CHAPTER XXI. FOREIGN BODIES, (Part 1)

CHAPTER XXI. FOREIGN BODIES, THE EYE. Foreign bodies lodged on the conjunctiva or comea are painful, and may soon provoke a conjunctivitis, more or less severe. ‘The offending particle may be concealed under the lid or be im~ bedded in the comes. The latter is especially likely to be the case with those who have to do with emery wheels, ‘The paticnt’s sensation is a very poor guide in locating the object; if it is on the cornea, be is likely to be certain it is under the upper lid. Begin by inspecting the eye under a good light and at various angles, Pull down the lower lid, instructing the patient to look upward. Evert the upper lid. ‘This is done by grasping the eyelashes between the thumb and fore-finger and pulling downward, at the same time making pressure upon the tarsal cartilage of the lid with a pencil, stylet, or the opposite thumb. Instruct the patient to look downward. Com- bined with this pressure, the eyelashes are now pulled upward and in this manner the lid is everted and exposed to inspection. ‘The novice does Letter, perhaps, to stand behind the patient, but the special ist sits in front of the patient and turns the lid with one hand, If the foreign body is free, it is readily picked up with the point of the stylet wrapped with cotton, but if it is imbedded in the cormes, considerable curettement may be required wo dislodge it. The im strument must be sterile, otherwise corneal ulcer may follow the manip- ulation, In the case of nervous or sensitive individuals or when the conjunctiva is much congested, the manipulation must be preceded by the instillation of a few drops of a 4 per cent. solution of cocaine, which should be fresh and must be #1 Everything used must be sterile hands, instruments, cotton, and solutions, Following the extraction, irrigate with normal salt solution and still two drops of 2 per cent. collargsbum solution or 10 to 25 pers 388 FOREIGN BODIES IN THE EAR, 389 argyrol solution and direct the patient to wash the eye frequently with boracie or normal salt solution; if there is much congestion, bandage the eye for one or two days. If the foreign body has penetrated to the anterior chamber, the iris, or the posterior chamber, the immediate treatment must be limited to such measure as will prevent infection—boracic irrigation and band- age—until the case can be placed in the hands of a specialist or until special text-hooks can be carefully consulted. Tt may be necessary to employ the X-ray in diagnosis in these cases. The extraction may require a delicate operation or the use of the electro-magnet, and finally the removal of the globe may be necessary. Chemical irritants should be removed by free irrigation. For lime in the eye, a solution of sugar in vinegar is recommended, the sugar forming a soluble compound with the lime. A few drops are used, followed by free flushing with water. Afterward atropine, gr. 1 to the ounce is imperative. THE EAR, ‘The foreign bodies most frequently found in the ear are pebbles, shoe-buttons, peas, beans, pens, pieces of tooth-pick, pieces of cotton, ete, etc. Children may place these objects in their ears in play or innocent experimentation or adults may meet with the accident, attempting to relieve an itching in the auditory canal, A tampon may be le/t in the ear by the doctor. The body usually lodges in the outer part of the canal, and only reaches the tympanic membrane after ill-advised efforts at extraction. ‘The pain and discomfort are usually moderate; and, as a rule, there are no very urgent indications for intervention. But if the object rests against the drum, the pain is severe and may even produce mental disturbance. ‘The first thing to do, then, is always to confirm the diagnosis. The patient's belief in the matter must, under no ciccumsiances, we ac cepted as final. ‘There is only one way to confirma the Magness sss 399 FOREIGN BODIES. that is by careful inspection of the whole canal, if the object is not seen in the outer portion, Draw the external ear upward and backward, and the tragus for- ward, Under good illumination and with the aid of a head-mirror and otascope, the dram is readily seen, If nothing can be seen, and provided there have been no blind efforts atextraction, it may be defi- nitely concluded that the patient is mistaken. If, on the other hand, you locate the object, do not hurriedly intro duce a forceps into the ear secking to grasp the object; unless, indeed, it is of such a nature that it may be easily seized, for you will almost always make matters worse, pushing it further into the canal. Re- fo, 295 —Kar Forceps member that however desirable it may be to empty the ear, there is, as a rule, no great urgency in the matter and you have plenty of time to take counsel with yourself (Fig. 293). In some cases, a small hooked instrument may be cautiously pushed past the object and withdrawn, pulling the object out, or a small blent curette may be similarly employed, Usually o large syringe ts the proper instrument, Throw a stream of warm, sterile water into the ear with the purpose of forcing the body out by the “ris a herga.