CHAPTER XXI. FOREIGN BODIES, (Part 2)

inflamma- tion may ensue with the most diverse sequences, depending upon the location of the object: edema of the glottis, diphtheritic inflammation, abscess of the larynx, phlegmon of the neck, hemorrhage due to erosion of the large vessels or even of the heart, tracheitis, bronchitis, bron- chiectasis, pneumonia, gangrene of the lung, empyema, purulent peri- carditis, mediastinitis, or phthisis. Treatment.—Asphyxia demands immediate action; there is no time for examination and inquiry. Make a burried effort to remove the body by passing the finger into the larynx, and if this fails, without further delay do a tracheotomy (see page 414). Tm the less urgent cases, one may be more deliberate, endeavoring to ascertain the character of the object and to locate the point of lodg- ment. The history of the case, the symptoms and the physical signs derived from auscultation, will furnish valuable information. Various procedures are recommended. “Inversion and violent shaking of the body do not enjoy their former popularity. Even the conservative Weist considers manipula- tion of this sort dangerous and only justifiable after trachcotomy.” Still it does not seem likely that it can result in harm if the body is known to be small so that it may readily pass between the vocal cords. “The simplest way is to follow the suggestion of Sanders, and let the body hang over the edge of the bed and rest on the hands during the attack of coughing."” “Generally speaking, emetics are unreliable and their use not without danger.” 398 1. ther fa tise, the Larrupseonye taey Bs SaaS and extraction, Mio, 192.—Killlan Dronchescope, (Kin) Th any case after the urgent sy nthe bonds of Haale, ete | scope often furnishes a happy solution tothe — difficulty (Fig. 297). It is to be boped that the technic of bronchoscopy, now familiar only to the specialists, will soon be popular ized with the profession at large. Im cases less urgent, the X-ray may be used locate the substance, But after all, trachootomy or laryngotomy is the chief reliance of the practitioner left t» his own resources, and be must be prepared for immediste operation while other measures are tentatively tried, that an attendant be at hand ready for ie stant operation as long as the body is known to be free in the bronebus or trachea. “Tt makes no difference what one’s view" fact remains that no physician will deny necessity of this step when the danger of suffocation is great.” “The author bas become convinced th the danger of tracheotomy nowadays is) nificant compared with that of a for body in the air passages and does not tate, even when the body is. n larynx, to remove the offending through an incision should vies naturalis be impossibile.'* “Tracheotomy is positively when the foreign body is movable trachea.’ sproms have subsided, “op FOREIGN NODIES IN THE RECTUM, 399 interference is the special form of treatment most rational and the form of operation depends upon the situation.” “If the extraction means laceration, it is justifiable to split the larynx itself or a sub- hyold pharyngotomy may be indicated, “The expectant treatment, to which so many patients formerly fell victim, is to be condemned. ‘This method is only justifiable in a small number of cases, in which the body has fallen far down into the bronchus where it cannot be reached. “The death rate shown by statistics should not decide the question of operation: the clinical picture of the particular case and the unfortu- nate cases should guide the surgeon. Those that died after the opera- tion did not do so because they were operated upon, but because they were operated upon too late. In an individual case the doctor can never count upon spontaneous expulsion. Every hour the offending material remains dm sifu Jessens the chances more and more, while operation furnishes conditions most favorable for its removal. Open ing the air passages, then, is the most rational procedure except for the cases in which endolaryngeal methods can be used.” RECTUM, The objects which have been removed from the rectum at one time or another, cover a wide range—bottles, pieces of wood, ete., pushed in to stop a diarrhea, to satisfy a perverted sexual impulse, or by the insane, It is scarcely necessary to indicate all the instruments and artifices which have been employed in their extraction, but it is helpful, as Lejars points out, to formulate certain general rules of procedure. The necessity of these formule cannot be doubted when one cons siders the difficulties of extraction, often considerable, and the fre- quency with which the rectum is lacerated by misguided effort. Often the patient does not admit the nature of his difficulty, con sulting the doctor on some other pretext, such as constipation or some rectal trouble quite different from the real condition. In the ‘case of obscure trouble in the natural orifices, the doctor should be on his guard. If the nature of the complaint is admitted, proceed to a methodical examination and endeavor to get your bearings. —— 400 FOREIGN BODIES. Introduce a finger, which has been well ofled, into the rectum Sometimes you will find the object just within the orifice, of such size and shape that it can be readily extracted with the finger or with a forceps without further trouble, but you cannot count foo much om that, If the examination shows it to be lodged high up in the concavity of the sacrum, impacted and perhaps completely filling the rectum, make no effort at extraction, but prepare for a formal operation. Pou. 094. —oreumn body tm the rectum 9, Bottle: © Coney, (hetrad: Under a general anesthetic, put the patient in the lithotomy position: with the thighs well flexed, the hips elevated, and the anal agood light. Dilete she anus with the fingers as completely as: ani then determine the exact “presentation” of the