CHAPTER XXVIII

THE OESOPHAGUS

Surgical Anatomy--Methods of examination--Wounds--Rupture--Swallowing of caustics--Impaction of foreign bodies--Infective conditions: _Oesophagitis_; _Peri-oesophagitis_; _Tuberculosis_; _Syphilis_--Varix--Conditions causing difficulty in swallowing: _Impaction of foreign bodies_; _Compression of the gullet from without_; _Spasm of the muscular coat_; _Cardiospasm_; _Paralysis of the gullet_; _Diverticula_ or _pouches of the gullet_; _Innocent stricture_; _Malignant stricture, including cancer at the junction of pharynx and gullet and cancer at the lower end of the gullet_.

#Surgical Anatomy.#--The oesophagus extends from the level of the cricoid cartilage to about the level of the lower end of the sternum. The distance from the upper incisor teeth to the commencement of the oesophagus is about 5 or 6 inches, and the oesophagus measures from 9 to 10 inches. The whole distance, therefore, from the teeth to the stomach is from 14 to 16 inches.

The cervical portion of the oesophagus, extending from the cricoid cartilage to the upper edge of the sternum, measures about 2 inches. It lies behind and to the left of the trachea, and in the groove between them on each side runs the recurrent nerve. The thoracic portion is about 7 inches long, and traverses the posterior mediastinum lying slightly to the left of the middle line. It is crossed by the left bronchus, and below this level has the pericardium immediately in front of it. The left pleura is closely related to the anterior surface of the oesophagus throughout, while the right pleura passes behind it in its lower part. This accounts for the frequency with which growths in the oesophagus invade the pleura. The oesophagus passes through the diaphragm about an inch above the cardiac opening of the stomach.

There are three points at which the oesophagus shows narrowing of the lumen: (1) at the lower border of the cricoid--the "mouth of the oesophagus"; (2) where it is crossed by the left bronchus; and (3) where it passes through the diaphragm. It is at these points that foreign bodies tend to become impacted. The mucous membrane of the oesophagus is insensitive to tactile and painful stimuli, but is sensitive to heat and cold and to exaggerated peristaltic contractions.

#Methods of Examination.#--It is sometimes possible to detect an impacted foreign body, a distended diverticulum, or a new growth in the cervical portion of the oesophagus by _palpation_.

_Auscultation_ while the patient is drinking sometimes aids in the diagnosis of stricture; the stethoscope is placed at various points along the left side of the dorsal spine, and abnormal sounds may be heard as the fluid impinges against the stricture or trickles through it.

_Introduction of Bougies._--Oesophageal bougies or probangs are used for diagnostic purposes in cases of suspected stricture, and to aid in the detection of foreign bodies. Various forms are employed, of which the most generally useful are the round-pointed gum-elastic or silk-web bougie, and the olive-headed metal bougie, consisting of a flexible whalebone stem, to which one of a graduated series of aluminium or steel bulbs is screwed. For some purposes, such as pushing onward an impacted bolus of food, the sponge probang--which consists of a small round sponge fixed on a whalebone stem--is to be preferred.

Before passing bougies, it is necessary to make certain that the symptoms are not due to the pressure of an aneurysm on the oesophagus, as cases have been recorded in which a thin-walled aneurysm has been perforated by a bougie. The existence of ulceration or of an abscess pressing on the gullet also contra-indicates the use of bougies.

For the passage of a bougie the patient should be seated on a chair with the head thrown back and supported from behind by an assistant, and he is directed to take full deep breaths rapidly. The bougie, lubricated with butter or glycerine, and held like a pen, is guided with the left forefinger. As soon as the instrument engages in the opening of the oesophagus, the chin is brought down towards the chest, and if the patient is now directed to swallow, the instrument may be carried down the oesophagus, or can be passed on by gentle pressure. Great gentleness must be exercised, and no attempt should be made to force the instrument past any obstruction. The instrument may catch against the hyoid bone, and this may be mistaken for an obstruction.

It is to be borne in mind that in some cases the passage of a bougie may be attended with a considerable degree of shock, and cases are on record in which this has proved fatal without any gross lesion being found after death.

