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.
Fig. 517
Stricture of the esophagus. (Dennis.)
Fig. 518
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.