THE OESOPHAGUS
Surgical Anatomy--Methods of examination--Wounds--Rupture--Swallowing
of caustics--Impaction of foreign bodies--Infective conditions:
_Oesophagitis_; _Peri-oesophagitis_; _Tuberculosis_;
_Syphilis_--Varix--Conditions causing difficulty in swallowing:
_Impaction of foreign bodies_; _Compression of the gullet from
without_; _Spasm of the muscular coat_; _Cardiospasm_; _Paralysis
of the gullet_; _Diverticula_ or _pouches of the gullet_;
_Innocent stricture_; _Malignant stricture, including cancer at
the junction of pharynx and gullet and cancer at the lower end of
the gullet_.
#Surgical Anatomy.#--The oesophagus extends from the level of the
cricoid cartilage to about the level of the lower end of the sternum.
The distance from the upper incisor teeth to the commencement of the
oesophagus is about 5 or 6 inches, and the oesophagus measures from 9
to 10 inches. The whole distance, therefore, from the teeth to the
stomach is from 14 to 16 inches.
The cervical portion of the oesophagus, extending from the cricoid
cartilage to the upper edge of the sternum, measures about 2 inches.
It lies behind and to the left of the trachea, and in the groove
between them on each side runs the recurrent nerve. The thoracic
portion is about 7 inches long, and traverses the posterior
mediastinum lying slightly to the left of the middle line. It is
crossed by the left bronchus, and below this level has the pericardium
immediately in front of it. The left pleura is closely related to the
anterior surface of the oesophagus throughout, while the right pleura
passes behind it in its lower part. This accounts for the frequency
with which growths in the oesophagus invade the pleura. The oesophagus
passes through the diaphragm about an inch above the cardiac opening
of the stomach.
There are three points at which the oesophagus shows narrowing of the
lumen: (1) at the lower border of the cricoid--the "mouth of the
oesophagus"; (2) where it is crossed by the left bronchus; and (3)
where it passes through the diaphragm. It is at these points that
foreign bodies tend to become impacted. The mucous membrane of the
oesophagus is insensitive to tactile and painful stimuli, but is
sensitive to heat and cold and to exaggerated peristaltic
contractions.
#Methods of Examination.#--It is sometimes possible to detect an
impacted foreign body, a distended diverticulum, or a new growth in
the cervical portion of the oesophagus by _palpation_.
_Auscultation_ while the patient is drinking sometimes aids in the
diagnosis of stricture; the stethoscope is placed at various points
along the left side of the dorsal spine, and abnormal sounds may be
heard as the fluid impinges against the stricture or trickles through
it.
_Introduction of Bougies._--Oesophageal bougies or probangs are used
for diagnostic purposes in cases of suspected stricture, and to aid in
the detection of foreign bodies. Various forms are employed, of which
the most generally useful are the round-pointed gum-elastic or
silk-web bougie, and the olive-headed metal bougie, consisting of a
flexible whalebone stem, to which one of a graduated series of
aluminium or steel bulbs is screwed. For some purposes, such as
pushing onward an impacted bolus of food, the sponge probang--which
consists of a small round sponge fixed on a whalebone stem--is to be
preferred.
Before passing bougies, it is necessary to make certain that the
symptoms are not due to the pressure of an aneurysm on the oesophagus,
as cases have been recorded in which a thin-walled aneurysm has been
perforated by a bougie. The existence of ulceration or of an abscess
pressing on the gullet also contra-indicates the use of bougies.
For the passage of a bougie the patient should be seated on a chair
with the head thrown back and supported from behind by an assistant,
and he is directed to take full deep breaths rapidly. The bougie,
lubricated with butter or glycerine, and held like a pen, is guided
with the left forefinger. As soon as the instrument engages in the
opening of the oesophagus, the chin is brought down towards the chest,
and if the patient is now directed to swallow, the instrument may be
carried down the oesophagus, or can be passed on by gentle pressure.
Great gentleness must be exercised, and no attempt should be made to
force the instrument past any obstruction. The instrument may catch
against the hyoid bone, and this may be mistaken for an obstruction.
It is to be borne in mind that in some cases the passage of a bougie
may be attended with a considerable degree of shock, and cases are on
record in which this has proved fatal without any gross lesion being
found after death.
_Intubation_, or the passage of a cannula through a stricture, is
referred to later.