_Intubation_, or the passage of a cannula through a stricture, is referred to later.

_Oesophagoscopy._--The _oesophagoscope_--a form of speculum which enables the oesophagus to be illuminated by an electric lamp--is employed for the detection and removal of foreign bodies, for the examination of ulcers, diverticula, and strictures of the tube, and with its aid it is possible to remove a portion of a growth for microscopic examination. The mouth, pharynx, and entrance to the oesophagus having been cleansed and cocainised, the patient is placed in the recumbent or sitting posture, and the tube introduced. For prolonged examinations a general anaesthetic is preferred.

The mouth of the oesophagus is closed by the sphincter-like action of the lower fibres of the inferior constrictor muscle, and the cervical part of the tube appears as a transverse slit, due to the backward pressure of the trachea. The thoracic portion is more open and may contain air, so that it is possible to see down to the lower end, the closed cardiac orifice appearing as an oblique cleft surrounded by a rosette-like cushion of mucous membrane. The pulsation of the aorta can be seen just above the prominence formed by the left bronchus.

_Radiography._--Opaque foreign bodies can be detected by the screen or in a radiogram; and the position of a stricture by making the patient swallow capsules containing bismuth and examining with the screen. To determine the position and size of a diverticulum, a radiogram is taken after the patient has swallowed some food, such as porridge mixed with bismuth.

#Wounds# of the oesophagus inflicted from without, for example stabs, cut-throat or gun-shot injuries, are rare, and are almost invariably accompanied by lesions of other important structures in the neck, which may rapidly prove fatal. It is more common to meet with wounds inflicted from within, for example by the swallowing of rough and irregularly shaped foreign bodies, or by unskilful attempts to remove such bodies or to pass bougies along the oesophagus. The severity of the lesion varies from a scratch of the mucous membrane to a perforation of the tube. The less severe injuries are attended with pain on swallowing and a sensation as if something had lodged in the oesophagus. In more severe cases there is bleeding, followed by attacks of coughing and expectoration of blood-stained mucus. When the oesophagus is perforated, diffuse cellulitis of the neck or of the posterior mediastinum may ensue. In the treatment of these injuries the chief point is to give the oesophagus rest by feeding the patient entirely by the rectum or through an opening made in the stomach--gastrostomy.

#Rupture# of the oesophagus has occurred during violent vomiting, and during lavage. The tear is longitudinal and is usually near the cardiac orifice. It is probably due to increased pressure within the gullet. The accident has usually been met with in alcoholics, and has proved fatal by setting up left-sided empyema or cellulitis.

#Swallowing of Corrosive Substances.#--The oesophagus is damaged by the swallowing of strong chemicals, such as sulphuric acid, nitric acid, carbolic acid, or caustic potash. These substances produce their worst effects at the two ends of the oesophagus, but in some cases the whole length of the tube suffers. The mucous membrane alone may be destroyed, or the muscular and even the fibrous coats may also be implicated. The damaged tissue undergoes necrosis, and when the sloughs separate, raw surfaces are left, and are very slow to heal.

If not rapidly fatal from shock and oedema of the glottis, these injuries are usually attended with intense pain, severe thirst, and vomiting, the vomit containing shreds of mucous membrane and blood. Complications, such as cellulitis, perforation of the oesophagus, or peri-oesophageal abscess, may follow. Later, cicatricial contraction takes place at the injured portions, producing the most intractable form of fibrous stricture.

The _treatment_ consists in administering solutions of carbonate of potash, of soda, or of magnesia when an acid has been swallowed, or vinegar diluted with water in the case of an alkali. When carbolic acid has been swallowed, a large quantity of olive oil should be administered. The stomach should be washed out with water, the tube being passed with the greatest gentleness to avoid perforating the softened oesophageal wall. Subsequently the patient should be fed by the rectum, but, in the majority of cases, gastrostomy is called for to enable the patient to take nourishment and put the gullet at rest.

As soon as the oesophagus has healed, say in three or four weeks, bougies should be passed every three or four days to prevent cicatricial contraction. As the calibre of the tube is restored, the instruments may be passed less frequently, but for some years--it may be for the rest of the patient's life--a full-sized bougie should be passed at least once a month.

