[258] _String-swallowing_, with the pa.s.sage of olives threaded over the string has yielded good results in the hands of some operators.

The string may be used to pull up dilators in increasing sizes, introduced through a gastrostomic fistula. The string stretched across the stomach from the cardia to the pylorus, is fished out with the author's pillar retractor, or is found with the retrograde esophagoscope (Fig. 43). The string is attached to a dilator (Fig.

35), and a fresh string is pulled in to replace the one pulled out.

This is the safest of the blind methods. It is rarely possible to get a child under two years of age to swallow and tolerate a string. It is better after each treatment to draw the upper end of the string through the nose, as it is not so likely to be chewed off and is less annoying. With the esophagoscope, the string is not necessary, because the lumen of the stricture can be exposed to view by the esophagoscope.

_Retrograde esophagoscopy_ through a gastrostomy wound offers some advantages over peroral treatment; but unless the gastrostomy is high, the procedure is undoubtedly more difficult. The approach to the lowest stricture from below is usually funnel shaped and free from dilatation and redundancy. It must be remembered the stricture seen from below may not be the same one seen from above. Roentgenray examination with barium mixture or esophagoscopes simultaneously in situ above and below are useful in the study of such cases.

_Impermeable strictures_ of the cervical esophagus are amenable to external esophagotomy, with plastic reformation of the esophagus.

Those in the middle third have not been successfully treated by surgical methods, though various ingenious operations for the formation of an extrathoracic esophagus have been suggested as means of securing relief. Impermeable strictures of the lower third can with reasonable safety be treated by the Brenneman method, which consists in pa.s.sing the esophagoscope down to the stricture while the surgeon, inserting his finger up into the esophagus from the stomach, can feel the end of the esophagoscope. An incision through the tissue barrier is then made from below, pa.s.sing the knife along the finger as a guide. A soft rubber stomach-tube is pulled up from below and left in situ, being replaced at intervals by a fresh one, pulled up from the stomach, until epithelialization of the new lumen is complete.

Catheters are used in children. In replacing the catheter or stomach tube the fresh one is attached to the old one by st.i.tching in a loop of braided silk. Frequent esophagoscopic bouginage will be required to maintain the more or less fistulous lumen until it is epithelialized, and in occasional cases, for a long time thereafter.

In cases of absolute atresia the saliva does not reach the stomach. No one realizes the quant.i.ty of normal salivary drainage, nor its importance in nutritive processes. Oral insalivation is of little consequence compared to esophagogastric drainage. Gastrostomized children with absolute atresia of the esophagus do not thrive unless they regurgitate the salivary acc.u.mulations into the funnel of the gastrostomic feeding tube. This has been abundantly proven by observations at the Bronchoscopic Clinic. My attention was first called to this clinical fact by Miss Frances Groves who has charge of these cases.

_Intubation of the esophagus_ with soft rubber tubes has occasionally proven useful.

[260] CHAPTER x.x.xIII--DISEASES OF THE ESOPHAGUS (_Continued_)

DIVERTICULUM OF THE ESOPHAGUS

Diverticula may, and usually do, consist in a pouching by herniation, of the whole thickness of the esophageal wall; or they may be herniations of the mucosa between the muscular layers. They are cla.s.sified according to their etiology, as traction and pulsion diverticula.

[FIG. 99.--Traction diverticulum of the esophagus rendered visible in the roentgenogram by a swallowed opaque mixture. Case of H. W.

Dachtler, Am. Journ. Roentgenology.]

_Traction diverticulum of the esophagus_ (Fig. 99) is a rare condition, usually occurring in the thorax, and as a rule const.i.tuting a one-sided enlargement of the gullet rather than a true pouch formation. It is supposed to be formed by the pulling during cough, respiration, and swallowing, on localized adhesions of the esophagus to periesophageal structures, such as inflammatory peribronchial glands.

_Diagnosis_ is often incidental to examination of the gastrointestinal tract for other conditions, because traction diverticula usually cause no symptoms. Unless a very large esophagoscope be used, a traction diverticulum may easily be overlooked in the mucosal folds. Careful lateral search, however, will reveal the dilatation, and the localized periesophageal fixation may be demonstrated. The subdiverticular esophagus is readily followed, its lumen opening during inspiration unless very close to the diaphragm, which is very rare. Perhaps most cases will be discovered by the roentgenologist. It has been said that traction diverticula are more readily demonstrated in the roentgenologic examination, if the patient be placed with pelvis elevated.