™ To inject the stream properly, lift the pinna upward and backward 28 in inspection, and direct the stream along the posterior) using moderate force. Use one syringeful after another, Offending substance is washed away ot the yatlent Ws ired out, — YOREIGN BODIES IN THE NOSE. 308 “Tf you have failed, instill into the ear a few drops of glycerine or warm oil, lightly tampon, and direct the patient to sleep on the affected side, returning the next day for another trial, ‘The chances are greatly in favor of ultimate success without injury to the car. In the case of a live insect in the car, fill the car with oil and sub- sequently the “cadaver" may be removed by irrigation. ‘Tf “instrumentation” seems advisable, there must be no blind grasping for the object—it must be kept clearly in view. Tt has happened, in violation of this rule, that the middle ear has been in- yaded and the ossicles dragged out. Death has occurred from such manipulation, though the post-mortem showed that no foreign body had ever been present. In the case of children, instrumental extraction will, as a rule, re- quire an anesthetic. If the ear has become much inflamed or the body pushed through the drum, the case is one for the specialist. ‘On the whole, the practitioner might adopt the rule, that if left in the ear, untouched, the foreign body is leas likely to do harm than rude and maladroit efforts at removal. THE NOSE, ‘The catalogue of bodies, recorded as lodged in the nose, is long. Naturally, children are more frequently the subject of these mishaps, although lunatics and hysterical women may intentionally plug the nose. Occasionally, a foreign body previously swallowed, may be coughed up and lodge in the posterior nares. Pledgets of cotton and pieces of gauze, which have been used as tampons, may be overlooked and act as foreign bodies. In the case of the irresponsible, the presence of a foreign body may not be suspected, 80 few are the symptoms, until there develops a profuse sero-mucous discharge. There may be frequent attacks of sneezing; and, if the body remains long, the mucous membranes be- come swollen and perhaps the skin of the affected side also. ‘There may be headache or facial neuralgia. These foreign bodies should be removed as soon as possible, first having determined their nature, si and situation. Begin by a careful examination of the anterior nates, and Ai Wes ie 392 FOREIGN RODIES. not sufficiently instructive, examine the posterior mares by hooking the finger up behind the soft palate. ‘The examination and removal are often facilitated by the use af cocaine, and in the case of children, 8 few whiffs of chloroform may be necessary. Chloroform is also the effectual remedy for animate foreign bodies, such as insects and maggots. Used in this manner, it is not inhaled, bat is shaken up with an equal amount of water and syringed inter the nose before the two ingredients separate, Poo, 2938 —Angular forceps fer foreign busty in the mone. A body lying in the anterior nares is usually readily removed by = mouse-toothed forceps; or a curved probe or small curette may be necessary to dislodge it. An angular forceps is sometimes convenient (Fig. 293 2). In other cases, the obstruction may be removed by drawing a tampon through the nasal cavity from behind, as reooei: mended by Sajous If the body is lodged in the posterior nares, it is usually pushed backward into the pharynx, care being taken that it does not drop down into the larynx or esophagus. “In the case of infants, a small body may be removed by blowing forcibly into the mouth.” (John J. Kyle.) PHARYNX AND ESOPHAGUS. Many diverse objects may lodge in these passageways, through ineffectual efforts at swallowing ot ‘vy inadvertently TREATMENT OF FOREIGN BODIES IN THE PHARYNX. 393 from the mouth. False teeth are often loosened and carried into the pharynx or esophagus during sleep, The point of lodgment, the immediate effect, the dangers, and the difficulty of removal, depend upon the size and shape of the object. ‘The pharyngo-esophageal canal is narrowest behind the larynx, opposite the ericoid cartilage and the sixth cervical vertebra; at this point a large body is likely to lodge. A second constriction lies two and three-quarter inches further down, behind the Jeft bronchus; and a third where the esophagus passes through the diaphragm. Larger bodies, then, are liable to lodge opposite the larynx. Sharp and pointed objects, such as needles and fishbones, may anchor at any point without refer- ence to the caliber of the conduit. ‘The immediate effects of the lodgment of a foreign body vary from instant asphyxia to merely slight difficulty in swallowing. Later there may occur, even in the case of a slight obstruction, the dangerous conditions following infection—erosion of the walls, perforation of the bronchi or lungs, of the pericardium, the aorta, or carotids—one has but to think of the numerous relations of the esophagus in the neck and thorax to understand how diverse the consequences of such spreading infection might be in various cases. Very naturally, the deeper down the object — ria. »04—Iore-hair lodges, the greater the difficulty in locating and fie” =P" 84 Teaching it. Trestment.—Asphyscia, due to occlusion of the lower part of the pharynx involving the larynx, demands immediate action, The patient is livid, gasping, and struggling. Run the finger into the throat over the cpiglottis, where the body may be felt and hooked out. If you fail in this, do not waste time in these cases of extreme ‘urgency, trying tentative measures, such as inversion, but do a teache- olomy, or laryngotomy in the adult (sec page 414). Alter tne oyeredivon., 34 PORKIGN BODIES. the foreign body may be expelled spontancously in the efforts of cough- ‘ing or vomiting. : Ta the less urgent cases, the first indication is to confirm the diagno sis and definitely locate the object. ‘The sensation of the patient is net sufficient index as to the presence and situation of an obstruction the gullet, for the pain may be due to a wound made by the foreige body in passing. Tnspect the mouth, the fauces, and the tonsils. Palpate the region of the glottis and behind the soft palate. Palpate externally along the anterior border of the sternomastoid, pressing deeply to reach the esophagus, most superficial on the left side. Even if the foreigs body is believed to be located in the neck, as a result of this palpation, | it is better to make certain by passing an esophageal sound. oO ‘Vee, 195. —Coin catchers, In