Manual of Surgery Volume II Part 65

The _treatment_ consists in administering solutions of carbonate of potash, of soda, or of magnesia when an acid has been swallowed, or vinegar diluted with water in the case of an alkali. When carbolic acid has been swallowed, a large quant.i.ty of olive oil should be administered. The stomach should be washed out with water, the tube being pa.s.sed with the greatest gentleness to avoid perforating the softened sophageal wall. Subsequently the patient should be fed by the r.e.c.t.u.m, but, in the majority of cases, gastrostomy is called for to enable the patient to take nourishment and put the gullet at rest.

As soon as the sophagus has healed, say in three or four weeks, bougies should be pa.s.sed every three or four days to prevent cicatricial contraction. As the calibre of the tube is restored, the instruments may be pa.s.sed less frequently, but for some years--it may be for the rest of the patient's life--a full-sized bougie should be pa.s.sed at least once a month.

#Impaction of Foreign Bodies in the Pharynx and sophagus.#--It is an interesting fact that foreign bodies, even as large as a dinner fork, when intentionally swallowed, can pa.s.s through the pharynx and sophagus and enter the stomach without apparent difficulty. When the body is accidentally swallowed impaction is more liable to take place, probably on account of the spasm induced by fright and by inco-ordinated attempts to eject it. For obvious reasons the accident is most liable to occur in children, in epileptics, and in those who are under the influence of alcohol. It happens also during anaesthesia for the extraction of teeth or if the patient vomits solid substances.

The clinical aspects vary according as the object is impacted in the pharynx or in the sophagus.

_In the Pharynx._--If a large bolus of unmasticated food becomes impacted in the pharynx, it blocks the openings of both the sophagus and the larynx, and the patient may, without manifesting the usual signs of suffocation, suddenly fall back dead, and if he happens to be alone at the time of the accident, the cause of death is liable to be overlooked unless the pharynx is examined at the post-mortem examination. Most surgical museums contain specimens ill.u.s.trating the impaction of a bolus of meat in the pharynx; this fatal accident has occurred especially in men in a condition of alcoholic intoxication.

An object of irregular shape, for example a large denture, also, is most likely to lodge in the pharynx, obstructing the openings of both the sophagus and the larynx, and causing suffocation. The face immediately becomes blue and engorged, the patient is speechless, and violent efforts are made to eject the object by retching and coughing.

It may be seen from the mouth and touched with the finger.

In the case of small sharp bodies, such as fish, game, and mutton bones, there is not the same urgency, and a methodical search for the foreign body is carried out. Even after the foreign body has been got rid of, the patient may have the sensation that it is still present.

This may be due to a scratch of the mucous membrane, or to spasm, in which case the swallowing of a few drops of cocain solution will cause the sensation to disappear.

_Treatment._--In the presence of impending suffocation, the mouth must be forced open by an extemporised gag, the finger pa.s.sed into the back of the throat, and the body hooked out. If this is impossible, and if suitable forceps are not at hand, it may be necessary at once to perform laryngotomy, followed by artificial respiration, because, although the patient may appear lifeless, the heart continues to beat after breathing has ceased. The foreign body should then be removed with forceps. Sub-hyoid pharyngotomy, which consists in opening the pharynx by a mesial vertical incision carried through the hyo-thyreoid membrane, may be called for, as in the case of a denture, the hooks of which have penetrated the wall of the pharynx.

_In the sophagus._--Smaller bodies, such as coins, bones, or pins, usually enter the sophagus, and the great majority become impacted above the level of the manubrium sterni. Those that pa.s.s farther down are liable to stick where the tube is narrowed at the crossing of the bronchus, or at the opening through the diaphragm. In children, coins predominate and are nearly always arrested at the level of the upper end of the sternum; in adults, dentures are the commonest foreign bodies, and may be impacted anywhere.

At the moment of impaction there is pain, which a.s.sumes the character of cramp due to spasm of the muscular coat, and which is increased on attempting to swallow, and violent retching and coughing are set up; in many cases, as when bodies are impacted in the pharynx, respiratory distress is again the predominant feature. If the pa.s.sage is completely obstructed, food and saliva--sometimes blood-stained--are regurgitated with retching soon after being swallowed. When the obstruction is incomplete, fluids may pa.s.s into the stomach while solids are regurgitated.

If the mucous membrane is injured, there is severe stabbing pain and choking attacks, both due to spasm, sometimes even after the body has pa.s.sed on, and the pain is not always referred to the seat of the injury.

The _diagnosis_ is made by the history, and by the use of the fluorescent screen, or X-ray photographs (Figs. 283, 284). The sophagoscope is also of great value, both for diagnostic purposes and as an aid in the removal of the impacted body. Bougies are to be employed with great care, as there is a danger of pushing the foreign body farther down, or of wedging it more firmly in the sophagus, and the information obtained is often misleading.