_Oesophagoscopy._--The _oesophagoscope_--a form of speculum which
enables the oesophagus to be illuminated by an electric lamp--is
employed for the detection and removal of foreign bodies, for the
examination of ulcers, diverticula, and strictures of the tube, and
with its aid it is possible to remove a portion of a growth for
microscopic examination. The mouth, pharynx, and entrance to the
oesophagus having been cleansed and cocainised, the patient is placed
in the recumbent or sitting posture, and the tube introduced. For
prolonged examinations a general anaesthetic is preferred.
The mouth of the oesophagus is closed by the sphincter-like action of
the lower fibres of the inferior constrictor muscle, and the cervical
part of the tube appears as a transverse slit, due to the backward
pressure of the trachea. The thoracic portion is more open and may
contain air, so that it is possible to see down to the lower end, the
closed cardiac orifice appearing as an oblique cleft surrounded by a
rosette-like cushion of mucous membrane. The pulsation of the aorta
can be seen just above the prominence formed by the left bronchus.
_Radiography._--Opaque foreign bodies can be detected by the screen or
in a radiogram; and the position of a stricture by making the patient
swallow capsules containing bismuth and examining with the screen. To
determine the position and size of a diverticulum, a radiogram is
taken after the patient has swallowed some food, such as porridge
mixed with bismuth.
#Wounds# of the oesophagus inflicted from without, for example stabs,
cut-throat or gun-shot injuries, are rare, and are almost invariably
accompanied by lesions of other important structures in the neck,
which may rapidly prove fatal. It is more common to meet with wounds
inflicted from within, for example by the swallowing of rough and
irregularly shaped foreign bodies, or by unskilful attempts to remove
such bodies or to pass bougies along the oesophagus. The severity of
the lesion varies from a scratch of the mucous membrane to a
perforation of the tube. The less severe injuries are attended with
pain on swallowing and a sensation as if something had lodged in the
oesophagus. In more severe cases there is bleeding, followed by
attacks of coughing and expectoration of blood-stained mucus. When the
oesophagus is perforated, diffuse cellulitis of the neck or of the
posterior mediastinum may ensue. In the treatment of these injuries
the chief point is to give the oesophagus rest by feeding the patient
entirely by the rectum or through an opening made in the
stomach--gastrostomy.
#Rupture# of the oesophagus has occurred during violent vomiting, and
during lavage. The tear is longitudinal and is usually near the
cardiac orifice. It is probably due to increased pressure within the
gullet. The accident has usually been met with in alcoholics, and has
proved fatal by setting up left-sided empyema or cellulitis.
#Swallowing of Corrosive Substances.#--The oesophagus is damaged by
the swallowing of strong chemicals, such as sulphuric acid, nitric
acid, carbolic acid, or caustic potash. These substances produce their
worst effects at the two ends of the oesophagus, but in some cases the
whole length of the tube suffers. The mucous membrane alone may be
destroyed, or the muscular and even the fibrous coats may also be
implicated. The damaged tissue undergoes necrosis, and when the
sloughs separate, raw surfaces are left, and are very slow to heal.
If not rapidly fatal from shock and oedema of the glottis, these
injuries are usually attended with intense pain, severe thirst, and
vomiting, the vomit containing shreds of mucous membrane and blood.
Complications, such as cellulitis, perforation of the oesophagus, or
peri-oesophageal abscess, may follow. Later, cicatricial contraction
takes place at the injured portions, producing the most intractable
form of fibrous stricture.
The _treatment_ consists in administering solutions of carbonate of
potash, of soda, or of magnesia when an acid has been swallowed, or
vinegar diluted with water in the case of an alkali. When carbolic
acid has been swallowed, a large quantity of olive oil should be
administered. The stomach should be washed out with water, the tube
being passed with the greatest gentleness to avoid perforating the
softened oesophageal wall. Subsequently the patient should be fed by
the rectum, but, in the majority of cases, gastrostomy is called for
to enable the patient to take nourishment and put the gullet at rest.
As soon as the oesophagus has healed, say in three or four weeks,
bougies should be passed every three or four days to prevent
cicatricial contraction. As the calibre of the tube is restored, the
instruments may be passed less frequently, but for some years--it may
be for the rest of the patient's life--a full-sized bougie should be
passed at least once a month.
