TWO CASES 
OP 
(ESOPHAGOTOMY 
FOB. THE 
REMOVAL OF FOREIGN BODIES: 
"WITH A 
HISTORY OF THE OPERATION. 
By DAVID W. CHEEYER, M.D. 
ASSISTANT PROFESSOR OF ANATOMY IN HARVARD UNIVERSITY } SURGEON TO THE CITY HOSPITAL $ 
SURGEON TO THE BOSTON DISPENSARY *, 
RECORDING SECRETARY OF THE MASSACHUSETTS MEDICAL SOCIETY. 
BOSTON: 
DAVID CLAPP & SON, PRINTERS. 
18 6 7. INTRODUCTORY REMARKS. 
The removal of foreign bodies from the oesophagus, by external 
incision, has been so little treated of in surgery, that it is dismissed, 
by most authors, with a bare allusion, or an obscure description, as 
of some remote possibility, which the surgeon should know of, but 
which he need have no expectation of being called on to undertake. 
And it has been so rarely performed, that, after diligent search, 
we have been able to find a record of only fifteen authentic cases; of 
which seven were in France, one in Italy, one in Belgium, one in India, 
and five in Great Britain. 
The ingenuity of the surgeon has been exhausted in devising means 
to withdraw foreign bodies through the natural passages; an intention 
which cannot be too highly commended, but which has often led to 
irritation, ulceration and perforation of the digestive tube, by the 
too zealous employment of instruments, as dangerous as the foreign 
bodies themselves. 
By reviewing the history of the operation, and by our own cases, 
we hope to show that, as in strangulated hernia, urinary extravasa- 
tion, or croup, so in oesophagotomy, the danger is in delay. That 
the risks of the operation depend on skill in its performance, and 
not on its sequences. That if done early, it can be done safely. 
And that it deserves its place among operations of necessity, and 
not of expediency, as one which can relieyp a fellow being from 
exquisite suffering, and from extreme peril. CESOPHAGOTOMY. 
CASE I. 
Mr. L ■, a young man of temperate habits, and strong, muscu- 
lar frame, an engineer by profession, while eating a dinner of chow- 
der, on the 9th of November, 1866, suddenly became conscious that 
he had a bone in his throat. Violent strangling and efforts at ejection 
came on, followed by vomiting. The fragment was not dislodged. 
A physician, having arrived, caused him to masticate and swallow 
some ship-bread, without moving the foreign body. His throat being 
violently congested, he was directed to go home, and dress it with 
cold water, and if trouble continued, to send for me. On the samo 
afternoon I was sent for, but was not at home, and word wras not left 
for me to visit him. Distress in the throat continued, and while 
repeatedly applying cold water, continued chills came on. He passed 
a bad night, swallowing only water. The next day, as bad as ever. 
He now, Nov. 10th, sent for me again, and I saw him between 2 
and 3 o’clock, P.M., a little more than twenty-four hours after the ac- 
cident. He was in much distress at each effort to swallow; his face 
was suffused; his eyes congested; the palate swollen, the uvula 
touching the tongue, and provoking attempts to swallow an over- 
secretion of mucus which collected in the fauces. There was no swell- 
ing of the tonsils, or tongue. The latter was coated; the pulse a 
little accelerated. Pains radiated up and down the neck from a 
point on a level with the cricoid cartilage, on the right side. He 
had slept none the past night. Having placed him opposite a good 
light, I explored the pharynx with my forefinger. I was able to 
reach over and behind the larynx, and searched the base of the 
fauces and the folds around the epiglottis, as well as the back of the 
pharynx. I felt nothing. He vomited a little mucus, and expressed 
himself relieved. He now swallowed a whole goblet of water, 
without much wincing. I then left him, with directions to rub the CESOPIIAGOTOMY. 
neck gently with a liniment containing one-third laudanum, and to 
wait and see whether the distress returned. We both of us had 
hopes that the foreign body had passed down. This was on Saturday 
afternoon. I heard no more from him until Monday morning, when 
I was sent for early, and found him worse. 
It seems that the distress, on swallowing, returned in two hours 
after I explored the fauces on Saturday, and had continued to increase. 
The two nights (Saturday and Sunday) were poor ones. He could 
sleep only a half hour at a time, by lying with his mouth open and 
allowing the saliva to dribble away. As soon as it accumulated, the 
effort to swallow woke him up. These naps were promoted by rub- 
bing in the laudanum, of which he had used large quantities. He 
had swallowed nothing but water and a very littled strained broth. 
He could not drink milk, and could distinguish the difficulty of swal- 
lowing between it and water. His efforts to swallow were attended 
with violent contortions. His suffering was evident and great. His 
aspect was worse everyway. His tongue and throat the same as on 
Saturday. His pulse 116. 
Having prepared a soft sponge, large enough to fill the oeso- 
phagus, and attached it to a long probang, I passed it down 
twice. The first time it was passed, he vomited; the second time, 
he fainted and declined another trial, which, indeed, I was not dis- 
posed to make. The sponge passed down almost to the sternum, 
and beyond the seat of pain, without meeting any obstruction. On 
withdrawing it the second time a single drop of fresh blood appeared 
on its left side, corresponding to the right side of the throat. No 
blood tinged the mucus expectorated, before or afterwards. He 
continued to refer the centre of pain to the right side of the cricoid 
cartilage. Tenderness on pressure was greater there than elsewhere, 
much greater than on the other side of the neck. Pain radiated 
down on the chest, upwards to the temple, and from the throat to the 
ear. It was almost impossible for him to swallow, and he would 
not attempt it unless urged to do so. I now gave him some morphia, 
directed his bowels to be cleared by a purgative enema, preparatory 
to using nutritive injections, and left him for a few hours. 
My diagnosis at this time was, that a small fragment of fish bone 
was imbedded in the wall of ihe (esophagus on the right side, oppo- 
site the cricoid cartilage, this being the line of junction of the 
pharynx and oesophagus. The reasons on which this opinion was 
based were: CESOPHAGOTOMY. 
7 
1st. The history of the case; it being now the third day since the 
accident, and the symptoms increasing in severity. 
2d. The morbid appearances in the fauces, of the palate, uvula 
and tongue, were not sufficient to account for the symptoms. 
3d. That the foreign body was small, because the fingers, lifting 
forward the larynx and trachea and embracing the oesophagus, could 
detect nothing externally, and the probang encountered no obstruction. 
4th. That it was situated opposite the cricoid cartilage on the 
right side, and was imbedded there:— 
Because this was the narrowest part of the oesophagus; 
Because this was the centre of pain and tenderness; 
Because the drop of blood on the sponge corresponded to this side. 
At 1.30, P.M., Dr. Buckingham saw him with me. Since I last 
saw him he had had a violent rigor, followed by heat and sweating. 
His pulse was 120, sharp and irritable; oedema of the right side 
of the neck had come on. His face was haggard; his eyes and skin 
much congested. He expressed the opinion that he could not endure 
his sufferings many nights and days longer. Dr. Buckingham wisely 
refrained from exploring the parts, in view of their cedematous con- 
dition, and the constitutional disturbance. He concurred with me in 
the opinion that oesophagotomy should be attempted, as the only safe 
course; and that the operation was imperatively demanded and 
could do no harm. 
1st. Because, if the diagnosis were correct, and the foreign body 
there, it was working through the walls of the oesophagus, and could 
be reasonably reached in no other way. 
2d. Because, if the diagnosis were incorreet, and the foreign body 
gone, the irritation it had excited was about to lead to abscess, wjiich 
might end in suffocation, and for which the incisions of oesophagotomy 
must be the ultimate treatment. 
The risks and chances having been detailed to the patient, he as- 
sented promptly to the operation. He was conveyed to the City 
Hospital, and having been kept under the influence of morphia, and 
stimulated by an alcoholic enema, the operation was begun at 7, P.M., 
with the very valuable assistance of Drs. Buckingham and Thaxter. (E80PHAG0T0MY. 
The patient had a short, thick-set neck, with powerful muscles, and 
the veins were congested and full. The neck having been extended 
and the face turned to the opposite side, an incision was begun oppo- 
site the top of the thyroid cartilage, midway between it and the 
sterno-mastoid, and carried down parallel to the muscle, three and a 
half inches, to the sternum. This divided the skin, superficial fascia 
and platysrffa. The edge of the sterno-mastoid was now sought for 
and dissected out. In completing this dissection just above the top 
of the sternum, the anterior jugular vein, a vessel of moderate size, 
was divided. This, which would have been of no importance other- 
wise, gave rise to two consecutive sucking sounds, as if two bubbles 
of air had been drawn into the vein. Dr. Buckingham promptly ap- 
plied his finger to the mouth of the vein, and no perceptible effect 
was produced in the heart’s action by this accident. This vessel, 
although it did not bleed, was subsequently tied, as a matter of pre- 
caution ; and this was the only ligature required during the operation. 
The carotid sheath was next sought for and exposed with the 
point of a director, and then drawn outwards with the sterno-mas- 
toid. Then the upper belly of the omo-hyoid muscle was denuded, 
and drawn outwards also. The edge of the sterno-hyoid next pre- 
sented itself, the thyroid gland, and the side of the cricoid cartilage. 
A slow dissection with the director and the handle of the knife, and 
with the finger, was now carried on through the cellular tissue, down 
between the oesophagus and the carotid sheath, which in the lower 
part of the incision ran in contact, side by side. The side of the 
oesophagus having been reached, the larynx and trachea were lifted 
and*tilted over, and the foreign body felt for, in vain. 
The next step was to stretch the oesophagus from the inside, so that 
its walls might be presented in a single layer to the finger. To do this 
the tube of a stomach pump was introduced into the oesophagus by the 
fauces. Considerable difficulty was experienced in passing the tube 
into the oesophagus, as it repeatedly brought up in the larynx and 
trachea. The swollen state of the soft palate threw the tube forward 
into the glottis, and the patient being profoundly mtherized, the epi- 
glottis did not exclude it, and he breathed through it in a rhythmical 
manner, and without lividity. After sundry vain attempts by myself 
and others, Dr. Thaxter succeeded in drawing forward the opening 
OPERATION. 9 
(ESOPHAGOTOMY. 
of the glottis, and in guiding the tube, over his finger, into the 
pharynx and oesophagus. No obstruction was met with in the latter, 
and the tube was pushed down to the sternum. 
A careful search with the finger now revealed a foreign body lying 
between it and the stomach tube. Opposite the cricoid cartilage, at the 
junction of the pharynx and oesophagus, on the right side, some sharp, 
small substance was pricking through the walls of the oesophagus, a 
little towards the vertebral or back side of the gullet. The depth of the 
wound, and the oozing of blood, made it impossible to see the foreign 
body, which was sought for, and ultimately withdrawn, by touch alone. 
The intervening portion of the wall of the oesophagus was pricked 
through with a director and dressing forceps, and, after several flat 
scales had been removed, the main portion of the bone was drawn 
out. It consisted of a rough, sharp-edged, but flattened, piece of the 
fin-bone of a fish, and was one-half an inch long, by one-fourth broad. 
No other pieces being detected the tube was withdrawn. The 
wound was left entirely open, as it was thought that it would be 
extremely difficult to remove stitches placed in the oesophagus, 
even if they did good, while the freest exit should be allowed the 
discharges. The wound of the gullet being a lacerated one, did not 
bleed. The patient was given an injection, subcutaneously, of one- 
fourth of a grain of morphia, and removed to bed. 
