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.

[258] _String-swallowing_, with the passage 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 passing 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, passing 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 stitching 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 quantity 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 accumulations 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 XXXIII--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 classified 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 constituting 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 classified as an esophageal disease.

[FIG. 100.--Schema illustrative 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 passes 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 mass 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 passed 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 bismuth 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 passed 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 XXXIV--DISEASES OF THE ESOPHAGUS (_Continued_)

PARALYSIS OF THE ESOPHAGUS

The passage 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 deglutition, 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 unassociated with like lesions of contiguous organs.

_Motor paralysis of the esophagus_ is first manifested by inability to swallow. This is associated with the accumulation 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 passed 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 passage. 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 associated 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.

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 accumulation 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 institution of a strict antituberculous 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 passage 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 rectum, scrotum, 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 associated with deviations produced by a thoracic mass.

[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 masses 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 mass has been cauterized by a vertical application of the incandescent knife. D, Completely and permanently cured after repeated cauterizations. Direct view; recumbent patient.

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

[273] CHAPTER XXXV--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 illustrations 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 space 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 mass 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 entitled 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 assistance 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 assumes 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 unassisted are passed per rectum, 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 pass 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 XXXVI--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. Accumulation 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 hoarseness, 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 XXXVII--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 spaces. 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.

_The instruments_ required for an orderly tracheotomy are: Headlight Scalpels 2 Retractors Trousseau dilator 6 Hemostats Scissors (dissecting) Tracheal cannulae (six sizes) Curved needles Needle holder Hypodermic syringe for local anesthesia No. 1 plain catgut ligatures Linen tape Gauze sponges

These are sterilized and kept in a sterile copper box ready for instant use. Beside the patient's bed following the tracheotomy the following sterile materials are placed: Sterile gloves 1 Hemostat Sterile new gauze Trousseau dilator Scissors Duplicate tracheotomy tube Silver probe Basin of Bichloride of mercury solution, 1 : 10,000

Tracheotomy is one of the oldest operations known to surgery, yet strange to say, it is probably more often improperly performed today, and more often followed by needless mortality, than any other operation. The two chief preventable sequelae are death from improper routine surgical care and wrongly fitted tube, and stenosis from too high an operation. The classical descriptions of crico-thyroidotomy and high and low tracheotomy have been handed down to generations of medical students without revision. Every medical graduate has been taught that there are two kinds of tracheotomy, high and low, the low operation being very difficult, the high operation very easy. When he is suddenly called upon to do an emergency tracheotomy, this erroneous teaching is about all that remains in the dim recesses of his memory; consequently he makes sure of doing the operation high enough, and goes in through the larynx, usually dividing the cricoid cartilage, the only complete ring in the trachea. As originally made the distinction between high and low as applied to tracheotomy referred to operations above and below the isthmus of the thyroid gland, in a day when primitive surgery attached too much importance to operations upon the thyroid gland. The isthmus is entitled to absolutely no consideration whatever in deciding the location at which to incise so vital a structure as the trachea. Students are taught different short skin incisions for these two operations, and it is no wonder that they, as did their predecessors, find tracheotomy a difficult, bloody, and often futile operation. The trachea is searched for at the bottom of a short, deep wound filled with blood, the source of which is difficult to find and impossible to control.

_Tracheotomic cannulae_ should be made of sterling silver. German silver plated with pure silver is good enough for temporary use, but the plating soon wears off under the galvanic action set up between the two metals. Aluminum becomes roughened by boiling and contact with secretions, and causes the formation of granulations which in time lead to stenosis. Hard rubber tubes cannot be boiled, the walls are so thick as to leave too little lumen, and the rubber is irritating to the tissues. All tracheotomy tubes should be fitted with pilots. Many of the tubes furnished to patients have no pilots to facilitate the introduction, and the tubes are inserted with somewhat the effect of a cheese tester, and with great pain and suffering on the part of the patient. Most of the the tubes in the shops are too short to allow for the swelling of the tissues of the neck following the operation. They may reach the trachea at the time of the operation, but as soon as the reactionary swelling occurs, the end of the tube is pulled out (Fig. 103) of the tracheal incision; the air hissing along the tube is considered by the attendant to indicate that the tube is still in place, and the increasing dyspnea and accelerated respiratory rate are attributed to supposed pneumonia or edema of the lungs, under which erroneous diagnosis the patient is buried. In all cases in which it is reported that in spite of tracheotomy the dyspnea was only temporarily relieved, the fault is the lack of a "plumber." That is, an attendant who will make sure that there is at all times a clear airway all the way down to the lungs. With a bronchoscope and aspirator he will see that the airway is clear. To begin with, a proper sized cannula must be selected. The series of different sized, full curved tubes, one of which is illustrated in Fig. 104, will under all conditions reach the trachea. If the tube seems to be too long in any given case, it will usually be found that the tracheotomy has been done too high, and a lower one should be done at once. If the operation has not been done too high, and the cannula is too long, a pad of gauze under the shield will take up the surplus length. In cases of tracheal compression from new growth, thymus or other such cases, in which the ordinary tube will not pass the obstruction, the author's long cane-shaped cannula (see Fig. 104) can be inserted past the obstruction, and if necessary into either bronchus. The fenestrum placed in the cannula in many of the older tubes, with the supposed function of allowing partial breathing through the larynx, is a most pernicious thing. A properly fitted tube should not take up more than half of the cross section of the trachea, and should allow the passage of sufficient air for free laryngeal breathing when it is completely corked. The fenestrum is, moreover, rarely so situated that air can pass through it; the fenestral edges act as a constant irritant to the wound, producing bleeding and granulation tissue.

[FIG. 103.--Schema showing thick pad of gauze dressing, filling the space, A, and used to hold out the author's full-curved cannula when too long, prior to reactionary swelling, and after subsidence of the latter. At the right is shown the manner in which the ordinary cannula of the shops permits a patient to asphyxiate, though some air is heard passing through the tracheal opening, H, after the cannula has been partially withdrawn by swelling of the tissues, T.]

[FIG. 104.--The author's tracheotomic cannulae. A, shows cane-shaped cannula for use in intrathoracic compressive or other stenoses. B, shows full curved cannula for regular use. Pilots are made to fit the outer cannula; the inner cannula not being inserted until after withdrawal of the pilot.]