#Impaction of Foreign Bodies in the Pharynx and Oesophagus.#--It is an interesting fact that foreign bodies, even as large as a dinner fork, when intentionally swallowed, can pass through the pharynx and oesophagus and enter the stomach without apparent difficulty. When the body is accidentally swallowed impaction is more liable to take place, probably on account of the spasm induced by fright and by inco-ordinated attempts to eject it. For obvious reasons the accident is most liable to occur in children, in epileptics, and in those who are under the influence of alcohol. It happens also during anaesthesia for the extraction of teeth or if the patient vomits solid substances. The clinical aspects vary according as the object is impacted in the pharynx or in the oesophagus.

_In the Pharynx._--If a large bolus of unmasticated food becomes impacted in the pharynx, it blocks the openings of both the oesophagus and the larynx, and the patient may, without manifesting the usual signs of suffocation, suddenly fall back dead, and if he happens to be alone at the time of the accident, the cause of death is liable to be overlooked unless the pharynx is examined at the post-mortem examination. Most surgical museums contain specimens illustrating the impaction of a bolus of meat in the pharynx; this fatal accident has occurred especially in men in a condition of alcoholic intoxication.

An object of irregular shape, for example a large denture, also, is most likely to lodge in the pharynx, obstructing the openings of both the oesophagus and the larynx, and causing suffocation. The face immediately becomes blue and engorged, the patient is speechless, and violent efforts are made to eject the object by retching and coughing. It may be seen from the mouth and touched with the finger.

In the case of small sharp bodies, such as fish, game, and mutton bones, there is not the same urgency, and a methodical search for the foreign body is carried out. Even after the foreign body has been got rid of, the patient may have the sensation that it is still present. This may be due to a scratch of the mucous membrane, or to spasm, in which case the swallowing of a few drops of cocain solution will cause the sensation to disappear.

_Treatment._--In the presence of impending suffocation, the mouth must be forced open by an extemporised gag, the finger passed into the back of the throat, and the body hooked out. If this is impossible, and if suitable forceps are not at hand, it may be necessary at once to perform laryngotomy, followed by artificial respiration, because, although the patient may appear lifeless, the heart continues to beat after breathing has ceased. The foreign body should then be removed with forceps. Sub-hyoid pharyngotomy, which consists in opening the pharynx by a mesial vertical incision carried through the hyo-thyreoid membrane, may be called for, as in the case of a denture, the hooks of which have penetrated the wall of the pharynx.

_In the Oesophagus._--Smaller bodies, such as coins, bones, or pins, usually enter the oesophagus, and the great majority become impacted above the level of the manubrium sterni. Those that pass farther down are liable to stick where the tube is narrowed at the crossing of the bronchus, or at the opening through the diaphragm. In children, coins predominate and are nearly always arrested at the level of the upper end of the sternum; in adults, dentures are the commonest foreign bodies, and may be impacted anywhere.

At the moment of impaction there is pain, which assumes the character of cramp due to spasm of the muscular coat, and which is increased on attempting to swallow, and violent retching and coughing are set up; in many cases, as when bodies are impacted in the pharynx, respiratory distress is again the predominant feature. If the passage is completely obstructed, food and saliva--sometimes blood-stained--are regurgitated with retching soon after being swallowed. When the obstruction is incomplete, fluids may pass into the stomach while solids are regurgitated.

If the mucous membrane is injured, there is severe stabbing pain and choking attacks, both due to spasm, sometimes even after the body has passed on, and the pain is not always referred to the seat of the injury.

The _diagnosis_ is made by the history, and by the use of the fluorescent screen, or X-ray photographs (Figs. 283, 284). The oesophagoscope is also of great value, both for diagnostic purposes and as an aid in the removal of the impacted body. Bougies are to be employed with great care, as there is a danger of pushing the foreign body farther down, or of wedging it more firmly in the oesophagus, and the information obtained is often misleading.

It should be borne in mind that drunkards may suffer from a form of spasm of the oesophagus, which simulates the impaction of a foreign body; hospital records also show that the patient may only have dreamt that he has swallowed a foreign body, usually a denture. These possibilities should be always excluded before further procedures are undertaken.

