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Valsalva manoeuvre: A confusing dichotomatic misnomer
International Journal of Pediatric Otorhinolaryngology 79 (2015) 1851–1855
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Valsalva manoeuvre: A confusing dichotomatic misnomer Albert Mudry * Department of Otolaryngology – Head & Neck Surgery, Stanford University School of Medicine, 801 Welch Road, Stanford, CA 94305-5739, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Received 23 June 2015 Received in revised form 12 August 2015 Accepted 14 August 2015 Available online 24 August 2015
Objectives: The aim of this study is to try to understand the origin of the definition of the Valsalva manoeuvre by going back to original documents and finding out at which moment, the eponym was given to these two different manoeuvres, and their congruence to reality. Methods: Historical study of selected textbooks and articles about the Valsalva manoeuvre. Results: Valsalva effectively described the manoeuvre against closed nostrils and mouth at the beginning of the 18th century, but he was not the first. On the contrary, Valsalva did not describe the manoeuvre against a closed glottis. This was a mid-20th century creation. Conclusions: Two questions remain: 1. What should be done with the eponymous appellation of the manoeuvre with closed mouth and nostrils? Certainly to keep it, even if Valsalva was not the first to clearly describe it. 2. What to do with the eponymous appellation of the manoeuvre with a closed glottis? It would be ideal to change it, as it is misnamed, confusing, and only recently formulated. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Valsalva Manoeuvre History Eponym Definition
1. Introduction In standard medical dictionaries, such as the 2012 Dorland’s Illustrated Medical Dictionary, the Valsalva manoeuvre is defined as: 1. ‘‘Forcible exhalation effort against a closed glottis’’ with increases of the intrathoracic pressure interfering with venous return to the heart, also called ‘‘Valsalva’s experiment’’, and 2. ‘‘Forcible exhalation effort against occluded nostrils and a closed mouth causes increased pressure in the Eustachian tube and middle ear’’, with an open glottis, also called ‘‘Valsalva’s method or test’’ [1]. These two different definitions have a point in common, a forced expiration against a closed airway, but at different levels, the former being the glottis, and the latter the mouth and nostrils. Accordingly they have two different effects, the first one on a cervico-thoracico-abdominal level and the second one in the ears and head. In fact they are two different manoeuvres with a common name. The aim of this study is to try to understand the origin of this divergent definition by going back to original documents, and finding out at which moment, the eponym was given to these two different manoeuvres, with their congruence to reality. Different aspects were studied: 1. Valsalva’s and Morgagni’s original related writings. 2. Selected writings before Valsalva. 3. Selected writings after Valsalva and the moment when the eponymous appellations
* Tel.: +1 41 21 3124333; fax: +1 41 21 3238325. E-mail address: [email protected] http://dx.doi.org/10.1016/j.ijporl.2015.08.023 0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
were introduced. 4. The evolution of the definitions in the different editions of the referenced and largely diffused Dorland’s Illustrated Medical Dictionary. Limitations to this study are related to the improbable existence of unindexed texts written by Valsalva, and the selection of writings before and after Valsalva. 2. Original Valsalva descriptions In 1704, Antonio Maria Valsalva (1666–1723; Fig. 1) described his manoeuvre [2,3] of the insufflation of the middle ear in two different places in his treatise on the human ear (Fig. 2). Firstly in the treatment of an ulcer growing in the ear. Valsalva remarks that ‘‘pus continuously flowed out from his ear, with which lumpy blood had meanwhile admixed [. . .] I therefore saw the tympanic membrane moistened by a portion of superior liquid, and at a specific locus; from this place in like manner, I sighted a diseased fluid rushing out simultaneously along with air, whenever an ailing person held back breath by force, as I ordered, with nostrils and mouth closed’’ [4]. A few chapters later: ‘‘I will explain about the expurgation of praeternatural cranial matters: he who has inflated his mouth and nose allows air to reach as far as the dura mater. It is clear that these apertures permit relief by extruding pus in penetrating head injuries from the cranial cavity through the wound when air is forced inwards with occluded mouth and nostril. In fact by the same effort air is forced through the Eustachian tube to the tympanic cavity and backwards through the apertures against the brain [. . .] To propose here in front of everybody a thing that I indicated elsewhere, if someone having on
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A. Mudry / International Journal of Pediatric Otorhinolaryngology 79 (2015) 1851–1855
the tympanic membrane or in a surrounding ulcer, a lesion from which fluid flows continually in the external auditory canal, if, I say, this person, in closing mouth and nostrils, tries hard to compress the air inside, by this action, some pus is pushed in profusion into the external auditory canal to the point that for the cleaning of the lesion I recommend no remedy prompter and more effective than the averagely frequent practice of this effort’’. In his writings, Valsalva did not describe another such manoeuvre against closed glottis. The detailed study of the publications of Valsalva’s student Giovanni Battista Morgagni (1682–1771), and notably the Letter XIX, published in 1761 (Fig. 3), does not demonstrate the description of a manoeuvre by Valsalva of forceful expiration against a closed glottis. On the other hand, it demonstrates that Valsalva knew the effect of expiration on the circulation of blood: ‘‘Valsalva, therefore, having cut open the skin in the neck, and laid bare the jugular veins, observed that these vessels, which were turgid with blood, became less turgid, when the dog inspired; but in expiration, that they again became turgid, especially when the respiration approached more closely to its natural state [. . .] The veins swell at the time of inspiration, and are depleted at the time of expiration’’ [5,6]. Furthermore, in studying the cause of death in hung people, he made a correlation between blocked respiration and blood circulation: ‘‘If respiration be totally impeded [. . .] for the air, that was lately drawn in by the lungs, dilates itself, and, because it cannot now return from that warm place, as it used to do, more strongly compresses the small vessels, Fig. 1. portrait of Valsalva (from Politzer’s Geschichte der Ohrenheilkunde, 1907).
