Chapter XLIII: The Thorax and Its Contents (2)

THE HEART.

There is but little to be said about the heart in addition to that elsewhere stated, where such injuries as gunshot wounds, stab wounds, etc., are considered. _Rupture_ of the heart without external injury is possible under conditions of fatty degeneration or softening produced in consequence of embolus or thrombus. _Aneurysms of the heart_ are also known by which it is weakened and permitted later to give way. The final rupture is usually the consequence of some emotion or extra exertion, although it may occur with injury to some other part of the body, as after a blow upon the abdomen. Death may be instantaneous, or occur more slowly as the result of filling of the pericardial sac and rapidly increasing embarrassment of heart action.

_Wounds of the heart_ produce syncope and shock, restlessness, extreme anxiety, with dyspnea and such disturbance of heart activity as to materially change the sounds heard on auscultation.

The treatment of such cases not primarily fatal should include opium narcosis, but not stimulants intended to excite the heart to extra activity. The operations justified under these conditions are elsewhere described.[50]

[50] Borchardt has collected 83 cases of operations upon the
heart, of which 78 included heart suture. Of these 78, 46 died and
32 recovered. He quotes a statement of Billroth, made when this
surgeon was sixty years of age: “Paracentesis of the pericardium
is an operation which, according to my view, closely approaches to
what might be considered a prostitution of surgical art, or, as
some surgeons would call it, a surgical frivolity, an operation
which altogether has more interest for the anatomist than for the
physician. Possibly a later generation will regard it differently.
Internal medicine is constantly becoming more surgical, and those
physicians who concern themselves especially with internal medicine
will find themselves compelled to make the most daring operation.”
The rapid advances made in surgery during the past three decades
cannot be better illustrated than by contrasting Billroth’s statement
of a few years ago with the standard practice of today.

_Pericarditis_, either of idiopathic or traumatic origin, may produce a degree of distention, either _hydropericardium_ or _pyopericardium_, calling for surgical intervention--in the former case with the aspirating needle, in the latter either with the needle or the knife. When a pericardium is greatly distended with fluid there is marked change in the position of the apex beat, with embarrassment of heart action, accompanied by distress and distention of the veins of the upper part of the body, as well as much alteration of the ordinary physical signs, the area of dulness being correspondingly enlarged and the lung sounds being lost over the area occupied by the distended sac. Great distention, with marked precordial trouble and distress of heart and lung function, always requires _paracentesis_.

_Paracentesis pericardii_ is performed ordinarily by puncturing (a previously sterilized area) 3 to 5 Cm. to the left of the left border of the sternum, and in the fifth intercostal space, with a sterilized needle. Here are found the internal mammary artery and the pleura. Too rapid withdrawal of fluid may lead to syncope. It should, therefore, be allowed to escape slowly. Should it prove purulent it may be incised, passing the knife-blade along the needle; or the sac may be emptied, when, if fluid re-collect, a free incision should then be made. Roberts has shown that recovery follows in at least 40 per cent. of cases of empyema of the pericardium thus treated. Gauze drainage may be provided, but irrigation of the cavity should not be practised.

Allingham has suggested to open the pericardium from below by an incision three inches in length, carried along the lower margin of the seventh left costal cartilage, to separate the cartilage from the abdominal muscles, pull outward and upward the lower surface of the diaphragm, expose the cellular interval between its attachment to the cartilages and to the tip of the sternum, to expose and enlarge by blunt dissection, until there appears a mass of fat which belongs above the diaphragm in the interval between the pericardium behind, the sternum in front, and the diaphragm below. When this is removed the pericardium is exposed and can here be opened. Throughout the procedure injury to the pericardium which lines the upper surface of the diaphragm should be avoided. By this method the pleura need not be opened and better drainage may be secured. (Dennis.)

_Abscess in the heart wall_ is an exceedingly rare lesion, usually accompanying pyopericardium, but occasionally met without it. It was the writer’s experience in one case, in puncturing for what was supposed to be a pyopericardium, to withdraw pus and give temporary relief. Later postmortem examination showed that this pus came from a large abscess in the wall of the heart, which had been thus entered by the aspirating needle without immediate bad consequences, but, on the contrary, with temporary relief.

THE LUNGS.

In the fact that the lung never completely fills the pleural cavity we find explanation for the kindred fact that small effusions produce little if any compression symptoms. Collapse of one lung after opening the chest is never _complete_ if the other lung be uninjured and functionating. Moreover, a partial collapse on the affected side will be quickly atoned for when the pressure of the external atmosphere is taken off.

Two or three serious pathological conditions of the lung occasionally require surgical intervention.

HYDATIDS OF THE LUNG.

