Primary lesions appear as superficial erosions or ulcerations, with a surrounding yellowish granular zone, or the granules may alone be present. The mucosa in tuberculous lesions is usually pallid, the absence of vascularity being marked. Invasion from the periesophageal organs produces more or less localized compression and fixation of the esophagus. The character of open ulceration is modified by the mixed infections. Healed tuberculous lesions, sometimes resulting from the evacuation of tuberculous mediastinal lymph nodes into the esophagus may be encountered. The local fixation and cicatricial contraction may be the site of a traction diverticulum. Tuberculous esophago-bronchial fistulae are occasionally seen.

_Diagnosis_, to be certain, requires the demonstration of the tubercule bacilli and the characteristic cell acc.u.mulation of the tubercle in a specimen of tissue removed from the lesion.

Actinomycosis must be excluded, and the possibility of mixed luetic and tuberculous lesions is to be kept in mind. Post-tuberculous cicatrices have no recognizable characteristics.

_Treatment_.--The maintenance of nutrition to the highest degree, and the inst.i.tution of a strict ant.i.tuberculous regime are demanded. Local applications are of no avail. Gastrostomy for feeding should be done if dysphagia be severe, and has the advantage of putting the esophagus at rest. The pa.s.sage of a stomach-tube for feeding purposes may be done, but it is often painful, and is dangerous in the presence of ulceration. Pain is not marked if the lesion be limited to the esophagus, though if it is present orthoform, anesthesin, or apothesin, in powder form, swallowed dry, may prove helpful.

VARIX AND ANGIOMA OF THE ESOPHAGUS

These lesions are sometimes the cause of esophageal hemorrhage, the regurgitated blood being bright red, and alkaline in reaction, in contradistinction to the acid "coffee ground" blood of gastric origin.

Esophageal varices may coexist with the common dilatation of the venous system in which the veins of the r.e.c.t.u.m, s.c.r.o.t.u.m, and legs are most conspicuously affected. Cirrhosis and cancer of the liver may, by interference with the portal circulation, produce dilatation of the veins in the lower third of the esophagus. Angioma of the esophagus is amenable to radium treatment.

ACTINOMYCOSIS OF THE ESOPHAGUS

_Esophageal actinomycosis_ has been autoptically discovered. Its diagnosis, and differentiation from tuberculosis, would probably rest upon the microscopic study of tissue removed esophagoscopically, though as yet no such case has been reported.

ANGIONEUROTIC EDEMA

_Angioneurotic edema_ involving the esophagus, may produce intermittent and transient dysphagia. The lesions are rarely limited to the esophagus alone; they may occur in any portion of the gastrointestinal, genitourinary, or respiratory tracts, and concomitant cutaneous manifestations usually render the diagnosis clear. The treatment is general.

DEVIATION OF THE ESOPHAGUS

_Deviation of the esophagus_ may be marked in the presence of a deformed vertebral column, though dysphagia is a very uncommon symptom. The lack of esophageal symptoms in deviation of spinal production is probably explained by the longitudinal shortening of the spine which accompanies the deflection. Compression stenosis of the esophagus is commonly a.s.sociated with deviations produced by a thoracic ma.s.s.

[PLATE IV

A, Gastroscopic view of a gastrojejunostomy opening drawn patulous by the tube mouth. (Gastrojejunostomy done by Dr. George L. Hays.) B, Carcinoma of the lesser curvature. (Patient afterward surgically explored and diagnosis verified by Dr. John J. Buchanan.) C, Healed perforated ulcer. (Patient referred by Dr. John W. Boyce.)

Drawn from a case of postdiphtheric subglottic stenosis cured by the author's method of direct galvanocauterization of the hypertrophies.

A, Immediately after removal of the intubation tube; hypertrophies like turbinals are seen projecting into the subglottic lumen. B, Five minutes later; the ma.s.ses have now closed the lumen almost completely.

The patient became so cyanotic that a bronchoscope was at once introduced to prevent asphyxia. C, The left ma.s.s has been cauterized by a vertical application of the incandescent knife. D, Completely and permanently cured after repeated cauterizations. Direct view; rec.u.mbent patient.

PHOTOPROCESS REPRODUCTIONS OF THE AUTHOR'S OIL-COLOR DRAWINGS FROM LIFE]

[273] CHAPTER x.x.xV--GASTROSCOPY

The stomach of any individual having a normal esophagus and normal spine can be explored with an open-tube gastroscope. The adult size esophagoscope being 53 cm. long will reach the stomach of the average individual. Longer gastroscopes are used, when necessary, to explore a ptosed stomach. Various lens-system gastroscopes have been devised, which afford an excellent view of the walls of the air-inflated stomach. The optical system, however, interferes with the insertion of instruments, so that the open-tube gastroscope is required for the removal of gastric foreign bodies, the palpation of, or sponging secretions from, gastric lesions. The open-tube gastroscope may be closed with a window plug (Fig. 6) having a rubber diaphragm with a central perforation for forceps, when it is desired to inflate the stomach.