In reviewing the steps of an operation to reach the oesophagus by 
external incision, it appears, first of all, that this incision cannot 
well exceed three, to three and a half inches, in length. This is 
about the distance, in average necks, from the top of the thyroid 
cartilage to the sternum. If we cut above the thyroid cartilage we 
endanger the hypoglossal nerve and lingual artery, in a deep dissec- 
tion ; and, more important, the superior laryngeal nerve. The latter 
crosses the space between the hyoid bone and top of the thyroid 
cartilage to enter the larynx, and its section would destroy the sensi- 
bility of one vocal cord, and one-half of the glottis. Through a 
comparatively short incision, therefore, we are obliged to make a 
very deep dissection, down to the prevertebral muscles, and to draw 
various important structures out of harm’s way as we proceed. 
First, the carotid sheath, containing the artery, vein and pneumo- 
gastric nerve, which closer and closer towards the oeso- 
phagus as we descend the neck. Above and below are the superior 
and inferior thyroid arteries. On the inside, the thyroid gland. OESOPHAGOTOMY 
Below the finger, the sympathetic nerve. And, finally, running up 
between the oesophagus and trachea, to the back of the larynx, the 
inferior, or recurrent laryngeal nerve, the motor nerve of the larynx, 
whose section would paralyze one-half of the glottis; and the partial 
division of some filaments of which, in one case of oesophagotomy, 
led to a permanent alteration of the voice. This nerve lying upon 
the front of the oesophagus principally, is to be avoided by opening 
the gullet towards its posterior part. The oesophagus is easier found 
also on the left side of the neck, as it naturally inclines to that side. 
And the rule has been laid down that oesophagotomy should be done 
on the left side as the place of election, unless we are sure of cutting 
down on the foreign body on the right side. The deeper dissection 
being carried on chiefly with the director, it is possible to reach the 
oesophagus not only without injuring any nerves, except the unimportant 
superficial branches of the anterior cervical plexus, but also, as we 
shall show in the second case, without tying a vessel. 
For the following very minute of the subsequent history of 
■the case, I am indebted to my House-surgeon, Dr. J. B. Brewster, to 
whose devoted care the operation owes much of its success. 
The patient was removed to the steam-room. At 11, P.M., he is 
sleeping. Respiration 30, and not very noisy. Enema of beef-tea 
given. 
Nov. 13 5 4, A .M. Awake; voice is husky; says that swallowing 
is more painful than before the operation. Wound dressed with a 
wet compress. 
8, A.M. Pulse 120, full; tongue slightly coated, and easily pro- 
truded. Slight suppuration in wound; great thirst. To have his 
mouth moistened with a wet cloth, and his arms and wrists bathed 
freely with cold water, to relieve his thirst. Absolute diet; not to 
talk; not to swallow, and to allow the saliva to run from mouth. 
Room to be kept full of steam, both to relieve the larynx and to 
check the watery transudation from skin; beef-tea encmata, ter die; 
morphia, p. r. n. 
6, P.M. Can swallow a little easier; pulse 120; feels quite com- 
fortable, slept most of afternoon; at 8, P.M. to have beef-tea enema; 
at 9, morphia), gr. T3Eth, subcutaneously. • 
Nov. 14; 6, A.M. Slept well until 2, A.M. Feels more comfort- 
able, and thinks he could swallow water without pain, but is not (ESOPHAGOTOMY. 
11 
allowed to do so. Feels hungry, and has beef-tea § ij. per rectum, 
which immediately satisfies his desire for food. Morph, sulpli. 
gr. x\th, subcutaneously. 
9, A.M. Neck less swollen; suppuration in the wound. 
2, P.M. Purulent expectoration. 
6, P.M. Patient is much worse; no morphia since morning; ex- 
pectoration very troublesome; pulse 120, and more compressible. 
Ordered morphia and enemata. 
Nov. 15 ; 2, A.M. House-surgeon was called in haste by the nurse, 
because patient breathed badly. The difficulty was found to arise 
from a collection of mucus and purulent matter in the throat. It 
was dislodged by swallowing a little water. 
9, A.M. Pulse 108; swallowed a little milk and water without 
much pain; a part of it ran out through the wound. Third day since 
the operation. • 
Nov. 16; 9, A.M. 'Has had enemata,and morphia; a good night; 
not much expectoration. But little discharge from wound, which is 
clean and healthy. Ligature upon anterior jugular came away. 
Pulse 112, of good strength. Drank a little cream and water; most 
of it ran out of the wound. To drink nothing but water; continue 
enemata. 
6, P.M. Aphthous ulceration on lips and tongue; ordered borax 
and glycerine. Thirst continues; drinks much water, a part of 
which escapes through the wound. Talks more plainly. 
Nov. 17; 9, A.M. Slept well; pulse 88, and good; countenance 
improved; voice stronger; aphthae troublesome; wound clear and 
healthy. 
6, P.M. Tongue very sore; more suppuration in the wound. No 
morphia through day, but obliged to give it in the night. 
Nov. 18. Pulse 96; swallowing less painful; not so much thirst; 
more suppuration; several sloughs have been discharged from the 
wound. 
Nov. 19. Aphthae better; a slight diphtheritic exudation upon the 
gums. Slept all night without morphia. More large sloughs from 
wound. Two-thirds of the water taken passes into stomach. 
Nov. 20. A good night, without morphia. Profuse reddish dis- 
charge from wound. Pulse 96, compressible. Enemata continued. 
One week since operation. Drank cream § ij., and beef-tea § iij., 
and but little escaped from the wound. The effort of swallowing 12 
(ESOPHAGOTOMY. 
presses out quite a quantity of dark pus, and several sloughs; after 
swallowing food, felt a little sore. 
The steam was shut off. To inhale twice daily chlorate potassse, 
atomized. Increase frequency of enemata. To drink beef-tea, also. 
This P.M. had a healthy evacuation of the bowels. 
Nov. 21. To have milk § viii., 3 times a day; but little flows 
through the wound. The dryness and discomfort of throat relieved 
by the atomizer. 
Nov. 22. Pulse 72; mouth not so sore. Discharge from wound 
is of excellent character. During the night drank three tumblers of 
milk. 
Nov. 23. Hurts less and less to swallow. 
Nov. 24. Wound full of granulations, and healing at ends. No 
morphia for a week past. 
Nov. 25. Only a drop or two of milk flows through the wound; 
suppuration less. * 
Nov. 26. Sat up half an hour; two weeks since operation. No 
milk came out of the wound this morning. 
Nov. 27. Swallowing without pain. 
Nov. 28. Takes three quarts of milk daily, and four enemata of 
beef-tea. 
Nov. 29. Sits up half an hour, twice a day. 
Nov. 30. Granulations in wound exuberant; caustic applied. 
Dec. 1. Is troubled by a tickling in throat, which causes him to 
swallow constantly. Upon examination, the uvula was found elonga- 
ted, and the palate very pale in color. Touch uvula with a solution 
of arg. nitrat..grs. xxx. ad aquas § j. R. Ferri et potassae tart, 
grs. x. ter die, in milk. 
Dec. 2. When he drinks, hardly loses a drop. 
Dec. 4. Three weeks since operation. From this date the oesopha- 
geal fistula seemed definitely closed. Patient gaining flesh and strength. 
Dec. 6. Pain and stiffness in trapezius muscle. To omit beef-tea 
enemata; to have milk and chicken broth, ad libitum. 
Dec. 9. Sat up four hours; went to bed on account of pain in 
shoulder, which seems to be rheumatic. Morphia subcutaneously. 
Dec. 12. External opening of wound small, but Oxtending into a 
cavity two inches deep, whence pus can be pressed out; to be syringed 
out daily. 
Dec. 15. Pain in shoulders more severe. Ordered mustard sina- 
pism, and morphia. (ESOPHAGOTOMY. 
Dec. 19. Except for rheumatism, feels perfectly well. Fistula 
diminishing, and skin contracting; sits up all day; takes rice in his 
broth; oat-meal gruel, made thick, and soft toast; to have his shoul- 
ders covered with flannel and sulphur. 
Dec. 21. Rheumatism continues; urine examined, and found alka- 
line. Ordered, R. Yini colchici gtts. x.; Fid. magnesia? § ss., bis 
die. Eats beefsteak. 
Dec. 31. Well, so far as his oesophagus is concerned. Still 
troubled with the rheumatism, for which he remained in the hospital 
several weeks longer. 
CASE II. 
Ox Friday, the 16th of November, 1866, four days only after the 
preceding operation, there presented himself to me at the Surgical 
Room of the Boston Dispensary, Daniel B ■, a young man of 
average strength and health. He stated that while hastily eating 
some cabbage at supper time, on Wednesday, the 14th, he felt some 
foreign substance lodge in the fauces, which, on reflection, he con- 
cluded to be a fragment of bone, boiled off from the meat with which 
the cabbage had been cooked. He had made many efforts to dis- 
lodge it, in vain. His nights had been sleepless; pain and difficulty 
on swallowing were nearly as great as in the first case. His pulse 
was 120; tongue foul. The sensation of a foreign body, the tender- 
ness and so forth, were referred to about the level of the cricoid 
cartilage on the left side. The power of locating the exact spot 
where the foreign body might be, was not so clear as in the former 
case. The patient gave signs of severe suffering on trying to swallow. 
He had taken no food since the accident occurred. An inspection of 
the fauces revealed nothing of importance. 
A sponge probang was genftly passed down to the sternum. No 
obstruction was felt. No blood was brought up on the sponge. But 
the first expectoration following was slightly tinged with blood. 
He now, as in the first case, expressed himself relieved, and swal- 
lowed a glass of cold water, with but little effort. He was now 14 
(ESOPHAGOTOMY. 
directed a full opiate, and to drink some broth, if not too painful. 
In other respects to let the throat alone, and to report himself on the 
following day. 
The next morning he appeared, walking in a dejected, stooping 
attitude, the head being bent to the left, to relax and favor the muscles 
of that side. He declared himself much worse. The pain in swal- 
lowing had recurred in the evening previous. The use of the pro- 
bang had been followed by a severe chill. He had had neither drink 
nor food. His fauces were a little more swollen, on inspection; the 
uvula pendulous and flabby, and the tongue thickly coated. There 
was no swelling of the tonsils; efforts to swallow occasioned ex- 
quisite suffering. The mucus and saliva dribbled from his mouth, as 
he was unwilling to swallow them. A line extending from the spi- 
nous process of the cervical vertebras, to thfl* central angle of the 
thyroid cartilage, measured half an inch more on the left, than on the 
right side. There was greater tenderness, but it was more diffused. 
The focus of soreness was still referred to the vicinity of the cricoid 
cartilage. 
It was therefore supposed that a spicula of bone was imbedded in 
the wall of the oesophagus, near the cricoid cartilage; that it was 
still there, because of the persistence of thq symptoms; that it was 
small, because it offered no resistance to the sponge probang, filling 
the oesophagus; that it was imbedded, because it had not passed 
down, and because the expectoration was tinged with blood. 
