Nineteenth-century medical journals are not short of ghastly occupational injuries. Factories, building sites and the new railways were frightening places, and there is barely an issue of a major journal that does not contain at least one article about terrible accidents caused by inadequate safety arrangements in the workplace. But this example, published in the Provincial Medical and Surgical Journal in 1844, is a highly unusual species of industrial accident. It was contributed by W. H. Ranking, a doctor from Bury St Edmunds:
J.G., aged 17, the son of a wealthy farmer near Newmarket, of remarkably robust frame, was first seen by Mr. Peck, on the afternoon of the 28th of September. He complained of sore throat, with difficulty in moving the tongue. The soft parts forming the floor of the mouth were much engorged, and with the terminations of the sublingual ducts were raised upon a level with the teeth of the lower jaw.
‘Sublingual’ means literally ‘under the tongue’. The sublingual ducts carry saliva from a number of salivary glands into the mouth. They are also known, rather more poetically, as the ducts of Rivinus.
Deglutition [swallowing] was painful, from the difficulty experienced in moving the tongue, articulation was impeded, and there was considerable fever.
This description of inflammation strongly suggests infection – and possibly one that was already well established.
Upon making enquiry as to the onset of the complaint, it appeared that on Wednesday, the 25th, while engaged on the farm, he put a grain of barley into his mouth, with a portion of the beard attached, and feeling that it pricked him beneath the tongue he removed it, but was not confident that he had not left a portion sticking in the mouth. He felt no further uneasiness until the Friday, when his throat became swollen, and fever and restlessness ensued.
This being 1844, the doctor naturally worried about the boy’s bowels:
Leeches were applied, followed by a blister, and the bowels were freely acted upon by calomel and senna. On Sunday the swelling had increased, and several deep punctures were therefore made with a bistoury, in the neighbourhood of the sublingual ducts.
A bistoury is a long knife. This measure may sound barbaric, but in certain circumstances doctors might still do something similar. Dr Ranking suspected an abscess, and wanted to drain it to evacuate the infected material. Today we appreciate that abscesses are reservoirs of bacterial pathogens, but Dr Ranking knew only that it contained a source of disease.
No appearance of the barley “haw” could be discovered. On Monday he had a severe rigor, and his pulse became rapid and lost power; his features likewise became collapsed. Under the impression that abscess had formed, the part was again punctured deeply, but without giving issue to pus. As the symptoms rapidly became more severe, I was sent for and met Mr. Peck, at half past eight, p.m. The patient was at that time evidently sinking; he was without pulse at the wrist, extremely restless, but perfectly collected. Brandy and ammonia were ordered, and half a grain of morphia was administered immediately, and the effects sustained by smaller doses at intervals.
None of these measures was likely to have any effect, except the morphia (morphine), a derivative of opium which would have helped considerably with the pain and also acted as a sedative.
He became more quiet under this treatment, and his pulse rallied for a short time, but he gradually sank and died on Tuesday.
The boy died within a week of the incident supposed to have caused the illness –an event so trivial that I doubted when I first read this that it had much to do with it. But I was wrong:
Post-mortem examination thirty hours after death, in the presence of Mr. Peck, his son, and myself. Decomposition rapid; the neck livid and puffed up with emphysema [accumulated gas]; brain healthy, but slightly congested. Upon cutting into the neck, the cellular tissue was found to be dark, and filled with air. Dissecting inwards, through the genio-hyoid muscles, we came to a gangrenous abscess, the size of a turkey’s egg.
A very large abscess.
The genio-hyoglossus, and lingualis muscles, and the substance of the tongue, as far back as the epiglottis, were converted into a complete putrilage [mass of putrefaction]. In the centre of this mass of gangrene was found a portion of barley “haw,” or beard, an inch in length.
It seems extraordinary that such a trivial injury – a small piece of grass getting stuck in the tongue – should have such catastrophic consequences. It may have carried some particularly unpleasant bacterium with it. Whatever the explanation, this young man was very, very unlucky.