Fish Bones in the Throat, 
And what they Suggest Concerning 
Deglutition. 
BY 
ADOLPH RUPP, M. D. 
REPRINTED PROM THE 
Neto ¥orft iHeUtcal 
for May 19, 189$. Reprinted from the New York Medical Journal 
for May 19, 1894. 
FISH BONES IN THE THROAT, 
AND WHAT THEY SUGGEST CONCERNING DEGLUTITION * 
By ADOLPH RUPP, M. D. 
I. Frequency and Diagnosis.-Some authors who have 
written on foreign bodies in the throat have said nothing 
concerning the question, How came those foreign bodies 
to be lodged at or in the particular places where they are 
found ? Others have given only a partial and inadequate 
answer, based on reasoning of secondary importance at 
best, and which, in some respects, implies a misconception 
of the anatomy and physiology of the throat. 
In this paper I do not propose to discuss those sub- 
stances which give rise to obstructive symptoms on ac- 
count of their bulk, but only of fish bones and similar 
sharp-pointed and slender substances, such as pins and nee- 
dles, splinters of wood, etc. 
My reason for limiting the discussion to these substances 
is that they usually have the quality of staying where 
they become fixed or lodged, but more particularly because 
they lend themselves very well in the way of illustration 
for answering the question, How came these foreign bodies 
to be lodged or fixed in or at the particular places where 
they are found ? The answer to this question involves 
problems of deglutition, as well as secondary questions of 
pathology, anatomical peculiarities, and personal habits. 
Foreign bodies-fish bones, needles, etc.-so lodged in the 
* Read before the Laryngological Section of the New York Academy 
of Medicine, March 28, 1894. 
Copybight, 1894, by D. Appleton and Company, 2 
FISH BONES IN THE THROAT. 
throat as to demand surgical assistance in their removal 
are, comparatively speaking, very rare accidents. During 
over one years' service in the throat and ear class of the 
Northern Dispensary of this city, during the years 1881 
and 1882, I saw only one case-and then the fish bone was 
as much in the larynx as in the pharynx. In private prac- 
tice during a period of thirteen years, I removed four fish 
bones from the throats of as many patients. At the New 
York Eye and Ear Infirmary during five years (1885, 1887, 
1888, 1889, and 1890) seven thousand eight hundred and 
forty patients applied at the Throat Department for treat- 
ment. None of these patients had any foreign body in 
the pharynx, palate, fauces, or tonsils-that is to say, in the 
throat. Fifteen of these patients had foreign bodies in the 
larynx, and in sixteen patients foreign bodies were found 
in the nasal cavities. At the clinic of Professor Jurasz (1), 
at Heidelberg, during a period of about seven years and a 
half, four thousand and forty-eight patients were treated 
for the various troubles of the upper respiratory organs. 
Nineteen of these patients, ranging in age from four years 
to sixty-eight years, applied to have foreign bodies taken 
from their throats ; but in only four of the throats could a 
foreign body be found after careful examination. During a 
period of ten years, Schaffer (2), of Bremen, met with for- 
eign bodies in the throat only seven times in as many pa- 
tients, and six times the foreign bodies were fish bones. 
Although not a frequent it is a common experience to 
be called on to remove foreign bodies from the throats of 
patients-children as well as adults-when really none are 
present or discoverable. In cases where no foreign bod- 
ies are present the pain and discomfort will be found to be 
due to local trouble of some kind. These patients are not 
necessarily hysterical and neurasthenic people. In my 
experience they have been people addicted to tobacco 
and alcohol excesses. A history of foreign body may or 
may not be given when a foreign body is or is not present. 
Whatever the case may be, a careful and thorough exam- 
ination should always be made. I have been called three 
times to treat children who it was supposed had pins and 
bones in their throats. In one of these cases the child, 
nine months old, was supposed to have swallowed an open FISH BONES IN THE THROAT. 
3 
diaper pin. The pin had been mislaid by the mother, and 
was afterward found in a safe place-not in the child. 
Another child, not quite a year old, swallowed part of the 
spinal column of a herring. This causing choking symp- 
toms, the father looked for the trouble in the throat, and 
luckily pushed the vertebra down the child's oesophagus. 
These bones were passed per anum next day. The third 
case was one of fright and suspicion and developed noth- 
ing more. Cases in children, easy enough to diagnosticate 
and easy enough to treat when due care is exercised, may 
lead to grave results if handled carelessly or in ignorance 
of a practical knowledge of this subject. Thus Walter F. 