The foreign body had now been in the throat three days, and 
neither food nor sleep had been obtained by the sufferer. His pulse 
was 120, sharp and irritable. He confessed to the habitual use of 
stimulants; and he had much less muscular power than the former 
patient. The imperative necessity of some measure for relief was 
now apparent to the patient, as well as to the surgeon; the former 
readily consented to an operation. He was accordingly sent (Nov. 
17th) to the City Hospital; put under the influence of morphia, 
given subcutaneously, and the bowels cleared by a purgative injec- 
tion. The operation was performed at 5, P.M., with the assistance 
of Hr. Thaxter, and in the presence ofHrs. Homans and Swan, of the 
Hospital staff, and of the house-officers and a few students. CESOPHAGOTOMY. 
OPERATION'. 
The incision was made upon the left side. It was three and a 
half inches long, reaching from opposite the top of the thyroid car- 
tilage, to the sternum; starting midway between the stcrno-mastoid 
and the larynx, it ran down parallel to the inner edge of that muscle. 
The skin and platysma having been divided,*the edge of the sterno- 
mastoid was laid bare. Next the upper belly of the omo-hyoid mus- 
cle was dissected out, and the lower boundary of the superior caro- 
tid triangle fairly exposed. The omo-hyoid was then drawn to the 
inside, or central line of the neck—the reverse of the first operation, 
where it was drawn outwards. This second manoeuvre afforded much 
more room than the other method. The carotid sheath was now 
plainly felt, and drawn outwards. Next, beneath the edge of the 
sterno-thyroid and -hyoid muscles, an unusually large thyroid gland 
bulged into view. The veins on its surface were dilated, and the 
gland seemed puffed out and full. By a gentle dissection with the 
director, the handle of the scalpel, and an occasional touch with the 
edge of the knife, this gland was lifted and turned over on its isthmus, 
without wounding either it, or its vessels. The inferior thyroid 
artery, especially, was enucleated from the cellular tissue, and pre- 
served intact. The wall of the carotid sheath was now seen in con- 
tact with the trachea. A separation was effected with the director; 
and the artery drawn outwards, the thyroid and trachea inwards, 
with blunt retractors. 
So little haemorrhage had taken place, that with a light reflected 
into the bottom of this deep wound, there could bo plainly seen, the 
silvery fascia and tendons of the prevertebral group of muscles, be- 
tween two distinct walls, formed on the outside by the carotid sheath, 
on the inside by the oesophagus. No foreign body was found. 
After some manipulation, as in the former case, the stomach tube 
was passed into the oesophagus by Dr. Thaxter, and its presence 
proved, both by its being felt behind the trachea, and by the gastric 
smell issuing from its open end. Contrary to our hopes, no foreign 
body could be discovered. 
I now decided to open the oesophagus, and explore within. A 
vertical incision was made upon the stomach tube, just below the 
cricoid cartilage, through the wall of the oesophagus, towards its pos- 
terior aspect. This wound having been dilated, the tube was with- (ESOPHAGOTOMY. 
drawn, and the forefinger passed into the oesophagus up to the meta- 
carpus. Searching first above, I reached as high as the top of the 
larynx and epiglottis, in the fauces, without finding anything. Next 
turning the finger downwards, I felt beneath the sternum, a long, 
slender, hard substance lying across the posterior wall of the oesopha- 
gus. Both ends were imbedded in the gullet, and the centre could 
not be lifted out. Passing down a director upon my finger I picked 
one end free, drew it outwards, and freeing the other end, I withdrew, 
instead of a bone, a common brass pin, an inch and a quarter long. 
It was blackened and corroded, and lay diagonally across the oeso- 
phagus, its head to the right side, just beneath the manubrium of the 
sternum. The head was entangled, and the point imbedded in the 
wall of the oesophagus. 
As in the former case, the wound was left open. Another subcu- 
taneous injection of morphia and an enema of beef-tea were adminis- 
tered, and the patient placed in a room freely permeated with steam. 
These precautions to keep up a warm moist atmosphere were 
taken because laryngitis, or spasm of the glottis, was feared. First, 
as a consequence of the handling and tilting of the trachea and 
larynx. Second, on account of the disturbance of the recurrent 
laryngeal nerve, which was not only liable to be stretched at the 
time, but to be pressed upon by subsequent effusion, when suppura- 
tion was being established. Our fears were realized, in each case, 
but only to a moderate degree. 
9, P.M. Feels nicely; can swallow easier than before the opera- 
tion ; no haemorrhage. Repeat morphia. 
Nov. 18. Has slept most of night; pulse 112. Complained of 
trouble in breathing, which was relieved by gargling the throat with 
water, and in this way removing some obstruction. Ordered abso- 
lute diet; no drink; beef-tea enemata, morphia, bathing, as in the 
former case. 
8, P.M. Smart reaction; skin hot; swallowing more painful; 
wound quiet. 
Nov. 19. Pulse 96; voice more clear; respiration easy; tongue 
and lips sore; considerable expectoration; sweats profusely. Order- 
ed chlorate potassse, atomized. 
Nov. 20. Pulse 84; coughs a little; swallowing not so painful as 
yesterday; suppuration established. 
6, P.M. Three days since operation. Complains that he feels (ESOPHAGOTOMY. 
hungry all the time; allowed to drink half a tumbler of milk. A good 
deal came out of the wound, but did not occasion pain; his hunger 
was appeased. 
Nov. 21. Breathing easy; voice more hoarse; drank a tumbler of 
milk, and lost one-fourth through the wound; wound looks sloughy. 
To have a glass of milk twice a day, and a half ounce of rum with 
each enema of beef-tea; morphia pro re nata. 
Nov. 22. Pulse 72; slept well; retains enemata. Not much dis- 
charge from the wound, which is filled with a large gray slough, and 
emits a bad odor. Can swallow easily. Took three glasses of milk 
and four enemata. A large part of the slough was removed in the 
.evening. 
Nov. 23. Pulse 72; slept well; swallows easily; wound cleaner 
and discharging; a slight cough. During the day drank seven tum- 
blers of milk, losing one-fourth of it. Feels very well. 
Nov. 24. One weeJc since operation. Pulse 84, and strong; wound 
throwing off sloughs. To be dressed with a weak solution of liq. 
sodas chlorinatae. 
Nov. 25. Drank ten glasses of milk; lost one-third. 
Nov. 26. Cough continues, otherwise doing well. To try tinct. 
hyoscyami with the chlorat. potass. 
Nov. 2 7. Throat feels better; cough less troublesome; wound 
discharges more healthy pus. Takes over three quarts Of milk daily, 
and loses less. 
Nov. 28. Looks bright and feels well; pulse 72 ; swallowing less 
painful; wound healthy. 
Dec. 1. Two weeks since operation. Wound looking well; but 
little pain on swallowing, and only a small amount escapes through 
the wound. 
Dec. 2. Wishes to omit enemata. R. Ferri et. potassm tart., 
grs. x., ter die, in his milk. 
Dec. 4. Feels that he gets enough food by the mouth; granula- 
tions of wound exuberant; sat up two hours to-day. 
Dec. 5. Asks to have enemata resumed. When he drinks with 
his head thrown back, but very little flows from the wound; when he 
bends the head forward, it comes out with a jet. 
Dec. 8. Wound closing rapidly; but little discharge from it; sits 
up four hours; consumes a large amount of milk. 
Dec. 11. Has been up all day; swallows without pain. 18 
OESOPHAGOTOMY. 
Dec. 13. When he drinks milk, not more than two or three drops 
escape through the wound. 
Dec. 15. Four weeks since the operation. None of the liquids hence- 
forward come out of the wound. Patient sits up all day; reads and 
amuses himself. Continue milk and iron. 
The wound was larger in the oesophagus in this case than in the 
first one. It closed in four, 'weeks, but the other in three weeks. The 
second patient, however, after four weeks, made a more uninterrupted 
recovery than the first one. 
Dec. 17. Wound has healed; to be strapped with adhesive 
plaster. May take soup for dinner; no pain on swallowing. 
Dec. 22. Eats solid food. 
Discharged well, Dec. 29th, six weeks since operation. 
Wc think two causes can he assigned as the reason why the second 
case recovered so much more promptly than the first. 
1st. Because constitutional irritation had not gone so far in the 
second. For in the first case swallowing was impossible; and that 
suppuration was imminent, was proved by pus appearing in the wound 
twelve hours after the operation. 
2d. Because in the second case the wound was cleaner cut, less 
bruised, and the passage down to the oesophagus more direct; the 
omo-hyoid was drawn toward the median line, while in the other case 
it was drawn outwardly and snapped over the sinus and closed it 
on being released. We should remember, however, that the cut into 
the oesophagus was twice as large in the second as in the first case; 
but it was not bruised. 
With regard to the treatment of the wound, all authors advise that 
it be left open, except Gross. In his Surgery he directs that the 
oesophagus be closed by silk sutures, cut off short, in the expectation 
that after union has taken place they will ulcerate through and drop 
into the oesophagus, as they do after injuries of the intestines. This 
opinion is based on no personal experience of oesophagotomy, and 
on no cited authorities. 
With respect to the treatment of the patient after operation, 
Boyer* is the first who advises absolute diet for a week, and the 
* Trgite des Maladies Chirurgicales, t. vii., p. 193, CESOPHAGOTOMY 
non-employment of elastic tubes to feed the patient through. Others, 
as Mr. Syme, recommend the early use of the stomach tube, or an 
elastic catheter passed through the nostrils to convey nourishment past 
the wound, without irritating it. In our cases we have followed 
Boyer’s plan, and it seems to us the most rational. The irritation 
of passing tubes, however gently, is considerable; and the risk of 
touching granulations and breaking up adhesions is very great. For 
a few days the diet, per orem, should be absolute, for if we allow 
drink even, at an earlier period, it will infiltrate among the long 
muscles of the neck, and lead to suppuration. After a few days a 
safe sinus is established by adhesions, and drink can be taken freely 
and without risk. Milk then forms the blandest, and the most com- 
prehensive article of food. 
Boyer, after describing the lateral operation, advises us not to 
operate unless there be a projection externally. 
With regard to nourishment, it is well known that life can be sup- 
ported a long while by nutritious enemata. Hennen, in his Military 
Surgery, gives the case of a man with a gun-shot wound of the 
throat, who was sustained for eighteen days with baths of milk, and 
with clysters. In our patients from two to three ounces of beef- 
extract were thrown up the rectum every six hours for many days, 
forming, at first, the sole nourishment. These were alternated with 
occasional enemata of soap and water to clear the bowel. Water 
was supplied the first few days by bathing the wrists, and flexures of 
the arm, and by wetting the lips. 
HISTORY. 
We now pass to the History of the operation, embracing the opin- 
ions and experience of high surgical authorities; an analysis of the 
different varieties of foreign bodies by M. Hevin; of the memoir on 
cesophagotomy of Guattani, the earliest systematic writer on the 
operation; a detailed account of the operations of Begin, Martini, 
Delaroeherie, Arnott, Cock and Demarquay; an analysis of cases CESOPHAGOTOMY. 
and the results of experiments on the lower animals by M. le Docteur 
Crequy; and finally, such brief general rules as we can deduce from 
these authorities for our guidance. 
We will examine first the opinions of Fergusson, Nelaton, Syme and 
Yelpeau. Sir William Fergusson, in a very brief allusion to the 
operation in his Surgery, cautions his readers, that however simple 
cesophagotomy may appear on the dead subject, it is attended with 
much danger on the living, and we should proceed with great caution. 
