Mary Cappello

by Swallow: Foreign Bodies

  One of the many things that makes swallowing such a singularly complex activity is the “intimate association of the airway with the food path.” Contiguous, enmeshed, interdependent: where swallowing exists, breathing can’t be far behind. Respiration subtends and supports swallowing even as our airway is suspended (temporarily sealed) each time the esophagus opens to receive a bit of (hopefully well-masticated) food. Of course there is a literal difference between a fbdy inspirated into the windpipe and down into a bronchus (an aspirated foreign body) and one that’s made its way into the throat, esophagus, or stomach (an ingested foreign body). And what might jar us laymen most is the knowledge that a fbdy can obstruct but not entirely cut off an airway. In fact, fbdies can enjoy a silent interval or symptomless period for days, months, and years, what Chevalier Jackson was apt to call a period of “delusional calm.”

  What becomes curiouser and curiouser with each plumbing of a Chevalier Jackson foreign body drawer is the always immanent conflation of airway and foodway, ingestion and aspiration. “Tracheo-bronchial symptoms are present in almost all cases of obstructive foreign bodies in the esophagus,” Jackson explains in his 1925 “Discussion on Overlooked Cases of Foreign Body in the Air and Food Passages.” An aspirated foreign body can manifest in difficulty swallowing, and an ingested foreign body can mask its locale by presenting as labored breathing. Because the esophagus and airway share a party wall, a fbdy sometimes erodes from one site into the other. If the lodged object distends the esophagus, it can cause an airway obstruction, and diagnosing a fbdy is always complicated by the fact that the symptoms of aspiration and ingestion are identical or referred. Choking, gagging, coughing, and wheezing, Jackson remarks, may occur regardless of the fbdy’s residence: lung, stomach, or throat.

  In the course of each day, one puts one’s faith in the “unerring passage of the bolus” (the medical term for chewed-up food), to use doctor-writer Dr. Sherwin Nuland’s felicitous phrase from “Voyage Through the Gut,” but all it takes to disrupt a swallow’s smooth functioning is a cough or a sudden inspiration. The process is easily disrupted, and yet, at the same time, a fbdy, in order to enter the wrong orifice, must “run the gauntlet,” as Jackson suggestively puts it, “of the epiglottis, the upper laryngeal orifice, the ventricular bands, the vocal cords, and bechic blast”—a fancy phrase for the blast of air that enables and accompanies a cough (DAFP, 20). A fbdy makes its way past and in when the body’s normal protective mechanisms fail or relax or malfunction or are distracted from their watchful purpose by a laugh, say, or a sob. “Swallowing is elicited by a peculiar combination of conscious and subconscious cues,” notes Kahrilas, and I begin to imagine the idiosyncrasies of your laugh or my cry, at which point fbdy ingestion seems peculiarly tied to personality. “Laughter, sobbing, and crying,” Jackson writes, “in addition to the altered inspiratory rhythm, bring into play other movements”—buccal (of or relating to the cheeks or mouth cavity), pharyngeal (implicating the small tube into which food passes before it enters the esophagus), and laryngeal (relative to the voice box)—“and also extraordinary respiratory movements of a special and unusual character” (DAFP, 22). Sometimes the body’s efforts to resist or repel a foreign body are self-sabotaging, since an outward exhaling push requires a sequential, even deeper intake of breath, and the next thing a person knows in her attempt to prevent the swallowing of a fbdy, she has accidentally inhaled it instead.

  Swallowing’s and breathing’s intersections seem to prompt Jackson to make quirky observations, collect anomalous statistics, and draw strange differences. For example, “it may be cited that certain foreign bodies of relatively frequent occurrence in the air passages have never lodged in the normal esophagus” (DAFP, 17), but he doesn’t say which those are. Though more watermelon seeds are swallowed than inhaled in the course of a year, more get stuck in the airway than the foodway (DAFP, 32), and “more fishbones have become lodged in the tonsil than in any other portion of the anatomy” (DAFP, 32). Most foreign bodies, if they are going to enter an airway, tend toward the right lower lobe bronchus because of the greater diameter of its opening—medically speaking, its wider lumen—and the fact that it doesn’t deviate much from the tracheal axis. But individual anatomy, posture, and gravity play a part as well.

