PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. 22 page

could now be felt beating feebly); at 15 ounces the breathing became

regular and deep; at 18 ounces the man opened his eyes, but did not

appear to be conscious. The clamped vessels were now tied with catgut

and the wound cleansed with phenol lotion and dressed with

cyanid-gauze. The man was surrounded by hot-water bottles and the foot

of the bed elevated 18 inches. In the course of an hour the patient had

recovered sufficiently to answer in a squeaky voice to his name when

called loudly. Improvement proceeded rapidly until the twenty-second

day, when violent hemorrhage occurred, preceded a few hours previously

by a small trickle, easily controlled by pressure. The wound was at

once opened and blood found oozing from the distal extremities of the

carotid artery and jugular vein, which were promptly clamped. The

common carotid artery was not sound, so that ligatures were applied to

the internal and external carotids and to the internal jugular with a

small branch entering into it. The patient was in great collapse, but

quickly rallied, only to suffer renewed hemorrhage from the internal

carotid nine days later. This was controlled by pressure with sponges,

and a quart of hot water was injected into the rectum. From this time

on the patient made a slow recovery, a small sinus in the lower part of

the neck disappearing on the removal of the catgut ligature.

Adams describes the case of a woman who attempted suicide with a common

table-knife, severing the thyroid, cricoid, and first three rings of

the trachea, and lacerating the sternohyoid and thyroid arteries; she

finally recovered.

There is a curious case of suicide of a woman who, while under the

effects of opium, forced the handle of a mirror into her mouth. From

all appearances, the handle had broken off near the junction and she

had evidently fallen forward with the remaining part in her mouth,

driving it forcibly against the spine, and causing the point of the

handle to run downward in front of the cervical vertebrae. On

postmortem examination, a sharp piece of wood about two inches long,

corresponding to the missing portion of the broken mirror handle, was

found lying between the posterior wall of the esophagus and the spine.

Hennig mentions a case of gunshot wound of the neck in which the musket

ball was lodged in the posterior portion of the neck and was

subsequently discharged by the anus.

Injuries of the cervical vertebrae, while extremely grave, and declared

by some authors to be inevitably fatal, are, however, not always

followed by death or permanently bad results. Barwell mentions a man of

sixty-three who, in a fit of despondency, threw himself from a window,

having fastened a rope to his neck and to the window-sill. He fell 11

or 12 feet, and in doing so suffered a subluxation of the 4th cervical

vertebra. It slowly resumed the normal position by the elasticity of

the intervertebral fibrocartilage, and there was complete recovery in

ten days. Lazzaretto reports the history of the case of a seaman whose

atlas was dislocated by a blow from a falling sail-yard. The

dislocation was reduced and held by adhesive strips, and the man made a

good recovery. Vanderpool of Bellevue Hospital, N.Y., describes a

fracture of the odontoid process caused by a fall on the back of the

head; death, however, did not ensue until six months later. According

to Ashhurst, Philips, the elder Cline, Willard Parker, Bayard, Stephen

Smith, May, and several other surgeons, have recorded complete recovery

after fracture of the atlas and axis. The same author also adds that

statistic investigation shows that as large a proportion as 18 per cent

of injuries of the cervical vertebrae occurring in civil practice,

recover. However, the chances of a fatal issue in injuries of the

vertebrae vary inversely with the distance of the point of injury from

the brain. Keen has recorded a case in which a conoidal ball lodged in

the body of the third cervical vertebra, from which it was extracted

six weeks later. The paralysis, which, up to the time of extraction,

had affected all four limbs, rapidly diminished. In about five weeks

after the removal of the bullet nearly the entire body of the 3d

cervical vertebra, including the anterior half of the transverse

process and vertebral foremen, was spontaneously discharged. Nearly

eight years afterward Keen saw the man still living, but with his right

shoulder and arm diminished in size and partly paralyzed.

Doyle reports a case of dislocated neck with recovery. During a runaway

the patient was thrown from his wagon, and was soon after found on the

roadside apparently dead. Physicians who were quickly summoned from the

immediate neighborhood detected faint signs of life; they also found a

deformity of the neck, which led them to suspect dislocation. An

ambulance was called, and without any effort being made to relieve the

deformity the man was placed in it and driven to his home about a mile

distant. The jolting over the rough roads greatly aggravated his

condition. When Doyle saw the patient, his general appearance presented

a hopeless condition, but being satisfied that a dislocation existed,

Doyle immediately prepared to reduce it. Two men were told to grasp the

feet and two more the head, and were directed to make careful but

strong extension. At the same time the physician placed his right hand

against the neck just over the pomum Adami, and his left against the

occiput, and, while extension was being made, he flexed the head

forward until the chin nearly touched the breast, after which the head

was returned to its normal position. The manipulation was accompanied

by a clicking sensation, caused by the replacement of the dislocated

vertebra. The patient immediately showed signs of relief and improved

rapidly. Perceptible but feeble movements were made by all the limbs

except the right arm. The patient remained in a comatose condition for

eight or nine days, during which he had enuresis and intestinal torpor.

