Cones and bones

You may have seen this recent story about a man who thought he had lung cancer before learning that his persistent cough had an altogether less sinister cause. Doctors discovered that the shadow on his chest X-rays was caused not by a tumour, but by a toy traffic cone he had inhaled as a child some 40 years earlier.

The clinicians who removed the Playmobil toy from the lucky patient’s lung suggest that ‘to our knowledge this is the first case of a tracheobronchial foreign body that was overlooked this length of time’. Intrigued, I decided to see if I could find a more extreme example. And at first I thought I’d succeeded. Samuel Gross’s monumental A Practical Treatise on Foreign Bodies in the Air-passages (1854), a 450-page compendium of unusual objects aspirated by accident, contains one case in which a piece of bone inhaled in childhood remained lodged in a bronchus for no less than sixty years.

But then I realised that the key word is ‘overlooked’: what is so remarkable about the toy traffic cone story is that the patient remained asymptomatic for over forty years. He had absolutely no idea that it was there. Nevertheless, this tale, first reported in 1846 in the New York Journal of Medicine, is pretty astonishing:

lodgement and retention of foreign body in bronchus for 60 years

Richard Moore, of Salisbury, Connecticut, now aged sixty-three years, inherited a good constitution, but when three years old, swallowed accidentally a piece of bone, which nearly suffocated him at the time, and which, from that day to the present, has produced a series of phenomena, which could only be accounted for, on the supposition that the bone was lodged in some portion of the bronchial tree.

The bronchial tree being the network of tubes which convey air to the lungs. The windpipe, the trachea, divides into two bronchi, one for each lung, which then subdivide into a number of smaller passages.

bronchial tree
The larynx, trachea and bronchial tree, from Gray’s Anatomy (1918)

As a child, Mr Moore was ‘harassed night and day with cough’, and often struggled to breathe. Doctors could hear a sinister rattling in his chest, and he also had bad breath and pain in his right side.

These symptoms continued to harass him until nearly the age of puberty, when other symptoms appeared, of a still more alarming nature. At this period, the cough began to be accompanied with expectoration of purulent matter, tinged with blood; attended also with marasmus or atrophy, and other symptoms of confirmed pulmonary disease.

Marasmus is undernourishment, which caused the boy to be small for his age.

At the age of nineteen, he was suddenly attacked with haemoptysis [spitting blood], which continued, at irregular intervals, for a series of years; during which time his general health and strength were greatly impaired, so that he was incapable of much exertion, being, indeed, confined to the house for more than eight years.

He was, in fact, virtually an invalid. Removing a piece of bone like this one would be a relatively straightforward procedure today; but in the late eighteenth century doctors could only hope the patient would manage to cough it up.

At about the age of twenty-eight, his general health began to mend; although still troubled with cough. For the next fifteen or twenty years, he was able to perform some labour, though not without considerable inconvenience from the symptoms above mentioned. In January, 1844, for the first time, since the third year of his age, the cough suddenly left him, and did not return for several months, when it again began suddenly to harass him as before.

A cruel twist. After more than half a century of pain and discomfort, he must have thought the problem had finally gone away.

On the 8th of October, 1845, he experienced a remarkably uneasy sensation, of a pricking nature, deep in the right side, which excited violent coughing, and after one or two severe paroxysms, he experienced a sensation as if something had ruptured, or given way. This was instantly followed by the passage of something into the trachea, producing suffocation, which was forcibly ejected upon the floor, succeeded by the expectoration of purulent matter streaked with blood.

On examination, the foreign body turned out to be a bone, nearly three fourths of an inch in length, one fourth of an inch in breadth, and one twelfth in thickness, oblong and somewhat triangular in form, smooth and convex upon one surface, the other covered with sulci and protuberances.

Sulcus = ‘furrow or fissure’. This was a pretty substantial foreign body, especially considering the amount of time it had spent inside his chest. Smaller ones have frequently proved fatal. What probably saved him was its shape: a round object might have entirely blocked the bronchus. This one was long and pointed, allowing air to flow past it.

It appeared that the bone which he had originally swallowed, from the traditionary accounts preserved in the family, was a splinter from a rib from which he was sucking the meat, and it seemed highly probable, on examining the piece ejected, that this also was originally a portion of the same bone.

‘Traditionary’ is an archaic form of ‘traditional’. This story was so old that it had already entered family folklore. An oral tradition, if you will.

Now, then, are we not authorized in believing that this bone was lodged in one of the rami [branches] of the right bronchus for this long period of 60 years, producing the phenomena, which I have briefly described; including partial ulceration, whence proceeded the blood, and purulent matter, etc.?

Well, possibly. The ‘purulent matter’ (i.e., pus) was a sign of infection. Assuming the story is true, the greatest mystery is why his body tolerated the piece of bone for so long. As contemporary textbooks make clear, inhaling solid objects usually had one of three outcomes. Some patients died in a matter of hours through asphyxiation; others more slowly after infection set in; and the luckiest managed to cough up the object, usually within a few days or weeks. The most frequently inhaled objects, particularly in children, were beans. These would sometimes break down inside the body, making it easier to cough them up. But no such hope with a bone fragment, which usually caused an abscess, widespread infection and death. This man was very lucky indeed.

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