Treatment.

—A foreign body which produces the slightest discomfort or recognizable symptoms should be removed. Only occasionally can this be done by making the patient endeavor to swallow something else, this being too uncertain a method of procedure; although I have known a peach-stone impacted in the esophagus to be pushed into the stomach by the passage of an esophageal bougie. The situation and the nature of the object being known, one then decides how best to proceed. The available methods of operation are:

The esophagoscope is an instrument of comparatively recent device and perfection. We owe it largely to the ingenuity of Mikulicz. It is to the esophagus what the endoscope is to the urethra, and may be regarded as essentially an enlarged endoscope. Its introduction is comparatively easy, but its retention is distressing to the patient, so that opportunity may thus not be afforded for profiting by its use. The employment of cocaine anesthesia, and perhaps of morphine hypodermically, will sometimes enable it to be used satisfactorily. It may also be used for exploratory purposes previous to commencing a formal operation under general anesthesia. There are furnished with the instrument itself forceps and extractors, by which it may be possible, when the object is once seen, to grasp and withdraw it. The use of the esophagoscope is, moreover, not limited to these lesions, since it can be used in revealing the character of strictures, small wounds, diverticular openings, and the like. Endeavors may be first made to locate the body by those possessing such an instrument and expert in its use.

The esophageal snare is a simple instrument which, after being introduced, is shortened in such a way as to cause to protrude a basket-like meshwork of bristles in which, as the instrument is withdrawn, a small object may be entangled and so withdrawn. In the same way an ingeniously made coin catcher is furnished, which, in cases of impacted coins or similar shaped objects in the esophagus, may be introduced beyond them and then withdrawn, the object being caught in a miniature cradle, from which it cannot escape until brought up into the pharynx. Esophageal forceps are made with long blades, curved like all the instruments used within the pharynx, and serving admirably for grasping objects impacted high in the tube ([Figs. 515] and [516]).

Dislodgement being impossible by either of the above-mentioned expedients, recourse may be had to the operation of external esophagotomy. This may require to be done as an emergency measure, but is practically always indicated when an impacted object cannot be otherwise removed. A dangerous location for a foreign body in the esophagus is at a distance of about nine inches from the upper incisor tooth, at which point it will be located directly behind the arch of the aorta, at which level ulceration would perhaps result disastrously, as Richardson has shown. The operation was devised by Goursault, in 1773, and has proved a satisfactory surgical measure. It is performed upon the left side of the neck. The incision is made along the anterior margin of the sternocleidomastoid from the middle of the neck downward. The larynx and trachea are separated to the inner side, the muscles and the large vessels to the outer side, the omohyoid divided, the descendens noni and the recurrent laryngeal nerves, which lie in the groove between the trachea and the gullet, are protected from injury, and the esophageal tube thus exposed. The surgeon will feel more secure in opening it if he now pass downward through the mouth a bougie or instrument upon whose beak or tip he may cut down. The esophagus being opened, the margins of the wound are secured by sutures which serve as retractors, and the interior of the tube is then subjected to the necessary manipulation. Even now it may not be an easy matter to dislodge a pointed object, which may have become partially impacted. Thus it may be dislodged at first by pushing it down a short distance and turning it, the direction having been already indicated by an x-ray picture. The manipulation should be as gentle as possible. Extraction having been accomplished, the esophageal wound is closed by the sutures introduced for traction purposes. Over this the external wound is closed, with suitable provision for drainage, as it is almost certain to have been infected during the procedure. In rare cases it has been necessary to combine a gastrotomy with this operation, in order that by combined manipulation a peculiarly shaped object may be dislodged.

Gastrotomy will be necessary in but few instances, as, for instance, when an object known to be one which cannot pass through the pylorus has been dislodged into the stomach by pressure from above—as plates containing false teeth, and various similar objects. It will probably be safer to open the stomach and remove the object than to leave a patient to his otherwise uncertain fate. On the other hand objects which are sure to be in time dissolved or disintegrated by the stomach juices may be allowed to remain to await this event.

WOUNDS OF THE ESOPHAGUS.

Wounds of the esophagus occurring in other ways than those above indicated may be the result of gunshot and various perforating injuries. The tube may be also partially cut across in so-called cut-throat.

Any external wound of the esophagus which can be recognized should be closed with sutures, and the parts brought together, if possible, with provision for drainage. Those lacerated wounds constituting some forms of cut-throat, however, permit of very little in this direction, for when seen they are too infected. Through an esophageal opening thus inflicted the patient may be fed for a time by a tube, the wound being left to close later by granulation or by a secondary operation. When the esophagus has been anywise injured it would be better to abstain from feeding or else to introduce food through an esophageal tube.