The Retrospectoscope

Edmund Prince Fowl= Linking Basic and Clinical Sdence

t is such a pleasure to look back at the dominant themes in the lives of the pioneers in our spe- I cialty who have shown us what can be accom-

plished through personal commitment. Edmund Princc Fowler, for example, demonstrated beauti- fully that there is a seamless connection between sound basic research and the steady advance of clinical medicine. He was a man of vision and ideas, and by his efforts, the fields of audiology and otol- ogy were linked and then advanced significantly.

In his Presidential Address to the Triological So- ciety Section Meetings, Frank Ritter, MD, reminded us of many of the details of Fowler's lifel:

Edmund Prince Fowler, Sr., M.D. was one of the early otologists in America. He is remembered for his many legislative efforts, both state and national, on be- half of patients for better hearing and also as one of the pioneer developers of the clinical audiometer used

He was born in New York City of English and Dutch anast~~. His grandfather and father were physicians, and his father was also an otolaryngologist. After receiv- ing his MD degree from Columbia University in 1900, he todc additional training at The Manhattan Eye and Ear Hospital.

After his training, he apprenticed himself to Albert H. Buck, M.D., the fmt exclusive otologist in America and known to this day for inventing the Buck's ear curette. In 1933, Dr. Fowler became a member of The Manhattan Eye and Ear Hospital and clinical professor at Columbia University.

In stature he was thin, average height, alert, full of energy, a very active doctor and caring father. He had many talents, among them an ability to play the guitar- good enough it is said to have wooed his musician-wife,

today.

They had five children, all of whom served in World War 11. One son, Edmund Prince Fowler, Jr., M.D., was also an otolaryngologist in New York City (1905-1964). One son was killed in the Bade of Kessering Pass in North Africa. The senior Fowler had been a colonel in World War I and had been decorated for performing round-the-clock surgery under shell-fire in the Battle of the Hindenburg Line at Willers-Faucan, France. So strong were his army ties that he had the New York City Otological society meetings held in the Seventh Regiment Armory for many years. He was accorded a military funeral at this same armory.

He tested many patients and soon became aware that some patients with severe or unilateral losses had suprathreshdd hearing values, a condition he coined as "recruitment." This clinical finding resulted in his Alter- nate Binaural Loudness h h c e test, the first to separate cochlear from retrocochlear losses.

His academic writings and medical effom are le- gion. He had interests in blood sludging, estrogens, cho- lesterol, calcium and metabolic diseases as they affected the ear. Altogether, he wrote 113 papers. Twenty seven of these were delivered before the American Otological Society as were 43 reports. He wrote 14 of the papers af- ter the age of 75. His last paper in 1965, written at the age of 92, was delivered by Georg von Bekesy because of Fowler's temporary ill health. It was noted that, "Never before in the history of American Otological Society was a paper by a 92-year-old otologist delivered and dis- cussed by a Nobel Laureate."

In addition, Dr. Fowler was: (1) Member of 31 Soci- eties and boards; (2) Vice President of the Eastern k- tion of The Triological Society in 1930 and President of the Society in 1932; (3) President of the American O t e logical Society in 1937; (4) Guest of Honor and also re- cipient of the Award of Merit of the American Otological Society in 1952, the first individual so honored; ( 5 ) Founder of the first hearing center in the United States in New York City; (6) Dedicated worker for years at city, state, and national levels to obtain legislation for the hard of hearing; and (7) Called the "Dean of Audiology."

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Fig. 1. Edmund Prince Fowler, MD.

Dr. Fowler served the Triological Society as President at its 38th Annual Meeting in Atlantic City in May 1932. His address2 was titled, “Prevention and Management of Deafness” and it reflected his unique perspectives on several issues as revealed by the following excerpts:

Let us, therefore, consider the symptom (deafness) in a little different light than is customary. Let us look at it more from the patient’s standpoint. What does he want to know when he goes to his doctor? He wants to know if he is deafened and how deaf he is. He wants to know whether or not his deafness is transient or permanent, or apt to become permanent, progressive or total. He wants to know whether it is congenital, hereditary, or acquired through chance or contact with others. He wants to know whether or not he might transmit it to his children. He wants to know if his better ear is going to be deaf like his bad ear. He is thinking of deafness as a disease and if he happens to Fall into the hands of the quack or the semi-quacks who flourish in our midst his so-called “dis- ease” will receive most careful consideration although the real disease which is causing the deafness may re- ceive the identical useless routine treatment no matter what may be its etiology, pathology or prognosis.