_Pulsion diverticulum of the esophagus_ is an acquired hernia of the mucosa between the circular and oblique fibers of the inferior constrictor muscle of the pharynx. A congenital anatomic basic factor in etiology probably exists. The pouching develops in the middle part of the posterior wall, between the orbicular and oblique fibers of the cricopharyngeus muscle, at which point there is a gap, leaving the mucosa supported only by a not very resistant fascia (Fig. 100). When small, the sac is in the midline, but with increase in size, it presents either to the right or the left side, commonly the latter.

The sac may be very small, or it may be sufficiently large to hold a pint or more, and to cause the neck to bulge when filled. When large, the pouch extends into the mediastinum. It will be seen that anatomically the pulsion diverticulum has its origin in the pharynx; the symptoms, however, are referable to the esophagus and the subdiverticular esophagus is stenosed by compression of the pouch; therefore, it is properly cla.s.sified as an esophageal disease.

[FIG. 100.--Schema ill.u.s.trative of the etiology of pressure diverticula. O, oblique fibers of the cricopharyngeus attached to the thyroid cartilage, T. The fundiform fibers, F, encircle the mouth of the esophagus. Between the two sets of fibers is a gap in the support of the esophageal wall, through which the wall herniates owing to the pressure of food propelled by the oblique fibers, O, advance of the bolus being resisted by spasmodic contraction of the orbicular fibers, F.]

_Etiology_.--Pressure diverticula occur after middle life, and more often in men than in women. The hasty swallowing of unmasticated food, too large a bolus, defective or artificial teeth, flaccidity of tissues, and spasm of the cricopharyngeus muscle, are etiologic factors. Cicatricial stenosis below the level of the inferior constrictor is a contributory cause in some cases.

_Prognosis_.--After the pouch is formed, it steadily increases in size, since the swallowed food first fills and distends the sac before the overflow pa.s.ses down the esophagus. When a pendulous sac becomes filled with food, it presses on the subdiverticular esophagus, and produces compression stenosis; so that there exists a "vicious circle." The enlargement of the sac produces increasing stenosis with consequent further distension of the pouch. This explains the clinically observed fact, that unless treated, pulsion diverticula increase progressively in size, and consequently in distressing symptoms. The sac becomes so large in some cases as to contribute to the occurrence of cerebral apoplexy by interference with venous return. Practically all cases can be cured by radical operation. The operative mortality varies with the age, state of nutrition, and general health of the patient. In general it may be said to have a mortality of at least 10 per cent, largely due to the fact that most cases are poor surgical subjects. Recurrences after radical operation are due to a persistence of the original causes, i.e., bolting of food; stenosis, spasmodic or organic, of the esophageal lumen; and weakness in the support of the esophageal wall, which, unsupported, has little strength of its own.

_Symptoms_.--Dysphagia, regurgitation, a gurgling sound and subjective bubbling sensation on swallowing, sour odor to the breath, and cough, are the chief symptoms. With larger pouches, emaciation, pressure sensation in the neck and upper mediastinum, and the presence of a ma.s.s in the neck when the sac is filled, are present. Tracheal compression by the filled pouch may produce dyspnea. The sac may be emptied by pressure on the neck, this means of relief being often discovered by the patient. The sac sometimes spontaneously empties itself by contraction of its enveloping muscular layer, and one of the most annoying symptoms is the paroxysm of coughing, waking the patient, when during the relaxation of sleep the sac empties itself into the pharynx and some of its contents are aspirated into the larynx. There are no pathognomonic symptoms. Those recited are common to other forms of esophageal stenosis, and are urgent indications for diagnostic esophagoscopy.

_Diagnosis_.--Roentgenray study with barium mixtures, is the first step in the diagnosis (Fig. 101). This is to be followed by diagnostic esophagoscopy. Malignant, spasmodic, cicatricial, and compression stenosis are to be excluded by esophagoscopic appearances. Aneurysm is to be eliminated by the usual means. The Boyce sign is almost invariably present, and is diagnostic. It is elicited by telling the patient to swallow, which action imprisons air in the sac. The imprisoned air is forced out by finger-pressure on the neck, over the sac. The exit of the air bubble produces a gurgling sound audible at the open mouth of the patient.