Fig. 2. Valsalva’s title page De aure humana tractatus, 1704.
Fig. 3. Morgagni’s title page De sedibus et causis morborum, 1761.
A. Mudry / International Journal of Pediatric Otorhinolaryngology 79 (2015) 1851–1855
which carry the blood through the lungs, so that it must of consequence stagnate in large quantity, in the lungs; the right ventricle of the heart, and the vena cava’’. This allows one to demonstrate that Valsalva does not describe the manoeuvre against closed glottis, and thus its eponymous appellation is confused. In its original conception, the Valsalva manoeuvre must only be understood as a ‘‘forceful expiration against closed nostrils and mouth in order to increase intrathoracic pressure that is transmitted through the open glottis to the oro-naso-pharyngeal cavity, and thus opens the Eustachian tube and inflates the middle ear’’ [7]. It has nothing to do with a manoeuvre against a closed glottis. To practice the original Valsalva manoeuvre the glottis must be open, a closed glottis renders impossible its main objective the insufflation of the Eustachian tube and annexed organs. 3. Pre-valsalvian descriptions of the manoeuvre against closed mouth and nostrils As early as the 1st century, and for removal of foreign bodies [8], which in his opinion could cause convulsions, Archigenes (54–117) recommended that the patient shake his head violently and be given sternutatory drugs as well; sneezing with nose and mouth closed will cause the air stream to enter the ear and eject the foreign body through the external auditory canal. Mesue the Younger (?– 1015) prescribed the same method, and instructed the patient to hold his nose and mouth closed when sneezing in order to force the full intensity of the air stream into the ear [9]. Arnold of Villanova (1240–1311) also suggested using the same method for the treatment of chronic deafness of long duration caused by excessive accumulation of ‘‘humours’’ [10]: ‘‘Then we provoke sneezing with white hellebore powder or condisi powder, or pepper powder and other similar things. When sneezing begins, the patient must firmly hold the nostrils, or to be held by someone else, in order that he might not breathe through the nose when he sneezes. By this way, numerous people deaf since a long time were really healed’’ [11]. Another indication [12] discussed by Leonard of Bertapaglia (ca. 1380–1463) was to recognize the place of fracture of the skull: ‘‘Frequently, if the patient exhales, closing his mouth and his nares with his hand, he expels the discharge from under the bone’’ [13]. Ambroise Pare´ (1510–1590) [14] also discussed the practice of this manoeuvre for the same reason: ‘‘Put into the wound a smooth pipe of lead; with two holes in the end; commanding the patient to stop his mouth, and his nostrils, and to expire with all strength, holding his head downwards; so that by the pipe much matter came away, which was collected between the skull and the meninges’’ [15]. Fabricius Hildanus (1560–1634) also enlarged the indication of this manoeuvre, to recognize the presence of a tympanic perforation. He observed that when the patient expired forcefully with mouth and nostrils closed, bubbles appeared in the pus found in the external auditory canal, indicating that air was escaping from the ear: ‘‘In this affection, it occurs this fact worthy of observation: nose and mouth closed, he exhaled so violently the air out of the ears, that if we place feathers or wisps of straw, it blows it out and produces bubbles in the pus’’ [16]. After Hildanus repeated this procedure several times the hearing and general condition of the patient improved considerably. Forced expiration against closed mouth and nostrils has been known since Antiquity and has various indications, notably to expel foreign bodies from the external auditory canal, recognize the presence of a fracture of the skull, or a perforation of the tympanic membrane. 4. Birth and conception of the eponym for the manoeuvre against closed mouth and nostrils After Valsalva’s original description, this manoeuvre was sporadically mentioned in otological literature, without a specific
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appellation, notably to expel foreign bodies from the external auditory canal. Alexandre Nicolas (1654–1723) suggested using this manoeuvre to push tobacco smoke into the middle ear as a therapeutic agent for tinnitus [17]. Jean Marc Gaspard Itard (1775– 1838) used it to expel pus from the middle ear [18]. William Wilde (1815–1876) enlarged its use during the auscultation of the ear particularly to analyze the permeability of the Eustachian tube [19]. It sometimes allowed for the discovery of a small perforation in the tympanic membrane. Jean-Pierre Bonnafont (1805–1891) confirmed that it demonstrated the presence of a tympanic perforation, but without auscultation [20]. In the mid-19th century the appellation ‘‘Valsalva experiment’’ was introduced into otological literature to name this manoeuvre. Anton von Tro¨ltsch (1829–1890) seems to be one of the first to use this eponymous appellation. In 1862, he wrote: ‘‘the well known experiment of pressing the air into the tympanic cavity, when the mouth and nostrils are closed. This is called the Valsalva experiment [Valsalva’scher Versuch]’’ [21]. As early as 1861, Tro¨ltsch mentioned the ‘‘Valsalva experiment’’ or ‘‘inflation of the tympanic membrane’’ [22]. Rapidly and since then, the ‘‘Valsalva experiment’’ or the ‘‘Valsalvian experiment’’ was mentioned in nearly all of the reference books in otology. It quickly appeared in the medical dictionaries, as in 1874: ‘‘This consists in inflating the Eustachian tube by closing the nose and mouth and employing a forcible expiration’’ [23]. In 1886, the Valsalva experiment was quoted as ‘‘being performed by inflating the Eustachian tube by closing the nose and mouth and employing a forcible expiration, for the purpose of showing or establishing a communication between the pharynx and the ear’’ [24]. Of special note, at the end of the 18th century [25] until the mid-19th century, the appellations ‘‘Valsalva method’’ and ‘‘Valsalva treatment’’ were attributed to the ‘‘employment of repeated bloodlettings, and of prolonged and rigorous course of low diet’’ [26], to treat various aneurysms. Demonstrated inefficient, this Valsalva method fell into disrepute in the second part of the 19th century. 