_Treatment._--There being no urgency, a careful examination is carried out, not only to confirm the impaction of a foreign body, but its site and its relation to the wall of the gullet. In skilled hands, the safest and most certain means of removing impacted foreign bodies is with the aid of the oesophagoscope. If this apparatus is not available, other measures must be adopted varying with the nature of the body, its site, and the manner of its impaction.

A bolus of food, for example, or a small smooth object that is likely to pass safely along the alimentary canal, if it cannot be extracted with forceps, may be pushed on into the stomach by the aid of a bulbous-headed or sponge probang. This must be done gently, especially if the body has been impacted for any time, as the inflammatory softening of the oesophageal wall may predispose to rupture.

Small, sharp, or irregular objects, such as fish bones, tacks, or pins, may be dislodged by the "umbrella probang"--an instrument which, after being passed beyond the foreign body, is expanded into the form of a circular brush which, on withdrawal, carries the foreign body out among its bristles.

Coins usually lodge edgewise in the oesophagus, and are best removed by means of an instrument known as a "coin-catcher", which is passed beyond the coin, and on being withdrawn catches it in a hinged flange. In emergencies a loop of stout silver wire bent so as to form a hook makes an excellent substitute for a coin-catcher.

In difficult cases the removal of solid objects is facilitated by carrying out the manipulations in the dark room with the aid of the X-rays and the fluorescent screen.

Irregular bodies with projecting edges or hooks, such as tooth-plates, tend to catch in the mucous membrane, and attempts to withdraw them by forceps or other instruments are liable to cause laceration of the wall. When situated in the cervical part of the oesophagus, these should be removed by the operation of _oesophagostomy_ (_Operative Surgery_, p. 195).

If the foreign body is lodged near the lower end of the gullet, it may be necessary to perform _gastrostomy_ (_Operative Surgery_, p. 291), making an opening in the anterior wall of the stomach large enough to admit suitable forceps, or, if necessary, the whole hand, in order that the body may be extracted by this route; experience shows that an impacted body is more easily extracted from below, that is, from the stomach, than from above.

When the surgeon fails to remove the body by either of these routes, _gastrostomy_ must be performed both to feed the patient and to place the gullet at rest. Smooth bodies may lie latent for long periods, but those with points or hooks damage the mucous membrane, cause ulceration and perforation with the risk of erosion of vessels and secondary haemorrhage or of cellulitis of the neck or mediastinum and empyema.

Other complications include septic broncho-pneumonia from damage to the air-passage, and suppurative thyreoiditis.

#Infective conditions# due to pyogenic infection (_oesophagitis_ and _peri-oesophagitis_) are rare.

A _chronic form of oesophagitis_ is occasionally met with in alcoholic subjects, giving rise to symptoms that simulate those of impacted foreign body, or of stricture.

In _tuberculous_ lesions the symptoms are pain, dysphagia, and regurgitation of food mixed with blood, and the condition is liable to be mistaken for gastric ulcer or for cancer of the oesophagus.

_Syphilitic affections_ of the oesophagus are rare.

#Varix# at the lower end of the oesophagus may give rise to haematemesis, and be mistaken for gastric ulcer. Bleeding from the dilated veins may follow the use of bougies or of the oesophagoscope.

CONDITIONS CAUSING DIFFICULTY IN SWALLOWING

Difficulty in swallowing may arise from a wide variety of causes which it is convenient to consider together.

#Impaction of Foreign Bodies# has already been discussed, and attention has been drawn to the importance of the history given by the patient and to the various sources of fallacy or deception--in children it may be artful reticence or misrepresentation, in adults, the possibility of nightmare and of dreams.

#Compression of the Gullet from without.#--Any one of the numerous structures in relation to the gullet may, when enlarged as a result of disease, give rise to narrowing of its lumen, for example a lymph-sarcoma at the root of the lung, or any enlargement of the thyreoid or of the mediastinal lymph glands. The possibility of aneurysm must always be kept in mind because of the risk attending the passage of instruments for diagnostic purposes.

