The Bristol
Medico-Chirurgical Journal "
Scire est
nescire, nisi id
me
Scire alius sciret
/
:
SUMMER,
FOREIGN
E.
BODIES
1929.
IN
THE\ GULLET.
Watson-Williams, M.C., Ch.M., F.R.C.S.
Surgeon-in-charge Ear, Nose and Throat Department, Bristol Royal Infirmary.
The
treatment of
&
the
patients with foreign bodies impacted
branch of surgery that has in recent gullet years undergone a complete change. Although the and were examined in the living stomach oesophagus subject by means of a tube as far back as the middle of the eighteenth century, clinical application of this method has been developed only during the twentieth. Before that development the means of dealing with such The accidents were distinctly primitive. down mass was or hooked up by pushed obstructing in
is
a
blind instrumentation.
oesophagotomy procedures Vol. XLVI.
were
No. 172.
in
the
fraught
If this neck
was
failed,
an
external
necessary.
with considerable
Both
risk, and k
110
Mr. E. Watson-Williams
accompanied by a serious mortality. One must admire ingenuity of the expanding probang and the hinged
the
But
coin-catcher. the
in
delicate
so
a
tube
the
as
of such
and
instruments, gentle oesophagus skilful though it were, carried a real danger of damage ; not solely from the instrument itself, but still more from the sharp edges or points of the foreign body. In a civilized community these appliances have now only one place?the museum. The cardinal principle of treatment is the avoidance of all blind methods, every step being conducted under direct vision. The patient or parent generally knows what the foreign body is, and how long it has been use
get some idea of where it is lodged. It must, however, be remembered that babies swallow a strange assortment of objects, and present.
the
Often, too,
possibility
looked in the
of
can
foreign body
a
of
case
we
small
a
should not be
patient
who has
over-
suddenly
degree of this smooth, flat, foreign body symptom more commonly fluids little disturbance cause ; may a few cases In taken. nothing at all can only can be be swallowed, owing to the size of the foreign body The
developed dysphagia.
varies much.
or
is
food
A
while if the obstruction is low
to reflex spasm ;
down
actual
taken
but
immediately returned. Difficulty in swallowing is not always due to the actual presence of a foreign body. Damage inflicted by its passage, or during attempts to dislodge it, may from spasm increase the feeling that there is something "
there." Pain indicates irritation
oesophagus. swallowing,
With
was
verified
cases
actual laceration of the it
slight damage
and fluids
records of six
or
can
usually
occurs
only
be taken.
on
I have
of this nature in which the laceration
by oesophagoscopy.
In two
cases
it had
Foreign Bodies
the
in
Gullet
111
been caused
by a probang, in one by thrusting down (? sharp edge or finger-nail), in three by the passage of the foreign body itself. For example, a woman who said she had swallowed a piece of glass in preserved fruit was found to have a deep laceration of the mucosa extending 2 cm. down from the lower a
sweet
border of the cricoid. mouthwash is used at
lozenges
In such
and formalin
frequent intervals,
be sucked.
can
disinfectant
a
cases
Food should be
fluid, sterile
and
iced, and if necessary half a drachm of orthoform given twenty minutes before feeding. Bismuth should follow a meal:?
powder may be
Bismuth.
&.
Oxycarb.
Lactos. A
powder
to be
.
.
placed
..
on
the
gr.
..
xx.
gr. xl.
..
tongue and swallowed
dry. Where
serious
damage has been inflicted complete inability to swallow, attempts increasing the pain which does .not cease in the more
there may be
intervals.
Some fever is
breath is fetid.
usual, and in
bad
a
Reflex salivation adds
case
materially
the to
the discomfort, and these patients should be nursed prone, the head to one side with only a small pillow under the
occiput. In this position saliva can dribble from the mouth, instead of overflowing into the trachea and rendering rest impossible. Proctoclysis two or three days until a fluid diet Three of my patients have needed this A still more serious condition was found
may be needed for
possible. treatment. m another, who said she had swallowed A
probang
had been
passed,
without
but from that time she could swallow
found that immediately below the
the
mucosa
had been
stripped
plum-stone. retrieving it,
a
nothing. I oesophageal entrance
from almost the whole
112
Mr. E. Watson-Williams
circumference
hung Gastrostomy was
distance of
over a
the
in
like
lumen
performed:
was
just
none
of the above
Two further
seen.
complete recovery. any foreign body
a
cases was
cases
are
described
safety-pin penetrated the wall pharynx ; the patient recovered. In sharp splinter of bone had been made oesophagus, with fatal results. one
At the other end of the scale evidence
only disappearance or
of
an
of
are
swallowing
is found in the
hypo-
the second to
pierce
those
A
!
grate
a
a
the
patients
the
is
sudden
object held in the mouth,
It is curious how often
denture.
