PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. 21 page

commenced, but abandoned, and an attempt made to push the fish down

with a probang, which was, in a measure, successful. However, the

patient gave a convulsive struggle, and, to all appearances, died. The

trachea was immediately opened, and respiration was restored. During

the course of the night the man vomited up pieces of fish bone softened

by decomposition. In 1863 White mentions that the foregoing accident is

not uncommon among the natives of India, who are in the habit of

swimming with their mouths open in tanks abounding with fish. There is

a case in which a fisherman, having both hands engaged in drawing a

net, and seeing a sole-fish about eight inches long trying to escape

through the meshes of the net, seized it with his teeth. A sudden

convulsive effort of the fish enabled it to enter the fisherman's

throat, and he was asphyxiated before his boat reached the shore. After

death the fish was found in the cardiac end of the stomach. There is

another case of a man named Durand, who held a mullet between his teeth

while rebaiting his hook. The fish, in the convulsive struggles of

death, slipped down the throat, and because of the arrangement of its

scales it could be pushed down but not up; asphyxiation, however,

ensued. Stewart has extensively described the case of a native

"Puckally" of Ceylon who was the victim of the most distressing

symptoms from the impaction of a living fish in his throat. The native

had caught the fish, and in order to extract it placed its head between

his teeth, holding the body with the left hand and the hook with the

right. He had hardly extracted the hook, when the fish pricked his palm

with his long and sharp dorsal fin, causing him suddenly to release his

grasp on the fish and voluntarily open his mouth at the same time. The

fish quickly bolted into his mouth, and, although he grasped the tail

with his right hand, and squeezed his pharynx with his left, besides

coughing violently, the fish found its way into the esophagus. Further

attempts at extraction were dangerous and quite likely to fail; his

symptoms were distressing, he could not hold his head erect without the

most agonizing pain and he was almost prostrated from fright and

asphyxia; it was thought advisable to push the fish into the stomach,

and after an impaction of sixteen hours the symptoms were relieved. The

fish in this instance was the Anabas scandens or "walking perch" of

Ceylon, which derives its name from its power of locomotion on land and

its ability to live out of water for some time. It is from four to five

inches long and has a dorsal fin as sharp as a knife and directed

toward the tail, and pectoral fins following the same direction; these

would admit of entrance, but would interfere with extraction. MacLauren

reports the history of a young man who, after catching a fish, placed

it between his teeth. The fish, three inches long, by a sudden

movement, entered the pharynx. Immediately ensued suffocation, nausea,

vomiting, together with the expectoration of blood and mucus. There was

emphysema of the face, neck, and chest. The fish could be easily felt

impacted in the tissues, but, after swallowing much water and vinegar,

together with other efforts at extraction, the fins were

loosened--about twenty-four hours after the accident. By this time the

emphysema had extended to the scrotum. There was much expectoration of

muco-purulent fluid, and on the third day complete aphonia, but the

symptoms gradually disappeared, and recovery was complete in eight

days. Dantra is accredited with describing asphyxiation, accompanied by

great agony, in a man who, while swimming, had partially swallowed a

live fish. The fish was about three inches in length and one in

breadth, and was found lying on the dorsum of his tongue and, together

with numerous clots of blood, filled his mouth. Futile attempts to

extract the fish by forceps were made. Examination showed that the fish

had firmly grasped the patient's uvula, which it was induced to

relinquish when its head was seized by the forceps and pressed from

side to side. After this it was easily extracted and lived for some

time. There was little hemorrhage after the removal of the offending

object, and the blood had evidently come from the injuries to the sides

of the mouth, caused by the fins. The uvula was bitten, not torn.

There is an interesting account of a native of India, who, while

fishing in a stream, caught a flat eel-like fish from fifteen to

sixteen inches long. After the fashion of his fellows he attempted to

kill the eel by biting off its head; in the attempt the fish slipped

into his gullet, and owing to its sharp fins could not be withdrawn.

The man died one hour later in the greatest agony; so firmly was the

eel impacted that even after death it could not be extracted, and the

man was buried with it protruding from his mouth.

A Leech in the Pharynx.--Granger, a surgeon in Her Majesty's Indian

Service, writes:--"Several days ago I received a note from the

political sirdar, asking me if I would see a man who said he had a

leech in his throat which he was unable to get rid of. I was somewhat

sceptical, and thought that possibly the man might be laboring under a

delusion. On going outside the fort to see the case, I found an old

Pathan graybeard waiting for me. On seeing me, he at once spat out a

large quantity of dark, half-clotted blood to assure me of the serious

nature of his complaint. His history--mostly made out with the aid of

interpreters--was that eleven days ago he was drinking from a

rain-water tank and felt something stick in his throat, which he could

not reject. He felt this thing moving, and it caused difficulty in

swallowing, and occasionally vomiting. On the following day he began to

spit up blood, and this continued until he saw me. He stated that he

once vomited blood, and that he frequently felt that he was going to

choke.

