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Choking

CHOKING General Remarks. The meaning of the word choke, as generally used, implies suffocation, throttling, or strangulation (strangulo—I choke). In its veterinary sense, however, it denotes the presence or arrest of a foreign body in the pharynx or cesophagus, thus preventing the animal from swallowing either solids or liquids, or doing so with great difficulty.

Choking varies in degree, depending upon the amount of obstruction caused by the foreign body itself or the tissue changes induced by the presence of the latter in the gullet.

Again, small bodies such as pins and needles may cause complete choking owing to the severe spasms and pains which they induce, or, when they are of a less irritating nature, through excessive irritability of the cesophageal wall. The gullet in all animals is much less liable to inflammation than other parts of the alimentary tract, but it is more exposed to direct injury from substances swallowed. Choking in man as a result of spasm of the muscle of the gullet, apart from the actual presence of a foreign body, sometimes occurs in neurotic individuals, but it is doubtful if this condition is found in the lower animals.

Symptoms of choking may exist, apart from spasm or the presence of any substance or body lingering in the lumen of the gullet, being due to disease of the walls of the latter, or change in adjoining parts, such as an enlarged gland or an abscess either at the back of the throat or lower down in the mediastinum; in such cases swallowed food may accumulate above the affected parts. Normally the gullet is found in an empty condition, it being some what intolerant of substances loitering, but Sir F. Smith states that a trifling amount of food may sometimes be found in the gullet of the horse near the stomach. As a rule any substance capable of producing irritation if arrested in its downward course towards the stomach quickly induces symptoms of choking. The cesophageal tissues, however, soon seem to acquire some tolerance to the presence of a foreign body within its lumen, and after the first stage of reaction, so to speak, has passed, and in the absence of inflammation, a substance may long remain in the tube if only partially obstructing it without inducing much disturb ance. Li man this tolerance is very marked, and a foreign body may lie quiescent in the gullet for many years. In all cases, however, sooner or later it will cause the death of the patient unless removed by nature or art.

This tolerance of the cesophagus to the presence of foreign bodies after the initial and often very severe symptoms have passed or have been relieved should be remembered by those in charge, as indicating in many cases the absence of great urgency in the removal of the offending body, especially when the nature of the latter is doubtful. Its non recognition has been responsible for many of the catastrophes which have followed too hasty attempts at removing the object, these latter being often both vigorous and crude; especially has this been the case with choking in cattle. Many horses and cattle have been sacrificed in this way, when by judicious waiting all would have been well, and yet it is precisely in cases of choking that valuable assistance can be rendered animals by so - called"first aid,"which is not often possible in other accidents or conditions affecting them. From this we may conclude that there is a natural tendency to spontaneous relief in ordinary cases of choking when once the initial severe symptoms, if existing, have been overcome. The choking body, tightly held for a time by the muscular wall of the gullet, is subsequently released, and the local nervous mechanism stimulated by the object in the lumen of the tube starts a peristalsis which moves it onwards to the stomach. We have watched an animal closely at the moment when relief must have occurred, and have not noticed any actual swallowing movements such as would probably occur from impulses sent out from the swallowing centre in the medulla. It is said that after the vagus nerve has been cut for twenty-four hours or more, distension of the cesophagus by food may cause a peristalsis passing on to the stomach. It is possible that the swallowing centre, more or less exhausted by the over-stimulation following the occurrence of choking, is supplemented later by local movements as above indicated. In some cases many hours elapse before these movements become sufficiently powerful or sustained to effect relief, and during this period some change also probably occurs in the foreign body itself by the action of the swallowed saliva or other secretions, and thus favours its being moved on. Sharp, hard, large, or irregularly formed substances are not commonly removed in this way, and they frequently penetrate the mucous membrane and the deeper parts of the wall of the gullet, thus inducing a spreading inflammation or cellulitis.

A great variety of substances have been met with obstructing the cesophagus of different animals, ranging from a lamp chimney to a whip handle and even a snake. There are two main classes of bodies which cause choking, the sharp wound-producing substance already mentioned, and bodies which are arrested on account of their size, and to these two may be added a third class, those bodies which become arrested through some untoward occurrence during mastication or deglutition. The first two are most often seen in the ox and dog, and the third furnishes the majority of the cases of choking in the horse.