#Impaction of Foreign Bodies in the Pharynx and Oesophagus.#--It is an
interesting fact that foreign bodies, even as large as a dinner fork,
when intentionally swallowed, can pass through the pharynx and
oesophagus and enter the stomach without apparent difficulty. When the
body is accidentally swallowed impaction is more liable to take place,
probably on account of the spasm induced by fright and by
inco-ordinated attempts to eject it. For obvious reasons the accident
is most liable to occur in children, in epileptics, and in those who
are under the influence of alcohol. It happens also during anaesthesia
for the extraction of teeth or if the patient vomits solid substances.
The clinical aspects vary according as the object is impacted in the
pharynx or in the oesophagus.
_In the Pharynx._--If a large bolus of unmasticated food becomes
impacted in the pharynx, it blocks the openings of both the oesophagus
and the larynx, and the patient may, without manifesting the usual
signs of suffocation, suddenly fall back dead, and if he happens to be
alone at the time of the accident, the cause of death is liable to be
overlooked unless the pharynx is examined at the post-mortem
examination. Most surgical museums contain specimens illustrating the
impaction of a bolus of meat in the pharynx; this fatal accident has
occurred especially in men in a condition of alcoholic intoxication.
An object of irregular shape, for example a large denture, also, is
most likely to lodge in the pharynx, obstructing the openings of both
the oesophagus and the larynx, and causing suffocation. The face
immediately becomes blue and engorged, the patient is speechless, and
violent efforts are made to eject the object by retching and coughing.
It may be seen from the mouth and touched with the finger.
In the case of small sharp bodies, such as fish, game, and mutton
bones, there is not the same urgency, and a methodical search for the
foreign body is carried out. Even after the foreign body has been got
rid of, the patient may have the sensation that it is still present.
This may be due to a scratch of the mucous membrane, or to spasm, in
which case the swallowing of a few drops of cocain solution will cause
the sensation to disappear.
_Treatment._--In the presence of impending suffocation, the mouth must
be forced open by an extemporised gag, the finger passed into the back
of the throat, and the body hooked out. If this is impossible, and if
suitable forceps are not at hand, it may be necessary at once to
perform laryngotomy, followed by artificial respiration, because,
although the patient may appear lifeless, the heart continues to beat
after breathing has ceased. The foreign body should then be removed
with forceps. Sub-hyoid pharyngotomy, which consists in opening the
pharynx by a mesial vertical incision carried through the hyo-thyreoid
membrane, may be called for, as in the case of a denture, the hooks of
which have penetrated the wall of the pharynx.
_In the Oesophagus._--Smaller bodies, such as coins, bones, or pins,
usually enter the oesophagus, and the great majority become impacted
above the level of the manubrium sterni. Those that pass farther down
are liable to stick where the tube is narrowed at the crossing of the
bronchus, or at the opening through the diaphragm. In children, coins
predominate and are nearly always arrested at the level of the upper
end of the sternum; in adults, dentures are the commonest foreign
bodies, and may be impacted anywhere.
At the moment of impaction there is pain, which assumes the character
of cramp due to spasm of the muscular coat, and which is increased on
attempting to swallow, and violent retching and coughing are set up;
in many cases, as when bodies are impacted in the pharynx, respiratory
distress is again the predominant feature. If the passage is
completely obstructed, food and saliva--sometimes blood-stained--are
regurgitated with retching soon after being swallowed. When the
obstruction is incomplete, fluids may pass into the stomach while
solids are regurgitated.
If the mucous membrane is injured, there is severe stabbing pain and
choking attacks, both due to spasm, sometimes even after the body has
passed on, and the pain is not always referred to the seat of the
injury.
The _diagnosis_ is made by the history, and by the use of the
fluorescent screen, or X-ray photographs (Figs. 283, 284). The
oesophagoscope is also of great value, both for diagnostic purposes
and as an aid in the removal of the impacted body. Bougies are to be
employed with great care, as there is a danger of pushing the foreign
body farther down, or of wedging it more firmly in the oesophagus, and
the information obtained is often misleading.
[Illustration: FIG. 283.--Radiogram of Safety-pin impacted in the
Gullet and perforating the Larynx.
(Professor Annandale's case. Radiogram by Dr. Dawson Turner.)]
[Illustration: FIG. 284.--Denture impacted in Oesophagus.
(Professor F. M. Caird's case.)]