Fig. 2. The first audiometer, modified from a phonograph around 1925.

Let us not take away the hope of holding on to at least what hearing there is. The patient’s last hope is that he will not necessarily grow worse. Brutally stating even that the inevitable will happen is not a kind and not a good treatment. Let us not forget to treat the patient as a sensitive human being and aid him in surmounting the drawbacks and psychological reactions to his disability. Deafness is not only a problem in deficient hearing- deafness is a problem in readjustment to deficient hear- ing. Let us have a better understanding of the patient’s re- actions to his disability. Let us explain to him in plain words just what is causing his deafness because no mat- ter how complicated the pathology it can always be made understandable in simple words, and the progno- sis explained, both for the deafness and the disease of the ear, even though in some cases we know that the cure of the disease may make the deafness more marked (ie. OMSC). A routine careful examination of thousands of deafened adults and children proves beyond a doubt that a large percentage need otolaryngological guidance or treatment. If their deafness be one of the more hope- less forms proper management is often more important than slight changes in the hearing. In this connection the Leagues for the Hard of Hearing throughout our country are rendering invaluable services. Otologists should make themselves acquainted with the leagues and make con- tact therewith for their deafened patients.

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Therefore all of the children with impaired hearing should receive careful otological examination and subse- quent management and treatment depending upon cir- cumstances, first in the school, and second in the otologi- cal clinics or at the hands of a competent otologist.

There should be attached to every otolaryngologi- cal clinic a pediatrist so that the chest and other parts of the body may receive a thorough examination when in- dicated. Nerve deafness needs special care to eliminate the possibilities of poison or toxines such as foods, focal infections of the sinuses, teeth, tonsils, nasopharynx, kid- neys, tuberculosis and congenital syphilis (intracutane- ous tuberculin tests and Wassermann). All cases should be required to report regularly for treatment and a check up on their ear condition and the hearing. Every brother and sister and the father and mother of every markedly deafened child should be examined otologically as ad- vised above, because many kinds of deafness besides otosclerosis run in families.

If you will do but these obvious things I kow from experience that much can be and will be accomplished. And I know further that the more we progress in our knowledge of diseases of the ear the more important will become these examinations to detect deafness in its in- cipiency. I believe that there will never be a time, no mat- ter how far knowledge is perfected, when it will not be necessary to carry out these same or similar examina- tions. Moreover, if this were not so we might just as well throw up the sponge, give up the ghost, and say, “We cannot do anything about it, if you are going to be deaf you are going to be deaf, and may God help you.” This is the old defeatist attitude. It is not the attitude of those who accomplish things worth while.2

Kenneth Day, MD, (longtime Triological Soci- ety Treasurer) had become the President of the So- ciety when it met in Hollywood, Florida in March 1955. Dr. Day chose Fowler as his Guest of Honor for that meeting, and at the age of 83, Fowler demonstrated that his wit was as sharp as ever. After receiving the customary scroll and enduring the singing of ”He’s a jolly good fellow,” Dr. Fowler remarked,:

I regret having to say that most of my early associ- ates are no longer in our midst, but I am sure that if by “Hi-fi” electronic communication from Cloud Eight, or from whatever other cloud they may now be piloting, they could listen in they would enjoy a joke about them- selves as much as they did when they were on this mun- dane sphere, maybe more so, because they now should have a broader and more revealing view of mice and men than when mixed up with these critters on earth. You know, human nature is a curious thing: although it is widely distributed among people, sometimes it’s a little stuffy until it has felt the humanizing effects of a few well chosen liquid refreshments. I’d better stop this line of

thought right here; but, “Ain’t it the truth?”

Speaking of fluids, the Triological was born long before prohibition, but it bravely overcame that drought and emerged strong and prosperous in spite of recurring wars, police actions, bathtub gin, bingo, McCarthy, the lugubrious predictions of some of our members, and the psychiatrists who think they understand the emotional reactions of our patients better than we do. It even sur- vived the slaughter of the tonsils and the reduction of simple mastoidectomies, which incidentally had started with the conservatives long before the advent of the an- tibiotics, cliches to the contrary notwithstanding.