He mentions three cases of foreign bodies in the oesophagus. 
I. An epileptic swallowed his false teeth. Four years and a half 
afterwards he died from bronchitis. The teeth were found at the 
lower part of the pharynx. The attending surgeon had not operated, 
for fear of causing fatal laceration. 
II. The metallic setting of some false teeth were swallowed, and 
caused death by perforation of the arch of the aorta. 
III. The only case Sir William saw himself. A little girl swal- 
lowed a small padlock. It could not be felt or seen; she was not 
believed in her statement. After suffering some days, coughing and 
vomiting came on, the foreign body was thrown up into sight, and 
withdrawn through the mouth. 
Certainly a moral might be drawn here, rather in favor of the 
operation than against it. 
Nelaton. u Elemens de Pathologie Chirurgicale.” 
(Esojikagotomy. “ We must not conceal from ourselves the dangers 
inherent in this operation, which is, certainly, one of the gravest and 
most difficult in surgery—we must, therefore, advise it only in cases 
where other means have failed. 
“ But in view of the accidents which arise from the impaction of a 
foreign body in the oesophagus, such as asphyxia and death; or, con- 
secutively, from its continued presence, such as perforation of the 
oesophagus, of the aorta, of the carotid, et cetera, the surgeon ought 
not to remain inactive, and a passive spectator of consequences which, 
in a great number of cases, lead to the death of the patient; and 
which, in other cases, cause him to undergo dangers, often greater 
than those which are peculiar to the operation itself.” 
“ Should we operate only when the foreign body can be felt from 
the outside ? Although this is a favorable condition, we do not think 
the absence of it a contra-indication to the operation. We think, 
then, that the operation should be performed, when the foreign body (ESOPHAGOTOMY. 
cannot be withdrawn through the mouth, and when it cannot, or 
ought not to, be pushed down into the stomach.” 
According to M. Begin, when a sharp foreign body enters the 
oesophagus, the muscular fibres, irritated into excessive action by 
the pricking of the mucous coat, contract spasmodically above and 
below it, and hold it inclosed in a sort of sac, whence the efforts of 
neither swallowing nor vomiting extricate it. 
Nelaton advises to operate on the median line. 
1st. By making the incision for tracheotomy. 
2d. Separating the sterno-hyoid muscles. 
3d. Passing a double ligature on either side of the thyroid gland. 
4th. Tying, and then dividing the isthmus of the thyroid gland. 
5th. Turning over the left lobe of the thyroid gland, and finding 
the oesophagus beneath and to the left of the trachea. 
The objection to the median operation would seem to be that we 
fall upon the front of the oesophagus, where the recurrent laryngeal 
nerve runs, between the gullet and the trachea, and thus endanger 
the nerve or its filaments more than by the lateral operation, in 
which we attack the oesophagus at the side and behind. And the 
median cannot be more free from haemorrhage than*the lateral ope- 
ration, widen can be conducted (vide Case II.) without dividing any 
vessels large enough to require ligature. 
M. Nelaton continues, “Asa resume of diagnosis; the history of 
the case, an examination outside the neck, inspection of the fauces, 
and catheterism tof the oesophagus, suffice, usually, to make it clear. 
“ The prognosis is easily deduced from the facts previously stated. 
Speaking generally, it may be considered a grave accident when a 
foreign body retains its position in the oesophagus; for operations for 
its extraction are far from being innocent, and if these attempts fail, 
the retention of the foreign body subjects the patient to most serious 
risks.” 
These risks are primary, and secondary. 
Primary, suffocation and haemorrhage. 
Secondary, inflammation, suppuration, perforation, caries, et cetera. 
“ If the foreign body remain, and lead to suppuration, it may be 
vomited up, but most frequently retains its position where it was 
arrested, and the suppuration becomes so abundant, with emaciation, 
fever and purulent expectoration, as to give the appearances of 
phthisis. It may happen that the abscess formed in the walls of the OESOPHAGOTOMY. 
oesophagus, after perforating them, produces purulent deposits in the 
neighboring parts, which carry with them the foreign body, and may 
cause deep-seated disorganization in the neighboring tissues. Some 
of these purulent collections open and discharge at the side of the 
neck; others at more distant spots, and still others penetrate the 
chest, and discharge pus and alimentary matters into the pleural 
cavity.” 
It will be remembered as an anatomical point, that the superior 
thoracic fascia arches over the oesophagus at the upper border of the 
thorax, and leaves a free passage for pus to gravitate behind the 
oesophagus into the posterior mediastinum. 
“Amongthe secondary dangers,” continues M. Nelaton, “there are 
some, which though less frequent than inflammation, are none the less 
to be feared; such are perforations of blood-vessels or the trachea, 
in consequence of adhesions established between these organs and 
the oesophagus. Thus the aorta, the carotid, the right subclavian, 
the vena cava, the vena azygos, have all been perforated by foreign 
bodies through the oesophagus, with fatal haemorrhage as the result. 
Dupuytren had a patient who coughed up his food, and died in con- 
sequence of the false passage. Andral reports a similaj^case.” 
“ Finally, an organic disease of the vertebrae may be set up by the 
presence of a foreign body in the oesophagus. A child of twenty-two 
months swallowed a little flat, triangular bone. Two months later 
it died, of profound marasmus, and the posterior wall of the pharynx 
wras found pierced, and caries of the vertebrae opposite. Analogous 
facts have been observed in connection with retro-pharyngeal abscess.” 
“ It may happen,” says M. Begin, (op. cit.) “that the foreign body 
cannot be withdrawn by the mouth, and that its presence does not 
immediately threaten life. Some advise, then, to wait; the foreign 
body may be expelled by suppuration, may soften, decay, or fall into 
the stomach. This plan of temporizing offers real dangers, and an 
experience of twenty unfortunate results, warrants us in prohibiting it.” 
Mr. Syme says, “ The object of the operation of oesophagotomy is 
to make an opening into the oesophagus to extract a foreign body 
that cannot be removed otherwise; but such a circumstance happens 
so rarely, that there are few instances of a surgeon being called upon 
to perform the operation in the whole course of his practice. Upon 
two occasions I have cut into the throat for the removal of a piece 
of bone, which had passed through the coats of the oesophagus and 
caused deep-seated suppuration.” (ESOPHAGOTOMY. 
11 In the first case the bone had been in six days, and I found the 
patient with a very anxious expression of countenance, and slight 
fulness of the neck, which was not discolored, but tender on pressure. 
She had, also, fits of dyspnoea. Not being able to reach the foreign 
body, and fearing it would cause suppuration, if it had not already 
done so, I decided to operate by oesophagotomy. In the second case 
the bone had been in the throat sixteen days; the voice was husky 
and breathing difficult; a deep-seated abscess was opened, and the 
foreign body found and removed.” 
• “ In a third case, a copper coin had been impacted in the oesopha- 
gus, more than two months, opposite the sternum. All these cases 
recovered.” 
“ Cutting through the coats of a sound oesophagus, for the removal 
of a foreign body, is an operation that can hardly ever be required, 
since, before it is warranted, there will almost necessarily have 
elapsed such a period of time, as must allow ulceration and suppura- 
tion to be induced by the intruder. Any hard substance so situated 
should be regarded with much apprehension, since, if urged in the 
wrong direction by probangs, it must expose the patient to extreme 
danger, from the formation of matter behind the larynx, or ulceration 
into the air-passages, or vessels.” 
Now it is precisely from these perils, that we claim that an early 
operation saves the patient. 
Velpeau says of oesophagotomy, “ Though this operation may not 
have been formally proposed by any person before Verduc and 
Guattani, we cannot avoid seeing that the idea of it is found in more 
ancient authors. The incision into an abscess containing a small 
bone, which had escaped from the oesophagus, was done by Arculanus 
and Plater; fish bones were extracted in the same way, by Honlier 
and Glandorp; But wounds of the oesophagus had been considered 
so dangerous that practitioners hesitated to operate. 
“ (Esophagotomy was done for the first time by Goursault, in 1738 : 
and next by Roland, in 1819. Since this operation has taken rank 
among the systematized ones of surgery, it has received various im- 
provements. But, according to B. Bell, there can be no settled plan 
for the incisions, as that depends upon the position of the foreign 
body. Bell knew that, with precaution, the recurrent nerve could be 
avoided. As to the after treatment, a gum elastic tube must be in- 
troduced through the nares or mouth, beyond the seat of operation, (ESOPHAGOTOMY. 
and not be withdrawn for three or four days, in order that aliments 
and drinks may not interfere with the agglutination of the wound of 
the oesophagus, or escape into the tissues of the infra-hyoid region.” 
He adds, “ If cesoph'agotomy, performed on the thirtieth day by 
Mr. Arnott, proved fatal, yet two patients operated on at the Val de 
Grace, by M. Begin, one on the eleventh, the other on the sixth day, 
were perfectly restored.” 
The verdict of M. Velpeau would therefore seem to be against 
delay in operating. 
IIE V I N. 
Precis d' Observations sur les Corps Strangers arretes dans V (Esophage.* 
In a very exhaustive article on the above subject the author 
divides foreign bodies into the following classes. 
1st. Those which can be pushed down into the stomach. 
2d. Those which ought to be withdrawn by the mouth. 
3d. Those which should be withdrawn, but which must be pushed 
down. 
4th. Those which can neither be withdrawn, nor pass through the 
natural passages. 
5th. Those which ought to be removed by incision. 
In the first class are pieces of money, morsels of food, and bodies, 
generally, without great bulk or inequalities. The chief danger from 
this class is suffocation. 
In the second class, are needles, pins, fragments of glass, blades 
of iron, nuts, and generally angular and hard bodies. The dangers 
from this class are abscess and perforation. 
In the third class, are those of the second which have passed be- 
yond our reach, and for which no other natural exit remains but by 
pushing them down. And although the latter alternative is full of 
risks, it should be taken rather than to employ reiterated attempts 
to remove them by the mouth; such repeated efforts at withdrawal 
augment the danger. 
Fabricius Hildanus relates the case of a young man who swallowed 
a small bone, and tried in vain to reject it by vomiting. Fabricius 
endeavored to touch the foreign body, first with a catheter, then with 
* Memoirs de l’Academie Royale de Chirurgie, tome i., 1819. (ESOPHAGOTOMY. 
a sponge, but could recognize only a sort of strictured portion of the 
oesophagus, and the seat of a dull pain. 
Judging that renewed attempts would only irritate the parts and 
occasion greater danger, he prescribed remedies to allay the inflam- 
mation. But the young man being impatient addressed himself to a 
village surgeon, who, by the introduction of various instruments into 
the oesophagus, irritated it to such a degree, that swallowing became 
impossible, and respiration impeded from the swelling and tension 
which ensued. Fabricius being recalled, employed in vain remedies 
to relieve him. At the autopsy the pharynx and oesophagus were 
found sphacelated, and the lungs inflamed, but the bone could not 
be found. 
The bones most liable to become engaged in the oesophagus are 
the sharp spines of the fish’s vertebra;. M. Hevin gives many in- 
stances, too long to quote here—and included in the fourth class. 
The last class includes cases of tracheotomy, cesophagotomy, and 
gastrotomy. 