He suffered from severe concussion of the brain, which accounted for

his prolonged coma. Delirium was present, but he was carefully watched

and not allowed to injure himself. His recovery was tedious and was

delayed by several relapses. His first complaint after consciousness

returned (on the tenth day) was of a sense of constriction about the

neck, us if he were being choked. This gradually passed off, and his

improvement went on without development of any serious symptoms. At

the time of report he appeared in the best of health and was quite able

to attend to his daily avocations. Doyle appends to his report the

statement that among 394 cases embraced in Ashhurst's statistics, in

treatment of dislocations in the cervical region, the mortality has

been nearly four times greater when constitutional or general treatment

has been relied on exclusively than when attempts had been made to

reduce the dislocation by extension, rotation, etc. Doyle strongly

advocates attempts at reduction in such cases.

Figure 205 represents a photograph of Barney Baldwin, a switchman of

the Louisville and Nashville Railroad, who, after recovery from

cervical dislocation, exhibited himself about the country, never

appearing without his suspensory apparatus.

Acheson records a case of luxation of the cervical spine with recovery

after the use of a jury-mast. The patient was a man of fifty-five, by

trade a train-conductor. On July 10, 1889, he fell backward in front of

a train, his head striking between the ties; the brake-body caught his

body, pushing it forward on his head, and turned him completely over.

Three trucks passed over him. When dragged from beneath the train, his

upper extremities were paralyzed. At noon the next day, nineteen hours

after the accident, examination revealed bruises over the body, and he

suffered intense pain at the back of the neck and base of the skull.

Posteriorly, the neck presented a natural appearance; but anteriorly,

to use the author's description, his neck resembled a combined case of

mumps and goiter. The sternomastoid muscle bulged at the angle of the

jaw, and was flaccid, and his "Adam's apple" was on a level with the

chin. Sensation in the upper extremities was partially restored, and,

although numb, he now had power of movement in the arms and hands, but

could not rotate his neck. A diagnosis of cervical dislocation was

made, and violent extension, with oscillation forward and backward, was

practiced, and the abnormal appearance subsided at once. No crepitus

was noticed. On the fourth day there was slight hemorrhage from the

mouth, which was more severe on the fifth and sixth days. The lower jaw

had been forced past the upper, until the first molar had penetrated

the tissues beneath the tongue. A plaster-of-Paris apparatus was

applied, and in two months was exchanged for one of sole-leather. In

rising from the recumbent position the man had to lift his head with

his hands. Fifty days after the accident he suffered excruciating pain

at the change of the weather, and at the approach of a storm the

joints, as well as the neck, were involved. It was believed (one

hundred and seven days after the accident) that both fracture and

luxation existed. His voice had become guttural, but examination of the

fauces was negative. The only evidence of paralysis was in the fingers,

which, when applied to anything, experienced the sensation of touching

gravel. The mottling of the tissues of the neck, which appeared about

the fiftieth day, had entirely disappeared.

According to Thorburn, Hilton had a patient who lived fourteen years

with paraplegia due to fracture of the 5th, 6th, and 7th cervical

vertebrae. Shaw is accredited with a case in which the patient lived

fifteen months, the fracture being above the 4th cervical vertebra.

In speaking of foreign bodies in the larynx and trachea, the first to

be considered will be liquids. There is a case on record of an infant

who was eating some coal, and being discovered by its mother was forced

to rapidly swallow some water. In the excitement, part of the fluid

swallowed fell into the trachea, and death rapidly ensued. It is hardly

necessary to mention the instances in which pus or blood from ruptured

abscesses entered the trachea and caused subsequent asphyxiation. A

curious instance is reported by Gaujot of Val-de-Grace of a soldier who

was wounded in the Franco-Prussian war, and into whose wound an

injection of the tincture of iodin was made. The wound was of such an

extent as to communicate with a bronchus, and by this means the iodin

entered the respiratory tract, causing suffocation. According to

Poulet, Vidal de Cassis mentions an inmate of the Charite Hospital, in

Paris, who, full of wine, had started to vomit; he perceived Corvisart,

and knew he would be questioned, therefore he quickly closed his mouth

to hide the proofs of his forbidden ingestion. The materials in his

mouth were forced into the larynx, and he was immediately asphyxiated.