It should be borne in mind that drunkards may suffer from a form of
spasm of the oesophagus, which simulates the impaction of a foreign
body; hospital records also show that the patient may only have dreamt
that he has swallowed a foreign body, usually a denture. These
possibilities should be always excluded before further procedures are
undertaken.
_Treatment._--There being no urgency, a careful examination is carried
out, not only to confirm the impaction of a foreign body, but its site
and its relation to the wall of the gullet. In skilled hands, the
safest and most certain means of removing impacted foreign bodies is
with the aid of the oesophagoscope. If this apparatus is not
available, other measures must be adopted varying with the nature of
the body, its site, and the manner of its impaction.
A bolus of food, for example, or a small smooth object that is likely
to pass safely along the alimentary canal, if it cannot be extracted
with forceps, may be pushed on into the stomach by the aid of a
bulbous-headed or sponge probang. This must be done gently, especially
if the body has been impacted for any time, as the inflammatory
softening of the oesophageal wall may predispose to rupture.
Small, sharp, or irregular objects, such as fish bones, tacks, or
pins, may be dislodged by the "umbrella probang"--an instrument which,
after being passed beyond the foreign body, is expanded into the form
of a circular brush which, on withdrawal, carries the foreign body out
among its bristles.
Coins usually lodge edgewise in the oesophagus, and are best removed
by means of an instrument known as a "coin-catcher", which is passed
beyond the coin, and on being withdrawn catches it in a hinged flange.
In emergencies a loop of stout silver wire bent so as to form a hook
makes an excellent substitute for a coin-catcher.
In difficult cases the removal of solid objects is facilitated by
carrying out the manipulations in the dark room with the aid of the
X-rays and the fluorescent screen.
Irregular bodies with projecting edges or hooks, such as tooth-plates,
tend to catch in the mucous membrane, and attempts to withdraw them by
forceps or other instruments are liable to cause laceration of the
wall. When situated in the cervical part of the oesophagus, these
should be removed by the operation of _oesophagostomy_ (_Operative
Surgery_, p. 195).
If the foreign body is lodged near the lower end of the gullet, it may
be necessary to perform _gastrostomy_ (_Operative Surgery_, p. 291),
making an opening in the anterior wall of the stomach large enough to
admit suitable forceps, or, if necessary, the whole hand, in order
that the body may be extracted by this route; experience shows that an
impacted body is more easily extracted from below, that is, from the
stomach, than from above.
When the surgeon fails to remove the body by either of these routes,
_gastrostomy_ must be performed both to feed the patient and to place
the gullet at rest. Smooth bodies may lie latent for long periods, but
those with points or hooks damage the mucous membrane, cause
ulceration and perforation with the risk of erosion of vessels and
secondary haemorrhage or of cellulitis of the neck or mediastinum and
empyema.
Other complications include septic broncho-pneumonia from damage to
the air-passage, and suppurative thyreoiditis.
#Infective conditions# due to pyogenic infection (_oesophagitis_ and
_peri-oesophagitis_) are rare.
A _chronic form of oesophagitis_ is occasionally met with in alcoholic
subjects, giving rise to symptoms that simulate those of impacted
foreign body, or of stricture.
In _tuberculous_ lesions the symptoms are pain, dysphagia, and
regurgitation of food mixed with blood, and the condition is liable to
be mistaken for gastric ulcer or for cancer of the oesophagus.
_Syphilitic affections_ of the oesophagus are rare.
#Varix# at the lower end of the oesophagus may give rise to
haematemesis, and be mistaken for gastric ulcer. Bleeding from the
dilated veins may follow the use of bougies or of the oesophagoscope.
CONDITIONS CAUSING DIFFICULTY IN SWALLOWING
Difficulty in swallowing may arise from a wide variety of causes which
it is convenient to consider together.
#Impaction of Foreign Bodies# has already been discussed, and
attention has been drawn to the importance of the history given by the
patient and to the various sources of fallacy or deception--in
children it may be artful reticence or misrepresentation, in adults,
the possibility of nightmare and of dreams.
#Compression of the Gullet from without.#--Any one of the numerous
structures in relation to the gullet may, when enlarged as a result of
disease, give rise to narrowing of its lumen, for example a
lymph-sarcoma at the root of the lung, or any enlargement of the
thyreoid or of the mediastinal lymph glands. The possibility of
aneurysm must always be kept in mind because of the risk attending the
passage of instruments for diagnostic purposes.
