_Foreign bodies in the pleural cavity_ should be immediately removed.
The esophageal speculum inserted through a small intercostal incision
makes an excellent pleuroscope, its spatular tip being of particular
value in moving the lung out of the way. This otherwise dark cavity is
thus brilliantly illuminated without the necessity of making a large
flap resection, an important factor in those cases in which there is
no infection present. The pleura and wound may be immediately closed
without drainage, if the pleura is not infected. Excessive plus
pressure or pus may require reopening. In one case in which the author
removed a foreign body by pleuroscopy, healing was by first intention
and the lung filled in a few days. Drainage tubes that have slipped up
into the empyemic cavity are foreign bodies. They are readily removed
with the retrograde esophagoscope even through the smallest fistula.
The aspirating canal keeps a clear field while searching for the
drain.
_Pleuroscopy for Disease_.--Most pleural diseases require a large
external opening for drainage, and even here the pleuroscope may be of
some use in exploring the cavities. Usually there are many adhesions
and careful ray study may reveal one or more the breaking up of which
will improve drainage to such an extent as to cure an empyema of long
standing. Repeated severing of adhesions, aspiration and sometimes
incision of the thickened visceral pleura may be necessary. The author
is so strongly imbued with the idea that local examination under full
illumination has so revolutionized the surgery of every region of the
body to which it has been applied, that every accessible region should
be thus studied. The pleural cavity is quite accessible with or
without rib-resection, and there is practically no risk in careful
pleuroscopy.
[201] CHAPTER XXI--BENIGN GROWTHS IN THE LARYNX
Benign growths in the larynx are easily and accurately removable by
direct laryngoscopy; but perhaps no method has been more often misused
and followed by most unfortunate results. It should always be
remembered that benign growths are benign, and that hence they do not
justify the radical work demanded in dealing with malignancy. The
larynx should be worked upon with the same delicacy and respect for
the normal tissues that are customary in dealing with the eye.
_Granulomata in the larynx_, while not true neoplasms, require
extirpation in some instances.
_Vocal nodules_, when other methods of cure such as vocal rest,
various vocal exercises, etcetera have failed may require surgical
excision. This may be done with the laryngeal tissue forceps or with
the author's vocal nodule forceps. Sessile vocal nodules may be cured
by touching them with a fine galvanocautery point, but all work on the
vocal cords must be done with extreme caution and nicety. It is
exceedingly easy to ruin a fine voice.
_Fibromata_, often of inflammatory genesis, are best removed with the
laryngeal grasping forceps, though the small laryngeal punch or tissue
forceps may be used. If very large, they may be amputated with the
snare, the base being treated with galvanocautery though this is
seldom advisable. Strong traction should be avoided as likely to do
irreparable injury to the laryngeal motility.
_Cystomata_ may get well after simple excision or galvanopuncture of a
part of the wall of the sac, but complete extirpation of the sac is
often required for cure. The same is true of _adenomata._
[202] Angiomata, if extensive and deeply seated, may require deep
excision, but usually cure results from superficial removal. Usually
no cauterization of the vessels at the base is necessary, either to
arrest hemorrhage or to lessen the tendency to recurrence. A diffuse
telangiectasis, should it require treatment, may be gently touched
with a needle-pointed galvanocaustic electrode at a number of
sittings. The galvanonocautery is a dangerous method to use in the
larynx. Radium offers the best results in this latter form of angioma,
applied either internally or to the neck.
_Lymphoma, enchondroma and osteoma_, if not too extensively involving
the laryngeal walls, may be excised with basket punch forceps, but
lymphoma is probably better treated by radium.* _True myxomata and
lipomata_ are very rare. _Amyloid tumors_ are occasionally met with,
and are very resistant to treatment. _Aberrant thyroid tumors_ do not
require very radical excision of normal base, but should be removed as
completely as possible.
In a general way, it may be stated that with benign growths in the
larynx the best functional results are obtained by superficial rather
than radical, deep extirpation, remembering that it is easier to
remove tissue than to replace it, and that cicatrices impair or ruin
the voice and may cause stenosis.
* In a case reported by Delavan a complete cure with perfect
restoration of voice resulted from radium after I had failed to cure
by operative methods. (Proceedings American Laryngological
Association, 1921.)
[203] CHAPTER XXII--BENIGN GROWTHS IN THE LARYNX (Continued)
PAPILLOMATA OF THE LARYNX IN CHILDREN
Of all benign growths in the larynx papilloma is the most frequent. It
may occur at any age of childhood and may even be congenital. The
outstanding fact which necessarily influences our treatment is the
tendency to recurrences, followed eventually in practically all cases
by a tendency to disappearance. In the author's opinion multiple
papillomata constitute a benign, self-limited disease. There are two
classes of cases. 1. Those in which the growth gets well
spontaneously, or with slight treatment, surgically or otherwise; and,
2, those not readily amenable to any form of treatment, recurrences
appearing persistently at the old sites, and in entirely new
locations. In the author's opinion these two classes of case represent
not two different kinds of growths, but stages in the disease. Those
that get well after a single removal are near the end of the disease.
Papillomata are of inflammatory origin and are not true neoplasms in
the strictest sense.
_Methods of Treatment_.--Irritating applications probably provoke
recurrences, because the growths are of inflammatory origin. Formerly
laryngostomy was recommended as a last resort when all other means had
failed. The excellent results from the method described in the
foregoing paragraph has relegated laryngostomy to those cases that
come in with a severe cicatricial stenosis from an injudicious
laryngofissure; and even in these cases cure of the stenosis as well
as the papillomata can usually be obtained by endoscopic methods
alone, using superficial scalping off of the papillomata with
subsequent laryngoscopic bouginage for the stenosis. Thyrotomy for
papillomata is mentioned only to be condemned. Fulguration has been
satisfactory in the hands of some, disappointing to others. It is
easily and accurately applied through the direct laryngoscope, but
damage to normal tissues must be avoided. Radium, mesothorium, and the
roentgenray are reported to have had in certain isolated cases a
seemingly beneficial action. In my experience, however, I have never
seen a cure of papillomata which could be attributed to the radiation.
I have seen cases in which no effect on the growths or recurrence was
apparent, and in some cases the growths seemed to have been stimulated
to more rapid repullulations. In other most unfortunate cases I have
seen perichondritis of the laryngeal cartilages with subsequent
stenosis occurring after the roentgenotherapy. Possibly the disastrous
results were due to overdosage; but I feel it a duty to state the
unfavorable experience, and to call attention to the difference
between cancer and papillomata. Multiple papillomata involve no danger
to life other than that of easily obviated asphyxia, and it is
moreover a benign self-limited disease that repullulates on the
surface. In cancer we have an infiltrating process that has no limits
short of life itself.
_Endolaryngeal extirpation_ of papillomata in children requires no
anesthetic, general or local; the growths are devoid of sensibility.
If, for any reason, a general anesthetic is used it should be only in
tracheotomized cases, because the growths obstruct the airway.
Obstructed respiration introduces into general anesthesia an enormous
element of danger. Concerning the treatment of multiple papillomata it
has been my experience in hundreds of cases that have come to the
Bronchoscopic Clinic, that repeated superficial removals with blunt
non-cutting forceps (see Chapter I) will so modify the soil as to make
it unfavorable for repullulation. The removals are superficial and do
not include the subjacent normal tissue. Radical removal of a
papilloma situated, for instance, on the left ventricular band or
cord, can in no way prevent the subsequent occurrence of a similar
growth at a different site, as upon the epiglottis, or even in the
fauces. Furthermore, radical removal of the basal tissues is certain
to impair the phonatory function. Excellent results as to voice and
freedom from recurrence have always followed repeated superficial
removal. The time required has been months or a year or two. Only
rarely has a cure followed a single extirpation.
If the child is but slightly dyspneic, the obstructing part of the
growth is first removed without anesthesia, general or local; the
remaining fungations are extirpated subsequently at a number of brief
seances. The child is thus not terrified, soon loses dread of the
removals, and appreciates the relief. Should the child be very
dyspneic when first seen, a low tracheotomy is immediately done, and
after an interim of ten days, laryngoscopic removal of the growth is
begun. Tracheotomy probably has a beneficial effect on the disease.
Tracheal growths require the insertion of the bronchoscope for their
removal.
_Papillomata in the larynx of adults_ are, on the whole, much more
amenable to treatment than similar growths in children. Tracheotomy is
very rarely required, and the tendency to recurrence is less marked.
Many are cured by a single extirpation. The best results are obtained
by removal of the growths with the laryngeal grasping-forceps, taking
the utmost care to avoid including in the bite of the forceps any of
the subjacent normal tissue. Radical resection or cauterization of the
base is unwise because of the probable impairment of the voice, or
cicatricial stenosis, without in anyway insuring against
repullulation. The papillomata are so soft that they give no sensation
of traction to the forceps. They can readily be "scalped" off without
any impairment of the sound tissues, by the use of the author's
papilloma forceps (Fig. 29). Cutting forceps of all kinds are
objectionable because they may wound the normal tissues before the
sense of touch can give warning. A gentle hand might be trusted with
the cup forceps (Fig. 32, large size.)
Sir Felix Semon proved conclusively by his collective investigations
that cancer cannot be caused by the repeated removals of benign
growths. Therefore, no fear of causing cancer need give rise to
hesitation in repeatedly removing the repullulations of papillomata or
other benign growths. Indeed there is much clinical evidence elsewhere
in the body, and more than a little such evidence as to the larynx, to
warrant the removal of benign growths, repeated if necessary, as a
prophylactic of cancer (Bibliography, 19).
[207] CHAPTER XXIII--BENIGN GROWTHS PRIMARY IN THE TRACHEOBRONCHIAL
TREE
Extension of papillomata from the larynx into the cervical trachea,
especially about the tracheotomy wound, is of relatively common
occurrence. True primary growths of the tracheobronchial tree, though
not frequent, are by no means rare. These primary growths include
primary papillomata and fibromata as the most frequent, aberrant
thyroid, lipomata, adenomata, granulomata and amyloid tumors.
Chondromata and osteochondromata may be benign but are prone to
develop malignancy, and by sarcomatous or other changes, even
metaplasia. Edematous polypi and other more or less tumor-like
inflammatory sequelae are occasionally encountered.
_Symptoms of Benign Tumors of the Tracheobronchial Tree_.--Cough,
wheezing respiration, and dyspnea, varying in degree with the size of
the tumor, indicate obstruction of the airway. Associated with
defective aeration will be the signs of deficient drainage of
secretions. Roentgenray examination may show the shadow of
enchondromata or osteomata, and will also show variations in aeration
should the tumor be in a bronchus.