Atlee, M. D., tells of the case of a seventeen-months-old 
child that lost its life, he reports, because " a well-known 
and experienced physician " made only an imperfect ex- 
amination, and treated the child for a simple angina by 
giving a harmless chlorate-of-potassium mixture. In the 
course of four or five days the symptoms became alarming, 
and Dr. Atlee was called in to see the case. He found, on 
passing his finger into the child's mouth and throat, a pin 
firmly fixed between the right faucial pillar by one end, and 
the other end in the posterior wall of the pharynx. The 
child died the day after Dr. Atlee removed the pin, and 
five or six days after the pin had been swallowed. 
However, cases occur, now and then, which foil the best 
efforts of the best-equipped laryngoscopists. 0. Chiari (4), 
(Vienna), narrates the case of a man who swallowed a piece 
of wooden toothpick which gave rise to swelling of the left 
half of the velum. After a good deal of trouble and care- 
ful search he gave up the hunt, having been unsuccessful. 
The next day the patient coughed out the splinter spon- 
taneously. Patients have been known to have gone to as 
many as half a dozen doctors before the site of a foreign 
body was located. Schaffer tells of such an instance in his 
experience, and where the foreign body was in one of the 
vallecules. The following case of an eighteen-months-old 
child, reported by George White, M. D. (5), (Chicago), is 
interesting in this respect, and again because of the length 
of time the pin remained in the child's throat without 
doing any serious damage-differing in this respect from 
the case reported by Atlee and just quoted. Several physi- 4 
FISH BONES IN THE THROAT. 
cians successively had been called in to see the case before 
Dr. White discovered the pin and its location. CEdema of 
the pharynx had been made the excuse for failure in find- 
ing and locating the pin. In this case the pin had been in 
the child's throat about eight months when Dr. White 
was called in to see the case. On depressing the child's 
tongue with his finger, the little one retched, and, looking 
into the throat at the same time, he saw the pin lying 
across the pharynx just behind the tonsils. All these cases 
show how little the mere history of a case is to be de- 
pended on, one way or the other. The careful examina- 
tion of the throat by means of well-directed light is of the 
utmost importance. And no matter how good the light 
may be in which the throat is examined, if the examining 
physician or surgeon has no practical knowledge of the 
throat, the chances are he will fail in his search. A num- 
ber of first-rate authorities recommend examining the 
throat and its different localities by means of a sound. 
And the use of the finger is also recommended. What 
has been said in reference to good light and visual exami- 
nation holds good for the tactus eruditus. Dr. Atlee, 
who has just been quoted, confirms this by writing: " I 
heard even Nelaton say that in a certain case, after push- 
ing the finger deeply into the pharynx and feeling a small 
resisting body, he made several attempts to seize it with a 
forceps before discovering it to be the great horn of the 
hyoid bone." There are a number of other points in the 
throat which the unknowing touch might mistake for a 
foreign body. Roe quotes Cohen as saying that the pos- 
terior faucial pillar-its border-might be mistaken for a 
fish bone. In searching for foreign bodies, when they can 
not be seen after careful visual inspection, the naso-pharynx 
may be explored by the finger ; and, when possible, a rhino- 
scopic and post-rhinoscopic examination should be made. 
The foreign body may have been swallowed and then vom- 
ited, and so been forced into the naso-pharynx or into the 
nose. Or it may have been worked into the post-nasal 
space by spasmodic efforts on the part of the pharynx to 
get rid of it. Moreover, especially in the case of fish 
bones, more than one may be present; and concerning 
this possibility Sir M. Mackenzie (7) relates the following FISH BONES IN THE THROAT. 
5 
instructive instance which occurred in his own experience: 
" An eminent Glasgow surgeon consulted me on account of 
a fish bone which had become lodged in his throat three or 
four months previously. I succeeded in removing a fish 
bone from the lower part of the pharynx. I told him ' he 
might feel the sensation for a day or two, but there could 
be nothing more in the throat.' Two days afterward the 
gentleman returned, saying that there was another bone 
near the site of the one I had removed, and making an ex- 
amination I found that his sensations were accurate, and 
that a second bone was lodged in the throat at the spot in- 
dicated. The removal of the bone removed all unpleasant 
sensations. Between the removal of the first and the sec- 
ond bone no fish had been eaten." In my five cases-the 
reports of which will now be given-the diagnoses were 
readily made by means of reflected light and sight. In 
only one case was it necessary to use the laryngeal mir- 
ror ; but the laryngeal and post-nasal mirrors were used 
in all cases. Three of the patients were males and two 
females. None of them exhibited any physical abnorm- 
ity in the mouth, fauces, pharynx, or larynx, nor were any 
of them bolters of food. 