_Technic_.--Relaxation by general anesthesia permits lateral displacement of the dome of the diaphragm along with the esophagus, and thus makes possible a wider range of motion of the distal end of the gastroscope. All of the recent gastroscopies in the Bronchoscopic Clinic, however, have been performed without anesthesia. The method of introduction of the gastroscope through the esophagus is precisely the same as the introduction of the esophagoscope (q.v.). It should be emphasized that with the lens-system gastroscopes, the tube should be introduced into the stomach under direct ocular guidance, without a mandrin, and the optical apparatus should be inserted through the tube only after the stomach has been entered. Blind insertion of a rigid metallic tube into the esophagus is an extremely dangerous procedure.

The descriptions and ill.u.s.trations of the stomach in anatomical works must be disregarded as cadaveric. In the living body, the empty stomach is usually found, on endoscopic inspection, to be a collapsed tube of such shape as to fit whatever s.p.a.ce is available at the particular moment, with folds and rugae running in all directions, the impression given as to form being strikingly like searching among a ma.s.s of earth worms or boiled spaghetti. The color is pink, under proper illumination, if no food is present. Poor illumination may make the color appear deep crimson. If food is present, or has just been regurgitated, the color is bright red. To appreciate the appearance of gastritis, the eye must have been educated to the endoscopic appearances under a degree of illumination always the same. The left two-thirds of the stomach is most easily examined. The stomach wall can be pushed by the tube into almost any position, and with the aid of gentle external abdominal manipulation to draw over the pylorus it is possible to examine directly almost all of the gastric walls except the pyloric antrum, which is reachable in relatively few cases. A lateral motion of from 10 to 17 cm. can be imparted to the gastroscope, provided the diaphragmatic musculature is relaxed by deep anesthesia. The stomach is explored by progressive traverse. That is, after exploring down to the greater curvature, the tube-mouth is moved laterally about 2 centimeters, and the withdrawing travel explores a new field. Then a lateral movement affords a fresh field during the next insertion. This is repeated until the entire explorable area has been covered. Ballooning the stomach with air or oxygen is sometimes helpful, but the distension fixes the stomach, lessens the mobility of the arch of the diaphragm, and thus lessens the lateral range of gastroscopic vision. Furthermore, ballooning pushes the gastric walls far away from the reach of the tube-mouth. A window plug (Fig. 6) is inserted into the ocular end of the gastroscope for the ballooning procedure.

[275] Like many other valuable diagnostic means, gastroscopy is very valuable in its positive findings. Negative results are ent.i.tled to little weight except as to the explorable area.

The gastroscopist working in conjunction with the abdominal surgeon should be able to render him invaluable a.s.sistance in his work on the stomach. The surgeon with his gloved hand in the abdomen, by manipulating suspected areas of the stomach in front of the tube-mouth can receive immediately a report of its interior appearance, whether cancerous, ulcerated, hemorrhagic, etc.

_Lens-system ballooning gastroscopy_ may possibly afford additional information after all possible data from open-tube gastroscopy has been obtained. Care must be exercised not to exert an injurious degree of air-pressure. The distended portion of the stomach a.s.sumes a funnel-like form ending at the apex in a depression with radiating folds, that leads the observer to think he is looking at the pylorus.

The foreshortening produced by the lens system also contributes to this illusion. The best lens-system gastroscope is that of Henry Janeway, which combines the open-tube and the lens system.

_Gastroscopy for Foreign Bodies_.--The great majority of foreign bodies that reach the stomach una.s.sisted are pa.s.sed per r.e.c.t.u.m, provided the natural protective means are not impaired by the administration of cathartics, changes in diet, etcetera. This, however, does not mean that esophageal foreign bodies should be pushed into the stomach by blind methods, or by esophagoscopy, because a swallowed object lodged in the esophagus can always be returned through the mouth. Foreign bodies in the stomach and intestines should be fluoroscopically watched each second day. If an object is seen to lodge five days in one location in the intestines, it should be removed by laparotomy, since it will almost certainly perforate.

Certain objects reaching the stomach may be judged too large to pa.s.s the pylorus and intestinal angles. These should be removed by gastroscopy when such decision is made. It is to be remembered that gastric foreign bodies may be regurgitated and may lodge in the esophagus, whence they are easily removed by esophagoscopy. The double-planed fluoroscope of Manges is helpful in the removal of gastric foreign bodies, but there is great danger of injury to the stomach walls, and even the peritoneum, unless forceps are used with the utmost caution.