_Bronchoscopic removal of benign growths_ is readily accomplished with
the endoscopic punch forceps shown in Figs. 28 and 33. Quick action
may be necessary should a large tumor producing great dyspnea be
encountered, for the dyspnea is apt to be increased by the congestion,
cough, and increased respiration and spasm incidental to the presence
of the bronchoscope in the trachea. General anesthesia, as in all
cases showing dyspnea, is contraindicated. The risks of hemorrhage
following removal are very slight, provided fungations on an
aneurismal erosion be not mistaken for a tumor.
Multiple papillomata when very numerous are best removed by the
author's "coring" method. This consists in the insertion of an
aspirating bronchoscope with the mechanical aspirator working at full
negative pressure. The papillomata are removed like coring an apple;
though the rounded edge of the bronchoscope does not even scratch the
tracheal mucosa. Many of the papillomata are taken off by the holes in
the bronchoscope. Aspiration of the detached papillomata into the
lungs is prevented by the corking of the tube-mouth with the mass of
papillomata held by the negative pressure at the canal inlet orifice.
CHAPTER XXIV--BENIGN NEOPLASMS OF THE ESOPHAGUS
As a result of prolonged inflammation edematous polypi and granulomata
are not infrequently seen, but true benign tumors of the esophagus are
rare affections. Keloidal changes in scar tissue may occur. Cases of
retention, epithelial and dermoid cysts have been observed; and there
are isolated reports of the finding of papillomata, fibromata,
lipomata, myomata and adenomata. The removal of these is readily
accomplished with the tissue forceps (Fig. 28), if the growths are
small and projecting into the esophageal lumen. The determination of
the advisability of the removal of keloidal scars would require
careful consideration of the particular case, and the same may be said
of very large growths of any kind. The extreme thinness of the
esophageal walls must be always in the mind of the esophagoscopist if
he would avoid disaster.
[210] CHAPTER XXV--ENDOSCOPY IN MALIGNANT DISEASE OF THE LARYNX
The general surgical rule applying to individuals past middle life,
that benign growths exposed to irritation should be removed, probably
applies to the larynx as well as to any other epithelialized
structure. The facility, accuracy and thoroughness afforded by
skilled, direct, laryngeal operation offers a means of lessening the
incidence of cancer. To a much greater extent the facility, accuracy,
and thoroughness contribute to the cure of cancer by establishing the
necessary early diagnosis. Well-planned, careful, external operation
(laryngofissure) followed by painstaking after-care is the only
absolute cure so far known for malignant neoplasms of the larynx; and
it is a cure only in those intrinsic cases in which the growth is
small, and is located in the anterior two-thirds of the intrinsic
area. By limiting operations strictly to this class of case,
eighty-five per cent of cures may be obtained.* In determining the
nature of the growth and its operability the limits of the usefulness
of direct endoscopy are reached. It is very unwise to attempt the
extirpation of intrinsic laryngeal malignancy by the endoscopic
method, for the reason that the full extent of the growth cannot be
appreciated when viewed only from above, and the necessary radical
removal cannot be accurately or completely accomplished.
* The author's results in laryngofissure have recently fallen to 79
per cent of relative cures by thyrochondrotomy.
_Malignant disease of the epiglottis_, in those rare cases where the
lesion is strictly limited to the tip is, however, an exception. If
amputation of the epiglottis will give a sufficiently wide removal,
this may be done en masse with a heavy snare, and has resulted in
complete cure. Very small growths may be removed sufficiently widely
with the punch forceps (Fig. 33); but piece meal removal of malignancy
is to be avoided.
_Differential Diagnosis of Laryngeal Growths in the Larynx of
Adults_.--Determination of the nature of the lesion in these cases
usually consists in the diagnosis by exclusion of the possibilities,
namely,
1. Lues.
2. Tuberculosis, including lupus.
3. Scleroma.
4. Malignant neoplasm.
In the Bronchoscopic Clinic the following is the routine procedure:
1. A Wassermann test is made. If negative, and there remains a
suspicion of lues, a therapeutic test with mercury protoiodid is
carried out by keeping the patient just under the salivation point for
eight weeks; during which time no potassium iodid is given, lest its
reaction upon the larynx cause an edema necessitating tracheotomy. If
no improvement is noticed lues is excluded. If the Wassermann is
positive, malignancy and the other possibilities are not considered as
excluded until the patient has been completely cured by mercury,
because, for instance, a leutic or tuberculous patient may have
cancer; a tuberculous patient may have lues; or a leutic patient,
tuberculosis.
2. Pulmonary tuberculosis is excluded by the usual means. If present
the laryngeal lesion may or may not be tuberculous; if the
laryngoscopic appearances are doubtful a specimen is taken. Lupoid
laryngeal tuberculosis so much resembles lues that both the
therapeutic test and biopsy may be required for certainty.
3. In all cases in which the diagnosis is not clear a specimen
is taken. This is readily accomplished by direct laryngoscopy under
local anesthesia, using the regular laryngoscope or the anterior
commissure laryngoscope. The best forceps in case of large growths are
the alligator punch forceps (Fig. 33). Smaller growths require tissue
forceps (Fig. 28). In case of small growths, it is best to remove the
entire growth; but without any attempt at radical extirpation of the
base; because, if the growth prove benign it is unnecessary; if
malignant, it is insufficient.
_Inspection of the Party Wall in Cases of Suspected Laryngeal
Malignancy_.--When taking a specimen the party wall should be
inspected by passing a laryngoscope or, if necessary, an esophageal
speculum down through the laryngopharynx and beyond the
cricopharyngeus. If this region shows infiltration, all hope of cure
by operation, however radical, should be abandoned.
_Radium and the therapeutic roentgenray_ have given good results, but
not such as would warrant their exclusive use in any case of
malignancy in the larynx operable by laryngofissure. With inoperable
cases, excellent palliative results are obtained. In some cases an
almost complete disappearance of the growth has occurred, but
ultimately there has been recurrence. The method of application of the
radium, dosage, and its screening, are best determined by the
radiologist in consultation with the laryngologist. Radium may be
applied externally to the neck, or suspended in the larynx;
radium-containing needles may be buried in the growth, or the
emanations, imprisoned in glass pearls or capillary tubes, may be
inserted deeply into the growth by means of a small trocar and
cannula. For all of these procedures direct laryngoscopy affords a
ready means of accurate application. Tracheotomy is necessary however,
because of the reactionary swelling, which may be so great as to close
completely the narrowed glottic chink. Where this is the case, the
endolaryngeal application of the radium may be made by inserting the
container through the tracheotomic wound, and anchoring it to the
cannula.
The author is much impressed with Freer's method of radiation from the
pyriform sinus in such cases as those in which external radiation
alone is deemed insufficient.
The work of Drs. D. Bryson Delavan and Douglass M. Quick forms one of
the most important contributions to the subject of the treatment of
radium by cancer. (See Proceedings of the American Laryngological
Association, 1922; also Proceedings of the Tenth International
Otological Congress, Paris, 1922.)
[214] CHAPTER XXVI--BRONCHOSCOPY IN MALIGNANT GROWTHS OF THE TRACHEA
The trachea is often secondarily invaded by malignancy of the
esophagus, thyroid gland, peritracheal or peribronchial glands.
Primary malignant neoplasms of the trachea or bronchus have not
infrequently been diagnosticated by bronchoscopy. Peritracheal or
peribronchial malignancy may produce a compressive stenosis covered
with normal mucosa. Endoscopically, the wall is seen to bulge in from
one side causing a crescentic picture, or compression of opposite
walls may cause a "scabbard" or pear shaped lumen. Endotracheal and
endobronchial malignancy ulcerate early, and are characterized by the
bronchoscopic view of a bleeding mass of fungating tissue bathed in
pus and secretion, usually foul. The diagnosis in these cases rests
upon the exclusion of lues, and is rendered certain by the removal of
a specimen for biopsy. Sarcoma and carcinoma of the thyroid when
perforating the trachea may become pedunculated. In such cases
aberrant non-pathologic thyroid must be excluded by biopsy.
Endothelioma of the trachea or bronchus may also assume a pedunculated
form, but is more often sessile.
_Treatment_.--Pedunculated malignant growths are readily removed with
snare or punch forceps. Cure has resulted in one case of the author
following bronchoscopic removal of an endothelioma from the bronchus;
and a limited carcinoma of the bronchus has been reported cured by
bronchoscopic removal, with cauterization of the base. Most of the
cases, however, will be subjects for palliative tracheotomy and radium
therapy. It will be found necessary in many of the cases to employ the
author's long, cane-shaped tracheal cannula (Fig. 104, A), in order to
pipe the air down to one or both bronchi past the projecting neoplasm.
It has recently been demonstrated that following the intravenous
injection of a suspension of the insoluble salt, radium sulphate, that
the suspended particles are held in the capillaries of the lung for a
period of one year. Intravenous injections of a watery suspension, and
endobronchial injections of a suspension of radium sulphate in oil,
have had definite beneficial action. While as yet, no relatively
permanent cures of pulmonary malignancy have been obtained, the
amelioration and steady improvement noted in the technic of radium
therapy are so encouraging that every inoperable case should be thus
treated, if the disease is not in a hopelessly advanced stage.
In a case under the care of Dr. Robert M. Lukens at the Bronchoscopic
Clinic, a primary epithelioma of the trachea was retarded for 2 years
by the use of radium applied by Dr. William S. Newcomet,
radium-therapist, and Miss Katherine E. Schaeffer, technician.
[216] CHAPTER XXVII--MALIGNANT DISEASE OF THE ESOPHAGUS
Cancer of the esophagus is a more prevalent disease than is commonly
thought. In the male it usually develops during the fourth and fifth
decades of life. There is in some cases the history of years of more
or less habitual consumption of strong alcoholic liquors. In the
female the condition often occurs at an earlier age than in the male,
and tends to run a more protracted course, preceeded in some cases by
years of precancerous dysphagia.
Squamous-celled epithelioma is the most frequent type of neoplasm. In
the lower third of the esophagus, cylindric cell carcinoma may be
found associated with a like lesion in the stomach. Sarcoma of the
esophagus is relatively rare (Bibliography 1, p. 449).
The sites of the lesion are those of physiologic narrowing of the
esophagus. The middle third is most frequently involved; and the lower
third, near the cardia, comes next in frequency. Cancer of the lower
third of the esophagus preponderates in men, while cancer of the upper
orifice is, curiously, more prevalent in women. The lesion is usually
single, but multiple lesions, resulting from implantation metastases
have been observed (Bibliography 1, p. 391). Bronchoesophageal fistula
from extension is not uncommon.