Laennec, Merat, and many other writers have mentioned death caused by

the entrance of vomited materials into the air-passages. Parrot has

observed a child who died by the penetration of chyme into the

air-passages. The bronchial mucous and underlying membrane were already

in a process of digestion. Behrend, Piegu, and others cite analogous

instances.

The presence of a foreign body in the larynx is at all times the cause

of distressing symptoms, and, sometimes, a substance of the smallest

size will cause death. There is a curious accident recorded that

happened to a young man of twenty-three, who was anesthetized in order

to extract a tooth. A cork had been placed between the teeth to keep

the mouth open. The tooth was extracted but slipped from the forceps,

and, together with the cork, fell into the pharynx. The tooth was

ejected in an effort at vomiting, but the cork entered the larynx, and,

after violent struggles, asphyxiation caused death in an hour. The

autopsy demonstrated the presence of the cork in the larynx. A somewhat

analogous case, though not ending fatally, was reported by Hertz of a

woman of twenty-six, who was anesthetized for the extraction of the

right second inferior molar. The crown broke off during the operation,

and immediately after the extraction she had a fit of coughing. About

fifteen days later she experienced pain in the lungs. Her symptoms

increased to the fifth week, when she became so feeble as to be

confined to her bed. A body seemed to be moving in the trachea,

synchronously with respiration. At the end of the fifth week the

missing crown of the tooth was expelled after a violent fit of

coughing; the symptoms immediately ameliorated, and recovery was rapid

thereafter. Aronsohn speaks of a child who was playing with a toy

wind-instrument, and in his efforts to forcibly aspirate air through

it, the child drew the detached reed into the respiratory passages,

causing asphyxiation. At the autopsy the foreign body was found at the

superior portion of the left bronchus. There are other cases in which,

while sucking oranges or lemons, seeds have been aspirated; and there

is a case in which, in a like manner, the claw of a crab was drawn into

the air-passages. There are two cases mentioned in which children

playing with toy balloons, which they inflated with their breath, have,

by inspiration, reversed them and drawn the rubber of the balloon into

the opening of the glottis, causing death. Aronsohn, who has already

been quoted, and whose collection of instances of this nature is

probably the most extensive, speaks of a child in the street who was

eating an almond; a carriage threw the child down and he suddenly

inspired the nut into the air-passages, causing immediate asphyxia The

same author also mentions a soldier walking in the street eating a

plum, who, on being struck by a horse, suddenly started and swallowed

the seed of the fruit. After the accident he had little pain or

oppression, and no coughing, but twelve hours afterward he rejected the

seed in coughing.

A curious accident is that in which a foreign body thrown into the air

and caught in the mouth has caused immediate asphyxiation. Suetonius

transmits the history of a young man, a son of the Emperor Claudius,

who, in sport, threw a small pear into the air and caught it in his

mouth, and, as a consequence, was suffocated. Guattani cites a similar

instance of a man who threw up a chestnut, which, on being received in

the mouth, lodged in the air-passages; the man died on the nineteenth

day. Brodie reported the classic observation of the celebrated

engineer, Brunel, who swallowed a piece of money thrown into the air

and caught in his mouth. It fell into the open larynx, was inspired,

causing asphyxiation, but was removed by inversion of the man's body.

Sennert says that Pope Adrian IV died from the entrance of a fly into

his respiratory passages; and Remy and Gautier record instances of the

penetration of small fish into the trachea. There are, again,

instances of leeches in this location.

Occasionally the impaction of artificial teeth in the neighborhood of

the larynx has been unrecognized for many years. Lennox Browne reports

the history of a woman who was supposed to have either laryngeal

carcinoma or phthisis, but in whom he found, impacted in the larynx, a

plate with artificial teeth attached, which had remained in this

position twenty-two months unrecognized and unknown. The patient, when

questioned, remembered having been awakened in the night by a violent

attack of vomiting, and finding her teeth were missing assumed they

were thrown away with the ejections. From that time on she had suffered

pain and distress in breathing and swallowing, and became the subject

of progressive emaciation. After the removal of the impacted plate and

teeth she soon regained her health. Paget speaks of a gentleman who

for three months, unconsciously, carried at the base of the tongue and

epiglottis, very closely fitted to all the surface on which it rested,

a full set of lost teeth and gold palate-plate. From the symptoms and

history it was suspected that he had swallowed his set of false teeth,

but, in order to prevent his worrying, he was never informed of this

suspicion, and he never once suspected the causes of his symptoms.

