As the better class of medic knew, there was already plenty of evidence to prove otherwise. Paré himself examined the body of a duelist who had managed to run two hundred paces with a large sword wound in his heart. Others found scars in the cardiac tissue of patients who had died from natural causes—the remnants of injuries inflicted months or years earlier. Galen’s assertion was thoroughly debunked, but in some quarters, it clung on stubbornly, a persistent medical myth. Cases of prolonged survival (or even recovery) after cardiac injury were still of sufficient novelty value in the 1830s to merit publication. This example, submitted to a journal in 1834 by Thomas Davis from Upton-upon-Severn in Worcestershire, is one of the best. Davis described himself as a surgeon but, like many provincial medics of the period, was in fact an apothecary without any formal qualifications.*
On Saturday evening, January the 19th, 1833, I was summoned to attend William Mills, aged 10, living at Boughton, two miles from Upton. When I arrived, his parents informed me that their son had shot himself with a gun made out of the handle of a telescope toasting-fork.
Certainly an unusual way to greet a doctor. If you’ve decided to construct an improvised firearm, a toasting fork is unlikely to be the first implement that comes to mind.
To form the breech of the gun, he had driven a plug of wood about three inches in length into the handle of the fork. The touch hole of the gun was made after the charge of powder had been deposited in the hollow part of the handle.
Ingenious, if not particularly wise.
The consequence was that when the gunpowder exploded it forced the artificial breech, or piece of stick, from the barrel part of the gun, with such violence that it entered the thorax of the boy, on the right side, between the third and fourth ribs, and disappeared. Immediately after the accident the boy walked home, a distance of about forty yards.
The fact that he was still able to walk appeared a good sign, and when the doctor examined the boy, the case did not immediately seem a serious one.
By the time I saw him, he had lost a considerable quantity of blood, and appeared very faint; when I turned him on his right side, a stream of venous blood issued from the orifice through which the stick entered the thorax. Several hours elapsed before any degree of reaction took place. He complained of no pain.
Indeed, in the aftermath of the incident, he hardly seemed to have been affected by it.
For the first ten days or a fortnight after the accident he appeared to be recovering, and once, during that time, walked into his garden, and back, a distance of about eighty yards; and whilst there, he amused himself with his flowers, and even stirred the mould.
Hobbies: horticulture and firearms. A slightly odd combination for a ten-year-old.
He always said he was well, and was often cheerful, and even merry. There was no peculiar expression of countenance, excepting that his eyes were rather too bright. After the first fortnight he visibly emaciated, and had frequent rigors, which were always followed by faintness. The pulse was very quick. There was no cough nor spitting of blood. The secretions were healthy. He had no pain throughout his illness. He died on the evening of the 25th of February, exactly five weeks and two days after the accident occurred.
The doctor was essentially helpless to intervene. He had no way of finding out where in the body the piece of wood had ended up, and without anesthetics (still over a decade away), it was impossible to perform an exploratory operation. There was an autopsy; Dr. Davis was joined by three colleagues and, strangely, the boy’s father:
On opening the thorax, a small cicatrix* was visible between the cartilages of the third and fourth ribs, on the right side, about half an inch from the sternum. The lungs appeared quite healthy, excepting that there was a small tubercle* in the right lung, and at its root, near to the pulmonary artery, a small blue mark in the cellular tissue, corresponding, in size, with the cicatrix on the parietes* of the chest.
All this is consistent with a wound caused by the piece of wood, which had apparently passed through the chest between two ribs and entered the right lung. But then came a surprise.
The heart, externally, appeared healthy. When an incision was made into the heart so as to expose the right auricle and ventricle we were astonished to find, lodged in that ventricle, the stick which the boy had used as the breach of the gun, the one end of it pressing against the extreme part of the ventricle, near the apex of the heart, and forcing itself between the columnae carneae and the internal surface of the heart; the other end resting upon the auriculo-ventricular valve, and tearing part of its delicate structure, and being itself encrusted with a thick coagulum, as large as a walnut.
The stick had lodged in the right side of the heart, the side that propels deoxygenated blood toward the lungs. The right auricle (known today as the right atrium) is the chamber by which blood enters the heart, before passing through the tricuspid (auriculo-ventricular) valve into the pumping chamber of the right ventricle. The columnae carneae (from the Latin, literally “meaty ridges”) are a series of muscular columns that project into the ventricle. The stick had somehow become wedged underneath them, and a large clot had formed around it—as one would expect when a foreign body spends any length of time in the bloodstream.
We searched, in vain, for any wound, either in the heart itself, or in the pericardium, by which the stick could have found its way into the ventricle.
Highly significant. If the stick had simply pierced the wall of the heart, two things are likely to have happened. First, the boy would almost certainly have died within minutes: A wound big enough to admit such a large object would have caused catastrophic bleeding. Second, in the unlikely event that he had survived, it would have left a significant scar on the heart muscle.