GU ATT ANI. 
The earliest distinct account of the operation is an Essay on 
CEsophogatomy, by M. Guattani, in the Memoirs of the Royal Acad- 
emy of Surgery, Yol. 3, 1819. This author gives the result of nu- 
merous experimental operations on animals, describes at length, and 
insists upon the operation in the human being, and narrates the fol- 
lowing melancholy case. 
“ The patient, a man forty years of age, threw up into the air a 
boiled chestnut, and catching it in his mouth, it became arrested in 
his oesophagus. He complained of being unable to swallow, and was 
sent to the Hospital of Saint-Esprit, in Rome, of which I was in charge. 
Having examined and questioned the patient, the fact was doubted, 
both because he was intoxicated, and because he breathed and spoke 
without difficulty; and also, because he had vomited. Moreover, 
there was no tumor visible from without; yet, since he felt pain on 
the left side when the larynx was pressed, we suspected that the 
chestnut might be engaged in the oesophagus. The usual remedies 
were tried. The bougie was used with difficulty, because the lower 
jaw was in convulsive action, and the finger could hardly be intro- 
duced. The countenance was congested, the tongue moist, the pulse 
frequent, he complained of great inward heat, and showed signs of 26 
CESOPHAGOTOMY. 
delirium. Since he could not swallow, nutritious enemata were given; 
he desired nothing but cold water and ice. The sixth day, notwith- 
standing frequent bleedings, he had nose-bleed. The eighth day his 
respiration began to be impeded; fever continued, with a feeble 
pulse; he coughed continually, and the expectoration was purulent. 
The tenth day he was so prostrated, that he was thought to be near 
his end, yet he swallowed a little wine and broth. A peculiar noise 
was heard when he swallowed. The fifteenth day he had renewed 
epistaxis. The nineteenth day, he died.” 
u The autopsy revealed an adhesion of the oesophagus to the larynx 
and trachea, with a sphacelated perforation, between the two tubes; 
an abscess, containing the chestnut, enclosed in a sort of pouch of 
the oesophagus, and situated just below and to the left of the cricoid 
cartilage. The abscess pressed on the trachea, and burst as soon as 
it was touched.” 
u It is assuredly in such a case,” continues M. Guattani, u that an 
operation is absolutely indicated. Yerduc well said that it could be 
hazarded; he acknowledges that the operation is difficult, but he 
adds, 1 it is better to undertake it than to see the patient die.’ I am 
entirely of his opinion; the anatomical structure of the parts to be 
operated on assures us that cesophagotomy is practicable.” 
M. Guattani then goes on to describe the inode of operating, pre- 
ferring the central incision, as in tracheotomy, between the sterno- 
hyoid muscles, and thence down by the side of the trachea to the 
oesophagus. He advises the stopping of venous haemorrhage by pres- 
sure, and instructs how to avoid the recurrent laryngeal nerve. He 
disengages and lifts over the thyroid gland. He urges an early ope- 
ration, if we operate. He gives very little nourishment by the mouth 
at first, but mostly by the rectum. 
Here follow three experiments. 
1st. “ The 9 th of March, 1747, I did cesophagotomy on a dog. I 
united the lips of the wound by two sutures. I then applied com- 
presses and uniting bandages. The next day, I made the dog swral- 
low some milk by force; on the fourth day he began to eat soup. 
In the evening I removed the dressing; the cicatrix was well formed, 
excepting a little suppuration in the sutures; there was a species of 
tumor as large as a pigeon’s egg. On pressing it, nothing escaped. 
The dog being entirely well after a week, I thought best to kill and 
examine him. I found that the cicatrix of the wound of the oesopha- 
gus was formed by adhesions to the neighboring parts, as happens^ (ESOPHAGOTOMY. 
generally in the intestines. By means of these adhesions a little 
pouch had formed, in which liquid was found. I suspected that this 
defect had been caused by the food, which I had forced the dog to 
swallow too soon.” 
2d. “The 15th of April, 1747, I operated on another dog. I ap- 
proximated exactly the lips of the wound, and applied on either side 
graduated compresses, and the uniting bandage. No food was forced 
upon him; but the day after the operation he ate some soup, set be- 
fore him. He was entirely well in nine days. I dissected the dog 
to examine the cicatrix of the cut in the oesophagus, which had been 
made obliquely; it was perfectly united, and without any adhesion to 
the neighboring parts.” 
3d. “ At the Hospital of La ChariU, in Paris, in presence of M. 
Faget, Surgeon in Chief, I operated on a human subject, which was 
cedematous, and which had the thyroid gland so swollen that it cov- 
ered the oesophagus. Notwithstanding all these obstacles, which 
seemed to be the only ones which could be found in this operation, 
M. Faget saw that it was easy to open the oesophagus, without 
danger.” 
Richerand says, “ However exact may be the anatomical knowledge 
of the operation, the risks are too great to render it practicable.” 
Delpech says, “ A foreign body producing alarming inflammation 
in the oesophagus, ought to be extracted by an operation. Experi- 
ence has sufficiently proved the possibility, and the little danger of 
such an operation.” 
We should remember, when considering the rapid closure of the 
oesophageal wounds just recorded, that they were made on the lower 
animals, and that their gullets had not been irritated by foreign 
bodies. 
We adduce the following as a typical case of a small foreign body 
impacted in the walls of the gullet, and of the usual termination of 
such a case, if the fragment remains. 
Case of non-removal of foreign body, in oesophagus, followed by 
death; by Thos. Cock, M.D., 1809.* 
“ Mrs. IF, set. 73, eating without teeth, swallowed a piece of meat 
without chewing, and complained that it was lodged in her throat. 
Various domestic attempts to remove it failed; a physician gave 
emetics, without effect. She could still swallow liquids. A surgeon 
* Eye’s Cases in Surgery. 28 
(ESOPHAGOTOMY. 
next introduced a probang, with much pain, repeatedly, but without 
relief. The surgeon’s fingers failed to reach the obstruction. The 
probang passed to the stomach. She could now swallow no fluids. 
She continued in this situation thirteen days, without nourishment, and 
in great suffering. She still insisted that something was lodged in 
her throat. Dr. Cock saw her the day she died, and proposed to 
operate, but it proved to be too late. 
“ The autopsy revealed a large abscess communicating with the 
(esophagus, and containing a fragment of jagged bone, an inch and a 
half long.” 
Thus proving the entire inadequacy of all means taken to remove 
it; and that early opening the cesophagus from without, might have 
afforded relief. 
Also the following case. Retro-pliaryngeal abscess, mistaken for 
oedema of the glottis; laryngotomy; death.* 
“ The patient, a man of forty years and intemperate habits, was 
admitted to the Hospital, Sept. 27,1837, under the care of M. Ballot 
(Yoyez Archives Generales). The pharynx was red and dry; deglu- 
tition difficult, and he was unable to speak aloud. He complained 
of a foreign body in the throat. The finger felt a tense, elastic 
swelling, on a level with the larynx. He was bled 18 ounces, and 
treated autiphlogistically. Next day, bled Again 18 ounces; thirty 
leeches to throat, and blister to nape of neck. 
“ Laryngotomy, Oct. 8th, to prevent suffocation. During the night 
the tube became displaced, and he died asphyxiated. 
“Autopsy. No tumefaction of glottis, but its orifice closed by a 
fluctuating swelling, the size of a hazel-nut, which projected over it. 
This was a collection of healthy pus between the vertebral column 
and the oesophagus. 
“ In any similar case, tracheotomy should be preferred to laryn- 
gotomy.” 
ARNOTT. 
Mr. Arnott, at the date at which he writes, namely, 1833, can find 
no record of the operation having been done in England.! 
The following extracts comprise the essential parts of his case. 
* American Journ. Med. Sciences. April, 1842. 
f Case of (Esophagotomy, with Remarks, by James M. Arnott, Surgeon to the Middlesex 
Hospital. Medico-Chirurgical Transactions, Yol. 18. CESOPHAGOTOMY. 
“December 22d, 1833,1 was called to see a boy, two years and a 
quarter old, who had swallowed, six days previously, a portion of 
mutt&i bone. Nothing but fluids had been swallowed since. On 
introducing the finger, to its utmost extent, deep below the glottis, on 
the right side, a' piece of bone could just be touched, projecting up- 
wards. Forceps, hooks, emetics, and so forth, were tried in vain. 
There were no urgent symptoms, and some hope was entertained 
that the bone might become loosened and be expelled, or swallowed. 
For a fortnight there was no suffering, but emaciation. On the 16th 
of January he was again brought to the Hospital, and I again felt, 
and tried to extract the bone. After consultation, and some delays 
due to the parents, I determined to operate, particularly as the child’s 
breathing was becoming occasionally oppressed. The bone formed 
no prominence, and could not be felt externally. As it was fixed at 
the junction of the pharynx and oesophagus, I decided to cut behind 
the cricoid cartilage. The operation was done on the 21st of Janu- 
ary, four weeks after the accident. The incision was made midway 
between the sterno-mastoid and trachea; the deeper dissection made 
by the handle of the scalpel, and the oesophagus was incised on a 
male catheter introduced by the mouth. 
“ The spinous process of one of the lower dorsal vertebrae of a 
sheep was withdrawn. The child bore the operation well. It was 
fed through an elastic catheter. The breathing became more labor- 
ed, and it died fifty-six hours after the operation. 
“ On examination of the body, there were two points of superficial 
ulceration, or rather abrasion, on opposite sides of the oesophagus. 
There was no suppuration between the pharynx and oesophagus, and 
cervical vertebrae. The larynx was normal; the lower part of the 
trachea and bronchi were inflamed; the right lung was hepatized; 
the left lung less so.” 
Mr. Arnott thus sums up his opinion of the operation. 
“ The occasional necessity for the of cesophagotomy has 
been recognized by most systematic writers on surgery, and they have 
adduced certain circumstances as conditions justifying its perform- 
ance. They have stated that when a foreign body cannot be extract- 
ed, or conveyed into the stomach—when it impedes deglutition, and 
by pressure on the trachea threatens suffocation—if it projects exter- 
nally, the operation of cesophagotomy ought to be performed. Now 
in this case which has been related, deglutition was not totally inter- 
rupted ; there was no apprehension of suffocation from pressure on 30 
OESOPHAGOTOMY. 
the trachea; the body did not project externally, and yet the opera- 
tion was requisite. 
“ That extraneous substances have occasionally remained forborne 
time in the oesophagus, as in other mucous canals, the trachea, bron- 
chi and urethra, without producing threatening symptoms, or imme- 
diate injury, and have afterwards been expelled, or made their way 
out, is well known; but experience has shown that fatal consequences, 
from ulceration of the larynx, trachea, and carotid artery—all of 
which have taken place—may likewise ensue. The issue of the 
present case proves that an additional sequence is to be feared in 
the form of pneumonia. 
“ The rule of practice, then, ought to be, when a solid substance, 
though only of moderate size and irregular shape, has become fixed 
at the commencement of the oesophagus, or low in the pharynx, and 
has resisted a fair trial for its extraction or displacement, that its 
removal should at once be effected by incision, although no urgent 
symptoms may be present. 
“ I insist the more upon this point, because I have reason to be- 
lieve that the operation has been in several instances omitted, when 
it ought to have been performed, chiefly from its supposed danger 
and difficulty, but also from a reliance upon the powers of nature. 