In
below.
of the
a
whose
polypus.
after three weeks she
able to take fluids and made
In
2 cm., and
over
oedematous
an
missing
a
pin
denture
skiagram should always
immediately precede any operative search for the foreign body?immediately, as these bodies sometimes change their position. Before resorting to this we have, of course, examined the pharynx and larynx with the aid of suffices to locate farther down
an
and
;
object that the patient thought we
A or
must not
forget
that
a
body
of the Eustachian orifice
in the be
Quite often this method
mirror.
a
may neighbourhood along the border of the thyroid cartilage. skiagram will certainly show a denture, a needle, any but the most minute fragment of metal. Figures "
felt
"
41 and 42 show the appearance of
coin and
toy Glass, celluloid, fish-bones, possibly small pieces of wood or bone may escape detection, a
watch.
though
even
with
afford
some
help.
small
baby
that
because he had
"
these One
was
an can
may opaque meal recall the case of a
subjected
swallowed
"
a
to
oesophagoscopy safety-pin, which a
subsequent skiagram showed in the similar
a
meat and
case
I
was
myself
invited to
nose
!
remove
In
a very from the
Foreign Bodies
gullet of "
had
three weeks old
baby
a
Gullet
the
in
113
safety-pin
a
that he
The skiagram revealed it in the where it could not be seen from the
swallowed."
naso-pharynx, month and
felt
was
only
Once located its removal
with considerable was
easy.
43.) On another occasion I was by means of the oesophagoscope
skiagram When
disclosed in the
difficulty. (Figures 37 and retrieve
asked to a
needle that the
caecum.
have thus located the
foreign body, or when we feel, despite negative skiagraphy, that it is reasonably probable that there is one in the gullet, we
we
examine this
to
proceed
region by
The latter is
oesophagoscope. appropriate
to the age of the
electric
at the distal end.
as
light being more
delicate in
a
means
of
an
metal tube of size
patient, with
I use it without
manoeuvre.
a
small
a
handle,
It is
passed
down with great gentleness, no force at all being permissible ; and the oesophagus is closely examined "
the whole movement, to avoid over-riding.'* The need for care cannot be over-emphasized ; even
during an
object
so
blunt
as
penetrate the thin wall
general anaesthetic for It
nurslings. adults
even
is
can
many minutes.
farthing has been made to of the oesophagus. I prefer a this operation, except with
a
with
necessary
children, and few
tolerate the presence of the tube for It is extremely important that every-
proceed smoothly and without hurry or iuss. Coins are, as a rule, easily removed, though even with these one may regret demonstrating"
thing
should
"
uistead of
removing the coin
appearance of
a
half-penny
as
soon
as
when viewed
found.
The
through the With bulky
oesophagoscope is shown in Figure 22. objects, needing to be divided with shears, or bodies having hooks or spikes that require disimpaction, a problem of real difficulty may occur. Finally, special
114
Mr. E. Watson-Williams "
closer instruments may be called for, such as the for safety-pin point upward," illustrated in Figure 45.
Figuke 45. Figure 45.
Safety-pin closer, showing method of
A short
description
is
appended
use.
of the
fifty-three
objects in this series, so far as it is interesting (or recorded). Measurements are in each case from the incisor teeth to the nearest part of the foreign body. The youngest patient was three weeks old, the oldest 73 years, and with the made a good recovery. Coins.
Sixpence. Age 1.
Coin three
Coin found at 10
Penny. Age
Two
cm.
exception
one
Twenty-four days
in
mentioned all
Cases.
throat,
can
take fluids
from teeth and removed.
only. (Fig. 19.)
cases.
penny for the collection in his hand put the latter to his mouth to cover a cough, and Recovered from the thoracic inlet. the coin slipped down. 11.
(Fig. 2.) Age 6.
A
choir-boy, holding
A penny at level of
top
a
of sternum removed.
(Fig. 3.)
PLATE
Fig.1
cjl Flu.-2
Fig. 5
X.
Fig. 71
3?ig. (a
Fig. 9
Fio.1.5 Fig.1S
Fig.12.
6 Fig.1 Fig.16
Fig. 15
Era.714
Fig. 17
Fig. a 8
FigTII
EMJM
Fig.13
riG.3
^?PrEMZ3 Fig. 3
Em. 19 Eia.19
Fio.20 Fig .20
S5a:ZZ Fig.2! FSa.23. Fio.23
Foreign Bodies
Half-penny.
Eighteen
in
Gullet
the
115
cases.
Coin present two days, no symptoms. Radiogram shows it level with top of clavicle ; removed. (Fig. 1.) 1.
Age
Age 2. Coin swallowed same day, suprasternal notch. (Fig. 4., Coin
3.
Age
40 seconds.
just
below
removed from level of
removed in
cricoid,
Age
Coin at thoracic inlet ;
removed.
Age
3.
Coin at thoracic inlet ;
removed.
Coin in centre of chest,
4.
Age
removed. Coin
4.
Age
3
present
days,
can
take
no
Age
Removed from thoracic inlet.
Age
3.
Removed from
Age
3.
No
just
symptoms.
(Fig. 8.)
same
day,
found
(Fig. 9.)
of coin level with bottom of cricoid ; removed.
Age
2.
Top
Age
5.
Coin removed from
just
below cricoid in 1 minute
(Fig. 10.)
Age
3.
Removed from
Age
4.
Found at 12
15 seconds.
Age
above sternum.
Coin swallowed
behind cricoid and removed.
G.
Skiagram
(Fig. 7.)
7.
30 seconds.
solids.
Removed from behind left auricle at
in 15 minutes.
cm.
(Fig. 41.)
found at 20*5 cm. from
(Fig. 6.)
shows it behind heart. 255
minute
(Fig. 5.)
