less hazardous. Perforation of the esophagus
by the foreign body, or by blind instrumentation, is a
contraindication to esophagoscopy. It is manifested by such signs as
subcutaneous emphysema, swelling of the neck, fever, irritability,
increase in pulsatory and respiratory rates, and pain in the neck or
chest. Gaseous emphysema is present in some cases, and denotes a
dangerous infection. Esophagoscopy should be postponed and the
treatment mentioned at the end of this chapter instituted. After the
subsidence of all symptoms other than esophageal, esophagoscopy may be
done safely. Pleural perforation is manifested by the usual signs of
pneumothorax, and will be demonstrated in the roentgenogram.

ESOPHAGOSCOPIC EXTRACTION OF FOREIGN BODIES

It is unwise to do an endoscopy in a foreign-body case for the sole
purpose of taking a preliminary look. Everything likely to be needed
for extraction of the intruder should be sterile and ready at hand.
Furthermore, all required instruments for laryngoscopy, bronchoscopy
or tracheotomy should be prepared as a matter of routine, however
rarely they may be needed.

Sponging should be done cautiously lest the foreign body be hidden in
secretions or food accumulation, and dislodged. Small food masses
often lodge above the foreign body and are best removed with forceps.
The folds of the esophagus are to be carefully searched with the aid
of the lip of the esophagoscope. If the mucosa of the esophagus is
lacerated with the forceps all further work is greatly hampered by the
oozing; if the laceration involve the esophageal wall the accident may
be fatal: and at best the tendency of the tube-mouth to enter the
laceration and create a false passage is very great.

_"Overriding" or failure to find a foreign body known to be present_
is explained by the collapsed walls and folds covering the object,
since the esophagoscope cannot be of sufficient size to smooth out
these folds, and still be of small enough diameter to pass the
constricted points of the esophagus noted in the chapter on anatomy.
Objects are often hidden just distal to the cricopharyngeal fold,
which furthermore makes a veritable chute in throwing the end of the
tube forward to override the foreign body and to interpose a layer of
tissue between the tube and the object, so that the contact at the
side of the tube is not felt as the tube passes over the foreign body
(Fig. 91). The chief factors in overriding an esophageal fore