A CASE OF GASTROTOMY FOR PEACH-STONE IN THE 
(ESOPHAGUS. 
By J. M. T. Finney, M. D., 
Associate in Surgery, Johns Hopkins Hospital. 
[From The Johns Hopkins Hospital Bulletin, No. 2fi, October-November, 1892.] [From The Johns Hopkins Hospital Bulletin, No. 26, October-November. 1892. J 
A CASE OF GASTROTOMY FOR PEACH-STONE IN THE 
OESOPHAGUS. 
By J. M. T. Finney, M. D., 
Associate in Surgery, Johns Hopkins Hospital. 
The patient was a man, 49 years of age, a farmer by occu- 
pation. His family and personal history are good. He is of 
temperate habits, and beyond a severe pneumonia of the left 
lung, four years ago, has enjoyed excellent health. The 
patient says that for many years he has been subject at inter- 
vals to a slight difficulty in swallowing. There was no trouble 
with the act of deglutition itself, but the food would stop in 
the oesophagus if swallowed in too large masses. He says that 
several of his brothers are troubled in the same wray. Six 
years ago a piece of meat lodged in the oesophagus and stuck 
there for thirty hours, then passed down spontaneously. 
During that time he suffered with exactly the same symptoms. 
The piece of meat stopped at the same place where he thought 
he felt the obstruction present, indicating with his finger a 
point about the middle of the sternum. 
Four days prior to his admission, while walking in his 
orchard, he picked up a peach which was not very ripe, and 
while eating it he stumbled and fell; in the sudden effort to 
recover himself he swallowed the stone. He thinks a con- 
siderable portion of the peach was still attached. He im- 
mediately felt that the stone had become lodged in the oeso- 
phagus " about half-way down." 
Prolonged and forcible attempts at removal were made by 
doctors in White Sulphur Springs, Va., immediately after 
swallowing the stone. They worked over him, passing 
bougies, etc., until, as he expressed it, " he bled like a stuck 
pig." All efforts were unavailing, and he was brought to 
Baltimore to the Johns Hopkins Hospital, where he arrived 
September 5, 1892. He said he had been unable to swallow 
anything whatever since the accident, except a half tea- 
spoonful of water at a time. Had a constant feeling, at times painful, of something in the gullet, and was tormented by a 
continual inclination to swallow. Expectorated at short 
intervals, apparently clear saliva, in considerable quantity. 
Examination upon entrance revealed the following: " Fairly 
well nourished, rather spare man, medium large frame, nutri- 
tion normal, pupils normal, pulse full and strong. Patient 
quite weak from having taken no food for four days and 
from fatigue incident to an all-night journey. Heart, lungs 
and abdominal organs negative. If he attempts to swallow 
anything more than the smallest quantity of water, the fluid 
is at once regurgitated." * 
An ivory-tipped probang, 1 cm. in diameter, was passed into 
the oesophagus, meeting with no resistance until 32 cm. down 
from the incisor teeth. Here an obstruction was encountered 
and the probang could not be passed beyond this point. A 
distinct sensation of tapping something by the hard point of 
the instrument, similar to the sensation of stone in the bladder, 
was felt. It was impossible to dislodge the obstruction by 
the use of bougies. No force was used because the oesophagus 
had been greatly irritated by previous efforts of the other 
physicians. It was impossible without ether to pass anything 
beyond the obstruction. 
I told the patient that I thought it advisable, if the obstruc- 
tion could not be dislodged under ether, to open the stomach. 
He consented. Meantime he was given nutritive enemata, 
and next morning, September 6, he was placed under ether. 
I could then pass by the obstruction with the same probang 
(1 cm. in diameter). The obstruction always seemed to be on 
the left side. When I turned the point of the probang to the 
right I felt nothing, but to the left and a little posterior I 
could feel the stone distinctly. The instrument was passed 
with some little difficulty and then withdrawn. It caught 
slightly, but did not dislodge the peach-stone in the least. 
Then a horse-hair probang was tried, which would not pass at 
all. Next was tried a flexible bougie, of small size, which 
passed the obstruction a short distance, and on being with- 
drawn was caught by some sharp object and scratched con- 
siderably. Up to this time there had been some slight doubt 
as to whether or not the patient had actually swallowed a 
peach-stone. I was now assured that there was some hard 
object present, and the sharp, scratching point made me think 
its removal imperative. The field of operation having been previously prepared, I 
made an incision about 15 cm. long, parallel to the left costal 
border and 2 cm. below, exposed the stomach, lifted it out of 
the abdominal wound, and after having carefully surrounded 
it with sterile salt sponges, made an opening 5 to 6 cm. long, 
and introduced the longest pair of curved forceps at hand. 
Without difficulty I got into the oesophagus and could touch 
the obstruction from below, but the same difficulty was 
encountered as from above-1 could simply touch it, that was 
all. After trying various instruments, among others Bige- 
low's lithotrite, without success, I enlarged the wound so as to 
introduce my whole hand into the stomach. With my hand 
in the stomach, I passed my finger through the cardiac orifice 
and could just touch the obstruction, but no more. Then 
through the stomach wound I introduced the small probang, 
passed again the obstruction and brought it out of the 
patient's mouth. At the suggestion of Dr. Parker, I tied a 
strong piece of silk to its tip, and to the silk a small piece of 
sponge, and to the sponge another piece of silk, by which I 
could withdraw it if necessary. This I pulled down through 
the oesophagus, and by means of it dislodged the stone; then, 
with my finger, hooked it out into the stomach and removed it. 
