My advice? If you’re planning to break out of prison, just get a friend to bake a file inside a cake.
SUFFOCATED BY A FISH
Surgeons in Pondicherry, southern India, were just about to begin a routine operation in 2004 when an urgent beeping indicated that all was not well with their patient. A fit and healthy young man, he had been under general anesthesia for only a few minutes when his heart rate plummeted and monitors showed that he was being starved of oxygen. Suspecting that the tube inserted into the patient’s airways had been dislodged, the anesthetist pulled it out and started to ventilate him by hand. The man’s condition quickly stabilized, but when the anesthetist looked at what he had just removed from the patient’s airways, he nearly passed out in shock: Coiled around the end of the tube was the cause of the trouble—a huge parasitic worm.*
Foreign objects lodged in the airway are a common cause of hospital admission, particularly among children—but generally speaking, the items that get into the “wrong tube” are not alive at the time. However, there are well-documented cases of worms, leeches and even fish being inhaled by mischance or misadventure—as in this “news in brief” item published in 1863:
A warder of the Bagne at Toulon has just met his death in the following manner: he was amusing himself, while off duty, with fishing in the dock, when having caught a fish about seven inches long and two broad, and not knowing where to place it while baiting his hook conceived the idea of holding it between his teeth. The fish struggling in the convulsions of death, ended by slipping its head first into the mouth, and thence, owing to the viscous matter with which the scales were covered, down his throat, completely filling up the cavity. The man rushed about for aid, but soon dropped dead from suffocation.
Extraordinary, but not unique. Four years earlier, a similar case had been reported in a colonial medical journal, The Indian Lancet:
In 1859, Dr White reported the case of a strong Madras Bheestee,* into whose mouth a fish had jumped while he was bathing. On opening the mouth, the tail of a large catfish presented itself with the body firmly fixed within the fauces, and filling up the isthmus completely.
The fauces is the arch of tissue at the back of the mouth; the isthmus of the fauces is the opening it surrounds. All things considered, it’s surprising he hadn’t already suffocated.
It had entered flat, so that the fin of one side was posterior to the velum,* and opened out on any attempt being made to withdraw the fish. The operation of oesophagotomy was commenced and abandoned. A piece of cane was made into a probang,* and with it attempts were made to press the fish downwards into the oesophagus. It did pass downwards, when the patient at once ceased to breathe, gave one convulsive struggle, and died to all appearance.
Not so good. As soon became clear, the fish had not been pushed into the stomach as intended, but instead had become lodged in the trachea, obstructing the airway. The doctor quickly realized that the only option was to attempt a tracheotomy.
The trachea was immediately opened, and respiration was restored. In the course of the night the man coughed up the fish, the fins having become softened by decomposition.
Nice. Nevertheless, better to cough up a decomposing fish than to die because it’s stuck in your throat.
Dr White states that “this is by no means an uncommon accident in India. Natives bathing and swimming, which they always do with their mouths wide open . . .
Really?
“. . . in tanks that abound in fish, are not unfrequently brought to hospital dying from suffocation and alarm with a large catfish firmly impacted in the fauces. It is a coarse kind of fish, with long bony fins very sharp indeed at their extremities.”
It seems difficult to believe that there really was an epidemic of fish inhalation in nineteenth-century India, but at least two virtually identical cases were reported over the next few years. One patient survived for an astonishing thirty-four hours with the rotting corpse of the unfortunate creature lodged in his airway. And it still happens today: A recent review found no fewer than seventy-five documented cases of live fish in the airways. After surveying the available evidence, the authors of the article make this helpful observation:
Live fish aspiration is frequently accidental or the result of poor judgment involving placing a live fish in the mouth.
A conclusion that I suspect most readers will have reached for themselves.
2
MYSTERIOUS ILLNESSES
HAVE YOU EVER wondered how many human diseases there are? I don’t mean just the infectious ones like influenza, leprosy and bubonic plague, but also noncommunicable diseases such as diabetes and cancer and the many genetic disorders. The question is impossible to answer, since new ones are being identified all the time. The World Health Organization oversees the publication of the International Classification of Diseases, a terrifying compendium of pretty much everything that can go wrong with you. When the first edition of this document appeared in 1893, it identified 161 separate disorders; the tenth, published a century later, listed more than 12,000. By some estimates, doctors now recognize as many as 30,000 distinct diseases, although nobody can agree on even an approximate figure.
Some, such as HIV/AIDS or Ebola, simply did not exist a hundred years ago and emerged as a result of the evolution of new and particularly unpleasant pathogens. Others are being identified only because recent advances in gene sequencing make it possible to locate the precise mutation that causes an otherwise mystifying set of symptoms. Thousands of these conditions are classified as rare diseases, meaning that they affect less than 0.05 percent of the population—and are encountered so infrequently that treatment options are few, and often virtually untested.