4.
teeth ;
1
just
cm.
above sternum.
(Fig. 11.)
from teeth, removed in 1 minute
(Fig. 12.) Coin at 15
Removed in
Age 4.
cm.
from teeth, i.e. well in thoracic inlet.
2 minutes 12 seconds.
This coin I found 1
cm.
(Fig. 13.) below
cricoid,
i.e. at thoracic
inlet. While demonstrating it, it was dislodged, and slipped down. It was recovered from just above the cardia ; time 16 minutes.
(Fig. 14.)
in throat, no symptoms ; removed from level of thoracic inlet. (Fig. 15.)
Age
3.
Coin two
Age
3.
Removed from
days
just
above sternum.
(Fig. 16.)
Mr. E. Wats on-Williams
116
Farthings.
Three
cases.
Age 2. Coin swallowed two days before, can only ; some dyspnoea. Coin removed from level (Fig. 17.) Age
4.
"
He has swallowed
half-penny."
a
found at level of left bronchus, 5
was
cm.
take fluids of clavicle. A
farthing
below thoracic inlet.
Time 20 minutes.
(Fig- 18.) Was playing with his money-box and swallowed a Age 4. farthing." Skiagram shows it level with top of sternum. On passing oesophagoscope edge of coin was seen and demonstrated ?it showed particularly well. On removal it was found that forceps had grasped two exactly apposed farthings. (Fig. 20.) "
Bones.
Female, aged
A chicken bone swallowed the
43.
removed from 35
Ten Cases.
cm.
below the teeth.
day before,
(Fig. 24.)
A rabbit bone
Female, aged lay in the left pyriform fossa, the point just visible by indirect laryngoscopy. (Fig. 25.) 42.
Meat bone swallowed three
days before ; oedema of left pyriform fossa observed by indirect laryngoscopy. Bone removed from immediately beneath this point by direct oesophagoscopy. (Fig. 26.) Male, aged
33.
38.
Female, aged
A rabbit bone
lying
much distress
the
sharp points causing opposite walls of the pharynx every which was frequently. (Fig. 27.) Male, aged
11.
This
case
is the
behind the
epiglottis, they pricked the the patient retched,
as
time
tragedy
of the series.
While
eating rabbit a bone stuck in his throat. His mother thrust cleared the throat." Next day he was her finger down and to me brought looking very ill, unable to swallow at all, with in the neck, worse on attempting to swallow. low great pain "
The breath
was
fetid and the temperature lOO^0 F.
A radio-
gram failed to show any foreign body, but does show some commencing opacity of the tissues behind the top of the sternum
(not noted before operation). and found
immediately
I
passed
an
below the cricoideus
oesophagoscope, sharp splinter
a
tLATE XI.
Fig. 24 Fig.31
.?FiG.za Fig728
Fkj.32 Fig.32
Fig. 25 Z5
Fig.29
Fig.26
3 Fig.3 Fl?-33
?mil
Era.32 Fig.M Fro.34 Fig.34
C?N TIMETA?S
Fig.27; 7 Fig.2
Lull mil mi
36 Fid. ?ia36
Fig. Fig. 35 35
Fig.37 Fio_37
Fio.3& Fig. 38
Fio.40 Fig.40 iFiG.3Q
(Note?Fig. (Note?Fig.
28 28 not to not to
scale). scale).
Foreign Bodies of bone
(Fig. 28) sticking
in the
Gullet
ont of the left wall of the
117
gullet,
which
The bone, which measured 2 2 cm., had penetrated the wall for about one-third of its length. On removing it, beads of pus began to escape. With punch forceps was
I
oedematous.
abscess into the lumen, and about a drachm of stinking pus welled up. Next day he could swallow fluids, but seemed ill, and on the third day there was definite broncho-
opened
an
pneumonia. to the
right
in front.
opacity. could be
An
of dullness could be
area
percussed
rather
of the mid-line in first and second intercostal spaces radiogram (Fig. 44) showed a large patch of
The
He remained very ill, so ill that no further operation done, and had attacks of faintness followed by gulping
up of fetid
pus?the abscess was draining, though not properly. Subsequent radiograms showed a diminution of the shadow, but increasing lung changes. Getting steadily worse, he died on the seventh day from the accident. At autopsy we found an abscess cavity, fairly well defined, running down outside the left wall of the oesophagus, and ending among the great Almost certainly vessels, and severe broncho-pneumonia. the bone had been pushed through the oesophageal wall by well meaning but disastrous attempts to dislodge it. It is of bone from and that that stews, noteworthy splinters soups and be be to cause severe sterile, always might supposed if and while infection immediate toys pins they penetrate ; that are often not even reasonably clean tend to produce much less damage. Female, aged
A mutton bone 17
42.
cm.
from the teeth,.
i.e. in thoracic inlet.
(Fig. 29.) Figure 30 is included here to show large what people will sometimes attempt to swallow ; it appears to have been lodged behind the cricoid, and was hawked up by the patient while preparations were being made to bone in
The
remove
of
it.
Female, aged 54. A large fish bone, apparently haddock, at thoracic inlet. (Fig. 31.)
Male, aged (Fig. 32.)
50.
from skull
Fish bone embedded in the vallecula.