Case I. Fish Bone in Right Tonsil Six Years-the Cause of 
Recurrent Tonsillitis, etc.-George M., aged thirty years, came 
under my care for follicular amygdalitis. Had many attacks 
during recent years. Complained that the right tonsil always 
pained him more or less. The right tonsil was larger than the 
left, and cheesy concretions in the lacunae more marked. In 
cleaning away the cheesy masses from the right tonsil the blunt 
hook rasped against a hard substance which was supposed to 
be a calculus. Finally this rough and hard substance was removed 
from about the center of the tonsil and proved to be a short, 
thick piece of fish bone about two fifths of an inch long. The 
patient stated the bone must have been lodged in the tonsil six 
years. He had consulted a doctor in Scotland on account of 
pain in the throat after having eaten fish six years ago. It is 
now (1894) four years since the bone was removed, and there 
has been no recurrence of amygdalitis. 
Case II.-A girl, aged sixteen years, while eating fish sud- 
denly felt a severe pain in the throat, and, the pain continuing, 
she sought medical aid. A fish bone an inch and a half long 
was taken from the right tonsil. The bone had penetrated the 
upper back portion of the tonsil from above and behind, allow- 6 
FISH BONES IN THE THROAT. 
ing the free end to prod the soft palate. The bone stuck in the 
tonsil half an inch; a slight amount of bleeding followed its 
removal, and with the bone all pain disappeared. 
Case III.-A strong, healthy woman while eating fish was 
suddenly taken with severe spasmodic coughing and vomiting. 
I was called to see this woman in great haste. In this case 
a long, slender fish bone had penetrated the posterior faucial 
pillar (left), the longer and thinner end swinging against the 
posterior pharyngeal wall, the other thicker end pressing now 
against the tonsil, now against the base of the tongue. Every 
time the woman attempted to talk or swallow an attack of 
coughing and vomiting ensued, and to such an extent as to make 
her turn blue in the face. The bone was about an inch and 
three quarters long. It was easily removed with an ordinary 
dressing forceps, and with its removal the cough and vomiting 
ceased. 
Case IV.-A boy, aged eight years, was suddenly taken 
with pain in the throat while eating fish, and in such a way that 
he could neither swallow nor cry without aggravating the pain. 
This fish bone was fixed in the left lateral wall of the pharynx by 
one end; the other penetrated the left lateral and middle glosso- 
epiglottic folds. In removing this bone it was necessary to 
push it toward the median line of the throat to free it from 
the lateral pharyngeal wall, and then it was easily pulled out. 
This w'as done with a long dressing forceps, the base of the 
tongue being depressed while the tongue was pulled out by its 
tip. Complete relief followed the removal of the bone and no 
bad results followed. 
Case V is the dispensary case already alluded to, and was 
also examined by my colleague, Dr. George T. Jackson. In this 
case the bone was very firmly fixed in the right aryepiglottic 
ligament. About a sixth or an eighth of an inch of it protruded 
into the pharynx. For want of a good instrument I failed to 
remove it. The cannular (laryngeal) forceps that was used let 
go its hold when traction was made. What subsequently be- 
came of the bone and the patient I do not know. 
Since these fish bones were removed from their throats, 
these people have eaten fish often without a recurrence of 
the accidents for which they were treated. They had 
often eaten fish before that time with impunity. In view 
of some of the notions taught concerning the lodgment of 
fish bones in the throat these facts are important. 
II. Reasons for Lodgment or Fixation.-The cases just 
narrated seemed to me worth recording, and as being a not FISH BONES IN THE THROAT. 
7 
uninstructive addition to the many already recorded by a 
number of laryngologists and other physicians and sur- 
geons. While studying cases of this kind-where fish 
bones, pins, needles, etc., have become lodged or fixed in the 
pharynx or throat-ideas are apt to suggest themselves that 
will not harmonize with the teachings often found in laryn- 
gological literature respecting the reasons given for ac- 
counting for the impaction of foreign bodies in the throat. 
