Extraction of Foreign Bodies from the Strictured Esophagus.—Foreign bodies of relatively small size will lodge in a strictured esophagus. Removal may be rendered difficult when the patient has an upper stricture relatively larger than the lower one, and the foreign body passing the first one lodges at the second. Still more difficult is the case when the second stricture is considerably below the first, and not concentric. Under these circumstances it is best to divulse the upper stricture mechanically, when a small tube can be inserted past the first stricture to the site of lodgement of the foreign body.
Prolonged sojourn of foreign bodies in the esophagus, while not so common as in the bronchi is by no means of rare occurrence. Following their removal, stricture of greater or less extent is almost certain to follow from contraction of the fibrous-tissue produced by the foreign body.
Fluoroscopic esophagoscopy is a questionable procedure, for the esophagus can be explored throughout by sight. In cases in which it is suspected that a foreign body, such as pin, has partially escaped from the esophagus, the fluoroscope may aid in a detailed search to determine its location, but under no circumstances should it be the guide for the application of forceps, because the transparent but vital tissues are almost certain to be included in the grasp.
[197] Complications and Dangers of Esophagoscopy for Foreign Bodies. Asphyxia from the pressure of the foreign body, or the foreign body plus the esophagoscope, is a possibility (Fig. 91). Faulty position of the patient, especially a low position of the head, with faulty direction of the esophagoscope may cause the tube mouth to press the membranous tracheo-esophageal wall into the trachea, so as temporarily to occlude the tracheal lumen, creating a very dangerous situation in a patient under general anesthesia. Prompt introduction of a bronchoscope, with oxygen and amyl nitrite insufflation and artificial respiration, may be necessary to save life. The danger is greater, of course, with chloroform than with ether anesthesia. Cocain poisoning may occur in those having an idiosyncrasy to the drug. Cocain should never be used with children, and is of little use in esophagoscopy in adults. Its application is more annoying and requires more time than the esophagoscopic removal of the foreign bodies without local anesthesia. Traumatic esophagitis, septic mediastinitis, cervical cellulitis, and, most dangerous, gangrenous esophagitis may be present, caused by the foreign body itself or ill-advised efforts at removal. Perforation of the esophagus with the esophagoscope is rare, in skillful hands, if the esophageal wall is sound. The esophageal wall, however, may be weakened by ulceration, malignant disease, or trauma, so that the possibility of making a false passage should always deter the endoscopist from advancing the tube beyond a visible point of weakening. To avoid entering a false passage previously created, is often exceedingly difficult, and usually it is better to wait for obliterative adhesive inflammation to seal the tissue layers together.
Treatment.—Acute esophagitis calls for rest in bed, sterile liquid food, and the administration of bismuth powder mentioned in the paragraph on contraindications. An ice bag applied to the neck may afford some relief. The mouth should be hourly cleansed with the following solution: Dakin's solution 1 part Cinnamon water 5 parts. Emphysema unaccompanied by pyogenic processes usually requires no treatment, though an occasional case may require punctures of the skin to liberate the air. Gaseous emphysema and pus formation urgently demand early external drainage, preferably behind the sternomastoid. Should the pleura be perforated by sudden puncture pyo-pneumothorax is inevitable. Prompt thoracotomy for drainage may save the patient's life if the mediastinum has not also been infected. Foreign bodies ulcerating through may reach the lung without pleural leakage because of the sealing together of the visceral and parietal pleurae. In the serious degrees of esophageal trauma, particularly if the pleura be perforated, gastrostomy is indicated to afford rest of the esophagus, and for alimentation. A duodenal feeding tube may be placed through an esophagoscope passed into the stomach in the usual way through the mouth, avoiding by ocular guidance the perforation into which a blindly passed stomach tube would be very likely to enter, with probably dangerous results.
[199] CHAPTER XX—PLEUROSCOPY
Foreign bodies in the pleural cavity should be immediately removed. The esophageal speculum inserted through a small intercostal incision makes an excellent pleuroscope, its spatular tip being of particular value in moving the lung out of the way. This otherwise dark cavity is thus brilliantly illuminated without the necessity of making a large flap resection, an important factor in those cases in which there is no infection present. The pleura and wound may be immediately closed without drainage, if the pleura is not infected. Excessive plus pressure or pus may require reopening. In one case in which the author removed a foreign body by pleuroscopy, healing was by first intention and the lung filled in a few days. Drainage tubes that have slipped up into the empyemic cavity are foreign bodies. They are readily removed with the retrograde esophagoscope even through the smallest fistula. The aspirating canal keeps a clear field while searching for the drain.
Pleuroscopy for Disease.—Most pleural diseases require a large external opening for drainage, and even here the pleuroscope may be of some use in exploring the cavities. Usually there are many adhesions and careful ray study may reveal one or more the breaking up of which will improve drainage to such an extent as to cure an empyema of long standing. Repeated severing of adhesions, aspiration and sometimes incision of the thickened visceral pleura may be necessary. The author is so strongly imbued with the idea that local examination under full illumination has so revolutionized the surgery of every region of the body to which it has been applied, that every accessible region should be thus studied. The pleural cavity is quite accessible with or without rib-resection, and there is practically no risk in careful pleuroscopy.
[201] CHAPTER XXI—BENIGN GROWTHS IN THE LARYNX
Benign growths in the larynx are easily and accurately removable by direct laryngoscopy; but perhaps no method has been more often misused and followed by most unfortunate results. It should always be remembered that benign growths are benign, and that hence they do not justify the radical work demanded in dealing with malignancy. The larynx should be worked upon with the same delicacy and respect for the normal tissues that are customary in dealing with the eye.