5. Birth and conception of the eponym for the manoeuvre against closed glottis In 1850, the German physiologist Eduard Friedrich Weber (1806–1871) explained that he could interrupt at will for a moment, the beating of his heart and the pulsation of his arteries by hindering the air from entering into his chest which he compressed at the same time [27]. He clearly demonstrated, yet again, a correlation between respiration, or rather the absence of respiration, and cardiac function. This interruption of respiration and its effect on life had been acknowledged since Antiquity, but it did not exactly correspond to the manoeuvre against a closed glottis which is also composed of a forcible expiration. In 1869, the French physiologist Franc¸ois Achille Longet (1811–1871) went a step further in mentioning Valsalva: ‘‘Every time when the chest dilates and makes interiorly an emptiness in which air rushes in, venous blood, found in the vicinity of this cavity also rushes into the intra-thoracic veins. Valsalva was the first, according to Morgagni, to remark this influence of respiration of venous blood flow’’ [28]. He referred this text to ‘‘Valsalva, see Morgagni, letter XIX’’. In 1880, the German physiologist Ludimar Hermann (1838– 1914) mentioned, probably for the first time, the eponym Valsalva experiment in relation to this problematic: ‘‘Initial, soon transitory increase, then decrease of the blood pressure in compressed air during expiration (Valsalva’s test)’’ [29]. He does not give a reference. The effects of the holding of respiration then began to be studied by many physiologists. The Italian physiologist Luigi Luciani (1840–1919), is probably the first to clearly describe the manoeuvre against closed glottis at the beginning of the 20th century: ‘‘If the glottis is closed after a
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A. Mudry / International Journal of Pediatric Otorhinolaryngology 79 (2015) 1851–1855
deep inspiration, and a strenuous and prolonged expiratory effort is then made, such pressure can be exerted on the heart and intrathoracic vessels that the movements and flow are temporarily arrested (Valsalva)’’ [30]. Luciani did not mention a reference for his text, just Valsalva in brackets. In 1943, the American physiologist Percy Millard Dawson (1873–1970), in referring to Luciani, quoted exactly Luciani’s English translation text, which he definitively attributed to Valsalva [31]. Dawson added: ‘‘I have as yet found no reference to it prior to 1869 when it appears in Longet’s textbook but by 1880 the volontary compression of the chest with consequent modification of the circulation had become so well known as the ‘‘Valsalva experiment’’ that this designation could be used without comment in the best German ‘‘Handbook’’ of the time edited by L. Hermann’’. Dawson’s quotation became the reference Valsalvian text for this manoeuvre against a closed glottis. Until the mid-20th century, this manoeuvre was not mentioned in the standard dictionaries. By 1949, the Valsalva manoeuvre was defined as ‘‘forceful expiration against the closed glottis’’ [32]. In 1958 Victor Almon McKusick quoted Dawson, and added: ‘‘I have been unable to locate it in the translation of Benjamin Alexander [i.e. the English translation of Morgagni De sedibus, et causis morborum], published in 1769’’ [6,33].
against a closed glottis, was probably in correlation with the work of Dawson and his erroneous interpretation of Luciani’s writings. In the face of this dichotomatic definition of the Valsalva manoeuvre, two questions remain: 1. Should the eponymous appellation of the manoeuvre against closed mouth and nostrils be kept? Certainly, even if Valsalva was not the first to mention it, but he clearly described it. 2. What to do with the eponymous appellation of the manoeuvre against a closed glottis? It would be good to change it because it is misnamed, confusing, and only recently formulated [38]. Perhaps Luciani’s manoeuvre would be more historically and eponymously correct? Or forced expiration against a closed glottis? Or simply abdominal straining?
6. Evolution of the definition of the Valsalva manoeuvre in Dorland’s Illustrated Medical Dictionary
[1] Dorland’s Illustrated Medical Dictionary, 32nd ed., Saunders, Philadelphia, 2012p. 1094. [2] Editorials, Antonio Maria Valsalva (1666–1723) Valsalva maneuver, JAMA 211 (4) (1970) 655. [3] E.H. Jellinek, The Valsalva maneuver and Antonio Valsalva (1666–1723), J. R. Soc. Med. 99 (2006) 448–451. [4] A. Valsalva, De aure humana tractatus, Pisarius, Bononiae, 1704, pp. 108–109, p. 21. [5] G.B. Morgagni, De sedibus, et causis morborum per anatomen indagatis libri quinque, vol. I, Remondini, Venetiis, 1761, pp. 370–374. [6] G.B. Morgagni, The Seats and Causes of Diseases Investigated by Anatomy, vol. I, Millar & Cadell, London, 1769, , pp. 518–519525. [7] H. Talasz, M. Kofler, M. Lechleitner, Misconception of the Vasalva maneuver, Int. Urogynecol. J. 22 (2011) 1197–1198. [8] Quoted by Galen. De compositione medicamentorum secundum locos III, 1. Ku¨hn, vol. XII, pp. 656–657. [9] Mesue the Younger, Joannis Mesuae Damasceni medici clarissini opera, Iuntas, Venetiis, 1581, Lib. II, Summa VI, Cap. 1–8.. [10] K. Baas, Historische Notiz u¨ber den Valsalvaschen Versuch und das Politzersche Verfahren, Muenchener Med. Wochenschr. 