The habits during feeding may favour the occurrence of choking as witnessed in the ox and dog, both being greedy feeders, and these animals may swallow substances readily which would easily choke a horse. The latter exer cises considerable caution in prehension, and as a rule rejects unsuitable bodies.

The gullet or grass pipe varies in different animals; its inner lining or mucous membrane is covered by strong stratified epithelium, and when at rest is thrown into folds which obliterate the lumen of the tube. The loose, connective tissue between the inner coat and the muscle wall is noticeable, and its presence adds to the danger of cellulitis following wounds and abrasions on the inner surface of the tube, and similar remarks apply to wounds involving the tissues surrounding the cesophagus itself.

Choking in Cattle.This is rather a common accident, and is due to several causes some of which have relation to the mechanical condition of the food, and others to the attempts of the animals to swallow bulky substances with in sufficient mastication. This latter habit is. predisposed to, by the tendency of many bovines to elevate the head and straighten the neck while chewing, and so work the substances between the teeth. With the head thus held and the mouth widely open, bodies get back too. far for chewing, and are bolted, only to be arrested lower down the tube and cause choking.

Pieces of turnip, inangold, potatoes, apples, etc., frequently induce this trouble, as also do a great many other substances varying from the recently discharged fcetal membranes to linen articles, bones, sticks, etc. Cases of impaction of the gullet or so-called"dry choking"are rarely or never seen in cattle apart from struc tural disease of the cesophagus, but we have seen a bullock with its gullet full of green material, the trouble passing away after some days. Foreign bodies which have gained an entrance to the rumen may ultimately be arrested in the cesophagus on their way up or down with the"cud,"and thus cause choking. Irwensen found a hair ball in the gullet of an ox eructated from the stomach, and we once saw a small cannula, of the kind used for tapping horses, introduced to relieve the urgent tympany in a choked ox. The strong rolling action of the rumen broke the cannula about the middle, and the distal part passed into the stomach. Some days later when the beast was slaughtered, the tube was found in the cervical portion of the gullet.

The seat of obstruction in a case of choking may be at any point between the pharynx and the stomach, being most common close behind the pharynx, or at the lower part of the upper third of the gullet. Many cattle have a habit of picking up odd articles in their mouth, and sometimes attempt to swallow them, thus get ting choked.

In mining districts where old wire rope is used for fencing, the pieces from broken strands fall on the grass and are taken in by the animals during grazing, causing symptoms of choking and ultimately inducing pericarditis.

Symptoms.The beast stops feeding, is rest less, coughs, and gasps, and may attempt to vomit. There is an abundant flow of saliva which is ejected along with any unswallowed food present in the mouth. The distress con tinues and tympany is soon manifest. The severity and duration of the symptoms will depend largely on: (1) the size, nature, outline, etc., of the foreign body inducing the choking; (2) the quantity and nature of the contents of the stomachs, and (3) the degree of reaction to the presence of the foreign body by the master tissues concerned, nerve and muscle. An out standing feature of choking in cattle is usually the rapid onset of tympany (hoven) affecting the rumen. This quick distension of the stomach with gas is usually said to be due to the presence of the foreign body not allowing the normal eructation of gases by way of the gullet; but the sudden arrest of normal digestion prob ably also plays an important part in favouring the formation of an unusual amount of gas. This tympany may quickly threaten the animal's life, and it demands prompt relief. The ten dency to stomach distension in such cases is greatest immediately following the arrest of the foreign body in the tube, and it gradually becomes less marked as time passes. There is no doubt that the reaction of the neuromuscular mechanism of the oesophagus varies greatly in different animals, and is not altogether due to the size and nature of the offending body itself. The latter, however, if large and lying at the entrance of the gullet, always induces distressing symptoms. The animal may be almost suffo cated, gasping and coughing, with other move ments suggestive of distress. In many cases, however, when the object is arrested lower down, the symptoms will be comparatively mild, especially in lean cattle, and at no stage assume a threatening character. In such cases there is a low degree of irritability of the parts, and the spasm or reaction is slight. The animal may take water, which is presently ejected with but little distress, some, perhaps, passing on into the stomach. Here, also, saliva to some extent will pass down, assisting to macerate and loosen the body, thus preparing it to be passed on with the development of sufficiently strong swallowing efforts on the advent of local peri staltic movements.

