The history of vestibular science

​

The evolution of knowledge about the vestibular system, its anatomy and physiology is as fascinating as the science itself. The knowledge took two millennia to evolve and kept pace with different epochs and cultural revolutions in human civilisation.

​

Antiquity

Antiquity was a glorious age of a blossoming human civilisation. The earliest known mention of giddiness as an illness was described in the Ebers papyrus in Egypt circa 1500 BC. Erasistratus of Chios in circa 3rd century BC mentioned the role of the brain in providing balance. Hippocrates, Aristotle and Lucretius all described dizziness with different drugs from 4th century BC until 3rd century AD. Ptolemy described dizziness in busy surroundings. It was Claudius Galenus or Galen who dissected a pigeon’s ear and identified the inner ear labyrinth. He named it ‘labyrinthos’ after the Greek legend of the abode of the monster Minotaur in Crete. Archigenes at the same time discovered a disease where a subject presented with tinnitus, hearing loss and dizziness that later came to be identified as Meniere’s disease.

​

​

​

​

​

 

 

 

 

 

 

 

 

Middle ages

After the fall of the Roam empire, European civilisation took a back seat and plunged into the dark ages where knowledge stagnated. However, medical knowledge flourished in the middle east and in the Arabian peninsula that ushered in a golden age of knowledge in the Islamic Caliphate. Gariopontus in the 11th century ascribed ‘darkening of eyes’ to vertigo and thought that it originated in the stomach.  3 influential Arabic physicians Avicenna, Rhasis and Constantine the African all have described classical spinning sensations and proposed possible causes either in the head or in the stomach. Rhasis replicated Archigenes’ designated syndrome.  These seminal texts were translated and found their way to Europe by the monks form the Salerno medical school in Italy at great personal peril risking death as heretics.

​

​

​

​

​

​

​

​

​

​

​

​

​

 

 

16th-17th century – the Renaissance

As one can see that from antiquity up to the middle ages, it was well recognised that there was a sensation involving an illusion of motion but there was no knowledge on how it happened or what caused it.The time was ripe for an explosion of knowledge in vestibular sciences from the Renaissance period. Parallel to the art forms expressing the age of enlightenment and glorifying the creator, the human quest to explain nature by science emerged and flourished. Along with this profound change blossomed the science of anatomy.

​

Vesalius, Fallopius, Eustachi and Morgagni described the semicircular canals in the human in the 16th and early 17th centuries being all gifted artists. The association of vertigo as a neurological disorder was first proposed by the English physician Thomas Willis (1621-1675) who tried to explain vertigo in Galenic animal spirits causing motion in head through nerves. The best-known treatise on the human vestibular system after an initial description by Fallopius was the now almost forgotten Traite de l’Organe de l’Ouie published 1695, the first dedicated text book on otology in history and was a benchmark in inspiring future generations to embark on ground breaking research. This was written by Guichard Joseph Duverney (1648 – 1730), a French anatomist.

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

 

18th – 19th century – the Romantic period and beyond

The 18th and the 19th century can be ascribed as the golden age in the research in vestibular sciences. This mirrored the political revolution in Europe and the change in world order and the birth of the Romantic movement in art which glorified the human spirit.This inspired the vestibular scientists to explain nature by discoveries and innovations which they designed and experimented with. It was an age of scientific and spiritual discovery.

​

Domenico Cotugno (1775) described an inner membraneous labyrinth and outer bony labyrinth. Antonio Scarpa (1789) described the semicircular duct system, ampulla, utricle and saccule and the vestibulo cochlear nerve. Head on body rotation generates vertigo, slumber and laughter was identified by Erasmus Darwin (1731-1802) and Joseph Cox (1763-1818) with the first experimental device in vestibular history. William Porterfield (1696 – 1771) and William Wells (1757 – 1817) were the first to point out the role of vision and eye movements in response to rotation. Moritz Romberg (1785 – 1873) in Lehrbuch der Nervenkrankheiten des Menschen, 1840 accurately described different vertiginous syndromes not knowing where they originated from.