My natural bashfulness (remember that time?) slow- ly waned after joining the Trio in 1912. Like the other novitiates I was awed by the giants of old, but as the years fade away younger men gain confidence, especial- ly as they manage to dig up something of interest. The gi- ants of old possessed virtues many of us lack today: they spoke out and did not always resort to writing their dis- cussions. Some of them took particular joy, after mildly complimenting an essayist, in plucking him clean and roasting him to a turn. Most of them, however, did it in good humor, and it did us good.

But enough of the past. Let us take “the wings of morning and pierce the Barkan wilderness” of the future, about which old men are not expected to say much, be- cause for them there is supposed to be no future, at least on earth, and their knowledge about it elsewhere, sketchy to say the least.

Envision a future which in spite of the fact that too much technical knowledge will not necessarily be con- ducive to brilliant speculation, technology will have solved many of our present problems. Maybe we will have devised glamorous spare parts not only for the less respectable portions of the human body but for some of the respectable parts as well, even for the ear, nose and throat.

Envision the time when we will be able to diagnose the many kinds of vertigo with ease, and when a patient complains of tinnitus and whirling in his tortured mind you will tell him that although his otic labyrinth was con- sidered tops some years ago it is now an obsolete model; however, you will try to dig up some old spare parts and fit them in (accent on the fitting of course), and maybe install a shock absorber in the cupula of the particular semicircular canal which is out of order, or put a baffle plate in its lumen.

These gadgets without doubt will alleviate over- stimulation of the end-organs and guard against sudden or excessive reactions to stimulation. In other words, no matter what you do you have no vertigo, your road through life will be smooth and straight (not necessarily narrow), even though you tack homeward from oasis to oasis in the early morning hours. But beware! These sta- bilizers, although installable by only one of you alone, may create dead labyrinths, and even more “dead heads” than we have today.

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You will learn to drill holes at equal intervals along any offending semicircular canal so that a change in pres- sure will pop out a stopple or two and emit a note of warning like a tea kettle whistling when it is coming to a boil. Or in certain somatotypes you may install leaded windows along all of the canals so that each patient may have a whistle to his liking and no longer make it neces- sary for him to whistle with his mouth. Any rise in blood pressure will suffice to pop the signal. As for the fenestra- tion operation, this will of course have gone out the win- dow. After all it will be successful only in 99 and 99/100 per cent o f those operated upon.

Soon evesything will be standardized and made in- visible so that even extra cuticular contrivances like the pinhead hearing aid will be fashioned into tiny invisible, without weight, bubbles, to fit into depressions located far from the ear. For the immediate future present trends indicate that the umbilicus will probably be a favorite nesting place, and this will open new vistas; but even nowadays this location might be too obvious on stage, screen and beach.

I trust that although I am obeying orders to stop short and never go again at the end of exactly nine min- utes, 59 and 99/100 seconds, I shaU really not stop until “the old man dies,” and I hope that all of you will do like- wise; because if you keep going, sooner or later you will stumble over something worthwhile-something which in your younger days, due to your sure and elastic step, you might have skipped over and failed to observe.

The LRYNGOSCOPE was one of Fowler’s favorite outlets for his work, and his last publication in this journal appeared in 1965.4 At the ripe old age of 93, he was still intrigued by difficult, unsolved clinical problems in otology. He was interested in the symptom of tinnitus, wondered about its various etiologies, and proposed that more should be done to help patients with this complaint. In this article Fowler stated:

Such an ubiquitous symptom as tinnitus deserves intensive investigation; it has not received it. The patient is too frequently told to ignore it, and the physician pays little attention to it unless it occurs with some obviously serious disease associated with the ear.

Etiobgical Factors: Spontaneous tinnitus is initiated by an irritation or activation of the sensory elements of the hearing apparatus. It may be caused by a faulty me- tabolism, particularly by an anoxia, local in the end or- gan, or in some of the neurones and ganglia of the audi- tory mechanism, including the brain. Pathology central to the end organ may cause tinnitus by setting up lesions both central or peripheral to it. Tinnitus may be directly or indirectly brought on by neuro-circulatory factors, transient or prolonged, such as vascular spasm and intra- vascular agglutination of the blood (sludge) or by any le- sion producing sufficient anoxia in the auditory tissues.

Remember that tinnitus is a homologue of a pares- thesia, an illusion of sound, but not of sensation, and is recognized by the patient as such. Only in mental disor- ders is it a delusion or hallucination.