Various methods are adopted in the examina tion of a beast affected with choking: By direct examination; on passing the hand through the mouth one may locate the foreign body in the pharynx or impacted in the upper end of the gullet, and at the same time with dfaw it.

Animals often greatly resent this method of examining the throat from within, especially if there is any respiratory distress, as they seem to have a sense or dread of impending suffo cation. A good gag or mouth speculum should be used, and there should be room behind the examiner.

When the arrest has occurred in the neck the object can usually be felt on the left side in the jugular furrow, by palpating the parts, and here we should not mistake the larynx for a foreign body.

The diagnosis of choking when the substance is lodged in the chest is a more difficult matter, and one has to depend upon the history and general symptoms presented, while the careful passing of a probang may assist in forming an opinion.

Choking may always be suspected in the presence of attempts at vomition, retching, profuse salivation, ejection of fluids, and tympany.

Course.In many cases of choking relief takes place spontaneously with the disappear ance of the tympany. The latter when severe is not only dangerous to life, but the distended stomach by the pull it exerts on the gullet prevents any relaxation of the walls of the latter. Similarly a gag placed in the mouth affords relief by diminishing the length of the gullet, and thus incidentally favouring its relaxation. Large bodies impacted at the entrance of the gullet may cause sudden death from dyspncea, and attempts at swallowing the afterbirth may kill in this way; oedema of the glottis is also sometimes seen. Rupture of the walls of the gullet with resulting cellulitis is somewhat frequently met with in cattle; formerly, when nearly all choked animals were promptly"tubed"in some way or other, it was a very common occurrence. Rupture may occur quite early apart from the use of the probang: two such cases occurred within fourteen days of each other in a house containing eight large bullocks. Their neck-chains were rather tight and short, and they were being fed with whole mangolds the choked beasts, blown and distressed, en deavoured to free themselves, and the resulting neck pressure induced rupture of the tightened oesophagus. Both animals were slaughtered within eighteen hours of being choked, and a piece of mangold was found in each at the seat of the lesions. There is a tendency to recurrence for a time when choking has once occurred, and there is an increased liability to rupture in such cases.

We have seen instances when an animal has been slaughtered after a second choking, and the injury resulting from the first accident could be plainly seen. It is astonishing how soon the neck begins to swell in cases of rupture of the gullet, and how serious the result may be in a few hours, especially so in the case of fat cattle. Any swelling in the neck or chest following symptoms of choking may be taken as almost certain evidence of a lesion in the gullet, especially if there are any indications of gas (emphysema) accompanying the swelling or oedema of the neck. In such cases the animal should be promptly slaughtered if it has any food value: we have seen the tissues of the neck in quite a putrid condition eighteen hours after the first onset of symptoms of choking. In fat animals particularly the loose connective tissues surrounding the gullet form an excellent breeding-ground for organisms, anaerobic and otherwise. The emphysema when present is usually regarded as resulting from gas from the rumen passing through the rent in the tube, but it is often associated with the growth of gas producing organisms in the tissues of the neck.

Gas may be absent from the swollen tissues in cases in which a large rent is subsequently found in the tube, and in other cases there may be evidence of an extensive collection of gas in the upper portion of the neck, and at the post mortem one finds that the (esophageal wall has not entirely given way, but that a condition like gangrene exists, extending right along the channel of the neck. One has only to compare the mildly irritating nature of the gas, etc., escaping from the rumen when the latter has been punctured with a knife in the upper part of the left flank, as shown by the absence of inflammation subsequently from the parts, with the rapid onset of gangrene in the neck resulting from the entrance of similar material into the tissues through a rent in the gullet. In such cases the gas when present tends to rise to the upper region of the neck and form a balloon-like swelling around the throat, while the serum poured out in large quantities collects in the mediastinum, where it not only embarrasses the heart and lungs, but forms a depth from whence infective material is quickly carried to other parts. Such cases are always fatal, but the rapid downward course following a rupture of the gullet as sketched above occurs chiefly in fat and stall-fed cattle, and all degrees of in fection may be met with in store and lean animals: Where turnips are very hard and cattle receive them sliced, the pieces having sharp points, the latter may easily puncture the wall of the gullet causing a slit on the way down, and no symptoms of actual choking may be noticed at the time. In such instances a gradually-increasing swelling of the neck is the first indication of anything being amiss.