  If Chevalier Jackson waxes poetical about a fbdy, it is likely to be an umbrella-headed tack, inviting us to stroll an imaginary pathway of the marvelous as he figures the body’s upper cavities as a windswept terrain.

  This preponderance of incidence of the umbrella-headed tack may be due partly to its shape. The umbrella-shaped head with the weighty stem for ballast certainly is well constructed for being drawn in by the inspiratory blast, like a parachute on a rising wind, and the convexly rounded shape of the advancing head offers a favorable form for entering through the glottic chink. This shape, as well as the point, resists bechic expulsion unless the tack is overturned; we all know the pull of an umbrella when the wind gets under it. (DAFP, 35)

  In spite of Chevalier Jackson’s asceticism, he could lavish attention on a pencil. The Eldorado 5B was a favorite. That’s not a rosary he’s saying in the photograph in which he bends forward attentively, emanating quiet joy (see figure 5). That is, according to its caption in his autobiography, “a characteristic attitude studying a duplicate foreign body.” Jackson studies the object as an afterimage, an aftereffect: the Thing mastered. Here there is benediction and an eerie inhabitance of an in-between space, the space between what the Thing was and what the Thing now is in Jackson’s hands. Rather than look at the camera, Jackson looks into the Thing until the photo seems not to be of him at all but of a constellation of relative items: a round-topped wooden table, a Legion of Honor boutonnière, a pair of spectacles.

  Every collection is a verge in the sense that it wishes to postpone or defer the inevitable. Do we tremble together on the threshold of the archive or take refuge in the bottomless cabinet we can return to at the end of the day, our computers and our iPods in which everything is stored and nothing is not known? Nothing is curious about those collections and everything inside them is safely out of reach. The archive is another kind of catalog in which things are arranged and ordered and stowed, but archival pages can also plummet, soar, and turn, winged matter ascending from an open drawer.

  Fig. 5. Chevalier Jackson “in a characteristic attitude studying a duplicate foreign body.” Chevalier Jackson Papers, 1890-1964, MS C 292, Modern Manuscripts Collection, History of Medicine Division, National Library of Medicine, Bethesda, Maryland.

  In the archives of the National Library of Medicine, I turn brittle pages with people’s case histories and trace the life and lines of photographs of Jackson embodied. I think about his having lived once—his contribution, superhuman—and thus the nearly unbelievable sense that he has really died.

  In the archive, I move from awe to investigation and back to awe with various forms of awfulness emerging in between.

  On a piece of letterhead, Jackson scribbled: “Death is an irreversible process; imminent asphyxia is not.”

  Tucked inside a litany of conclusions, a boldface fact: “Death often lurks under an overhanging epiglottis.”

  In the John Quincy Adams Library of Otolaryngology, the boxes with Jackson’s illustrations are so heavy they practically pull me to the ground. I wish I didn’t have a body. I wish I didn’t have to break for lunch. I hold the heft of his small wallet and wonder how it came to be here. I learn from the archivist that the fastidious doctor, preoccupied with control, carried a four-leaf clover in his purse. Is this a personal effect or an aftereffect? I turn the pages of small Naugahyde-covered three-ring notebooks, the many fbdy diaries, and the daybooks filled with the details of each case; wallet-size photographs of objects; photographs of X-rays; a photograph of fingers splayed, abstracted, illustrative of the “clubbing” that results from a foreign body lodged in the lungs too long, a photograph that could match the formalist masterpieces of Man Ray; the hand-hewn illustration
s; and occasionally a return to the language of his maternal ancestors, which makes the objects, sinister, seem like bonbons, badly taken, mal prise, or well taken, bonne prise : chataigne (chestnut), noix de coco (coconut), pince à cheveux (hair-clip), les bijoux (jewelry), sifflet (whistle), un clou (nail), broquettes (tacks).

  Boxes, cartons, means of preservation; crates with reinforced edges, indestructible, maybe even fireproof; cardboard, white, the lumen of the stomach salmon-colored; and silence, hours of quiet in the room shared by me, the archivist, and a librarian.

  In the Jefferson University Archives, I begin to feel the moments of Jackson’s early training, the grain of his day, a tone of voice, his peculiar third-person address, a sliver of paper with his scribblings in an ink not yet dry. Is it possible the ink of Jackson’s letters to his mother is still fresh?

