Chapter XXIV: Benign Neoplasms of the Esophagus (1)

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.