Pregnant cows may abort as the result of the extreme distension of the rumen causing the death of the foetus, and other results of choking are inflammation of the walls of the gullet and subsequent contraction.

Bronchopneumonia, septic and otherwise, may also follow, especially when the animal has been given brine with a view to relieving the choking, since salt in strong solution seems peculiarly liable to cause spasm of the glottis in cattle. The terminations are those pertaining to acci dents or disease of similar structures or channels in other parts of the body.

As regards the prognosis generally in cases of choking in cattle, it must be considered fairly good if the case is properly managed, and no bungling attempts are made to force either tubes or irritating fluids down the course of the gullet.

Treatment. Prevention. As choking is more liable to occur in cattle when they masticate with the head well up, a bar may be -placed across the feeding place so as to prevent them raising the head. Roots may be pulped or finger-sliced, and this should always be done for a few days after a beast has suffered from chok ing, and for reasons given above pointed pieces are to be avoided. It is difficult to prevent cases of choking when potatoes, apples, or small roots are thrown about on the ground, and the animals feeding under such conditions should be fre quently seen.

In choking, severe symptoms may manifest themselves almost at once, and the owner or attendant will have to give"first-aid"or the animal may succumb. The beast should be turned loose if stall-tied, and the rumen should be punctured whenever tympany is severe; in the absence of a trocar and cannula a sharp knife may serve in an emergency, taking care to keep the instrument well away from the left kidney. A piece of wood to act as a gag may also be placed in the mouth of the animal, maintained in position by a cord passed around the base of the horns. With the gag in, the head is carried in the best position to afford relief. The opera tion of tapping is the most important procedure in the management of a case of choking in the ox, and it should be carried out even when the tympany is mild; in such cases a strong instru ment of small bore may be used, and allowed to remain in as long as necessary. A small cut is first made in the skin to facilitate the introduc tion of the instrument.

Having adopted these measures the majority of cases of choking in the ox will recover in the course of a short time, and nothing further should be attempted except at the hands of a professional attendant. Other cases, however, will require further handling, and various measures may have to be carried out.

Direct or Manual Extraction. If the obstacle is lodged in the throat, or can be felt impacted. in the gullet, an attempt should be made to remove it through the mouth. A good, gag should be used, the head steadied by two assistants, and the examiner, holding the tongue with the help of a cloth with the left hand, uses the right one to explore the throat internally.

Some animals will resent this examination strenuously, and especially if there is any difficulty in breathing. In such cases if there is any danger, and relief is urgent, a preliminary tracheotomy may be performed. It is remark able how much more easy it is to manipulate the throat internally when the animal has a tube in the trachea, and the operation is so easy to perform and free from objection that no risks need be run as regards asphyxiating the animal, or from the latter injuring the attendant in its struggles.

We have often adopted this plan before open ing an abscess in the pharynx of cattle or removing a polypus therefrom.

Taxis or External Manipulation. This is useful in cases of upper cervical choking. The animal's head is depressed, the mouth kept open and pressure exerted with the fingers on either side of the neck behind the obstacle, the operator taking care to avoid being injured by the horns of the animal. If the body move upward the pressure should not be relaxed until it has entered the mouth or falls out. In cases where the choking is lower down the gullet, external manipulation is not of much use and must be carefully carried out if at all.

Use of the Probang. In former days nearly every case of choking had something or other promptly pushed down the and often with disastrous results. A probang should not be passed if the rumen is distended with gas. We have seen this attempted, unsuccessfully; the rumen was then punctured, but before one could again pass the probang the cause of the choking had disappeared.