_Symptoms_.--Malignant disease of the esophagus is rarely seen early,
because of the absence, or mildness, of the symptoms. Dysphagia, the
one common symptom of all esophageal disease, is often ignored by the
patient until it becomes so marked as to prevent the taking of solid
food; therefore, the onset may have the similitude of abruptness. Any
well masticated solid food can be swallowed through a lumen 5
millimeters in diameter. The inability to maintain the nutrition is
evidenced by loss of weight and the rapid development of cachexia.
When the stenosis becomes so severe that the fluid intake is limited,
rapid decline occurs from water starvation. Pain is usually a late
symptom of the disease. It may be of an aching character and referred
to the vertebral region or to the neck; or it may only accompany the
act of swallowing. Blood-streaked, regurgitated material, and the
presence of odor, are late manifestations of ulceration and secondary
infection. In some cases, constant oozing of blood from the ulcerated
area adds greatly to the cachexia. If the recurrent laryngeal nerves
are involved, unilateral or bilateral paralysis of the larynx may
complicate the symptoms by cough, dyspnea, aphonia, and possibly
septic pneumonia.
_Diagnosis_.--It has been estimated that 70 per cent of stenoses of
the esophagus in adults are malignant in nature. This should stimulate
the early and careful investigation of every case of dysphagia. When
all cases of persistent dysphagia, however slight, are endoscopically
studied, precancerous lesions may be discovered and treated, and the
limited malignancy of the early stages may be afforded surgical
treatment while yet there is hope of complete removal. Luetic and
tuberculous ulceration of the esophagus are to be eliminated by
suitable tests, supplemented in rare instances by biopsy. Aneurysm of
the aorta must in all cases of dysphagia be excluded, for the dilated
aorta may be the sole cause of the condition, and its presence
contraindicates esophagoscopy because of the liability of rupture.
Foreign body is to be excluded by history and roentgenographic study.
Spasmodic stenosis of the esophagus may or may not have a malignant
origin. Esophagoscopy and removal of a specimen for biopsy renders the
diagnosis certain. It is to be especially remembered, however, that it
is very unwise to bite through normal mucosa for the purpose of taking
a specimen from a periesophageal growth. Fungations and polypoid
protuberances afford safe opportunities for the removal of specimens
of tissue.
_The esophagoscopic appearances of malignant disease_, varying with
the stage and site of origin of the growth, may present as follows:--
1. Submucosal infiltration covered by perfectly normal membrane,
usually associated with more or less bulging of the esophageal wall,
and very often with hardness and infiltration.
2. Leucoplakia.
3. Ulceration projecting but little above the surface at the edges.
4. Rounded nodular masses grouped in mulberry-like form, either dark
or light red in color.
5. Polypoid masses.
6. Cauliflower fungations.
In considering the esophagoscopic appearances of cancer, it is
necessary to remember that after ulceration has set in, the cancerous
process may have engrafted upon it, and upon its neighborhood, the
results of inflammation due to the mixed infections. Cancer invading
the wall from without may for a long time be covered with perfectly
normal mucous membrane. The significant signs at this early stage are:
1. Absence of one or more of the normal radial creases between the
folds.
2. Asymmetry of the inspiratory enlargement of lumen.
3. Sensation of hardness of the wall on palpation with the tube.
4. The involved wall will not readily be made to wrinkle when pushed
upon with the tube mouth.
In all the later forms of lesions the two characteristics are (a) the
readiness with which oozing of blood occurs; and (b) the sense of
rigidity, or fixation, of the involved area as palpated with the
esophagoscope, in contrast to the normally supple esophageal wall.
Esophageal dilatation above a malignant lesion is rarely great,
because the stenosis is seldom severely obstructive until late in the
course of the disease.
_Treatment_.--The present 100 per cent mortality in cancer of the
esophagus will be lowered and a certain percentage of surgical cures
will be obtained when patients with esophageal symptoms are given the
benefit of early esophagoscopic study. The relief or circumvention of
the dysphagia requires early measures to prevent food and water
starvation. _Bouginage_ of a malignant esophagus to increase
temporarily the size of the stenosed lumen is of questionable
advisability, and is attended with the great risk of perforating the
weakened esophageal wall.
_Esophageal intubation_ may serve for a time to delay gastrostomy but
it cannot supplant it, nor obviate the necessity for its ultimate
performance. The Charters-Symonds or Guisez esophageal intubation tube
is readily inserted after drawing the larynx forward with the
laryngoscope. The tube must be changed every week or two for cleaning,
and duplicate tubes must be ready for immediate reinsertion.
Eventually, a smaller, and then a still smaller tube are needed, until
finally none can be introduced; though in some cases the tube can be
kept in the soft mass of fungations until the patient has died of
hemorrhage, exhaustion, complications or intercurrent disease.
_Gastrostomy_ is always indicated as the disease progresses, and it
should be done before nutrition is greatly impaired. Surgeons often
hesitate thus to "operate on an inoperable case;" but it must be
remembered that no one should be allowed to die of hunger and thirst.
The operation should be done before inanition has made serious
inroads. As in the case of tracheotomy, we always preach doing it
early, and always do it late. If postponed too long, water starvation
may proceed so far that the patient will not recover, because the
water-starved tissues will not take up water put in the stomach.
_Radiotherapy_.--Radium and the therapeutic roentgenray are today our
only effective means of retarding the progress of esophageal malignant
neoplasms. No permanent cures have been reported, but marked temporary
improvement in the swallowing function and prolongation of life have
been repeatedly observed. The combination of radium treatment applied
within the esophageal lumen and the therapeutic roentgenray through
the chest wall, has retarded the progress of some cases.
The dosage of radium or the therapeutic ray must be determined by the
radiologist for the particular individual case; its method of
application should be decided by consultation of the radiologist and
the endoscopist. Two fundamental points are to be considered, however.
The radium capsule, if applied within the esophagus, should be so
screened that the soft, irritating, beta rays, and the secondary rays,
are both filtered out to prevent sloughing of the esophageal mucosa.
The dose should be large enough to have a lethal effect upon the
cancer cells at the periphery of the growth as well as in the center.
If the dose be insufficient, development of the cells at the outside
of the growth is stimulated rather than inhibited. It is essential
that the radium capsule be accurately placed in the center of the
malignant strictured area and this can be done only by visual control
through the esophagoscope (Fig. 95)
Drs. Henry K. Pancoast, George E. Pfahler and William S. Newcomet have
obtained very satisfactory palliative effects from the use of radium
in esophageal cancer.
[221] CHAPTER XXVIII--DIRECT LARYNGOSCOPY IN DISEASES OF THE LARYNX
The diagnosis of laryngeal disease in young children, impossible with
the mirror, has been made easy and precise by the development of
direct laryngoscopy. No anesthetic, local or general, should be used,
for the practised endoscopist can complete the examination within a
minute of time and without pain to the patient. The technic for doing
this should be acquired by every laryngologist. Anesthesia is
absolutely contraindicated because of the possibility of the presence
of diphtheria, and especially because of the dyspnea so frequently
present in laryngeal disease. To attempt general anesthesia in a
dyspneic case is to invite disaster (see Tracheotomy). It is to be
remembered that coughing and straining produce an engorgement of the
laryngeal mucosa, so that the first glance should include an
estimation of the color of the mucosa, which, as a result of the
engorgement, deepens with the prolongation of the direct laryngoscopy.
_Chronic subglottic edema_, often the result of perichondritis, may
require linear cauterization at various times, to reduce its bulk,
after the underlying cause has been removed.
_Perichondritis and abscess_, and their sequelae are to be treated on
the accepted surgical precepts. They may be due to trauma, lues,
tuberculosis, enteric fever, pneumonia, influenza, etc.
_Tuberculosis of the larynx_ calls for conservatism in the application
of surgery. Ulceration limited to the epiglottis may justify
amputation of the projecting portion or excision of only the ulcerated
area. In either case, rapid healing may be expected, and relief from
the odynphagia is sometimes prompt. Amputation of the epiglottis is,
however, not to be done if ulceration in other portions of the larynx
coexist. The removal of tuberculomata is sometimes indicated, and the
excision of limited ulcerative lesions situated elsewhere than on the
epiglottis may be curative. These measures as well as the
galvanocautery are easily executed by the facile operator; but their
advisability should always be considered from a conservative
viewpoint. They are rarely justifiable until after months of absolute
silence and a general antituberculous regime have failed of benefit.
_Galvanopuncture_ for laryngeal tuberculosis has yielded excellent
results in reducing the large pyriform edematous swellings of the
aryepiglottic folds when ulceration has not yet developed. Deep
punctures at nearly a white heat, made perpendicular to the surface,
are best. Care must be exercised not to injure the cricoarytenoid
joint. Fungating ulcerations may in some cases be made to cicatrize by
superficial cauterization. Excessive reactions sometimes follow, so
that a light application should be made at the first treatment.
_Congenital laryngeal stridor_ is produced by an exaggeration of the
infantile type of larynx. The epiglottis will be found long and
tapering, its lateral margins rolled backward so as to meet and form a
cylinder above. The upper edges of the aryepiglottic folds are
approximated, leaving a narrow chink. The lack of firmness in these
folds and the loose tissue in the posterior portion of the larynx,
favors the drawing inward of the laryngeal aperture by the inspiratory
blast. The vibration of the margins of this aperture produces the
inspiratory stridor. Diagnosis is quickly made by the inspection of
the larynx with the infant diagnostic laryngoscope. No anesthetic,
general or local, is needed. Stridorous respiration may also be due to
the presence of laryngeal papillomata, laryngeal spasm, thymic
compression, congenital web, or an abnormal inspiratory bulging into
the trachea of the posterior membranous tracheo-esophageal wall. The
term "congenital laryngeal stridor" should be limited to the first
described condition of exaggerated infantile larynx.
_Treatment of congenital laryngeal stridor_ should be directed to the
relief of dyspnea, and to increasing the nutrition and development of
the infant. The insertion of a bronchoscope will temporarily relieve
an urgent dyspneic attack precipitated by examination; but this rarely
happens if the examination is not unduly prolonged. Tracheotomy may be
needed to prevent asphyxia or exhaustion from loss of sleep; but very
few cases require anything but attention to nutrition and hygiene.
Recovery can be expected with development of the laryngeal structures.
_Congenital webs of the larynx_ require incision or excision, or
perhaps simply bouginage. Congenital goiter and congenital laryngeal
paralysis, both of which may cause stertorous breathing, are
considered in connection with other forms of stenosis of the air
passages.
