ESOPHAGUS, Foreign Bodies in.
Thu fluorescent screen, a skiagram or the cesophagoscope should be employed to determine the position and nature of the impacted object when the history of the case and the signs do not afford sufficient data for treatment. Small angular objects, fish-bones, pins, &c., are best dealt with by the umbrella probang made of horsehair, which is gently coaxed past the object; on withdrawal, the expanding brush entangles the foreign body, which is brought up in its meshes. Cheatle's steriliser forceps are frequently successful in withdrawing coins or other similar objects lodged about the level of the larynx.
Coins can be extracted sometimes in the same manner, as they are easily passed by the instrument, since they generally lie edgewise in the gullet; but the instrument known as the coin-catcher or money probang is more suitable. In the absence of a suitable probang a skein of thread attached to the end of a flexible Bougie makes a suitable substitute, in which the body may he entangled as it is withdrawn. Cregny advises in such cases that a skein of thread rolled up in a globular form, to which a piece of stout ligature silk is attached, should be swallowed in jam or butter, and after the foreign body has been passed the thread may be pulled up by dragging upon the silk. As it is withdrawn, the foreign body may be found entangled in its meshes. Swallowing a large bolus of bread may carry small fish-bones and bristles before it into the stomach. Where the foreign body is soft, it may be gently pushed down by the point of the prohang or by the tube of the stomach-pump until it enters the stomach.
Occasionally the act of vomiting may be made to dislodge impactions. This may he induced by tickling the mucus or by giving Apomorphine gr.) If) podermieally. It is not, however, a safe practice when the body is of sulficient dimensions to completely block up the tube, as a rupture below it might possibly take place. A smart slap with the open hand, applied between the shoulders. is a popular. safe, and sometimes successful procedure when the body is lodged high up.
If a hard angular body be pushed down into the stomach in the efforts used for its removal. purgatives should not be administered. but firm pultaceous food or dry biscuits may be given with the view of enveloping the object and shielding the intestinal and gastric walls from its angu larities. A diet of hard-boiled eggs is, in the writer's opinion. the best means of carrying out this object.
A hard angular body should never he pushed downwards by the probang or Bougie. A careful attempt may be made to extract it by using a suitable curved forceps guided by the cesophagoscope or the X rays, but no considerable degree of force should he applied, otherwise dangerous laceration may be produced. This is liable to occur with the sharp hooks
or edges of dental plates. and as a rule, when such have entered well into the gullet, they should be removed by the operation of cesophag,otomy. If the plate has become impacted in the pharynx or entrance of the gullet, it may be possible to extract it by the fingers of the surgeon, as a pretty accurate estimate of the danger of laceration may be made by the degree of resistance experienced. Before any attempt at cesophagotomy can he made the presence of urgent symptoms of suffocation may demand a prompt opening of the larynx or trachea in order to admit air to the lungs, and even artificial respiration may be necessary.
The operation of cesophagotomy is performed by an incision 34 to 4 inches long made immediately in front of the interior border of the left sterno mastoid muscle. The gullet is reached after retracting the carotid sheath, sterno-mastoid and omohyoid outwards and the depressors of the hyoid bone and the trachea inwards. The tube is opened in its long axis over the end of a soft stomach-tube introduced through the mouth, care being taken to avoid injury to the recurrent laryngeal nerve which lies in front of it. The foreign body is then cautiously extracted with gentleness and the wound in the oesophagus sutured with catgut and suitable drainage instituted for the skin wound. No food should be allowed for 3 or 4 days, and then liquids may be introduced into the stomach through a soft rubber tube, rectal feeding being instituted in the meantime. This operation, like that for an msophageal pouch, is often done in two stages as described in last article. _ Where the foreign body has lodged in the lower end of the gullet near the stomach, the operation of gastrotomy should be performed, and the object extracted through the gastric opening. When its removal is found impossible it should be left in situ and the patient fed through the gastric opening with the hope that after the subsidence of spasm the body may drop into the stomach, from which it can afterwards be removed through the original opening. Mediastinal cesophagotomy is almost invariably fatal, and the best procedure is to leave the case to Nature and patient feeding through the gastric opening without attempting to pull the foreign body upwards through the mouth by probangs or coin-catchers.
Torek's operation for the resection of the thoracic portion of the gullet in cancer by the transpleural route by an incision through the entire length of the seventh intercostal space and the division of the fourth to the seventh ribs has demonstrated the possibility of reaching any foreign body in the lower part of the gullet.