#Spasm of the Muscular Coat.#--As in other tubular structures containing circular muscular fibres, sudden contraction or spasm may occur in the oesophagus and cause narrowing of the lumen, attended with difficulty in swallowing. This spasmodic dysphagia includes such widely varying conditions as the "globus hystericus" of neurasthenic women, the spasm of chronic alcoholics, and the affection known as _cardiospasm_ or "hiatal oesophagismus."

In contrast with other affections causing difficulty in swallowing, spasmodic dysphagia usually has a sudden and unexplained onset, the progress of symptoms is irregular and erratic, while the remission of symptoms common to all affections of the oesophagus, and the influence of mental impressions, such as excitement, hurry in the presence of strangers, are exaggerated.

In testing the calibre of the gullet it is found that on one occasion a full-sized bougie may pass easily and be completely arrested at another.

Apart from the treatment of the neurosis underlying the dysphagia, reliance is placed upon dilatation of the portion of gullet affected.

#Cardiospasm# is the name given to "a recurrent interference with deglutition by spasmodic contraction of the lower end of the oesophagus." As there is no muscular or nervous mechanism at the cardiac end of the oesophagus forming a true sphincter, the term "oesophagospasm" would be more accurate (D. M. Greig).

According to H. S. Plummer, who has had an experience of 130 cases, there are three stages in the development of this condition. In the initial stage, the first attack occurs suddenly and unexpectedly; a choking sensation is felt at some point in the gullet, usually at its lower end. Attacks of choking with difficulty in swallowing occur chiefly at meals, but they have also been known to occur apart from the taking of food. In this stage the peristalsis of the gullet is sufficient to force the food through the cardia.

In the second stage, the peristalsis of the gullet above being no longer able to overcome the contraction, there is regurgitation of food, which at first is returned to the mouth immediately after being swallowed, but, as the gullet becomes dilated, is retained for longer periods.

In the third stage, the gullet becomes more and more dilated, and the food collects in it and is regurgitated at irregular intervals. The patient complains of a sensation of weight and discomfort in the lower part of the chest, and sometimes of regurgitation of food into the nasal passages during sleep.

Cardiospasm should be suspected as the cause of difficulty in swallowing if a rubber tube cannot be passed into the stomach while a solid one can. When it is impossible to pass a solid instrument in the ordinary way it can always be passed on a silk thread as a guide. The patient is directed to swallow 6 yards of silk thread, half in the afternoon and the remainder on the following morning. The first portion forms a snarl in the gullet or stomach which passes out into the intestine during the night; the proximal end is fixed to the cheek by a strip of plaster. The olive heads of the bougies are drilled for threading from the tip to one side of the base.

The _treatment_ consists in dilating the contracted segments by a bougie. The results are immediate and are most striking, the patients being almost invariably able to take any kind of food at the following meal, and the gain in weight and strength is rapid. In a small proportion of cases, dilatation fails to give relief, and recourse has been had to anastomosing the lower end of the dilated and pouched oesophagus with the stomach.

#Paralysis of the Gullet.#--As the passage of the food along the gullet is entirely dependent upon muscular peristalsis, when the muscular coat is paralysed, as it may be after diphtheria, for example, the patient is unable to swallow and the food materials are regurgitated, with consequent loss of flesh and strength. The difficulty may be tided over for a time by feeding through a rubber tube, but it is to be remembered that, in children, struggling in resisting the passage of the tube may seriously strain a heart that is already threatened by the toxins of diphtheria.

#Diverticula or Pouches of the Gullet.#--A diverticulum consists in the protrusion of the mucous and submucous coats through a defect or weak part in the muscular tunic; it is therefore of the nature of a hernia and not a localised dilatation of the tube as a whole. Anatomically, there is such a weak spot in the posterior wall opposite the cricoid cartilage, known as the _pharyngeal dimple_, between the circular and oblique fibres of the crico-pharyngeus muscle. As the pouch increases in size by pressure from within, it usually extends downwards and to the left. This pouch is described as a _pressure or pulsion diverticulum_ because the hernial protrusion is ascribed to increased pressure within the pharynx, not only the normal increase caused by the act of swallowing, but an abnormal pressure from the too rapid swallowing or bolting of imperfectly masticated food materials.