#Spasm of the Muscular Coat.#--As in other tubular structures
containing circular muscular fibres, sudden contraction or spasm may
occur in the oesophagus and cause narrowing of the lumen, attended
with difficulty in swallowing. This spasmodic dysphagia includes such
widely varying conditions as the "globus hystericus" of neurasthenic
women, the spasm of chronic alcoholics, and the affection known as
_cardiospasm_ or "hiatal oesophagismus."
In contrast with other affections causing difficulty in swallowing,
spasmodic dysphagia usually has a sudden and unexplained onset, the
progress of symptoms is irregular and erratic, while the remission of
symptoms common to all affections of the oesophagus, and the influence
of mental impressions, such as excitement, hurry in the presence of
strangers, are exaggerated.
In testing the calibre of the gullet it is found that on one occasion
a full-sized bougie may pass easily and be completely arrested at
another.
Apart from the treatment of the neurosis underlying the dysphagia,
reliance is placed upon dilatation of the portion of gullet affected.
#Cardiospasm# is the name given to "a recurrent interference with
deglutition by spasmodic contraction of the lower end of the
oesophagus." As there is no muscular or nervous mechanism at the
cardiac end of the oesophagus forming a true sphincter, the term
"oesophagospasm" would be more accurate (D. M. Greig).
According to H. S. Plummer, who has had an experience of 130 cases,
there are three stages in the development of this condition. In the
initial stage, the first attack occurs suddenly and unexpectedly; a
choking sensation is felt at some point in the gullet, usually at its
lower end. Attacks of choking with difficulty in swallowing occur
chiefly at meals, but they have also been known to occur apart from
the taking of food. In this stage the peristalsis of the gullet is
sufficient to force the food through the cardia.
In the second stage, the peristalsis of the gullet above being no
longer able to overcome the contraction, there is regurgitation of
food, which at first is returned to the mouth immediately after being
swallowed, but, as the gullet becomes dilated, is retained for longer
periods.
In the third stage, the gullet becomes more and more dilated, and the
food collects in it and is regurgitated at irregular intervals. The
patient complains of a sensation of weight and discomfort in the lower
part of the chest, and sometimes of regurgitation of food into the
nasal passages during sleep.
Cardiospasm should be suspected as the cause of difficulty in
swallowing if a rubber tube cannot be passed into the stomach while a
solid one can. When it is impossible to pass a solid instrument in the
ordinary way it can always be passed on a silk thread as a guide. The
patient is directed to swallow 6 yards of silk thread, half in the
afternoon and the remainder on the following morning. The first
portion forms a snarl in the gullet or stomach which passes out into
the intestine during the night; the proximal end is fixed to the cheek
by a strip of plaster. The olive heads of the bougies are drilled for
threading from the tip to one side of the base.
The _treatment_ consists in dilating the contracted segments by a
bougie. The results are immediate and are most striking, the patients
being almost invariably able to take any kind of food at the following
meal, and the gain in weight and strength is rapid. In a small
proportion of cases, dilatation fails to give relief, and recourse has
been had to anastomosing the lower end of the dilated and pouched
oesophagus with the stomach.
#Paralysis of the Gullet.#--As the passage of the food along the
gullet is entirely dependent upon muscular peristalsis, when the
muscular coat is paralysed, as it may be after diphtheria, for
example, the patient is unable to swallow and the food materials are
regurgitated, with consequent loss of flesh and strength. The
difficulty may be tided over for a time by feeding through a rubber
tube, but it is to be remembered that, in children, struggling in
resisting the passage of the tube may seriously strain a heart that is
already threatened by the toxins of diphtheria.
#Diverticula or Pouches of the Gullet.#--A diverticulum consists in
the protrusion of the mucous and submucous coats through a defect or
weak part in the muscular tunic; it is therefore of the nature of a
hernia and not a localised dilatation of the tube as a whole.
Anatomically, there is such a weak spot in the posterior wall opposite
the cricoid cartilage, known as the _pharyngeal dimple_, between the
circular and oblique fibres of the crico-pharyngeus muscle. As the
pouch increases in size by pressure from within, it usually extends
downwards and to the left. This pouch is described as a _pressure or
pulsion diverticulum_ because the hernial protrusion is ascribed to
increased pressure within the pharynx, not only the normal increase
caused by the act of swallowing, but an abnormal pressure from the too
rapid swallowing or bolting of imperfectly masticated food materials.
