//ATI X Wr [From (be Richmond and Louisville Medical Journal, May, 1869.] Foreign Body in the Esophagus: Obstruction, Abscess, (Esophagotomy, Recovery. By DONALD MACLEAN, M.D., L.R.C.S., Edinburgh, Professor of Suryery and Clinical Surgery in the Louisville Medical College. Cases are regarded as worthy a place in the annals of surgery, sometimes on account of extreme rarity as sur- gical curiosities, and sometimes on account of lessons of practical value which may be learned from them. In recording the following cases I am influenced by both of these considerations. On the 18th of February, my colleague, Dr. Goodman, asked me to see E. R., a girl, ret. 23 months, who was sup- posed to have a piece of bone lodged in the oesophagus. The history of the case, up to this date, is thus given by Dr. Goodman. On the 10th of February, Mr. K,, the patient's father, called at Dr. Goodman's office, late at night, and stated that the child had, two days before, been eating mutton hash, when she suddenly became "choked till she was black in the face;" that the mother, becoming alarmed and excited, forced the mouth open and passed her finger as far as possible down the throat, where she felt what she supposes to have been a piece of bone similar to one that she had, on a previous occasion, succeeded in extracting, under similar circumstances, from the same child's throat. On the present occasion, how- ever, she failed to seize the piece of bone, but felt it move downwards, beyond the reach of her finger; the child coughed violently for a few minutes and spat up a little (2) % blood, and then appeared quite relieved, but refused S* to swallow anything but fluids, and had gradually be- come more and more restless and feverish, till the advice of Dr. Goodman was asked. An emetic was pre- scribed and administered, and early on the 11th, Dr. G. visited the case and found extensive bronchitis, with the usual amount of accompanying general indisposition. He examined the throat as carefully as possible, but could find no evidence of obstruction of any kind and con- cluded that the child's unwillingness to swallow solid food was caused by want of appetite and not by loss of the power of deglutition. The bronchitis gradually sub- sided under treatment, and in a few days the doctor's at- tendance seemed no longer necessary. On the 16th, Dr. Goodman was again called and found well marked roseola, and ..noticed that there was some diffuse swelling of the neck, in the neighborhood of the thyroid cartilage, on both sides, but chiefly on the left: the patient carried her head on one side, the left, and carefully avoided all motion, especially lateral. There was now, also, total inability to swallow even fluids, al- though the little patient, evidently suffering very much from thirst, was never tired of making the attempt. Nu- tritive and stimulant enemata were prescribed, from which considerable benefit was derived. On the 17th the symptoms continued, and in addition, her breathing became somewhat embarrassed, and on the morning of the 18th, I saw her with Dr. Good- man. By this time the roseola had disappeared, but otherwise her condition was unchanged, except that the swelling of the throat was greater and her breathing more embarrassed than when Dr. G. saw her on the pre- vious evening. The pulse was too rapid and feeble to be counted, the skin hot and dry, the tongue furred, the face livid v3) and bearing an expression of restless anxiety, the breath- ing very much oppressed and accompanied by a loud whistling sound, suggestive of oedema glottidis, which, however, did not exist, The swelling of the neck was very difficult to define, owing, partiy to its depth and partly to the compression by the larynx and neighboring muscles. Moreover, the child, who was very small of her age, had a remarkably short, thick and fat neck. At this and several subsequent visits paid during the day, the most careful manipulation failed to determine, posi- tively, whether suppuration had actually occurred, or to afford any precise information as to the condition of the deep structures. On questioning the mother during my first visit, she informed us. that, while endeavoring to swallow one of the doses prescribed by Dr. Goodman for the bronchitis, the child had "coughed up a small splinter of wood." During the day hot, soothing applications to the sur- face and inhalations by the atomizer were sedulously em- ployed with the effect of affording a slight degree of temporary relief. Towards evening, however, I was sent for in a great hurry and informed that death, by stran- gulation, seemed imminent. It was now quite evident that there was but one resource left, viz : operation, and that there was no time to be lost. I proposed to cut right down through the swelling, partly with the hope of dis- covering and extracting a foreign body, but mainly with the confident expectation that a deep-seated abscess would be evacuated, and immediate relief afforded to the function of respiration. In this proposal Dr. Henry Miller, also Drs. Satterwhite and Goodman, acquiesced, and I immediately proceeded to carry it into execution, not, I must admit, without feeling deeply that my position was one of more than ordi- narv responsibility. The age and exhausted condition of (■*) the patient, the unsatisfactory history, the indefinite character of the swelling, and the obscurity of the ordi- nary anatomical landmarks produced thereby, the close proximity of important anatomical structures, injury to which would in any case be disastrous, and in this inevi- tably and instantaneously fatal, all