118
Mr. E. Watson-Williams
Male, aged 33. Fish bone in base of tonsil, out of sight. The difficulty in these two cases was more (Fig. 34.) that of detecting the almost hair-like foreign body than of removing it. Male, aged 28. Stout fish bone at thoracic inlet. (Fig. 33.) Meat.
Seven Cases.
Pieces of meat may be
insufficiently chewed and so become swallowing being attempted ; or there may be impacted some pathological condition of the oesophagus producing arrest of a normal bolus. The cases included here are those only in because something stuck." which the patient came Female, aged 59. A piece of meat stuck the day before ; a probang had been used, which pushed it down about an The meat was firmly held by the lower part of the inch. on
"
inferior constrictor, and on removal was found to be two inches long, the middle constricted as if a string had been tied round it.
Female, aged
Bolus of hard
54.
meat
gristly
impacted
at
entrance.
oesophageal Female, aged 48. Some meat had stuck the previous day, since when everything she swallows comes up at once ; lower end of sternum. She has the behind always had pain of meat was found A a small swallow." large piece firmly impacted in the cardia ; so firmly that many fragments broke off when removal was attempted and the whole operation took nearly an hour. Male, aged 73. Never any trouble in swallowing till a "
"
"
week ago some meat stuck. Since then he has been unable to swallow anything at all. The skiagram shows an apparently normal
oesophagus
from teeth meat
with barium arrested in centre.
found, occupying
was
On removal, at 25
7
cm.
At 19
cm.
of the lumen.
small ulcer of the
posterior wall, bleeding easily touching. The lumen beyond was quite normal. Pathological report : carcinoma. Female, aged 55. Meat stuck in throat one day. A bolus of meat was found just above the cardia, which was apparently cm.
was seen a
on
PLATE XII.
Fig. 41
Fig. 43
Fig. 42
Fig. 44
Foreign Bodies
in
Gullet
the
completely obstructed by malignant growth ; difficulty in swallowing. Gastrostomy performed. Male, aged
carcinoma of the
swallowing
He had
55.
oesophagus,
no
been under
previously
previous
came
for
me
and after radium treatment
After several weeks he
well.
unable to take
119
was
up much worse,
and I
but
naturally supposed anything liquids, growth had recurred. On examination I found at the site of the growth, 22 cm. from teeth, a moderately firm fibrous stricture, covered with normal epithelium, and in it a small wedge of decomposing meat (confirmed by section). The stricture was dilated, without producing bleeding, and he is is doing well. the
Male, 34-5
36.
aged A
cm.
mass
Subject of an occupied 9
of meat
old
lye
cm.
of the
at
stricture,
oesophagus
above this. Dentures.
Four Cases.
Male, aged 33. A denture carrying two incisor teeth lodged top of sternum. Under direct oesophagoscopy it
at level of was
found that
of the
a
oesophagus,
metal hook the
pin
was
firmly
from which
a
fixed
broken being fixed in the right wall. version
on
the left wall
third tooth had been A
"
double internal
"
was needed to disimpact the two hooks, gullet being lifted away, and afterwards protected, by means of the lip of the oesophagoscope. At the moment when this had been accomplished, and before the denture could be seized, the patient vomited, and swallowed it down ; it was passed per vias naturales four days later. (Fig. 21.)
the
manoeuvre
wall of the
Male, aged 49. A large upper oesophageal entrance, and removed Female, aged 26. attempting to seize it, Male, aged
slipped
in
under
impacted in the general anaesthesia.
thoracic
down and
was
entrance.
passed
On
later.
large upper denture lying in the hypodays, the upper part visible by indirect Removed under local anaesthesia. (Fig. 23.)
48.
A
for seventeen
pharynx laryngoscopy.
Denture it
denture
120
Foreign Bodies Pins.
in
the
Gullet
Four Cases.
Baby noticed to have difficulty in Age 9 months. swallowing, and pin then missed. No dyspnoea. Radiogram shows pin lying open, to right of mid-line, point upwards at level of hyoid. Removed by direct pharyngoscopy. (Fig. 35.) Age 9 months. Swallowed a safety-pin thirteen days ago. Brought up with extreme dyspnoea, and much swelling of neck, and Mr. Angell James performed tracheotomy ; three days later he removed the pin through an incision in the neck swelling, only the head of it being then in the lumen of the hypopharynx. Recovery. Age Age larynx,
3 weeks.
See page 113.
A
10.
drawing-pin sticking removed. (Fig. 36.)
Age 1. fluids only. (Fig. 38.) 6.
Swallowed
a
"
Age
A brass disc the size of
will not take
rested.
Age
mucosa
days before,
anything.
a
key
take
and removed.
farthing
removed from
Watch removed from on
39 and
(Figs.
can
joint.
mucosa
Swallowed the
of the
cm.
Swallowed his tin watch two
ulceration of
Recovery. 3.
two
A small tin goat found at 13
11 months.
entrance ;
"
tin horse
the level of the sterno-clavicular
now
in the
Four Cases.
Toys.
Age
(Fig. 37.)
of
days before, oesophageal
either side where it had
42.) a
clockwork
mouse.
It
lay
top of the sternum, and the wings Removed from this shank upward. position under general
with the two
anaesthesia,
level with the
45 seconds.
(Fig. 40.)