This case strikes me as one of the most interesting on record. In the first place, that this child should have survived such an accident as the lodgement of a stick, three inches in length, in the right ventricle, and have been afterwards equal to so much muscular exertion as he was, appears wonderful, especially if we consider the mechanical difficulty which the heart had thereby to encounter in carrying on the circulation of the blood. In the next place, it appears somewhat difficult to point out how the stick found its way into the right ventricle of the heart. There was no wound, nor remnant of a wound, either in the pericardium, or in the muscular structure of the heart.
Dr. Davis now comes up with an explanation that must have seemed deeply implausible to many of his colleagues. But it’s probably correct. During the First World War, surgeons encountered a number of soldiers who had a bullet in the cardiac chambers that had been swept there in the bloodstream, having entered through a blood vessel such as the vena cava (the body’s largest vein, which takes deoxygenated blood back to the heart). Something similar seems to have happened in this case:
I am inclined, myself, to think that the stick, after wounding the lung, passed into the vena cava, and was carried by the stream of blood first into the right auricle, and then into the right ventricle, where it became fixed, in the manner before specified, and as is shewn in the accompanying plate.
This was indeed a remarkably interesting case, so we’re lucky that the doctor took the trouble to commission an illustration. Bear in mind that the boy lived for over a month with this stick in situ.
MR. DENDY’S EGGCUP CASE
Although Walter Cooper Dendy practiced as a surgeon, his most lasting contribution to the world of medicine was not an operation or instrument, but a word. In 1853, he wrote an article entitled “Psychotherapeia, or the Remedial Influence of Mind” detailing his interest in the therapeutic possibilities of the new science of psychology. Dendy’s books about skin diseases and chicken pox may have been forgotten, but the discipline he named, psychotherapy, marches on.
If there’s any justice in this world, he will also be remembered for a gem of a story he contributed to The Lancet in 1834. The heading at the top of e
ach page refers to it simply as “Mr Dendy’s Egg-Cup Case”—a splendid description of a splendid case:
Mr Adams, a man 60 years of age, had been afflicted with inguinal hernia 25 years, which, although very frequently descending into the scrotum, had never been strangulated.
Even if you’ve no idea what this means, phrases like “descending into the scrotum” and “strangulated” make it abundantly clear that it’s not much fun. An inguinal hernia is one affecting the groin. This relatively common condition occurs when part of the abdominal contents (usually a portion of intestine) drops through the inguinal canal, a passage between the abdominal cavity and the external genitalia. It usually manifests as a soft swelling around the pubic bone, although in more severe cases in men, the hernia can even protrude into the scrotum. A “strangulated” hernia is one in which the compression of local blood vessels leads eventually to tissue death.
Three months previous to his death he laboured under diarrhoea, which terminated in dysentery, from which he was partially relieved.
Dysentery, diarrhea accompanied by blood, may have been caused by some degree of strangulation. The doctors first tried using leeches, laxatives and emetics in an attempt to reduce inflammation—a regime known as the antiphlogistic plan and very much in vogue in the 1830s. If you can imagine donating blood while simultaneously throwing up and enduring constant diarrhea, you’ll have a rough idea of how enjoyable it was for the patient. The initial signs in this case were encouraging; but then . . .
About a week subsequent to this the acute symptoms returned, with other signs, indicating strangulation or obstruction, such as stercoraceous vomiting and singultus, tumefaction of the abdomen, etc.—the bowels however repeatedly ejecting very scanty fluid evacuations.
Stercoraceous is an unpleasant word for an unpleasant phenomenon: The patient was vomiting what appeared to be feces. Singultus is an unnecessary piece of medical jargon meaning “hiccups.” Mr. Dendy knew that such symptoms indicated that the small intestine was blocked, so he had another look at the hernia to see if he could identify the affected part of the gut.
On minute examination I discovered a very small knuckle of intestine deeply situated, which appeared to be intimately adherent to the mouth of the sac. As there was in this tumour extreme tenderness, I did not hesitate, after a brief endeavour to return it by the taxis, to propose an immediate operation.
Taxis is manipulation. Strangulated hernia is a medical emergency that is rarely, if ever, resolved without surgical intervention; Mr. Dendy’s instincts were absolutely correct.
The friends consented, but the patient refused, stating no reason but that he did not like to be cut.
In 1833, this certainly would have been a frightening prospect, but the patient may have had other reasons for declining the operation, as it later transpired.
I therefore contented myself with palliative means, having by repeated gentle pressure returned the knuckle to the mouth of the sac, after which the stercoraceous vomiting ceased.
A positive sign, but deceptive.
He sank gradually, the abdomen becoming more and more distended, and on the 4th of December he died at three p.m., without having at any time during his illness made the slightest allusion to the circumstance which was eventually proved to have been the essential cause of his severe disorder.
This “circumstance” became clear as soon as Mr. Dendy performed a postmortem: The man’s bowels contained an unexpected item of crockery.
