destruction of brain-substance around the Rolandic area; there was
recovery but with loss of the so called muscular sense. The patient, a
workman of twenty-nine, while cutting down a gum-tree, was struck by a
branch as thick as a man's arm, which fell from 100 feet overhead,
inflicting a compound comminuted fracture of the cranium. The right eye
was contused but the pupils equal; the vertex-wound was full of
brain-substance and pieces of bone, ten of which were removed, leaving
an oval opening four by three inches. The base of the skull was
fractured behind the orbits; a fissure 1/4 inch wide was discernible,
and the right frontal bone could be easily moved. The lacerated and
contused brain-substance was removed. Consciousness returned six days
after the operation. The accompanying illustrations (Figs. 196 and
197) show the extent of the injury. The lower half of the ascending
frontal convolution, the greater half of the sigmoid gyrus, the
posterior third of the lower and middle frontal convolutions, the base
and posterior end of the upper convolution, and the base of the
corresponding portion of the falciform lobe were involved. The sensory
and motor functions of the arm were retained in a relative degree.
There was power of simple movements, but complex movements were
awkward. The tactile localization was almost lost.
Morton mentions a patient of forty-seven, who was injured in a railroad
accident near Phoenixville, Pa.; there was a compound comminuted
fracture of the skull involving the left temporal, spheroid, and
superior maxillary bones. The side of the head and the ear were
considerably lacerated; several teeth were broken, and besides this
there was injury to the aura and cerebral substance. There was profound
coma for ten days and paralysis of the 1st, 2d, 3d, 4th, 6th, and 7th
cranial nerves, particularly affecting the left side of the face. There
was scarcely enough blood-supply left to the orbit to maintain life in
the globe. The man primarily recovered, but ninety-one days from the
injury he died of cerebral abscess.
There is the record of a curious brain-injury in a man of twenty-two,
who was struck on the skull by a circular saw. The saw cut directly
down into the brain, severing the superior longitudinal sinus, besides
tearing a branch of the meningeal artery. The wound was filled with
sawdust left by the saw while it was tearing through the parts. After
ordinary treatment the man recovered.
Bird reports a compound comminuted fracture of the left temporal
region, with loss of bone, together with six drams of brain-substance,
which, however, was followed by recovery. Tagert gives an instance of
compound depressed fracture of the skull, with loss of brain-substance,
in which recovery was effected without operative interference. Ballou,
Bartlett, Buckner, Capon, Carmichael, Corban, Maunder and many others,
cite instances of cranial fracture and loss of brain-substance, with
subsequent recovery. Halsted reports the history of a boy of seventeen,
who, while out fowling, had the breech-pin of a shot-gun blown out, the
sharp point striking the forehead in the frontal suture, crushing the
os frontis, destroying 1 3/4 inches of the longitudinal sinus, and
causing severe hemorrhage from both the longitudinal and frontal
sinuses. The pin was pulled out by the boy, who washed his own face,
and lay down; he soon became semi-comatose, in which condition he
remained for some days; but, after operation, he made complete recovery.
Loss of Brain-substance from Cerebral Tumor.--Koser is accredited with
reporting results of a postmortem held on a young man of twenty who
suffered from a cerebral tumor of considerable duration. It was stated
that, although there was a cavity in the brain at least five inches in
length, the patient, almost up to the time of death, was possessed of
the senses of touch, taste, hearing, and smell, showed considerable
control over his locomotor muscles, and could talk. In fact, he was
practically discommoded in no other way than by loss of vision, caused
by pressure on the optic centers. It was also stated that the retention
of memory was remarkable, and, up to within two weeks of his death, the
patient was able to memorize poems. The amount of involvement
discovered postmortem in cases similar to the preceding is astonishing.
At a recent pathologic display in London several remarkable specimens
were shown.
Extensive Fractures of the Skull. Jennings mentions an instance of
extensive fracture of the skull, 14 pieces of the cranium being found.