[Illustration: FIG. 285.--Radiogram, after swallowing an opaque meal,
in a man suffering from malignant stricture of lower end of Gullet.]
The _clinical features_ are not so characteristic of difficulty in
swallowing as might be expected. The patient, usually a man over forty
years of age, complains of dryness in the throat and of a sensation as
of a foreign body; later there is regurgitation of saliva and of food
with occasional choking. In about one-third of the cases, there is a
fullness, or a palpable tumour in the neck, about three times more
often on the left than on the right side, which may increase in size
after a meal, and pressure on which may cause a gurgling sound and, it
may be, regurgitation of food.
It is suggestive of a pouch, if the patient regurgitates food
materials which can be identified as having been swallowed several
days before, currants perhaps being those most easily recognised and
remembered.
Diverticula are also met with at a lower level, springing from the
gullet at or below the upper opening of the thorax; the distension of
the pouch with food materials presses upon the gullet with more
serious effect, even to the extent of complete obstruction and
consequent rapid emaciation. In men over fifty, the resemblance to
carcinoma may be very close.
In this, as in all cases of difficulty in swallowing, chief stress
should be laid on the X-ray appearances after the administration of an
opaque meal; a pouch shows as a uniform, spherical shadow of from one
to two inches in circumference.
_Treatment_ is influenced by the manner in which the patient may have
learned to overcome the difficulty of getting food into his
stomach--Lord Jeffrey, who was the possessor of the pharyngeal pouch
shown in Fig. 286, was in the habit of emptying it, after a meal, by
means of a long silver spoon. Some patients learn to feed themselves
through a soft rubber tube.
[Illustration: FIG. 286.--Diverticulum of the Oesophagus at its
junction with the Pharynx.
(Anatomical Museum, University of Edinburgh.)]
If an _operation_ is decided upon, and for this it is essential that
the pouch should be accessible from the neck, the general condition is
improved by feeding through a stomach tube and by rectal and
subcutaneous salines. The operation consists in exposing and isolating
the pouch by a dissection on the left side of the neck, and either
excising it as if it were a tumour or cyst, or if the risk of
infection of the deeper planes of cellular tissue is regarded with
apprehension, the pouch may be _infolded_ into the lumen of the
gullet, or the excision be carried out in two _stages_. At the first
stage, the pouch is isolated and rotated on its pedicle, in which
condition it is fixed by sutures; after an interval of from ten to
fourteen days it is excised.
Should the diverticulum be inaccessible from the neck, and the
difficulty of swallowing be attended with progressive emaciation,
_gastrostomy_ may be required to avert death by starvation.
_Traction diverticula_ are due to the contraction of scar tissue
outside the gullet, as for example that resulting from tuberculous
glands in the posterior mediastinum; they are rarely attended with
symptoms, and are rather of pathological than surgical interest.
#Innocent Stricture or Cicatricial Stenosis of the Gullet.#--The
innocent or fibrous stricture follows upon the swallowing of corrosive
substances, usually by inadvertence, sometimes with suicidal intent.
Having recovered from the initial effects of the corrosive agent, the
patient suffers from gradually increasing difficulty in swallowing,
first with solids and later with fluids. There is the usual variation
or intermittence of symptoms that attend upon all conditions causing
difficulty of swallowing, the exacerbations being due to superadded
spasm of the muscular coat and congestion of all the coats. As the
gullet dilates above the stricture, there is an increasing
accumulation of what has been swallowed, and this the patient
regurgitates at intervals; this is usually described as "vomiting,"
but the material ejected shows no signs of gastric digestion. There is
pain referred to the epigastrium or between the shoulder-blades, the
patient suffers from hunger and thirst, and may present an extreme
degree of emaciation.
The _diagnosis_ is suggested by the history, and is confirmed by the
oesophagoscope or by the X-rays after an opaque meal. The use of
bougies has taken a secondary place since the introduction of these
methods of examination, but, when other means are not available, the
passage of bougies having a whalebone shaft and a series of metal
heads shaped like an olive, may give useful information regarding the
site, number, and size of the strictures that require to be dealt
with.
_Treatment._--If the patient is in a critical state from starvation,
gastrostomy must be performed to enable him to be fed; otherwise he is
prepared for treatment of the stricture by rest in bed, sedatives, and
suitable liquid or some solid foods to improve his general condition
and eliminate the muscular spasm and congestion already referred to.
