A Tale of Two Maneuvers – Part II

Robert Traynor
March 5, 2013

toynbee2.jpgAs discussed last week, there were two great anatomists who led audiologists and otolaryngologists to their Toynbeefundamental knowledge of the auditory mechanism. Both were famous for their own middle ear equalization maneuvers.  Of course, these were the Valsalva and Toynbee maneuvers, created over a century apart. Each of these researchers made major contributions to knowledge of the auditory system, its anatomy and physiology and diseases.

In Part I we looked at Valsalva and his contributions and this week, in Part II,  Hearing International examines Joseph Toynbee, his contributions to the field, and his somewhat mysterious demise.

Fast Forward 100 Years…….

Fast forward  a hundred years or so from Valsalva. Atoynbee6.jpgnother scientific mind was exploring the auditory system.  Although there had been others interested in the auditory system since Valsalva, Toynbee was facinated with the ear for his entire career.  His maneuver is referred to by audiologists and otolaryngologists as “The Toynbee”.

Similar to the Valsalva, the Toynbee has the patient swallow with the nostrils pinched. Swallowing pulls open the Eustachian tubes while the movement of the tongue, with one’s nostrils closed, compresses air against them, forcing air into the middle ear and offering an alternative, somewhat more gentle, method of “clearing the ear.”

Joseph Toynbee (30 December 1815 – 7 July 1866) was an English otologist whose career was dedicated to pathological and anatomical studies of the ear.  Joseph was the second son of George Toynbee of Heckington, Lincolnshire, a prominent farmer whose family had long been established in that county.

Toynbee and Sir William Wilde of Dublin are recognized by some as the greatestoynbee12t English-speaking pioneers of otology, and there are many parallels between their careers. Both were born in the same year and for both of them medical work was only part of their career path. Wilde was a great archaeologist and statistician, whose fame in this area was exceeds his reputation in otology. Toynbee, a man of great charm, was a connoisseur of the arts and devoted a great part of his life to philanthropy and social reform.

Power states that Toynbee was educated at King’s Lynn grammar school, and then, at age 17, he was apprenticed to William Wade of the Westminster general dispensary in Gerrard Street, Soho, in London. He studied anatomy under George Derby Dermott at the Little Windmill Street school of medicine, where he learned to be an enthusiastic dissector. He then attended the practice of St. George’s and University College Hospitals, and was admitted as a member of the College of Surgeons of England in 1838.  He became a fellow of the Royal Society in 1842 for his research and in 1843 was among the first toynbee7.jpgto be nominated to the newly established order of fellows of the Royal College of Surgeons of England.

Toynbee lived in Argyll Place while he was surgeon to the St. James’s and St. George’s Dispensary, and began the practice of his speciality as an aural surgeon. His practice soon became very large, and he moved it  to Savile Row. In 1852, he was elected aural surgeon at St. Mary’s Hospital and lecturer on diseases of the ear in its medical school, appointments which he resigned in 1864 to devote more time to research.

His contemporary Sir William Wilde said of Toynbee, “The labours and investigations of Mr. Toynbee have affected more for aural pathology than those of all his predetoynbee3cessorstoynbee11.jpg either in England or on the continent.”  That he dissected some 2000 ears gives some idea of the extent of his research. These preparations formed the Toynbee Collection in the Museum of the Royal College of Surgeons of England. He wrote the results of his researches in a catalogue that includes descriptions of 1,659 human ears. This catalogue formed the basis for modern otology for all time. This purely pathological catalogue was completed in 1860 with the publication of a more clinical book, The Diseases of the Ear: their Nature, Diagnosis and Treatment.

Toynbee appears to have been the first to describe the pathological changes in otosclerosis. In his book, Diseases of the Ear, he describes the condition clearly, recognizing “anchylosis of the stapes to the fenestra ovalis” in 136 temporal bones. He also aligned the subjective, visual and ausculatory tests for Eustachian tubal patency that we use today. Adam Politzer, a famous otologist in his own right, said, “Toynbee was the first who realized in otology that therapeutic progress depends on the knowledge of anatomy.”

The injection heard ’round the world……

Toynbee’s death is of interest to audiologists and otologists as a classic example of why researchers should not experiment on themselves.  On July 7, 1866, Toynbee was apparently doing experimental research on the effects of chloroform and other substances on tinnitus aurium, when he injected hydrocyanic acid into the cavity of his own tympanum (middle ear).

The story toynbee13from his obituary goes that ….Toynbee was last seen alive by his “man-servant” on the afternoon of July 8 about four o’clock.   Shortly afterwards, on coming into the room, the servant found Toynbee lying on a couch, with a piece of cotton-wool over his mouth and nose. He spoke to him, but, receiving no answer, removed the cotton-wool; alarmed at his appearance, he ran for assistance. Dr. Markham arrived almost immediately, but found Mr, Toynbee  dead. There was a smell of chloroform in the room, and the cotton wool smelled strongly of chloroform. Close to the hand of the deceased were two bottles, which had been procured from a chemist’s that afternoon. One contained rectified ether, and had not been opened; the other was rather more than half-full of hydrocyanic acid. Underneath the head of the dead man was a six-ounce bottle which had contained chloroform, but was completely empty. There was no smell of hydrocyanic acid, but the toynbee8.jpgodour of that substance, it is well known, disappears very rapidly.

A letter was produced, written by the deceased [Toynbee] on the 6th instant [on July 6th], in which was expressed an opinion that, by Clover’s apparatus for inhaling, the vapour of hydrocyanic acid could be safely applied to the tympanum. The vapor was inhaled to the back of the throat, and, by holding the mouth and nostrils, was forced into the cavities of the ears, thus removing the singing and other nervous sensibility. An inquest was held upon the body, when the above and various other facts were stated in evidence. The verdict of the jury was, “That the deceased met with his death accidentally, while prosecuting his experiments, by inhaling a combination of chloroform and prussic acid; and the jury desire to express their deep sympathy with the family of the unfortunate deceased gentleman.” 

Toynbee raised aural surgery from a neglected condition of quackery to a recognized position as a legitimate branch of surgery. As a philanthropist, he ardently advocated for the improvement of working men’s dwellings and surroundings at a time when government’s role in public health had hardly beguntoynbee14 to be appreciated. His benevolent efforts centered on Wimbledon, where he took a country house in 1854 and formed a village club as well as a local museum. He publishedtoynbee10.jpg ‘Hints on the Formation of Local Museums’ (1863) as well as ‘Wimbledon Museum Notes,’ and his enthusiastic advocacy was of great value in furthering the establishment of similar clubs and museums in various parts of the kingdom.

Toynbee’s main contribution to otology, other than his Maneuver, was his previously mentioned text, The Diseases of the Ear: their Nature, Diagnosis, and Treatment published in London and Philadelphia in 1860 and translated into German in 1863.  After his death a new edition of the text was published in 1968 with a supplement by James Hinton.  Toynbee’s work placed the subject of aural surgery upon a firm basis. One can only imagine how much farther Otology would have progressed without his untimely death.




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