The _clinical features_ are not so characteristic of difficulty in swallowing as might be expected. The patient, usually a man over forty years of age, complains of dryness in the throat and of a sensation as of a foreign body; later there is regurgitation of saliva and of food with occasional choking. In about one-third of the cases, there is a fullness, or a palpable tumour in the neck, about three times more often on the left than on the right side, which may increase in size after a meal, and pressure on which may cause a gurgling sound and, it may be, regurgitation of food.

It is suggestive of a pouch, if the patient regurgitates food materials which can be identified as having been swallowed several days before, currants perhaps being those most easily recognised and remembered.

Diverticula are also met with at a lower level, springing from the gullet at or below the upper opening of the thorax; the distension of the pouch with food materials presses upon the gullet with more serious effect, even to the extent of complete obstruction and consequent rapid emaciation. In men over fifty, the resemblance to carcinoma may be very close.

In this, as in all cases of difficulty in swallowing, chief stress should be laid on the X-ray appearances after the administration of an opaque meal; a pouch shows as a uniform, spherical shadow of from one to two inches in circumference.

_Treatment_ is influenced by the manner in which the patient may have learned to overcome the difficulty of getting food into his stomach--Lord Jeffrey, who was the possessor of the pharyngeal pouch shown in Fig. 286, was in the habit of emptying it, after a meal, by means of a long silver spoon. Some patients learn to feed themselves through a soft rubber tube.

If an _operation_ is decided upon, and for this it is essential that the pouch should be accessible from the neck, the general condition is improved by feeding through a stomach tube and by rectal and subcutaneous salines. The operation consists in exposing and isolating the pouch by a dissection on the left side of the neck, and either excising it as if it were a tumour or cyst, or if the risk of infection of the deeper planes of cellular tissue is regarded with apprehension, the pouch may be _infolded_ into the lumen of the gullet, or the excision be carried out in two _stages_. At the first stage, the pouch is isolated and rotated on its pedicle, in which condition it is fixed by sutures; after an interval of from ten to fourteen days it is excised.

Should the diverticulum be inaccessible from the neck, and the difficulty of swallowing be attended with progressive emaciation, _gastrostomy_ may be required to avert death by starvation.

_Traction diverticula_ are due to the contraction of scar tissue outside the gullet, as for example that resulting from tuberculous glands in the posterior mediastinum; they are rarely attended with symptoms, and are rather of pathological than surgical interest.

#Innocent Stricture or Cicatricial Stenosis of the Gullet.#--The innocent or fibrous stricture follows upon the swallowing of corrosive substances, usually by inadvertence, sometimes with suicidal intent. Having recovered from the initial effects of the corrosive agent, the patient suffers from gradually increasing difficulty in swallowing, first with solids and later with fluids. There is the usual variation or intermittence of symptoms that attend upon all conditions causing difficulty of swallowing, the exacerbations being due to superadded spasm of the muscular coat and congestion of all the coats. As the gullet dilates above the stricture, there is an increasing accumulation of what has been swallowed, and this the patient regurgitates at intervals; this is usually described as "vomiting," but the material ejected shows no signs of gastric digestion. There is pain referred to the epigastrium or between the shoulder-blades, the patient suffers from hunger and thirst, and may present an extreme degree of emaciation.

The _diagnosis_ is suggested by the history, and is confirmed by the oesophagoscope or by the X-rays after an opaque meal. The use of bougies has taken a secondary place since the introduction of these methods of examination, but, when other means are not available, the passage of bougies having a whalebone shaft and a series of metal heads shaped like an olive, may give useful information regarding the site, number, and size of the strictures that require to be dealt with.

