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PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. 21 pagecommenced, 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 Date: 2014-12-29; view: 736
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