Foreign Bodies in the Pharynx and Esophagus, Part 7

Anomalies and Curiosities of Medicine
by George M. Gould, M.D., Walter L. Pyle, M.D.

(Page 33 of 41)

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.