  Feb. 7, 1921

  Just had a tooth cap in the lung that they could not get out at Johns Hopkins. “My Chevie”—he did it. Lady was brought in on a stretcher, bad heart disease. Poor old Lady was badly used up by the long bronchoscope under ether at Hopkins. My Chevie he took it out with only a little local anaesthetic. Nice old Lady—kissed my hand and prayed long and fervently for me. Guess I need it. But they wanted to cut out some ribs and go in through the outside chest wall. She never would have survived.

  Love, Chevie

  Feb. 16 1921

  Dear Mother—

  On my way to University for the removal of bone from a woman’s lung—

  All well

  Hope you are too

  Love, Chevie

  Undated

  Sent you a few French sardines. Box looked like ones Mark Mitchell used to get at the rooms and drink the oil after eating the ’dines.

  . . . You know me—neither rest nor let anybody else rest.

  . . . Have so many little children that I am able to help. I save many lives.

  The Mütter Museum’s curator, Anna Dhody, turns a wheel and I expect the earth beneath the two of us to move or a sail to flap open, but instead the walls move, walls made of drawers interlocking, beyond the reach of a ladder, velvet-lined cases with bronchoscopes and distal lights and a plaster cast of Jackson’s hand. I’m Alice to her Mad Hatter—she resides here while I just have happened to fall in. Her realm is anything but glamorous: the archive is in the basement, the building’s bowels, where it’s all low ceilings, fake wood paneling, and exposed pipes; they’re currently working on maintaining a street-level window. She opens drawers for me and lets me linger, but the sesame is in the opening of an internal door that offers immediate access to the main galleries. I expected the door was an exit onto a Philadelphia street, but instead it opens onto a promontory, like a seascape hidden behind a dune. The galleries now seem false, and the archive true; the galleries a show, the archive the machinery; the galleries, a public palace, the archive the place for private moles.

  In all of these archives, in the drawers within drawers, there are lists. Endless lists. Lists upon lists, and indexes. The tome-like grid that appears with the fbdy collection in the Mütter Museum is only one of numerous kinds of catalogs that Jackson devised for the Things. As though in search of the ideal form for the things, or the form that would make the collection most useful, he sometimes relied on chronology and sometimes didn’t. Sometimes the lists are alphabetical, and other times they are arranged numerically. Now they read top to bottom; now they read right to left. Sometimes the record is scattershot; other times it is stacked, bi-columned or tri-columned; sometimes it is devoid of description and other times briefly descriptive, but each and every object and case is recorded in mind-bogglingly multiple ways.

  Even lists, seemingly meaningless place markers, speak; they intone a presence, documentary and mythological at once. They fail to stay in their place as mere data. When the names appear detached from the detailed account of a case, they have the effect of a roll call of untoward swallowers, an incantation of contact with the indigestible, a queer sort of club. And when the names, only the names, appear together this way, with or without their objects and their dates and places of treatment, they are so many and so familiar that you begin at first to find people you know there, you become convinced that all the world’s people appear here, you stand at the ready for your own name’s appearance. Yes, you must have at one time in your life swallowed a piece of the object world and been treated to a Jacksonian extraction along with Victor Moulton, Elizabeth Fielder, James Fox, Maude Smith, Reverend Lamuel Blair, Eleonor Slocum, John Walton, Martin Mosley, Kate Shapiro, John Jones, Charles Malloy, Barton Cunningham, Mattie Thompson, Anna Solt, Mildred Strong, Wilmer Ditzer, Marian McCleary, Daisy Dietrich, Rita Barecca, Emma White, Roy Stinson, Moe Jacobs, John White, Minnie Rankins, Patricia North, Salvatore Sabatino, Lolita Waller, Peter Ford, and Harold Mintzmyer, who had fragments of paper stuck in his left lower bronchus while others were beset by three pieces of squirrel bone, a fifty-cent piece, a gold locket, a meat bolus, and a portion of a Christmas tree ball.