_Anesthesia_.--No dyspneic patient should be given a general anesthetic; because any patient dyspneic enough to need a tracheotomy for dyspnea is depending largely upon the action of the accessory respiratory muscles. When this action is stopped by beginning unconsciousness, respiration ceases. If the trachea is not immediately opened, artificial respiration instituted, and oxygen insufflated, the patient dies on the table. Skin infiltration along the line of incision with a very weak cocaine solution (1/10 of 1 per cent), apothesine (2 per cent), novocaine, Schleich's fluid or other local anesthetic, suffices to render the operation painless. The deeper structures have little sensation and do not require infiltration. It has been advocated that an interannular injection of cocaine solution with a hypodermic syringe be done just prior to incision of the trachea for the purpose of preventing cough after the incision of the trachea and the insertion of the cannula. It would seem, however, that this introduces the risk of aspiration pneumonia and pulmonary abscess, by permitting the aspiration and clotting of blood in small bronchi, followed by subsequent breaking down of the clots. As the author has so often said, "The cough reflex is the watch dog of the lungs," and if not drugged asleep by local or general anesthesia can safely be relied upon to prevent all possibility of the blood or the pus which nearly always is present in acute or chronic conditions calling for tracheotomy, being aspirated into the deeper air-passages. Cocaine in any form, by any method, and in any dosage, is dangerous in very young children.

_Technic_.--The patient should be placed in the recumbent position, with the extended head held in the midline by an assistant. The shoulders, not the neck, should be slightly raised with a sand bag. The head should be somewhat lower than the feet, to lessen the danger of aspiration of blood. A midline incision dividing the skin and fascia is made from the thyroid notch to just above the suprasternal notch. The cricoid is now located, and the deeper dissection is continued from below this point. The ribbon muscles are separated with dissecting scissors or knife, and held apart with retractors. If the isthmus of the thyroid gland is in the way, it may be retracted upward; if large, however, it should be divided and ligated, for it is apt to slip over the tracheal incision afterward, and render difficult the quick finding of the incision during after-care. This covering of the tracheal incision by the slipping back of the drawn-aside thyroidal isthmus is one of the most frequent avoidable causes of mortality, because it deflects the cannula off into the tissues when it is replaced after cleaning during the early postoperative period. The corrugated surface of the trachea can be felt, and its exact location can be determined by the index finger. If the tracheotomy is proceeding in an orderly manner, all bleeding points should be caught and tied with plain catgut (No. 1) before the trachea is opened. Because of distension of vessels during cough, all but the tiniest vessels should be ligated. Side-cut veins are particularly treacherous. They should be freed of tissue, cut across and the divided ends ligated.

The _incision in the trachea_ should be as low as possible, and should never be made through the first ring. The incision should be through the third, fourth and fifth rings. Only in cases of laryngoptosis will it be necessary to incise the trachea higher than this. The incision must be made in the midline, and in the long axis of the trachea, and care must be exercised that the point of the knife does not perforate the posterior tracheal wall. Stab incisions are always to be avoided. If the incision in the trachea is found to be of insufficient length, the original incision must be found and elongated. A second incision must not be made, for the portion of cartilage between the two incisions will die and will almost certainly make a site of future tracheal stenosis. The cricoid should never be cut, for stenosis is almost sure to follow the wearing of a cannula in this position. A Trousseau dilator should now be inserted in the tracheal incision, its blades gently separated. With the tracheal lumen thus opened, a cannula of proper size is introduced with absolute certainty of its having entered the trachea. A quadruple-folded square of gauze in the form of a pad about four inches square is moistened with mercuric chloride solution (1:10,000) and is slit from the lower border to its midpoint. This pad is slipped from above downward under the tape holder of the cannula, the slit permitting the tubal part of the cannula to reach the central part of the pad (Fig. 108), and completely covers the wound. No attempt should be made to suture the skin wound, for this tends to form a pocket in which lodge the bronchial secretions that escape alongside the tube, resulting in infection of the wound. Furthermore it renders the daily changing of the tube much more difficult. In fact it prevents the attendant from being certain that the tube is actually placed in the trachea. Suturing of the skin to the trachea should never be done, for the sutures soon tear out and often set up a perichondritis of the tracheal cartilages, with resulting difficult decannulation.

[FIG. 105.--Schema of practical gross anatomy to be memorized for emergency tracheotomy. The middle line is the safety line, the higher the wider. Below, the safety line narrows to the vanishing point VP. The upper limit of the safety line is the thyroid notch until the trachea is bared, when the limit falls below the first tracheal ring. In practice the two-dark danger lines are pushed back with the left thumb and middle finger as shown in Fig. 106, thus throwing the safety line into prominence. This is generally known as Jackson's tracheotomic triangle.]

[FIG. 106.--Schema showing the author's method of rapid tracheotomy. First stage. The hands are drawn ungloved for the sake of clearness. The upper hand is the left, of which the middle finger (M) and the thumb are used to repress the sterno-cleido-mastoid muscles, the finger and thumb being close to the trachea in order to press backward out of the way the carotid arteries and the jugular vein. This throws the trachea forward into prominence, and one deep slashing cut will incise all of the soft tissues down to the trachea.]

_Emergency Tracheotomy_.--Stabbing of the cricothyroid membrane, or an attempted stabbing of the trachea, so long taught as an emergency tracheotomy, is a mistake. The author's "two stage, finger guided" method is safer, quicker, more efficient, and not likely to be followed by stenosis. To execute this promptly, the operator is required to forget his textbook anatomy and memorize the schema (Fig. 105). The larynx and trachea are steadied by the thumb and middle finger of the left hand, which at the same time push back the important nerves and vessels which parallel the trachea, and render the central safety line more prominent (Fig. 106). A long incision is now made from the thyroid notch almost to the suprasternal notch, and deep enough to reach the trachea. This completes the first stage.

[FIG. 107.--Illustrating the author's method of quick tracheotomy. Second stage. The fingers are drawn ungloved for the sake of clearness. In operating the whole wound is full of blood, and the rings of the trachea are felt with the left index which is then moved slightly to the patient's left, while the knife is slid down along the left index to exactly the middle line when the trachea is incised.]