Hydatids of the lung have been mentioned (see above). Seventy-five per cent. of these cases terminate fatally without surgical help, and in reality more prospective benefit can be offered by it than without it. Serious and even fatal collapse has attended the sudden withdrawal of fluid from hydatid cysts in this location. Aspiration may be made, but even this is scarcely less dangerous while it is less satisfactory than free exposure and drainage.

ACTINOMYCOSIS OF THE LUNG.

Actinomycosis of the lung may be recognized by the sputum and also by the pus discharged from any breaking-down cavity within the affected area. (See section on the Pleura.) If a localized focus could be diagnosticated or recognized after exposure the portion of the lung thus involved might be removed.

ABSCESS OF THE LUNG.

Abscess of the lung is always the result of some local or distant infectious process. The mechanism of production of the multiple metastatic abscesses which characterize pyemia has been described in the earlier portion of this work. For such conditions surgery affords no aid. Circumscribed abscess may be the result of the presence of a foreign body--_i. e._, a bullet or a parasite--or it may result from embolism with infarct, in consequence of such affections as ulcerative endocarditis, puerperal septicemia, sloughing fibroid, an otitis media, or a septic pneumonia produced from any cause. It may be the result of extension from an osteomyelitis of some portion of the bony wall of the thorax, which itself may result either from injury or from local infection. Abscess of the lung is seen not infrequently in connection with _empyema_, and often results from suppurating tuberculous _bronchial nodes_. It may be produced, also, by extension of trouble from below the diaphragm, as hepatic abscess, subphrenic abscess, and the like. It is always a secondary rather than a primary affection.

Such abscesses are to be recognized by the character and offensiveness of the sputum, the pus discharged being colored green or brown, containing shreds of tissue, with masses of bacteria and crystals of fat. Some believe the presence of elastic fibers to be pathognomonic. When pulmonary abscess is diagnosticated it is necessary, in addition, to determine whether multiple lesions or a circumscribed collection are to be dealt with. In the former instance it is of little avail to intervene. In the latter the physical signs will usually furnish evidence of adhesions between the lung and the chest wall, by whose presence the operative procedure is simplified.

The term _pneumotomy_ is applied to the exposure and evacuation of pus in the lung, whether it be found in connection with an ordinary abscess or a suppurating hydatid cyst. It is essentially a thoracotomy, plus the added measure of whatever may be done to the lung itself, and will be described in connection with other operations upon the chest.

If a tuberculous abscess could be located it also might be treated upon the same general principles. Thus Lane and others have suggested early operations for relief of tuberculous lesions. For obvious reasons, however, the method has not found general acceptance.

GANGRENE OF THE LUNG.

Gangrene of the lung is the terminal stage of a local infection, and unless relieved may prove fatal to the patient. It is due to the causes above mentioned as producing abscess in the lung, while to them may perhaps be added a few others, especially expressions of embolism or thrombus of the pulmonary circulation by which, the blood supply being cut off, death of tissue occurs before there is time for phlegmonous development. Thus it is met with occasionally after the acute exanthems and the infectious fevers and after violent pertussis. When diffuse it is of the miliary type. When circumscribed it may be due to more localized causes. In any event it is more frequent in the lower portions of the lung.

Pulmonary gangrene may be recognized by the extreme condition of the patient, offensive odor of the breath, and expectoration of sputum which may at first be frothy and bloody, but becomes rapidly purulent and finally necrotic in type. Meantime, the function of the lung being materially interfered with, respiration is rapid and there will be more or less cough, pain, and finally collapse. When the sputum is allowed to stand in a test tube there will form an upper layer, opaque and frothy; a middle, more frothy layer; while the lower and denser portion will be of a dirty green color and contain shreds of dead tissue with bacteria, crystals of triple phosphates, fat debris, and pus. According to the nature of the case the cavity or the area of dead lung may be outlined by physical signs. There is a form of _fetid bronchitis_ which has been mistaken for pulmonary gangrene, but the character of the sputum and the progress of the case will be quite different.

Gangrenous areas of limited size have in certain favorable cases cleared up and the patients have recovered, but ordinarily for this condition surgery affords the only prospect of relief, the operation being begun with a _thoracotomy_ and completed by the _removal of the gangrenous lung tissue_. The operative procedure is essentially the same as that for abscess and above described.

_Septic pneumonia_ is the term applied to those forms of pneumonitis which occur in connection with septic lesions in other parts of the body, or with the less typical forms--_e. g._, aspiration pneumonia, due to the passage into the finer bronchioles of material from the mouth or nose. It gives rise to the same physical signs, though it is perhaps more often irregularly located than is the consolidation of the ordinary lobar pneumonia. Viewed in this way it will be regarded as a serious complication of various other conditions, many of which are surgical, and it is frequently a primary expression of infection. The physical signs by which it may be recognized are scarcely different from those of ordinary pneumonia, except that, in addition to the latter, there may be distinct expressions of general septic infection and of profound toxemia, and that the disease may progress to the point of producing pulmonary abscess or gangrene. While the milder types of septic pneumonia are not necessarily fatal, it is always a serious complication, and, as such, dreaded by the surgeon. It is not, however, essentially a surgical complication, but calls for the treatment generally given to pneumonia, plus whatever may be needed for the primary condition behind it.