The patient lived five weeks and two days after the injury, the
immediate cause of death being edema of the lungs. His language was
incoherent and full of oaths. Belloste, in his "Hospital Surgeon,"
states that he had under has care a most dreadful case of a girl of
eleven or twelve years, who received 18 or 19 cutlass wounds of the
head, each so violent as to chip out pieces of bone; but,
notwithstanding her severe injuries, she made recovery. At the
Emergency Hospital in Washington, D.C., there was received a negress
with at least six gaping wounds of the head, in some cases denuding the
periosteum and cutting the cranium. During a debauch the night before
she had been engaged in a quarrel with a negro with whom she lived, and
was struck by him several times on the head with an axe. She lay all
night unconscious, and was discovered the next morning with her hair
and clothes and the floor on which she lay drenched with blood. The
ambulance was summoned to take her to the morgue, but on the arrival of
the police it was seen that feeble signs of life still existed. On
admission to the hospital she was semi-comatose, almost pulseless,
cold, and exhibiting all the signs of extreme hemorrhage and shock. Her
head was cleaned up, but her condition would not permit of any other
treatment than a corrosive-sublimate compress and a bandage of
Scultetus. She was taken to the hospital ward, where warmth and
stimulants were applied, after which she completely reacted. She
progressed so well that it was not deemed advisable to remove the
head-bandage until the fourth day, when it was seen that the wounds had
almost entirely healed and suppuration was virtually absent. The
patient rapidly and completely recovered, and her neighbors, on her
return home, could hardly believe that she was the same woman whom, a
few days before, they were preparing to take to the morgue.
A serious injury, which is not at all infrequent, is that caused by
diving into shallow water, or into a bath from which water has been
withdrawn. Curran mentions a British officer in India who, being
overheated, stopped at a station bath in which the previous night he
had had a plunge, and without examining, took a violent "header" into
the tank, confidently expecting to strike from eight to ten feet of
water. He dashed his head against the concrete bottom 12 feet below
(the water two hours previously having been withdrawn) and crushed his
brain and skull into an indistinguishable mass.
There are many cases on record in which an injury, particularly a
gunshot wound of the skull, though showing no external wound, has
caused death by producing a fracture of the internal table of the
cranium. Pare gives details of the case of a nobleman whose head was
guarded by a helmet and who was struck by a ball, leaving no external
sign of injury, but it was subsequently found that there was an
internal fracture of the cranium. Tulpius and Scultetus are among the
older writers reporting somewhat similar instances, and there are
several analogous cases reported as having occurred during the War of
the Rebellion. Boling reports a case in which the internal table was
splintered to a much greater extent than the external.
Fracture of the base of the skull is ordinarily spoken of as a fatal
injury, reported instances of recovery being extremely rare, but
Battle, in a paper on this subject, has collected numerous statistics
of nonfatal fracture of the base of the brain, viz.:--
Male. Female.
Anterior fossa, . . . . . . . . . . . 16 5
Middle fossa, . . . . . . . . . . . . 50 6
Posterior fossa,. . . . . . . . . . . 10 1
Middle and anterior fossae, . . . . . 15 5
Middle and posterior fossae,. . . . . 4 1
Anterior, middle, and posterior fossae, 1 0
------ ------
96 18 Total, 114.
In a paper on nonmortal fractures of the base of the skull, Lidell
gives an account of 135 cases. MacCormac reports a case of a boy of
nine who was run over by a carriage drawn by a pair of horses. He
suffered fracture of the base of the skull, of the bones of the face,
and of the left ulna, and although suppuration at the points of
fracture ensued, followed by an optic neuritis, an ultimate recovery
was effected. Ball, an Irish surgeon, has collected several instances
in which the base of the skull has been driven in and the condyle of
the jaw impacted in the opening by force transmitted through the lower
maxilla.
The tolerance of foreign bodies in the brain is most marvelous. In the
ancient chronicles of Koenigsberg there is recorded the history of a
man who for fourteen years carried in his head a piece of iron as large
as his finger. After its long lodgment, during which the subject was
little discommoded, it finally came out by the palatine arch. There is
also an old record of a ball lodging near the sella turcica for over a
year, the patient dying suddenly of an entirely different accident.
Fabricius Hildanus relates the history of an injury, in which, without
causing any uncomfortable symptoms, a ball rested between the skull and
dura for six months.
Amatus Lusitanus speaks of a drunken courtesan who was wounded in a
fray with a long, sharp-pointed knife which was driven into the head.
No apparent injury resulted, and death from fever took place eight
years after the reception of the injury. On opening the head a large
piece of knife was found between the skull and dura. It is said that
Benedictus mentions a Greek who was wounded, at the siege of Colchis,
in the right temple by a dart and taken captive by the Turks; he lived
for twenty years in slavery, the wound having completely healed.