47 (1903) 2057–2058. [11] A. Villanova, Breviarium Practicae, Baptista de Tortis, Venice, 1494. [12] C. Worthington, Valsalva maneuver: a misnomer, J. Neurosurg. 75 (1991) 497. [13] L. Bertapaglia, in: J.C. Ladenheim (Ed.), On Nerves Injuries and Skull Fractures, Futura, New York, 1989, p. 81. [14] B.N. Nathan, Vasalva maneuver or Pare´ maneuver? J. Neurosurg. 74 (1991) 690. [15] A. Pare´, An Explanation of the Fashion and Use of Three and Fifty Instruments of Chirurgery, Sparke, London, 1634p. 62. [16] F. Hildanus, Centuriae tertiae, de Bry, Oppenheim, 1614p. 42. [17] A. Nicolas, La me´decine et la chirurgie des pauvres, Le conte, Paris, 1714p. 55. [18] J.M.G. Itard, Traite´ des maladies de l’oreille et de l’audition, vol. I, Me´quignonMarvis, Paris, 1821, p. 178234. [19] W. Wilde, Practical Observations on Aural Surgery, Blanchard & Lea, Philadelphia, 1853p. 74. [20] J.P. Bonnafont, Traite´ the´orique et pratique des maladies de l’oreille, Baillie`re, Paris, 1860p. 272. [21] A. Tro¨ltsch, Die Krankheiten des Ohres, Stahel, Wu¨rzburg, 1862p. 88. [22] A. Tro¨ltsch, Der Katheterismus der Ohrtrompete. Seine Ausfu¨hrung und sein praktischer Werth, Dtsch Klin. 13 (1861) 232–234. [23] R. Dunglison, A Dictionary of Medical Science, New ed., Henry, Philadelphia, 1874p. 1088. [24] J. Thomas, A Complete Pronouncing Medical Dictionary, Lippincott, Philadelphia, 1886p. 772. [25] R. Caillot, Essai sur l’ane´vrisme, Migneret, Paris, 1799p. 36. [26] T. Brady, On the Treatment of Internal Aneurism by the Method of Valsalva, Fannin, Dublin, 1859p. 3. [27] E.F. Weber, Ueber ein Verfahren den Kreislauf des Blutes und die Function des Herzens willku¨rlich zu unterbrechen, Ber. Verh. Sa¨chs. Ges. Wiss. Leipz. (1850) 29–48. [28] F.A. Longet, 3rd ed., Traite´ de physiologie, vol. II, Baillie`re, Paris, 1869p. 245. [29] L. Hermann, Handbuch der Physiologie, vol. IV, Vogel, Leipzig, 1880p. 293. [30] L. Luciani, Fisiologia dell’uomo, vol. I, Socie´ta` editrice libraria, Milano, 1901p. 397; L. Luciani, Human Physiology, vol. I, Macmillan, London, 1911p. 436. [31] P.M. Dawson, An historical sketch of the Valsalva experiment, Bull. Hist. Med. 14 (1943) 295–320, 297–298. [32] N.E. Freeman, T.M. Fullenlove, E.J. Wylie, R.S. Gilfillan, The Valsalva maneuver: an aid for the contrast visualization of the aorta and great vessels, Ann. Surg. 130 (1949) 398–414.
Until 1947 and the 21st ed. of Dorland’s Illustrated Medical Dictionary, Vasalva experiment or manoeuvre was defined as an ‘‘inflation of the Eustachian tube by closing the nose and mouth and employing a forcible expiration’’ [34]. In the 22nd ed. (1951), Valsalva experiment was related to: ‘‘closing the mouth and nose and making a forcible expiratory effort tend to inflate the Eustachian tube and to increase the intrathoracic pressure and thus to check the return flow of blood which is manifested by engorged veins in the neck’’ [35]. In the 23th ed. (1957) the definition completely changed and became an ‘‘increase of intrapulmonic pressure by forcible exhalation against the closed glottis’’ [36]. The original Valsalva manoeuvre thus disappeared and was replaced by a new definition related to a manoeuvre against a closed glottis. It remained the same until the 26th ed. (1985) and the re-introduction of the original definition, thus resulting in two separate definitions for the Valsalva manoeuvre: ‘‘1. Forcible exhalation effort against a closed glottis; the resultant increase in intrathoracic pressure interferes with venous return to heart. 2. Forcible exhalation effort against occluded nostrils and a closed mouth; the increased pressure in the Eustachian tube and middle ear causes the tympanic membrane to move outward’’ [37]. It remained unchanged until 2012 [1]. 7. Historical perspective This study allows one to demonstrate that 1. Valsalva only described the manoeuvre against closed mouth and nostrils. Thus, the manoeuvre against a closed glottis has nothing to do with Valsalva. 2. Valsalva was not the first to describe this manoeuvre against closed mouth and nostrils. It was already known in Antiquity, and mentioned by various authors up until Valsalva. 3. The eponymous appellation for the manoeuvre against closed mouth and nostrils was introduced in the mid-19th century by the otologists, notably Tro¨ltsch. 4. The eponymous appellation for the manoeuvre against a closed glottis was introduced in the mid-20th century. 5. It is not possible to explain why the eponym Valsalva is given to the manoeuvre against closed mouth and nostrils. It is possible that the only reason is because Valsalva was a very famous physician. 6. The introduction of the eponym to the manoeuvre
Conflict of interest No conflict of interest. Funding No financial disclosure. References
A. Mudry / International Journal of Pediatric Otorhinolaryngology 79 (2015) 1851–1855 [33] V.A. McKusick, Cardiovascular Sound in Health and Disease, Williams & Wilkins, Baltimore, 1958p. 35. [34] W.A.N. Dorland, The American Illustrated Medical Dictionary, 21st ed., Saunders, Philadelphia, 1947p. 1597. [35] W.A.N. Dorland, The American Illustrated Medical Dictionary, 22nd ed., Saunders, Philadelphia, 1951p. 535.
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[36] W.A.N. Dorland, The American Illustrated Medical Dictionary, 23rd ed., Saunders, Philadelphia, 1957p. 794. [37] Dorland’s Illustrated Medical Dictionary, 26th ed., Saunders, Philadelphia, 1985p. 774. [38] J. Van Gijn, J.P. Gijselhart, Valsalva en zijn maneuver, Ned. Tijdschr. Geneeskd. 154 (2010) A1803.