On opening the abdomen the small intestines were seen much distended and discoloured, and on turning the superior folds aside, my finger came in contact with a hard substance which projected through the coats of the intestine. This intestine was the cross-fold of the ileum, and on further examination we were astonished to discover, through its attenuated* coats, an earthenware eggcup closely impacted within it—the bevelled and indented edge of the cup resting on the spine—the broken stem of the cup, which projected through the bowel, near the crista of the left ilium.
The “crista,” or crest, of the ilium is the curved part at the top of the pelvic bone. The eggcup had actually pierced the intestine—at this date, an inevitably fatal injury, as the gut contents would rapidly cause infection. Mr. Dendy found that there were therefore two separate injuries to the bowel: the hernia and the puncture caused by the eggcup. Naturally enough, he was keen to establish how this unusual foreign object had found its way into the patient’s small intestine.
I therefore requested my friend, Mr Stephens (as I was engaged with my pencil at this point), to trace the colon from the caecum downwards.
The cecum is a blind pouch at the junction of the small and large intestines.
This inspection demonstrated the whole course of the large intestines to be in a comparatively healthy condition. The small intestines, on the contrary, the ileum especially, were extremely distended and discoloured—the graduated tints of crimson and dull purple evincing long-continued disease, which was still further confirmed by numerous patches of ulceration.
What does this tell us about the eggcup’s likely route of ingress? Let’s face it, the options for eggcup self-insertion are somewhat limited. Mr. Dendy concluded that the patient had swallowed the item of breakfast crockery rather than inserting it through the anus, his reasoning being that the lower part of the gut appeared healthy, while the small intestine was obviously diseased. But, as he admits, most people would be incapable of getting such a large object past the back of the throat. Mr. Dendy dismisses this objection to his theory with the observation that the circumstances “render it one of the most curious instances of which we have any record.”*
I suspect that most modern experts would agree, if only on psychological grounds, that it’s far more likely that a patient would stick an eggcup up their bottom than swallow it. This would also explain why the unfortunate patient was so unwilling to mention the large foreign body lodged in his gut. The article concludes with a drawing of the eggcup (presumably the work of Mr. Dendy, who was a talented artist), complete with its charmingly naïve decoration.
It’s obviously one of the imitation Chinese designs that became enormously popular toward the end of the eighteenth century: This particular example is a pattern called Broseley, which was used by many china and porcelain manufacturers of the period. But there is one quirk of the design that may permit an even more specific identification: The figures crossing the bridge are holding a parasol and a shepherd’s crook. Of all the firms that used the Broseley pattern, only one seems to have included these props: Rathbone, a company active in the Staffordshire Potteries between 1812 and 1835. We may be no nearer to understanding how Mr. Dendy’s patient came to have an eggcup inside his small intestine, but at least we know where it came from.
BROKEN GLASS AND BOILED CABBAGE
A significant proportion of the strangest medical cases on record fall neatly into a category we might call “unbelievably stupid things done by young men.” As a student, I made my own contribution to this sizable canon when I somehow contrived to burn my nose while ironing a shirt.*
An even more idiotic self-inflicted injury was recorded in a book about emergency medicine published in 1787 by the anatomist Antoine Portal, personal physician to Louis XVIII and the founder of the French Royal Academy of Medicine. In a chapter dealing with the accidental ingestion of various dangerous substances, he recalls his inventive treatment of one particularly tricky patient:
I saw a young man who during a drinking bout challenged his companions to swallow a part of his glass; he broke fragments from his glass with his teeth and then swallowed them; but not with impunity.
One would rather expect there to be consequences of some kind.
He was soon seized with frightful cardialgia;* convulsive movements came on, and fears were entertained for the life of this giddy-headed young fellow, when his friends came for me.
Giddy-headed seems qui
te mild under the circumstances.
I first had him bled; but as the principal object of the treatment was to extract the glass which caused the symptoms, I was much embarrassed as to the means of doing so. On the one hand, I saw that tartar emetic would increase the irritation and contraction of the stomach, and that the glass would get more closely into its parietes; on the other hand, purgatives would drive the glass into the intestinal canal, the long extended surfaces of which would probably become excoriated.
A subtle and suitably cautious train of thought. There were only two options: The glass had to be either vomited out or evacuated through the anus. Portal knew that he could use tartar emetic to provoke vomiting, but he also realized that the muscular contractions could drive the shards of glass through the stomach wall. The alternative was even worse: If the glass were allowed to get any lower into the digestive tract, with its many coils and turns, it would certainly cause a massive hemorrhage. A dilemma indeed. The solution he came up with was beautifully ingenious:
I thought it right, therefore, to advise the patient to fill his stomach with some food which might serve as a recipient to the glass, and then to produce vomiting. Some cabbages were procured and boiled; the patient ate a considerable quantity of them, and I then gave him two grains of tartar emetic in a glass of water.
I’d love to know how many cabbages constituted “a considerable quantity,” but I’m guessing it was more than two. Let’s hope the patient liked cabbage.
The Mystery of the Exploding Teeth and Other Curiosities From the History of Medicine Page 3