Obtaining his liberty, he came to Sidon, and five years after, as he
was washing his face, he was seized by a violent fit of sneezing, and
discharged from one of his nostrils a piece of the dart having an iron
point of considerable length.
In about 1884 there died in the Vienna Hospital a bookbinder of
forty-five, who had always passed as an intelligent man, but who had at
irregular intervals suffered from epileptic convulsions. An iron nail
covered with rust was discovered in his brain; from the history of his
life and from the appearances of the nail it had evidently been lodged
in the cerebrum since childhood.
Slee mentions a case in which, after the death of a man from septic
peritonitis following a bullet-wound of the intestines, he found
postmortem a knife-blade 5/16 inch in width projecting into the brain
to the depth of one inch. The blade was ensheathed in a strong fibrous
capsule 1/2 inch thick, and the adjacent brain-structure was apparently
normal. The blade was black and corroded, and had evidently passed
between the sutures during boyhood as there was no depression or
displacement of the cranial bones. The weapon had broken off just on a
level with the skull, and had remained in situ until the time of death
without causing any indicative symptoms. Slee does not state the man's
age, but remarks that he was a married man and a father at the time of
his death, and had enjoyed the best of health up to the time he was
shot in the abdomen. Callaghan, quoted in Erichsen's "Surgery," remarks
that he knew of an officer who lived seven years with a portion of a
gun-breech weighing three ounces lodged in his brain.
Lawson mentions the impaction of a portion of a breech of a gun in the
forehead of a man for twelve years, with subsequent removal and
recovery. Waldon speaks of a similar case in which a fragment of the
breech weighing three ounces penetrated the cranium, and was lodged in
the brain for two months previous to the death of the patient.
Huppert tells of the lodgment of a slate-pencil three inches long in
the brain during lifetime, death ultimately being caused by a slight
head-injury. Larry mentions a person who for some time carried a six
ounce ball in the brain and ultimately recovered. Peter removed a
musket-ball from the frontal sinus after six years' lodgment, with
successful issue. Mastin has given an instance in which the blade of a
pen-knife remained in the brain six months, recovery following its
removal. Camden reports a case in which a ball received in a gunshot
wound of the brain remained in situ for thirteen years; Cronyn mentions
a similar case in which a bullet rested in the brain for eight years.
Doyle successfully removed an ounce Minie ball from the brain after a
fifteen years' lodgment.
Pipe-stems, wires, shot, and other foreign bodies, are from time to
time recorded as remaining in the brain for some time. Wharton has
compiled elaborate statistics on this subject, commenting on 316 cases
in which foreign bodies were lodged in the brain, and furnishing all
the necessary information to persons interested in this subject.
Injuries of the nose, with marked deformity, are in a measure combated
by devices invented for restoring the missing portions of the injured
member. Taliacotius, the distinguished Italian surgeon of the sixteenth
century, devised an operation which now bears his name, and consists in
fashioning a nose from the fleshy tissues of the arm. The arm is
approximated to the head and held in this position by an apparatus or
system of bandages for about ten days, at which time it is supposed
that it can be severed, and further trimming and paring of the nose is
then practiced. A column is subsequently made from the upper lip. In
the olden days there was a timorous legend representing Taliacotius
making noses for his patients from the gluteal regions of other
persons, which statement, needless to say, is not founded on fact.
Various modifications and improvements on the a Talicotian method have
been made; but in recent years the Indian method, introduced by Carpue
into England in 1816, is generally preferred. Syme of Edinburgh, Wood,
and Ollier have devised methods of restoring the nose, which bear their
names.
Ohmann-Dumesnil reports a case of rhinophyma in a man of seventy-two,
an alcoholic, who was originally affected with acne rosacea, on whom he
performed a most successful operation for restoration. The accompanying
illustration shows the original deformity--a growth weighing two
pounds--and also pictures the appearance shortly after the operation.
This case is illustrative of the possibilities of plastic surgery in
the hands of a skilful and ingenious operator.
About 1892 Dr. J. P. Parker then of Kansas City, Mo., restored the
missing bridge of a patient's nose by laying the sunken part open in
two long flaps, denuding the distal extremity of the little finger of
the patient's right hand of nail, flesh, tendons, etc., and binding it
into the wound of the nose until firm union had taken place. The finger
was then amputated at the second joint and the plastic operation
completed, with a result pleasing both to patient and operator.