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Valsalva manoeuvre: A confusing dichotomatic misnomer Albert Mudry * Department of Otolaryngology – Head & Neck Surgery, Stanford University School of Medicine, 801 Welch Road, Stanford, CA 94305-5739, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Received 23 June 2015 Received in revised form 12 August 2015 Accepted 14 August 2015 Available online 24 August 2015
Objectives: The aim of this study is to try to understand the origin of the definition of the Valsalva manoeuvre by going back to original documents and finding out at which moment, the eponym was given to these two different manoeuvres, and their congruence to reality. Methods: Historical study of selected textbooks and articles about the Valsalva manoeuvre. Results: Valsalva effectively described the manoeuvre against closed nostrils and mouth at the beginning of the 18th century, but he was not the first. On the contrary, Valsalva did not describe the manoeuvre against a closed glottis. This was a mid-20th century creation. Conclusions: Two questions remain: 1. What should be done with the eponymous appellation of the manoeuvre with closed mouth and nostrils? Certainly to keep it, even if Valsalva was not the first to clearly describe it. 2. What to do with the eponymous appellation of the manoeuvre with a closed glottis? It would be ideal to change it, as it is misnamed, confusing, and only recently formulated. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Valsalva Manoeuvre History Eponym Definition
1. Introduction In standard medical dictionaries, such as the 2012 Dorland’s Illustrated Medical Dictionary, the Valsalva manoeuvre is defined as: 1. ‘‘Forcible exhalation effort against a closed glottis’’ with increases of the intrathoracic pressure interfering with venous return to the heart, also called ‘‘Valsalva’s experiment’’, and 2. ‘‘Forcible exhalation effort against occluded nostrils and a closed mouth causes increased pressure in the Eustachian tube and middle ear’’, with an open glottis, also called ‘‘Valsalva’s method or test’’ [1]. These two different definitions have a point in common, a forced expiration against a closed airway, but at different levels, the former being the glottis, and the latter the mouth and nostrils. Accordingly they have two different effects, the first one on a cervico-thoracico-abdominal level and the second one in the ears and head. In fact they are two different manoeuvres with a common name. The aim of this study is to try to understand the origin of this divergent definition by going back to original documents, and finding out at which moment, the eponym was given to these two different manoeuvres, with their congruence to reality. Different aspects were studied: 1. Valsalva’s and Morgagni’s original related writings. 2. Selected writings before Valsalva. 3. Selected writings after Valsalva and the moment when the eponymous appellations
* Tel.: +1 41 21 3124333; fax: +1 41 21 3238325. E-mail address: [email protected] http://dx.doi.org/10.1016/j.ijporl.2015.08.023 0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
were introduced. 4. The evolution of the definitions in the different editions of the referenced and largely diffused Dorland’s Illustrated Medical Dictionary. Limitations to this study are related to the improbable existence of unindexed texts written by Valsalva, and the selection of writings before and after Valsalva. 2. Original Valsalva descriptions In 1704, Antonio Maria Valsalva (1666–1723; Fig. 1) described his manoeuvre [2,3] of the insufflation of the middle ear in two different places in his treatise on the human ear (Fig. 2). Firstly in the treatment of an ulcer growing in the ear. Valsalva remarks that ‘‘pus continuously flowed out from his ear, with which lumpy blood had meanwhile admixed [. . .] I therefore saw the tympanic membrane moistened by a portion of superior liquid, and at a specific locus; from this place in like manner, I sighted a diseased fluid rushing out simultaneously along with air, whenever an ailing person held back breath by force, as I ordered, with nostrils and mouth closed’’ [4]. A few chapters later: ‘‘I will explain about the expurgation of praeternatural cranial matters: he who has inflated his mouth and nose allows air to reach as far as the dura mater. It is clear that these apertures permit relief by extruding pus in penetrating head injuries from the cranial cavity through the wound when air is forced inwards with occluded mouth and nostril. In fact by the same effort air is forced through the Eustachian tube to the tympanic cavity and backwards through the apertures against the brain [. . .] To propose here in front of everybody a thing that I indicated elsewhere, if someone having on
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A. Mudry / International Journal of Pediatric Otorhinolaryngology 79 (2015) 1851–1855
the tympanic membrane or in a surrounding ulcer, a lesion from which fluid flows continually in the external auditory canal, if, I say, this person, in closing mouth and nostrils, tries hard to compress the air inside, by this action, some pus is pushed in profusion into the external auditory canal to the point that for the cleaning of the lesion I recommend no remedy prompter and more effective than the averagely frequent practice of this effort’’. In his writings, Valsalva did not describe another such manoeuvre against closed glottis. The detailed study of the publications of Valsalva’s student Giovanni Battista Morgagni (1682–1771), and notably the Letter XIX, published in 1761 (Fig. 3), does not demonstrate the description of a manoeuvre by Valsalva of forceful expiration against a closed glottis. On the other hand, it demonstrates that Valsalva knew the effect of expiration on the circulation of blood: ‘‘Valsalva, therefore, having cut open the skin in the neck, and laid bare the jugular veins, observed that these vessels, which were turgid with blood, became less turgid, when the dog inspired; but in expiration, that they again became turgid, especially when the respiration approached more closely to its natural state [. . .] The veins swell at the time of inspiration, and are depleted at the time of expiration’’ [5,6]. Furthermore, in studying the cause of death in hung people, he made a correlation between blocked respiration and blood circulation: ‘‘If respiration be totally impeded [. . .] for the air, that was lately drawn in by the lungs, dilates itself, and, because it cannot now return from that warm place, as it used to do, more strongly compresses the small vessels, Fig. 1. portrait of Valsalva (from Politzer’s Geschichte der Ohrenheilkunde, 1907).