Second stage. The entire wound is full of blood and the trachea cannot be seen, but its corrugations can be very readily felt by the tip of the free left index finger. The left index finger is now moved a little to the patient's left in order that the knife shall come precisely in the midline of the trachea, and three rings of the trachea are divided from above downward (Fig. 107). The Trousseau dilator should now be inserted, the head of the table should be lowered, and the patient should be turned on the side to allow the blood to run away from the wound. If respiration has ceased, a cannula is slipped in, and artificial respiration is begun. Oxygen insufflation will aid in the restoration of respiration, and a pearl of amyl nitrite should be crushed in gauze and blown in with the oxygen. In all such cases, excessive pressure of oxygen should be avoided because of the danger of producing ischemia of the lungs. Hope of restoring respiration should not be abandoned for half an hour at least. One of the author's assistants, Dr. Phillip Stout, saved a patient's life by keeping up artificial respiration for twenty minutes before the patient could do his own breathing.

The _after-care_ of the tracheotomic wound is of the utmost importance. A special day and night nurse are required. The inner tube of the cannula must be removed and cleaned as soon as it contains secretion. Secretion coughed out must be wiped away quickly, but gently, before it is again aspirated. The gauze dressing covering the wound must be changed as soon as soiled with secretions from the wound and the air-passages. Each fresh pad should be moistened with very weak bichloride of mercury solution (1:10,000). The outer tube must be changed every twenty-four hours, and oftener if the bronchial secretion is abundant. Student-physicians who have been taught my methods and who have seen the cases in care of our nurses have often expressed amazement at the neglect unknowingly inflicted on such cases elsewhere, in the course of ordinary routine surgery. It is not unusual for a patient to be sent to the Bronchoscopic Clinic who has worn his cannula without a single changing for one or two years. In some cases the tube had broken and a portion had been aspirated into the trachea.

[FIG. 108.--Method of dressing a tracheotomic wound. A broad quadruple, in-folded pad of gauze is cut to its centre so that it can be slipped astride of the tube of the cannula back of the shield. No strings, ravellings or strips of gauze are permissible because of the risk of their getting down into the trachea.]

If the respiratory rate increases, instead of attributing it to pulmonary complications, the entire cannula should be removed, the wound dilated with the Trousseau forceps, the interior of the trachea inspected, and all secretions cleaned away. Then the tracheal mucosa below the wound should be gently touched with a sterile bent probe, to induce cough to rid the lower air passages of accumulated secretions. In many cases it is a life-saving procedure to insert a sterile long malleable aspirating tube to remove secretions from the lower air-passages. When all is clear, a fresh sterile cannula which has been carefully inspected to see that its lumen has been thoroughly cleaned, is inserted, and its tapes tied. Good "plumbing," that is, the maintenance at all times of a clear, clean passage in all the "pipes," natural and artificial, is the reason why the mortality in the Bronchoscopic Clinic has been less than half of one per cent, while in ordinary routine surgical care in all hospitals collectively it ranges from 10 to 20 per cent.

_Bronchial Aspiration_.--As mentioned above, bronchial aspiration is often necessary. When the patient is unable to get up secretions, he will, as demonstrated by the author many years ago, "drown in his own secretions." In some cases bronchoscopic aspiration is required (Peroral Endoscopy, p. 483). Occasionally, very thick secretions will require removal with forceps. Pus may become very thick and gummy from the administration of morphin. Opiates do not lessen pus formation, but they do lessen the normal secretions that ordinarily increase the quantity and fluidity of the pus. When to this is added the dessicating effect of the air inhaled through the cannula, unmoistened by the upper air-passages, the secretions may be so thick as to form crusts and plugs that are equivalent to foreign bodies and require removal with forceps. Diphtheritic membrane in the trachea may require removal with bronchoscope and forceps. Thinner secretions may be removed by sponge-pumping. In most cases, however, secretions can be brought up through an aspirating tube, connected to a bronchoscopic aspirating syringe (Fig. 11), an ordinary aspirating bottle, or preferably, a mechanical aspirator such as that shown in Fig. 12. In this, combined with bronchoscopic oxygen insuflation (q.v.), we have a life-saving measure of the highest efficiency in cases of poisoning by chlorine and other irritant and asphyxiating gases. An aspirating tube for insertion into the deeper air passages should be of copper, so that it can be bent to the proper curve to reach into the various parts of the tracheobronchial tree, and it should have a removable copper-wire core to prevent kinking, and collapse of the lumen. The distal end should be thickened, and also perforated at the sides, to prevent drawing-in of the mucosa and trauma thereto. A rubber tube may be used, but is not so satisfactory. The one shown in Fig. 10 I had made by Mr. Pilling, and it has proved very satisfactory.

_Decannulation_.--When the tracheal incision is placed below the first ring, no difficulty in decannulation should result from the operation per se. When by temporarily occluding the cannula with the finger it is evident that the laryngeal aperture has regained sufficient size to allow free breathing, a smaller-sized tracheotomic tube should be substituted to allow free passage of air around the cannula in the trachea. In doing this, the amount of secretion and the handicap of impaired glottic mobility in the expulsion of thick secretions must be borne in mind. Babies labor under a special handicap in their inefficient bechic expulsion and especially in their small cannulae which are so readily occluded. If breathing is not free and quiet with the smaller tube; the larger one must be replaced. If, however, there is no trouble with secretions, and the breathing is free and quiet, the inner cannula should be removed, and the external orifice of the outer cannula firmly closed with a rubber cork. If the laryngeal condition has been acute, decannulation can usually be safely done after the patient has been able to sleep quietly for three nights with a corked cannula. If free breathing cannot be obtained when the cannula is corked, the larynx is stenosed, and special work will be required to remove the tube. Children sometimes become panic stricken when the cannula is completely corked at once and they are forced to breathe through the larynx instead of the easier shortcut through the neck. In such a case, the first step is partially to cork the cannula with a half or two-thirds plug made from a pure rubber cord fashioned in the desired shape by grinding with an emery wheel (Fig. 112). Thus the patient is gradually taught to use the natural air-way, still feeling that he has an "anchor to windward" in the opening in the cannula. When some swelling of the laryngeal structures still exists, this gradual corking has a therapeutic effect in lessening the stenosis by exercising the muscles of abduction of the cords and mobilizing the cricoarytenoid articulation during the inspiratory effort. The forced respiration keeps the larynx freed from secretions, which are more or less purulent and hence irritating. After removing the cannula, in order that healing may proceed from the bottom upward, the wound should be dressed in the following manner: A single thickness of gauze should be placed over the wound and the front of the neck, and a gauze wedge firmly inserted over this to the depths of the tracheotomic wound, all of this dressing being held in place by a bandage. If the skin-wound heals before the fibrous union of the tracheal cartilages is complete, exuberant granulations are apt to form and occlude the trachea, perhaps necessitating a new tracheotomy for dyspnea.