"On examining his throat, a large clot of blood was found to be

adherent to the posterior wall of the pharynx. On removing this clot of

blood, no signs of the presence of a leech could be detected. However,

on account of the symptoms complained of by the patient I introduced a

polypus forceps into the lower part of the pharynx and toward the

esophagus, where a body, distinctly moving, was felt. This body I

seized with the forceps, and with considerable force managed to remove

it. It was a leech between 2 1/2 and three inches in length, and with a

body of the size of a Lee-Metford bullet. No doubt during the eleven

days it had remained in the man's throat the leech had increased in

size. Nevertheless it must have been an animal of considerable size

when the man attempted to swallow it. I send this case as a typical

example of the carelessness of natives of the class from which we

enlist our Sepoys, as to the nature of the water they drink. This man

had drunk the pea-soup like water of a tank dug in the side of the

hill, rather than go a few hundred yards to a spring where the water is

perfectly clear and pure. Though I have not met with another case of

leeches being taken with drinking water, I am assured that such cases

are occasionally met with about Agra and other towns in the North-West

Provinces. This great carelessness as to the purity or impurity of

their drinking water shows the difficulty medical officers must

experience in their endeavors to prevent the Sepoys of a regiment from

drinking water from condemned or doubtful sources during a cholera or

typhoid epidemic."

Foreign Bodies in the Pharynx and Esophagus.--Aylesbury mentions a boy

who swallowed a fish-hook while eating gooseberries. He tried to pull

it up, but it was firmly fastened, and a surgeon was called. By

ingeniously passing a leaden bullet along the line, the weight of the

lead loosened the hook, and both bullet and hook were easily drawn up.

Babbit and Battle report an ingenious method of removing a piece of

meat occluding the esophagus--the application of trypsin. Henry speaks

of a German officer who accidentally swallowed a piece of beer bottle,

3/8 x 1/8 inch, which subsequently penetrated the esophagus, and in its

course irritated the recurrent laryngeal and vagi, giving rise to the

most serious phlegmonous inflammation and distressing respiratory

symptoms. A peculiar case is that of the man who died after a fire at

the Eddystone Lighthouse. He was endeavoring to extinguish the flames

which were at a considerable distance above his head, and was looking

up with his mouth open, when the lead of a melting lantern dropped down

in such quantities as not only to cover his face and enter his mouth,

but run over his clothes. The esophagus and tunica in the lower part

of the stomach were burned, and a great piece of lead, weighing over 7

1/2 ounces, was taken from the stomach after death.

Evans relates the history of a girl of twenty-one who swallowed four

artificial teeth, together with their gold plate; two years and eight

days afterward she ejected them after a violent attack of retching.

Gauthier speaks of a young girl who, while eating soup, swallowed a

fragment of bone. For a long time she had symptoms simulating phthisis,

but fourteen years afterward the bone was dislodged, and, although the

young woman was considered in the last stages of phthisis, she

completely recovered in six weeks. Gastellier has reported the case of

a young man of sixteen who swallowed a crown piece, which became lodged

in the middle portion of the esophagus and could not be removed. For

ten months the piece of money remained in this position, during which

the young man was never without acute pain and often had convulsions.

He vomited material, sometimes alimentary, sometimes mucus, pus, or

blood, and went into the last stage of marasmus. At last, after this

long-continued suffering, following a strong convulsion and syncope,

the coin descended to the stomach, and the young man expectorated great

quantities of pus. After thirty-five years, the coin had not been

passed by the rectum.

Instances of migration of foreign bodies from the esophagus are

repeatedly recorded. There is an instance of a needle which was

swallowed and lodged in the esophagus, but twenty-one months afterward

was extracted by an incision at a point behind the right ear. Kerckring

speaks of a girl who swallowed a needle which was ultimately extracted

from the muscles of her neck. Poulet remarks that Vigla has collected

the most interesting of these cases of migration of foreign bodies.

Hevin mentions several cases of grains of wheat abstracted from

abscesses of the thoracic parietes, from thirteen to fifteen days after

ingestion. Bonnet and Helmontius have reported similar facts.