_Aphonia_ due to cicatricial webs of the larynx may be cured by
plastic operations that reform the cords, with a clean, sharp anterior
commissure, which is a necessity for clear phonation. The laryngeal
scissors and the long slender punch are often more useful for these
operations than the knife.
[224] CHAPTER XXIX--BRONCHOSCOPY IN DISEASES OF THE TRACHEA AND
BRONCHI
_The indications for bronchoscopy in disease_ are becoming
increasingly numerous. Among the more important may be mentioned:
1. Bronchiectasis.
2. Chronic pulmonary abscess.
3. Unexplained dyspnea.
4. Dyspnea unrelieved by tracheotomy calls for bronchoscopic search
for deeper obstruction.
5. Paralysis of the recurrent laryngeal nerve, the cause of which is
not positively known.
6. Obscure thoracic disease.
7. Unexplained hemoptysis.
8. Unexplained cough.
9. Unexplained expectoration.
_Contraindications to bronchoscopy in disease_ do not exist if the
bronchoscopy is really needed. Serious organic disease such as
aneurysm, hypertension, advanced cardiac disease, might render
bronchoscopy inadvisable except for the removal of foreign bodies.
_Bronchoscopic Appearances in Disease_.--The first look should note
the color of the bronchial mucosa, due allowance being made for the
pressure of tubal contact, secretions, and the engorgement incident to
continued cough. The carina trachealis normally moves slowly forward
as well as downward during deep inspiration, returning quickly during
expiration. Impaired movement of the carina indicates peritracheal and
peribronchial pathology, the fixation being greatest in advanced
cancer. In children and in the smaller tubes of the adult, the
lengthening and dilatation of the bronchi during inspiration, and
their shortening and contraction during expiration are readily seen.
_Anomalies of the Tracheobronchial Tree_.--Tracheobronchial anomalies
are relatively rare. Congenital esophagotracheal and esophagobronchial
fistulae are occasionally seen, and cases of cervicotracheal fistulae
have been reported. Congenital webs and diverticula of the trachea are
cited infrequently. Laryngoptosis and deviation of the trachea may be
congenital. Substernal goitre, aneurysm, malignant growths, and
various mediastinal adenopathies may displace the trachea from its
normal course. The emphysematous chest fixed in the deep voluntary
inspiratory position produces in some cases an elevation of the
superior thoracic aperture simulating laryngoptosis (Bibliography r,
pp. 468, 594).
_Compression Stenosis of the Trachea and Bronchi_.--Compression of the
trachea is most commonly caused by goiter, substernal or cervical,
aneurysm, malignancy, or, in children, by enlarged thymus. Less
frequently, enlarged mediastinal tuberculous, leukemic, leutic or
Hodgkin's glands compress the airway. The left bronchus may be
stenosed by pressure from a hypertrophied cardiac auricle. Compression
stenosis of the trachea associated with pulmonary emphysema accounts
for the dyspnea during attacks of coughing.
The endoscopic picture of compression stenosis is that of an
elliptical or scabbard-shaped lumen when the bronchus is at rest or
during inspiration. Concentric funnel-like compression stenosis, while
rare, may be produced by annular growths.
_Treatment of Compression Stenoses of the Trachea_.--If the thymus be
at fault, rapid amelioration of symptoms follows roentgenray or radium
therapy. Tracheotomy and the insertion of the long cane-shaped cannula
(Fig. 104) past the compressed area is required in the cases caused by
conditions less amenable to treatment than thymic enlargement.
Permanent cure depends upon the removability of the compressive mass.
Should the bronchi be so compressed by a benign condition as to
prevent escape of secretions from the subjacent air passages,
bronchial intubation tubes may be inserted, and, if necessary, worn
constantly. They should be removed weekly for cleansing and oftener if
obstructed.
_Influenzal Laryngotracheobronchitis_.--Influenzal infection, not
always by the same organism, sweeps over the population, attacking the
air passages in a violent and quite characteristic way. Bronchoscopy
shows the influenzal infection to be characterized by intense
reddening and swelling of the mucosa. In some cases the swelling is so
great as to necessitate tracheotomy, or intubation of the larynx; and
if the edema involve the bronchi, occlusion may be fatal. Hemorrhagic
spots and superficial erosions are commonly seen, and a thick,
tenacious exudate, difficult of expectoration, lies in patches in the
trachea. Infants may asphyxiate from accumulation of this secretion
which they are unable to expel. The differential diagnosis from
diphtheria is sometimes difficult. The absence of true membrane and
the failure to find diphtheria bacilli in smears taken from the
trachea are of aid but are not infallible. In doubtful cases, the
administration of diphtheria antitoxin is a wise precaution pending
the establishment of a definite diagnosis. The pseudomembrane
sometimes present in influenzal tracheobronchitis is thinner and less
pulpy than that of the earlier stages of diphtheria. The casts of the
later stages do not occur in influenzal tracheobronchitis
(Bibliography I, p. 480).
_Edematous Tracheobronchitis_.--This is chiefly observed in children.
The most frequently encountered form is the epidemic disease to which
the name "Influenza" has been given (q.v. supra). The only noticeable
difference between the epidemic and the sporadic cases is in the more
general susceptibility to the infective agent, which gives the
influenzal form an appearance of being more virulently infective.
Possibly the sporadic form is simply the attack of children not
immunized by a previous attack during an epidemic.
There is another form of edematous tracheobronchitis often of great
severity and grave prognosis, that results from the aspiration of
irritating liquids or vapors, or of certain organic substances such as
peanut kernels, watermelon seeds, etcetera. Tracheotomy should be done
if marked dyspnea be present. Secretions can then be easily removed
and medication in the form of oily solutions be instilled at will into
the trachea. In the Bronchoscopic Clinic many children have been kept
alive for days, and their lives finally saved by aspiration of thick,
tough, sometimes clotted and crusted secretions, with the aspirating
tube (Fig. 10). It is better in these cases not to pass the
bronchoscope repeatedly. If, however, evidences of obstruction remain,
after aspiration, it is necessary to see the nature of the obstruction
and relieve it by removal, dilatation, or bronchial intubation as the
case may require. It is all a matter of "plumbing" i.e., clearing out
the "pipes," and maintaining a patulous airway.
_Tracheobronchial Diphtheria_.--Urgent dyspnea in diphtheria when no
membrane and but slight lessening of the laryngeal airway is seen,
calls for bronchoscopy. Many lives have been saved by the
bronchoscopic removal of membrane obstructing the trachea or bronchi.
In the early stages, pulpy masses looking like "mother" of vinegar are
very obstructive. Later casts of membrane may simulate foreign bodies.
The local application of diphtheria antitoxin to the trachea and
bronchi has also been recommended. A preparation free from a chemical
irritant should be selected.
_Abscess of the Lung_.--If of foreign-body origin, pulmonary abscess
almost invariably heals after the removal of the object and a regime
of fresh air and rest, without local measures of any kind. Acute
pulmonary abscess from other causes may require bronchoscopic drainage
and gentle dilatation of the swollen and narrowed bronchi leading to
it. Some of these bronchi are practically fistulae. Obstructive
granulations should be removed with crushing, not biting forceps. The
regular foreign-body forceps are best for this purpose. Caution should
be used as to removal of the granulations with which the abscess
"cavity" is filled in chronic cases. The term "abscess" is usually
loosely applied to the condition of drowned lung in which the pus has
accumulated in natural passages, and in which there is neither a new
wall nor a breaking down of normal walls. Chronic lung-abscess is
often successfully treated by weekly bronchoscopic lavage with 20 cc.
or more of a warm, normal salt solution, a 1:1000 watery potassium
permanganate solution, or a weak iodine solution as in the following
formula:
Rx. Monochlorphenol (Merck) .12
Lugol's solution 8.00
Normal salt solution 500.
Perhaps the best procedure is to precede medicinal applications by the
clearing out of the purulent secretions by aspiration with the
aspirating bronchoscope and the independent aspirating tube, the
latter being inserted into passages too small to enter with the
bronchoscope, and the endobronchial instillation of from 10 to 30 cc.
of the medicament. The following have been used: Argyrol, 1 per cent
watery solution; Silvol, 1 per cent watery solution; Iodoform, oil
emulsion 10 per cent; Guaiacol, 10 per cent solution in paraffine oil;
Gomenol, 20 per cent solution in oil; or a bismuth subnitrate
suspension in oil. Robert M. Lukens and William F. Moore of the
Bronchoscopic Clinic report excellent results in post-tonsillectomy
abscesses from one tenth of one per cent phenol in normal salt
solution with the addition of 2 per cent Lugol's solution. Chlorinated
solutions are irritating, and if used, require copious dilution.
Liquid petrolatum with a little oil of eucalyptus has been most often
the medium.
_Gangrene of the Lung_.--Pulmonary gangrene has been followed by
recovery after the endobronchial injection of oily solutions of
gomenol and guaiacol (Guisez). The injections are readily made through
the laryngoscope without the insertion of a bronchoscope. A silk woven
catheter may be used with an ordinary glass syringe or a long-nozzled
laryngeal syringe, or a bronchoscopic syringe may be used.
_Lung-mapping_ by a roentgenogram taken promptly after the
bronchoscopic insufflation of bismuth subnitrate powder or the
injection of a suspension of bismuth in liquid petrolatum is advisable
in most cases of pulmonary abscess before beginning any kind of
treatment.
_Bronchial Stenosis_.--Stenosis of one or more bronchi results at
times from cicatricial contraction following secondary infection of
leutic, tuberculous or traumatic lesions. The narrowing resulting from
foreign body traumatism rarely requires secondary dilatation after the
foreign body has been removed. Tuberculous bronchial stenoses rarely
require local treatment, but are easily dilated when necessary. Luetic
cicatricial stenosis may require repeated dilatation, or even
bronchial intubation. Endobronchial neoplasms may cause a subjacent
bronchiectasis, and superjacent stenosis; the latter may require
dilatation. Cicatricial stenoses of the bronchi are readily
recognizable by the scarred wall and the absence of rings at or near
the narrowing.
_Bronchiectasis_.--In most cases of bronchiectasis there are strong
indications for a bronchoscopic diagnosis, to eliminate such
conditions as foreign body, cicatricial bronchial stenosis, or
endobronchial neoplasm as etiologic factors. In the idiopathic types
considerable benefit has resulted from the endobronchial lavage and
endobronchial oily injections mentioned under lung abscess. It is
probable that if bronchoscopic study were carried out in every case,
definite causes for many so-called "idiopathic" cases would be
discovered. Lung-mapping as elsewhere herein explained is invaluable
in the study of bronchiectasis.