If the probang be used, it should be in good condition, about six feet long and not too small. An attendant should be on each side with one hand to the horn, the other holding the gag; the head of the animal is kept straight, and care should be taken to have plenty of room. The probang well lubricated is passed down with caution, and if any obstruction is met with, a moderately increasing pressure, with some give and take, may be tried. If this fail, and especi ally if the animal be restive, it is better to desist, for there is reason to think that the greater number of cases susceptible of relief in this way would be relieved naturally some hours later. Nothing therefore should be done in a case of choking which will in any way prevent this natural relief taking place. Damage to the wall of the gullet is so easily inflicted that too much care cannot be observed. The absence of blood around the end of the probang when withdrawn does not negative the existence of rupture, but its presence there is very signifi cant. The use of all corkscrew arrangements, snares, forceps, etc., with a view to withdrawing bodies through the mouth, is to be avoided, as their field of usefulness is extremely narrow and the risk of their doing injury is very great. Their rational use demands direct illumination of the oesophageal canal so that the operator may see what he is actually doing, a procedure hardly practicable at present, at least in the case of the ox.

The use of a probang if an animal has been choked some days is not advisable, or if any inflammatory swelling exists along the tissues of the neck.

Medical Treatment. Lubricants, such as lard or oil, may be given in small amounts, but care must be taken lest bronchopneumonia result. The hypodermic injection of agents which control spasm is sometimes useful; pilocarpine, eserine, arecoline, morphine, and especially apo morphine, have been used in this way. Chloral hydrate in solution to overcome the spasms may also be given, and preferably through the cannula directly into the rumen. In this way also one may relieve the thirst of the animal, which is so distressing in some of these cases, and milk or gruel may be substituted if food be demanded. A choked animal soon presents a sorry appearance; the eyes are sunken, the abdomen in the absence of gas is tucked up, and there are muscular tremors. These symptoms are greatly improved with an in crease in the volume of fluids in the body, and the excretory organs will the better perform their functions.

Operation. If the carcass value of the animal be small or other reasons obtain, an operation may be performed in a case of un relieved cervical choking. An incision is made directly over the foreign body and the latter removed. For reasons already given, parti cular attention must be paid to the drainage of any wound in connection with the gullet, and the leaner the beast the more hopeful the result. Secondary suture is better than a too hasty closure of wounds, seeing that the latter will probably have some dead spaces in them and that they are inflicted in an area where infection is so difficult to prevent.

Choking in the Horse.This accident is less common than in the ox, but it is a rather more serious condition. The equine oesophagus is relatively long and narrow, and the walls strong and thick, particularly between the diaphragm and the entrance to the stomach. The anatom ical arrangement of the parts here renders vomition very difficult, and at the same time also predisposes the animal to choking at this point. Material ejected from the gullet of the horse passes out by way of the nostrils owing to the arrangement of the palate, but occasion ally some of it appears to reach the mouth.

Foreign bodies are not often lodged in the pharynx of the horse, but we have found them impacted at the entrance to the gullet. A common point of arrest is at the upper part of the middle third of the neck. Balls or capsules given to horses are often stopped at this point for a short time. We have seen them remain for fifteen minutes without the animal showing the slightest inconvenience.

