Making a mark

Foreign body in Wharton's ductOne evening in 1877 a medical student at the University of Paris, a young man by the name of Vielle, made a little piece of medical history – although perhaps not in a way he might have hoped for. This is how he later recalled the experience:

About 10 o’clock P.M., April 6th, 1877, I felt a smarting pain, heat, and very severe pricking in the region of the tongue; I was so distressed that I could not perform any movements of deglutition or suction; every movement of the tongue increased my slight suffering.

‘Deglutition’ is swallowing.

Desiring to account for this unusual phenomenon, I very carefully examined the region, but, despite my eagerness and the extreme care which I employed in my examination, I could discover nothing. No redness, no ulceration, no foreign body to explain the pain, which rendered me uneasy and roused my curiosity for an explanation.

Like any conscientious medical student, he was apparently more interested in reaching a diagnosis than securing his own comfort.

I lay down in bed, and my sleep, which was not at all interfered with by the slight distress, was calm and deep, like that of a perfectly healthy man. Upon waking, the movements of the tongue gave rise to the same pain as during the night previous, but direct examination showed a slight redness in the midst of the ostium umbilicale.

The ostium umbilicale – known today as the sublingual caruncle – is a tiny hole underneath the tongue. If you look at the underside of your tongue in a mirror, you may see a little saliva squirting from it.  It’s the external opening of the submandibular duct, which connects two of the major salivary glands with the mouth.

The mucous membrane at this point was swollen, tense, oedematous, and the heat and pricking were thus due, to a certain extent, to this cause. There was nothing to be done at this time, as there was no indication to fulfil. I visited the hospital, in the morning, as usual; at midday I felt, during a movement of deglutition, a somewhat more intense pain, and the sensation of a foreign body which changed its position.

M. Vielle then had a moment of inspiration: he remembered a course he had attended a few months earlier, during which the lecturer had explained the symptoms of salivary stones. These are much like bladder stones – hard masses of calcified material which form inside the salivary ducts or glands. Maybe this was the cause of his pain?

Without taking time to look into a mirror in order to see whether anything presented at the opening of the excretory canal of the submaxillary gland, I asked my friend Chauvet to remove a foreign body from my Wharton’s duct.

‘Wharton’s duct’ is an older term for the submandibular duct – named in honour of the seventeenth-century anatomist Thomas Wharton, who discovered it.

Wharton's submanidbular duct image
The submandibular ducts of an ox, from Thomas Wharton’s Adenographia (1656)

The latter saw, in the opening of the canal discovered by Van Horne, something resembling a hair.

Pedantic note: he means the Dutch anatomist Johannes van Horne, but it was Wharton, not van Horne, who discovered Wharton’s duct. The clue’s in the name.

Anyway, the important point is that his friend Chauvet thinks he’s spotted a hair stuck inside this duct underneath his tongue.

I looked into a mirror and observed the same thing. There was nothing else to do except remove it, but no instrument or forceps was at hand. The end projected too little to be seized by the fingers; moreover, the fear of pushing it in made us immediately renounce this method of extraction.

What would you do in such an emergency? Bear in mind that he’s a medical student, in a hospital.

Would you:

a) ask one of the tutors/qualified medics to take a look, and remove the foreign body with appropriate instruments; or

b) get your student friend to do it with the first object that comes to hand?

As no stone is left unturned in a moment of danger, my friend took two matches and seized the end of the foreign body between the two sharp edges of these pieces of wood.

Correct! It’s option b), of course.

At the third attempt, he removed a hair 1.5 cm long. When compared with the hair of my toothbrush, it had the same length, colour and consistency, so that there was no doubt in this regard. The painful sensation disappeared immediately; the redness alone persisted, but was gone on the following day.

To be fair to the student duo, even if sorting out the problem themselves probably wasn’t the most sensible option, the treatment was at least successful. Young Chauvet, the wielder of the matches, was so delighted with this success that he decided to devote his M.D. thesis to the subject of submandibular foreign bodies – which was duly accepted by the University of Paris a few months later.

When the Parisian surgeon Alfred Poulet published his Treatise on Foreign Bodies in Surgical Practice in 1880, he could find only six cases of foreign bodies in the submandibular duct in the entire medical literature – and Chauvet’s case was one of only two in which it was possible to establish how the object had got there. I can find no more information about young M. Vielle – this is apparently the only mark he has left on the history of medicine.

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