Volgnarius has seen a grain of wheat make its exit from the axilla, and

Polisius mentions an abscess of the back from which was extracted a

grain of wheat three months after ingestion. Bally reports a somewhat

similar instance, in which, three months after ingestion, during an

attack of peripneumonia, a foreign body was extracted from an abscess

of the thorax, between the 2d and 3d ribs. Ambrose found a needle

encysted in the heart of a negress. She distinctly stated that she had

swallowed it at a time calculated to have been nine years before her

death. Planque speaks of a small bone perforating the esophagus and

extracted through the skin.

Abscess or ulceration, consequent upon periesophagitis, caused by the

lodgment of foreign bodies in the esophagus, often leads to the most

serious results. There is an instance of a soldier who swallowed a bone

while eating soup, who died on the thirty-first day from the rupture

internally of an esophageal abscess. Grellois has reported the history

of a case of a child twenty-two months old, who suffered for some time

with impaction of a small bone in the esophagus. Less than three months

afterward the patient died with all the symptoms of marasmus, due to

difficult deglutition, and at the autopsy an abscess was seen in the

posterior wall of the pharynx, opposite the 3d cervical vertebra;

extensive caries was also noticed in the bodies of the 2d, 3d, and 4th

cervical vertebrae. Guattani mentions a curious instance in which a man

playing with a chestnut threw it in the air, catching it in his mouth.

The chestnut became lodged in the throat and caused death on the

nineteenth day. At the autopsy it was found that an abscess

communicating with the trachea had been formed in the pharynx and

esophagus.

A peculiarly fatal accident in this connection is that in which a

foreign body in the esophagus ulcerates, and penetrates one of the

neighboring major vessels. Colles mentions a man of fifty-six who,

while eating, perceived a sensation as of a rent in the chest. The pain

was augmented during deglutition, and almost immediately afterward he

commenced to expectorate great quantities of blood. On the following

day he vomited a bone about an inch long and died on the same day. At

the autopsy it was found that there was a rent in the posterior wall of

the esophagus, about 1/2 inch long, and a corresponding wound of the

aorta. There was blood in the pleura, pericardium, stomach, and

intestines. There is one case in which a man of forty-seven suddenly

died, after vomiting blood, and at the autopsy it was demonstrated that

a needle had perforated the posterior wall of the esophagus and wounded

the aorta. Poulet has collected 31 cases in which ulceration caused by

foreign bodies in the esophagus has resulted in perforation of the

walls of some of the neighboring vessels. The order of frequency was as

follows: aorta, 17; carotids, four; vena cava, two; and one case each

of perforation of the inferior thyroid artery, right coronary vein,

demi-azygos vein, the right subclavicular artery (abnormal), and the

esophageal artery. In three of the cases collected there was no autopsy

and the vessel affected was not known.

In a child of three years that had swallowed a half-penny, Atkins

reports rupture of the innominate artery. No symptoms developed, but

six weeks later, the child had an attack of ulcerative stomatitis, from

which it seemed to be recovering nicely, when suddenly it ejected two

ounces of bright red blood in clots, and became collapsed out of

proportion to the loss of blood. Under treatment, it rallied somewhat,

but soon afterward it ejected four ounces more of blood and died in a

few minutes. At the autopsy 3/4 pint of blood was found in the stomach,

and a perforation was discovered on the right side of the esophagus,

leading into a cavity, in which a blackened half-penny was found. A

probe passed along the aorta into the innominate protruded into the

same cavity about the bifurcation of the vessel.

Denonvilliers has described a perforation of the esophagus and aorta by

a five-franc piece. A preserved preparation of this case, showing the

coin in situ, is in the Musee Dupuytren. Blaxland relates the instance

of a woman of forty-five who swallowed a fish bone, was seized with

violent hematemesis, and died in eight hours. The necropsy revealed a

penetration of the aorta through the thoracic portion of the esophagus.

There is also in the Musee Dupuytren a preparation described by

Bousquet, in which the aorta and the esophagus were perforated by a

very irregular piece of bone. Mackenzie mentions an instance of death

from perforation of the aorta by a fish-bone.

In some cases penetration of the esophagus allows the further

penetration of some neighboring membrane or organ in the same manner as

the foregoing cases. Dudley mentions a case in which fatal hemorrhage

was caused by penetration of the esophagus and lung by a chicken-bone.