It is so important to fix indelibly in the mind the cardinal points concerning tracheotomy that I have appended to this chapter the teaching notes that I have been for years giving my classes of students and practitioners, hundreds of whom have thanked me for giving them the clear-cut conception of tracheotomy that enabled them, when their turn came to do an emergency tracheotomy, to save human life.

RESUME OF TRACHEOTOMY

_Instruments_. Headlight Sandbag Scalpel Hemostats Small retractors Tenaculum Tracheotomic cannulae (proper kind) Long. Half area cross-section trachea. Proper curve: Radius too short will press ant. tracheal wall; too long, post. wall. Sterling Silver Tracheobronchial aspirator. Probe. Tapes for cannulae Trousseau dilator Sponges Infiltration syringe and solution Oxygen tank.

_Indications_: Laryngeal dyspnea. (Indrawing guttural and clavicular fossae and at epigastrium. Pallor. Restlessness. Drowning in his own secretions.)

Do it early. Don't wait for cyanosis. [294] Never use general anesthesia on dyspneic patient. Forget about "high" and "low" distinctions until trachea is exposed. Memorize Jackson's tracheotomic triangle. Patient recumbent, sand bag under shoulders or neck. Nose to zenith. Infiltration, _Intra_dermatic. Incise from Adam's apple to guttural fossa. Hemostasis. Keep in middle line. Feel for trachea. Expose isthmus of thyroid gland. Draw it upward or downward or cut it. Ligature, torsion, etc. before incising trachea. Hold trachea with tenaculum. Incise trachea below first ring. Avoid cutting cricoid or first ring. Cut 3 rings vertically. Don't hack. Don't cut posterior wall which almost touches the anterior wall during cough. Spread carefully, with Trousseau dilator. Insert cannula; _see_ it enter tracheal lumen; remove pilot; tie tapes. Don't suture wound. Dress with large squares. Don't give morphine. Decannulation by corking partially, after changing to smaller cannula. Do not remove cannula permanently until patient sleeps without indrawing with corked cannula.

RESUME OF EMERGENCY TRACHEOTOMY

The following notes should be memorized. 1. Essentials: Knife and pair of hands (but full equipment better). [295] 2. Don't do a laryngotomy, or stabbing. 3. "Two stage, finger guided" operation better. 4. Sand bag or substitute. 5. Press back danger lines with left thumb and middle finger, making safety line and trachea prominent. 6. Memorize Jackson's tracheotomic triangle. 7. Incise exactly in middle line from Adam's apple to sternum. 8. Feel for tracheal corrugations with left index in pool of blood, following trachea with finger downward from superficial Adam's apple. 9. Pass knife along index and incise trachea (not too deeply, may cut posterior wall). 10. Don't mind bleeding; but keep middle line and keep head straight; keep head low; don't bother about thyroid gland. 11. Don't expect hiss when trachea is cut if patient has stopped breathing. 12. Start artificial respiration. 13. Amyl nitrite. Oxygen. 14. Practice palpation of the neck until the tracheal landmarks are familiar. 15. Practice above technic, up to point of incision, at every opportunity. 16. _Jackson's tracheotomic triangle_: A triangulation of the front of the neck intended to facilitate a proper emergency tracheotomy. Apex at suprasternal notch. Sides anterior edge sternomastoids. Base horizontal line lower edge cricoid.

RESUME OF AFTER-CARE OF A TRACHEOTOMIC CASE

1. Always bear in mind that tracheotomy is not an ultimate object. The ultimate object is to pipe air down into the lungs. Tracheotomy is only a means to that end. 2. Sterile tray beside bed should contain duplicate (exact) tracheotomy tube, Trousseau dilator, hemostat, thumb forceps, silver probe, scissors, scalpel, probe-pointed curved bistoury. Sterile gloves ready. 3. Special nursing necessary for safety. 4. Laxative. 5. Sponge away secretions before they are drawn in. 6. Cover wound with wide large gauze square slit so it fits around cannula under the tape holder. Pull off ravelings. Keep wet with 1 : 10,000 Bichloride solution. 7. Change dressing every hour or oftener. 8. Abundance of fresh air, temperature preferably about 70 degrees. 9. _Nurse should remove inner cannula as often as needed and clean it with pipe cleaner before boiling._ 10. Outer cannula should be changed every day by the surgeon or long-experienced tracheotomy nurse. A pilot should be used and care should be taken not to injure the cut ends of the tracheal cartilage. 11. A sterile, bent probe may be inserted downward in the trachea with both cannulae out to excite cough if necessary to expel secretions. An aspirating tube should be used, when necessary. 12. A patient with a properly fitted cannula free of secretions breathes noiselessly. Any sound demands immediate attention. 13. If the respiratory rate increase it is much more likely to be due to obstruction in, malposition of, or shortness of the cannula than to lung complications. 14. Be sure that: (a) The cannula is clear and clean. (b) The cannula is long enough to reach well down into the trachea. A cannula that was long enough when the operation was done may be too short after the cervical tissues swell. (c) The distal end of the cannula actually is deeply in the trachea. The only way to be sure is, when inserting the cannula, to spread the wound and the tracheal incision with a Trousseau dilator, then _see_ the interior of the tracheal lumen and _see_ the cannula enter therein. 15. If after attending to the above mentioned details there are still signs of obstructive dyspnea, a bronchoscopy should be done for finding and removal of the obstruction in the trachea or main bronchi. 16. If all the "pipes," natural and instrumental, are clear there can be no such thing as obstructive dyspnea. 17. Pneumonia and pulmonary edema may exist before tracheotomy, but they are rare sequelae. 18. Decannulation, in cases of tracheotomy done for temporary conditions should not be attempted until the patient has slept at least 3 nights with his cannula tightly corked. A properly fitted cannula (i.e. one not larger than half the area of cross section of the trachea) permits the by-passage of plenty of air. A partial cork should be worn for a few days first for testing and "weaning" a child away from the easier breathing through the neck. In cases of chronic laryngeal stenosis a prolonged test is necessary before attempting decannulation. 19. A tracheotomic case may be aphonic, hence unable to call for help. 20. The foregoing rules apply to the post-operative periods. After the wound has healed and a fistula is established, the patient, if not a child, may learn to care for his own cannula. [298] 21. Do not give cough-sedatives or narcotics. The cough reflex is the watch dog of the lungs.