It was a stone of rather small size, with a very sharp point. 
There ■was considerable hemorrhage. I used as little force as 
possible, but of course the mucous membrane was somewhat 
disturbed. I sewed up the wound, using the interrupted 
quilted suture for the wound in the stomach, and two rows of 
buried silk sutures in the abdominal wound, without drainage. 
The operation lasted over two hours. The patient had an 
uneventful convalescence for two weeks, the temperature and 
pulse varying but slightly from the normal. He did not 
vomit once after the operation. At first he was fed by 
rectum. On the third day he was allowed a little water and 
crushed ice by the mouth; on the fifth day a little milk, and, 
a day or two later, a diet of soft solids. In ten days he was 
up, and on the twelfth day he -was out of doors on the terrace, 
and while there had a slight chill. His temperature rose to 
102.5°, but his pulse did notrise correspondingly. From that 
time he had a varying elevation of temperature. An examina- 
tion of his blood showed no malarial organisms. A count of the 
corpuscles showed a moderate leucocytosis. He was examined very carefully from time to time, but no cause for the rise in 
temperature could at first be discovered. 
On October 8th, however, a slight dullness was detected 
over a small area at the base of the left chest posteriorly, 
with slight change in character of the breath sounds. This 
area increased slowly in extent until October 22, when it 
extended from the base upwards to the seventh rib, and 
laterally as far as the mid-axillary line. An aspirating needle 
was inserted and the presence of pus revealed, thus confirming 
our previous diagnosis of probable abscess in the .mediastinum. 
Two days later the patient was again etherized, a portion of 
the eighth rib excised, and a large pus cavity evacuated, which 
appeared to have no communication with the pleural cavity, 
but seemed to be behind it. 
The pleura was much thickened and the adjacent portion 
of the lung somewhat consolidated. The diaphragm formed 
the floor of the abscess. It was bounded in front by the 
thickened pleura and lung, behind and on the left by the 
chest-wall. On the right it extended beyond the median line 
and around the bodies of the vertebrae, thus apparently occu- 
pying the mediastinal space. A tube was inserted for drain- 
age. 
The pus had very little odor, was thick and hemorrhagic, 
with small yellowish points suspended in it. These were 
found to be composed of polynuclear leucocytes and shreds 
of tissue, with many compound granular cells and fatty 
detritus. No tubercle bacilli or other bacteria were present. 
Agar-agar and gelatine cultures were all sterile. 
After the evacuation of the pus his condition improved 
steadily, and on November 21, 1892, he left the Hospital well. 
I am indebted to Drs. Flexner and Bloodgood, of the Johns 
Hopkins Hospital, for the examination of the pus. 
The reasons which induced me to open the stomach at once 
were the very uncomfortable condition of the patient,-his 
inability to swallow, the fear of possible injury produced by 
the evident very sharp point of the stone, with the liability to 
subsequent inflammation, ulceration and perforation of import- 
ant adjacent structures, the failure of natural efforts to expel 
the stone, and our inability to dislodge it by instrumental aid. 
Its position excluded oesophagotomy. There was, therefore, 
no other course of treatment to pursue but the expectant. In 
view of the probable result, I did not feel justified in waiting. 
The operation was undertaken at once while the patient was in comparatively good, condition, rather than to wait until his 
strength was well-nigh exhausted. 
It is possible, indeed it seemed to me probable, that the 
peach-stone had become lodged in a diverticulum of the oeso- 
phagus, and this may explain why it was felt only on the left 
side. A slight stricture may have existed at that point, but 
if so it was not detected. The fact related in his history of 
several previous attacks of a similar nature would seem to 
bear out this hypothesis. 
Loreta, Bergman, Schattauer, Von Hacker, Winslow and 
others have dilated oesophageal strictures by passing bougies 
and divulsors through pre-existing gastric fistulae, or small 
openings made into the stomach for that purpose, but Dr. 
Maurice H. Richardson, of Boston, was the first, I believe, to 
do a gastrotomy for the removal of a foreign body lodged in 
the oesophagus. On August 5, 1886, he removed from the 
oesophagus of a man a plate containing four false teeth, and 
about the size of a silver half-dollar, which had been impacted 
there for 101 months. He was unable to dislodge the teeth by 
means of forceps through a small opening, so enlarged the 
opening sufficiently to admit his whole hand. With his 
fingers he then readily loosened the plate, and removed it 
without further difficulty. The patient made a prompt 
recovery. This case I was fortunate enough to see. 
Following closely upon this case, Dr. W. T. Bull, of New 
York, reported the removal, by gastrotomy, of a peach-stone 
lodged in the lower part of the oesophagus. He introduced a 
probang from above, passed the obstruction and brought the 
end out through the stomach wound, tied the string and 
sponge to it and then withdrew, bringing up the peach-stone 
out of the patient's mouth. This case made a good recovery. 
Richardson has collected and tabulated all reported cases of 
gastrotomy for the removal of foreign bodies from the stomach, 
33 in all; of these, 26 recovered, 4 died, and the result in 3 
cases is unknown. Of the 3 cases of gastrotomy for removal 
of a foreign body from the lower part of the oesophagus, two 
of which, Richardson's and the one just related, were compli- 
cated by peri-oesophageal abscess, all recovered. The operation 
may therefore be considered a fairly successful one. Under 
ordinary circumstances it should not be attended with any 
very great difficulty, but it may recpiire the exercise of some 
patience and perseverance before the removal of the foreign 
body is accomplished.