_Bronchial asthma_ affords a large field for bronchoscopic study. As
yet, sufficient data to afford any definite conclusions even as to the
endoscopic picture of this disease have not been accumulated. Of the
cases seen in the Bronchoscopic Clinic some showed no abnormality of
the bronchi in the intervals between attacks, others a chronic
bronchitis. In cases studied bronchoscopically during an attack, the
bronchi were found filled with bubbling secretions and the mucosa was
somewhat cyanotic in color. The bronchial lumen was narrowed only as
much as it would be, with the same degree of cough, in any patient not
subject to asthma. The secretions were removed and the attack quickly
subsided; but no influence on the recurrence of attacks was observed.
It is essential that the bronchoscopic studies be made, as were these,
without anesthesia, local or general, for it is known that the
application of cocain or adrenalin to the larynx, or even in the nose,
will, with some patients, stop the attack. When done without local
anesthesia, allowance must be made for the reaction to the presence of
the tube. In those cases in which other means have failed to give
relief, the endobronchial application of novocain and adrenalin,
orthoform, propaesin or anesthesin emulsion may be tried. Cures have
been reported by this treatment. Argentic nitrate applied at weekly
intervals has proven very efficient in some cases. Associated
infective disease of the bronchial mucosa brings with it the questions
of immunity, allergy, anaphylaxis, and vaccine therapy; and the often
present defective metabolism has to be considered.
_Autodrownage_.--Autodrownage is the name given by the author to the
drowning of the patient in his own secretions. Tracheobronchial
secretions in excess of the amount required to moisten the inspired
air, become, in certain cases, a mechanical menace to life, unless
removed. The cough reflex, forced expiration, and ciliary action,
normally remove the excess. When these mechanisms are impaired, as in
profound asthenia, laryngeal paralysis, laryngeal or tracheal
stenosis, etc.; and especially when in addition to a mild degree of
glottic stenosis or impaired laryngeal mobility, the secretions become
excessive, the accumulation may literally drown the patient in his own
secretions. This is illustrated frequently in influenza and arachidic
bronchitis. Infants cannot expectorate, and their cough reflex is
exceedingly ineffective in raising secretion to the pharynx;
furthermore they are easily exhausted by bechic efforts; so that age
may be cited as one of the most frequent etiologic factors in the
condition of autodrownage. Bronchoscopic sponge-pumping (_q.v._) and
bronchoscopic aspiration are quite efficient and can save any patient
not afflicted with conditions that are fatal by other pathologic
processes.
_Lues of the Tracheobronchial Tree_.--Compared to laryngeal
involvement, syphilis of the tracheobronchial tree is relatively rare.
The lesions may be gummatous, ulcerative, or inflammatory, or there
may be compressive granulomatous masses. Hemoptysis may have its
origin from a luetic ulceration. Excision of fungations or of a
portion of the margin of the ulceration for biopsy is advisable. The
Wassermann and therapeutic tests, and the elimination of tuberculosis
will be required for confirmation. Luetic stenoses are referred to
above.
_Tuberculosis of the Tracheobronchial Tree_.--The bronchoscopic study
of tuberculosis is very interesting, but only a few cases justify
bronchoscopy. The subglottic infiltrations from extensions of
laryngeal disease are usually of edematous appearance, though they are
much more firm than in ordinary inflammatory edema. Ulcerations in
this region are rare, except as direct extensions of ulceration above
the cord. The trachea is relatively rarely involved in tuberculosis,
but we may have in the trachea the pale swelling of the early stage of
a perichondritis, or the later ulceration and all the phenomena
following the mixed pyogenic infections. These same conditions may
exist in the bronchi. In a number of instances, the entire lumen of
the bronchus was occluded by cheesy pus and debris of a peribronchial
gland which had eroded through. As a rule, the mucosa of tuberculosis
is pale, and the pallor is accentuated by the rather bluish streak of
vessels, where these are visible. Erosion through of peri-bronchial or
peri-tracheal lymph masses may be associated with granulation tissue,
usually of pale color, but occasionally reddish; and sometimes oozing
of blood is noticed. A most common picture in tuberculosis is a
broadening of the carina, which may be so marked as to obliterate the
carina and to bulge inward, producing deformed lumina in both bronchi.
Sometimes the lumina are crescentic, the concavity of the crescent
being internal, that is, toward the median line. Absence of the normal
anterior and downward movement of the carina on deep inspiration is
almost pathognomonic of a mass at the bifurcation, and such a mass is
usually tuberculous, though it may be malignant, and, very rarely,
luetic. The only lesion visible in a tuberculous case may be
cicatrices from healed processes. In a number of cases there has been
a discharge of pus coming from the upper-lobe bronchus.
[Fig. 96.--The author's tampons for pulmonary hemostasis by
bronchoscopic tamponade. The folded gauze is 10 cm. long; the braided
silk cord 60 cm. long.]
_Hemoptysis_.--In cases not demonstrably tuberculous, hemoptysis may
require bronchoscopic examination to determine the origin. Varices or
unsuspected luetic, malignant, or tuberculous lesions may be found to
be the cause. It is mechanically easy to pack off one bronchus with
the author's packs (Fig. 96) introduced through the bronchoscope, but
the advisability of doing so requires further clinical tests.
_Angioneurotic Edema_.--Angioneurotic edema manifests itself by a pale
or red swollen mucosa producing stenosis of the lumen. The temporary
character of the lesion and its appearance in other regions confirm
the diagnosis.
_Scleroma of the trachea_ is characterized by infiltration of the
tracheal mucosa, which greatly narrows the lumen. The infiltration may
be limited in area and produce a single stricture, or it may involve
the entire trachea and even close a bronchial orifice. Drying and
crusting of secretions renders the stenosis still more distressing.
This disease is but rarely encountered in America but is not
infrequent in some parts of Europe. Treatment consists in the
prevention of crusts and their removal. Limited stenotic areas may
yield to bronchoscopic bouginage. Urgent dyspnea calls for
tracheotomy. Radium and roentgenray therapy have been advised, and
cure has been reported by intravenous salvarsan treatment (see article
by S. Shelton Watkins, on Scleroma in Surg. Gynecol. and Obst., July,
1921, p. 47).
_Atrophic tracheitis_, with symptoms quite similar to atrophic
rhinitis is a not unusual accompaniment of the nasal condition. It may
also exist without nasal involvement. On tracheoscopy the mucosa is
thinned, pale and dry, and is covered with patches of thick
mucilaginous secretion and crusts. Decomposition of secretion produces
tracheal "ozena," while the accumulated crusts give rise to the
sensation of a foreign body and may seriously interfere with
respiration, making bronchoscopic removal imperative. The associated
development of tracheal nodular enchondromata has been described. The
internal administration of iodine and the intratracheal injection of
bland oily solutions of menthol, guaiacol, or gomenol are helpful.
[235] CHAPTER XXX--DISEASES OF THE ESOPHAGUS
The more frequent causes of the one common symptom of esophageal
disease, dysphagia, are included in the list given below. To avoid
elaboration and to obtain maximum usefulness as a reminder,
overlapping has not been eliminated.
1. Anomalies.
2. Esophagitis, acute.
3. Esophagitis, chronic.
4. Erosion.
5. Ulceration.
6. Trauma.
7. Stricture, congenital.
8. Stricture, spasmodic, including cramp of the diaphragmatic
pinchcock.
9. Stricture, inflammatory.
10. Stricture, cicatricial.
11. Dilatation, local.
12. Dilatation, diffuse.
13. Diverticulum.
14. Compression stenosis.
15. Mediastinal tumor.
16. Mediastinal abscess.
17. Mediastinal glandular mass.
18. Aneurysm.
19. Malignant neoplasm.
20. Benign neoplasm.
21. Tuberculosis.
22. Lues.
23. Actinomycosis.
24. Varix.
25. Angioneurotic edema.
26. Hysteria.
27. Functional antiperistalsis.
28. Paralysis.
29. Foreign body in (a) pharynx, (b) larynx, (c) trachea, (d)
esophagus.
[236] _Diagnosis_.--The swallowing function can be studied only with
the fluoroscope; esophagoscopy for diagnosis, should therefore always
be preceded by a fluoroscopic study of deglutition with a barium or
other opaque mixture and examination of the thoracic organs to
eliminate external pressure on the esophagus as the cause of stenosis.
Complete physical examination and Wassermann reaction are further
routine preliminaries to any esophagoscopy. Special laboratory tests
are done as may be indicated. The physical examination is meant to
include a careful examination of the lips, tongue, palate, pharynx,
and a mirror examination of the larynx when age permits.
_Indications for Esophagoscopy in Disease_.--Any persistent abnormal
sensation or disturbance of function of the esophagus calls for
esophagoscopy. Vague stomach symptoms may prove to be esophageal in
origin, for vomiting is often a complaint when the patient really
regurgitates.
_Contraindications to Esophagoscopy_.--In the presence of aneurysm,
advanced organic disease, extensive esophageal varicosities, acute
necrotic or corrosive esophagitis, esophagoscopy should not be done
except for urgent reasons, such as the lodgment of a foreign body; and
in this case the esophagoscopy may be postponed, if necessary, unless
the patient is unable to swallow fluids. Esophagoscopy should be
deferred, in cases of acute esophagitis from swallowing of caustics,
until sloughing has ceased and healing has strengthened the weak
places. The extremes of age are not contraindications to
esophagoscopy. A number of newborn infants have been esophagoscoped by
the author; and he has removed foreign bodies from patients over 80
years of age.
_Water starvation_ makes the patient a very bad surgical subject, and
is a distinct contraindication to esophagoscopy. Water must be
supplied by means of proctoclysis and hypodermoclysis before any
endoscopic or surgical procedure is attempted. If the esophageal
stenosis is not readily and quickly remediable, gastrostomy should be
done immediately. _Rectal feeding_ will supply water for a limited
time, but for nutrient purposes rectal alimentation is dangerously
inefficient.
_Preliminary examination of the pharynx and larynx with tongue
depressor_ should always precede esophagoscopy, for any purpose,
because the symptoms may be due to laryngeal or pharyngeal disease
that might be overlooked in passing the esophagoscope. A high degree
of esophageal stenosis results in retention in the suprajacent
esophagus of the fluids which normally are continually flowing
downward. The pyriform sinuses in these cases are seen with the
laryngeal mirror to be filled with frothy secretion (Jackson's sign of
esophageal stenosis) and this secretion may sometimes be seen
trickling into the larynx. This overflow into the larynx and lower air
passages is often the cause of pulmonary symptoms, which are thus
strictly secondary to the esophageal disease.