_Esophagoscopic Appearances in Pulsion Diverticulum_.--The esophagoscope will without difficulty enter the mouth of the sac which is really the whole bottom of the pharynx, and will be arrested by the blind end of the pouch, the depth of which may be from 4 to 10 cm. In some cases the bottom of the pouch is in the mediastinum. The walls are often pasty, and may be eroded, or ulcerated, and they may show vessels or cicatrices. On withdrawing the tube and searching the anterior wall, the subdiverticular slit-like opening of the esophagus will be found, though perhaps not always easily. The esophageal speculum will be found particularly useful in exposing the subdiverticular orifice, and through this a small esophagoscope may be pa.s.sed into the esophagus, thus completing the diagnosis. Care must be exercised not to perforate the bottom of the diverticular pouch by pressure with the esophagoscope or esophageal speculum. The walls of the sac are surprisingly thin.

[FIG. 101.--Pulsion diverticulum filled with bis.m.u.th mixture in a man of fifty years.]

_Treatment of Pulsion Diverticulum_.--If the pouch is small, the subdiverticular esophageal orifice may be dilated with esophagoscopic bougies, thus overcoming the etiologic factor of spastic or organic stenosis. The redundancy remains, however, though the symptoms may be relieved. Cutting the common wall between the esophagus and the sac by means of scissors pa.s.sed through the endoscopic tube, has been successfully done by Mosher.

Various methods of external operation have been devised, among which are: (1) Freeing the sac through an external cervical incision and suturing its fundus upward against the pharynx, which has proved successful in some cases. (2) Inversion of the sac into the pharynx and suture of the mouth of the pouch. In a case so treated the pouch was blown out again during a fit of sneezing eight months after operation. (3) Plication of the walls of the sac by catgut sutures, as in the Matas obliterative operation for aneurysm. (4) Freeing and removing the sac, with suture of the esophageal wound. (5) Removal of the sac by a two-stage operation, in which method the initial step is the deliverance of the sac into the cervical wound, where it remains surrounded by gauze packing until adhesions have walled off the mediastinum. The work is completed by cutting off the sac and either suturing the esophageal wound or touching it with the cautery, and allowing it to heal by granulation. External exposure and amputation of the sac has been more frequently done than any other operation.

Unless the pouch is large, it is extremely difficult to find after the surgeon has exposed the esophagus, for the reasons that at operation it is empty and that when the adhesions about it are removed the walls of the sac contract. After removal, the sac is disappointingly small as compared with its previous size in the roentgenogram, which shows it distended with opaque material. It has been the chagrin of skilled surgeons to find the diverticulum present functionally and roentgenographically precisely the same as before the performance of the very trying and difficult operation. The time of operation may be shortened at least by one-half by the aid of the esophagoscopist in the Gaub-Jackson operation. Intratracheally insufflated ether is the anesthesia of choice. After the surgeon has exposed the esophagus by dissection, the endoscopist introduces the esophagoscope into the sac, and delivers it into the wound, while the surgeon frees it from adhesions. The esophagoscope is now withdrawn from the pouch and entered into the esophagus proper, below the diverticulum, while the surgeon cuts off the hernial sac and sutures the esophagopharyngeal wound over the esophagoscope. The presence of the esophagoscope prevents too tight suture and possible narrowing of the lumen (Fig.

102).

[FIG. 102.--Schematic representation of esophagoscopic aid in the excision of a diverticulum in the Gaub-Jackson operation. At A the esophagoscope is represented in the bottom of the pouch after the surgeon has cut down to where he can feel the esophagoscope. Then the esophagoscopist causes the pouch to protrude as shown by the dotted line at B. After the surgeon has dissected the sac entirely loose from its surroundings, traction is made upon the sac as shown at H and the esophagoscope is inserted down the lumen of the esophagus as shown at C. The esophagoscope now occupies the lumen which the patient will need for swallowing. It only remains for the surgeon to remove the redundancy, without risk of removing any of the normal wall. The esophagoscope here shown is of the form squarely cut off at the end.

The standard form of instrument with slanted end will serve as well.]

_After-care_.--Feeding may be carried on by the placing of a small nasal feeding tube into the stomach at the time of operation.

Gastrostomy for feeding as a preliminary to the esophageal operation has been suggested, and is certainly ideal from the viewpoint of nutrition and esophageal rest. The decision of its performance may perhaps be best made by the patient himself. Should leakage through the neck occur, the fistula should be flushed by the intake of sterile water by mouth. Oral sepsis should, of course, be treated before operation and combated after operation by frequent brushing of the teeth and rinsing of the mouth with Dakin's solution, one part, to ten parts of peppermint water. A postoperative barium roentgenogram should be made in every case as a matter of record and to make certain the proper functioning of the esophagus.