There is a case quoted of a young man who, when first seen by his
medical attendant, had all the soft parts of the nose gone, except
one-third of the left ala and a thin flap of the septum which was lying
on the upper lip. The missing member was ferreted out and cleansed, and
after an hour's separation sutured on. The nostrils were daily syringed
with a corrosive sublimate solution, and on the tenth day the dressing
was removed; the nose was found active and well, with the single
exception of a triangular notch on the right side, which was too
greatly bruised by the violence of the blow to recover. When we
consider the varicosity of this organ we can readily believe the
possibility of the foregoing facts, and there is little doubt that more
precaution in suturing severed portions of the nose would render the
operation of nose making a very rare one.
Maxwell mentions a curious case of attempted suicide in which the ball,
passing through the palatine process of the superior maxillary bone,
crushing the vomer to the extent of its own diameter, fell back through
the right nostril into the pharynx, was swallowed, and discharged from
the anus.
Deformities of the nose causing enormous development, or the condition
called "double-nose" by Bartholinus, Borellus, Bidault, and others, are
ordinarily results of a pathologic development of the sebaceous glands.
In some cases tumors develop from the root of the nose, forming what
appears to be a second nose. In other cases monstrous vegetations
divide the nose into many tumors. In the early portion of this century
much was heard about a man who was a daily habitue of the Palais-Royal
Gardens. His nose was divided into unequally sized tumors, covering
nearly his entire face. Similar instances have been observed in recent
years. Hey mentions a case in which the tumor extended to the lower
part of the under lip, which compressed the patient's mouth and
nostrils to such an extent that while sleeping, in order to insure
sufficient respiration, he had to insert a tin-tube into one of his
nostrils. Imbert de Lannes is quoted as operating on a former Mayor of
Angouleme. This gentleman's nose was divided into five lobes by
sarcomatous tumors weighing two pounds, occupying the external surface
of the face, adherent to the buccinator muscles to which they extended,
and covering the chin. In the upright position the tumors sealed the
nostrils and mouth, and the man had to bend his head before and after
respiration. In eating, this unfortunate: person had to lift his tumors
away from his mouth, and during sleep the monstrous growths were
supported in a sling attached to his night cap. He presented such a
hideous aspect that he was virtually ostracized from society The growth
had been in progress for twelve years, but during twenty-two months'
confinement in Revolutionary prisons the enlargement had been very
rapid. Fournier says that the most beautiful result followed the
operation which was considered quite hazardous.
Foreign bodies in the nose present phenomena as interesting as wounds
of this organ. Among the living objects which have been found in the
nose may be mentioned flies, maggots, worms, leeches, centipedes, and
even lizards. Zacutus Lusitanus tells of a person who died in two days
from the effects of a leech which was inadvertently introduced into the
nasal fossa, and there is a somewhat similar case of a military
pharmacist, a member of the French army in Spain, who drank some water
from a pitcher and exhibited, about a half hour afterward, a persistent
hemorrhage from the nose. Emaciation progressively continued, although
his appetite was normal. Three doctors, called in consultation,
prescribed bleeding, which, however, proved of no avail. Three weeks
afterward he carried in his nostril a tampon of lint, wet with an
astringent solution, and, on the next day, on blowing his nose, there
fell from the right nostril a body which he recognized as a leech.
Healey gives the history of four cases in which medicinal leeches were
removed from the mouth and posterior nares of persons who had, for some
days previously, been drinking turbid water. Sinclair mentions the
removal of a leech from the posterior nares.
In some regions, more particularly tropical ones, there are certain
flies that crawl into the nostrils of the inhabitants and deposit eggs,
in the cavities. The larvae develop and multiply with great rapidity,
and sometimes gain admission into the frontal sinus, causing intense
cephalalgia, and even death.
Dempster reports an instance of the lodgment of numerous live maggots
within the cavity of the nose, causing sloughing of the palate and
other complications. Nicholson mentions a case of ulceration and
abscess of the nostrils and face from which maggots were discharged.
Jarvis gives the history of a strange and repeated hemorrhage from the
nose and adjacent parts that was found to be due to maggots from the
ova of a fly, which had been deposited in the nose while the patient
was asleep. Tomlinson gives a case in which maggots traversed the
Eustachian tube, some being picked out of the nostrils, while others
were coughed up. Packard records the accidental entrance of a
centipede into the nostril. There is an account of a native who was
admitted to the Madras General Hospital, saying that a small lizard had
crawled up his nose. The urine of these animals is very irritating,
blistering any surface it touches. Despite vigorous treatment the
patient died in consequence of the entrance of this little creature.