If the passage of bougies with the object of dilating the stricture is
difficult or impossible, it may be made easier or possible by getting
a silk thread through the stricture. The patient swallows several
yards of a reliable silk thread a day or two before the proposed
dilatation is carried out; the thread is expected to pass through the
stricture of the stomach, and to enter for some distance into the
small intestine; the metal head of the bougie, which is canalised in
its long axis, is "threaded" on the silk, and the latter acting as a
guide, the bougie is passed safely and confidently through the
stricture. Larger olive-shaped heads are passed at intervals until the
normal calibre of the gullet is exceeded, after which it is usually
easy to pass an ordinary full-sized instrument at intervals of a month
or so.
In the event of failure, recourse must be had to gastrostomy, and
through the stomach it may be possible to dilate the stricture by the
"retrograde" route. In aggravated cases, the gastrostomy opening must
be retained in order to prevent death from starvation.
#Malignant Stricture--Carcinoma of the Gullet.#--This is met with in
two forms which present widely different pathological and clinical
features.
Cancer of the _cervical_ portion affects the gullet at its junction
with the pharynx, and for some unexplained reason is much more common
in women, and at the comparatively early age of between thirty and
fifty. Cancer of the _thoracic_ portion affects the extreme lower end
of the gullet, and is met with almost exclusively in men over fifty.
#Cancer of the Cervical Portion.#--Difficulty of swallowing may arise
suddenly; more often it is slow and progressive over a period of
months and, in some cases, even of years. Pain on swallowing is not a
constant or prominent feature; it may be referred to the site of the
lesion or to one or both ears. In a considerable number of cases, the
complaints of the patient are referred to the larynx; coughing, with
abundant mucous expectoration disturbing the night's rest, hoarseness,
or even loss of voice, which symptoms are due either to direct
invasion of the larynx or to implication of one or other recurrent
nerve; for the same cause, difficulty of breathing may supervene,
sometimes of such a nature as to render tracheotomy imperative. A
gurgling noise on swallowing, and regurgitation of food are
occasionally observed.
Palpation of the neck, and particularly of the larynx and trachea,
should be carried out in all cases presenting the symptoms described;
and as bearing on the question of operation, enlargement of the
cervical lymph glands and of the thyreoid should be looked for; cancer
of the thyreoid is sometimes secondary to disease at the
pharyngo-oesophageal junction.
Direct and indirect laryngoscopic examination is then made; if the
laryngeal mirror fails to reveal anything abnormal, suspension
laryngoscopy, which gives a more extensive view of that part of the
pharynx lying behind the larynx, may be employed, or the
oesophagoscope may be preferred. A portion of the growth may be
removed for microscopical examination.
The use of the oesophageal bougie as a diagnostic agent must be
deprecated; it gives no satisfactory explanation of the cause of the
obstruction, and its employment when malignant ulceration is present,
is not free from serious risk to the patient (Logan Turner).
_Treatment._--The surgeon is dependent on the help of the
laryngologist not only for the diagnosis of the disease at the
earliest stage possible, but also for information as to its extent,
especially with regard to involvement of the larynx.
_Oesophagectomy_, or resection of the cancerous segment of the gullet,
in suitable cases, even if it does not yield a permanent cure, not
only prolongs life but relieves the patient of her most distressing
symptoms. It is rarely possible to secure an end-to-end anastomosis,
but the feeding by means of a tube introduced into the open end of the
gullet is more satisfactory and the laryngeal symptoms are more
efficiently relieved, than by either of the purely palliative
operations. In the majority of cases, however, only the palliative
measures of _oesophagostomy_ or _gastrostomy_ can be adopted.
Oesophagostomy presents the advantage, that by exposing the cervical
portion of the gullet, the operator is enabled to investigate the
extent of the disease and to revise his opinion on the feasability of
its removal if necessary. In advanced cases, when the disease has
spread widely in the neck and involved, it may be, the thyreoid and
the larynx, it may only be possible to relieve the urgent distress of
the patient by gastrostomy. _Tracheotomy_ may also become necessary
because of the spread of the cancer to the interior of the larynx.
#Cancer of the Lower End of the Gullet.#--The remarkable preference of
this location of oesophageal cancer for the male sex has already been
referred to; it affects the same type of male patients as are subject
to squamous epithelioma in other parts of the body. So far as we have
observed, its association with chronic irritation of the mucous
membrane in which it takes origin, or with any pre-cancerous
condition, has not been demonstrated.