ANOMALIES OF THE ESOPHAGUS
_Congenital esophagotracheal fistulae_ are the most frequent of the
embryonic developmental errors of this organ. Septic pneumonia from
the entrance of fluids into the lungs usually causes death within a
few weeks.
_Imperforate esophagus_ usually shows an upper esophageal segment
ending in a blind pouch. A lower segment is usually present and may be
connected with the upper segment by a fistula.
_Congenital stricture_ of the esophagus may be single or multiple, and
may be thin and weblike, or it may extend over a third or more of the
length of the esophagus. It may not become manifest until solids are
added to the child's diet; often not for many months. The lodgment of
an unusually large bolus of unmasticated food may set up an
esophagitis the swelling of which may completely close the lumen of
the congenitally narrow esophagus. It is not uncommon to meet with
cases of adults who have "never swallowed as well as other people,"
and in whom cicatricial and spasmodic stenosis can be excluded by
esophagoscopy, which demonstrates an obvious narrowing of the
esophageal lumen. These cases are doubtless congenital.
_Webs in the upper third of the esophagus_ are best determined by the
passage of a large esophagoscope which puts the esophagus on the
stretch. The webs may be broken by the insertion of a closed alligator
forceps, which is then withdrawn with opened blades. Better still is
the dilator shown in Fig. 26. This retrograde dilatation is relatively
safe. A silk-woven esophagoscopic bougie or the metallic tracheal
bougie may be used, with proper caution. Subsequent dilatation for a
few times will be required to prevent a reproduction of the stenosis.
_Treatment of Esophageal Anomalies_.--Gastrostomy is required in the
imperforate cases. Esophagoscopic bouginage is very successful in the
cure of all cases of congenital stenosis. Any sort of lumen can be
enlarged so any well masticated food can be swallowed. Careful
esophagoscopic work with the bougies (Fig. 40) will ultimately cure
with little or no risk of mortality. Any form of rapid dilatation is
dangerous. Congenital stenosis, if not an absolute atresia, yields
more readily to esophagoscopic bouginage than cicatricial stenosis.
RUPTURE AND TRAUMA OF THE ESOPHAGUS
These may be spontaneous or may ensue from the passage of an
instrument, or foreign body, or of both combined, as exemplified in
the blind attempts to remove a foreign body or to push it downwards.
Digestion of the esophagus and perforation may result from the
stagnation of regurgitated gastric juice therein. This condition
sometimes occurs in profound toxic and debilitated states. Rupture of
the thoracic esophagus produces profound shock, fever, mediastinal
emphysema, and rapid sinking. Pneumothorax and empyema follow
perforation into the pleural cavity. Rupture of the cervical esophagus
is usually followed by cervical emphysema and cervical abscess, both
of which often burrow into the mediastinum along the fascial layers of
the neck. Lesser degrees of trauma produce esophagitis usually
accompanied by fever and painful and difficult swallowing.
The treatment of traumatic esophagitis consists in rest in bed,
sterile liquid food, and the administration of bismuth subnitrate
(about one gramme in an adult), dry on the tongue every 4 hours.
Rupture of the esophagus requires immediate gastrostomy to put the
esophagus at rest and supply necessary alimentation. Thoracotomy for
drainage is required when the pleural cavity has been involved, not
only for pleural secretions, but for the constant and copious
esophageal leakage. It is not ordinarily realized how much normal
salivary drainage passes down the esophagus. The customary treatment
of shock is to be applied. No attempt should be made to remove a
foreign body until the traumatic lesions have healed. This may require
a number of weeks. Decision as to when to remove the intruder is
determined by esophagoscopic inspection.
Subcutaneous emphysema does not require puncture unless gaseous, or
unless pus forms. In the latter event free external drainage becomes
imperative.
ACUTE ESOPHAGITIS
This is usually of traumatic or cauterant origin. If severe or
extensive, all the symptoms described under "Rupture of the Esophagus"
may be present. The endoscopic appearances are unmistakable to anyone
familiar with the appearance of mucosal inflammations. The pale,
bluish pink color of the normal mucosa is replaced by a deep-red
velvety swollen appearance in which individual vessels are invisible.
After exudation of serum into the tissues, the color may be paler and
in some instances a typical edema may be seen. This may diminish the
lumen temporarily. Folds of swollen mucosa crowd into the lumen if the
inflammation is intense. These folds are sometimes demonstrable in the
roentgenogram by the bismuth or barium in the creases between which
the prominence of the folds show as islands as beautifully
demonstrated by David R. Bowen in one of the author's cases. If the
inflammation is due to corrosives, a grayish exudate may be visible
early, sloughs later.
ULCERATION OF THE ESOPHAGUS
Superficial erosions of the esophagus are by no means an uncommon
accompaniment of the stagnation of food and secretions. From the
irritation they produce, spastic stenosis may occur, thus constituting
a vicious circle; the spasm of the esophagus increases the stagnation
which in turn results in further inflammation and ultimate ulceration.
Healing of such ulcers may result in cicatricial contraction and
organic stenosis. Ulceration may follow trauma by instrument, foreign
body, or corrosive.
DIFFERENTIAL DIAGNOSIS OF ULCER OF THE ESOPHAGUS
_Simple ulcer_ requires the exclusion of lues, tuberculosis,
epithelioma, endothelioma, sarcoma, and actinomycosis. Simple ulcer of
the esophagus is usually associated with stenosis, spastic or organic.
_Luetic ulcers_ commonly show a surrounding inflammatory areola, and
they usually have thickened elevated edges, generally free from
granulation tissue, with a pasty center not bleeding readily when
sponged. The Wassermann reaction may contribute to the diagnosis; but
if negative, a thorough and prolonged test with mercury is imperative.
It must be remembered that a person with lues may have a simple,
mixed, or malignant ulceration of the esophagus, or the three lesions
may even be combined. It may be in some cases possible to demonstrate
the treponema pallidum in scrapings taken from the ulcer.
The single _tuberculous ulcer_ is usually pale, superficial, and
granular in base. If it is a continuation from more extensive
extra-esophageal tuberculous ulceration, pale cauliflower granulations
may be present. Slight cicatrices may be seen. Tuberculosis in other
organs can almost always be demonstrated by roentgenographic,
physical, or laboratory studies. Tuberculin tests and animal injection
with an emulsion of a specimen of tissue may be required. The specimen
must be taken very superficially to avoid risk of perforation.
_Sarcomatous ulcers_ do not differ materially in appearance from those
of carcinoma, but they are much more rare.
_Carcinomatous ulcer_ is usually characterized by the very vascular
bright red zone, raised edges, fungations, granulation tissue that
bleeds freely on the lightest touch, and above all, it is almost
invariably situated on an infiltrated base which communicates a
feeling of hardness to the pressure of sponges or the esophagoscope
itself. A scar may be from the healing of an ulcer from stasis, or one
of specific or precancerous character. It may be a cancerous process
developing on the site of a scar, so that the presence of scar tissue
does not absolutely negative malignancy. As a rule, however, scars are
absent in cancer of the esophagus. The firm and sometimes prominent
ridge of the crossing of the left bronchus must not be mistaken for
infiltration, and the esophagoscopist must be familiar with the normal
rigidity of the cricopharyngeus.
[242] Mixed infection gives to all esophageal ulceration a certain
uniformity of appearance, so that laboratory studies of smears or
histologic and bacteriologic study of tissue specimens taken from
fungations or thickened edges are often required to confirm the
endoscopic diagnosis. If the edges are thin and flat, the taking of a
specimen involves some risk; fungations can be removed without risk;
so can nodules, but care must be taken that projecting folds are not
mistaken for nodules. It is always wise to push the therapeutic test
with potassium iodid and especially mercury in any case of esophageal
ulceration unassociated with stasis.
_Treatment of Acute and Subacute Inflammation and Ulceration of the
Esophagus_.--Bismuth subnitrate in doses of about one gramme, given
dry on the tongue and swallowed without water, has a local antiseptic
and protective action. Its antiseptic power may be enhanced by the
addition of calomel to the powder, in such amount as may be tolerated
by the bowels. If pain be present the combination of a grain or two of
anesthesin or orthoform with the bismuth will be grateful. The local
application of argyrol in 25 per cent watery solution is also of great
value. The mouth and teeth are to be kept clean with a mouth wash of
Dakin's solution, 1 part, to peppermint water, 6 parts. The esophagus
must be placed at rest as far as possible by liquid diet or, if need
be, by gastrostomy.
CHRONIC ESOPHAGITIS
This is usually a result of stagnation of food or secretion, and will
be considered under spasmodic stenosis and diffuse dilatation of the
esophagus.
A very marked case with local distress and pain extending through to
the back was seen by the author in consultation with Dr. John B.
Wright who had made the diagnosis. The patient was a sufferer from
ankylostomiasis.
[243] COMPRESSION STENOSIS OF THE ESOPHAGUS
The esophagus may be narrowed by the pressure of any periesophageal
disease or anomaly. The lesions most frequently found are:
1. Goiter, cervical or thoracic.
2. Malignancy of any of the intrathoracic viscera.
3. Aneurysm.
4. Cardiac and aortic enlargement.
5. Lymphadenopathies. Hodgkins' disease.
Leukemia.
Lues.
Tuberculosis.
Simple infective adenitis.
6. Lordosis.
7. Enlargement of the left hepatic lobe.
Endoscopically, compression stenosis of the esophagus is manifested by
a slit-like crevice which occupies the place of the lumen and which
does not open up readily before the advancing tube. The long axis of
the slit is almost always at right angles to the compressive mass, if
the esophageal wall be uninvolved. The covering mucosa may be normal
or it may show signs of chronic inflammation. Malignant compressions
are characterized by their hardness when palpated with the tube.
Associated pressure on the recurrent laryngeal nerve often makes
laryngeal paralysis coexistent. The nature of the compressive mass
will require for its determination the aid of the roentgenologist,
internist, and clinical laboratory. Compression by the enlarged left
auricle has been observed a number of times. The presence of aneurysm
is a distinct contraindication to esophagoscopy for diagnosis except
in case of suspected foreign body.
_Treatment of compressive stenosis of the esophagus_ depends upon the
nature of the compressive lesion and is without the realm of
endoscopy. In uncertain cases potassium iodid, and especially mercury,
should always be given a thorough and prolonged trial; an occasional
cure will result. Esophageal intubation is indicated in all conditions
except aneurysm. Gastrostomy should be done early when necessary.
