Biomedical Ephemera, or: A Frog for Your Boils

Physicians with Head Mirrors

Ever wonder where the stereotypical headband mirror thing that you see on old illustrations of doctors came from?

It's actually a reflector. Before we had battery-powered and flexible electrical lights, gas and oil-powered flames were the best we could do, but you don't want to put that too close to the patient.

The concave reflective surface of the mirror focuses the diffuse light to a point inside the patient, which the physician can see through the hole in the center of the device.

Today, these reflectors are not frequently used in developed nations, as their primary purpose (otolaryngology - that is, ear, nose, and throat doctors) now has instruments which can illuminate the cavities being examined without an external source of light. However, they're still very useful in countries with intermittent or unreliable power sources, and are often kept on hand in surgical suites and hospitals in those countries, in case of power outage during a procedure.

Diseases of the Nose and Accessory Cavities. W. Spencer Watson, 1890.

Bones, cartilage, and muscles of the larynx.

The laryngeal folds are where voice is produced, and is located just below where the pharynx separates into the esophagus and the larynx. During the swallowing action, if solid matter enters the larynx, a strong coughing reflex is triggered to protect the lungs. This is also triggered at other times, if solid matter touches the glottis. Should that coughing reflex not dislodge the bolus, suffocation can occur.

During puberty, the protective laryngeal cartilage (specifically the thyroid cartilage) expands and forms the Adam's apple - in males, the cartilage fuses at approximately a 90° angle, and in females, it fuses at approximately 120°. Everyone has an Adam's apple! The difference in fusion means that the male vocal cords have more room to grow outward, and form a deeper voice. 

When an adult is hanged, throttled or strangled in a murder, the hyoid bone - the only bone in the body not directly connected to other bones - is almost always cracked or split apart. However, since it does not completely fuse until early adulthood, children and adolescents do not always show this distinctive sign.

Atlas d'Anatomie Descriptive du Corps Humain. C. Bonamy and Paul Broca, 1866.

Top: Incision for inferior tracheotomy

Bottom: Tracheal anatomy and surrounding structures

In diphtheria patients with a significant formation of leathery pseudo-membrane, providing a way to breathe is paramount. Since the putrid pus that hardened into the membrane would be pushed into the bronchi if regular intubation was used, a technique that allowed air in below the upper pharynx (where most of the membrane formed) was needed. The concept of the tracheotomy has been around for hundreds of years, but it wasn't until the 18th century that more than a handful of patients survived the procedure when it came to diphtheria and other membranous croups. Well, if you consider 25% to be "more than a handful".

By the point a patient would need a tracheotomy, the procedure would need to be done quickly and accurately, but because of the relative size of veins, arteries, nerves, and tendons surrounding a child's trachea, it would be incredibly difficult to do this successfully. However, once the medical schools began teaching this as a standard procedure in the mid-1800s, the success rate (meaning the survival of the patient, not just the procedure being done correctly) increased to around 45%. Given how sick someone with advanced pseudo-membranous laryngeal diphtheria is, that's not bad at all.

Atlas and Epitome of Operative Surgery. Otto Zuckerkandel, translated by J. Chalmers DaCosta, 1902.

A Treatise on Diphtheria including Croup, Tracheotomy, and Intubation. Henry Z. Gill, 1887.

Mouth, oropharynx, and detail of oropharyngeal nerve

Traité complet de l’anatomie de l’homme comprenant la medecine operatoire, par le docteur Marc Jean Bourgery. Nicolas Henri Jacob (artist), 1831.

Ulceration of the trachea by mustard gas.

When the mucous membrane of the trachea and bronchi is exposed to mustard gas, it reacts much the same way as the skin, with intense inflammation followed by sloughing of the necrotic tissue. The dead epithelium combined with the exuded fibrin and pus creates an ideal environment for microorganisms to flourish, and infection can be difficult to prevent, especially since a fair proportion of the debris ends up gathering at the bottom of the lungs.

Should a patient be able to avoid infection and fatal bleeding from ulcers, the raw bronchi underneath the sloughed layer often remains intensely painful upon movement for at least a week, leading to dysphagia (resistance to eating - the esophagus pushes against the trachea when food is swallowed). A nutritive liquid formula should be provided if available. 

An Atlas of Gas Poisoning. Medical Research Council, 1918.

Cross-section of neck at first thoracic vertebra

You can see the blood vessels and relations of the throat structures here. To get a better idea of where this is, it's right below the "Adam's apple" (laryngeal prominence). The thyroid gland can move forward, up, or down, in response to the body pushing the trachea forward when the esophagus (the squished tube behind the trachea) expands during swallowing.

Applied Surgical Anatomy. George Woosley, 1902.

"Thyroid Disease"

I'm thinking this is likely more than just a goiter....

1817 illustration by Jean-Louis Alibert

The Pharynx and its Muscles

The pharynx is the structure that passes directly behind the mouth and nose, and delivers both food and air into the proper receiving tubes. The massive number of muscles that you can see layered on top of each other are required to both pass the food bolus into the esophagus, and ensure that the trachea is closed off when food or drink is passing by it.

The Dissection of the Human Body. George Viner Ellis and G. H. Ford, 1891.

1953 DK Winter illustration.

Atlas and Epitome of Operative Surgery. Dr. Otto Zukerkandi, 1902.

You can see the larynx in front of the opening, and the esophagus behind it.

Atlas and Epitome of Operative Surgery. Dr. Otto Zukerkandi, 1902.

Atlas and Epitome of Operative Surgery. Dr. Otto Zukerkandi, 1902.

666 Salve: for head or chest colds, headache or neuralgia, irritation of throat or nasal passages due to colds.

The devil will fix your catarrh and cold! Just rub him on your chest!