6. Trauma.

7. Stricture, congenital.

8. Stricture, spasmodic, including cramp of the diaphragmatic pinchc.o.c.k.

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 ma.s.s.

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 deglut.i.tion 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 Wa.s.sermann 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 pa.s.sing 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 pa.s.sages 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 pa.s.sage 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 pa.s.sage 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 bis.m.u.th 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 pa.s.ses 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 bis.m.u.th 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 const.i.tuting 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 a.s.sociated 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 Wa.s.sermann 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 sc.r.a.pings 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 pota.s.sium iodid and especially mercury in any case of esophageal ulceration una.s.sociated with stasis.

_Treatment of Acute and Subacute Inflammation and Ulceration of the Esophagus_.--Bis.m.u.th 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 bis.m.u.th 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.