CHYLOTHORAX.

This implies a collection in one of the pleural cavities, usually the left, of fluid which is practically unchanged chyle, which has probably escaped from the thoracic duct. The number of cases on record is not over fifty, of which about one-third have followed unrecognized injury with probable rupture of the duct. Most of these cases have occurred in connection with fracture of the spine. The duct may be opened by the progress of ulcerative disease, and carcinoma is often the predecessor of chylothorax. Rupture may also occur in connection with tuberculous lymphatics about the course of the duct, and when the condition occurs in children this is the usual explanation. It should be differentiated from so-called _chyloid effusions_ into the pleural cavity, which are more often seen in connection with cancer than tuberculosis, the fluid in this case being mixed with fat and degenerated leukocytes or cells. Pure chyle contains sugar, while chyloid fluid contains but a trace of it. The former also is thicker, and compares with the latter as does cream with skimmed milk.

The prognosis is not usually favorable. Nevertheless recovery has ensued without operation. Mere pressure of the effusion may occlude the opening through which it occurs until the latter shall heal. When the fluid gives rise to severe symptoms the chest should be aspirated.

HYDROTHORAX; HEMOTHORAX; PYOTHORAX.

Under these terms are included the presence of fluid in the pleural cavity, between the lung and the chest wall; this fluid, in the first instance, being _serum_, which may be slightly admixed with pus and blood; in the second, _blood_; and in the third, _pus_.

Hydrothorax may be a primary condition, the result of pleurisy with effusion, or of pleuropneumonia. It may also occur as does a similar collection in the abdomen, as the result of disease of the chest wall, the lung itself, or in consequence of serious cardiac or renal disease, with tendency to dropsical accumulations in various parts of the body. Thus it is seen in connection with tuberculous disease or cancer of the lung, as well as cancer of the chest wall. There is, moreover, a miliary expression of tuberculous pleuritis in which hydrothorax is always a complication.

The serious features of hydrothorax result from the compression which it may make upon a lung with consequent embarrassment of lung function and from the possibility of infection by pyogenic organisms and the consequent conversion of a hydrothorax into a pyothorax.

Collections of serum within the pleural cavity which manifest a kindly tendency to disappear by resorption do not require surgical intervention, but all such accumulations which do not quickly evince this tendency should be removed by the operation of paracentesis, which, applied to the thorax, is called _thoracentesis_, _i. e._, aspiration through the hollow needle. No lung should be allowed to have its capacity long reduced by compression.

_Hemothorax_ may be idiopathic or traumatic. In the former case it is an expression of malignant disease, or of advanced septic lesions which have permitted erosion of bloodvessels and escape of blood. It may also result from rupture of an aneurysm, and will then prove fatal. It is seen in surgical cases in connection with injuries to the chest wall or its contents, as in compound fracture of a rib or perforation of a rib fragment into the chest, with injury to the lung.

In case of the sudden escape of fluid into the chest, with symptoms of collapse and lung compression, it may be assumed that an acute hemothorax affords the explanation. Fluid accumulating _rapidly_ under any circumstance is more likely to be blood than serum. The exploring needle may be relied on to furnish the deciding test, in addition to the ordinary physical signs afforded by auscultation and percussion.

_Pyothorax_ is frequently referred to as _empyema_, the latter term indicating a collection of pus in a previously existing cavity, and, by common consent, made to refer to the pleural cavity unless some other be mentioned. Empyema is seldom a primary condition. Generally it is the result of a hydrothorax, which has become contaminated either by direct or by indirect access of germs. Under these circumstances it indicates the conversion of a relatively innocent collection of serum into a collection of pus, with all its attendant dangers. It may be looked for in cases of perforating injury of the chest, _e. g._, compound fracture of the ribs, gunshot wounds, and the like.

While returning the ordinary physical signs met with in fluid collections in this location, and being discoverable with the exploring needle, empyema has this additional feature, that the pus may, when long retained or accumulated in large amount, burrow and attempt to escape through whatever path may offer least resistance. In this way strange freaks will occur, as when it escapes behind a mammary gland and pushes the latter forward, thus forming a large retromammary abscess, which requires not merely the ordinary incision, but a thoracotomy and ample drainage as well. It may penetrate at other points and thus escape. The most remarkable illustration that the writer personally has known of this travelling of pus was in a colored man, in whom it perforated the diaphragm, then separated the peritoneum from the abdominal wall over a large area, collected in large amounts between the peritoneum and the abdomen in front, and even extended down into the pelvis. This man had such a peculiar abdomen that he was supposed to have dropsy. When the trocar was inserted there was a discharge of over a pailful of almost pure pus.