NOTES ON NURSING TRACHEOTOMIZED PATIENTS

Bedside tray should contain: Duplicate cannula Scalpel Trousseau dilator Hemostat Dressing forceps Sterile vaseline Scissors Tape Probe Gauze sponges Gauze squares Probe-pointed curved bistoury.

1. Room should be abundantly ventilated, as free from dust and lint as possible, and the air should be moistened by steam in winter. 2. Keep mouth clean. Tooth brush. Rinse alcohol 1:10. 3. Sponge away secretion after the cough before drawn in. 4. Remove inner cannula (not outer) as often as needed. Not less often than every hour. Replace immediately. Never boil a cannula until you have thoroughly cleaned it. 5. Obstruction of cannula calling for cleaning indicated by: Blue or ashy color. Indrawing at clavicles, sternal notch, epigastrium. Noisy breathing. (Learn sound.) 6. Surgeon (in our cases) will change outer cannula once daily or oftener. 7. Duplicate cannulae. 8. Be careful in cleaning cannulae not to damage. 9. Watch for loose parts on cannula. 10. Change dressing (in our cases) as often as soiled. Not less often than every hour. Large squares. Never narrow strips. 11. Watch color of lips and ears and face. [299] 12. Report at once if food or water leaks through wound. (Coughing and choking). 13. Never leave a tracheotomized patient unwatched during the first days or weeks, according to case. 14. Remember Trousseau dilator or hemostat will spread the tracheal wound or fistula when cannula is out. 15. Remember life depends on a clear cannula if the patient gets no air through the mouth. 16. Remember it takes very little to clog the small cannula of a child. 17. Remember a tracheotomized patient cannot call for help. 18. Decannulation. Testing by corking partially. Watch corks not too small, or broken. Attach them by braided silk thread. Pure rubber cord ground down makes best cork.

[300] CHAPTER XXXVIII--CHRONIC STENOSIS OF THE LARYNX AND TRACHEA

The various forms of laryngeal stenosis for which tracheotomy or intubation has been performed, and the difficulties encountered in restoring the natural breathing, may be classified into the following types: 1. Panic 2. Spasmodic 3. Paralytic 4. Ankylotic (arytenoid) 5. Neoplastic 6. Hyperplastic 7. Cicatricial (a) Loss of cartilage (b) Loss of muscular tissue (c) Fibrous

_Panic_.--Nothing so terrifies a child as severe dyspnea; and the memory of previous struggles for air, together with the greater ease of breathing through the tracheotomic cannula than through even a normal larynx, incites in some cases so great a degree of fear that it may properly be called panic, when attempts at decannulation are made. Crying and possibly glottic spasm increase the difficulties.

_Spasmodic stenosis_ may be associated with panic, or may be excited by subglottic inflammation. Prolonged wearing of an intubation tube, by disturbing the normal reciprocal equilibrium of the abductors and adductors, is one of the chief causes. The treatment for spasmodic stenosis and panic is similar. The use of a special intubation tube having a long antero-posterior lumen and a narrow neck, which form allows greater action of the musculature, has been successful in some cases. Repeated removal and replacement of the intubation tube when dyspnea requires it may prove sufficient in the milder cases. Very rarely a tracheotomy may be required; if so, it should be done low. The wearing of a tracheotomic cannula permits a restoration of the muscle balance and a subsidence of the subglottic inflammation. Corking the cannula with a slotted cork (Fig. 111) will now restore laryngeal breathing, after which the tracheotomic cannula may be removed.

[PLATE V--PHOTOPROCESS REPRODUCTIONS OF THE AUTHOR'S OIL-COLOR DRAWINGS FROM LIFE--LARYNGEAL AND TRACHEAL STENOSES:

1, Indirect view, sitting position; postdiphtheric cicatricial stenosis permanently cured by endoscopic evisceration. (See Fig. 5.) 2, Indirect view, sitting position; posttyphoid cicatricial stenosis. Mucosa was very cyanotic because cannula was re-moved for laryngoscopy and bronchoscopy. Cured by laryngostomy. (See Fig. 6.) 3, Indirect view, sitting position; posttyphoid infiltrative stenosis, left arytenoid destroyed by necrosis. Cured by laryngostomy; failure to form adventitious band (Fig. 7) because of lack of arytenoid activity. 4, Indirect view, recumbent position; posttyphoid cicatricial stenosis. Cured of stenosis by endoscopic evisceration with sliding punch forceps. Anterior commissure twice afterward cleared of cicatricial tissue as in the other case shown in Fig. 15. Ultimate result shown in Fig. 8. 5, Same patient as Fig. 1; sketch made two years after decannulation and plastic. 6, Same patient as Fig. 2; sketch made four years after decannulation and plastic. 7, Same patient as Fig. 3; sketch made three years after decannulation and plastic. 8, Same patient as Fig. 4; sketch made one year after decannulation, fourteen months after clearing of the anterior commissure to form adventitious cords. 9, Direct view, recumbent patient; web postdiphtheric (?) or congenital (?). "Rough voice" since birth, but larynx never examined until stenosed after diphtheria. Web removed and larynx eviscerated with punch forceps; recurrence of stenosis (not of web). Cure by laryngostomy. This view also illustrates the true depth of the larynx which is often overlooked because of the misleading flatness of laryngeal illustrations. 10, Direct laryngoscopic view; postdiphtheric hypertrophic subglottic stenosis. Cured by galvanocauterization. 11, Direct laryngoscopic view; postdiphtheric hypertrophic supraglottic stenosis. Forceps excision; extubation one month later; still well after four years. 12, Bronchoscopic view of posttracheotomic stenosis following a "plastic flap" tracheotomy done for acute edema. 13, Direct laryngoscopic view; anterolateral thymic compression stenosis in a child of eighteen months. Cured by thymopexy. 14, Indirect laryngoscopic (mirror) view; laryngostomy rubber tube in position in treatment of post-typhoid stenosis. 15, Direct view; posttyphoid stenosis after cure by laryngostomy. Dotted line shows place of excision for clearing out the anterior commissure to restore the voice. 16, Endoscopic view of posttracheotomic tracheal stenosis from badly placed incision and chondrial necrosis. Tracheotomy originally done for influenzal tracheitis. Cured by tracheostomy.]