Choking also occurs in the thoracic portion of the gullet with some frequency, especially with hard substances such as onions or carrots. It is here also that the form of choking due to constriction and diverticula commonly arises. The feeding habits of the horse help him to reject or let fall substances unsuitable for swallowing, while the ox is liable to pass on everything once it is in the mouth. The chief difference in choking in these two animals, how ever, is the greater tendency to impaction of the gullet with food in the horse—"dry choking."Greedy feeding, old age, or teeth irregularities play a part in bringing about this condition, and especially is it liable to happen when such animals are over-tired, or have been long with out food, and the condition may become serious. Offering thirsty animals water when their mouths are full of food is dangerous. We recently saw a bad case of choking induced in this way; a piece of marigold went on with the first gulp of water and it was arrested low down in the gullet, where it remained eight hours, causing very severe symptoms during the first part of the time. All sorts of substances have become arrested in the gullet of the horse, and it is unnecessary to allude to them here in detail. Organic change in the wall of the oesophagus and associated structures is sometimes respon sible for the condition of choking, and con striction at one point of the tube often leads to dilatation of the parts above, where a sort of reservoir is formed and filled with the swallowed food. This latter may be sub sequently passed on to the stomach or again ejected through the nostrils. Paralysis and enlarged glands may induce choking, as also wounds in the neighbourhood of the gullet. Horses may be readily choked, in the strict sense of the term, if care is not taken when drenching them, especially if their throat is sore. We recently saw quantities of milk and other fluids come through a tube inserted in the trachea every, time the animal drank, and this continued for some days. The horse rarely coughed, and seemed little disturbed by the fluid entering the larynx, neither did the lungs become affected, although it is highly probable that some of the fluid must have frequently reached the chest. It is to be remembered that when being drenched the horse's head is in precisely the position to favour choking, as we have already seen to be the case in the ox. Cases of choking have occurred through drench ing an animal when it has been holding in its mouth a ball given previously, and care should be exercised in this respect.

Symptoms. The indications of choking in the horse are largely those seen in the ox. The attempts at vomition are more pronounced and severe, the neck is arched, the head depressed, and the body drawn up. The animal makes a noise sometimes almost like a scream, and the muscles of the neck and throat are violently contracted. Tympany rarely becomes rapidly dangerous, but it is sometimes noted; the breathing is usually disturbed and there are fits of coughing. Liquids and solids may both be expelled with some force through the nostrils and much saliva is lost. The animal paws the ground, partial sweating may occur, and there is an anxious expression of countenance.

As in most other animals, the symptoms are usually acute and severe immediately after the arrest of the foreign body, and then gradually moderate. In this way diagnosis may be difficult if the animal be not seen until some time after the occurrence of the accident. If the body be lodged in the cervical or neck portion of the gullet it can be more easily felt than in the ox. In the subacute or chronic forms of obstruction in the horse the severity of the symptoms will depend on the degree of impaction present. After some of the impacted material has been got rid of, relief is obtained, the animal begins to feed again, and the symp toms will shortly recur.

Course. In many cases relief is obtained spontaneously, the solid body is passed on or the impacted material is loosened, some reach ing the stomach, other portions being coughed up. If the natural efforts or those of the surgeon are unsuccessful a fatal issue occurs sooner or later from pneumonia, or septi caemia results from infection developing at the seat of obstruction.

Again, the animal may die early from asphyxia or later from inanition and exhaustion.

Diagnosis. In the ox, chronic disease may induce conditions in which symptoms are observed suggestive of choking, but in the horse it is the acute sore throat which so often accompanies various febrile affections, and some difficulty may be experienced in arriving at a decision. The history of the case should always be carefully inquired into where any doubt exists.

Treatment. Avoid raising the head and pour ing fluid of any kind down the throat. If a foreign body is suspected to exist in the pharynx, or at the entrance to the gullet, the parts should be examined and extraction attempted by the hand. If asphyxia is threatening perform tracheotomy, which will also facilitate the examination of the parts. Hot water applied to the neck may relieve spasm and pain, and this can be further helped by some form of hypodermic medication. The administration of small capsules containing lubricants such as liquid paraffin or fat may be tried, and the general comfort of the animal attended to as regards location and body heat. At a later stage fluids may be introduced into the rectum to relieve thirst, etc. Apomorphine adminis tered hypodermically in a half to one and a half grain doses has been highly spoken of by some. Corm of Ohio states that it induces marked retching, and contractions may be seen passing down the cesophagus much the same as in drinking water. This lasts from thirty to forty minutes, and commences about fifteen minutes after the injection. The effect of atropin in causing dryness of the throat is objectionable, and similarly the use of agents like pilocarpine which greatly increase the flow of saliva may add to the distress of the animal. Eserine is, however, useful in cases of choking in the horse if there is a tendency to tympany.