In addition to the ordinary embarrassment which a considerable amount of pus thus collected causes, there should be reckoned the peculiar septic and toxic features, which can be easily accounted for by the nature of the contained fluid. Pyothorax will nearly always have septicemic in addition to local features, which give it an individuality of its own.

The operations practised for relief of these conditions are discussed at the conclusion of this chapter.

THE ESOPHAGUS.

Anatomically, the esophagus is a musculomembranous tube with downward projection into the thorax, its uppermost portion blending with the lower constrictor of the pharynx, the tube proper beginning at the level of the cricoid cartilage, and opposite the sixth cervical vertebra. Its conclusion opposite the tenth dorsal vertebra marks the cardiac orifice of the stomach. In its upper portion it is placed centrally, then inclines a little to the left, and, at the level of the third dorsal, lies about half an inch to the left of the middle line. This furnishes the reason for approaching it upon the left side in doing external esophagotomy. From here it passes to the middle line again until opposite the ninth vertebra, where it once more inclines a little to the left. It has an anteroposterior curve corresponding to the shape of the spine. Between it and the trachea, in the neck, lies the recurrent laryngeal nerve. Its nervous supply is derived from the sympathetic and the pneumogastric, and its lymphatics connect with the mediastinal nodes, the latter point being of importance in connection with cancer of the esophagus. Its average caliber is about three-quarters of an inch, save where it is crossed by the left bronchus and at the diaphragmatic opening. There is also a slight constriction at its upper opening.

CONGENITAL MALFORMATIONS OF THE ESOPHAGUS.

Congenital malformations include its absence, at least throughout some of its course. Communication between it and the treachea, so-called tracheo-esophageal fistula, has been noted. Its upper portions, into which may open the incompletely closed branchial clefts, are also subject to malformations with incomplete obliteration of the latter and consequent diverticula. Irregular dilatation is also occasionally of congenital origin, as well as acquired, in the latter case being due to fatty degeneration of muscle fibers. These dilatations should be differentiated from those which are mostly found on the proximal side of any constricted tubular passage, and which are produced by accumulation and distention from behind of whatever should be passed through it.

The most common _malformations_ of the esophagus which are not of the stenotic character are so-called _diverticula_, which appear in two forms--namely, _distention_ and _traction_, these being both acquired forms, while congenital formations of this character are also occasionally met.

_Congenital diverticula_ may appear anywhere along the course of the tube, but are probably more common in its upper portion. They constitute more or less irregular tubular sacs which lie alongside of and parallel to the main tube. The openings by which they connect may be large or small. These saccular defects, always small at first, may assume increasing proportions, because of the entrance therein of food and their consequent distention by foreign material, as well as by products of decomposition of the same. Thus slowly and insensibly a very mild form of such defect may in time assume serious proportions.

The _acquired diverticula_ of the _distention_ type are usually met with in the upper part, and are practically hernial protrusions of at least the mucosa through the fibers constituting the muscular portion of the tube, and cannot occur save by some preceding pathological change. _Traction diverticula_ are the results of adhesions to breaking down lymph nodes or other pathological conditions, by which the esophageal wall is first pulled out of position, then gradually sacculated, and the condition still further aggravated by accumulation therein of foreign material. The acquired diverticula attain considerable size, and when emptied one may be astonished at the accumulation which has occurred. Such a tube having been completely emptied may be again filled by the first food which is subsequently taken. After being filled, the balance of the food may then pass into the stomach, with partial or complete comfort or satisfaction to the patient.

The principal indication of an esophageal diverticulum, beside dysphagia, is regurgitation or vomiting of food. When food which has undergone decomposition is occasionally rejected, and when, at the same time, the stomach is shown to be not dilated and not at fault, the suspicion of a diverticulum may be considered well founded. Its opening into the esophagus may be so placed as to always engage the instrument which may be passed down for examination, either bougie or stomach tube. Should this be a constant phenomenon the diagnosis may be easily established. In such a case it may be possible to first empty and then distend the sac with food mixed with bismuth subnitrate, or perhaps to inject it with an emulsion of the same. If this can be done, the fluoroscope or a good radiograph will show a distinct shadow, and in this way a pictorial outline of the condition may be obtained.