[277] CHAPTER x.x.xVI--ACUTE STENOSIS OF THE LARYNX

_Etiology_.--Causes of a relatively sudden narrowing of the lumen of the larynx and subjacent trachea are included in the following list.

Two or more may be combined.

1. Foreign body.

2. Acc.u.mulation of secretions or exudate in the lumen.

3. Distension of the tissues by air, inflammatory products, serum, pus, etc.

4. Displacement of relatively normal tissues, as in abductor paralysis, congenital laryngeal stridor, etcetera.

5. Neoplasms.

6. Granulomata.

_Edema of the larynx_ may be at the glottic level, or in the supraglottic or subglottic regions. The loose cellular tissue is most frequently concerned in the process rather than the mucosal layer alone. In children the subglottic area is very vascular, and swelling quickly results from trauma or inflammation, so that acute stenosis of the larynx in children commonly has its point of narrowing below the cords. Dyspnea, and croupy, barking, cough with no change in the tone or pitch of the speaking voice are characteristic signs of subglottic stenosis. Edema may accompany inflammation of either the superficial or deep structures of the larynx. The laryngeal lesion may be primary, or may complicate general diseases; among the latter, typhoid fever deserves especial mention.

_Acute laryngeal stenosis_ complicating typhoid fever is frequently overlooked and often fatal, for the asthenic patient makes no fight for air, and hoa.r.s.eness, if present, is very slight. The laryngeal lesion may be due to cordal immobility from either paralysis or inflammatory arytenoid fixation, in the absence of edema.

Perichondritis and chondritis of the laryngeal cartilages often follow typhoid ulceration of the larynx, chronic stenosis resulting.

_Laryngeal stenosis in the newborn_ may be due to various anomalies of the larynx or trachea, or to traumatism of these structures during delivery. The normal glottis in the newborn is relatively narrow, so that even slight encroachment on its lumen produces a serious degree of dyspnea. The characteristic signs are inspiratory indrawing of the supraclavicular fossae, the suprasternal notch, the epigastrium, and the lower sternum and ribs. Cyanosis is seen at first, later giving place to pallid asphyxia when cardiac failure occurs. Little air is heard to enter the lungs, during respiratory efforts and the infant, becoming exhausted by the great muscular exertion, soon ceases to breathe. Paralytic stenosis of the larynx sometimes follows difficult forceps deliveries during which stretching or compression of the recurrent nerves occur.

_Acute laryngeal stenosis in infants, from laryngeal perichondritis_, may be a delayed result of traumatism to the laryngeal cartilages during delivery. The symptoms usually develop within four weeks after birth. Lues and tuberculosis are possible factors to be eliminated by the usual methods.

_Surgical Treatment of Acute Laryngeal Stenosis_.--Multiple puncture of acute inflammatory edema, while readily performed with the laryngeal knife used through the direct laryngoscope, is an uncertain measure of relief. Tracheotomy, if done low in the neck, will completely relieve the dyspnea. By its therapeutic effect of rest, it favors the rapid subsidence of the inflammation in the larynx and is the treatment to be preferred. Intubation is treacherous and unreliable except in diphtheritic cases; but in the diphtheritic cases it is ideal, if constant skilled watching can be had.

[279] CHAPTER x.x.xVII--TRACHEOTOMY

_Indications_.--Tracheotomy is indicated in dyspnea of laryngotracheal origin. The cardinal signs of this form of dyspnea are: 1. Indrawing at the suprasternal notch.

2. Indrawing around the clavicles.

3. Indrawing of the intercostal s.p.a.ces.

4. Restlessness.

5. Choking and waking as soon as the aid of the voluntary respiratory muscles ceases in falling to sleep.

6. Cyanosis is a dangerously late symptom.

As a therapeutic measure in diseases of the larynx its place has been thoroughly established. Marked improvement of the laryngeal lesions has been observed to follow tracheotomy in advanced laryngeal tuberculosis, and in cancer of the larynx. It has proven, in some cases, a useful adjunct in the treatment of luetic laryngitis, though it cannot be regarded as indicated, in the absence of dyspnea.

Perichondritis and other inflammations are benefited by tracheotomy. A marked therapeutic effect on multiple laryngotracheal papillomata in children has been noted by the author in hundreds of cases.

_Tracheotomy for foreign body_ is no longer indicated either for the removal of the intruder, or for the insertion of the bronchoscope.

Tracheotomy may be urgently indicated for foreign body dyspnea, but not for foreign body removal.

_Subcutaneous rupture of the trachea_ from external trauma may produce dyspnea and generalized emphysema, both of which will be relieved by tracheotomy.

[280] _Acromegalic stenosis of the larynx_ is a rare but urgent indication for tracheotomy.

_Contraindications_.--There are no contraindications to tracheotomy for dyspnea.