_Treatment._--If the patient is in a critical state from starvation, gastrostomy must be performed to enable him to be fed; otherwise he is prepared for treatment of the stricture by rest in bed, sedatives, and suitable liquid or some solid foods to improve his general condition and eliminate the muscular spasm and congestion already referred to. If the passage of bougies with the object of dilating the stricture is difficult or impossible, it may be made easier or possible by getting a silk thread through the stricture. The patient swallows several yards of a reliable silk thread a day or two before the proposed dilatation is carried out; the thread is expected to pass through the stricture of the stomach, and to enter for some distance into the small intestine; the metal head of the bougie, which is canalised in its long axis, is "threaded" on the silk, and the latter acting as a guide, the bougie is passed safely and confidently through the stricture. Larger olive-shaped heads are passed at intervals until the normal calibre of the gullet is exceeded, after which it is usually easy to pass an ordinary full-sized instrument at intervals of a month or so.

In the event of failure, recourse must be had to gastrostomy, and through the stomach it may be possible to dilate the stricture by the "retrograde" route. In aggravated cases, the gastrostomy opening must be retained in order to prevent death from starvation.

#Malignant Stricture--Carcinoma of the Gullet.#--This is met with in two forms which present widely different pathological and clinical features.

Cancer of the _cervical_ portion affects the gullet at its junction with the pharynx, and for some unexplained reason is much more common in women, and at the comparatively early age of between thirty and fifty. Cancer of the _thoracic_ portion affects the extreme lower end of the gullet, and is met with almost exclusively in men over fifty.

#Cancer of the Cervical Portion.#--Difficulty of swallowing may arise suddenly; more often it is slow and progressive over a period of months and, in some cases, even of years. Pain on swallowing is not a constant or prominent feature; it may be referred to the site of the lesion or to one or both ears. In a considerable number of cases, the complaints of the patient are referred to the larynx; coughing, with abundant mucous expectoration disturbing the night's rest, hoarseness, or even loss of voice, which symptoms are due either to direct invasion of the larynx or to implication of one or other recurrent nerve; for the same cause, difficulty of breathing may supervene, sometimes of such a nature as to render tracheotomy imperative. A gurgling noise on swallowing, and regurgitation of food are occasionally observed.

Palpation of the neck, and particularly of the larynx and trachea, should be carried out in all cases presenting the symptoms described; and as bearing on the question of operation, enlargement of the cervical lymph glands and of the thyreoid should be looked for; cancer of the thyreoid is sometimes secondary to disease at the pharyngo-oesophageal junction.

Direct and indirect laryngoscopic examination is then made; if the laryngeal mirror fails to reveal anything abnormal, suspension laryngoscopy, which gives a more extensive view of that part of the pharynx lying behind the larynx, may be employed, or the oesophagoscope may be preferred. A portion of the growth may be removed for microscopical examination.

The use of the oesophageal bougie as a diagnostic agent must be deprecated; it gives no satisfactory explanation of the cause of the obstruction, and its employment when malignant ulceration is present, is not free from serious risk to the patient (Logan Turner).

_Treatment._--The surgeon is dependent on the help of the laryngologist not only for the diagnosis of the disease at the earliest stage possible, but also for information as to its extent, especially with regard to involvement of the larynx.

_Oesophagectomy_, or resection of the cancerous segment of the gullet, in suitable cases, even if it does not yield a permanent cure, not only prolongs life but relieves the patient of her most distressing symptoms. It is rarely possible to secure an end-to-end anastomosis, but the feeding by means of a tube introduced into the open end of the gullet is more satisfactory and the laryngeal symptoms are more efficiently relieved, than by either of the purely palliative operations. In the majority of cases, however, only the palliative measures of _oesophagostomy_ or _gastrostomy_ can be adopted. Oesophagostomy presents the advantage, that by exposing the cervical portion of the gullet, the operator is enabled to investigate the extent of the disease and to revise his opinion on the feasability of its removal if necessary. In advanced cases, when the disease has spread widely in the neck and involved, it may be, the thyreoid and the larynx, it may only be possible to relieve the urgent distress of the patient by gastrostomy. _Tracheotomy_ may also become necessary because of the spread of the cancer to the interior of the larynx.

#Cancer of the Lower End of the Gullet.#--The remarkable preference of this location of oesophageal cancer for the male sex has already been referred to; it affects the same type of male patients as are subject to squamous epithelioma in other parts of the body. So far as we have observed, its association with chronic irritation of the mucous membrane in which it takes origin, or with any pre-cancerous condition, has not been demonstrated.