=Treatment.=--The treatment of these diverticula is of great difficulty, especially when the sac has attained a size which permits of retention of material. Sacs which contain decomposing matter should be emptied by the stomach tube and washed out at frequent intervals. If it be then possible to pass the tube beyond them the patient should be fed through it, or it may be possible to place the patient in the recumbent position, with the head lower than the body, and cause food or fluid to be swallowed in this attitude. It will then probably enter the stomach instead of the sac. Such measures as these failing, and nothing else affording relief, operations are occasionally undertaken. Much will depend upon the location of the sac, especially its height. A diverticulum in the neck may be more easily reached than one in the chest, and Richardson and myself have had remarkable success in the relief of aggravated cases of this kind. Cushing has shown the advantage of the administration of atropine before these operations, in order to limit the flow of saliva and keep the parts dry. The sac having been exposed by a long incision in front of the sternomastoid, it may be filled with a solution containing methyl blue, by which it may be identified, or it may be filled with paraffin, which, solidifying, will serve admirably for its identification. It then may be attacked as would be any solid tumor. The sac having been identified and extirpated its opening into the esophagus is then closed by sutures and the neck wound cared for as usual, with provision for drainage (Figs. 511 and 512).

Diverticulum freed from its attachments and delivered from the wound. (Richardson.)]

Shows the external layers of the esophagus closed by interrupted Lembert suture of silk. (Richardson.)]

Traction diverticula may be amenable to surgical intervention. Should the esophagus be diverted by adhesion to an advancing aneurysm nothing should be attempted. Among the operations which may be practised upon the thorax there may be mentioned a method of posterior exposure and attack upon some of these conditions which may or may not afford advantages, according to the nature and location of the various conditions.

_Cardiospasm_ (see chapter on the Stomach) produces a sacculation of the gullet often mistaken for diverticulum, and requiring to be differentiated from it.

FOREIGN BODIES IN THE ESOPHAGUS.

Foreign bodies may be lodged in any portion of the esophageal tube and cause a variety of troubles, according to their size, shape, location, and nature. There is scarcely any conceivable object which may be introduced into the mouth which has not been known to be impacted in the esophagus and produce more or less serious symptoms. Young children, imbeciles, and the insane may suffer unwittingly in this way, while the condition is usually accidental and unintentional.

The accompanying figures (Figs. 513 and 514), portraying in one case a jackstone lodged in the esophagus, a coin in the other, a case of my own, will furnish illustrations of what has just been said. (See also page 674.) The young and the insane may make no statement which will furnish a clue for the distress caused in attempts to swallow or the actual impossibilities of the act. In most instances, however, a history of impaction and a statement as to the nature of the foreign body may be obtained. The _symptoms_ produced are those of partial or complete inability to swallow, of more or less pain accompanying the act, and of the regurgitation often of blood or of bloody mucus. The object may be sufficiently large to produce dyspnea and suffocative symptoms, _e. g._, a plate with false teeth.

Jackstone lodged in esophagus. (Phelps.)]

Coin lodged in esophagus, successfully removed by external esophagotomy. From the Author’s Clinic. (Skiagram by Dr. Plummer.)]

The condition being suspected or made known, the location of the foreign body may be determined by the esophageal bougie and by the use of the _x_-rays. With certain irregularly shaped objects the latter prove a desirable help, especially when irregular plates containing false teeth, or toys have been passed into the esophagus. They afford an indication not only as to their exact situation and emplacement, but also as to the best method of attack, that is, whether from without or within. Considerable distress may be produced by even small particles, as chips from an oyster-shell, small pieces of glass, and the like.

Esophageal forceps.]

Horse hair probang, expanded and unexpanded.]

=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:

1. The introduction of a bougie and the enforced passage of the
object into the stomach (questionable).

2. The use of the esophageal snare.

3. The use of the esophageal forceps or similar means of extraction.

4. The more directly operative methods by external incision.

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.

RUPTURE OF THE ESOPHAGUS.

Rupture of the esophagus has been known to occur in consequence of severe vomiting, there being some twenty-five cases of this character now on record. (Dennis.) A tear is rarely complete, but it may be followed by hernia and formation of a diverticulum. The accident will be indicated by violent pain following severe vomiting in connection with an effort to dislodge a foreign body. There will be more or less shock and perhaps collapse, with escape of blood. Emphysema of the neck and upper part of the chest may result and the injury prove fatal. The condition being suspected, it would be advisable to do an external esophagotomy or else to carefully introduce a stomach tube and leave it _in situ_.

PERFORATION OF THE ESOPHAGUS.

Perforation--_i. e._, rupture _without traumatism_--may result from the existence of ulcers or from the advance of malignant disease. It may occur in either direction. Thus while the mediastinum may be infected from entrance of septic material into it the direction may be reversed and an abscess or other lesion of the surrounding tissues may evacuate itself into the esophagus. Should this prove to be an aneurysm the patient will die with uncontrollable escape of blood. The treatment of such a case, if any be permitted, will depend entirely on the nature of the exciting cause. Perforation has also followed injudicious use of bougies when exploring or treating strictures (especially cancerous) of the esophagus.

ESOPHAGISMUS.

