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I  From  the  Richmond  and  Louisville  Medical  Journal,  May,  180'.). ] 

Foreign  Body  in  the  CEsophagus : 

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  case^j  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,  net.  23  months,  wTho  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.  II., 
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 
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. 
(jr.  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  poiver  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 


(3) 

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  wTas 
very  difficult  to  define,  owing,  parti}7  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- 
nary 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  4^  the  projecting  wall  of  the  oesophagus,  tmtbfrom 
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 
w7as  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  wround  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  wras  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  away 
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  oesophagotomy  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 
oesophagotomy  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 


(6) 

this  table;  some  of  the  cases  appear  hardly  entitled  to 
be  classed  under  the  head  of  oesophagotomy.  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:  2| 
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's  in  inverse 
proportion  to  the  size  and  age  of  the  patient. 

Owing  to  the  length  to  winch  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  oesophagot- 
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  only  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.  Cheever  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. 


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