Fig. 2. Valsalva’s title page De aure humana tractatus, 1704.
Fig. 3. Morgagni’s title page De sedibus et causis morborum, 1761.
A. Mudry / International Journal of Pediatric Otorhinolaryngology 79 (2015) 1851–1855
which carry the blood through the lungs, so that it must of consequence stagnate in large quantity, in the lungs; the right ventricle of the heart, and the vena cava’’. This allows one to demonstrate that Valsalva does not describe the manoeuvre against closed glottis, and thus its eponymous appellation is confused. In its original conception, the Valsalva manoeuvre must only be understood as a ‘‘forceful expiration against closed nostrils and mouth in order to increase intrathoracic pressure that is transmitted through the open glottis to the oro-naso-pharyngeal cavity, and thus opens the Eustachian tube and inflates the middle ear’’ [7]. It has nothing to do with a manoeuvre against a closed glottis. To practice the original Valsalva manoeuvre the glottis must be open, a closed glottis renders impossible its main objective the insufflation of the Eustachian tube and annexed organs. 3. Pre-valsalvian descriptions of the manoeuvre against closed mouth and nostrils As early as the 1st century, and for removal of foreign bodies [8], which in his opinion could cause convulsions, Archigenes (54–117) recommended that the patient shake his head violently and be given sternutatory drugs as well; sneezing with nose and mouth closed will cause the air stream to enter the ear and eject the foreign body through the external auditory canal. Mesue the Younger (?– 1015) prescribed the same method, and instructed the patient to hold his nose and mouth closed when sneezing in order to force the full intensity of the air stream into the ear [9]. Arnold of Villanova (1240–1311) also suggested using the same method for the treatment of chronic deafness of long duration caused by excessive accumulation of ‘‘humours’’ [10]: ‘‘Then we provoke sneezing with white hellebore powder or condisi powder, or pepper powder and other similar things. When sneezing begins, the patient must firmly hold the nostrils, or to be held by someone else, in order that he might not breathe through the nose when he sneezes. By this way, numerous people deaf since a long time were really healed’’ [11]. Another indication [12] discussed by Leonard of Bertapaglia (ca. 1380–1463) was to recognize the place of fracture of the skull: ‘‘Frequently, if the patient exhales, closing his mouth and his nares with his hand, he expels the discharge from under the bone’’ [13]. Ambroise Pare´ (1510–1590) [14] also discussed the practice of this manoeuvre for the same reason: ‘‘Put into the wound a smooth pipe of lead; with two holes in the end; commanding the patient to stop his mouth, and his nostrils, and to expire with all strength, holding his head downwards; so that by the pipe much matter came away, which was collected between the skull and the meninges’’ [15]. Fabricius Hildanus (1560–1634) also enlarged the indication of this manoeuvre, to recognize the presence of a tympanic perforation. He observed that when the patient expired forcefully with mouth and nostrils closed, bubbles appeared in the pus found in the external auditory canal, indicating that air was escaping from the ear: ‘‘In this affection, it occurs this fact worthy of observation: nose and mouth closed, he exhaled so violently the air out of the ears, that if we place feathers or wisps of straw, it blows it out and produces bubbles in the pus’’ [16]. After Hildanus repeated this procedure several times the hearing and general condition of the patient improved considerably. Forced expiration against closed mouth and nostrils has been known since Antiquity and has various indications, notably to expel foreign bodies from the external auditory canal, recognize the presence of a fracture of the skull, or a perforation of the tympanic membrane. 4. Birth and conception of the eponym for the manoeuvre against closed mouth and nostrils After Valsalva’s original description, this manoeuvre was sporadically mentioned in otological literature, without a specific
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appellation, notably to expel foreign bodies from the external auditory canal. Alexandre Nicolas (1654–1723) suggested using this manoeuvre to push tobacco smoke into the middle ear as a therapeutic agent for tinnitus [17]. Jean Marc Gaspard Itard (1775– 1838) used it to expel pus from the middle ear [18]. William Wilde (1815–1876) enlarged its use during the auscultation of the ear particularly to analyze the permeability of the Eustachian tube [19]. It sometimes allowed for the discovery of a small perforation in the tympanic membrane. Jean-Pierre Bonnafont (1805–1891) confirmed that it demonstrated the presence of a tympanic perforation, but without auscultation [20]. In the mid-19th century the appellation ‘‘Valsalva experiment’’ was introduced into otological literature to name this manoeuvre. Anton von Tro¨ltsch (1829–1890) seems to be one of the first to use this eponymous appellation. In 1862, he wrote: ‘‘the well known experiment of pressing the air into the tympanic cavity, when the mouth and nostrils are closed. This is called the Valsalva experiment [Valsalva’scher Versuch]’’ [21]. As early as 1861, Tro¨ltsch mentioned the ‘‘Valsalva experiment’’ or ‘‘inflation of the tympanic membrane’’ [22]. Rapidly and since then, the ‘‘Valsalva experiment’’ or the ‘‘Valsalvian experiment’’ was mentioned in nearly all of the reference books in otology. It quickly appeared in the medical dictionaries, as in 1874: ‘‘This consists in inflating the Eustachian tube by closing the nose and mouth and employing a forcible expiration’’ [23]. In 1886, the Valsalva experiment was quoted as ‘‘being performed by inflating the Eustachian tube by closing the nose and mouth and employing a forcible expiration, for the purpose of showing or establishing a communication between the pharynx and the ear’’ [24]. Of special note, at the end of the 18th century [25] until the mid-19th century, the appellations ‘‘Valsalva method’’ and ‘‘Valsalva treatment’’ were attributed to the ‘‘employment of repeated bloodlettings, and of prolonged and rigorous course of low diet’’ [26], to treat various aneurysms. Demonstrated inefficient, this Valsalva method fell into disrepute in the second part of the 19th century. 