I have particularized the low situation of the substance, as a reason 
against unnecessary delay, because great difficulty is experienced in 
seizing it when so placed, and the attempts will, I believe, usually fail. 
“ By most writers oesophagotomy has been represented as only 
warranted when the foreign body projects externally, which they 
seem to consider requisite as a clear indication of its presence, and as 
a guide for the division of the soft parts. This projection may facili- 
tate the operation, but is not essential to its safe performance. As 
long as we are certain of the presence of the extraneous substance, 
the operation may and ought to be undertaken, even though it not 
only does not project, but cjftnot be felt externally.” 
COCK. 
In connection with the Records of a Case of Pharyngotomy by 
Mr. Edward Cock,* we find the following remarks: “ The operation 
appears to have been one of great rarity, and I can find but very few 
cases recorded in which the pharynx and oesophagus have been open- 
* Guy’s Hospital Reports. Third Series, vol. iv., 1858. CESOPHAGOTOMY. 
ed for the purpose of extracting a foreign body. A vast number of 
cases are on record of foreign bodies retained in the gullet. In some 
instances they have been extracted through the mouth, in others they 
have been pushed into the stomach; or the means employed having 
failed to produce either of these solutions of the difficulty, they have 
been left until some favorable process or fortunate effort of nature 
has got rid of the mischief; or else, as has frequently occurred, the 
patient has perished either from the retention of the body in the 
gullett, or from the violence which had been used to effect its dis- 
lodgment. 
“ Directions for exposing and opening the gullet may be found in 
several books of operative surgery; but, generally speaking, they are 
vague and speculative in their character, and evidently not founded 
on the results of practical experience. 
“In the year 1832, M. Begin had the satisfaction of performing the 
operation of cesophagotomy in two cases, with perfect success. A 
soldier had swallowed a beef-bone, which stuck in the oesophagus, at 
the lower part of the neck. Various attempts were made to dislodge 
it without success, and on the twelfth day after the accident, the ope- 
ration was performed. Much difficulty was experienced, but the 
bone was eventually extracted, and the patient speedily recovered. 
In the second case, M. Begin removed from the lower part of the 
cervical portion of the oesophagus a large fragment of bone swallow- 
ed eight days previously. The patient- recovered. 
“ In 1845, Dr. Martini incised the neck for the purpose of extract- 
ing a portion of bone, which had been swallowed four days previously. 
The foreign body could be felt from the exterior projecting above 
the clavicle, and the incision was made on that spot. It would seem, 
however, that the patient anticipated the intentions of the surgeon, 
and swallowed the bone before it could be seized and extracted 
Death from collapse took place two days after. The pharynx was found 
in a gangrenous condition, and the stomach and duodenum were in- 
flamed. The bone had passed into the rectum. There can, I think, 
be no doubt, that in this case the fatal result was brought about, not 
by the operation, but by the severe and somewhat extraordinary 
means which were previously used to dislodge the bone. When we 
read that the man was repeatedly bled, that sixty separate attempts 
at dislodgment were made with levers and forceps, that enemata of 
belladona were employed, that, finally, tartar emetic was injected into 
the veins, followed up by clysters of vinegar and opium to counteract 32 
(ESOPHAGOTOMY. 
its effects; moreover that during this ordeal the patient was unable 
to swallow even a drop of water, it is not surprising that he finally 
succumbed. 
“In 1845, also, M. Delarocherie, Professor of Clinical Surgery at 
Liege, removed a large portion of bone from the gullet of a man by 
cesophagotomy. The operation was performed the eighth day after 
the accident, and not until the patient’s life had been nearly compro- 
mised by the repeated and strenuous efforts made to dislodge the 
foreign body, giving rise to profuse bleeding and severe injury to the 
gullet, which seems to have become ulcerated through its walls pre- 
vious to the operation. The wound sloughed; but the patient had 
recovered by the twenty-sixth day.” 
Mr. Cock’s case.—“ Mr. T. G , having been in the habit of 
wearing a false central incisor tooth, fixed in a gold plate, which ex- 
tended some distance on either side, while asleep, January 17, 1856, 
it became detached, and he swallowed it. There could be no doubt 
that the foreign body had lodged in the cervical portion of the gullet, 
.but its exact situation was not clearly indicated. The irritation, 
pain and tenderness were referred to the top of the oesophagus, just 
below the larynx; but no projection could be detected outside. The 
patient swallowed fluids with great difficulty and in small quantities. 
The breathing was not impeded, but he had an irritating laryngeal 
cough. A bougie passed down found a total obstruction about the 
lower edge of the larynx. A pair of forceps detected the plate, but 
it could not be grasped, or moved. 
“ The next day it appeared very doubtful whether any fluid, which 
he took into his mouth, went into the oesophagus. Attempts were 
made with several instruments to grasp the plate, but they proved 
abortive. A number five flexible catheter was passed down beyond 
the obstruction, and through this an emetic was conveyed into the 
stomach. It failed to excite the slightest nausea. A mode of ad- 
ministering nourishment had, however, been obtained, and it was de- 
cided to wait a little longer. On the 19th, another fruitless attempt 
was made to dislodge the foreign body. He could not swallow a 
drop. On the 21st, some operation was imperative. (Esophagotomy 
was performed on this, the fourth day since the accident. The ope- 
ration was the lateral one. The omo-hyoid muscle was divided. 
Several arteries were tied. The foreign body was found behind the 
cricoid cartilage, and extracted. CESOPHAGOTOMY. 
“ The patient was fed through a catheter, and afterwards through 
a stomach-tube, and not allowed to swallow. At the end of three 
weeks, he swallowed; at the end of four weeks, the wound was closed.” 
It will be noticed that this period was about the same as in our 
two cases, where no tubes were employed, and the patients allowed 
to swallow freely after three or four days, the liquids passing con- 
stantly through the wound. 
“ The operation, however, had produced a very decided alteration 
in the voice, which had previously been clear and strong—when he 
left the hospital he spoke in a hoarse whisper. Indeed, there was 
an almost entire loss of those tones which appear to depend on the 
tension of the vocal chords, and as there was no reason to suppose 
that the mechanism of the larynx had suffered from the temporary 
lodgment of the foreign body, it seems fair to infer that the filaments 
of the recurrent laryngeal nerve, which supply the arytsenoid muscles, 
had been partially or wholly divided in the operation. 
“ Two years later, the patient was well, and the voice strong, but 
it had undergone a decided transformation. Formerly tenor, it was 
now bass. 
“ Much valuable instruction may be gained from the monographs 
of Begin and Arnott, whose decisive views and opinions on the sub- 
ject, founded on practical experience, may well supersede the more 
timid and vacillating policy advocated in many books of surgery. 
CEsophagotomy has been too rarely performed to allow us to speak 
with absolute certainty as to the dangers which may be incident to 
it as an operation, or its positive success as a remedial measure. 
There can, however, be no doubt that the fatal result in the two cases 
out of seven recorded, depended, not on the operation, but in the one 
on the delay and the presence of severe pulmonary mischief, and in 
the other on the unmerciful palliative treatment which preceded the 
use of the knife. It is somewhat singular, that in all the successful 
cases the precise locality of the foreign body was neither marked 
by any external prominence, nor indicated by any accurate reference 
of pain to one particular spot. Indeed we can hardly expect that 
either of these conditions should ever occur, although their .presence 
has been strongly insisted upon as necessary guides in the perform- 
ance of the operation, and, indeed, as a sine qua non as to the pro- 
priety of undertaking it. 
“ However slender our experience may be, the feasibility of the 
operation is established by the facts, that it is quite possible to make CESOPHAGOTOMY. 
a long deep incision along the side of the neck, and to continue the 
dissection down to the bodies of the vertebrae, without compromising 
any vitally important organ. That a considerable longitudinal in- 
cision can be made into the gullet, whether pharynx or oesophagus, 
without present mischief or future detriment. That experience shows 
how much more likely the gullet is to suffer from the retention of the 
foreign body or the means used for its extraction, than from the knife 
of the surgeon. 
u I am inclined to believe that a foreign body might be extracted 
from any portion of the cervical gullet, from the pharynx to the 
sternum. We might even extract it from the thoracic portion of the 
oesophagus, if it could be reached with forceps. 
“ The most accessible part of the gullet is, doubtless, the two first 
inches of the oesophagus, included between the upper and lower 
thyroid arteries. Below this point, as we approach the upper open- 
ing of the chest, the difficulties of the operation increase in conse- 
quence of the closer proximity of the carotid sheath to the treachea 
and oesophagus.” 
CREQUY.* 
“ The opportunity having been afforded us, while serving as Interne 
to M. Demarquay, to observe two cases of this kind, we have looked 
to see if other analogous cases could be found, and if any practical 
deductions could be derived from them. 
“ Case I. A sou arrested in the upper part of the oesophagus, 
leading to a perforation, a retro-pharyngeal abscess, and finally per- 
foration of the pleural cavity and death. 
“ The 26th of June, 1855, a little boy of five years of age, while 
playing with a sou which he threw up in the air and caught in his 
mouth, accidentally swallowed it, and it became arrested in his 
oesophagus. The child suffered but little at the time of the accident. 
A physician, who was called, administered an emetic, which acted; 
but from this moment severe pain was felt, a sense of oppression, and 
inability to swallow. M. Demarquay saw the child the 27th, and 
passed down Graefe’s sound. The instrument touched the foreign 
body, but, after several attempts, he could not dislodge it. The child 
* “ Observations de Corps Etrangers arretes dans l’CEsophage. (Esopliagotomie; oppor- 
tunity de cette operation, par le Docteur Crequy, ancien interne des hopitaux.” 
Gazette Hebdomadaire de Medecine et de Chirurgie. Nov. 1861. OESOPHAGOTOMY. 
35 
now felt better, and resumed its play; but in four hours complained 
of severe pain in the neck; he began to cry, and the parents per- 
ceived that the head and neck began to swell. 
“ On the 29th, the child entered the Maison Municipale de Sante, 
in the service of M. Demarquay. 
“ He now lay upon his back; the cheeks, the neck, and the chest 
below the clavicles, were swollen, and mostly on the right side. A 
fine, emphysematous crackling was felt on pressure over these parts. 
“ The swallowing of liquids was difficult, and of solids, impossible; 
the drinks were regurgitated with a large quantity of saliva. The 
respiration was impeded, and accompanied with a gurgling sound. 
Fever and anxiety, increasing. 
“ On the 3d of July, four days after his entrance, he sank and died. 
“ The autopsy showed the anterior and posterior mediastinum infil- 
trated with pus and air. The trachea inflamed. At the,junction of 
the oesophagus with the pharynx, on the right side, a perforation 
about one and a half centimetres wide, communicating with a retro- 
pharyngeal abscess. This extended from the basilar process of the 
occiput, down to the fifth dorsal vertebra. The pharynx and oeso- 
phagus were completely separated. The carotid, the jugular, and 
the pneumogastric were denuded by pus. The sou lay at the bottom 
of the abscess, penetrating the right pleura, by a perforation. 
Through this the drinks taken had passed into the pleural cavity. 
There was another opening from the posterior mediastinum into the 
pleura.” 
Case II. “ A franc piece caught in the upper part of the oesopha- 
gus. Futile attempts at extraction; oesophagotomy; retro-pharyn- 
geal abscess; death. 