Esophagismus, or spasmodic contraction of the esophagus, is usually an expression of hysteria, or else is a reflex spasmodic effect due to the presence of some neighboring irritation. In the esophagus, as in the urethra, there may be spasmodic stricture, which will afford considerable obstruction. Thus I have seen it as a functional neurosis, absolutely without explanation, in an apparently healthy workingman. It is noticed also in connection with hemorrhoids and with hepatic lesions. It is seen in pregnancy, and a certain degree of it will complicate many cases of gastric ulcer, gastritis, or esophagitis such as is produced by swallowing mild caustics. While producing dysphagia and obstructive phenomena it is intermittent and interposes little real obstacle to the passage of a full-sized bougie or tube. It is frequently accompanied in the hysterical by globus hystericus, and by regurgitation of whatever food the patient attempts to swallow.

The local treatment consists of dilatation by the passage of full-sized instruments at frequent intervals. If a neurosis the patient may require other treatment, addressed either to the nervous system or to any well-marked constitutional condition.

STRICTURE OF THE ESOPHAGUS.

Stricture of the esophagus has an etiology practically identical with that which pertains to stricture of any other passage of the body. It may be due to extrinsic or intrinsic influence. Among the former may be mentioned the presence of tumors, either benign or malignant, or of cicatricial tissue, while among the latter should be mentioned the injuries resulting from the presence of foreign bodies, the extensive ulcerations due to the swallowing of various caustic fluids, and the cicatricial contraction which may follow other lesions like ulceration. Those cases which are due to serious congenital defects will usually die early. Of the ulcerative lesions which lead to stricture the most common are the cancerous. Syphilitic and tuberculous ulcerations may occasionally produce the same effect. By far the most common causes are the traumatic, which are connected either with foreign bodies or with the unfortunate accidental use of caustics.

_Esophageal strictures_ are recognized by the difficulty in swallowing which they produce and the later dilatation of the esophagus above, which is the frequent result of their long existence. The degree of difficulty experienced by the patient in deglutition is to a considerable degree a measure of the extent of contraction. It may be nearly always assumed that such a stricture as is produced by the swallowing of caustic fluids will leave a tortuously contracted passage-way, and the instrument passed for its recognition, while arrested in its upper portion, may give little or no correct idea as to the arrangement below. In some instances it may be possible here, as in the case of diverticula, to introduce sufficient bismuth emulsion into the esophagus to make it cause a shadow in an _x_-ray picture, and in this way to give pictorial information not otherwise attainable.

The surgeon should distinguish between hysterical spasm or esophagismus and cicatricial stenosis. The former will offer but little obstacle to the passage of a full-sized bougie. In fact it will be frequently benefited, usually cured by it, while in the latter instance this is almost impossible.

Stricture of the esophagus. (Dennis.)]

Esophageal bougies.]

Fig. 517 shows the possibilities in a case of actual obstruction, and how different such a condition is from mere esophagismus or globus hystericus. It has been recently shown, especially by Dennis, that during or just after typhoid fever, ulcers occur in the esophagus which may produce serious stenosis. At present writing I have under observation a little girl of nine years who has an extreme condition of this kind. It is with difficulty that she can swallow fluid nourishment, and she was so nearly starved that her life was only saved by a gastrotomy. Those congenital defects which may produce esophageal stricture are usually of such a serious and extensive character as to afford no opportunity for relief.

The location and caliber of these strictures may be ascertained by the use of esophageal bougies, such as represented in Fig. 518. These are made of various sizes, and are fastened upon the end of a flexible rubber handle, which affords a degree of elasticity in manipulation. _They should be used with care and caution_, as minor degrees of injury produced by them may cause a spreading infection, while still more harm may be done by rupture of an ulcerated area, or perhaps the perforation of an aneurysm.

The patient should sit before the surgeon, with the head thrown backward, the mouth comfortably widely opened, while the surgeon, standing, introduces the left forefinger into the pharynx and with it depresses the tongue and guides the tip of the instrument, be it bougie or tube, along this finger, which serves as a guide. Unruly or hysterical patients will not only gag, but may attempt to bite the operator’s finger. To prevent such accidents a metal thimble is made, which, being inserted between the teeth, protects the finger, but makes the manipulation more awkward. Should the patient show any tendency to folly of this kind, it should be remembered that when the finger is forced back into the pharynx the mouth is instinctively opened. If necessary, at the same time, the nostrils may be grasped and held closed, in which case the patient is sure to open the mouth widely and thus release the finger. After the tip of the instrument is engaged in the pharynx it sometimes assists in the manipulation if the patient’s head be now tipped a little forward. This manipulation is not very different from that by which a small and long flexible rubber tube may be inserted through the nostril into the stomach for the purpose of feeding, as is frequently done with the insane who refuse to eat, or may be done in the presence of certain diseased conditions.