The _clinical features_ resemble those of cicatricial stricture; the
difficulty of swallowing is usually of gradual onset, it concerns
solids in the first instance, then semi-solids like porridge or bread
and milk, and finally fluids. As in other forms of oesophageal
obstruction, the difficulty of swallowing varies quite remarkably from
time to time, presumably from variations in the degree of congestion
of the mucous membrane and of spasm of the muscular coat, but also
from mere nervousness, the patient having greater difficulty when in a
hurry, as in a railway refreshment room, or embarrassed by the
presence of strangers.
As the lumen of the gullet becomes narrower, the food materials
accumulate above the obstruction, and the consequent dilatation of the
gullet above the stricture accounts for the large amount that may be
regurgitated and for the patient describing it as vomiting. Along with
food materials there is abundant saliva, and, if the cancer has
ulcerated, of pus and blood. Contrary to what might be expected, there
is little or no complaint of hunger, in spite of the progressive
starvation and emaciation which inevitably supervene.
Death takes place within a year or so of the onset of symptoms,
usually from starvation, but the fatal issue may be precipitated by
ulceration and perforation of the gullet into a large blood vessel or
into the left pleural sac; in the latter event, there follows a basal
_empyema_ which may contain gas and food materials.
_Diagnosis._--In the majority of cases the history is so
characteristic that there is little doubt regarding the diagnosis; the
most reliable corroboration, with least risk and distress to the
patient, is obtained by radiographic examination after an opaque meal;
the appearance of the dilated gullet is that of an elongated sausage,
parallel with the vertebral column, and terminating abruptly at the
site of stricture (Fig. 285). A filiform, tortuous shadow of the
bismuth may be continued downwards and show up the lumen of the
stricture. The use of the oesophagoscope and of bougies is to be
deprecated as not free from risk.
_Treatment._--The lower end of the gullet is one of the most
inaccessible portions of the body, and although it has been removed by
operation the prospects of success are so small that it is not at
present regarded as justifiable.
Among _palliative measures_, may be mentioned _intubation_ of the
stricture with a view to increasing the amount of food that can be
swallowed; a funnel-shaped tube like that of Symonds or of Hill is
introduced into the lumen of the stricture by means of a bougie or
with the help of the oesophagoscope. The tube is anchored
to a denture, or by means of a silk thread to the cheek by
sticking-plaster. Our experience of intubation is that it merely
serves to tide the patient over a critical period of starvation, so
that he may regain some strength for any other procedure that may be
indicated.
The value of making a fistula in the stomach--_gastrostomy_--in order
to feed the patient, is a question about which widely different
opinions are held both by patients and by surgeons. Many patients
allege that they would prefer to die rather than prolong a precarious
existence by being fed through a tube; some surgeons look upon the
operation with disfavour because they doubt whether it even prolongs
life, and it is often followed by a pneumonia which rapidly proves
fatal. Variation in the results of gastrostomy observed by different
surgeons is partly due to differences in the stage of the disease at
which the operation is performed, and probably to a greater extent to
the confusion between cases of slowly growing squamous epithelioma of
the lower end of the gullet and cases of glandular carcinoma of the
cardiac end of the stomach, these being grouped together under the
clinical heading of "malignant stricture of the lower end of the
gullet." In our experience cases of epithelioma of the gullet (in the
strict sense of the term) benefit greatly if subjected to gastrostomy
as soon as the condition is recognised. In a case operated upon by
Thomas Annandale the patient survived the operation for three years
and some months.
_Radiation._--The introduction of a tube of radium into the stricture
and its retention there, the silk thread attached to the tube being
secured to the cheek by a strip of plaster, is described by Hill and
Finzi as the most valuable palliative measure that has so far been
employed in cancer of the gullet; the capacity of swallowing may be
regained to a considerable extent. The employment of radium is
rendered easier and more efficient if it is preceded by gastrostomy.
_The Roux-operation._--This consists in making a new gullet to replace
that which is obstructed; the abdomen is opened and a loop of jejunum
is isolated; its lower end is anastomosed--end to side--to the
stomach; the intestine is brought upwards through a tunnel made for it
between the skin and the sternum, and the upper end is brought out and
fixed to the skin, in the supra-sternal notch. It has scarcely passed
beyond the experimental stage.