Wrench mentions a case illustrative of the extent to which imagination

may produce symptoms simulating those ordinarily caused by the

swallowing of false teeth. This man awoke one morning with his nose and

throat full of blood, and noticed that his false teeth, which he seldom

removed at night, were missing. He rapidly developed great pain and

tumor in the larynx, together with difficulty in deglutition and

speech. After a fruitless search, with instrumental and laryngoscopic

aid, the missing teeth were found--in a chest of drawers; the symptoms

immediately subsided when the mental illusion was relieved.

There is a curious case of a man drowned near Portsmouth. After the

recovery of his body it was seen that his false teeth were impacted at

the anterior opening of the glottis, and it was presumed that the shock

caused by the plunge into the cold water had induced a violent and deep

inspiration which carried the teeth to the place of impaction.

Perrin reports a case of an old man of eighty-two who lost his life

from the impaction of a small piece of meat in the trachea and glottis.

In the Musee Valde-Grace is a prepared specimen of this case showing

the foreign body in situ. In the same museum Perrin has also deposited

a preparation from the body of a man of sixty-two, who died from the

entrance of a morsel of beef into the respiratory passages. At the

postmortem a mobile mass of food about the size of a hazel-nut was

found at the base of the larynx at the glossoepiglottic fossa. About

the 5th ring of the trachea the caliber of this organ was obstructed by

a cylindric alimentary bolus about six inches long, extending almost to

the bronchial division. Ashhurst shows a fibrinous cast, similar to

that found in croup, caused by a foreign body removed by Wharton,

together with a shawl-pin, from a patient at the Children's Hospital

seven hours after the performance of tracheotomy. Search for the

foreign body at the time of the operation was prevented by profuse

hemorrhage.

The ordinary instances of foreign bodies in the larynx and trachea are

so common that they will not be mentioned here. Their variety is

innumerable and it is quite possible for more than two to be in the

same location simultaneously. In his treatise on this subject Gross

says that he has seen two, three, and even four substances

simultaneously or successively penetrate the same location. Berard

presented a stick of wood extracted from the vocal cords of a child of

ten, and a few other similar instances are recorded.

The Medical Press and Circular finds in an Indian contemporary some

curious instances of misapplied ingenuity on the part of certain

habitual criminals in that country. The discovery on a prisoner of a

heavy leaden bullet about 3/4 inch in diameter led to an inquiry as to

the object to which it was applied. It was ascertained that it served

to aid in the formation of a pouch-like recess at the base of the

epiglottis. The ball is allowed to slide down to the desired position,

and it is retained there for about half an hour at a time. This

operation is repeated many times daily until a pouch the desired size

results, in which criminals contrive to secrete jewels, money, etc., in

such a way as to defy the most careful search, and without interfering

in any way with speech or respiration. Upward of 20 prisoners at

Calcutta were found to be provided with this pouch-formation. The

resources of the professional malingerer are exceedingly varied, and

testify to no small amount of cunning. The taking of internal

irritants is very common, but would-be in-patients very frequently

overshoot the mark and render recovery impossible. Castor-oil seeds,

croton beans, and sundry other agents are employed with this object in

view, and the medical officers of Indian prisons have to be continually

on the lookout for artificially induced diseases that baffle diagnosis

and resist treatment. Army surgeons are not altogether unfamiliar with

these tricks, but compared with the artful Hindoos the British soldier

is a mere child in such matters.

Excision of the larynx has found its chief indication in carcinoma, but

has been employed in sarcoma, polyps, tuberculosis, enchondroma,

stenosis, and necrosis. Whatever the procedure chosen for the

operation, preliminary tracheotomy is a prerequisite. It should be made

well below the isthmus of the thyroid gland, and from three to fifteen

days before the laryngectomy. This affords time for the lungs to become

accustomed to the new manner of breathing, and the trachea becomes

fixed to the anterior wall of the neck.