_Paralysis_.--Bilateral abductor laryngeal paralysis causes severe stenosis, and usually tracheotomy is urgently required. In cadaveric paralysis both cords are in a position midway between abduction and adduction, and their margins are crescentic, so that sufficient airway remains. Efforts to produce the cadaveric position of the cords by division or excision of a portion of the recurrent laryngeal nerves, have been failures. The operation of _ventriculocordectomy_ consists in removing a vocal cord and the portion or all of the ventricular floor by means of a punch forceps introduced through the direct laryngoscope. Usually it is better to remove only the portion of the floor anterior to the vocal process of the arytenoid. In some cases monolateral ventriculocordectomy is sufficient; in most cases, however, operation on both sides is needed. An interval of two months between operations is advisable to avoid adhesions. In almost all cases, ventriculocordectomy will result in a sufficient increase in the glottic chink for normal respiration. The ultimate vocal results are good. Evisceration of the larynx, either by the endoscopic or thyrotomic method, usually yields excellent results when no lesion other than paralysis exists. Only too often, however, the condition is complicated by the results of a faultily high tracheotomy. A rough, inflexible voice is ultimately obtained after this operation, especially if the arytenoid cartilage is unharmed. In recent bilateral recurrent paralysis, it may be worthy of trial to suture the recurrent to the pneumogastric. Operations on the larynx for paralytic stenosis should not be undertaken earlier than twelve months from the inception of the condition, this time being allowed for possible nerve regeneration, the patient being made safe and comfortable, meanwhile, by a low tracheotomy.

_Ankylosis_.--Fixation of the crico-arytenoid joints with an approximation of the cords may require evisceration of the larynx. This, however, should not be attempted until after a year's lapse, and should be preceded by attempts to improve the condition by endoscopic bouginage, and by partial corking of the tracheotomic cannula.

_Neoplasms_.--Decannulation in neoplastic cases depends upon the nature of the growth, and its curability. Cicatricial contraction following operative removal of malignant growths is best treated by intubational dilatation, provided recurrence has been ruled out. The stenosis produced by benign tumors is usually relieved by their removal.

_Papillomata_.--Decannulation after tracheotomy done for papillomata should be deferred at least 6 months after the discontinuance of recurrence. Not uncommonly the operative treatment of the growths has been so mistakenly radical as to result in cicatricial or ankylotic stenoses which require their appropriate treatments. It is the author's opinion that recurrent papillomata constitute a benign self-limited disease and are best treated by repeated superficial removals, leaving the underlying normal structures uninjured. This method will yield ultimately a perfect voice and will avoid the unfortunate complications of cicatricial hypertrophic and ankylotic stenosis.

_Compression Stenosis of the Trachea_.--Decannulation in these cases can only follow the removal of the compressive mass, which may be thymic, neoplastic, hypertrophic or inflammatory. Glandular disease may be of the Hodgkins' type. Thymic compression yields readily to radium and the roentgenray, and the tuberculous and leukemic adenitides are sometimes favorably influenced by the same agents. Surgery will relieve the compression of struma and benign neoplasms, and may be indicated in certain neoplasms of malignant origin. The possible coexistence of laryngeal paralysis with tracheal compression is frequently overlooked by the surgeon. Monolateral or bilateral paralysis of the larynx is by no means an uncommon postoperative sequel to thyroidectomy, even though the recurrent nerves have been in no way injured at operation. Probably a localized neuritis, a cicatricial traction, or inclusion of a nerve trunk accounts for most of these cases.

_Hyperplastic and cicatricial chronic stenoses_ preventing decannulation may be classified etiologically as follows: 1. Tuberculosis 2. Lues 3. Scleroma 4. Acute infectious diseases (a) Diphtheria (b) Typhoid fever (c) Scarlet fever (d) Measles (e) Pertussis 5. Decubitus (a) Cannular (b) Tubal 6. Trauma (a) Tracheotomic (b) Intubational (c) Operative (d) Suicidal and homicidal (e) Accidental (by foreign bodies, external violence, bullets, etc.)

Most of the organic stenoses, other than the paralytic and neoplastic forms, are the result of inflammation, often with ulceration and secondary changes in the cartilages or the soft tissues.

[304] _Tuberculosis_.--In the non-cicatricial forms, galvanocaustic puncture applied through the direct laryngoscope will usually reduce the infiltrations sufficiently to provide a free airway. Should the pulmonary and laryngeal tuberculosis be fortunately cured, leaving, however, a cicatricial stenosis of the larynx, decannulation may be accomplished by laryngostomy.

_Lues_.--Active and persistent antiluetic medication must precede and accompany any local treatment of luetic laryngeal stenosis. Prolonged stretching with oversized intubation tubes following excision or cauterization may sometimes be successful, but laryngostomy is usually required to combat the vicious contraction of luetic cicatrices.

_Scleroma_ is rarely encountered in America. Radiotherapy has been advocated and good results have been reported from the intravenous injection of salvarsan. Radium may be tried, and its application is readily made through the direct laryngoscope.