Tinnitus may be similar to but never exactly the same as applied sounds. There are no logarithmically spaced harmonics, and consequently it appears less agreeable. It varies according to 1 . the number and loca- tion of elements activated; 2. the difference in degrees of stimulation in the upper as compared with the lower fre- quency areas; 3. by a “recruitment” or “decruitment” ef- fect like that obtained with sounds applied to a neurally deafened ear; 4. by involvement of psychic (or cerebral) factors which may not only play a part in its causation but also make it appear higher or lower in frequency or in volume than would usually be expected.

There are so many therapeutic procedures for the treatment of tinnitus that it is evident no sure cure is available unless the diseases and disorders associated with it can be benefitted. Usually the depressant drugs seem only to dope the patient, and with prolonged use, make the tinnitus worse, or less tolerable. Some patients say that whatever treatment is used makes their head noises worse.

I will not bore you with the many remedies used, but we have had considerable success with antiaggluti- nation drugs; vascular dilators, several drugs, particularly thyroid and Lugol’s solution, nicotinic acid, cocaine, oth- er local anesthetics, and, when indicated, electric shock. Of major importance is obtaining the cooperation of the patient.

Politzerization, especially if supplemented by safe home inflations (as with my balloon inflator), is frequent- ly the only treatment required; in fact, anything that improves the hearing may relieve the tinnitus. Certain operations, particularly fenestrations and stapes mobi- lizations, have this effect when successful. The otologist should be optimistic, because by careful examination and treatment he can usually benefit his patient, at least to some extent. Today we have techniques to locate the lesions causing tinnitus; use them.

Upon Fowler’s death in 1966, Gordon Hoople, MD, of Syracuse, New York, captured much of the essence of his life in the following excerpted re- marks.5

It is recognized at the outset that what follows will be inadequate, for who can put down in words an ap- praisal of a life which spanned not one, but two genera- tions, who, in his 94th year, still held high a flaming torch which his energy had kept lit for so long a time? No, words are inadequate instruments with which to express an appreciation of such a life, but we have no other means at hand.

Dr. Edmund Prince Fowler’s parents must have been endowed with the gift of prophecy when they gave

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him his name. He was a prince among men, and his princely qualities were manifest throughout his life.

What makes a man great? Certainly it is not renown. One can easily think of hundreds of men who have been well known, who were not great. No, what makes a man great was said nearly 2,000 years ago by the man who was the greatest Teacher of all recorded history. He said: “The man who would be the greatest among you, let him be the sewant of all.” Dr. Fowler did this by devoting his life to a great cause: that of better hearing for all. He liter- ally devoted his whole life to this worthy endeavor.

Many things can be said of Dr. Fowler’s work. He did what he did with a vision which was far beyond that of his contemporaries. He was often 20 to 30 years ahead of his peers. Consequently, some of his early work was not appreciated at the time of its publication. This hap- pens to any man who is ahead of his time. We can be grateful that he was given the years that were his so he could learn that his work was truly appreciated. He coined the word “recruitment” and demonstrated the presence of his now famous alternate loudness balance test. It was not until nearly 25 years later that the signifi- cance of recruitment became popular and his test came into general use. It can be said without reservation that he was the man who was responsible for the modern clinical audiometer. Audiometers existed prior to the time of his contribution, but he made the suggestions which changed these machines from research tools to the clinical audiometer we know today.

In all of his endeavors he worked with a dogged de- termination. Yet this man was not objectionable. He had a delightful sense of humor which brightened many an otherwise sober moment.

He was a devoted family man. Certain holidays were set apart as times for family gatherings. He pre- pared appropriate remarks which were addressed to each member attending. He presided on these occasions with dignity. He was, in the finest sense of the word, a patriarch. He lost one son in World War I. This was a grievous loss to him. A few years before his death he had to he operated upon for newly discovered cancer. While he was in the hospital he was told of the death of his doc- tor son, Edmund P. Fowler, Jr. There were those who pre- dicted that this would bring about an early demise of Dr. Fowler. Although it was a great blow, he took this with- out any noticeable difference in the manner in which he conducted his affairs.

When he was 80 years old, two things happened which seemed to give him new life. This was in 1952. At that time he was the honored guest of the Otological So- ciety, and at the same meeting he was given the Award of Merit of that Society. Following this, up to the time of his death, he wrote 14 papers, many of which might have been the product of a brilliant young investigator.

One of the great lessons his life taught us is that, bank18 organic disease, one need never grow old; if the effort is made, one can always remain young.