Diagnosing a rare condition can pose a challenge to the most talented and experienced clinician, even one with the resources of a modern hospital at their disposal. So it is easy to sympathize with the eighteenth-century physician who visited a family in Suffolk and found them suffering from a strange and terrible disease that made their limbs wither and fall off. The illness was new to England, its cause was unknown and treatment impossible. He could do little more but try to relieve their pain and then set down the symptoms on paper so that his colleagues might recognize them in the future. I find these first encounters between a medic and a never-before-encountered adversary fascinating: You can often sense the doctor’s frustration as they try to work out what they’re up against.
But such descriptions of novel diseases were sometimes written for reasons less nobly scientific. In the seventeenth century, when the Philosophical Transactions and other early journals were founded, natural philosophers took a particular interest in monsters, deviations from the otherwise perfect productions of Nature. One typical article of this period was entitled “A Relation of Two Monstrous Pigs with the Resemblance of Human Faces, and Two Young Turkeys Joined by the Breast.” The desire to understand and study such anomalies was genuine, but these accounts also played to a very human fascination with the grotesque and freakish.
While the study of “prodigies and monsters” fell out of fashion in the eighteenth century, the sensationalist instincts of journal editors persisted for long afterward. A mysterious new disease with exotic symptoms (the weirder the better) almost guaranteed publicity, even if the supporting evidence was shaky. A description of a boy who apparently vomited a fetus was of little clinical value, but it made a terrific story. Most of the strange conditions documented in this chapter were probably genuine, although even the most open-minded expert might demur at the idea that it is possible for a patient to urinate through their ear.
A HIDEOUS THING HAPPENED IN HIGH HOLBORN
Little is known about the seventeenth-century physician Edward May, except that he moved in rather elevated social circles. He came from a distinguished Sussex family that produced numerous MPs, a dean of St. Paul’s Cathedral and several members of the royal household. Edward was himself apparently
a regular at the court of Charles I, holding the position of physician-extraordinary to Queen Henrietta Maria. He also taught at the Musæum Minervæ, a sort of finishing school for young noblemen, whose eccentric curriculum ranged from astronomy to riding and fencing.
But the most notable episode of Dr. May’s life was an incident so notorious and ghastly that one contemporary, the celebrated Welsh historian James Howell, described it as “a hideous thing that happened in High Holborn.” Dr. May recorded this unsettling experience in a pamphlet published in 1639 under this rather wonderful title:
The unfortunate young patient, John Pennant (deceased), was the scion of an aristocratic Welsh family that could trace its lineage back to the Norman Conquest. Edward May sets the scene:
The seventh of October this year current, 1637, the Lady Herris wife unto Sir Francis Herris Knight, came unto me and desired that I would bring a surgeon with me, to dissect the body of her nephew John Pennant, the night before deceased, to satisfy his friends concerning the causes of his long sickness and of his death; and that his mother, to whom myself had given help some years before concerning the stone, might be ascertained whether her son died of the stone or no?
Dr. May had previously treated the young man’s mother for bladder stones, which were far more prevalent in the seventeenth century than they are today. She naturally wondered whether this was the cause of his death.
Upon which entreaty I sent for Master Jacob Heydon, surgeon, dwelling against the Castle Tavern behind St Clements church in the Strand, who with his manservant came unto me. And in a word we went to the house and chamber where the dead man lay. We dissected the natural region and found the bladder of the young man full of purulent and ulcerous matter, the upper parts of it broken, and all of it rotten; the right kidney quite consumed, the left tumefied* as big as any two kidneys, and full of sanious matter. All the inward and carnouse* parts eaten away and nothing remaining but exterior skins.
Sanious matter means bloody pus. So far, so bad; it sounds as if a catastrophic infection had wrecked his urinary system.
Nowhere did we find in his body either stone or gravel. We ascending to the vital region* found the lungs reasonable good, the heart more globose* and dilated, than long; the right ventricle of an ashen colour shrivelled, and wrinkled like a leather purse without money, and not anything at all in it: the pericardium, and nervous membrane, which containeth that illustrious liquor of the lungs, in which the heart doth bathe itself, was quite dried also.
I like Dr. May’s turn of phrase: “wrinkled like a leather purse” is a vivid description of a diseased heart. The “illustrious liquor of the lungs” is pericardial fluid, whose main function is to lubricate the outer surface of the heart as it beats. In a healthy patient the pericardium, the tough sac surrounding the heart, normally contains a few teaspoons (around 50 milliliters) of this fluid.
The left ventricle of the heart, being felt by the surgeon’s hand, appeared to him to be as hard as a stone, and much greater than the right; wherefore I wished Mr Heydon to make incision, upon which issued out a very great quantity of blood; and to speak the whole verity, all the blood that was in his body left, was gathered to the left ventricle, and contained in it.
A common observation in early autopsy reports was that the major vessels were empty, leading some authorities to suggest that the blood somehow “retreated” to the heart after death. In reality, in the absence of a heartbeat, the blood obeys gravity, sinking to the lowest point of the body. In forensic pathology, this can offer a useful indication as to whether a body has been moved after death. Back to Dr. May:
No sooner was that ventricle emptied, but Mr Heydon still complaining of the greatness and hardness of the same, myself seeming to neglect his words, because the left ventricle is thrice as thick of flesh as the right is in sound men for conservation of vital spirits, I directed him to another disquisition: but he keeping his hand still upon the heart, would not leave it, but said again that it was of a strange greatness and hardness.