Buist speaks of a patient who swallowed two artificial teeth. On the

following day there was pain in the epigastrium, and by the fourth day

the pain extended to the vertebrae, with vomiting, delirium, and death

on the fifth day. At the autopsy it was found that a foreign body,

seven cm. long had perforated the pericardium, causing a suppurative

pericarditis. Dagron reports a unique instance of death by purulent

infection arising from perforation of the esophagus by a pin. The

patient was a man of forty-two, and, some six weeks before he presented

himself for treatment, before swallowing had experienced a severe pain

low down in the neck. Five days before admission he had had a severe

chill, followed by sweating and delirium. He died of a supraclavicular

abscess on the fifth day; a black steel pin was found against the

esophagus and trachea.

In connection with foreign bodies in the esophagus, it might be

interesting to remark that Ashhurst has collected 129 cases of

esophagotomy for the removal of foreign bodies, resulting in 95

recoveries and 34 deaths. Gaudolphe collected 142 cases with 110

recoveries.

Injuries of the neck are usually inflicted with suicidal intent or in

battle. Cornelius Nepos says that while fighting against the

Lacedemonians, Epaminondas was sensible of having received a mortal

wound, and apprehending that the lance was stopping a wound in an

important vessel, remarked that he would die when it was withdrawn.

When he was told that the Boeotians had conquered, exclaiming "I die

unconquered," he drew out the lance and perished. Petrus de Largenta

speaks of a man with an arrow in one of his carotids, who was but

slightly affected before its extraction, but who died immediately after

the removal of the arrow. Among the remarkable recoveries from injuries

of the neck is that mentioned by Boerhaave, of a young man who lived

nine or ten days after receiving a sword-thrust through the neck

between the 4th and 5th vertebrae, dividing the vertebral artery.

Benedictus, Bonacursius, and Monroe, all mention recovery after cases

of cut-throat in which the esophagus as well as the trachea was

wounded, and food protruded from the external cut. Warren relates the

history of a case in which the vertebral artery was wounded by the

discharge of a pistol loaded with pebbles. The hemorrhage was checked

by compression and packing, and after the discharge of a pebble and a

piece of bone from the wound, the man was seen a month afterward in

perfect health. Corson of Norristown, Pa., has reported the case of a

quarryman who was stabbed in the neck with a shoemaker's knife,

severing the left carotid one inch below its division. He was seen

thirty minutes later in an apparently lifeless condition, but efforts

at resuscitation were successfully made. The hemorrhage ceased

spontaneously, and at the time of report, the man presented the

symptoms of one who had had his carotid ligated (facial atrophy on one

side, no pulse, etc.). Baron Larrey mentions a case of gunshot wound in

which the carotid artery was open at its division into internal and

external branches, and says that the wound was plugged by an

artilleryman until ligation, and in this primitive manner the patient

was saved. Sale reports the case of a girl of nineteen, who fell on a

china bowl that she had shattered, and wounded both the right common

carotid artery and internal jugular vein. There was profuse and

continuous hemorrhage for a time, and subsequently a false aneurysm

developed, which ruptured in about three months, giving rise to

enormous momentary hemorrhage; notwithstanding the severity of the

injury and the extent of the hemorrhage, complete recovery ensued. Amos

relates the instance of a woman named Mary Green who, after complete

division of all the vessels of the neck, walked 23 yards and climbed

over an ordinary bar-gate nearly four feet high.

Cholmeley reports the instance of a Captain of the First Madras

Fusileers, who was wounded at Pegu by a musket-ball penetrating his

neck. The common carotid was divided and for five minutes there was

profuse hemorrhage which, however, strange to say, spontaneously

ceased. The patient died in thirty-eight hours, supposedly from spinal

concussion or shock.

Relative to ligature of the common carotid artery, Ashhurst mentions

the fact that the artery has been ligated in 228 instances, with 94

recoveries. Ellis mentions ligature of both carotids in four and a half

days, as a treatment for a gunshot wound, with subsequent recovery.

Lewtas reports a case of ligation of the innominate and carotid

arteries for traumatic aneurysm (likely a hematoma due to a gunshot

injury of the subclavian artery). The patient was in profound collapse,

but steadily reacted and was discharged cured on the forty-fifth day,

with no perceptible pulse at the wrist and only a feeble beat in the

pulmonary artery.

Garengeot, Wirth, Fine, and Evers, all mention perforating wounds of

the trachea and esophagus with recoveries. Van Swieten and Hiester

mention cases in which part of the trachea was carried away by a ball,

with recovery. Monro, Tulpius, Bartholinus, and Pare report severance

of the trachea with the absence of oral breathing, in which the divided

portions were sutured, with successful results. In his "Theatro

Naturae," Bodinus says that William, Prince of Orange, lost the sense

of taste after receiving a wound of the larynx; according to an old

authority, a French soldier became mute after a similar accident.

