in those having an idiosyncrasy to the drug. Cocain should
never be used with children, and is of little use in esophagoscopy in
adults. Its application is more annoying and requires more time than
the esophagoscopic removal of the foreign bodies without local
anesthesia. Traumatic esophagitis, septic mediastinitis, cervical
cellulitis, and, most dangerous, gangrenous esophagitis may be
present, caused by the foreign body itself or ill-advised efforts at
removal. Perforation of the esophagus with the esophagoscope is rare,
in skillful hands, if the esophageal wall is sound. The esophageal
wall, however, may be weakened by ulceration, malignant disease, or
trauma, so that the possibility of making a false passage should
always deter the endoscopist from advancing the tube beyond a visible
point of weakening. To avoid entering a false passage previously
created, is often exceedingly difficult, and usually it is better to
wait for obliterative adhesive inflammation to seal the tissue layers
together.

_Treatment_.--Acute esophagitis calls for rest in bed, sterile liquid
food, and the administration of bismuth powder mentioned in the
paragraph on contraindications. An ice bag applied to the neck may
afford some relief. The mouth should be hourly cleansed with the
following solution:
Dakin's solution 1 part
Cinnamon water 5 parts.
Emphysema unaccompanied by pyogenic processes usually requires no
treatment, though an occasional case may require punctures of the skin
to liberate the air. Gaseous emphysema and pus formation urgently
demand early external drainage, preferably behind the sternomastoid.
Should the pleura be perforated by sudden puncture pyo-pneumothorax is
inevitable. Prompt thoracotomy for drainage may save the patient's
life if the mediastinum has not also been infected. Foreign bodies
ulcerating through may reach the lung without pleural leakage because
of the sealing together of the visceral and parietal pleurae. In the
serious degrees of esophageal trauma, particularly if the pleura be
perforated, gastrostomy is indicated to afford rest of the esophagus,
and for alimentation. A duodenal feeding tube may be placed through an
esophagoscope passed into the stomach in the usual way through the
mouth, avoiding by ocular guidance the perforation into which a
blindly passed stomach tube would be very likely to enter, with
probably dangerous results.

[199] CHAPTER XX--PLEUROSCOPY

_Foreign bodies in