Medico-Chirurgical Journal "
Scire est
nescire, nisi id
me
Scire alius sciret
/
:
SUMMER,
FOREIGN
E.
BODIES
1929.
IN
THE\ GULLET.
Watson-Williams, M.C., Ch.M., F.R.C.S.
Surgeon-in-charge Ear, Nose and Throat Department, Bristol Royal Infirmary.
The
treatment of
&
the
patients with foreign bodies impacted
branch of surgery that has in recent gullet years undergone a complete change. Although the and were examined in the living stomach oesophagus subject by means of a tube as far back as the middle of the eighteenth century, clinical application of this method has been developed only during the twentieth. Before that development the means of dealing with such The accidents were distinctly primitive. down mass was or hooked up by pushed obstructing in
is
a
blind instrumentation.
oesophagotomy procedures Vol. XLVI.
were
No. 172.
in
the
fraught
If this neck
was
failed,
an
external
necessary.
with considerable
Both
risk, and k
110
Mr. E. Watson-Williams
accompanied by a serious mortality. One must admire ingenuity of the expanding probang and the hinged
the
But
coin-catcher. the
in
delicate
so
a
tube
the
as
of such
and
instruments, gentle oesophagus skilful though it were, carried a real danger of damage ; not solely from the instrument itself, but still more from the sharp edges or points of the foreign body. In a civilized community these appliances have now only one place?the museum. The cardinal principle of treatment is the avoidance of all blind methods, every step being conducted under direct vision. The patient or parent generally knows what the foreign body is, and how long it has been use
get some idea of where it is lodged. It must, however, be remembered that babies swallow a strange assortment of objects, and present.
the
Often, too,
possibility
looked in the
of
can
foreign body
a
of
case
we
small
a
should not be
patient
who has
over-
suddenly
degree of this smooth, flat, foreign body symptom more commonly fluids little disturbance cause ; may a few cases In taken. nothing at all can only can be be swallowed, owing to the size of the foreign body The
developed dysphagia.
varies much.
or
is
food
A
while if the obstruction is low
to reflex spasm ;
down
actual
taken
but
immediately returned. Difficulty in swallowing is not always due to the actual presence of a foreign body. Damage inflicted by its passage, or during attempts to dislodge it, may from spasm increase the feeling that there is something "
there." Pain indicates irritation
oesophagus. swallowing,
With
was
verified
cases
actual laceration of the it
slight damage
and fluids
records of six
or
can
usually
occurs
only
be taken.
on
I have
of this nature in which the laceration
by oesophagoscopy.
In two
cases
it had
Foreign Bodies
the
in
Gullet
111
been caused
by a probang, in one by thrusting down (? sharp edge or finger-nail), in three by the passage of the foreign body itself. For example, a woman who said she had swallowed a piece of glass in preserved fruit was found to have a deep laceration of the mucosa extending 2 cm. down from the lower a
sweet
border of the cricoid. mouthwash is used at
lozenges
In such
and formalin
frequent intervals,
be sucked.
can
disinfectant
a
cases
Food should be
fluid, sterile
and
iced, and if necessary half a drachm of orthoform given twenty minutes before feeding. Bismuth should follow a meal:?
powder may be
Bismuth.
&.
Oxycarb.
Lactos. A
powder
to be
.
.
placed
..
on
the
gr.
..
xx.
gr. xl.
..
tongue and swallowed
dry. Where
serious
damage has been inflicted complete inability to swallow, attempts increasing the pain which does .not cease in the more
there may be
intervals.
Some fever is
breath is fetid.
usual, and in
bad
a
Reflex salivation adds
case
materially
the to
the discomfort, and these patients should be nursed prone, the head to one side with only a small pillow under the
occiput. In this position saliva can dribble from the mouth, instead of overflowing into the trachea and rendering rest impossible. Proctoclysis two or three days until a fluid diet Three of my patients have needed this A still more serious condition was found
may be needed for
possible. treatment. m another, who said she had swallowed A
probang
had been
passed,
without
but from that time she could swallow
found that immediately below the
the
mucosa
had been
stripped
plum-stone. retrieving it,
a
nothing. I oesophageal entrance
from almost the whole
112
Mr. E. Watson-Williams
circumference
hung Gastrostomy was
distance of
over a
the
in
like
lumen
performed:
was
just
none
of the above
Two further
seen.
complete recovery. any foreign body
a
cases was
cases
are
described
safety-pin penetrated the wall pharynx ; the patient recovered. In sharp splinter of bone had been made oesophagus, with fatal results. one
At the other end of the scale evidence
only disappearance or
of
an
of
are
swallowing
is found in the
hypo-
the second to
pierce
those
A
!
grate
a
a
the
patients
the
is
sudden
object held in the mouth,
It is curious how often
denture.