Davies-Colley mentions a boy of eighteen who fell on a stick about the

thickness of the index finger, transfixing his neck from right to left;

he walked to a doctor's house, 250 yards away, with the stick in situ.

In about two weeks he was discharged completely well. During treatment

he had no hemorrhage of any importance, and his voice was not affected,

but for a while he had slight dysphagia.

Barker gives a full account of a barber who was admitted to a hospital

two and a half hours after cutting his throat. He had a deep wound

running transversely across the neck, from one angle of the jaw to the

other, cutting open the floor of the mouth and extending from the inner

border of the sternocleido-mastoid to the other, leaving the large

vessels of the neck untouched. The razor had passed through the

glosso-epiglottidean fold, a tip of the epiglottis, and through the

pharynx down to the spinal column. There was little hemorrhage, but the

man could neither swallow nor speak. The wound was sutured, tracheotomy

done, and the head kept fixed on the chest by a copper splint. He was

ingeniously fed by esophageal tubes and rectal enemata; in three weeks

speech and deglutition were restored. Shortly afterward the esophageal

tube was removed and recovery was virtually complete. Little mentions

an extraordinary case of a woman of thirty-six who was discharged from

Garland's asylum, where she had been an inmate for three months. This

unfortunate woman had attempted suicide by self-decapitation from

behind forward. She was found, knife in hand, with a huge wound in the

back of the neck and her head bobbing about in a ghastly manner. The

incision had severed the skin, subcutaneous tissues and muscles, the

ligaments and bone, opening the spinal canal, but not cutting the cord.

The instrument used to effect this major injury was a blunt

potato-peeling knife. Despite this terrible wound the patient lived to

the sixth day.

Hislop records a case of cut-throat in a man of seventy-four. He had a

huge gaping wound of the neck, extending to within a half inch of the

carotids on each side. The trachea was almost completely severed, the

band left was not more than 1/4 inch wide. Hislop tied four arteries,

brought the ends of the trachea together with four strong silk sutures,

and, as the operation was in the country, he washed the big cavity of

the wound out with cold spring-water. He brought the superficial

surfaces together with ten interrupted sutures, and, notwithstanding

the patient's age, the man speedily recovered. This emphasizes the fact

that the old theory of leaving wounds of this nature open was

erroneous. Solly reports the case of a tailor of twenty-two who

attempted suicide by cutting through the larynx, entirely severing the

epiglottis and three-fourths of the pharynx. No bleeding point was

found, and recovery ensued.

Cowles describes the case of a soldier of thirty-five who, while

escaping from the patrols, was shot by the Officer of the Day with a

small bullet from a pistol. The ball entered the right shoulder,

immediately over the suprascapular notch, passed superficially upward

and forward into the neck, wounding the esophagus posteriorly at a

point opposite the thyroid cartilage, and lodged in the left side of

the neck. The patient had little hemorrhage, but had expectorated and

swallowed much blood. He had a constant desire to swallow, which

continued several days. The treatment was expectant; and in less than

three weeks the soldier was returned to duty. From the same authority

there is a condensation of five reports of gunshot wounds of the neck,

from all of which the patients recovered and returned to duty.

Braman describes the case of a man on whom several injuries were

inflicted by a drunken companion. The first wound was slight; the

second a deep flesh-wound over the trapezius muscle; the third extended

from the right sterno-cleido-mastoid midway upward to the middle of the

jaw and down to the rapine of the trachea. The external jugular, the

external thyroid, and the facial arteries were severed. Braman did not

find it necessary to ligate, but was able to check the hemorrhage with

lint and persulphate of iron, in powder, with pressure. After fourteen

hours the wound was closed; the patient recovered, and was returned to

duty in a short time.

Thomas has reported the case of a man sixty-five years old who in an

attempt at suicide with a penknife, had made a deep wound in the left

side of the neck. The sternohyoid and omohyoid muscles were divided;

the internal jugular vein was cut through, and its cut ends were

collapsed and 3/4 inch apart; the common carotid artery was cut into,

but not divided; the thyroid cartilage was notched, and the external

and anterior jugular veins were severed. Clamp-forceps were immediately

applied to the cut vessels and one on each side the aperture in the

common carotid from which a small spurt of blood, certainly not half a

teaspoonful, came out. The left median basilic vein was exposed by an

incision, and 20 ounces of warm saline solution were slowly perfused,

an ordinary glass syringe with a capacity of five ounces, with an

India-rubber tubing attached to a canula in the vein being employed.

After seven ounces of fluid had been injected, the man made a short,

distinct inspiration; at ten ounces a deeper one (the radial pulse

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