5. Birth and conception of the eponym for the manoeuvre against closed glottis In 1850, the German physiologist Eduard Friedrich Weber (1806–1871) explained that he could interrupt at will for a moment, the beating of his heart and the pulsation of his arteries by hindering the air from entering into his chest which he compressed at the same time [27]. He clearly demonstrated, yet again, a correlation between respiration, or rather the absence of respiration, and cardiac function. This interruption of respiration and its effect on life had been acknowledged since Antiquity, but it did not exactly correspond to the manoeuvre against a closed glottis which is also composed of a forcible expiration. In 1869, the French physiologist Franc¸ois Achille Longet (1811–1871) went a step further in mentioning Valsalva: ‘‘Every time when the chest dilates and makes interiorly an emptiness in which air rushes in, venous blood, found in the vicinity of this cavity also rushes into the intra-thoracic veins. Valsalva was the first, according to Morgagni, to remark this influence of respiration of venous blood flow’’ [28]. He referred this text to ‘‘Valsalva, see Morgagni, letter XIX’’. In 1880, the German physiologist Ludimar Hermann (1838– 1914) mentioned, probably for the first time, the eponym Valsalva experiment in relation to this problematic: ‘‘Initial, soon transitory increase, then decrease of the blood pressure in compressed air during expiration (Valsalva’s test)’’ [29]. He does not give a reference. The effects of the holding of respiration then began to be studied by many physiologists. The Italian physiologist Luigi Luciani (1840–1919), is probably the first to clearly describe the manoeuvre against closed glottis at the beginning of the 20th century: ‘‘If the glottis is closed after a
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deep inspiration, and a strenuous and prolonged expiratory effort is then made, such pressure can be exerted on the heart and intrathoracic vessels that the movements and flow are temporarily arrested (Valsalva)’’ [30]. Luciani did not mention a reference for his text, just Valsalva in brackets. In 1943, the American physiologist Percy Millard Dawson (1873–1970), in referring to Luciani, quoted exactly Luciani’s English translation text, which he definitively attributed to Valsalva [31]. Dawson added: ‘‘I have as yet found no reference to it prior to 1869 when it appears in Longet’s textbook but by 1880 the volontary compression of the chest with consequent modification of the circulation had become so well known as the ‘‘Valsalva experiment’’ that this designation could be used without comment in the best German ‘‘Handbook’’ of the time edited by L. Hermann’’. Dawson’s quotation became the reference Valsalvian text for this manoeuvre against a closed glottis. Until the mid-20th century, this manoeuvre was not mentioned in the standard dictionaries. By 1949, the Valsalva manoeuvre was defined as ‘‘forceful expiration against the closed glottis’’ [32]. In 1958 Victor Almon McKusick quoted Dawson, and added: ‘‘I have been unable to locate it in the translation of Benjamin Alexander [i.e. the English translation of Morgagni De sedibus, et causis morborum], published in 1769’’ [6,33].
against a closed glottis, was probably in correlation with the work of Dawson and his erroneous interpretation of Luciani’s writings. In the face of this dichotomatic definition of the Valsalva manoeuvre, two questions remain: 1. Should the eponymous appellation of the manoeuvre against closed mouth and nostrils be kept? Certainly, even if Valsalva was not the first to mention it, but he clearly described it. 2. What to do with the eponymous appellation of the manoeuvre against a closed glottis? It would be good to change it because it is misnamed, confusing, and only recently formulated [38]. Perhaps Luciani’s manoeuvre would be more historically and eponymously correct? Or forced expiration against a closed glottis? Or simply abdominal straining?
6. Evolution of the definition of the Valsalva manoeuvre in Dorland’s Illustrated Medical Dictionary
[1] Dorland’s Illustrated Medical Dictionary, 32nd ed., Saunders, Philadelphia, 2012p. 1094. [2] Editorials, Antonio Maria Valsalva (1666–1723) Valsalva maneuver, JAMA 211 (4) (1970) 655. [3] E.H. Jellinek, The Valsalva maneuver and Antonio Valsalva (1666–1723), J. R. Soc. Med. 99 (2006) 448–451. [4] A. Valsalva, De aure humana tractatus, Pisarius, Bononiae, 1704, pp. 108–109, p. 21. [5] G.B. Morgagni, De sedibus, et causis morborum per anatomen indagatis libri quinque, vol. I, Remondini, Venetiis, 1761, pp. 370–374. [6] G.B. Morgagni, The Seats and Causes of Diseases Investigated by Anatomy, vol. I, Millar & Cadell, London, 1769, , pp. 518–519525. [7] H. Talasz, M. Kofler, M. Lechleitner, Misconception of the Vasalva maneuver, Int. Urogynecol. J. 22 (2011) 1197–1198. [8] Quoted by Galen. De compositione medicamentorum secundum locos III, 1. Ku¨hn, vol. XII, pp. 656–657. [9] Mesue the Younger, Joannis Mesuae Damasceni medici clarissini opera, Iuntas, Venetiis, 1581, Lib. II, Summa VI, Cap. 1–8.. [10] K. Baas, Historische Notiz u¨ber den Valsalvaschen Versuch und das Politzersche Verfahren, Muenchener Med. Wochenschr. 