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glottis, as easily as it would have done in the dead body; and the small quantity of blood which was ejected at the same time, and which had been manifestly furnished by the granulations of the external wound, sufficiently explains how this happened: as it is not to be supposed that blood could have been drawn into the trachea without the admission of air into it at the same instant. As connected with this part of the case, it may be well here to mention, that the distressing sensations arising from congestion in the vessels of the brain, while the head was in a depending position, were immediately and completely relieved by supporting the forehead with the hand, so as to keep the occiput in some degree inclined towards the back of the neck.
In the other object, for which the artificial opening was made, it must be confessed that we were wholly disappointed. In the dead body, with the assistance of proper forceps, there is no great difficulty in extracting a sixpence or a half-sovereign from the bronchus. But even here it is not always accomplished on the first trial. If the forceps be, as they ought to be, carefully and gently handled, the blades may actually slide over the surface of the coin without any sensation beingcommunicated to the hand of the surgeon which will make him aware of the circumstance: or they may be passed downwards on one side of the bronchus, while the coin lies on the other. In the attempt to seize it, the forceps sometimes grasps the bifurcation of the trachea, or one of the subdivisions of the bronchus, instead of the foreign body. Nor will these things appear remarkable to any one who bears in mind, that the parts in which the forceps is to be used are not only out of sight, but at a considerable distance from the surface. Including the depth of the external wound, the instrument must be introduced to the distance of from four and a half to five inches before it reaches the upper extremity of the bronchus, and in order that the whole of the bronchus should be explored, it must penetrate still one inch and a half further. But in the living person, there are difficulties of which no knowledge can be obtained from experiments on the dead body. We found that every attempt to use the forceps occasioned a convulsive action of the diaphragm and abdominal muscles, and violent coughing; and (contrary to the observations of M. Magendie on what happens in experiments on dogs) the result was nearly the same, whether the extremity of the instrument was directed upwards towards the glottis, or downwards towards the lungs. Dr. Williams has shown that the fibres of the whole of the bronchial tubes are endued with a high degree of contractility. The heart and its great vessels, the lungs, and the pulmonic plexus of the pneumo-gastric nerves, are immediately contiguous to the bronchi, and the phrenic nerves are only at a short distance on the forepart. How easy would it be for some unfortunate thrust of the forceps, for which, during a paroxysm of coughing, the hand of the surgeon could be in no wise responsible, to cause some such injury to these important organs as would prove fatal to the patient! It was these considerations which made us cautious in the use of the forceps in the first instance, and ready to abandon it afterwards, in favour of a safer method of proceeding.
The foregoing observations are of course intended to apply only to cases like the present, in which the foreign body is lodged in the bronchus or in one of its subdivisions. When it is impacted in the trachea itself, there can be no doubt that it ought to be removed by the forceps, and that this may be safely and easily accomplished. But under all circumstances, we have a right to conclude, that an artificial opening in the trachea must contribute to the security of the patient, and that the establishment of it at an early period, is the first and most important duty of the surgeon.
PATHOLOGY OF THE EAR.
BASED ON ONE HUNDRED AND TWENTY DISSECTIONS OF THAT ORGAN.
By JOSEPH TOYNBEE, F.R.S.,
SURGEON TO THE ST. GEORGES AND ST. JAMEs's DISPENSARY.
READ JUNE 27th, 1843.
Although the organ of hearing consists of several distinct parts, and exhibits much structural variety, but few successful attempts have hitherto been made to trace the local causes of deafness.
In a former paper, published in the Transactions of this Society,* I gave descriptions of several dissections of the human ear, as evidence of the fact, that the lining membrane of the tympanic cavity is frequently in a diseased condition. Subsequent dissections, and a careful investigation of numerous cases of deafness in living subjects, have led me to the conclusion that the most prevalent cause of deafness is chronic inflammation of the mucous membrane which lines the tympanic cavity; and that by far the greater majority of cases commonly called nervous deafness ought more properly to be attributed to this cause. This opinion derives support from an observation made to me by Mr. Swan, that in the whole course of his multiplied aural dissections he has not encountered one single instance of disease in the internal ear; an observation which embodies the result of repeated examinations to which I have myself subjected that part of the organ.
* Vol. xxiv. 1841.
At the same time that I advance this opinion as an inference fairly deducible from more than a hundred dissections, I am far from denying the necessity of more extended researches previous to its validity being admitted.
In the present communication it will be my endeavour to elucidate the different stages of this disease of the mucous membrane, and to point out the various morbid conditions to which it gives rise. In so doing, reference will be made as well to the cases published in my former paper, as to those which are appended to the present. And, bearing in mind the comparative novelty of the subject, it has appeared to me more desirable to state, briefly but accurately, the particulars rather than the general results of the dissections ; that the very interesting facts which they will be found to contain,