Painfully obvious

This spectacular case was published in the Medical Press and Circular, a leading Irish journal, in 1866. The author Dr Thomas Geoghegan was an eminent Dublin physician, particularly well known for his expertise in forensic medicine. (Dr Geoghegan makes a brief appearance in the book I’ve just finished writing, a true-crime thriller about an extraordinary Dublin murder case, which is out later this year.)

Doctors sometimes get fed up with patients who insist on self-diagnosing, but this particular patient proved remarkably incapable of doing so.

A gentleman, 60 years of age and previously healthy, who had presented his son at my house for surgical advice, requested me before leaving to inspect his own throat, which his friends feared was about to become the seat of cancerous disease. I learned that five months previously he had been seized, whilst in bed, with difficulty of breathing, and a sensation as if a bit of rough cane was moving up and down in his throat.

The man was naturally alarmed. He found that he could no longer swallow solids, and was forced to adopt a diet of soup and other pulpy foods. Strangely he had not sought medical help – perhaps he was frightened, or deterred by cost.

He now evinced slight hoarseness, and there was unusual fullness, with increased breadth externally in the situation of the base of the tongue and of the pharynx. The foreign body could not, however, be defined from without. Great relief was obtained from the application of a blister to the neck.

A blister was a therapeutic measure. An irritant (typically cantharides, a powder derived from a species of beetle, Lytta vesicatoria aka the Spanish fly) was applied to the skin in order to provoke a blister. This was part of the medical doctrine known as counter-irritation, which sought to relieve pain and inflammation in one part of the body by provoking it elsewhere.

An experienced practitioner who was called in at the time of the occurrence was informed that no cause except ‘cold’ could be assigned in explanation of the symptoms. Being unaware that a plate of false teeth had been habitually worn, and the patient himself not having volunteered any statement upon the subject, the greatest difficulties were thus interposed in the attempt to estimate the real nature of the case.

Proving once again the importance of a complete medical history.

When Dr Geoghegan looked down the man’s throat he could see nothing of interest. The laryngoscope had not yet entered mainstream practice (it would not do so until the 1880s) so it is likely that the doctor was relying on nothing more sophisticated than a small mirror, like those used by dentists.

Passing my finger well down the epiglottis, I at once encountered a hard body, which on further examination was found to traverse the entire breadth of the pharynx, and to have become impacted there, owing to the entanglement of its sharp and projecting extremities in the opposite sides of the canal. A curved catheter wire, when caused to strike the foreign body, elicited a clear ringing sound.

It certainly sounds an uncomfortable predicament.

An attempt to move the body caused efforts to vomit, spasmodic cough, and the ejection of abundant mucus, tinged with blood of an arterial tint.

Well, that ain’t cancer. So what was it? The doctor asked his patient whether he could shed any light on the matter.

With the above phenomena before me I inquired whether at any of his meals he was conscious of having swallowed any hard or unusual substance. To this he replied in the negative, but then, apparently for the first time, recalled the fact, that on rising in the morning following the occurrence he had missed his tooth plate, and stated that he imagined he had dropped it, and stated that having then imagined that it might have dropped into the urinal and been thrown away by his servant, he had dismissed the matter from his mind. The cause of the mischief thus stood revealed.

So on the same morning, this patient a) woke up choking and unable to swallow; and b) realised he had lost his false teeth. It is bizarre that he did not at any stage suspect that a) and b) might have been connected.

Dr Geoghegan was concerned that the sharp ends of the dental plate might cause more serious bleeding if he tried to extract it; but he explained the risks to the patient, who agreed that he should go ahead. It was not a straightforward procedure.

In the first place I tried to disengage the ends of the plate by hooking my forefinger on each alternately, exercising at the same time a moderate and cautious traction. I next tried to draw it upwards, having passed a stout and well-curved catheter wire beneath its centre. Lastly, I used a pair of polypus forceps through an opening in the plate where two incisors were wanting, and happily its removal was crowned with success.

Polypus forceps were (and are) used to remove polyps – and, in this case, ingested dental plates.

The plate, as seen in the accompanying woodcut, proved to be of hardened gutta-percha, coloured red, and felt light for its size. Its circumference was sharp, as were also its horns.

The case had a happy outcome, although the patient was left with some lingering symptoms, perhaps caused by scarring.

The removal of the offending body was speedily followed by the disappearance of the chief symptoms; but even seventeen months after the accident uneasiness was felt at the right side of the neck, and solid food, unless well masticated or in small volume, requires to be washed down by a mouthful of fluid.

It is notoriously easy for small foreign bodies to be swallowed or even inhaled without the patient realising that anything is wrong – but it’s not often that an object as big (and pointy) as this one sits around undetected for five months!