Theordore Roosevelt, years ago, delivered a speech at the Sorbonne in Paris. It could be said that Dr. Fowler, then a young man, adopted the climax of Roosevelt’s speech as his way of life. It reads:

“It is not the critic who counts, not the man who points how the strong man stumbles or when the doer of deeds could have done them better.

“The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood, who strives valiantly, who errs and comes short again, because there is no effort without error and short- coming, but who does actually strive to do the deeds, who knows the great enthusiasm, the great devotion, who spends himself in a worthy cause, who, at the best knows in the end the triumph of high achievement, and who, at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who know neither victory or defeat.”

In the arena, Dr. Fowler was a gallant soldier who fought nobly and who achieved victory after victory, al- most beyond number.

There are thousands upon thousands of people whose lives have been made fuller and richer because Edmund Prince Fowler passed this way.

During the 1960s there was an explosive growth in the quality and quantity of research in our specialty. The remarkable clinical advances in oto- laryngology-head and neck surgery had begun to attract outstanding young PhDs and MDs to our field and NIH funding for training and research added the fuel that pushed us to a higher level.

The Triological Society made the decision to es- tablish a second award for excellence of the thesis required for membership. Henceforth, the Mosher Award would be given to recognize excellence in the area of clinical research and the new award would focus upon basic science research.

The minutes of the Triological Society Council Meeting of April 1970 state the followingb:

F. Erecutiue Cornmitt-Doctor Silcox presented the report of the Executive Committee Meeting of March 11, 1970, which was held in Washington, DC, with the following members present: Joseph L. Goldman, Louis E. Silcox, Raymond E. Jordan, Joseph H. Ogum (ex officio).

Motion was made seconded and carried that two awards be given each year for outstanding theses: The Fowler Award, named for Edmund Prince Fowler, for outstanding basic research; The Mosher Award named for Harris P. Moshet, for outstanding clinical research. These awards are to be granted starting in 1971.

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The first Edmund Prince Fowler Award was giv- en in 1971 in San Francisco. The recipient was Richard R. Gacek, MD, who was honored for his thesis titled, “Anatomical Demonstration of the Vestibulo-Ocular Projections in the Cat.”7 This work employed the use of exciting new technology which allowed Gacek to create very small, precisely placed lesions in the vestibular nuclei and to trace the neural projections ascending to the extraocular nuclei as well as descending projections to the spinal cord.

The significance of the creation of the Mosher and Fowler Awards cannot be overemphasized. Our specialty has matured and moved beyond the realm of retrospective case reviews and anecdotal reports for the scientific base it needs in a new era. The action of the Triological Society in the 1960s re- flected the importance that would soon be placed on excellence in basic and clinical research in our discipline.

Beyond the recognition that would accrue to the individual candidates for membership, there was a larger significance to these awards. First, the prestige associated with the Mosher and Fowler awards would become a stimulus to young investi- gators. The cycle of pursuit of excellence, leading to outstanding creativity/productivity, leading to rec- ognition, leading to more pursuit, etc.-had been

set in motion (and it remains in place).

Second, and of greater importance, a revered, respected senior medical society had defined itself. The Triological Society had said in effect, “This is what we value.” The Society has only two awards, both are for excellence in research and both are be- stowed only after a rigorous process of review.

It is indeed fitting that these two awards bear the names that have been chosen. Surely, both of these giants, who gave so much to us, must be smil- ing as they watch the parade of winners who have not only followed in their footsteps, but have con- tinued to expand our capability to understand the disease processes with which we deal and to offer new hope to our patients.

BIBLIOGRAPHY

1. Ritter FN. Pioneer otologist Fowler praised. ~ Y N G O S C O P E . 1993;

2. Fowler EP. Prevention and management of deafness. Trasactions of 103:474-475.

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the American Laryngology, Rhinological and Otological Society, Inc., 1-7,1932.

3. Fowler EP. Address by the Guest of Honor. Transactions of the American Laryngology, Rhinological and Otological Society, Inc., 504-509,1955.

4. Fowler EP. Subjective head noises. LARYNGOSCOPF:. 1965;75:1610- 1618.

5. Hoople GD. Necrology: Edmund Prince Fowler, M.D. Transactions of the American Laryngology, Rhinological and Otological Soci- ety, Inc., 1110-1114, 1967.

6. Minutes of the Triological Society Council Meeting, Hollywood Beach, Fla., April 20, 1970.

7. Gacek RR. Anatomical demonstration of the vestibuloocular projec- tions in the cat. LARYNGOSCOPE. 1971;81:1559-1595.

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