[Ill.u.s.tration: FIG. 283.--Radiogram of Safety-pin impacted in the Gullet and perforating the Larynx.

(Professor Annandale's case. Radiogram by Dr. Dawson Turner.)]

[Ill.u.s.tration: FIG. 284.--Denture impacted in sophagus.

(Professor F. M. Caird's case.)]

It should be borne in mind that drunkards may suffer from a form of spasm of the sophagus, which simulates the impaction of a foreign body; hospital records also show that the patient may only have dreamt that he has swallowed a foreign body, usually a denture. These possibilities should be always excluded before further procedures are undertaken.

_Treatment._--There being no urgency, a careful examination is carried out, not only to confirm the impaction of a foreign body, but its site and its relation to the wall of the gullet. In skilled hands, the safest and most certain means of removing impacted foreign bodies is with the aid of the sophagoscope. If this apparatus is not available, other measures must be adopted varying with the nature of the body, its site, and the manner of its impaction.

A bolus of food, for example, or a small smooth object that is likely to pa.s.s safely along the alimentary ca.n.a.l, if it cannot be extracted with forceps, may be pushed on into the stomach by the aid of a bulbous-headed or sponge probang. This must be done gently, especially if the body has been impacted for any time, as the inflammatory softening of the sophageal wall may predispose to rupture.

Small, sharp, or irregular objects, such as fish bones, tacks, or pins, may be dislodged by the "umbrella probang"--an instrument which, after being pa.s.sed beyond the foreign body, is expanded into the form of a circular brush which, on withdrawal, carries the foreign body out among its bristles.

Coins usually lodge edgewise in the sophagus, and are best removed by means of an instrument known as a "coin-catcher", which is pa.s.sed beyond the coin, and on being withdrawn catches it in a hinged f.l.a.n.g.e.

In emergencies a loop of stout silver wire bent so as to form a hook makes an excellent subst.i.tute for a coin-catcher.

In difficult cases the removal of solid objects is facilitated by carrying out the manipulations in the dark room with the aid of the X-rays and the fluorescent screen.

Irregular bodies with projecting edges or hooks, such as tooth-plates, tend to catch in the mucous membrane, and attempts to withdraw them by forceps or other instruments are liable to cause laceration of the wall. When situated in the cervical part of the sophagus, these should be removed by the operation of _sophagostomy_ (_Operative Surgery_, p. 195).

If the foreign body is lodged near the lower end of the gullet, it may be necessary to perform _gastrostomy_ (_Operative Surgery_, p. 291), making an opening in the anterior wall of the stomach large enough to admit suitable forceps, or, if necessary, the whole hand, in order that the body may be extracted by this route; experience shows that an impacted body is more easily extracted from below, that is, from the stomach, than from above.

When the surgeon fails to remove the body by either of these routes, _gastrostomy_ must be performed both to feed the patient and to place the gullet at rest. Smooth bodies may lie latent for long periods, but those with points or hooks damage the mucous membrane, cause ulceration and perforation with the risk of erosion of vessels and secondary haemorrhage or of cellulitis of the neck or mediastinum and empyema.

Other complications include septic broncho-pneumonia from damage to the air-pa.s.sage, and suppurative thyreoiditis.

#Infective conditions# due to pyogenic infection (_sophagitis_ and _peri-sophagitis_) are rare.

A _chronic form of sophagitis_ is occasionally met with in alcoholic subjects, giving rise to symptoms that simulate those of impacted foreign body, or of stricture.

In _tuberculous_ lesions the symptoms are pain, dysphagia, and regurgitation of food mixed with blood, and the condition is liable to be mistaken for gastric ulcer or for cancer of the sophagus.

_Syphilitic affections_ of the sophagus are rare.

#Varix# at the lower end of the sophagus may give rise to haematemesis, and be mistaken for gastric ulcer. Bleeding from the dilated veins may follow the use of bougies or of the sophagoscope.

CONDITIONS CAUSING DIFFICULTY IN SWALLOWING

Difficulty in swallowing may arise from a wide variety of causes which it is convenient to consider together.

#Impaction of Foreign Bodies# has already been discussed, and attention has been drawn to the importance of the history given by the patient and to the various sources of fallacy or deception--in children it may be artful reticence or misrepresentation, in adults, the possibility of nightmare and of dreams.

