Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.

by Alexis Thomson; Alexander Miles

Wounds of the œsophagus inflicted from without, for example stabs, cut-throat or gun-shot injuries, are rare, and are almost invariably accompanied by lesions of other important structures in the neck, which may rapidly prove fatal. It is more common to meet with wounds inflicted from within, for example by the swallowing of rough and irregularly shaped foreign bodies, or by unskilful attempts to remove such bodies or to pass bougies along the œsophagus. The severity of the lesion varies from a scratch of the mucous membrane to a perforation of the tube. The less severe injuries are attended with pain on swallowing and a sensation as if something had lodged in the œsophagus. In more severe cases there is bleeding, followed by attacks of coughing and expectoration of blood-stained mucus. When the œsophagus is perforated, diffuse cellulitis of the neck or of the posterior mediastinum may ensue. In the treatment of these injuries the chief point is to give the œsophagus rest by feeding the patient entirely by the rectum or through an opening made in the stomach—gastrostomy.

Rupture of the œsophagus has occurred during violent vomiting, and during lavage. The tear is longitudinal and is usually near the cardiac orifice. It is probably due to increased pressure within the gullet. The accident has usually been met with in alcoholics, and has proved fatal by setting up left-sided empyema or cellulitis.

Swallowing of Corrosive Substances.—The œsophagus is damaged by the swallowing of strong chemicals, such as sulphuric acid, nitric acid, carbolic acid, or caustic potash. These substances produce their worst effects at the two ends of the œsophagus, but in some cases the whole length of the tube suffers. The mucous membrane alone may be destroyed, or the muscular and even the fibrous coats may also be implicated. The damaged tissue undergoes necrosis, and when the sloughs separate, raw surfaces are left, and are very slow to heal.

If not rapidly fatal from shock and œdema of the glottis, these injuries are usually attended with intense pain, severe thirst, and vomiting, the vomit containing shreds of mucous membrane and blood. Complications, such as cellulitis, perforation of the œsophagus, or peri-œsophageal abscess, may follow. Later, cicatricial contraction takes place at the injured portions, producing the most intractable form of fibrous stricture.

The treatment consists in administering solutions of carbonate of potash, of soda, or of magnesia when an acid has been swallowed, or vinegar diluted with water in the case of an alkali. When carbolic acid has been swallowed, a large quantity of olive oil should be administered. The stomach should be washed out with water, the tube being passed with the greatest gentleness to avoid perforating the softened œsophageal wall. Subsequently the patient should be fed by the rectum, but, in the majority of cases, gastrostomy is called for to enable the patient to take nourishment and put the gullet at rest.

As soon as the œsophagus has healed, say in three or four weeks, bougies should be passed every three or four days to prevent cicatricial contraction. As the calibre of the tube is restored, the instruments may be passed less frequently, but for some years—it may be for the rest of the patient's life—a full-sized bougie should be passed at least once a month.

Impaction of Foreign Bodies in the Pharynx and Œsophagus.—It is an interesting fact that foreign bodies, even as large as a dinner fork, when intentionally swallowed, can pass through the pharynx and œsophagus and enter the stomach without apparent difficulty. When the body is accidentally swallowed impaction is more liable to take place, probably on account of the spasm induced by fright and by inco-ordinated attempts to eject it. For obvious reasons the accident is most liable to occur in children, in epileptics, and in those who are under the influence of alcohol. It happens also during anæsthesia for the extraction of teeth or if the patient vomits solid substances. The clinical aspects vary according as the object is impacted in the pharynx or in the œsophagus.

In the Pharynx.—If a large bolus of unmasticated food becomes impacted in the pharynx, it blocks the openings of both the œsophagus and the larynx, and the patient may, without manifesting the usual signs of suffocation, suddenly fall back dead, and if he happens to be alone at the time of the accident, the cause of death is liable to be overlooked unless the pharynx is examined at the post-mortem examination. Most surgical museums contain specimens illustrating the impaction of a bolus of meat in the pharynx; this fatal accident has occurred especially in men in a condition of alcoholic intoxication.

An object of irregular shape, for example a large denture, also, is most likely to lodge in the pharynx, obstructing the openings of both the œsophagus and the larynx, and causing suffocation. The face immediately becomes blue and engorged, the patient is speechless, and violent efforts are made to eject the object by retching and coughing. It may be seen from the mouth and touched with the finger.

In the case of small sharp bodies, such as fish, game, and mutton bones, there is not the same urgency, and a methodical search for the foreign body is carried out. Even after the foreign body has been got rid of, the patient may have the sensation that it is still present. This may be due to a scratch of the mucous membrane, or to spasm, in which case the swallowing of a few drops of cocain solution will cause the sensation to disappear.