_Diphtheria_.--Chronic postdiphtheritic stenosis may be of the panic, spasmodic or, rarely, the paralytic types; but more often it is of either the hypertrophic or cicatricial forms. Only too frequently the stenosis should be called posttracheotomic rather than postdiphtheritic, since decannulation after the subsidence of the acute stenosis would have been easy had it not been for the sequelae of the faulty tracheotomy. Prolonged intubation may induce either a supraglottic or subglottic tissue hyperplasia. _The supraglottic type_ consists in an edematous thickening around the base of the epiglottis, sometimes involving also the glossoepiglottic folds and the ventricular bands. An improperly shaped or fitted tube is the usual cause of this condition, and a change to a correct form of intubation tube may be all that is required. Excessive polypoid tissue hypertrophy should be excised. The less redundant cases subside under galvanocaustic treatment, which may be preceded by tracheotomy and extubation, or the intubation tube may be replaced after the application of the cautery. The former method is preferable since the patient is far safer with a tracheotomic cannula and, further, the constant irritation of the intubation tube is avoided. _Subglottic hypertrophic stenosis_ consists in symmetrical turbinal-like swellings encroaching on the lumen from either side. Cautious galvanocauterant treatment accurately applied by the direct method will practically always cure this condition. Preliminary tracheotomy is required in those cases in which it has not already been done, and in the cases in which a high tracheotomy has been done, a low tracheotomy must be the first step in the cure. Cicatricial types of postdiphtheritic stenosis may be seen as webs, annular cicatrices of funnel shape, or masses of fibrous tissue causing fixation of the arytenoids as well as encroachment on the glottic lumen. (See color plates.)

As a rule, when a convalescent diphtheritic patient cannot be extubated two weeks after three negative cultures have been obtained the advisability of a low tracheotomy should be considered. If a convalescent intubated patient cough up a tube and become dyspneic a low tracheotomy is usually preferable to forcing in an oversized intubation tube.

_Typhoid Fever_.--Ulcerative lesions in the larynx during typhoid fever are almost always the result of mixed infection, though thrombosis of a small vessel, with subsequent necrosis is also seen. If the ulceration reaches the cartilage, cicatricial stenosis is almost certain to follow.

_Trauma_.--The chief traumatic factors in chronic laryngeal stenosis are: (a) prolonged presence of a foreign body in the larynx (b) unskilled attempts at intubation and the wearing of poorly fitting intubation tubes; (c) a faulty tracheotomy; (d) a badly fitting cannula; (e) war injuries; (f) attempted suicide; (g) attempted homicide; (h) neglect of cleanliness and care of either intubation tubes or tracheotomic cannulae allowing incrustation and roughening which traumatize the tissues at each movement of the ever-moving larynx and trachea.

_Treatment of Cicatricial Stenosis_.--A careful direct endoscopic examination is essential before deciding on the method of treatment for each particular case. Granulations should be removed. Intubated cases are usually best treated by tracheotomy and extubation before further endoscopic treatment is undertaken. A certain diagnosis as to the cause of the condition must be made by laboratory and therapeutic tests, supplemented by biopsy if necessary. Vigorous antiluetic treatment, especially with protiodide of mercury, must precede operation in all luetic cases. Necrotic cartilage is best treated by laryngostomy. Intubational dilatation will succeed in some cases.

[FIG. 109.--Schema showing the author's method of laryngostomy. The hollow upward metallic branch (N) of the cannula (C) holds the rubber tube (R) back firmly against the spur usually found on the back wall of the trachea. Moreover, the air passing up through the rubber tube (R) permits the patient to talk in a loud whisper, the external orifice of the cannula being occluded most of the time with the cork (K). The rubber tubing, when large sizes are reached may extend down to the lower end of the cannula, the part C coming out through a large hole cut in the tubing at the proper distance from the lower end.]

_Laryngoscopic bouginage_ once weekly with the laryngeal bougies (Fig. 42) will cure most cases of laryngeal stenosis. For the trachea, round, silk-woven, or metallic bougies (Fig. 40) are better.

[307] _Laryngostomy_ consists in a midline division of the laryngeal and tracheal cartilages as low as the tracheotomic fistula, excision of thick cicatricial tissue, very cautious incision of the scar tissue on the posterior wall, if necessary, and the placing of the author's laryngostomy tube for dilatation (Fig. 109). Over the upward branch of the laryngostomy tube is slipped a piece of rubber tubing which is in turn anchored to the tape carrier by braided silk thread. Progressively larger sizes of rubber tubing are used as the laryngeal lumen increases in size under the absorptive influence of the continuous elastic pressure of the rubber. Several months of wearing the tube are required until dilatation and epithelialization of the open trough thus formed are completed. Painstaking after-care is essential to success. When dilatation and healing have taken place, the laryngostomy wound in the neck is closed by a plastic operation to convert the trough into a trachea by supplying an anterior wall.

_Intubational treatment of chronic laryngeal stenosis_ may be tried in certain forms of stenosis in which the cicatrices do not seem very thick. The tube is a silver-plated brass one of large size (Fig. 110). A post which screws into the anterior surface of the tube prevents its expulsion. Over the post is slipped a block which serves to keep open the tracheal fistula. Detailed discussion of these operative treatments is outside the scope of this work, but mention is made for the sake of completeness. Before undertaking any of the foregoing procedures, a careful study of the complete descriptions in Peroral Endoscopy is necessary, and a practical course of training is advisable.

[FIG. 110.--The author's retaining intubation tube for treatment of chronic laryngeal stenosis. The tube (A) is introduced through the mouth, then the post (B) is screwed in through the tracheal wound. Then the block (C) is slid into the wound, the square hole in the block guarding the post against all possibility of unscrewing. If the threads of the post are properly fitted and tightly screwed up with a hemostat, however, there is no chance of unscrewing and gauze packing is used instead of the block to maintain a large fistula. The shape of the intubation tube has been arrived at after long clinical study and trials, and cannot be altered without risk of falling into errors that have been made and eliminated in the development of this shape.]