Besides, such cases are involuntary experiments which illus- 
trate some of the phases of mastication, and which have 
some influence in deciding the correctness of any theory of 
deglutition. 
George Henry Lewes defines a scientific explanation as 
being the discovery of those intermediate facts not obvious 
which link together the obvious phenomena. Now, if we 
go to our laryngological treatises and text-books, we will 
look in vain for any scientific explanation as to why these 
foreign bodies became lodged in the particular localities of 
the throat where they are found. Take, for instance, Dr. 
John O. Roe's excellent resume of the literature of foreign 
bodies in the throat, and what do we find ? In the first 
place, we are made to infer that the pharynx is a very im- 
perfect organ, since we are told that the natural irregulari- 
ties of the pharynx tend to the arrest of the different sub- 
stances that must pass through 'it in order to reach the 
stomach, etc. Other writers tell us a similar story. Such 
is the primary alleged fact. Then we are told that the par- 
ticular location in or at which the foreign body is caught 
depends on the anatomical structure of the locality and 
on the shape, size, and consistence of the foreign body. 
Thin pointed bodies, it is said, are apter to stick into or 
become lodged between the pillars of the fauces and ton- 
sils, or in the glosso-epiglottic folds ; although, it is fur- 
ther remarked, they may be arrested in any portion of the 
pharynx. All these assertions are obvious, but they explain 
nothing, and remain to be explained. When we are told 
that pathological conditions influence the deposition and 
fixation of foreign bodies, we are nearing an explana- 
tion. But to be told that bad teeth, inflammatory diseases 
of the mouth, syphilitic local processes, growths in and 
around the throat, spasms and palsies, etc., are causes of 8 
FISH BONES IN THE THROAT. 
deposition and fixation of foreign bodies in the throat, a 
scientific explanation is not given us by so doing. This is 
but indicating some of the conditions favoring such acci- 
dents, important of course, but not essential. The same 
holds true for personal carelessness, hurried eating, etc. 
Looking into the large number of cases reported by many 
medical men, we do not find the conclusion forced on us 
that careless or reckless people, or those who bolt their 
food, are those particularly afflicted with foreign bodies in 
the throat. I knew a dressmaker who often went to bed 
with dozens of pins in her mouth (as she expressed it), and 
who always awoke in the morning without having got any 
of them fixed in her throat. She, in a long life, was never 
bothered by any pin or needle getting into her throat. I 
know a half dozen carpet-layers and upholsterers, whose 
work obliges them to keep their mouths full of tacks for 
hours at a time, and neither are they bothered by tacks 
getting into their throats and becoming fixed there. Why ? 
Just because the mouth, fauces, and pharynx are the per- 
fect, exact, and wonderful organs they are. In this con- 
nection it may not be uninteresting to recall Ombani's 
experiments, with twelve young sucking animals (twelve 
kittens and two rabbits). Ombani forced these animals to 
swallow a hundred and twenty-seven needles and pins. The 
number swallowed by each animal varied from one to fifty- 
eight. Deglutition took place with ease, provided the 
needles or pins were placed on the tongue longitudinally 
and the mouth was kept shut. A hundred and ten needles 
passed away through the anus, one needle was found in the 
rectum above the sphincter, one transfixed the rectum, one 
was stuck fast in the walls of the stomach, and two were 
found in the appendix or caecum. Three animals, after 
they had been made to swallow needles, were given emetics. 
Two of these animals vomited needles. In all three, needles 
were found transfixing the walls of the stomach. Such is 
quite a good showing for an apparatus with a bad reputa- 
tion. 
If we turn to anatomists and physiologists for an an- 
swer to the question, Why are fish bones, needles, and such 
similar foreign bodies found caught at or in the particular 
localities where they are found ? they will not give us a FISH BONES IN THE THROAT. 
9 
direct or ready-made reply. It is easy to say that a for- 
eign body gets where it is found by being swallowed ; but 
so saying is only stating the problem in another way. 
This problem must take into account two processes : First, 
mastication, and second, deglutition. Under ordinary or 
normal conditions the tongue, cheeks, and teeth, in harmony 
with the jaw muscles and salivary glands, are sensitive to 
such a degree and their working qualities so well arranged 
and managed that the bolus is not transferred to the throat 
until it is properly prepared for propulsion downward. 