There have been instances among the older writers in which a pea has
remained in the nose for such a length of time as to present evidences
of sprouting. The Ephemerides renders an instance of this kind, and
Breschet cites the history of a young boy, who, in 1718, introduced a
pea into his nostril; in three days it had swollen to such an extent as
to fill the whole passage. It could not be extracted by an instrument,
so tobacco snuff was used, which excited sneezing, and the pea was
ejected.
Vidal and the Ephemerides report several instances of tolerance of
foreign bodies in the nasal cavities for from twenty to twenty-five
years. Wiesman, in 1893, reported a rhinolith, which was composed of a
cherry-stone enveloped in chalk, that had been removed after a sojourn
of sixty years, with intense ozena as a consequence of its lodgment.
Waring mentions the case of a housemaid who carried a rhinolith, with a
cherry-stone for a nucleus, which had been introduced twenty-seven
years before, and which for twenty-five years had caused no symptoms.
Grove describes a necrosed inferior turbinated bone, to which was
attached a coffee-grain which had been retained in the nostril for
twenty years., Hickman gives an instance of a steel ring which for
thirteen and a half years had been impacted in the nasopharyngeal fossa
of a child. It was detected by the rhinoscope and was removed. Parker
speaks of a gunbreech bolt which was removed from the nose after five
years' lodgment. Major mentions the removal of a foreign body from the
nose seven years after its introduction.
Howard removed a large thimble from the posterior nares, although it
had remained in its position for some time undetected. Eve reports a
case in which a thimble was impacted in the right posterior nares.
Gazdar speaks, of a case of persistent neuralgia of one-half of the
face, caused by a foreign body in the nose. The obstruction was
removed after seven years' lodgment and the neuralgia disappeared.
Molinier has an observation on the extraction of a fragment of a
knife-blade which had rested four years in the nasal fossae, where the
blade had broken off during a quarrel.
A peculiar habit, sometimes seen in nervous individuals, is that of
"swallowing the tongue." Cohen claims that in some cases of supposed
laryngeal spasm the tongue is swallowed, occluding the larynx, and
sometimes with fatal consequences. There are possibly a half score of
cases recorded, but this anomaly is very rare, and Major is possibly
the only one who has to a certainty demonstrated the fact by a
laryngoscopic examination. By the laryngoscope he was enabled to
observe a paroxysm in a woman, in which the tongue retracted and
impinged on the epiglottis, but quickly recovered its position. Pettit
mentions suffocation from "tongue swallowing," both with and without
section of the frenum. Schobinger cites a similar instance, due to
loosening of the frenum.
Analogous to the foregoing phenomenon is the habit of "tongue sucking."
Morris mentions a young lady of fifteen who spontaneously dislocated
her jaw, owing indirectly to this habit. Morris says that from infancy
the patient was addicted to this habit, which was so audible as to be
heard in all parts of the room. The continued action of the pterygoid
muscles had so preternaturally loosened the ligaments and muscular
structures supporting the joint as to render them unable to resist the
violent action of "tongue sucking" even during sleep.
Injuries to the Tongue.--Hobbs describes a man of twenty-three who,
while working, had a habit of protruding his tongue. One day he was hit
under the chin by the chain of a crane on a pier, his upper teeth
inflicting a wound two inches deep, three inches from the tip, and
dividing the entire structure of the tongue except the arteries. The
edges of the wound were brought into apposition by sutures, and after
the removal of the latter perfect union and complete restoration of the
sensation of taste ensued. Franck mentions regeneration of a severed
tongue; and Van Wy has seen union of almost entirely severed parts of
the tongue. De Fuisseaux reports reunion of the tongue by suture after
almost complete transverse division.
There is an account of a German soldier who, May 2, 1813, was wounded
at the battle of Gross-Gorschen by a musket ball which penetrated the
left cheek, carrying away the last four molars of the upper jaw and
passing through the tongue, making exit on the left side, and forcing
out several teeth of the left lower jaw. To his surprise, thirty years
afterward, one of the teeth was removed from an abscess of the tongue.
Baker speaks of a boy of thirteen who was shot at three yards distance.