47 (1903) 2057–2058. [11] A. Villanova, Breviarium Practicae, Baptista de Tortis, Venice, 1494. [12] C. Worthington, Valsalva maneuver: a misnomer, J. Neurosurg. 75 (1991) 497. [13] L. Bertapaglia, in: J.C. Ladenheim (Ed.), On Nerves Injuries and Skull Fractures, Futura, New York, 1989, p. 81. [14] B.N. Nathan, Vasalva maneuver or Pare´ maneuver? J. Neurosurg. 74 (1991) 690. [15] A. Pare´, An Explanation of the Fashion and Use of Three and Fifty Instruments of Chirurgery, Sparke, London, 1634p. 62. [16] F. Hildanus, Centuriae tertiae, de Bry, Oppenheim, 1614p. 42. [17] A. Nicolas, La me´decine et la chirurgie des pauvres, Le conte, Paris, 1714p. 55. [18] J.M.G. Itard, Traite´ des maladies de l’oreille et de l’audition, vol. I, Me´quignonMarvis, Paris, 1821, p. 178234. [19] W. Wilde, Practical Observations on Aural Surgery, Blanchard & Lea, Philadelphia, 1853p. 74. [20] J.P. Bonnafont, Traite´ the´orique et pratique des maladies de l’oreille, Baillie`re, Paris, 1860p. 272. [21] A. Tro¨ltsch, Die Krankheiten des Ohres, Stahel, Wu¨rzburg, 1862p. 88. [22] A. Tro¨ltsch, Der Katheterismus der Ohrtrompete. Seine Ausfu¨hrung und sein praktischer Werth, Dtsch Klin. 13 (1861) 232–234. [23] R. Dunglison, A Dictionary of Medical Science, New ed., Henry, Philadelphia, 1874p. 1088. [24] J. Thomas, A Complete Pronouncing Medical Dictionary, Lippincott, Philadelphia, 1886p. 772. [25] R. Caillot, Essai sur l’ane´vrisme, Migneret, Paris, 1799p. 36. [26] T. Brady, On the Treatment of Internal Aneurism by the Method of Valsalva, Fannin, Dublin, 1859p. 3. [27] E.F. Weber, Ueber ein Verfahren den Kreislauf des Blutes und die Function des Herzens willku¨rlich zu unterbrechen, Ber. Verh. Sa¨chs. Ges. Wiss. Leipz. (1850) 29–48. [28] F.A. Longet, 3rd ed., Traite´ de physiologie, vol. II, Baillie`re, Paris, 1869p. 245. [29] L. Hermann, Handbuch der Physiologie, vol. IV, Vogel, Leipzig, 1880p. 293. [30] L. Luciani, Fisiologia dell’uomo, vol. I, Socie´ta` editrice libraria, Milano, 1901p. 397; L. Luciani, Human Physiology, vol. I, Macmillan, London, 1911p. 436. [31] P.M. Dawson, An historical sketch of the Valsalva experiment, Bull. Hist. Med. 14 (1943) 295–320, 297–298. [32] N.E. Freeman, T.M. Fullenlove, E.J. Wylie, R.S. Gilfillan, The Valsalva maneuver: an aid for the contrast visualization of the aorta and great vessels, Ann. Surg. 130 (1949) 398–414.
Until 1947 and the 21st ed. of Dorland’s Illustrated Medical Dictionary, Vasalva experiment or manoeuvre was defined as an ‘‘inflation of the Eustachian tube by closing the nose and mouth and employing a forcible expiration’’ [34]. In the 22nd ed. (1951), Valsalva experiment was related to: ‘‘closing the mouth and nose and making a forcible expiratory effort tend to inflate the Eustachian tube and to increase the intrathoracic pressure and thus to check the return flow of blood which is manifested by engorged veins in the neck’’ [35]. In the 23th ed. (1957) the definition completely changed and became an ‘‘increase of intrapulmonic pressure by forcible exhalation against the closed glottis’’ [36]. The original Valsalva manoeuvre thus disappeared and was replaced by a new definition related to a manoeuvre against a closed glottis. It remained the same until the 26th ed. (1985) and the re-introduction of the original definition, thus resulting in two separate definitions for the Valsalva manoeuvre: ‘‘1. Forcible exhalation effort against a closed glottis; the resultant increase in intrathoracic pressure interferes with venous return to heart. 2. Forcible exhalation effort against occluded nostrils and a closed mouth; the increased pressure in the Eustachian tube and middle ear causes the tympanic membrane to move outward’’ [37]. It remained unchanged until 2012 [1]. 7. Historical perspective This study allows one to demonstrate that 1. Valsalva only described the manoeuvre against closed mouth and nostrils. Thus, the manoeuvre against a closed glottis has nothing to do with Valsalva. 2. Valsalva was not the first to describe this manoeuvre against closed mouth and nostrils. It was already known in Antiquity, and mentioned by various authors up until Valsalva. 3. The eponymous appellation for the manoeuvre against closed mouth and nostrils was introduced in the mid-19th century by the otologists, notably Tro¨ltsch. 4. The eponymous appellation for the manoeuvre against a closed glottis was introduced in the mid-20th century. 5. It is not possible to explain why the eponym Valsalva is given to the manoeuvre against closed mouth and nostrils. It is possible that the only reason is because Valsalva was a very famous physician. 6. The introduction of the eponym to the manoeuvre
Conflict of interest No conflict of interest. Funding No financial disclosure. References
A. Mudry / International Journal of Pediatric Otorhinolaryngology 79 (2015) 1851–1855 [33] V.A. McKusick, Cardiovascular Sound in Health and Disease, Williams & Wilkins, Baltimore, 1958p. 35. [34] W.A.N. Dorland, The American Illustrated Medical Dictionary, 21st ed., Saunders, Philadelphia, 1947p. 1597. [35] W.A.N. Dorland, The American Illustrated Medical Dictionary, 22nd ed., Saunders, Philadelphia, 1951p. 535.
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[36] W.A.N. Dorland, The American Illustrated Medical Dictionary, 23rd ed., Saunders, Philadelphia, 1957p. 794. [37] Dorland’s Illustrated Medical Dictionary, 26th ed., Saunders, Philadelphia, 1985p. 774. [38] J. Van Gijn, J.P. Gijselhart, Valsalva en zijn maneuver, Ned. Tijdschr. Geneeskd. 154 (2010) A1803.