#Compression of the Gullet from without.#--Any one of the numerous structures in relation to the gullet may, when enlarged as a result of disease, give rise to narrowing of its lumen, for example a lymph-sarcoma at the root of the lung, or any enlargement of the thyreoid or of the mediastinal lymph glands. The possibility of aneurysm must always be kept in mind because of the risk attending the pa.s.sage of instruments for diagnostic purposes.

#Spasm of the Muscular Coat.#--As in other tubular structures containing circular muscular fibres, sudden contraction or spasm may occur in the sophagus and cause narrowing of the lumen, attended with difficulty in swallowing. This spasmodic dysphagia includes such widely varying conditions as the "globus hystericus" of neurasthenic women, the spasm of chronic alcoholics, and the affection known as _cardiospasm_ or "hiatal sophagismus."

In contrast with other affections causing difficulty in swallowing, spasmodic dysphagia usually has a sudden and unexplained onset, the progress of symptoms is irregular and erratic, while the remission of symptoms common to all affections of the sophagus, and the influence of mental impressions, such as excitement, hurry in the presence of strangers, are exaggerated.

In testing the calibre of the gullet it is found that on one occasion a full-sized bougie may pa.s.s easily and be completely arrested at another.

Apart from the treatment of the neurosis underlying the dysphagia, reliance is placed upon dilatation of the portion of gullet affected.

#Cardiospasm# is the name given to "a recurrent interference with deglut.i.tion by spasmodic contraction of the lower end of the sophagus." As there is no muscular or nervous mechanism at the cardiac end of the sophagus forming a true sphincter, the term "sophagospasm" would be more accurate (D. M. Greig).

According to H. S. Plummer, who has had an experience of 130 cases, there are three stages in the development of this condition. In the initial stage, the first attack occurs suddenly and unexpectedly; a choking sensation is felt at some point in the gullet, usually at its lower end. Attacks of choking with difficulty in swallowing occur chiefly at meals, but they have also been known to occur apart from the taking of food. In this stage the peristalsis of the gullet is sufficient to force the food through the cardia.

In the second stage, the peristalsis of the gullet above being no longer able to overcome the contraction, there is regurgitation of food, which at first is returned to the mouth immediately after being swallowed, but, as the gullet becomes dilated, is retained for longer periods.

In the third stage, the gullet becomes more and more dilated, and the food collects in it and is regurgitated at irregular intervals. The patient complains of a sensation of weight and discomfort in the lower part of the chest, and sometimes of regurgitation of food into the nasal pa.s.sages during sleep.

Cardiospasm should be suspected as the cause of difficulty in swallowing if a rubber tube cannot be pa.s.sed into the stomach while a solid one can. When it is impossible to pa.s.s a solid instrument in the ordinary way it can always be pa.s.sed on a silk thread as a guide. The patient is directed to swallow 6 yards of silk thread, half in the afternoon and the remainder on the following morning. The first portion forms a snarl in the gullet or stomach which pa.s.ses out into the intestine during the night; the proximal end is fixed to the cheek by a strip of plaster. The olive heads of the bougies are drilled for threading from the tip to one side of the base.

The _treatment_ consists in dilating the contracted segments by a bougie. The results are immediate and are most striking, the patients being almost invariably able to take any kind of food at the following meal, and the gain in weight and strength is rapid. In a small proportion of cases, dilatation fails to give relief, and recourse has been had to anastomosing the lower end of the dilated and pouched sophagus with the stomach.

#Paralysis of the Gullet.#--As the pa.s.sage of the food along the gullet is entirely dependent upon muscular peristalsis, when the muscular coat is paralysed, as it may be after diphtheria, for example, the patient is unable to swallow and the food materials are regurgitated, with consequent loss of flesh and strength. The difficulty may be tided over for a time by feeding through a rubber tube, but it is to be remembered that, in children, struggling in resisting the pa.s.sage of the tube may seriously strain a heart that is already threatened by the toxins of diphtheria.

#Diverticula or Pouches of the Gullet.#--A diverticulum consists in the protrusion of the mucous and submucous coats through a defect or weak part in the muscular tunic; it is therefore of the nature of a hernia and not a localised dilatation of the tube as a whole.

Anatomically, there is such a weak spot in the posterior wall opposite the cricoid cartilage, known as the _pharyngeal dimple_, between the circular and oblique fibres of the crico-pharyngeus muscle. As the pouch increases in size by pressure from within, it usually extends downwards and to the left. This pouch is described as a _pressure or pulsion diverticulum_ because the hernial protrusion is ascribed to increased pressure within the pharynx, not only the normal increase caused by the act of swallowing, but an abnormal pressure from the too rapid swallowing or bolting of imperfectly masticated food materials.

[Ill.u.s.tration: FIG. 285.--Radiogram, after swallowing an opaque meal, in a man suffering from malignant stricture of lower end of Gullet.]