The bullet knocked out two teeth and passed through the tongue,
although it produced no wound of the pharynx, and was passed from the
anus on the sixth day. Stevenson mentions a case of an organist who
fell forward when stooping with a pipe in his mouth, driving its stem
into the roof of the pharynx. He complained of a sore throat for
several days, and, after explanation, Stevenson removed from the soft
palate a piece of clay pipe nearly 1 1/4 inches long. Herbert tells of
a case resembling carcinoma of the tongue, which was really due to the
lodgment of a piece of tooth in that organ.
Articulation Without the Tongue.--Total or partial destruction of the
tongue does not necessarily make articulation impossible. Banon
mentions a man who had nothing in his mouth representing a tongue. When
he was young, he was attacked by an ulceration destroying every vestige
of this member. The epiglottis, larynx, and pharynx, in fact the
surrounding structures were normal, and articulation, which was at
first lost, became fairly distinct, and deglutition was never
interfered with. Pare gives a description of a man whose tongue was
completely severed, in consequence of which he lost speech for three
years, but was afterward able to make himself understood by an
ingenious bit of mechanism. He inserted under the stump of the tongue a
small piece of wood, in a most marvelous way replacing the missing
member. Articulation with the absence of some constituent of the vocal
apparatus has been spoken of on page 254.
Hypertrophy of the Tongue.--It sometimes happens that the tongue is so
large that it is rendered not only useless but a decided hindrance to
the performance of the ordinary functions into which it always enters.
Ehrlich, Ficker, Klein, Rodforffer, and the Ephemerides, all record
instances in which a large tongue was removed either by ligation or
amputation. Von Siebold records an instance in which death was caused
by the ligature of an abnormally sized tongue. There is a modern record
of three cases of enormous tongues, the result of simple hypertrophy.
In one case the tongue measured 6 1/4 inches from the angle of the
mouth about the sides and tip to the opposite angle, necessitating
amputation of the protruding portion.
Carnochan reports a case in which hypertrophy of the tongue was reduced
to nearly the normal size by first tying the external carotid, and six
weeks later the common carotid artery. Chalk mentions partial
dislocation of the lower jaw from an enlarged tongue. Lyford speaks of
enlargement of the tongue causing death.
The above conditions are known as macroglossia, which is a congenital
hypertrophy of the tongue analogous to elephantiasis. It is of slow
growth, and as the organ enlarges it interferes with deglutition and
speech. It may protrude over the chin and reach even as far down as the
sternum.
The great enlargement may cause deformities of the teeth and lower jaw,
and even present itself as an enormous tumor in the neck. The
protruding tongue itself may ulcerate, possibly bleed, and there is
constant dribbling of saliva. The disease is probably due to congenital
defect aggravated by frequent attacks of glossitis, and the treatment
consists in the removal of the protruding portions by the knife,
ligation, the cautery, or ecraseur.
Living Fish in the Pharynx.--Probably the most interesting cases of
foreign bodies are those in which living fish enter the pharynx and
esophagus. Chevers has collected five cases in which death was caused
by living fish entering the mouth and occluding the air-passages. He
has mentioned a case in which a large catfish jumped into the mouth of
a Madras bheestie. An operation on the esophagus was immediately
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
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
breech of a fowling-piece from the face, at the root of the nose, after
a lodgment of four months; and Fraser cites an analogous instance in
which the breech was imbedded in the bones of the face for eight years
Smith records an instance in which a broken piece of tobacco-pipe
penetrated the cheek, remained there for seven months, but was
successfully extracted.
Before leaving accidents to the head and neck, a most curious case,
cited by O'Neill, will be briefly reviewed. A boy of twelve was
entrusted to carry a new iron pot to the destination of its purchaser.
Probably to facilitate transportation, the boy removed his hat and
placed the pot obliquely on the back part of his head, but a sudden
movement caused it to slip forward and downward over the head.
Unavailing efforts were made at the time and after he reached home, to
remove the pot from his head, but in vain, and he continued all the
night greatly prostrated by fright, hunger, and thirst, together with
the efforts at removal. The next morning he was taken to a neighboring
blacksmith, who, by greasing one of his fingers, managed to insinuate
it between the head and pot. Placing the other side of the pot against
an anvil he struck over the location of his finger a quick, heavy tap
with a hammer, and the pot fell to pieces. The little patient was much
exhausted by all his treatment and want of sleep, and, in fact, could
hardly have endured his situation much longer.