Esophagotomy for Jackstone in the Upper Esophagus^,JDeath from Exhaustion. A PAPER READ BEFORE THE SUR^ImRI^IWW1 T'A'e' COLLEGE OF PHYSICIANS,-AP^rew^T8^',M,www,*w BY W. W. KEEN, M.D., Professor of the Principles of Surgery and of Clinical Surgery, Jefferson Medical College, Philadelphia. REPRINTED FROM THE THERAPEUTIC GAZETTE, APRIL 15, i8q8. DETROIT, MICH. I WILLIAM M. WARREN, PUBLISHER. 1898. E SOP HA GO TO MY FOR JACKSTONE IN THE UPPER ESOPHAGUS; DEA TH FROM EXHA U STI ON. W. W. Keen, M.D. Ella D., aged thirteen months, was admit- ted to the Jefferson Hospital March 30, 1897. At five o'clock on March 27, while on the floor with other children, the child was no- ticed to have something in her mouth. A moment later she strangled. The mother attempted to clear the throat with her finger, with which she could feel a foreign body, but could not remove it through the mouth. She, therefore, tried to push it down into the stomach. Solid food was given the child in order to facilitate its being swallowed. The child was unable, however, to swallow the solid food and only took the breast milk. On the 29th of March the child was first brought to the out-patient department, and I saw her. The mother stated that she had swallowed a jackstone. A most careful ex- amination of the throat in the laryngological department did not reveal any such foreign body, nor did external palpation. I did not attempt to withdraw the body or to probe for it, but had a skiagraph taken immediately by Professor Coplin. This showed the jackstone opposite the bodies of the fourth and fifth cervical vertebrae. The next day the child 2 was brought to the hospital and operated upon. The finger could not touch the jack- stone, but a pair of curved forceps for foreign bodies in the urethra were found to serve the best purpose. With these the foreign body was caught several times both by Professor Hearn and myself, but it was so firmly embedded that by no possibility could it be extracted. The choice then lay between esophagotomy and gastrotomy. The ingenious snare of Dr. A. C. Wood was tried, but it was impossible to get the whalebone bougie past the jack- stone; it seemed entirely to fill the esophagus. The child had a very short neck, but I finally decided to do esophagotomy in view of the high position of the jackstone. An incision was made in the left side of the neck; the sterno-cleido-mastoid and the vessels were drawn outward and a large arterial branch, presumably one of the thy- roids, and a large vein were ligated. These were the only two vessels requiring ligation. The recurrent laryngeal nerve was looked for, but was not seen. As soon as the trachea was discovered and back of it the esophagus, the rounded knob of the jackstone was per- ceived, both by touch and sight. The tissues of the esophagus around it were already be- ginning to slough. An incision was made over the foreign body, and it was extracted with considerable difficulty and as slight laceration of the parts as was possible. The wound in the esophagus was closed by three catgut sutures and the external wound was packed with iodoform gauze. At the end of the operation the child was very comfortable and in good condition. 3 The child was fed every four hours for forty hours by the rectum with milk, and twenty drops of whiskey. On April i, 1897, at 6 a.m., the child nursed for the first time and took food very well. A slight amount of milk passed into the wound, necessitating the change of the dressing three times in the twenty-four hours. The child did not seem to be particularly hungry, fretful, or restless, and I saw no reason to suppose it would not do well. The wound was doing admirably. At 3 a.m., on April 2, she became very restless and died at 3 p.m., apparently from exhaustion. The highest temperature immediately after the operation was 99.6°, but on April 1 it rose to 101.40. The two points worthy of attention in this case are, first, the method of removing the obstruction, and secondly, the cause of death. Although the child's neck was very short and fat, I decided on esophagotomy on account of the high position of the jackstone. The operative result showed that this was the better plan. I doubt much whether in so young a child the jackstone could have been safely removed by the method adopted by White and Wood in their two cases {Univer- sity Medical Magazine, June and October, 1896). There would have been very severe laceration, I think, of the esophagus above or below the obstruction. For two days after the operation I fed the child by the rectum, and as she seemed en- tirely satisfied, was not restless, fretful, or in any other way exhibited signs of hunger, I did not deem it best to feed by an esophageal tube. I regretted afterwards that I had not done so. The child took the breast milk on the sixth day very well, but did not show any special signs of hunger or exhaustion till twelve hours before death. 4 FEBRUARY 15, 1898: WHOLB SERIES. VOL. XXIT. No. 2. THIRD SERIES, VOL. XIV. Therapeutic Gazette TH E- THE THERAPEUTIC GAZETTE FEBRUARY /898. A MONTHLY JOURNAL General, Special, and Pliysiological Therapeutics. GENERAL THERAPEUTIC*. H. A. HARE. M D , Professor of Therapeutics in the Jefferson Meditll Collage. SURGICAL ANO GENITO-URINARY THERAPEUTICS, EDWARD MARTIN. M.D., Clinical Profeaaor uf Gaalio-Urinary Diaeaaos. University of Pennsylvania. EDITORIAL OFFICE, 222 South Fifteenth St., Philadelphia, U.S.A. W Bubacrlptions and eommunicationa relating to the business management should be addressed to the PublBher. WILLIAM M. WABREN, DETliOIT, MICH., IL B. A. Published on the Fifteenth Day of Every Month. Suascu/PPON WCI, T*o DOLLARS A YHAff. EUROPEAN BRANCH: WILLIAM M. WARREN. MRDiCAi. 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