For mastication as well as for deglutition the tongue is the 
chief active factor. Taking physiologists together, we do 
not find them unanimous regarding all the details concern- 
ing the mechanism of deglutition. Whichever view be 
adopted, it does not seem irrational to assume that the 
tongue, after doing its share in the work of mastication 
and forming the bolus, gives the bolus a twist as it shoves 
or propels it down through the pharynx. It does not seem 
difficult, from its complicated anatomy and the multiplicity 
of its many possible movements, to suppose this to be the 
case-that is, to initiate the deglutitory movement with a 
screw-like motion or gyration, a movement which it would 
seem must facilitate the passage of the bolus, and which at 
the same time would lend force and expedition to the other 
deglutitory process acting on the down-speeding bolus. 
The conformation of the pharynx during deglutition would 
seem to favor this view. The pharynx is funnel-shaped ; 
and we know that fluid forced down a funnel gyrates. 
Then, too, it may be asked, May not that force, or one 
similar to what gunners call " windage," but conformant to 
the organic conditions of the pharynx, etc., be at work here 
and aid in the gyratory movement of the bolus through 
the pharynx ? We all know that it is easier to force a 
probe through a solid by pushing it with a rotatory move- 
ment ; and we also know that it is easier to pull a plug 
from its place of fixture by adding rotation to the pulling 
force. These instances are, of course, only analogies, and 
prove nothing positively; but they indicate possibilities. 
We all know by experience that we talk faster than the 
clock ticks, and Kronecker and Meltzer have, by means of 
ingenious mechanical contrivances, demonstrated that we 10 
FISH BONES IN THE THROAT. 
swallow much more quickly than we talk-that is, we 
swallow at the rate of about an inch in a hundredth of 
a second. Deglutition is in the dark in more senses 
than one. And, besides, it is no easy matter to ob- 
serve all that occurs, and how it all occurs, in so compli- 
cated and complex a process as deglutition is-everything 
taking place with almost " lightning rapidity." If, how- 
ever, the gyrating or screw-like movement of the "shoot- 
ing " bolus could be proved experimentally-that is, if this 
idea could be made a fact-the explanation of the fixation 
and impaction of foreign bodies like fish bones, etc., in the 
throat could be more easily explained than can be done by 
assuming that the food goes down in a straight line. It 
seems easier to conceive of a long fish bone stitching itself 
into the posterior faucial pillar-as in the case of the woman 
reported above-than by force thrust in a straight and un- 
deviating line. A rotating bolus, it seems to me, would 
much more readily free itself from any particle in it that 
had fixed itself at any point in the tract it is forced to 
travel. These foreign bodies-fish bones, pins, needles, etc. 
-vary in length, and lie at different and varying angles 
to the long or descending axis of the bolus, during both 
mastication and deglutition. During the rapid process of 
deglutition the shape of the bolus is necessarily changed by 
the forces acting on it. The fauces being the first station 
where these changes occur, the greater number of these 
foreign bodies are deposited here, especially in the tonsils 
(Brodie, Bosworth, Knight, and others). The deglutitory 
forces continuing to act, the bolus is continually changing 
its form, and the contained fish bones, etc., are necessarily 
shifting their places and the angles at which they lie to the 
long axis of the bolus; and the ceaseless transformation of 
the bolus and its contents being a matter of time and place, 
relatively considered, any point in the pharynx or oesopha- 
gus may be penetrated by the foreign body that may hap- 
pen to be in the bolus. But the original position in the 
bolus of a pin, needle, or fish bone immediately after masti- 
cation and as deglutition begins decides the fate of these 
foreign bodies, and hardly so any of the natural or normal 
irregularities of the fauces and pharynx as seen in a state 
of rest with the mouth open. Foreign bodies, such as we FISH BONES IN THE THROAT. 