“The 26th of July, 1854, a little girl of three years and a half 
swallowed a franc piece, which several people saw, at the bottom of 
her throat. One of them pushed it down farther, and it could not 
be seen or touched afterwards. M. Demarquay passed Graefe’s 
sound. It was arrested at the lower part of the neck by an obstacle 
which it passed with difficulty; but in withdrawing it, the hook glided 
over the foreign body, and all attempts at its extraction failed. 
“ These attempts were renewed three times within as many days. 
They caused some bleeding, and great suffering. 
“,On the 28th of July, she was admitted to the Maison Municipale 
de SanU. 36 
(ESOPHAGOTOMY. 
“ On the 5th of August, the child’s condition was constantly grow- 
ing worse; the oppression was considerable, deglutition very difficult, 
and the saliva was mixed with pus. 
“ CEsophogatomy was performed on this, the 10th day since the 
accident. The incision was made on the edge of the sterno-mastoid 
muscle, and the oesophagus reached between the sterno-thyroid, the 
trachea, and the carotid sheath. Very few, and small vessels were 
tied. No important parts were injured, as proved by the autopsy. 
The foreign body was found and extracted. 
“ August 6th. The child suffers but little; the respiration is easy, 
pulse 120. The patient is much enfeebled from inanition, having 
taken no solid food for eight days. The drinks swallowed now run 
out of the oesophageal opening. M. Demarquay endeavored to nour- 
ish the child by a tube passed down the oesophagus. These efforts 
were vainr as efforts at regurgitation rejected the drinks taken. 
The oesophageal opening was gaping and fetid, a peculiarity common 
to all wounds of the intestinal canal, wherever made. 
“August 7th. Pulse more frequent; a gurgling sound heard at the 
lower part of the neck. This sound, resembling that heard in the 
former case, makes the surgeon fear a mediastinal abscess. 
“ August 8th. The child died. 
“Autopsy. Beside the larynx a small, circumscribed abscess, 
which has no connection with any other parts. Opposite the upper 
border of the larynx, on the left side, a small perforation of the pos- 
terior wall of the oesophagus, with dark, gangrenous edges. 
“ This opening, caused, probably, by the pressure of the foreign 
body, communicates with a retro-pharyngeal abscess, which after 
having dissected up the posterior wall of the pharynx, opened into 
the right pleura. Below the larynx the posterior wall of the oeso. 
phagus has several perforations; one, on the left, made in the efforts 
at extraction during life; two others, above and below the right 
bronchus, communicate with the large abscess. No changes in the 
other organs. 
“In these two cases the pathological changes, due to identical 
causes, presented a remarkable analogy. The piece of money caught 
at the commencemeut of the oesophagus, set up an irritation in the 
walls of the canal, which communicated itself to the neighboring 
cellular tissue; pus formed rapidly in the latter, and there resulted a 
large purulent collection, which opened into the pleura. In the first 
case, the purulent collection was evidently preceded by a perforation 37 
(ESOPHAGOTOMT. 
of the alimentary canal; since this perforation took place the second 
day after the accident, as shown by the - symptoms. In the second 
case, nothing indicates that it was so; suppuration must have taken 
place in the cellular tissue around the oesophagus, before the wall of 
the canal was perforated. 
“ Facts which we have sought for in various authors do not enable 
us to decide this question; yet, if we may judge by what takes place 
in other canals, we may believe that for an abscess to be formed it 
is not necessary that the wall of the oesophagus should be first per- 
forated by a foreign body. It is thus that faecal accumulations, the 
stones and seeds of fruits, and other similar bodies, arrested in the 
large intestines, give rise to abscess of the iliac fossa, without pro- 
ducing a rupture of the walls of the canal which contains them. 
“ In the same way, when a clot is formed in a vein, the cellular 
tissue surrounding the vessel is often destroyed by suppuration, be- 
fore the vascular canal is destroyed itself. May it not be thus with 
the oesophagus ? 
“ A very important point to determine is the period when the ab- 
scess appears. It must necessarily vary with the form, volume, and 
consistence of the foreign body. Yet if we could determine the 
minimum time which elapses between the introduction of the foreign 
body and the formation of pus, we should then know how much time 
to allow for expectant treatment. 
“We will compare a few cases, although incomplete ones. 
I. “ An intoxicated man got a chestnut caught in his oesophagus. 
He died the nineteenth day. The autopsy showed an abscess com- 
municating with the trachea. 
II. “ A young man swallowed a turkey bone. He expired the 
thirteenth day. At the autopsy, the bone was found in an abscess. 
The oesophagus was perforated. 
III. “ A lady swallowed the spine of a carp. She died the four- 
teenth day. Autopsy: a tumor (of pus ?) filling the oesophagus. A 
circular perforation. 
IY. “ A foreign body in the throat occasioning death. Autopsy: 
an abscess opening into the chest. 
Y. “ A child of twenty-two months swallowed a bone, and died 
two months afterwards. Autopsy: the posterior wall of the oesopha- 
gus perforated opposite the third cervical vertebra. Caries of the 
second, third and fourth vertebrae. (ESOPHAGOTOMY. 
VI. 11A soldier swallowed a five franc piece. Death at the end 
of six months. The coin was found near the cardiac orifice of the 
stomach. The walls of the oesophagus were thickened and suppu- 
rating. 
VII. “A soldier swallowed a fragment of bone, and died the 
eighth day, after vomiting blood. Autopsy: the bone was found op- 
posite the fourth dorsal vertebra. Its two opposite angles had pass- 
ed through the walls of the oesophagus. The lungs on either side 
presented a lesion opposite these angles; and from these points in- 
flammation had radiated to the other lobes. 
VIII. “ A man swallowed a beef-bone. (Esophagotomy was per- 
formed on the ninth day, and the bone extracted. The patient died 
two days afterwards. The autopsy showed the oesophagus perforated 
in front and behind. A purulent collection extended behind the 
canal, down to the stomach. 
“ It results from these observations that, independently of lesions 
of the trachea and great vessels which environ the oesophagus, foreign 
bodies in this canal may lead to the formation of abscess severe 
enough to occasion death. 
“ At what period do these abscesses appear ? A solution of this 
question would teach us how long we could wait before performing 
oesophagotomy without compromising the success of the operation. 
“Now, in M. Demarquay’s first case the accident happened on the 
26th of June, and the next day (the 27th) emphysema was observed 
in the sides of the neck; perforation of the alimentary canal had 
already taken place, and, as it was close to the upper opening of the 
larynx, the cause of the emphysema is easy to perceive. The child 
died the 3d of July, a week after the accident, and we have seen 
what grave lesions had been produced in so short a time. 
“ In his second case the accident occurred the 26th of July. (Eso- 
phagotomy was performed the 5th of August, the tenth day. At this 
time the posterior wall of the oesophagus was already perforated, 
and it is probable that the purulent collection had been formed seve- 
ral days. It is almost certain that the want of success of the ope- 
ration was owing to this circumstance. 
“ In the first case which we have taken from other authors, death 
occurred the nineteenth day, after the formation of an abscess and an 
opening leading into the trachea. 
“ In the second, death occurred the thirteenth day, determined by 
an abscess and a perforation of the oesophagus. (ESOPHAGOTOMY. 
“ In the third, death the fourteenth day; and there was found a 
tumor in the oesophagus, and a perforation. 
u In cases four, five and six, death took place at a later period, 
hut from the same cause. 
“ In the seventh case, death, which took place the eighth day, was 
caused by a double perforation of the oesophagus, lesion of the lungs, 
and pneumonia. 
u The eighth case, that of M. Flaubert, of Rouen, bears a striking 
resemblance to the second one of M. Demarquay. (Esophagotomy 
was done to extract a bone, which had been in the oesophagus eight 
days. The patient died two days later, and the oesophagus was 
found perforated before and behind, with a purulent collection 
behind it. 
“By these cases we learn that suppuration occurs very quickly 
around a foreign body, and that it leads to death by the end of the 
first week, or in the course of the second. 
11 It is true that there are cases where it has not occurred until the 
end of several months, and even a year, or more; others, again, where 
the foreign bodies, after a considerable time, have come to the surface 
spontaneously, and been thus cured; but such cases are the excep- 
tion : and it seems to us to result, from the cases we have reported, 
particularly those of MM. Demarquay and Flaubert, that the opera- 
tion, when it is decided on, should not he deferred beyond the second or 
third day. 
“ In fact, if death does not occur before one or two weeks, suppu- 
ration precedes it by many days; and from the instant it takes place, 
there is but a small chance of success. 
“ This is an important point on which we shall insist. The death 
of the patients operated on by MM. Demarquay and Flaubert, must 
be referred to a temporizing policy pursued too long.” 
In the fatal cases of Arnott and Martini, referred to in our table, 
it will be observed that in the first, the operation was done after five 
weeks, and pneumonia existed at the time; in the second, the opera- 
tion was done on the fourth day, but the pharynx was already gan- 
grenous. 
“ Yet, notwithstanding what we have said of the gravity of perfo- 
ration and abscess, these complications are not a positive obstacle to 
the operation. 
“ Begin operated with success the twelfth day, when there was per- 
foration, and mediastinal abscess. The wound healed in five weeks. 40 
(ESOPHAGOTOMY. 
“ Lavacherie operated on the eighth day with success, when there 
was perforation, gangrene, and the foreign body pressing on the 
common carotid.” 
Symo, we would add, operated twice, with abscess—once on the 
sixth day, and once on the sixteenth. Both recovered. 
“ Again, it is not only perforation of the oesophagus and the forma- 
tion of retro-pharyngeal and retro-oesophageal abscess which ought 
to hasten the moment of operation; but fatal haemorrhages, from 
lesion of the great vessels, may take place very rapidly. Thus in 
twelve cases reported by Lavacherie, where a fatal result occurred 
from arterial lesions, death took place the sixth, eighth, ninth, and, 
twice, the tenth days. 
“ To determine at what period the surgeon ought to perform oeso- 
phagotomy, M. Demarquay instituted a series of experiments in order 
to fix the time when a foreign body introduced into the oesophagus 
brings on perforation, or retro-oesophageal abscess. To study the 
phenomena which occur in animals when foreign bodies are intro- 
duced, we must consider, first, their size, and second, their angularity; 
for the larger and rougher they are, the sooner they lead to inflam- 
mation and perforation. 
“ Now, in the dogs, into whose oesophagi, by the aid of oesophagoto- 
my, this surgeon introduced fragments of bone, which he fixed there, 
with a thread leading outside, the following state of things was ob- 
served on the fourth and sixth days. 
11 The bony prominences were already deeply impressed into the 
upper parts of the digestive tube, and little gangrenous points some- 
times corresponded to these impressions. But that which attracted 
his attention most was, that in the cellular tissue a,round the oesophagus, 
a vascidar congestion more or less vivid was seen, and, sometimes, pus, 
without the oesophagus being perforated. The continued presence of 
the foreign body was sufficient to bring on these disorders, which we 
can easily understand when we reflect on the vascularity of the digest- 
ive canal at this point, the looseness of the surrounding cellular 
tissue, and, above all, the epithelial layer which coats the inner sur- 
face of the oesophagus. Another noteworthy circumstance is that in 
animals, as in men, rough, foreign bodies arrested in the oesophagus 
bring on acute pain, and check the taking of food, both circumstances 
favorable to the formation of pus. 
u For all these reasons we would agree with the Surgeon of the 
Maison Municipale de Sante, in advising an early opening of the 41 
(ESOPHAGOTOMY. 
oesophagus, when the foreign body is large, or brings on severe pain, 
or renders the taking of food difficult or impossible. If we delay 
beyond the fifth or sixth day, we run the risk of finding a retro- 
oesophageal abscess; and we have seen all the gravity of this com- 
plication. 