Instrumental Aids. If the methods of treat ment suggested fail and the animal has been given time, other measures may be necessary. The use of the probang in the horse is not easy, and is more dangerous than in the ox. We have not seen great benefit from its use, and we regard the passing of all tubes or sounds in cases of choking as more or less experimental and beset with pitfalls. If an object can be located in the neck and is otherwise irremovable, it may be extracted by performing cesophagotomy.

Choking in the Dog and Cat.Various sub stances may cause choking in the dog and cat, but smooth, round objects are seldom found obstructing the channel. Lumps of food arrested in the pharynx are usually quickly ejected by way of the mouth. Pieces of bone irregular in shape, and with sharp outlines, may become fixed, and cause choking; fish-bones, needles, safety-pins, either open or closed, are common causes; stones, buttons, balls, corks, and such-like objects are to be looked for, and pieces of wood may also be found. Many of these, especially needles, pins, etc., become arrested in the pharynx, often close under the epiglottis, but may be stuck in any part of it. The upper portion of the gullet is narrowest, and this is the most usual seat of choking, the next common point of arrest being at the lower part of the neck and further on just before the cesophagus opens out to enter the stomach.

Symptoms. Frequent attempts at swallow ing alternated with efforts to vomit, salivation, return of fluids given or swallowed, restlessness, coughing, and general distress. Local mani pulation causes pain. Thread attached to needles may be seen in the mouth, or other indications of a foreign body noted. Externally the impacted body may be felt and the parts adjoining seen to be in a swollen condition. Sharp bodies penetrating and lacerating the walls of the gullet may induce ulceration, perforation, and death from haemorrhage owing to a large blood-vessel being opened, or from suppurative cellulitis. Large bodies impacted at the entrance to the gullet may cause death from dyspncea, and if the obstruction is not so great cedema of the glottis is likely to supervene. Bodies once entering the stomach usually give no further trouble; occasionally, however, serious results ensue. Late serious symptoms may sometimes follow the carrying out of heroic measures or explorations either for arriving at a diagnosis or relief of the choking. The use of a sound or any prodding for diagnostic purposes when a sharp body may be lying in the gullet is likely to do harm. Where the dog is a valuable one and means are available, the assistance of radiography should be had recourse to. The most perfect means of diagnosis, however, consists in the adoption of endoscopic methods enabling a direct inspection or view of the impacted body to be made. The use of direct illumination in exploring the cesophagus has so far not been attempted in the case of animals, but it would appear that the question is purely one of expense, and in the case of valuable dogs should not be impossible.

Treatment. Foreign bodies located in the pharynx or entrance to the gullet may be removed with long forceps. If the obstruction be lower down the use of emetics is not likely to be successful, and may do harm. If the nature of the obstacle be known and has no sharp edges or points likely to tear, a probang of suitable size may be passed. The mouth of the animal is kept open with a speculum, and the instrument lubricated before use with vaseline or melted butter. The expanding probang as used in man is commonly adopted in canine surgery; the expanding portion is made of thick loops of horse hair, and various sizes are obtainable. This instrument was formerly used to withdraw fish-bones, needles, pins, etc., lodged in the gullet of man, but it is now largely supplanted by the cesophagoscope whenever possible by specialists in throat surgery.

By its means foreign bodies, growths, strictures, etc., can be seen, and treatment controlled by direct vision can be adopted. It is better to desist than to continue pushing blindly a substance of unknown nature along the gullet, with the probable result of lacerating the tissues, and then directly bringing about a fatal termination. Alluding to the matter, Mr.

Herbert Tilley, F.R.C.S., says:"Blind groping in these regions has been responsible for an appalling number of fatalities. For this reason coin - catchers, umbrella probangs, arid such like, should be relegated to the historical sections of anatomical museums." If the body is so firmly fixed that it is impossible to remove it otherwise, it should be cut down upon and taken out. The operation of cesophagotomy, or opening the gullet, has been fairly successful in the dog, and is not very difficult.

Rectal feeding may be had recourse to for a few days, and any food given by the mouth must be limited in amount, and consist of milk, soups, jellies, etc. Complications must be dealt with as they arise. Bodies impacted near the cardiac orifice of the stomach may possibly be removed by opening directly into the stomach and reaching them from the distal end of the tube. _ _

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