Dr. May correctly points out that in a healthy human heart the muscle of the left ventricle, or pumping chamber, is approximately three times thicker than that of the right. This is because it operates at higher pressure, pumping oxygenated blood to the whole body, whereas the right ventricle must propel deoxygenated blood only as far as the lungs. But in this case the left ventricle was even larger than normal. This was almost certainly left ventricular hypertrophy, a thickening of the heart muscle. It has several possible causes, and its presence suggests that the man had been ill for some time, since it takes a while to develop.
Dr. May asked the surgeon to make a larger incision in the ventricle:
. . . by which means we presently perceived a carnouse substance, as it seemed to us wreathed together in folds like a worm or serpent; at which we both much wondered, and I entreated him to separate it from the heart, which he did, and we carried it from the body to the window, and there laid it out.
When May examined this object in daylight, he had quite a shock.
The body was white, of the very colour of the whitest skin of man’s body: but the skin was bright and shining, as if it had been varnished over; the head all bloody, and so like the head of a serpent, that the Lady Herris then shivered to see it, and since hath often spoken it, that she was inwardly troubled at it, because the head of it was so truly like the head of a snake. The thighs and branches were of flesh colour, as were also all these fibres, strings, nerves, or whatsoever else they were.
I wasn’t aware that snakes had thighs. Dr. May was at first skeptical that a human heart could contain a snake, and wondered aloud whether it might just be a “pituitose and bloody collection”—in other words, a large mass of blood and phlegm. This conjecture we will return to later. He decided to examine the strange creature more closely.
I first searched the head and found it of a thick substance, bloody and glandulous about the neck, somewhat broken (as I conceived) by a sudden or violent separation of it from the heart, which yet seemed to me to come from it easily enough. The body I searched likewise with a bodkin between the legs or thighs, and I found it perforate, or hollow, and a solid body, to the very length of a silver bodkin, as is here described; at which the spectators wondered.
Following the surgeon’s lead, the bystanders took it in turns to probe the “snake” with a metal bodkin, until they were all convinced that the object before them was a worm, serpent or other creature, with identifiable anatomical features including a digestive tract. Evidently aware that they might not be believed, they signed an affidavit confirming what they had seen.
Snake inside the heart of John Pennant, from Edward May’s A most certaine and true Relation (1639)
Was there really a snake inside the young man’s heart, or perhaps a worm? Almost certainly not. You may recall that Dr. May’s first thought was that the strange object was a “bloody collection”; in other words, a large clot. This seems far more likely, and two centuries later, a notable Victorian physician came to the same conclusion.
Benjamin Ward Richardson was a diligent and original researcher who discovered several novel anesthetic agents as well as the first effective drug for the treatment of angina pain, amyl nitrite. He also had a particular interest in the formation of thrombi, or blood clots. In December 1859, he gave a series of lectures* about the formation of “fibrinous depositions”—clots—inside the heart. Richardson noted that thrombi come in all shapes and sizes: Sometimes they form long filaments or even hollow tubes, with blood continuing to flow through a central channel. He suggested that this is precisely what Dr. May had found inside the young man’s heart: a monster clot that had grown to look like some sort of mythical serpent.
Assuming it was a clot, we can now make a tentative guess at a diagnosis. You’ll recall that the original surgeon remarked upon the unusual “greatness and hardness” of the left ventricle of the heart
. Not only was the muscle hypertrophied (increased in size), but it had become unnaturally rigid. This is something often seen in the case of a rare blood disorder, hypereosinophilic syndrome (HES), which is also associated with a high risk of extensive clotting in the heart. HES can also attack multiple organs simultaneously, which would explain the state of the young man’s kidneys. It’s impossible to be sure, of course, but the symptoms certainly seem to fit.
You may be wondering what happened to the “serpent” after the postmortem had been completed. Dr. May explains that the surgeon was keen to hold on to it for further study, but the dead man’s mother had other ideas:
The surgeon had a great desire to conserve it, had not the mother desired that it should be buried where it was born, saying and repeating, “As it came with him, so it shall go with him”; wherefore the mother staying in the place, departed not, till she had seen him sew it up again into the body after my going away.
As Nietzsche’s protagonist puts it in Also sprach Zarathustra: “You have evolved from worm to man, but much within you is still worm.”
THE INCREDIBLE SLEEPING WOMAN
Sometime in the 1750s (the precise date is unknown), a group of London doctors decided to get together periodically to discuss their own cases and any novel developments in medical practice. The enterprise was inspired by the foundation in 1731 of the Edinburgh Medical Society, though the London group never acquired a formal name.* It produced an occasional journal, the Medical Observations and Inquiries, intended to disseminate the society’s research to a wider audience. Its purpose was thoroughly modern: to improve medicine through evidence-based research, as the preface to the first volume, published in 1757, explained:
The Mystery of the Exploding Teeth and Other Curiosities From the History of Medicine Page 5