[309] CHAPTER XXXIX--DECANNULATION AFTER CURE OF LARYNGEAL STENOSIS

In order to train the patient to breathe again through the larynx it is necessary to occlude the cannula. This is best done by inserting a rubber cork in the inner cannula. At first it may be necessary to make a slot in the cork so as to permit some air to enter through the tube to supplement the insufficient supply obtainable through the insufficiently patulous glottis, new corks with smaller grooves being substituted as laryngeal breathing becomes easier. Corking the cannula is an excellent orthopedic treatment in certain cases where muscle atrophy and partial inflammatory fixation of the cricoarytenoid joints are etiological factors in the stenosis. The added pull of the posterior cricoarytenoid muscles during the slight effort at inspiration restores their tone and increases the mobility of all the attached structures. By no other method can panic and spasmodic stenosis be so efficiently cured.

[FIG. 111.--Illustration of corks used to occlude the cannula in training patients to breathe through the mouth again, before decannulation. The corks allow air leakage, the amount of which is regulated by the use of different shapes. A smaller and still smaller air leak is permitted until finally an ungrooved cork is tolerated. A central hole is sometimes used instead of a slot. A, one-third cork; B, half cork; C, three-quarter cork; D, whole cork.]

Following the subsidence of an acute laryngeal stenosis, it is my rule to decannulate after the patient has been able to breathe through the larynx with the cannula tightly corked for 3 days and nights. This rule does not apply to chronic laryngeal stenosis, for while the lumen under ordinary conditions might be ample, a slight degree of inflammation might render it dangerously small. In these cases, many weeks are sometimes required to determine when decannulation is safe. A test period of a few months is advisable in most cases of chronic laryngeal stenosis. Recurrent contractions after closure of the wound are best treated by endoscopic bouginage. The corks are best made of pure rubber cord, cut and ground to shape, and grooved, if desired, on a small emery wheel (Fig. 112). The ordinary rubber corks and those made of cork-bark should not be used because of their friability, and the possible aspiration of a fragment into the bronchus, where rubber particles form very irritant foreign bodies.

[FIG. 112.--This illustration shows the method of making safe corks for tracheotomic cannulae by grinding pure rubber cord to shape on an emery wheel. After grinding the taper, if a partial cork is desired, a groove is ground on the angle of the wheel. If a half-cork is desired half of the cork is ground away on the side of the wheel. Reliable corks made in this way are now obtainable from Messers Charles J. Pilling and Son.]

BIBLIOGRAPHY

The following list of publications of the author may be useful for reference: 1. Peroral Endoscopy and Laryngeal Surgery, Textbook, 1914. (Contains full bibliography to date of publication.) 2. Acromegaly of the Larynx. Journ. Amer. Med. Asso., Nov. 30, 1918, Vol. LXXI, pp. 1787-1789. 3. A Fence Staple in the Lung. A New Method of Bronchoscopic Removal. Journ. Amer. Med. Asso., Vol. LXIV, June 5, 1917, pp. 1906-7. 4. Amalgam Tooth-filling Aspirated into Lung During Extraction. Dental Cosmos, Vol. LIX, May, 1917, pp. 500-502. 5. Amalgam Filling Removed from Lung after a Seven Months' Sojourn: Case Report. Dental Cosmos, April, 1920. 6. A Mechanical Spoon for Esophagoscopic Use. The Laryngoscope, January, 1918, PP. 47-48. 7. An Anterior Commissure Laryngoscope. The Laryngoscope, Vol. XXV, Aug., 1915, P. 589. 8. Ancient Foreign Body Cases. Editorial. The Laryngoscope, Vol. XXVII, July, 1917, PP. 583-584. 9. An Esophagoscopic Forceps. The Laryngoscope, Jan., 1918, p. 49. 10. A New Diagnostic Sign of Foreign Body in Trachea or Bronchi, the "Asthmatoid Wheeze." Amer. Journ. Med. Sciences, Vol. CLVI, No. 5, Nov., 1918, p. 625. 11. A New Method of Working Out Difficult Mechanical Problems of Bronchoscopic Foreign-body Extraction. The Laryngoscope, Vol. XXVII, Oct., 1917, p. 725. 12. Arachidic Bronchitis. Journ. Amer. Med. Asso., Aug. 30, 1919, Vol. LXXIII, pp. 672-677. 13. Band of a Gold Crown in the Bronchus: Report of a Case. Dental Cosmos. Vol. LX, Oct., 1918, p. 905. 14. Bronchiectasis and Bronchiectatic Symptoms Due to Foreign Bodies. Penn. Med. Journ., Vol. XIX, Aug., 1916, pp. 807-814. 15. Bronchoscopic and Esophagoscopic Postulates. Annals of Otology, Rhinology and Laryngology, June, 1916, pp. 414-416. 16. Bronchoscopic Removal of a Collar Button after Twenty-six Years Sojourn in the Lung. Annals of Otology, Rhinology and Laryngology, June, 1913. 17. Bronchoscopy. Keen's Surgery, 1921, Vol. VIII. 18. Caisson Bronchoscopy in Lung-abscess Due to Foreign Body. Surg., Gyn. and Obstet., Oct., 1917, pp. 424-428. 19. Cancer of the Larynx. Is it Preceded by a Recognizable Precancerous Condition? Proceedings Amer. Laryngol. Soc., 1922. 20. Din. Editorial. The Laryngoscope, Vol. XXVI, Dec., 1916, pp. 1385-1387. 23. Endoscopie Perorale et Chirurgie Laryngienne. Arch. de Laryngol., T. XXXVII, No. 3, 1914, pp. 649-680. 24. Endoscopy and the War. Editorial. The Laryngoscope, Vol. XXVI, June, 1916, p. 992. 25. Endothelioma of the Right Bronchus Removed by Peroral Bronchoscopy. Amer. Journ. of Med. Sci., No. 3, Vol. CLII, March, 1917, p. 371. 26. Esophageal Stenosis Following the Swallowing of Caustic Alkalies, Journ. Amer. Med. Asso., July 2, 1921, Vol. LXXVII, pp. 22-23. 27. Esophagoscopic Radium Screens. The Laryngoscope, Feb., 1914. 28. Foreign Bodies in the Insane. Editorial. The Laryngoscope, Vol. XXVII, June, 1917, pp. 513-515. 29. 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