In
below.
of the
a
whose
polypus.
after three weeks she
able to take fluids and made
In
2 cm., and
over
oedematous
an
missing
a
pin
denture
skiagram should always
immediately precede any operative search for the foreign body?immediately, as these bodies sometimes change their position. Before resorting to this we have, of course, examined the pharynx and larynx with the aid of suffices to locate farther down
an
and
;
object that the patient thought we
A or
must not
forget
that
a
body
of the Eustachian orifice
in the be
Quite often this method
mirror.
a
may neighbourhood along the border of the thyroid cartilage. skiagram will certainly show a denture, a needle, any but the most minute fragment of metal. Figures "
felt
"
41 and 42 show the appearance of
coin and
toy Glass, celluloid, fish-bones, possibly small pieces of wood or bone may escape detection, a
watch.
though
even
with
afford
some
help.
small
baby
that
because he had
"
these One
was
an can
may opaque meal recall the case of a
subjected
swallowed
"
a
to
oesophagoscopy safety-pin, which a
subsequent skiagram showed in the similar
a
meat and
case
I
was
myself
invited to
nose
!
remove
In
a very from the
Foreign Bodies
gullet of "
had
three weeks old
baby
a
Gullet
the
in
113
safety-pin
a
that he
The skiagram revealed it in the where it could not be seen from the
swallowed."
naso-pharynx, month and
felt
was
only
Once located its removal
with considerable was
easy.
43.) On another occasion I was by means of the oesophagoscope
skiagram When
disclosed in the
difficulty. (Figures 37 and retrieve
asked to a
needle that the
caecum.
have thus located the
foreign body, or when we feel, despite negative skiagraphy, that it is reasonably probable that there is one in the gullet, we
we
examine this
to
proceed
region by
The latter is
oesophagoscope. appropriate
to the age of the
electric
at the distal end.
as
light being more
delicate in
a
means
of
an
metal tube of size
patient, with
I use it without
manoeuvre.
a
small
a
handle,
It is
passed
down with great gentleness, no force at all being permissible ; and the oesophagus is closely examined "
the whole movement, to avoid over-riding.'* The need for care cannot be over-emphasized ; even
during an
object
so
blunt
as
penetrate the thin wall
general anaesthetic for It
nurslings. adults
even
is
can
many minutes.
farthing has been made to of the oesophagus. I prefer a this operation, except with
a
with
necessary
children, and few
tolerate the presence of the tube for It is extremely important that every-
proceed smoothly and without hurry or iuss. Coins are, as a rule, easily removed, though even with these one may regret demonstrating"
thing
should
"
uistead of
removing the coin
appearance of
a
half-penny
as
soon
as
when viewed
found.
The
through the With bulky
oesophagoscope is shown in Figure 22. objects, needing to be divided with shears, or bodies having hooks or spikes that require disimpaction, a problem of real difficulty may occur. Finally, special
114
Mr. E. Watson-Williams "
closer instruments may be called for, such as the for safety-pin point upward," illustrated in Figure 45.
Figuke 45. Figure 45.
Safety-pin closer, showing method of
A short
description
is
appended
use.
of the
fifty-three
objects in this series, so far as it is interesting (or recorded). Measurements are in each case from the incisor teeth to the nearest part of the foreign body. The youngest patient was three weeks old, the oldest 73 years, and with the made a good recovery. Coins.
Sixpence. Age 1.
Coin three
Coin found at 10
Penny. Age
Two
cm.
exception
one
Twenty-four days
in
mentioned all
Cases.
throat,
can
take fluids
from teeth and removed.
only. (Fig. 19.)
cases.
penny for the collection in his hand put the latter to his mouth to cover a cough, and Recovered from the thoracic inlet. the coin slipped down. 11.
(Fig. 2.) Age 6.
A
choir-boy, holding
A penny at level of
top
a
of sternum removed.
(Fig. 3.)
PLATE
Fig.1
cjl Flu.-2
Fig. 5
X.
Fig. 71
3?ig. (a
Fig. 9
Fio.1.5 Fig.1S
Fig.12.
6 Fig.1 Fig.16
Fig. 15
Era.714
Fig. 17
Fig. a 8
FigTII
EMJM
Fig.13
riG.3
^?PrEMZ3 Fig. 3
Em. 19 Eia.19
Fio.20 Fig .20
S5a:ZZ Fig.2! FSa.23. Fio.23
Foreign Bodies
Half-penny.
Eighteen
in
Gullet
the
115
cases.
Coin present two days, no symptoms. Radiogram shows it level with top of clavicle ; removed. (Fig. 1.) 1.
Age
Age 2. Coin swallowed same day, suprasternal notch. (Fig. 4., Coin
3.
Age
40 seconds.
just
below
removed from level of
removed in
cricoid,
Age
Coin at thoracic inlet ;
removed.
Age
3.
Coin at thoracic inlet ;
removed.
Coin in centre of chest,
4.
Age
removed. Coin
4.
Age
3
present
days,
can
take
no
Age
Removed from thoracic inlet.
Age
3.
Removed from
Age
3.
No
just
symptoms.
(Fig. 8.)
same
day,
found
(Fig. 9.)
of coin level with bottom of cricoid ; removed.
Age
2.
Top
Age
5.
Coin removed from
just
below cricoid in 1 minute
(Fig. 10.)
Age
3.
Removed from
Age
4.
Found at 12
15 seconds.
Age
above sternum.
Coin swallowed
behind cricoid and removed.
G.
Skiagram
(Fig. 7.)
7.
30 seconds.
solids.
Removed from behind left auricle at
in 15 minutes.
cm.
(Fig. 41.)
found at 20*5 cm. from
(Fig. 6.)
shows it behind heart. 255
minute
(Fig. 5.)