The intent in this exploration is to determine the distance from the upper incisor teeth of the obstruction, as well as its caliber. When the instrument is withdrawn the surgeon marks the location of the teeth by grasping it at this point with the thumb, and the distance is measured off afterward so that it may be read in inches if desired. The caliber is determined by the success or non-success met with in passing an instrument of given diameter. The size with which the attempt should be made may be determined largely by the history and statement of the patient. With a patient who cannot swallow no ordinary bougie should be expected to pass, while a small solid instrument might produce a perforation. Flexible bougies are also provided by the instrument makers, made as are the silk catheters, some of them being loaded with small shot in order to give them a certain degree of weight. A small, soft, flexible instrument may be thus passed when the ordinary probang would fail. Here, as in the urethra, an olivary bougie may pass, after which the same sort of resistance will be offered upon its withdrawal. In this case the stricture is passed twice, going and coming. A slight degree of constriction is met opposite the cricoid cartilage at the entrance to the esophagus. This should not be mistaken for a pathological condition. Information may be afforded by material brought up by the instrument, such as shreds of tissue, blood, etc. A small bougie coated with sponge may be used for the purpose of retaining and bringing back such material as it may engage.

It will be of assistance to let the patients dissolve in the mouth a tablet containing a little cocaine and swallow it, or to spray or gargle the pharynx with a weak solution. It prevents the gagging and discomfort of an operation which otherwise is almost painless.

ESOPHAGEAL HEMORRHAGE.

Esophageal hemorrhage occurs especially in connection with cirrhosis of the liver. Stockton and others have called attention to a peculiar varicose condition of the esophageal veins in certain of these cases, and the possibility of repeated hemorrhages which may terminate fatally. The same is true of obstructive jaundice with Riedel liver.

CANCER OF THE ESOPHAGUS.

Cancer of the esophagus may be either primary or secondary, and may be either sarcoma or carcinoma. Its first expression will be ulcerative or stenotic, according as it originates on the inner surface or not. Sooner or later it will produce stricture, with the ordinary evidences thereof, and is to be detected in the same way. Cancer is usually of the carcinomatous type or squamous epithelioma. The disease is more common near the lower than the upper end of the canal. The disease spreads and involves the adjoining lymphatics, as well as various other structures. In addition to the ordinary evidences of stricture it is accompanied by a certain degree of pain, which is likely to be referred to the _interscapular_ region or the back of the neck. The emaciation which always accompanies it is not merely an expression of the disease itself, but of the starvation which stricture in time produces. Frequent expulsion of bloody mucus or shreds is extremely indicative.

Esophageal cancer admits only of esophagectomy, as a very unusual method of relief, or gastrostomy, which is a palliative measure intended to prevent death from starvation, but not affording exemption from the advance of the disease.

OPERATIONS UPON THE ESOPHAGUS.

Operations upon the esophageal canal include:

1. Dilatation;

2. Internal esophagotomy;

3. External esophagotomy;

4. Esophagectomy.

1. _Dilatation_ is practised ordinarily with olivary or conical-tipped bougies. The former are usually metal or ivory tips fastened to a firmer handle, while the latter are fashioned like silk catheters having more or less conical tips. These are introduced until they are engaged within the stricture, after which the amount of pressure or force used should be graduated to the character of the trouble, the density of the tissues, and the tolerance of the patient. Daily dilatation may be practised either for the prevention or relief of strictures following cicatrices due to caustic fluids and the like. A small passage may in time be stretched up to nearly the normal diameter, after which instruments may be passed at regular intervals, as the tendency to recontraction is inevitable. These methods of dilatation have taken the place of more complicated mechanical procedures performed with instruments like those intended for use in the urethra. The writer has, however, in one or two instances used with advantage the Otis dilating urethrotome in cicatricial strictures of the gullet.

2. _Internal esophagotomy_ is practised either with instruments carrying concealed blades, like those used within the urethra, or by a method suggested by Abbe, where the stomach is first opened, and a retrograde divulsion effected, or at least a small bougie is pushed upward from beneath. When its tip is felt in the mouth there is firmly attached to it a strong silk thread which, as the instrument is withdrawn, is brought down into the stomach and then out through the stomach opening. With one hand in the stomach and the other in the mouth this thread is then manipulated in such a way as to saw through the strictured passage. It is well, should the surgeon use silk in this way as he would use a Gigli saw, to pass it through a piece of rubber tubing, both above and below, in order that its sawing effect may be limited to the esophagus proper. This is a procedure which should be done with great precaution. The operator should stop at short intervals, and, by using a bougie, satisfy himself whether the strictured passage has been enlarged. When the desired result has been attained the thread is withdrawn, the stomach and abdominal wounds closed, and dilatation resorted to every day or two in order that the benefit gained may be maintained.

The use of the _esophagoscope_ may permit the exposure of a cicatricial band or an annular stricture, so placed that it may be divided by a fine knife directed through the tube. Whatever cutting is done in this region should be done cautiously, so as to avoid injuring adjoining structures.