“ As to the difficulties of the operation it is not to be denied that 
they are great, and that none but an experienced hand ought to 
undertake them. We need not add that this truly delicate operation 
should not be tried until we have made, with prudence, all the 
attempts at extraction recommended in such cases.” 
These attempts at extraction, we may be allowed to add, are 
capable of infinite mischief. In order to pass even a stomach tube 
into the oesophagus, we are obliged to keep close to the posterior wall. 
This wall has been perforated, even by a probang. Owing to its 
structure and connections it is especially prone to such accidents. 
United by loose connective tissue only to the prevertebral muscles, 
those who have made the coup du pharynx in the amphitheatre know 
how easily it can be separated. On this account it is readily pushed 
before the instrument, and perforated, or at least injured to the de- 
gree of bringing on ulceration, unless the greatest care be used. It 
is in this respect analogous to the membranous portion of the urethra, 
and should be handled as gently. We think that it is not commonly 
so regarded; and that greater force is often used here, than would be 
thought justifiable in the other mucous canal. 
Among the least objectionable of the instruments devised to with- 
draw foreign bodies are the soft sponge probang, and the snare, 
composed of many loops of thread. 
The former, when used to push down foreign bodies, is introduced 
moist and expanded; but when it is designed to withdraw the object, 
it is passed down dry and compressed, made to swell by drinking 
some water, and then drawn up, pressing the foreign body before it. 
A similar measure might be employed by passing down a collapsed 
rubber bag, with a tube attached, and inflating it before withdrawing. 
We must reflect that we do not know how the foreign body lies; 
and that if it be sharp and angular, it is much more likely to be im- 
bedded by any of these means, than to come up, or go down. The 
same objection applies to emetics. 
In comparing the chances of nature or of art in removing a foreign 
body from the pharynx or oesophagus, it is fair to say that although 42 
(ESOPHAGOTOMY. 
many such intruders are gotten rid of safely by the former, yet very 
many also lead to a fatal result. 
Constitutional irritation and inanition are prompt and firm sup- 
porters of suppuration; and they are always ready to act when a 
foreign body is retained in the throat beyond a few hours. Such 
retention, as we have seen, may lead to pressure on the air-passages 
and asphyxia; to abscess leading to the same accident, mechanically; 
to spasm of the glottis; to ulceration and perforation of the oesopha- 
gus, into the trachea, the blood-vessels, the bronchi, the mediastinum; 
while the pus of a retro-pharyngeal abscess may burrow rapidly down, 
unobstructed, into the pleura, or end in caries of the intervertebral sub- 
stance. Suppuration also may take place in the cellular tissue around 
the oesophagus before perforation be accomplished, as shown by the 
experiments on the lower animals, and as indicated by the rapid sup- 
puration in our first case. Such suppuration may become diffuse, 
and end in gangrene. 
In view of all these perils why should not oesophagotomy 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 Demarquay have 
proved that suppuration is imminent if we wait longer than the third 
or fourth day. In the whole seventeen cases we find only four deaths, 
or less than twenty-five per cent. And in every one of these, death 
was due to secondary complications; due either to delay, or to over- 
treatment in attempts at extraction. In one, there was pneumonia; 
in two, gangrene; in the remaining one, abscess. No projection ex- 
ternally of the foreign body need be waited for, or expected. As to 
the manner of the operation, we have given our reasons for the lateral 
method, which, indeed, is favored by most writers. We need not 
remind the anatomist, that the nerves are very constant in their dis- 
tribution, 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 vertebral 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. The following table comprises all the cases of oesophagotomy we 
have been able to find. Others may exist. But it will be noticed 
that we have collected double the number given in the article on this 
operation by Mr. Henry Gray, in Holmes’s System of Surgery. 
Beferences to authorities consulted, and to cases quoted, will be 
found on the page following the Table. 33 Z 
No. 
Date. 
Sex. 
Nature of 
Foreign Body. 
Point of 
Impaction. 
Treatment before 
Operation. 
Operation, when 
Performed. 
Result. 
Cause of Death. 
Operator. 
1 
1738 
M 
Portion of bone 
one inch long, six 
lines broad. 
(Esophagus; 
where, not stated; 
could be felt outside. 
Attempts to push it down, 
Not stated. 
Recovered. 
Goursauld. 
2 
No date. 
Probably a portion 
of bone. 
Not stated. 
Not stated. 
Not stated. 
Recovered. 
Roland. 
3 
1832 
M 
Portion of beef 
bone. 
(Esophagus; 
lower part of neck. 
Touched the foreign 
body ; attempts to dis- 
lodge it. 
Operation twelfth 
day, left side. 
Speedy 
recovery. 
Begin. 
4 
1832 
M 
Large conical frag- 
ment of bone. 
(Esophagus; 
lower part of neck. 
Touched the body; 
every means tried to 
dislodge it. 
Operation eighth 
day, left side. 
Recovered. 
Begin. 
5 
1833 
Spinous process of 
dorsal vertebra of 
a sheep. 
Lower part of 
pharynx. 
Emetics, and various 
attempts to dislodge it. 
Operation after five 
weeks, on right side. 
Death fifty-six 
hours after 
operation. 
Pneumonia, existing 
at time of operation. 
Arnott. 
6 
1844 
M 
Not stated. 
(Esophagus—per- 
foration of; lying on 
carotid. 
Not stated. 
Operation eighth day. 
Recovered. 
Lavaclierie. 
7 
1845 
M 
Portion of bone. 
Could be felt out- 
side, projecting 
above clavicle. 
Bleeding, tartar emetic 
in veins, belladonna ene- 
mata, and sixty attempts 
with instruments. 
Operation fourth day; 
bone swallowed. 
Death two 
days after 
operation. 
Collapse. Pharynx 
gangrenous, stomach 
inflamed. 
Martini. 
8 
1845 
Large fragment of 
bone. 
(Esophagus. 
Repeated attempts to dis- 
lodge, producing ulcera- 
tion of gullet. 
Operation eighth 
day, left side. 
Recovery by 
the twenty- 
sixth day. 
Delarocherie 
9 
1853 
M 
Small fish. 
Pharynx; 
tail seen in fauces. 
Vain attempts to with- 
draw through mouth. 
Operation after 
several days. 
Recovery in 
six weeks. 
Antoniesz. 
10 
1854 
F 
One franc piece. 
Upper part of 
oesophagus. 
Repeated efforts at ex- 
traction with Graefe’s 
sound and forceps. 
Operation tenth 
day. 
Death third 
day after 
operation. 
Retro-oesophageal 
abscess opening into 
pleura. 
Demarquay. 
TABLE OF CASES OF (ESOPHAGOTOMY.  
11 
1855 
Portion of bone. 
(Esophagus; 
abscess formed. 
Could not be reached 
by fauces. 
Operation sixteenth 
day. 
Recovery in 
two weeks. 
Syme. 
12 
1856 
M 
Gold tooth-plate 
containing a false 
incisor. 
Junction of pharynx 
and oesophagus. No 
external projection. 
Attempts at withdrawal 
with forceps; emetics. 
Operation fourth day, 
left side. 
Recov. in 4 w.; 
permanent alt- 
eration of voice 
Cock. 
13 
1857 
M 
Fragment of beef 
bone. 
(Esophagus, 
in neck. 
Attempts at extraction. 
Operation ninth day. 
Death second 
day after 
operation. 
Perforation front and 
behind. Retro-phar. 
abscess reach’g stom. 
Flaubert. 
14 
1861 
Thin piece of mutton 
bone one inch sq. 
(Esophagus; no 
external projection. 
Could not be touched 
by fauces. 
Operation sixth day. 
Recovery in 
two weeks. 
Syme. 
15 
1862 
A coin. 
Opposite top of 
sternum. 
Coin touched by bougie. 
Operation after two 
months. 
Recovery; 
swallowed in 
a week. 
Syme. 
16 
1866 
M 
Portion of fin bone 
of cod-fish, one half 
by one fourth inch. 
Junction of pharynx 
and oesophagus. No 
external projection. 
Spontaneous vomiting; 
pharynx explored by 
finger and probang, 
causing rigors. 
Operation third day, 
right side. 
Recoveiy in 
six weeks. 
Clieever. 
17 
1866 
M 
Brass pin, one inch 
and one fourth long. 
Just below top of 
sternum. No 
projection. 
Vomiting. Long pro- 
bang passed without 
obstruction. 
Operation third day, 
left side. 
Entire recove- 
ry in five w.; 
no adhesions. 
Cheever. 
Authentic Cases, 17. Deaths, 4. Recoveries, 13. 
[See References on next page.] 
18. Obscure allusion to the case of a beer-cork in the throat, in Portsea; neither operator, nor the details, nor the result given. 
(Vide Eve's Surgical Cases.) 
19. (Esophagus opened for malignant stricture, in 1843, by Dr. Watson, of New York. 
(Vide Dublin Journal, May, 1845.,) REFERENCES. 
Cases. 
Nos. 1, 7. Holmes’s Surgery, Vol. II., page 329. 
“ 2, 3, 4. Journal Hebdomadaire, 1838. 
“ 5. Medico-Chirurgical Transactions, Yol. XVin. 
“ 6. M6moires de l’Academie Royale de Belgique. 
“ 8. Journal de Chirurgie, November, 1845. 
“ 9. Lancet, 2, 1854, page 260. 
“ 10. Gazette Hebdomadaire de Medecine et Chirurgie, November, 1861. 
“ 11. Principles of Surgery, by James Syme. 
“ 12. Guy’s Hospital Reports, Vol. IV., 1858. 
“ 13. Gazette des Hopiteaux, 1857. 
“ 14. British Medical Journal, 1861. 
“ 15. Edinburgh Journal, 1862, page 1010. 
References to Writers of Monographs, or Special Articles. 
Berlinghieri. Florence, 1780. 
Hevin. Memoires de l’Academie de Chirurgie, Tome I., 1819. 
Verduc. Pathologie Chirurgicale. 
Guattani. Memoires de l’Academie Royale de Chirurgie, Tome III. 
Begin. Journal Hebdomadaire, 1833. 
Hebra. British and Foreign Medical Review, Vol. XVI., page 53. 
Lavacherie. Memoires de l’Academie Royale de Belgique, 1844. 
Crequy. Gazette Hebdomadaire de Medecine et Chirurgie, November, 1861. 
Arnott. Medico-Chirurgical Transactions, Vol. XVIII. 
Cock. Guy’s Hospital Reports, Vol. IV., 1858. 
Gray. Holmes’s Surgery, Vol. II., 1861. 
Authors consulted, or quoted. 
Boyer, Cooper (Surg. Diet.), Charles Bell, Hennen, Velpeau, Fergusson, Syme, 
Sedillot, Guerin, Erichsen, Holmes, Gross.