  The lists charm when you think you’ve hit upon the most spectacular example but keep finding others that outdo the last. Which is more outlandish: Ezra King’s swallowed padlock from 1929, Robert Hall’s swallowed belt buckle from 1941, or Laura Kragler’s shoe buckles (yes, in the plural) from 1942? I can’t for the life of me decide which is more extraordinary, but I begin to feel the tug of narrative. We have entered—let’s admit it—a form of literature and not of science, a philosophical treatise, a dramatis personae for a theater of the absurd, a medieval passion play when the names inside the catalogs inside the archives begin to match their Things. John Winhorn had a metal whistle in his esophagus, and Richard Stangle had a piece of glass in his trachea at the carina. And what to make of entire families being treated for the ingestion of foreign bodies, as in Frank Babb, who was treated for a peanut kernel in his bronchus, Edwin Babb, for whom a tack had lodged in his; and Arnold Babb, whose meat bolus stuck in his throat? Then there’s Doris Key, who in September 1930 came to the clinic with a pork bone in her lower left bronchus, only to be followed—and I might add, outdone—by a Rose Key who presented with an earring in her foodway nearly one year later.

  When objects gain a name by way of archives, the effect isn’t always to make the cases more real, but novelistic in a truth-is-stranger-than-fiction sort of way. Is it me, or do these names seem fabricated? Could you match each of these names with its literary mate or author? Rat Crancer (probably a gumshoe). Powder D. Coulter. Weymouth Crumpler (longtime friend of Little Miss Muffett). Pansy Hines. Donald Dumbleton (wouldn’t you know, he had a timothy-head screwdriver in his esophagus). Alice Dalrymple. Zadie Smallwood. Mrs. L. Stretch. Myrtle Yonders (sister of Thistle Near). Anna Skeen (I think she appears in Gertrude Stein’s Three Lives). Florabelle Sledge (an oxymoronish personage). Sister Mary Octave. Waldo Intermill. Evelyn Marie Loveless. Irma Erben (William Wilson’s cousin and Humbert Humbert’s wife). Linnwood Wheeloff (hadn’t Henry James made a place for him in The Americans?), and the incomparably unbelievable Sister Mary Pica—“pica” being the DSM-IV descriptor for disordered swallowing.

  Found objects yield found poetry in one version of a grid with offerings of “how.” There is something confluential here, and something pure, purely true, something kooky and something sad, and suggestively incomplete, much like personality, much like desire, much like life:

  Child alone in room found hairpin under pillow

  Nickel and half dollar in a glass of water, child pretended to drink

  Was playing on school ground, afraid of loosing 50 ct piece put it in her mouth

  Eating mashed potatoes, patient remembered that while mashing potatoes, small piece of enamel came off the pan, meant to throw potatoes away but forgot

  Playing around “wicker chair”

  Safety pin in mouth, suddenly stepped on dog’s foot

  Put toy in his mouth to hide it from sister

  Patient playing with tin cup containing a white pearl button. Child threw cup
up, patient’s mouth was open and button fell in.

  Eating clam chowder

  Eating grape fruit

  Suffering of melancholy

  Alone on floor with pile of buttons

  Every object in Chevalier Jackson’s collection is the product of a trajectory; each fbdy has gone from a thing in the world to a thing in the body, to a thing in Chevalier Jackson’s grasp, to a thing inlaid by Chevalier Jackson into a secular tabernacle. Each has been put through a particular system of meaning; it’s been made, by Jackson, to serve not exactly an epistemological inquiry nor a philosophical inquiry, but something like a physiological inquiry, an inquiry into corporeality. How can you wrest one body from another? In what sense does the precariousness of foreign-body ingestion point up the human body’s foreignness to the world of which it is a part, and the world of objects that it has, itself, produced?

  To each collection, a life of its own that it is said to “take on”; to each collection, an irrevocable attachment to its collector. What is the nature of this to-and-fro reciprocity that the fbdy collection ignites, a seesaw of identifications whereby its owner projects himself onto his arrangement at the same time that he takes on the qualities of the objects therein? Here’s Jackson: a forager for the stuff of life, for a heightened kind of “real,” tucked inside recalcitrant folds and intolerant viscera. There’s Jackson: enshrined inside his collection but not exactly caught, instead retreating into amplitude beyond all gustatory or esophageal measure. See the objects recede into their cabinet as body double, impervious and wide. Glimpse the outside, explore the inside; turn the inside out and the outside in.