3. _External esophagotomy_ is easily performed for the removal of foreign bodies. When done from below it may be combined with a gastrotomy, the cardiac end of the esophagus being thus exposed and exploring instruments or those intended for either removal of foreign material or division of stricture being thus introduced. After the measure is complete the stomach is first closed and then the abdomen.

4. _Esophagectomy_ is an operation undertaken from without, and is seldom performed for other purposes than for the removal of malignant growths. A cancer of the esophagus should be seen early and be favorably located in order to be amenable to such a radical measure, yet cases of this kind have been successful. Too often, however, they are done too late. The esophagus is exposed by the same incision as that described for esophagotomy, namely, on the left side along the anterior border of the sternomastoid, the vessels and nerves being retracted to either side in such a way as to permit its clear exposure. The portion to be removed is then isolated by blunt dissection and resected. This leaves two ends of the canal, which can usually be brought together by sutures, after the fashion of an end-to-end intestinal anastomosis. The principal difficulty met with will be adhesions and infiltration caused by extension of disease, and these of themselves in well-marked cases would be contra-indications to operation.

=Transthoracic Resection of the Esophagus.=--Bryant and others have shown how the esophagus may be exposed from the posterior aspect of the thorax by a _posterior thoracotomy_, made in the third and fifth intercostal spaces, where, by resection of the ribs and dissection, the esophagus may be exposed behind the hilum of the lung. The azygos vein which crosses it at about this level should be either retracted or divided after a double ligation. Experimentation has shown that it is possible at this point to stretch the tube in such a way as to permit of restoration of its caliber, if but a small amount have been removed, but great care should be exercised, otherwise tension would be extreme. Because of the doubt regarding the success of such a resection Mikulicz has suggested the following procedure of _externalization of the esophagus_: After exposure the distal end of the esophagus is closed and dropped back. An opening is next made along the anterior border of the sternomastoid, where the esophagus is exposed, pulled up and out of its situation--_i. e._, dislocated--and brought out through the upper opening, which can be done because of its loose connective-tissue surroundings. A third incision is then made over the second intercostal space in front, where a bridge of skin is lifted up, the esophagus drawn down beneath it and fastened, the intent being to connect this opening with the stomach through a gastric fistula by means of some special apparatus, thus making it possible to again feed the patient through the mouth. The incisions in the back are closed by layer sutures. The principal objection to this method is that the passage of fluid through the _externalized_ portion of the esophagus would have to be accomplished by massaging the part and forcing it down through the tube. Sauerbruch and others have shown that in animals at least it is possible to make a transdiaphragmatic anastomosis of the stomach and esophagus. By much the same method as that last above described, _i. e._, through a posterior opening, the esophagus can be exposed near its lower end, resected, and then turned into an opening in the stomach, the latter having been brought up through an opening in the diaphragm. It is hardly necessary to go into details of this operation here, since the occasions which would justify it are almost as rare as the individuals who could be entrusted with its performance.

OPERATIONS UPON THE THORAX.

_Exploratory puncture_, either of the pericardial sac or of a pleural cavity, is an exceedingly simple matter, the ordinary hypodermic needle sufficing for many instances, while in some cases the contained fluid will be too thick to flow through a finer needle and will necessitate the use of a larger one. Such needles are furnished, with so-called exploring syringes, and their use is a convenient preliminary to the use of the aspirator--_i. e._, _thoracentesis_--or open division--_i. e._, _thoracotomy_. It is essential that both the patient’s integument, the instrument, and the operator’s hands be absolutely clean. When several points are explored at one time and fluid is found at but one it is well to indicate this with a little nitrate of silver or tincture of iodine, which will make a temporary mark. Thoracentesis implies a withdrawal of fluid through a hollow needle, which will make a small puncture that will promptly close, a vacuum apparatus of some kind being attached to it. The needle may be introduced at various points to enter either the pericardium or the pleura. Ordinarily no harm pertains to exploratory puncture and but little to withdrawal of fluid, providing certain precautions are used, though fatal syncope has been known to immediately follow it. Beyond absolute sterilization the most important feature is to withdraw fluid slowly rather than rapidly, and to desist so soon as symptoms of a serious nature appear, such as faintness or collapse. When a collection of fluid has existed for some time in one of the pleural cavities it may have gradually so displaced the heart that its too sudden withdrawal may permit a too sudden restoration to its normal position--so sudden, in fact, as to place extra stress upon it and perhaps to seriously embarrass or completely check its action. This is always a matter requiring attention. The position of the patient also should be regarded, and a patient who is seated in a chair, in order that fluid may gravitate to the lower part of the chest cavity, should be promptly placed in the recumbent position so soon as alteration in pulse or coughing or serious embarrassment of respiration are noted.