RUPTURES AND PERFORATIONS OF THE (ESOPHAGUS. 157 



the third and fourth stages can sometimes be avoided by substituting for 

 them attempts to break down the foreign body by submucous manipula- 

 tion. The oesophagus, having been exposed and isolated, is punctured 

 with a straight tenotome immediately below the obstacle. A curved 

 tenotome is then introduced, and the root, potato, or fruit divided. As a 

 rule, a little pressure from the outside then causes one or other of the 

 fragments to move onwards and deglutition becomes normal. 



Attempts have also been made to divide the obstructing body directly 

 without previous incision and without isolating the oesophagus. It is 

 much more difficult, for the least movement of the patient changes the 

 relationships of the super-posed layers and introduces obstacles to the 

 manipulation of the blunt-pointed tenotome which is employed. More 

 success often attends attempts to puncture the object with a fine trocar. 



RUPTURES AND PERFORATIONS OF THE CESOPHAGUS, 



Causation. Wounds of the oesophagus caused by external violence 

 are rare, or at least secondary ; lacerations produced from wdthin, on 

 the contrary, as a result of clumsy manipulation are relatively frequent. 

 They may extend throughout the length of the tube, but in a far greater 

 number of cases are found near the entrance to the stomach at the point 

 where the oesophagus turns towards the left. 



The passage of the oesophageal sound or probang is apt to exaggerate 

 this curvature, and if pushed violently the instrument may produce first 

 a flexure, then a partial rupture or even a perforation of the tube. 



In other cases a rough, irregular, infected foreign body may when 

 swallowed penetrate the wall and cause inflammation, necrosis and 

 perforation of the oesophagus. 



The symptoms are always very grave, and of rapid development. 

 They consist in local oedematous swelling, sero-sanguineous infiltration 

 at the entrance to the chest, in the pretracheal region and along the 

 jugular furrows. 



The pneumo-gastric and inferior laryngeal nerves being compressed, 

 dyspnoea results. If the oesophagus is perforated in the thoracic cavity 

 septic j)leurisy at once sets in. 



Diagnosis. The diagnosis is easy, provided the history point to 

 perforation of the oesophagus. 



The prognosis is fatal whenever the perforation is within the thorax. 

 It is sometimes possible to intervene in cases of perforation in the 

 cervical region, but from the economic standpoint such intervention is 

 of little value. 