these circumstances combined to render the operation one of extreme diffi- culty and danger. Chloroform having been administered with the utmost caution by Dr. Goodman, I made an incision on the left side along the anterior margin of the sterno-mastoid muscle, extending from the level of the upper border of the thyroid cartilage down to a point opposite the lower border of the cricoids, I cut at once through the skin, platysma and fascia, pressed upwards the omo-hyoid muscle, divided the fibres of the sterno- hyoid and sterno-thyroid muscles; with the forefinger of my left hand pressed the carotid artery outwards as far as possible, and on the point of the same finger guided the knife downwards, inwards, and backwards, to be the projecting wall of the oesophagus, and from which, on the application of the edge of the knife to it, I hoped to witness a discharge of pus ; nor was this hope disappointed. The instant the opening was made there was a loud gurgling eructation of gas and an increased flow of blood from the wound, and the next moment all present became painfully sensible of a stench of the most penetrating character, and this was immediately followed by the discharge from the wound of about two table- spoonfuls of dark, grumous, foetid pus. I then intro- duced my finger into the wound and right into the in- terior of the oesophagus, but could not discover a foreign body of any kind; convinced, however, that the main object of the operation had been attained, and that, in case a foreign body was present, a more favorable oppor- tunity of exploring for it would be afforded subsequently, we gladly desisted from further manipulation, and per- mitted nature to restore consciousness without inter- ference of any kind. No vessels required to be tied. The result was precisely what we had anxiously anticipated; the breathing became quite natural, the whistling sound (produced no doubt by compression of the windpipe) entirely ceased, and when consciousness returned it was found that the function of deglutition was fully restored. The little sufferer was now able to enjoy a copious drink of milk, although with every act of deglutition a small quantity was discharged by the wound. (5) 19th—Morning. Slept very well; wound discharging copiously; drinks freely, but refuses solid food; can't speak above a whisper ; bronchitis lighted up again, and is pretty general in both lungs; pulse very rapid, but stronger than yesterday. Ordered beef tea, an expect- orant mixture, poultices to neck, and counter-irritation (mustard) to chest. Evening—Breathing suddenly much embarrassed ; high fever; countenance livid; pulse ex- tremely small and rapid ; discharge from wound almost entirely arrested. On passing a probe into the wound it was found that a valvular closure had been formed, prob- ably by the contraction of the neighboring muscular structures; the introduction of the probe was followed by a gush of healthy pus, and instantaneous relief of the urgent symptoms. A pledget of lint was then inserted to prevent the recurrence of this accident, and was re- placed at each dressing for the next few days. After this date everything went on well, the discharge poured awa}r very freely for some days, and then gradually diminished in quantity, and the wound closed up from the bottom, of its own accord, after having been probed in all direc- tions on several occasions, but without result so far as any foreign body is concerned; the bronchitis slowly subsided, the voice returned, and now, March 10, the child is quite well. Commentary.—On reference to the annals of surgery, it will be found that the cases of cesophagotomy are ex- tremely rare, while those of great distress, and even death from the impaction of foreign bodies in the oeso- phagus, are comparatively frequent. These facts consid- ered in connection with the brief and indefinite opinions expressed regarding it, and the air of difficulty and even impracticability thrown around the whole subject by many high authorities, induces the conviction that it is one which has not received the attention which its im- portance entitles it to. In a recently published monograph, Dr. David W. Cheever, of Boston, details the history of three cases of cesophagotomy in his own practice, and gives a somewhat comprehensive review of the literature of the subject, quoting the opinions and experiences of numerous surgi- cal authorities as Syme, Velpeau, Nelaton, Ferguson, Hevin, Gualtani, Begin, Martini, De Lavacherie, Arnott, Cock, Demarquay and Gross, with the following table of cases, to which is added the one described above. We must, however, confess to a doubt as to the correctness of (tf) this table; some of the cases appear hardly entitled to be classed under the head of cesophagotomy. Neverthe- less the table is a valuable and interesting one. Of the 22 cases it will be observed that 18 terminated in re- covery. Of those in which the age of the patient is given, Dr. Arnott's fatal case is the youngest, (viz: 24 years), except the one here described. In fact, I think we are justified in assuming that all the patients, except these two, were adults, and there can be no doubt that the difficulty and danger of the operation is in inverse proportion to the size and age of the patient. Owing to the length to which this paper has already extended, we can only find space for the following brief summary of Dr. Cheever's views: "In view of all these perils why thould not cesophagot- omy be the rule, after reasonable attempts at extraction have failed, just as an operation is the rule in strangulated