[268] CHAPTER x.x.xIV--DISEASES OF THE ESOPHAGUS (_Continued_)

PARALYSIS OF THE ESOPHAGUS

The pa.s.sage of liquids and solids through the esophagus is a purely muscular act, controlled, after the propulsive usually voluntary start given to the bolus by the inferior constrictor, by a reflex arc having connection with the central nervous system through the vagus nerve.

Gravity plays little or no part in the act of deglut.i.tion, and alone will not carry food or drink to the stomach. Paralysis of the esophagus may be said to be motor or sensory. It is rarely if ever una.s.sociated with like lesions of contiguous organs.

_Motor paralysis of the esophagus_ is first manifested by inability to swallow. This is a.s.sociated with the acc.u.mulation of secretion in the pyriform sinuses (the author's sign of esophageal stenosis) which overflows into the larynx and incites violent coughing. Motor paralysis may affect the constrictors or the esophageal muscular fibers or both.

_Sensory paralysis of the esophagus_ by breaking the continuity of the reflex arc, may so impair the peristaltic movements as to produce aphagia. The same filling of the pyriform sinuses will be noted, but as the larynx is usually anesthetic also, it may be that no cough is produced when secretions overflow into it.

_Etiology_.--1. Toxic paralysis as in diphtheria.

2. Functional paralysis as in hysteria.

3. Peripheral paralysis from neuritis.

4. Central paralysis, usually of bulbar origin.

Embolism or thrombosis of the posterior cerebral artery is a reported cause in two cases. Lues is always to be excluded as the fundamental factor in the groups 3 and 4. Esophageal paralysis is not uncommon in myasthenia gravis.

_Esophagoscopic findings_ are those of absence of the normal resistance at the cricopharyngeus, flaccidity and lack of sensation of the esophageal walls, and perhaps adherence of particles of food to the folds. The hiatal contraction is usually that normally encountered, for this is accomplished by the diaphragmatic musculature. In paralysis of sensation, the reflexes of coughing, vomiturition and vomiting are obtunded.

_Diagnosis_.--Hysteria must not be decided upon as the cause of dysphagia, until after esophagoscopy has eliminated paralysis.

Dysphagia after recent diphtheria should suggest paralysis of the esophagus. The larynx, lips, tongue, and pharynx also, are usually paralyzed in esophageal paralysis of bulbar origin. The absence of the cricopharyngeal resistance to the esophagoscope pa.s.sed without anesthesia, general or local, is diagnostic.

_Treatment_.--The internist and neurologist should govern the basic treatment. Nutrition can be maintained by feeding with the stomach-tube, which meets no resistance to its pa.s.sage. Should this be contraindicated by ulceration of the esophagus, gastrostomy should be done.

LUES OF THE ESOPHAGUS

_Esophageal syphilis_ is a rather rare affection, and may show itself as a mucous plaque, a gumma, an ulceration, or a cicatrix. Cicatricial stenosis developing late in life without history of the swallowing of escharotics or ulcerative lesions is strongly suggestive of syphilis, though the late manifestation of a congenital stenosis is a possibility.

_Esophagoscopic appearances_ of lues are not always characteristic. As in any ulcerative lesion, the inflammatory changes of mixed infections mask the basic nature. The mucous plaque has the same appearance as one situated on the velum, and gummata resemble those seen in the mucosa elsewhere. There is nothing characteristic in luetic cicatrices.

_The diagnosis_ of luetic lesions of the esophagus, therefore, depends upon the history, presence of luetic lesions elsewhere, the serologic reaction, therapeutic test, examination of tissue, and the demonstration of the treponema pallidum. The therapeutic test by prolonged saturation of the system with mercury is imperative in all suspected cases and no other negative result should be deemed sufficient.

_The treatment_ of luetic esophagitis is systemic, not local. Luetic cicatrices contract strongly, and are very resistant to treatment, so that esophagoscopic bouginage should be begun as early as possible after the healing of a luetic ulceration, in order to prevent stenosis. A silk-woven endoscopic bougie placed in position by ocular guidance, and left _in situ_ for from half to one hour daily, may prevent severe contraction, if used early in the stage of cicatrization. Prolonged treatment is required for the cure of established luetic cicatricial stenosis. If gastrostomy has been done retrograde bouginage (Fig. 35) may be used.

TUBERCULOSIS OF THE ESOPHAGUS

_Esophageal tuberculosis_ is not commonly met, but is probably not infrequently a.s.sociated with the dysphagia of tuberculous laryngitis.

It may rarely occur as a primary infection, but usually the esophagus is involved in an extension from a tuberculous process in the larynx, mediastinal lymphatics, pleura, bronchi, or lungs.