4.
teeth ;
1
just
cm.
above sternum.
(Fig. 11.)
from teeth, removed in 1 minute
(Fig. 12.) Coin at 15
Removed in
Age 4.
cm.
from teeth, i.e. well in thoracic inlet.
2 minutes 12 seconds.
This coin I found 1
cm.
(Fig. 13.) below
cricoid,
i.e. at thoracic
inlet. While demonstrating it, it was dislodged, and slipped down. It was recovered from just above the cardia ; time 16 minutes.
(Fig. 14.)
in throat, no symptoms ; removed from level of thoracic inlet. (Fig. 15.)
Age
3.
Coin two
Age
3.
Removed from
days
just
above sternum.
(Fig. 16.)
Mr. E. Wats on-Williams
116
Farthings.
Three
cases.
Age 2. Coin swallowed two days before, can only ; some dyspnoea. Coin removed from level (Fig. 17.) Age
4.
"
He has swallowed
half-penny."
a
found at level of left bronchus, 5
was
cm.
take fluids of clavicle. A
farthing
below thoracic inlet.
Time 20 minutes.
(Fig- 18.) Was playing with his money-box and swallowed a Age 4. farthing." Skiagram shows it level with top of sternum. On passing oesophagoscope edge of coin was seen and demonstrated ?it showed particularly well. On removal it was found that forceps had grasped two exactly apposed farthings. (Fig. 20.) "
Bones.
Female, aged
A chicken bone swallowed the
43.
removed from 35
Ten Cases.
cm.
below the teeth.
day before,
(Fig. 24.)
A rabbit bone
Female, aged lay in the left pyriform fossa, the point just visible by indirect laryngoscopy. (Fig. 25.) 42.
Meat bone swallowed three
days before ; oedema of left pyriform fossa observed by indirect laryngoscopy. Bone removed from immediately beneath this point by direct oesophagoscopy. (Fig. 26.) Male, aged
33.
38.
Female, aged
A rabbit bone
lying
much distress
the
sharp points causing opposite walls of the pharynx every which was frequently. (Fig. 27.) Male, aged
11.
This
case
is the
behind the
epiglottis, they pricked the the patient retched,
as
time
tragedy
of the series.
While
eating rabbit a bone stuck in his throat. His mother thrust cleared the throat." Next day he was her finger down and to me brought looking very ill, unable to swallow at all, with in the neck, worse on attempting to swallow. low great pain "
The breath
was
fetid and the temperature lOO^0 F.
A radio-
gram failed to show any foreign body, but does show some commencing opacity of the tissues behind the top of the sternum
(not noted before operation). and found
immediately
I
passed
an
below the cricoideus
oesophagoscope, sharp splinter
a
tLATE XI.
Fig. 24 Fig.31
.?FiG.za Fig728
Fkj.32 Fig.32
Fig. 25 Z5
Fig.29
Fig.26
3 Fig.3 Fl?-33
?mil
Era.32 Fig.M Fro.34 Fig.34
C?N TIMETA?S
Fig.27; 7 Fig.2
Lull mil mi
36 Fid. ?ia36
Fig. Fig. 35 35
Fig.37 Fio_37
Fio.3& Fig. 38
Fio.40 Fig.40 iFiG.3Q
(Note?Fig. (Note?Fig.
28 28 not to not to
scale). scale).
Foreign Bodies of bone
(Fig. 28) sticking
in the
Gullet
ont of the left wall of the
117
gullet,
which
The bone, which measured 2 2 cm., had penetrated the wall for about one-third of its length. On removing it, beads of pus began to escape. With punch forceps was
I
oedematous.
abscess into the lumen, and about a drachm of stinking pus welled up. Next day he could swallow fluids, but seemed ill, and on the third day there was definite broncho-
opened
an
pneumonia. to the
right
in front.
opacity. could be
An
of dullness could be
area
percussed
rather
of the mid-line in first and second intercostal spaces radiogram (Fig. 44) showed a large patch of
The
He remained very ill, so ill that no further operation done, and had attacks of faintness followed by gulping
up of fetid
pus?the abscess was draining, though not properly. Subsequent radiograms showed a diminution of the shadow, but increasing lung changes. Getting steadily worse, he died on the seventh day from the accident. At autopsy we found an abscess cavity, fairly well defined, running down outside the left wall of the oesophagus, and ending among the great Almost certainly vessels, and severe broncho-pneumonia. the bone had been pushed through the oesophageal wall by well meaning but disastrous attempts to dislodge it. It is of bone from and that that stews, noteworthy splinters soups and be be to cause severe sterile, always might supposed if and while infection immediate toys pins they penetrate ; that are often not even reasonably clean tend to produce much less damage. Female, aged
A mutton bone 17
42.
cm.
from the teeth,.
i.e. in thoracic inlet.
(Fig. 29.) Figure 30 is included here to show large what people will sometimes attempt to swallow ; it appears to have been lodged behind the cricoid, and was hawked up by the patient while preparations were being made to bone in
The
remove
of
it.
Female, aged 54. A large fish bone, apparently haddock, at thoracic inlet. (Fig. 31.)
Male, aged (Fig. 32.)
50.
from skull
Fish bone embedded in the vallecula.