11 
are considering, lying parallel with the long axis of the 
bolus will probably reach the stomach with the bolus; and 
once more, in the way of corroborative evidence, I may di- 
rect attention to Ombani's experiments. But if these 
foreign bodies are at an angle to the long axis of the bolus, 
the chances are that they may be held up somewhere in the 
throat, unless the forces acting on the bolus shift them 
parallel, or nearly so, to the long axis of the line of 
travel. According to the experimental results of Falk, 
Kronecker, and Meltzer, the bolus is thrown into the cardia 
before the muscles of the pharynx contract, and within a 
tenth of a second as to time. However, immediately after 
the bolus has passed through the throat the middle and in- 
ferior constrictors of the pharynx contract in a quick, 
graded, and regular order, and sweep down into the oesopha- 
gus the particles of food which detached themselves from 
the bolus and remained clinging to the pharyngeal walls as 
the bolus was hurried or shot downward. These observa- 
tions, it seems to me, can be plausibly utilized in explaining 
how fish bones become fixed in the throat; and, moreover, 
they do not stand in the way of the opinions bearing on 
this question as outlined, nor do they contradict them in 
any way. For instance, the mode of impaction of the fish 
bone in the Northern Dispensary case may be explained 
thus: Possibly the bone was shifting its position all the 
while the bolus was being whirled down the throat until its 
point struck the arytaeno-epiglottic fold; the onward whirl 
of the bolus stitched in the bone to a certain distance, tore 
itself loose, and whirled onward ; and immediately this was 
done the succeeding contraction of the pharyngeal constrict- 
ors pushed the bone still farther in. These possibilities are 
not excluded by hypothetical assumptions I have endeav- 
ored to explain, and the results of the Kronecker-Meltzer 
experiments. It must not be forgotten that these phe- 
nomena take place within the fraction of a second-primari- 
ly. Of course, subsequent pharyngeal contractions, tongue 
movements, the rising of the larynx, etc., would tend to 
drive an already fixed foreign body, like a fish bone or a 
pin, still deeper. 
Stuart and McCormick came to the conclusion, after 
observing the throat through a hole in the side of the neck 12 
FISH BONES IN THE THROAT. 
of a man,* that the epiglottis, at least so much of it as 
could be seen, does not move or bend over to cover the 
glottis during deglutition. When this patient was given 
an oyster to swallow they could see how it glided over the 
laryngeal surface of the epiglottis on its way downward. 
The oyster was received within the hollow of the tip of the 
epiglottis, along which they saw it glide for a certain dis- 
tance. When oysters were swallowed, twice in three times 
they were expelled from the pharynx through the surgical 
hole in the side of the neck. This seems to prove that the 
epiglottis is not the guide of the food downward immedi- 
ately after it leaves the base of the tongue; and, further- 
more, that the pharynx in a normal state exerts an equal- 
izing pressure on the descent of the bolus, if not (as 
Kronecker and Meltzer believe they have demonstrated) an 
active direct propulsive action.f 
Magendie, more than eighty years ago, demonstrated that 
the epiglottis is not necessary to successful swallowing. 
* This man had undergone four operations for the removal of epi- 
thelioma, and the hole in the neck was left after the following parts 
had been cut away: The parotid gland, the ramus of the jaw, a piece 
of the hypoglossal nerve, the pes anserinus of the facial nerve, portions 
of the internal, external, and common carotids, the greater part of the 
great horn of the hyoid bone, the posterior belly of the digastric mus- 
cle, the faucial pillars and faucial tonsil-all on one side. 
f The following observations are so interesting in themselves, and, 
I believe, in a measure assist in better understanding the mechanism 
of deglutition, that they may profitably be repeated here: Dr. Stuart 
had a meal with this patient, and he writes as follows (the patient had 
devised a pad for keeping the hole in the side of the neck closed): 
" The patient had no apparent difficulty with his food, whether liquid 
or solid. When he had his mouthful masticated and ready for swallow- 
ing, he laid his hand upon the pad, to more securely close the opening, 
just as he always does when he speaks, and then he swallowed quite 
well. His only common inconvenience is that sometimes in swallowing 
liquids a little remains behind, and when this is swallowed it is apt to 
get into ' the wrong throat.' This is easily understood when we re- 
member (1) the imperfectly contractile channels through which the 
liquids must pass; (2) one side of the lower jaw being absent, the ele- 
vators of the hyoid bone can hardly act so efficiently as normally; (3) 
the hypoglossal and part of the facial nerve of one side being want- 
ing. . . . Occasionally a little piece of solid food gets against the pad; 
then it may annoy him in the same way as the liquids referred to, but 
this does not very often happen." FISH BONES IN THE THROAT. 
