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.