hernia, after reasonable attempts at taxis have failed? "We onl}- lose by delay. The experiments of Demar- quay have proved that suppuration is imminent if we wait longer than the third or fourth day."' In the whole twenty-two cases we find only four deaths, or less than twenty per cent. "And in every one of these, death was due to secondary complications; due either to delay, or to overtreatment in attempts at extraction. In one, there was pneumonia; in two, gangrene ; in the remain- ing one, abscess. No projection externally of the foreign body need be waited for, or expected. As to the manner of the operation, we have given our reasons for the lat- eral method, which, indeed, is favored by most writers. We need not remind the anatomist, that the nerves are very constant in their distribution, and can all be avoided. And if anomalies of arteries are feared, there is but one of much consequence, and that very rare, namely, the origin of the right subclavian from the arch of the aorta, in which case it crosses behind the oesophagus. "In comparison with the perils of expectant treatment in surgery, we are almost ready to say, that no dangers from the knife, in an educated" hand, can equal those of delay." We have no hesitation in indorsing the practical con- clusions, to which Dr. (Jheever has arrived as the result of actual experience and careful consideration of the sub- ject, and we believe these views receive additional strength from the case here recorded. Tabic of Cases of (Esophaush it down. Not stated. inch long, six lines not stated; could broad. I be felt outside. Probably a portion of Not stated. Not stated. Not stated. s 1853 9 1853 10 1854 11 1855 12 1856 13 1861 hone. Portion of beef bone. Recovered. Recovered. (Esophagus: lower Touched the foreign body; Operation twelfth Speedy recov- part of the neck, i attempts to dislodge it. ; day, left side. cry. Cause of Death. I Operator. i __________________I___________ Goursauld. Roland. Begin. Begin. Large conical frag-(Esophagus: lower Touched the body; every 'Operation eighth day Recovered. mentofbone. part of the neck. means tried to dislodge: —leftside. Spinous process of Lower part of phar- Emetics and various at-Operation after five Death fifty-six Pneumonia, existing Arnott. dorsal vertebra of a ynx. '■ tempts to dislodge it. , weeks, on right; hours after at time of operation. sheep. Not stated. side. i operation. Operation eighth day Recovered. De Lavacherit [Portion of bone. iSmall fish. Oesophagus — perfo- Not stated. ration of: lying on carotid. ' ,, , _, . Could be felt outside. Bleeding, tartar emetics in Operation fourth day Death two days Collapse, pharynx gan-Martini projecting above veins, belladonna cue-; —bone swallowed.: after opera- grenous, stomach in clavicle. tion. flamed. niata, and sixty attempts with instruments. Pharynx; tail seen in Vain attempts to withdraw 'Operation after sev- Recovery in six fauces. through mouth. : cral days. weeks. Fragment of beef (Esophagus: in neck. Attempts at extraction. Operation ninth day. Death second Perforation front and I1 laubert. bone. day after oil- behind. Retro-phar. tion. abscess reach, stom. One franc piece. Upper part of eesoph- Repeated efforts at extrac-.Opevation tenth day..Death the third Retm-cesophageal air Demarquay, agus. ; tion with Oracle's sound : day after op-, scess opening into and forceps. oration. _ pleura. Portion of bone. (Esophagus; abscess Could not be reached by Operation sixteenth R e co very in; i formed. fauces. day. two weeks. Gold tooth-plate con- Junction of pharynx Attempts at withdrawal,Operation the fourth Recovery in 4 taining a false in-' and oesophagus.; with forceps: emetics. day, left side. weeks; per- cisor. ! No external pro- ! manent alter- jection. ' ation of voice Thin piece of mutton (Esophagus: no ex-Could not be touched by Operation sixth day. Recov ery i:i bone 1 inch square, ternal projection, fauces. two weeks. Ani< fryme. Cock. H I 1*62 A coin. [Opposite top of ster- Coin touched by bougie. i num. 1866 i M [Codfish bone. i^ ; 1866 | M Brass pin. 19 m\7 ! M JTooth-plate. 20 { 1867 I F iBrass pin. Operation after two months. Not stated. Not stated. Operation third day, right side. Operation third day, left side. Recovery! swallowed in a week. Recovered, Recovered. Recovered, 1863 i M JBone. iNot stated. Not stated. 18b! I T [Peach stone. (Not stated. Not stated. {Junction of pharynxiVomiting; exploration by and oesophagus.; finger and probang; rig- j No projection. j ors. Below top of ster- Vomiting; long probang. Operation third day, Recovery in 5 ! num. No projec- leftside. weeks. tion. (Opposite left cricoid. Various explorations. Operation third dav. Recovered, Apparently opposite Attempts during^ months.{Operation after four Recovered. ,. j left cricoid. I i months ; -i ■ 1808 j F Supposed to bo a pin. Junction of pharynxiVarious attempts. 'Operation after eightlRecovererl w l : ■ and oesophagus. month" •^ LSh9 : 1 .supposed to be piece Opposite thyroid car-lNone, except one emetic.'On tenth day after Recovered. __I_______.J__ot mutton bone. ! tuage. | j accident. I IFourier, I Arnold, Cheever, Cheever. Cock. Hitchcock, Cheever. Maclean. Foreign bodies : Authentic cases, 22; deaths, 4; recoveries, 18. Note. In cases 20 and 21 no foreign body was found. The lapse of time (four and eight months lowing of the puis) may have favored their escape, or becoming encysted outside the (esophagus. I of the symptoms, the reader is referred to the history of the cases. " after the swab or the severity NATIONAL LIBRARY OF MEDICINE NLH DM51bDbS T NLM045160659