Chapter X: Surgical Anomalies of the Head and Neck (3)

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.