DIFFUSE DILATATION OF THE ESOPHAGUS
This is practically always due to stagnation ectasia, which is
invariably associated with either organic or "spasmodic" stricture,
existing at the time of observation or at some time prior thereto. The
dilating effect of the repeatedly accumulated food results in a
permanent enlargement, so that the esophagus acts as the reservoir of
a large funnel with a very small opening. When food is swallowed the
esophagus fills, and the contents trickle slowly through the opening.
Gases due to fermentation increase the distension and cause substernal
pressure, discomfort, and belching. A very large dilatation of the
thoracic esophagus indicates spastic stenosis. Cicatricial stenoses do
not result in such large dilatations and the dilatation above a
malignant stenosis is usually slight, probably because of its
relatively shorter duration.
The _treatment of diffuse esophageal dilatation_ consists in dilating
the "diaphragmatic pinchcock" that is, the hiatal esophagus. Chronic
esophagitis is to be controlled by esophageal lavage, the regulation
of the diet to liquefiable foods and the administration of bismuth
subnitrate. The patient can be taught to do the lavage. The local
esophagoscopic application of a small quantity of a 25 per cent watery
solution of argyrol may be required for the static esophagitis. The
redundancy probably never disappears; but functional and subjective
cures are usually obtainable.
[245] CHAPTER XXXI--DISEASES OF THE ESOPHAGUS (_Continued_)
SPASMODIC STENOSIS OF THE ESOPHAGUS
_Etiology_.--The functional activity of the esophagus is dependent upon
reflex action. The food is propulsed in a peristaltic wave by the same
mechanism as, and through an innervation (Auerbach and Meissner
plexus) similar to that which controls intestinal movements. The vagus
also is directly concerned with the deglutitory act, for swallowing is
impossible if both vagi are cut. Anything which unduly disturbs this
reflex arc may serve as an exciting cause of spasmodic stenosis.
Bolting of food, superficial erosions, local esophageal disease, or a
small foreign body, may produce spasmodic stenosis. Spasm secondary to
disease of the stomach, liver, gall bladder, appendix, or other
abdominal organ is clinically well recognized. A perpetuating cause in
established cases is undoubtedly "nerve cell habit," and in many cases
there is an underlying neurotic factor. Shock as an exciting cause has
been well exemplified by the number of cases of phrenospasm developing
in soldiers during the World War.
_Cricopharyngeal spasmodic stenosis_ usually presents the subjective
symptom of difficulty in starting the bolus of food downward. Once
started, the food passes into the stomach unimpeded. Regurgitation, if
it occurs, is immediate. The condition consists in a tonic
contraction, ahead of the bolus, of the circular fibers of the
inferior constrictor known as the cricopharyngeus muscle, or in a
failure of this muscle to relax so as to allow the bolus to pass. In
either case the disorder may be secondary to an organic lesion. Local
malignant disease or foreign bodies may be the cause. Globus
hystericus, "lump in the throat," and the sense of constriction and
choking during emotion are due to the same spasmodic condition.
_Diagnosis_.--At esophagoscopy there will be found marked exaggeration
of the usual spasm which occurs at the cricopharyngeus during the
introduction of the tube. The lumen may assume various shapes, or be
so tightly closed that the folds form a mammilliform projection in the
center. If the spasm gradually yields, and a full-sized esophagoscope
passes without further resistance, it may be stated that the esophagus
is of normal calibre, and a diagnosis of spasmodic stenosis can be
made. Considerable experience is required to distinguish between
normal and pathologic spasm in an unanesthetized individual. To the
less experienced esophagoscopist, examination under ether anesthesia
is recommended. Deep anesthesia will relax the normal cricopharyngeal
reflex closure as well as any abnormal spasm, thus assisting in the
differentiation between an organic stricture and one of functional
character. Under deep general anesthesia, however, it is impossible to
differentiate between the normal reflex and a spasmodic condition,
since both are abolished. Many cases of intermittent esophageal
stenosis supposed to be spasmodic are due to organic narrowness of
lumen plus lodgement of food, obstructive in itself and in the
esophagitis resulting from its presence. The organic narrowing,
congenital or pathologic, is readily recognizable esophagoscopically.
_Treatment_.--The fundamental cause of the disturbance of the reflex
should be searched for, and treated according to its nature. Purely
functional cases are often cured by the passage of a large
esophagoscope. Recurrences may require similar treatment.
[247] FUNCTIONAL HIATAL STENOSIS. HIATAL ESOPHAGISMUS. PHRENOSPASM,
DIAPHRAGMATIC PINCHCOCK STENOSIS. (SO-CALLED CARDIOSPASM)
There is no sphincteric muscular arrangement at the cardiac orifice of
the esophagus, so that spasmodic stenosis at this level is not
possible and the term cardiospasm is, therefore, a misnomer. It was
first demonstrated by the author that in so-called cardiospasm the
functional closure of the esophagus occurred at the diaphragmatic
level, and that it was due to the "diaphragmatic pinchcock."
Anatomical studies have corroborated this finding by demonstrating a
definite sphincteric mechanism consisting of muscle bands springing
from the crura of the diaphragm and surrounding the esophagus at the
under surface of the hiatus. An inspection of the cadaveric diaphragm
from below will demonstrate an arrangement like double shears
admirably adapted to this "pinchcock" action. Further confirmation is
the fact that all dilatation of the esophagus incident to spasm at its
lower extremity is situated above the diaphragm. In passing it may be
stated that the pinchcock action, plus the kinking of the esophagus
normally prevents regurgitation when a man with a full stomach "stands
on his head" or inverts his body. For the upward escape of food from
the stomach an involuntary co-ordinated antiperistaltic cycle is
necessary. The dilatation resulting from phrenospasm may reach great
size (Fig. 96a), and the capacity of the sac may be as much as two
liters. While the esophagus is usually dilated, the stomach on the
other hand is often contracted, largely from lack of distention by
food, but possibly also because of a spastic state due to the same
causes as the phrenospasm. Recently Mosher has demonstrated that
hepatic abnormality may furnish an organic cause in many cases
formerly considered spasmodic.
The _symptoms of hiatal esophagismus_ are variable in degree.
Substernal distress, with a feeling of fullness and pressure followed
by eructations of gas and regurgitation of food within a period of a
quarter of an hour to several hours after eating, are present. If the
esophageal dilatation be great, regurgitation may occur only after an
accumulation of several days, when large quantities of stale food will
be expelled. The general nutrition is impaired, and there is usually
the history of weight loss to a certain level at which it is
maintained with but slight variation. This is explained by the
trickling of liquified food from the esophageal reservoir into the
stomach as the spasm intermittently relaxes, this occurring usually
before a serious state of inanition supervenes. At times the hiatal
spasms are extremely violent and painful, the pain being referred from
the xiphoid region to the back, or upward into the neck. Patients are
often conscious of the times of patulency of the esophagus; they will
know the esophagus to be open and will eat without hesitation, or will
refuse food with the certain knowledge that it will not pass into the
stomach. Periods of remission of symptoms for months and years are
noted. The neurotic character of the lesion in some cases is evidenced
by the occasionally sudden and startling cures following a single
dilatation, as well as by the tendency to relapse when the individual
is subject to what is for him undue nervous tension. In a very few
cases, with patients of rather a stolid type, all neurotic tendencies
seem to be absent.
The _diagnosis of hiatal esophagismus_ requires the exclusion of local
organic esophageal lesions. In the typical case with marked
dilatation, the esophagoscopic findings are diagnostic. A white,
pasty, macerated mucosa, and normally contracted hiatus esophageus
which when found permits the large esophagoscope to pass into the
stomach, will be recognized as characteristic by anyone who has seen
the condition. In the cases with but little esophageal distension the
diagnosis is confirmed by the constancy of the obstruction to a barium
mixture at the phrenic level, while at esophagoscopy the usual
resistance at the hiatus esophageus is found not to be increased, and
no other local lesion is found as the esophagoscope enters the
stomach. It is the failure of the diaphragmatic pinchcock to open, as
in the normal deglutitory cycle, rather than a spasmodic tightness,
that obstructs the food. The presence of organic stenosis at the
hiatus may remove the case altogether from the spasmodic class, or a
cicatricial or infiltrated narrowing may be the result of static
esophagitis. A compressive stenosis due to hepatic abnormality may
simulate spasmodic stenosis as shown by Mosher, who believes that 75
per cent of so-called cardiospasms are organic.
_Treatment of hiatal esophagismus (so-called cardiospasm)_ consists in
the over-dilatation of the "diaphragmatic pinchcock" or hiatus
esophageus, and in proper remedial measures for the removal of the
underlying neurosis. The simple passage of the esophagoscope suffices
to cure some cases. Further dilatation by endoscopic guidance may be
obtained by the introduction of Mosher's divulsor through the
esophagoscope, by which accurate placement is obtained. The distension
should not usually exceed 25 mm. Numerous water and air bags have been
devised for stretching the hiatus, and excellent results have been
obtained by their use. Possibly some of the cures have been due to the
dilatation of organic lesions, or to the crowding back of an enlarged
malposed, or otherwise abnormal left lobe of the liver, which Mosher
has shown to be an etiologic factor.
Certain cases prove very obstinate of cure, and require esophageal
lavage for the esophagitis, and feedings through the stomach tube to
increase nutrition and to dilate the contracted stomach. Gastrostomy
for feeding rarely becomes necessary, for a stomach tube can always be
placed with the esophagoscope if it will not pass otherwise.
Retrograde dilatation with the fingers through a gastrostomy opening
has been done, but seems hardly warranted in view of the excellent
results obtainable from above. Instructions should be given concerning
the proper mastication of food, and during treatment the frequent
partaking of small quantities of liquid foods is recommended. Liquids
and foods should be neither hot nor cold. The neurologist should be
consulted in cases deemed neurotic.
[96a.-Functional hiatal stenosis. Cramp of the diaphragmatic pinchcock
(so-called cardiospasm).]
Endocrine imbalance should be investigated and treated, as urged by
MacNab.
_Esophageal antiperistalsis_ is the name given by the author to a
heretofore undescribed disease associated with regurgitation of food
from the esophagus, the food not having reached the stomach. It may be
continuous or paroxysmal and may be of so serious a degree as to
threaten starvation. The best treatment in severe cases is gastrostomy
to put the esophagus at rest. Milder cases get well under liquid diet,
rest in bed, endocrine therapy, cure of associated abdominal disease,
etcetera.
