via the auditory meatus with great benefit'. However, it has found other uses, including as a way to terminate episodes of supraventricular tachycardia and stopping ear popping-pain on high altitude flights. ¹ But who was Valsalva?

Early life

Born 1666, Antonio Maria Valsalva (Figure 1) lived during a time of great change across Europe. The year 1666 would be known as the Annus Mirabilis. It was the year of the last major epidemic of bubonic plague in England, closing the University of Cambridge. An obsessive young academic by the name of Isaac Newton fled to his parents’ manor, where it is said he witnessed the falling of an apple. Later that year, the great fire of London would sweep through the old city, marking the changing times with horrific flair.

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Figure 1.

A portrait of Valsalva.

Valsalva grew up in Imola, ² in what would become northern Italy. He was the third of eight children born into an upper-middle-class family. His father, a goldsmith, adopted the name Valsalva from the location of the family home. Valsalva would go on to be educated by the Jesuits in the humanities, mathematics, and natural sciences, where he became inspired by the study of anatomy and physiology.

As a teenager, he moved to Bologna University (claimed to be the oldest university in continual operation), where he studied philosophy, mathematics and medicine. Whilst at university in Bologna, he became the favoured pupil of Marcello Malpighi (known as the Father of microscopical anatomy, histology, physiology and embryology). Valsalva graduated on 10 June 1687, seven days before his 21st birthday and was immediately appointed Inspector of Public Health in Bologna. Coincidentally, one month later, Isaac Newton’s fallen apple found its formula as the Principia was published by the Royal Society in London.

Career and medical discoveries

Valsalva practised at the Ospedale degli Incurabili in Bologna for 25 years. He worked in opthalmology, rhinology, vascular and tumour surgery, and performed nephrectomies. He invented many surgical instruments and was particularly noted for the way in which he handled aneurysms. An excellent physician and dedicated surgeon, he was sought out from afar for his diagnoses. The Pope wished to appoint Valsalva as his personal physician; however, Valsalva chose to remain at the university. The Senate of Bologna elected him Professor for Dissecting and Demonstrating Anatomy, and he remained in Bologna until his death.

Valsalva conducted many autopsies, which at the time was the chief method of furthering knowledge of both health and disease. The special interest of Valsalva was the middle and internal ear and he led detailed dissections covering the anatomy of the area. His landmark book ‘De aure humana tractatus' (Treatment of the human ear) was published in 1704. He was the first to describe the ear in three regions: inner, middle and external. His book became the standard text for over a century and was republished in several cities and translated into Dutch. He described and depicted the eardrum, muscles and nerves of the ear, He is credited with describing the structure and function of the Eustachian tube, naming it after Bartolomeo Eustachi, an Italian anatomist, who discovered it.

He studied in detail the aorta and aortic valve, describing the pocket-like dilation between the aortic valve wall and valve leaflets from which arise the coronary arteries, now known as the sinuses of Valsalva. Other areas of anatomy named after him include the Valsalva antrum, a cavity in the petrous portion of the temporal bone, Valsalva's ligament, attaching the pinna to the skull, and Valsalva's muscle, a band of vertical muscle fibres on the outer surface of the tragus which are innervated by the temporal branch of the facial nerve.

He experimented on animals, including monitoring the effects of ligating carotid arteries, conducting splenectomies, and the consequences of perforating ear drums. From his post-mortems and clinical work he noted the principle of unilateral dysfunction following from contralateral brain injury. Not always on the money, he postulated a “new foramina” linking the intracranial cavity with the ear. This “new foramina” would never be found.

Valsava was not limited to ‘hands-on’ learning by dissection, and really understood the longstanding physician principal of using all the senses. During the 17th century, there were no labs to test samples and no idea of microbes. A dedicated scientist, he is known to have sometimes tasted the fluids he encountered in cadavers in an effort to better describe them. ‘Gangrenous pus does not taste good’, he wrote, ‘leaving the tongue tingling unpleasantly for the better part of the day’. ³ For some reason, that piece of information has been lost from modern medical textbooks.

Tutor of Morgagni

Italy was a hotbed of anatomy learning at this period. Valsalva was a teacher of noteworthy scientists such as Giovanni Battista Morgagni. When Valsalva was asked by the Bologna Academy to censor the first volume of Morgagni's ‘Adversaria anatomica’, he requested extra time to give it more scrutiny, saying ‘That's how I am … I love Morgagni, but I love the truth more’. Morgagni may have had the last laugh; however, as he later had the responsibility of posthumously editing Valsalva’s complete writings and biography in 1740. In the brief biographical section, Morgagni eulogises Valsalva as an honest and self-critical physician, before writing 200 pages of anatomical observations and theories, stressing their derivation from Valsalva. He did not give much confidence to Valsalva’s ‘new foramina’ idea though. ² Morgagni later (1761) published ‘De sedibus et causis morborum’ which was perhaps unsurpassed as a guide to scientific medicine for the next 100 years.

Psychiatry

Antonio Valsalva was a pioneer in arguing that the suffering of mental health may have its origins in the physical rather than purely spiritual (this was not a new idea, having been supported by Hippocrates and others). He recommended the humanitarian treatment of mentally ill patients, at a time when mental asylums were being founded across Europe. After Valsalva, there was greater awareness of the need for psychiatric care throughout the period known as the enlightenment.

Later life

Aged 43, Valsalva married Elena Lisi, the 17-year-old daughter of a noble Bolognese senatorial family. ⁴ Together, they had six children, half of whom died in childhood. Whilst consultating with Morgagni in Venice in 1721, he suffered a temporary dyslalia. This he reasoned to be a symptom of ‘apoplexy’ – an old term which includes syndromes of sudden death and stroke. He died suddenly from apoplexy in Bologna two years later, aged 57, on 2 February 1723.