body, a Sims’ speculum, passing it, under the guidance of the finger, the coceyx, and then retract as widely as possible, "This ine done in the young, but may be diffeult in the adult When the coceyx is thus sprung wack, the body must be: FORKIGN BODINE IN THE RECTUM, 401 traction made in the axis of the outlet if the body is long (a bottle for ex- ample) and firmly fixed (Fig. 298). ‘The fingers or forceps may be used. If you are dealing with glass, the blades of the forceps must be covered with rubber to prevent slipping. If the ends of the foreign boily are pointed, and imbedded in the rectal wall so that traction is dangerous, great care must be exercised. In some cases morcellation will be possible, Vf the coccyx cannot be retracted and serves as the direct impedi- ment, it will have to be resected. If the body has found its way up into the left iliac region into the sigmoid, it may possibly be worked down into the rectum by external manipulation. Finally, in such a case, laparotomy and opening the bowel may be the only means of relief. Combs, of Indianapolis, reports a case which illustrates the principles of treatment involved (J. A. M. A., Oct. 23, 1909). After a drinking bout and a drunken sleep in the woods, the paticnt awoke with a pain in his rectum and found it impossible to empty hhis bowel. He applied to a physician who discovered a beer glass in the rectum, inserted there during the victim's drunken stupor by brutal comrades. An attempt was made to remove the glass without preliminary divulsion of the sphincter, During traction with forceps the glass was broken and the attempt failed. Some hours later he was seen at the hospital by Combs who found the small end of the glass resting on the promontory, and the large end imbedded in the hollow of the sacrum (Fig. 298), its broken edges buried in the soft tissues. By reason of the edema and swelling, divulsion was insufficient for removal, and consequently the contracted muscles were divided in the middle line posteriorly, when the glass, which ‘was four inches long and seven inches in circumference at its large end, was readily removed. On account of the swelling and evident infec- tion, the inelsion was left to heal by granulation, and on discharge from the hospital the patient had a perfect control of the sphincter. Combs remarks that the shape, size, and nature of the foreign body, the ‘edema and swelling, and the degree of traumatism will be the guiding indications for the course to pursue. It would certainly gem a rece instance in which amputation of the coccyx would be tequired. N&e~ eo | 402 FOREIGN BODIES, quate division of the muscles posteriorly with quick removal is advised in liew of prolonged efforts at removal by traction, especially of an object with cutting edges from which fatal wounds may result. THE URETHRA. A piece of sound may be broken off in the urethra. Boys or the insane may lose various objects in the urethra, slate pencils, pipe stems, pieces of watch chain, etc. As a rule, the accident is not immediately disastrous, for the impediment to urination is not complete, The object should be removed as soon as possible and with as little irritation to the urethra as possible. Pre, 199.—Urethral forceps of Collin (0), Lovory d'ici (8), tet Memtar Gh. I: is necessary merely to cnumerate some af the methods employed successfully in various cases, and each case must be treated on itt own merits, Often the body may be casily reached and extract! with forceps (Fig. 299). In certain instances, it may be gradually worked forward by external pressure; or in urination the meatus may be pinched up and when the urethra is ballooned out by the press of the urine, sudden release may result in the body being washed ox In ease the body i in the deeper part of che urethra, and manipulation is necessary, pressure should be appliod over the on the bladder side of the foreign bey, to wrevent its being: FORHIGN NODIES IN TITE URETHRA, 403 deeper. A piece of hallow sound or catheter may sometimes be re- moved by passing 4 smaller sound down into its lumen; or the urethral speculum or a larger hollow sound may be passed down to, and over the body, which permits its more ready seizure by a forceps passed through the speculum. Dayat shaped a lead sheet into the form of a hollow sound and, passing it beyond the object in the urethra, closed its lower end by using gaan Potlinetne pant ig Sinn fetal gal iowa ca pressure over the urcthra and in removing the lead catheter the foreign body came out with it. Tn another case, a stick forced into the urethra could not be with drawn on account of a hook on its lower end, but after being split into many pleces, its extraction was accomplished piecemeal. Tn the case of a pin lost in the urethra hea’ dow ward, its point may be driven through the skin and “version” accomplished ani Ye: head brought out through the meatus (Figs. 300, 301). 404 FOREIGN DODIES. In other cases it may be necessary to do an external and finally the object yaay have to Eos pacie iade ie Ra removed by suprapubic cystotomy. Hazzard describes a case in which a bat pin was lodged in the urethra, its head too high to manipulate. He bent the penis at 2 right angle to the direction of the pin and thus thrust its point through the skin, which enabled him to practice version (J. A. M. A., May 29, 1909). Hyde, of Kansas City, reports a shaw! pin slipped, head first, down the urethra and into the bladder, ‘The point could be felt at the peno- scrotal angle, An incision was made down to the urethra, the point was forced through the urethral wall into the incision, and the pin drawn out till the head reached the urethral floor; it was then reversed and delivered through the meatus without opening the urethra, The wound was closed by three deeply placed silkworm-gut sutures with prompt repair (J. A. M.A, March 13, 1909).