​

The title of the father of vestibular physiology can be ascribed to Marie Jean Pierre Flourens (1794-1867) as he with his revolutionary animal experiments in pigeons accurately localised the function of semicircular canals to balance. Johannes Evangelist Purkinje (1787 – 1869) identified the role of vestibulo cerebellar connections for posture. Friedrich Goltz (1834-1902) confirmed Flourens’ observations. Charles-Édouard Brown-Séquard (1817-1894) first identified the caloric reaction to ears in history in 1858 and described the vestibular nuclei yet to be named. Joseph Breuer (1842-1925) identified endolymphatic flow directional currents for stimulation of the semicircular canals and the role of otolith organs as translational sensors. Ernest Mach (1838-1916) independently arrived at the same conclusion as Breuer and the fact that the vestibule has no role in hearing was called ‘’ Mach-Breuer hypothesis’’. Ernest Ewald (1855 – 1921) determined direction of endolymphatic flow on stimulation called ‘’Ewald’s laws’’. Alexander Crum Brown (1838-1922) explained pairing of semicircular canals; vestibular pathologies, optic fixation & vestibular compensation. Endre Hogyes (1847 – 1906) identified the VOR and clinical effects in semicircular canal destruction with compensation.

​

2 scientists during this period challenged the established world scientific order during this time and can be called ‘Galileos’ of vestibular science. Prospere Meniere (1799 – 1862) attributed vertigo to a problem in the inner ear for the first time in history and described the syndrome bearing his name. This led to him being ostracised from the scientific community as this was considered almost heretic. Elias von Cyon (1843-1912) with his seminal work on semicircular canal function challenged for the first time the philosophical and metaphysical concept of orientation in space as propounded by Immanuel Kant.

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

Modern Age

The 20th century heralds the modern age. The development of the electron microscope and histochemical techniques paved the way for further delineation of vestibular anatomy. At the same time, ground breaking vestibular function research was spearheaded by two men who won Nobel Prizes in Medicine for their work. This tradition is continuing with technological advances at an accelerated pace to this day.

​

Santiago Ramón y Cajal (1852 – 1934) won the Nobel Prize in 1906 for describing systems in the brain that include the connections of the vestibular nerve to the vestibular nuclei. Robert  Barany (1876 – 1936) won the Nobel Prize in 1914 for describing vestibular physiology and pathology. Gustav Alexander (1873 – 1932) described Alexander’s law in 1912. Rafael Lorente de No (1902 – 1990) described the anatomical vestibulo ocular reflex arc for the first time in 1933. János Szentágothai (1912 – 1994) collated all previous information and delineates labyrinthine receptor – oculomotor nuclei connections in 1952. Margaret Dix (1902-1991) and Charles Hallpike (1900-1979) described the Dix Hallpike procedure for the first time in 1952.

​

​

​

​

​

​

​

​

​

​

 

 

 

 

​

 

Present day

The glorious legacy of scientific discovery continues in vestibular sciences. Modern-day scientists are involved  in cutting edge vestibular research for vestibular diagnostics and management. Knowledge is evolving at a rapid rate and still there are many things about the vestibular system that we do not know about.

​

History of pediatric vestibular science

​The difference between adults and children in terms physiology and disease processes relate to developed and developing physiological processes in the 2 groups. This was recognised in the ancient world by Hippocrates, Aristotle and Sushruta. However, pediatrics as a medical speciality was established much later in the mid-19th century in 1859. It was as early as 1887, that Hinsdale studied stabilometry in children.

​

In 1927, Galebsky in a seminal paper, for the first time observed vestibular nystagmus as a result of vestibulo-ocular reflex in the newborn where both a rotatory chair and caloric stimulation were used. Interest in vestibular physiology in children then somewhat stalled until Michishita in 1967 successfully used Jongkee’s ENG formula for children undergoing the caloric test. This was followed by Kaga who first published the caloric norms in the paediatric population in 1982. Ornitz in 1985 investigated norms for rotation induced vestibulo-ocular reflex in children.

​

The first person to record vestibular response in deaf children was Shambaugh in 1930. He investigated more than 5000 deaf children and observed that about a third of them showed vestibular dysfunction not related to the severity of the hearing loss. This finding resonates to this day. Still, the pioneer after whom was named a rheumatological disorder was the first in history to publish descriptions of episodic dizziness including spinning sensations accompanied with headache in 1924. This led to the discovery of the condition benign paroxysmic vertigo of childhood by Basser in 1964.

​

Pediatric vestibular disorders were then gradually discovered over a period of time but still there was no dedicated pediatric subspeciality in pediatric balance. The children with balance disorders were seen by a variety of medical specialists in pediatrics for example neurology, general pediatrics, developmental pediatrics and ENT surgeons. It was not until the 1990s that pediatric balance as a focussed subspeciality in pediatrics started to emerge spearheaded by pioneers like Wiener-Vacher, Snashall, Luxon, O’Reilly and Rinne.

​

​