13 
Since his time physiological experimentation and clinical 
observation have made this a fact and truism. Schaf- 
fer (11), (Bremen), has described a number of cases of de- 
formed epiglottis, and among the symptoms which the 
deformities gave rise to were deglutitory difficulties. The 
epiglottides in these cases were large and irregular in 
shape, and probably in a measure on these accounts inter- 
fered with the deglutatory phenomena. Stuart and Mc- 
Cormick, in their article already quoted from, state that the 
epiglottis in their case stood still against the base of the 
tongue during deglutition. Michel (12) speaks of a primary 
cedematous affection of the anterior aspect of the epiglottis 
which occurs when the pharyngeal condition might lead one 
to overlook it. He calls it angina epiglottica anterior, and 
says it presents a swelling of about the size of a hazelnut 
and more or less reddish-gray in color. In these cases the 
fossae glosso-epiglotticae were almost unrecognizable. This 
condition of the epiglottis gave rise to painful deglutition, 
and no doubt an abnormal position of the epiglottis, mak- 
ing it impossible to cover the glottis during deglutition, as 
well as standing up against the base of the tongue, as 
Stuart and McCormick have seen that it does. Wagner, of 
this city, has removed the epiglottis in toto by a sub- 
hyoidean operation, and no deglutitory difficulties ensued. 
Pathological instances might easily be multiplied to prove, 
what physiologists have demonstrated over and over again, 
that the epiglottis is an indifferent organ in so far as deg- 
lutition is concerned. Some phonatory functions have 
been claimed for it. It is in the pharynx during degluti- 
tion, and so it must be accounted for; and if foreign 
bodies get behind it (as in Schaffer's case, a fish bone in 
the left interglosso-epiglottic space) or alongside of it, or 
transfixed through the glosso-epiglottic folds, any theory of 
deglutition must account for such accidents, and in doing 
so the deglutitory theory gives an account of itself and in 
so far justifies its validity. In view of the observations 
made by Stuart and McCormick, and the physiological and 
pathological demonstrations referred to and mentioned, the 
shutter function of the epiglottis must be abandoned. 
When a foreign body has fallen in front of the epiglot- 
tis-the anatomical conditions being normal-into either 14 
FISH BONES IN THE THROAT. 
of the vallecules, it possibly became detached from the 
bolus very early in the series of deglutitory phenomena, 
or slipped along too late and missed being acted on as 
fully as the bolus was acted on, and consequently it slipped 
down between the tongue and epiglottis. Or the fish bone 
occupies a favorable position on the outside of the bolus- 
it attaches itself to the pharyngeal wall and, its point swing- 
ing into the glosso-epiglottic fold, the subsequent secondary 
pharyngeal contraction and after-contractions stitch it in 
to the limits of force and space. Of course, in all possible 
instances, one can vary the theorization of fish-bone im- 
paction at will-but only so within the limits of the forces 
named. 
I have not alluded to nor taken into account all the 
forces at work during deglutition. That was not the object 
of this paper. I believe, however, that what has been said 
from an anatomical, physiological, pathological, and experi- 
mental point of view allows the following conclusions to 
be drawn: 
1. The reasons for the impaction of foreign bodies, 
such as fish bones, needles, pins, and the like, are not to be 
sought for in the pharynx primarily. 
2. That, under normal conditions, the tongue, fauces, 
and pharynx, in so far as deglutition is concerned, are per- 
fect organs, looked at as a mechanico-physiological appa- 
ratus. 
3. The primary and chief cause of fish bones, needles, 
etc., being caught or entangled in the throat must be looked 
for in the bolus itself-the position of the fish bone or 
needle in the bolus, whether lying deep or on the surface, 
the angle the fish bone or pin occupies to the long axis of 
the bolus, and, besides, the varying and various forces that 
act on the bolus as it is forced toward the stomach. 
4. Possibly the bolus leaves the tongue and descends 
the pharynx with a twist or screw-like movement. 
5. The Falk-Kronecker-Meltzer conception of degluti- 
tion, based on experimental results, may be utilized in ex- 
plaining how fish bones become impacted in the throat- 
and these experimental results do not exclude the element 
of gyration as one of the forces that impel the onward- 
shooting bolus. FISH BONES IN THE THROAT. 
15 
6. The epiglottis is an indifferent organ in so far as 
deglutition is concerned-also for foreign bodies.* 
Bibliography. 
1. Professor A. Jurasz. Die Krankheiten der oberen Luft- 
uegen, etc. Heidelberg, 1891, p. 208. 
2. Dr. Med. Max Schaffer (Bremen). Chirurgische Erfah- 
'ungen in Rhinologie und Laryngologie aus den Jahren 1875 bis 
1885. 