Powers and White have gathered 69 cases of either total or partial

extirpation of the larynx, to which the 240 cases collected and

analyzed by Eugene Kraus, in 1890, have been added. The histories of

six new cases are given. Of the 309 operations, 101, or 32 per cent of

the patients, died within the first eight weeks from shock, hemorrhage,

pneumonia, septic infection, or exhaustion. The cases collected by

these authors show a decrease in the death ratio in the total

excision,--29 per cent as against 36 per cent in the Kraus tables. The

mortality in the partial operation is increased, being 38 per cent as

opposed to 25 per cent. Cases reported as free from the disease before

the lapse of three years are of little value, except in that they

diminish, by so much, the operative death-rate. Of 180 laryngectomies

for carcinoma prior to January 1, 1892, 72, or 40 per cent, died as a

result of the operation; 51 of the remaining 108 had recurrence during

the first year, and 11, or ten per cent of the survivors, were free

from relapse three or more years after operation. In 77 cases of

partial laryngectomy for cancer, 26, or 33 per cent, died during the

first two months; of the remaining 51, seven cases, or 13 per cent, are

reported as free from the disease three or more years after the

operation.

Injuries destroying great portions of the face or jaw, but not causing

death, are seldom seen, except on the battle-field, and it is to

military surgery that we must look for the most striking instances of

this kind. Ribes mentions a man of thirty-three who, in the Spanish

campaign in 1811, received an injury which carried away the entire body

of the lower jaw, half of each ramus, and also mangled in a great

degree the neighboring soft parts. He was transported from the field of

battle, and, despite enormous hemorrhage and suppuration, in two months

recovered. At the time of report the wounded man presented no trace of

the inferior maxillary bone, but by carrying the finger along the side

of the pharynx in the direction of the superior dental arch the

coronoid apophyses could be recognized, and about six lines nearer the

temporal extremity the ramus could be discovered. The tongue was

missing for about one-third its length, and was thicker than natural

and retracted on the hyoid bone. The sublingual glands were adherent to

the under part of the tongue and were red and over-developed. The

inferior parts of the cheeks were cicatrized with the lateral and

superior regions of the neck, and with the base of the tongue and the

hyoid bone. The tongue was free under and in front of the larynx. The

patient used a gilded silver plate to fix the tongue so that

deglutition could be carried on. He was not able to articulate sounds,

but made himself understood through the intervention of this plate,

which was fixed to a silver chin. The chin he used to maintain the

tongue-plate, to diminish the deformity, and to retain the saliva,

which was constantly dribbling on the neck. The same author quotes the

instance of a man of fifty, who, during the siege of Alexandria in

1801, was struck in the middle of his face, obliquely, by a cannonball,

from below upward and from right to left. A part of the right malar

bone, the two superior maxillary bones, the nasal bones, the cartilage,

the vomer, the middle lamina of the ethmoid, the left maxillary bone, a

portion of the left zygomatic arch, and a great portion of the inferior

maxilla were carried away, or comminuted, and all the soft parts

correspondingly lacerated. Several hours afterward this soldier was

counted among the number of dead, but Larrey, the surgeon-in-chief of

the army, with his typical vigilance and humanity, remarked that the

patient gave signs of life, and that, despite the magnitude of his

wound, he did not despair of his recovery. Those portions in which

attrition was very great were removed, and the splinters of bone taken

out, showing an enormous wound. Three months were necessary for

cicatrization, but it was not until the capitulation of Marabou, at

which place he was wounded, that the patient was returned to France. At

this time he presented a hideous aspect. There were no signs of nose,

nor cartilage separating the entrance of the nostrils, and the vault of

the nasal fossa could be easily seen. There was a part of the posterior

region of the right superior maxilla, but the left was entirely

gone--in fact, the man presented an enormous triangular opening in the

center of the face, as shown by the accompanying illustration. The

tongue and larynx were severely involved, and the sight in the left eye

was lost. This patient continually wore a gilded silver mask, which

covered his deformity and rendered articulation a little less

difficult. The saliva continually dribbled from the mouth and from the

inferior internal portion of his mask, compelling him to carry some

substance to receive the dribblings. Whymper mentions an analogous

instance of a gunner who had his whole lower jaw torn away by a shell,

but who recovered and used an ingenious contrivance in the shape of a

silver mask for remedying the loss of the parts. Steiner mentions a

wound from a cannon-ball, which carried away the left half of the

inferior maxilla, stripping the soft parts as high as the malar, and on

the left side of the neck to within 1 1/2 inches of the clavicle,

laying bare the transverse processes of the 2d and 3d vertebrae, end

exposing the external carotid and most of its branches.

It sometimes happens that a foreign body, such as the breech of a gun,

may be imbedded for some time in the face, with subsequent safe

removal. Keith mentions an instance of the successful removal of the

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