118
Mr. E. Watson-Williams
Male, aged 33. Fish bone in base of tonsil, out of sight. The difficulty in these two cases was more (Fig. 34.) that of detecting the almost hair-like foreign body than of removing it. Male, aged 28. Stout fish bone at thoracic inlet. (Fig. 33.) Meat.
Seven Cases.
Pieces of meat may be
insufficiently chewed and so become swallowing being attempted ; or there may be impacted some pathological condition of the oesophagus producing arrest of a normal bolus. The cases included here are those only in because something stuck." which the patient came Female, aged 59. A piece of meat stuck the day before ; a probang had been used, which pushed it down about an The meat was firmly held by the lower part of the inch. on
"
inferior constrictor, and on removal was found to be two inches long, the middle constricted as if a string had been tied round it.
Female, aged
Bolus of hard
54.
meat
gristly
impacted
at
entrance.
oesophageal Female, aged 48. Some meat had stuck the previous day, since when everything she swallows comes up at once ; lower end of sternum. She has the behind always had pain of meat was found A a small swallow." large piece firmly impacted in the cardia ; so firmly that many fragments broke off when removal was attempted and the whole operation took nearly an hour. Male, aged 73. Never any trouble in swallowing till a "
"
"
week ago some meat stuck. Since then he has been unable to swallow anything at all. The skiagram shows an apparently normal
oesophagus
from teeth meat
with barium arrested in centre.
found, occupying
was
On removal, at 25
7
cm.
At 19
cm.
of the lumen.
small ulcer of the
posterior wall, bleeding easily touching. The lumen beyond was quite normal. Pathological report : carcinoma. Female, aged 55. Meat stuck in throat one day. A bolus of meat was found just above the cardia, which was apparently cm.
was seen a
on
PLATE XII.
Fig. 41
Fig. 43
Fig. 42
Fig. 44
Foreign Bodies
in
Gullet
the
completely obstructed by malignant growth ; difficulty in swallowing. Gastrostomy performed. Male, aged
carcinoma of the
swallowing
He had
55.
oesophagus,
no
been under
previously
previous
came
for
me
and after radium treatment
After several weeks he
well.
unable to take
119
was
up much worse,
and I
but
naturally supposed anything liquids, growth had recurred. On examination I found at the site of the growth, 22 cm. from teeth, a moderately firm fibrous stricture, covered with normal epithelium, and in it a small wedge of decomposing meat (confirmed by section). The stricture was dilated, without producing bleeding, and he is is doing well. the
Male, 34-5
36.
aged A
cm.
mass
Subject of an occupied 9
of meat
old
lye
cm.
of the
at
stricture,
oesophagus
above this. Dentures.
Four Cases.
Male, aged 33. A denture carrying two incisor teeth lodged top of sternum. Under direct oesophagoscopy it
at level of was
found that
of the
a
oesophagus,
metal hook the
pin
was
firmly
from which
a
fixed
broken being fixed in the right wall. version
on
the left wall
third tooth had been A
"
double internal
"
was needed to disimpact the two hooks, gullet being lifted away, and afterwards protected, by means of the lip of the oesophagoscope. At the moment when this had been accomplished, and before the denture could be seized, the patient vomited, and swallowed it down ; it was passed per vias naturales four days later. (Fig. 21.)
the
manoeuvre
wall of the
Male, aged 49. A large upper oesophageal entrance, and removed Female, aged 26. attempting to seize it, Male, aged
slipped
in
under
impacted in the general anaesthesia.
thoracic
down and
was
entrance.
passed
On
later.
large upper denture lying in the hypodays, the upper part visible by indirect Removed under local anaesthesia. (Fig. 23.)
48.
A
for seventeen
pharynx laryngoscopy.
Denture it
denture
120
Foreign Bodies Pins.
in
the
Gullet
Four Cases.
Baby noticed to have difficulty in Age 9 months. swallowing, and pin then missed. No dyspnoea. Radiogram shows pin lying open, to right of mid-line, point upwards at level of hyoid. Removed by direct pharyngoscopy. (Fig. 35.) Age 9 months. Swallowed a safety-pin thirteen days ago. Brought up with extreme dyspnoea, and much swelling of neck, and Mr. Angell James performed tracheotomy ; three days later he removed the pin through an incision in the neck swelling, only the head of it being then in the lumen of the hypopharynx. Recovery. Age Age larynx,
3 weeks.
See page 113.
A
10.
drawing-pin sticking removed. (Fig. 36.)
Age 1. fluids only. (Fig. 38.) 6.
Swallowed
a
"
Age
A brass disc the size of
will not take
rested.
Age
mucosa
days before,
anything.
a
key
take
and removed.
farthing
removed from
Watch removed from on
39 and
(Figs.
can
joint.
mucosa
Swallowed the
of the
cm.
Swallowed his tin watch two
ulceration of
Recovery. 3.
two
A small tin goat found at 13
11 months.
entrance ;
"
tin horse
the level of the sterno-clavicular
now
in the
Four Cases.
Toys.
Age
(Fig. 37.)
of
days before, oesophageal
either side where it had
42.) a
clockwork
mouse.
It
lay
top of the sternum, and the wings Removed from this shank upward. position under general
with the two
anaesthesia,
level with the
45 seconds.
(Fig. 40.)