certain instances, the X-ray will be invaluable, though not ak ways to be relicd upon. In the hands of the expert, the esophagessope has proved to be useful. In the course of time this instrument will probably come to be a part of every doctor’s “arsenal.” It not only makes exact diagnosis possible, but esables the foreign body to be m= moved by sight, avoiding thus the injuries to theesophagus which Blind efforts often produce. The presence and location of the foreign bedy once extraction is indicated. Inversion is illusory and emesis dang If the body is in the pharyns, it may be seized with curved or dislodged with the finger or an improvised hook. ‘To employ forceps, seat yourself before the patient, whose mouth ix « open. When the object is once seized, incline the patient"s head. ward as the forceps is withdrawn. If you lose your hold, withdraw the forceps and remove the mouth gag and often the’ object will be cougbed out. = FOREIGN WODIES IN Tite ESOPHAGUS, 395 In the case of an infant, place the patient on its back with the head hanging over the edge of the table, thus preventing the body from dropping into the larynx. (Have everything ready for tracheotomy.) In extracting a body from the esophagus, the greatest caution is ‘necessary to prevent laceration. Rough manipulation only aggravates the muscular spasm, which is always present in some degree, and which, more than anything else, prevents the body safely reaching the stomach; and these esophageal muscles are excecd- ingly strong. ‘The esophageal forceps is used as in the pharynx. The horse-hair probang (Fig. 204), introduced past the object, opened up and then withdrawn, often succeeds in re- moving an Implanted needle or fish bone. Tn the case of a enin or similarly shaped object a “coin catcher” may be em- ployed (Fig. 295). Introduce the left index-finger as a guide and pass the instrument along its posterior wall until the coin is felt, when the catcher is passed ‘on beyond it. Now tilt the handle forward and slowly withdraw the instru- ment until assured by the sense of touch that the coin is engaged. Completely" i2"otinan “Eiijon) withdraw the instrument by stendy, con- tinuous, vertical traction. When the pharyngeal orifice is reached, it is necessary to accelerate the movement to achieve the final extraction (Lejars) (Fig. 296). Tf, in the course of the manipulation, the foreign body is dislodged and slips on down into the stomach, do not regard it as a calamity, un- Jess the object is very pointed. Indeed, if the object is deeply located, is known to be harmless in character, and extraction seems impossible, an effort should be made from the first to push it on into the stomach with the esophageal bougie. ‘This should never be done, if the char- acter of the substance is unknown. No effort should be prolonged ond above all else, no violence is permissible, Finally, 4 extraction Wits 306 TOREIGN novieSs, and propulsion into the stomach is out of the question, there is only ane thing left to be done—an esophagotomy. In certain cases where the body is firmly implanted, or when it & pointed and dangerous to mave, resort must be made to the operation atonce (See page 421.) LARYNX AND TRACHEA.* ‘The air passage is frequently involved, an accident always of com cern, often serious, and sometimes fatal, ‘The bodies finding their way into the larynx and trachea are of great variety, fluid and solid, animate and inanimate; most often aliments perhaps, and after these, the list may be indefinitely extended. Children are more often the sufferers, because of their habit of putting objects into their mouths at random. Many times particles of feed “go the wrong way,” the result of the patient’s speaking or laughing during the act of swallowing: the epiglottis is raised Inopportumely, and the morsel drops into the larynx. Small bodies are inhaled in ordinary breathing. ‘The accident sometimes happens during sleep, through the dislodgment of false teeth or something held in the mouth; it may follow an attack of vomiting, or it may occur during some operation | about the mouth; conditions such as anesthesia, which diminish | the reflex irritability or motility of the larynx, favor it, The point of lodgment depends chiefly upon the size and shape of the object. Pointed objects, such as pins and fish bones, frequently stick in the supraglottic portion of the larynx; flat bodies, coins and | buttons, usually lodge in the ventricles, while small globular, heavy bodies descend into the trachea or bronchus, usually the right. ‘The symptoms and sequeke, and therefore the dangers, may be grouped under two heads, obstructive and inflammatory. (a) If the body is large and lodged in the larynx, asphyxia may be the immediate result and may be almost immediately fatal, Eye small bodies may produce fatal asphyxia through reflex spasms of tae glouis, though usually the reflex spasm subsides. Retlexty, als coughing, sometimes violent, is induced, and this may be the eae whether the body, lies in the larynx, trachea, or bromchiss, Sometime * Quotations are from Vor Wergman. a ‘TREATMENT OF FOREIGN BODIES IN THE LARYNX. 397 the body may lodge between the vocal cords, thus preventing their closure and allowing some air to pass so that life may be sustained for some time, Tf the body is lodged fn the ventricles, there may not be so much obstruction, but there is hoarseness or aphonia and cough. Tf the body descends into the trachea, there may be no indication of obstruction, but there is much reflex irritation, evidenced by pain and cough. If the body is light, it may move backward and forward in the trachea, following the current of air. If a bronchus is obstructed, a whole or a portion of the lung may collapse, evidenced by altered pulmonary sounds. (b) The body may hecome encysted if not removed, or