The _clinical features_ resemble those of cicatricial stricture; the difficulty of swallowing is usually of gradual onset, it concerns solids in the first instance, then semi-solids like porridge or bread and milk, and finally fluids. As in other forms of oesophageal obstruction, the difficulty of swallowing varies quite remarkably from time to time, presumably from variations in the degree of congestion of the mucous membrane and of spasm of the muscular coat, but also from mere nervousness, the patient having greater difficulty when in a hurry, as in a railway refreshment room, or embarrassed by the presence of strangers.

As the lumen of the gullet becomes narrower, the food materials accumulate above the obstruction, and the consequent dilatation of the gullet above the stricture accounts for the large amount that may be regurgitated and for the patient describing it as vomiting. Along with food materials there is abundant saliva, and, if the cancer has ulcerated, of pus and blood. Contrary to what might be expected, there is little or no complaint of hunger, in spite of the progressive starvation and emaciation which inevitably supervene.

Death takes place within a year or so of the onset of symptoms, usually from starvation, but the fatal issue may be precipitated by ulceration and perforation of the gullet into a large blood vessel or into the left pleural sac; in the latter event, there follows a basal _empyema_ which may contain gas and food materials.

_Diagnosis._--In the majority of cases the history is so characteristic that there is little doubt regarding the diagnosis; the most reliable corroboration, with least risk and distress to the patient, is obtained by radiographic examination after an opaque meal; the appearance of the dilated gullet is that of an elongated sausage, parallel with the vertebral column, and terminating abruptly at the site of stricture (Fig. 285). A filiform, tortuous shadow of the bismuth may be continued downwards and show up the lumen of the stricture. The use of the oesophagoscope and of bougies is to be deprecated as not free from risk.

_Treatment._--The lower end of the gullet is one of the most inaccessible portions of the body, and although it has been removed by operation the prospects of success are so small that it is not at present regarded as justifiable.

Among _palliative measures_, may be mentioned _intubation_ of the stricture with a view to increasing the amount of food that can be swallowed; a funnel-shaped tube like that of Symonds or of Hill is introduced into the lumen of the stricture by means of a bougie or with the help of the oesophagoscope. The tube is anchored to a denture, or by means of a silk thread to the cheek by sticking-plaster. Our experience of intubation is that it merely serves to tide the patient over a critical period of starvation, so that he may regain some strength for any other procedure that may be indicated.

The value of making a fistula in the stomach--_gastrostomy_--in order to feed the patient, is a question about which widely different opinions are held both by patients and by surgeons. Many patients allege that they would prefer to die rather than prolong a precarious existence by being fed through a tube; some surgeons look upon the operation with disfavour because they doubt whether it even prolongs life, and it is often followed by a pneumonia which rapidly proves fatal. Variation in the results of gastrostomy observed by different surgeons is partly due to differences in the stage of the disease at which the operation is performed, and probably to a greater extent to the confusion between cases of slowly growing squamous epithelioma of the lower end of the gullet and cases of glandular carcinoma of the cardiac end of the stomach, these being grouped together under the clinical heading of "malignant stricture of the lower end of the gullet." In our experience cases of epithelioma of the gullet (in the strict sense of the term) benefit greatly if subjected to gastrostomy as soon as the condition is recognised. In a case operated upon by Thomas Annandale the patient survived the operation for three years and some months.

_Radiation._--The introduction of a tube of radium into the stricture and its retention there, the silk thread attached to the tube being secured to the cheek by a strip of plaster, is described by Hill and Finzi as the most valuable palliative measure that has so far been employed in cancer of the gullet; the capacity of swallowing may be regained to a considerable extent. The employment of radium is rendered easier and more efficient if it is preceded by gastrostomy.

_The Roux-operation._--This consists in making a new gullet to replace that which is obstructed; the abdomen is opened and a loop of jejunum is isolated; its lower end is anastomosed--end to side--to the stomach; the intestine is brought upwards through a tunnel made for it between the skin and the sternum, and the upper end is brought out and fixed to the skin, in the supra-sternal notch. It has scarcely passed beyond the experimental stage.