[251] CHAPTER XXXII--DISEASES OF THE ESOPHAGUS (_Continued_)
CICATRICIAL STENOSIS OF THE ESOPHAGUS
_Etiology_.--The accidental swallowing of caustic alkali in solutions
of lye or proprietary washing and cleansing powders, is the most
frequent cause of cicatricial stenosis. Commercial lye preparations
are about 95 per cent sodium hydroxide. The cleansing and washing
powders contain from eight to fifty per cent of caustic alkali,
usually soda ash, and are sold by grocers everywhere. The labels on
their containers not only give no warning of the dangerous nature of
the contents nor antidotal advice, but have such directly misleading
statements as : "Will not injure the most delicate fabric," "Will not
injure the hands," etc. Utensils used to measure or dissolve the
powders are afterward used for drinking, without rinsing, and thus the
residue of the powder remaining is swallowed in strong solution. At
other times solutions of lye are drunk in mistake for water, coffee,
or wine. These entirely preventable accidents would be rare if they
were as conspicuously labelled "Poison" as is required by law in the
case of these and any other poisons, when sold by druggists. The
necessity for such labelling is even greater with the lye preparations
because they go into the kitchen, whereas the drugs go to the medicine
shelf, out of the reach of children. "Household ammonia," "salts of
tartar" (potassium carbonate), "washing soda" (sodium carbonate),
mercuric chloride, and strong acids are also, though less frequently,
the cause of cicatricial esophageal stricture. Tuberculosis, lues,
scarlet fever, diphtheria, enteric fever and pyogenic conditions may
produce ulceration followed by cicatrices of the esophagus. Spasmodic
stenosis with its consequent esophagitis and erosions, and, later,
secondary pyogenic infection, may result in serious cicatrices. Peptic
ulcer of the lower esophagus may be a cause. The prolonged sojourn of
a foreign body is likely to result in cicatricial narrowing.
[FIG. 97.--Schematic illustration of a series of eccentric strictures
with interstrictural sacculations, in the esophagus of a boy aged four
years. The strictures were divulsed seriatim from above downward with
the divulsor, the esophageal wall, D, being moved sidewise to the
position of the dotted line by means of a small esophagoscope inserted
through the upper stricture, A, after divulsion of the latter.]
_Location of Cicatricial Esophageal Strictures_.--The strictures are
often multiple and their lumina are rarely either central or
concentric (Fig. 97). In order of frequency the sites of cicatricial
stenosis are: 1. At the crossing of the left bronchus; 2. In the
region of the cricopharyngeus; 3. At the hiatal level. Stricture at
the cardia has rarely been encountered in the Bronchoscopic Clinic.
Stenosis of the pylorus has been noted, but is rare.
_Prognosis_.--Spontaneous recovery from cicatricial stenosis probably
never occurs, and the mortality of untreated small lumen strictures is
very high. Blind methods of dilatation are almost certain to result in
death from perforation of the esophageal wall, because some pressure
is necessary to dilate a stricture, and the point of the bougie, not
being under guidance of the eye, is certain at sometime or other to be
engaged in a pocket instead of in the stricture. Pressure then results
in perforation of the bottom of the pocket (Fig. 98). This accident is
contributed to by dilatation with the wrinkled, scarred floor which
usually develops above the stricture. Rapid divulsion and internal
esophagotomy are mechanically very easily and accurately done through
the esophagoscope, and would yield a few prompt cures; but the
mortality would be very high. Under certain circumstances, to be
explained below, gentle divulsion of the proximal one of a series of
strictures has to be done. With proper precautions and a gentle hand,
the risk is slight. Under esophagoscopic bouginage the prognosis is
favorable as to ultimate cure, the duration of the treatment varying
with the number of strictures, the tightness, and the extent of the
fibrous tissue-changes in the esophageal wall. Mortality from the
endoscopic procedure is almost nil, and if gastrostomy is done early
in the tightly stenosed cases, ultimate cure may be confidently
expected with careful though prolonged treatment.
[FIG. 98.--Schema illustrating the mechanism of perforation by blind
bouginage. On encountering resilient resistance the operator, having a
false conception, pushes on the bougie. Perforation results because in
reality the bougie is in a pocket of the suprastrictural eccentric
dilatation.]
_Symptoms_.--Dysphagia, regurgitation, distress after eating, and loss
of weight, vary with the degree of the stenosis. The intermittency of
the symptoms is sometimes confusing, for the lodgment of relatively
large particles of food often simulates a spasmodic stenosis, and in
fact there is often an element of spasm which holds the foreign body
in the strictured area until it relaxes. Static esophagitis results in
a swelling of the esophageal walls and a narrowing of the lumen, so
that swallowing is more or less troublesome until the esophagitis
subsides.
_Esophagoscopic Appearances of Cicatricial Stenosis_.--The color of
the cicatricial area is usually paler than the normal mucosa. The
scars may be very white and elevated, or they may be flush with the
normal mucosa, or even depressed. Occasionally the cicatrix is
annular, but more often it is eccentric and involves only a part of
the circumference of the wall. If the amount of scar tissue is small,
the lumen maintains its mobility; opens and closes during respiration,
cough, and vomiturition. Between two strictures there is often a pouch
containing food remnants. It is rarely possible to see the lumen of
the second stricture, because it is usually eccentric to the first.
Stagnation of food results in superjacent dilatation and esophagitis.
Erosions and ulcerations which follow the stagnation esophagitis
increase the cicatricial stenosis in their healing.
_Differential Diagnosis_.--When the underlying condition is masked by
inflammation and ulceration, these lesions must be removed by frequent
lavage, the administration of bismuth subnitrate with the occasional
addition of calomel powder, and the limitation of the diet to strained
liquids. The cicatricial nature of the stenosis can then be studied to
better advantage. In most cases the cicatrices are unmistakably
conspicuous. Spasmodic stenoses are differentiated by the absence of
cicatrices and the yielding of the stenosis to gentle but continuous
pressure of the esophagoscope. While it is possible that spasmodic
stenosis may supplement cicatricial stenosis, it is certainly
exceedingly rare. Nearly all of the occasions in which a temporary
increase of the stenosis in a cicatricial case is attributed to an
element of spasm, the real cause of the intermittency is not spasm but
obstruction caused by food. This occurs in three ways: 1. Actual
"corking" of the strictured lumen by a fragment of food, in which case
intermittency may be due to partial regurgitation of the "corking"
mass with subsequent sinking tightly into the stricture. 2. The "cork"
may dissolve and pass on through to be later replaced by another. 3.
Reactionary swelling of the esophageal mucosa due to stagnation. Here
again the obstruction may be prolonged, or it may be quite
intermittent, due to a valve-like action of the swollen mucosal
surfaces or folds intermittently coming in contact. Cancerous stenosis
is accompanied by infiltration of the periesophageal tissue, and
usually by projecting bleeding fungations. Cancer may, however,
develop on a cicatrix, favored no doubt by chronic inflammation in
tissue of low resistance. Compression stenosis of the esophagus is
characterized by the sudden transition of the lumen to a linear or
crescentic outline, while the covering mucosa is normal unless
esophagitis be present. The compressive mass can be detected by the
sensation transmitted to the touch by the esophagoscope.
_Treatment_.--Blind bouginage should be discarded as an obsolete and
very dangerous procedure. If the stenosis be so great as to interfere
with the ingestion of the required amount of liquids, gastrostomy
should be done at once and esophagoscopic treatment postponed until
water hunger has been relieved. Gastrostomy aids in the treatment by
putting the esophagus at rest, and by affording the means of
maintaining a high degree of nutrition unhampered by the variability
or efficiency of the swallowing function. Careful diet and gentle
treatment will, however, usually avoid gastrostomy. The diet in the
gastrostomy-fed patients should be as varied as in oral alimentation;
even solids of the consistency of mashed potatoes, if previously
forced through a wire gauze strainer, may be forced through the tube
with a glass injector. Liquids and readily liquefiable foods are to be
given the non-gastrostomized patient, solids being added when
demonstrated that no stagnation above the stricture occurs. Thorough
mastication and the slow partaking of small quantities at a time are
imperative. Should food accumulation occur, the esophagus should be
emptied by regurgitation, following which a glassful of warm sodium
bicarbonate solution is to be taken, and this also regurgitated if it
does not go through promptly. The esophagus is thus lavaged and
emptied. In all these cases, whether being fed through the mouth or
the gastrostomic tube, it is very important to remember that milk and
eggs are not a complete dietary. A pediatrist should be consulted.
Prof. Graham has saved the lives of many children by solving the
nutritive problems in the cases at the Bronchoscopic Clinic. Fruit and
vegetable juices are necessary. Vegetable soups and mashed fruits
should be strained through a wire gauze coffee strainer. If the saliva
is spat out by the child because it will not go through the stricture
the child should be taught to spit the saliva into the funnel of the
abdominal tube. This method of improving nutrition was discovered by
Miss Groves at the Bronchoscopic Clinic.
_Esophagoscopic bouginage_ with the author's silk-woven steel-shank
endoscopic bougies (Fig. 40) has proven the safest and most successful
method of treatment. The strictured lumen is to be centered in the
esophagoscopic field, and three successively increasing sizes of
bougies are used under direct vision. Larger and larger bougies are
used at the successive treatments which are given at intervals of from
four to seven days. No anesthesia, general or local, is used for
esophagoscopic bouginage. The tightness of the grasping of the bougie
by the stricture on withdrawal, determines the limitation of sizes to
be used. When the upper stricture is dilated, lower ones in the series
are taken seriatim. If concentric, two or more closely situated
strictures may be simultaneously dilated. For the use of bougies of
the larger sizes, the special esophagoscopes with both the
light-carrier canal and the drainage canal outside the lumen of the
tube are needed. Functional cure is obtained with a relatively small
lumen at the point of stenosis. A lumen of 7 mm. will allow the
passage of any well masticated food. It is unwise and unsafe to
attempt to restore the lumen to its normal anatomic size. In
cicatricial stricture cases it is advisable to examine the esophagus
at monthly periods for a time after a functional cure has been
obtained, in order that tendency to recurrence may be early detected.
_Divulsion_ of an upper stricture may be deemed advisable in order to
reach others lower down, especially in cases of multiple eccentric
strictures (Fig. 97). This procedure is best done with the author's
esophagoscopic divulser, accurately placed by means of the
esophagoscope; but divulsion requires the utmost care, and a gentle
hand. Even then it is not so safe as esophagoscopic bouginage.
_Internal esophagotomy_ by the string-cutting instruments and
esophagotome are relatively dangerous methods, and perhaps yield in
the end no quicker results than the slower and safe bouginage per
tubam.
_Electrolysis_ has been used with varying results in the treatment of
cicatricial stenosis.
_Thermic bouginage_ with electrically heated bougies has been found
useful in some cases by Dean and Imperatori.