* While studying at some of the throat clinics in Germany during 
1880 and 1881, I often heard one of the deglutitory functions of the 
epiglottis explained as being a sort of guard standing firmly against 
the current of foods and liquids as it came down from the tongue. It 
was supposed that the epiglottis divided this current and caused the 
foods and liquids to course laterally around the larynx into the oesoph- 
agus, which stood open to receive them. Heavier or large morsels, 
which would not divide, toppled over the epiglottis into the oesophagus. 
This theory of deglutition always seemed to me grotesque and inade- 
quate. However, the most recent German book on the science and art 
of laryngology, very well written, as was to be expected, by Professor 
Dr. Moritz Schmidt, Frankfort a. M , still clings to this theory. If that 
were all, this note would not have been written; but Professor Schmidt 
also asserts in this same very good book that small, sharp-pointed for- 
eign bodies are caught up in the epiglottis quite often, and that they 
occasionally penetrate it (page 471). These statements are made in a 
general way, and no specific instances are narrated, nor are any refer- 
ences given of such. Has he seen such instances in his own extensive 
practice ? If foreign bodies do frequently fix themselves into the epi- 
glottis and occasionally penetrate it, two good arguments are always 
close at hand to defend the deglutitory guard, etc., theory of the epi- 
glottis (Schmidt, pages 44, 45). But, unfortunately, I can find neither 
instance nor any authority to corroborate the assertions made by Pro- 
fessor Schmidt. I have looked in vain for such instances in the indexes 
of the following special publications: (1) Annales des mal. des loreilles et 
du larynx, from 1875 to 1893; (1) A rch. de laryngologie et de rhinologie, 
1887 to 1892; (3) Internationales Centfalblatt fur Laryngologie, etc., 
nine vols.; (4) Monatsschrift fur Ohrenheilkunde sowie f. Kehlkopf- 
Nasenrachenkrankheiten; (5) the Journal of Laryngology, etc., 1887 
to 1893 ; (6) Elsberg's Arch, of Laryngology, four vols. And neither 
do any of the following standard writers mention, even in a general 
way, the epiglottis as a seat for sharp-pointed foreign bodies: Massei, 
Knight, Bosworth, Schuh, Jurasz, Schrotter, Mackenzie, McBride, Rethi, 
Rosenberg, Rae, Bresgen. In view of all this evidence against the as- 
sertions of even so genial a man as Professor Schmidt is known to be. 
I am sure this conclusion-the epiglottis is indilferent to foreign bodies, 
small and sharp-pointed-may fairly be allowed to stand. 16 
FISH BONES IN THE THROAT. 
3. Walter F. Atlee, M. D. Phil. Med. Times, March 21,1885, 
p. 474. 
4. Dr. Med. O. Chiari (Vienna). Erfahrungen auf dem Ge- 
biete der Hals- und Nasenkrankheiten. Vienna, 1887, p. 43. 
5. George White, M. D. Med. Record, April 7, 1888. 
6. W. F. Atlee. Loc. cit., p. 474. 
7. Sir M. Mackenzie, M. D., etc. A Manual of Diseases of 
the Throat, etc., London ed., 1880, p. 112. 
8. Die Krankheiten des unteren Theils des Pharynx und 
Oesophagus. Professor Dr. Konig. Deutsche Chirurgie, Lief. 
35, p. 102. 
9. Falk und Kronecker. Ueber den Mechanismus der Schluck- 
bewegung. Du Bois-Reymond's Archie, 1830. II. Kronecker 
u. S. Meltzer. Der Schluckmechanismus, etc. Du Bois-Rey- 
mond's Archie, 1883, Supplement. Also a summary: Recent 
Experimental Contributions to the Physiology of Deglutition, 
by S. J. Meltzer, in the N. K Med. Jour., March 31, 1894. 
10. The Position of the Epiglottis in Swallowing. By T. P. 
Anderson Stuart, M. D., Professor of Physiology, and Alexander 
McCormick, M. D., Lecturer on Surgery, University of Sydney. 
The Journal of Anatomy and Physiology, vol. xxvi, 1892, Lon- 
don. 
11. Dr. Max Schaffer (Bremen). Op. cit., p. 60. 
12. Dr. Carl Michel (Coin). Zur Behandlung der Krank- 
heiten der Mundrachenhohle und des Kehlkopfes, 1880, p. 4. 
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