Manual of Surgery Volume II Part 66

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 circ.u.mference.

_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.

[Ill.u.s.tration: FIG. 286.--Diverticulum of the sophagus at its junction with the Pharynx.

(Anatomical Museum, University of Edinburgh.)]

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 acc.u.mulation 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 sophagoscope 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 pa.s.sage 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 pa.s.sage 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 pa.s.s through the stricture of the stomach, and to enter for some distance into the small intestine; the metal head of the bougie, which is ca.n.a.lised in its long axis, is "threaded" on the silk, and the latter acting as a guide, the bougie is pa.s.sed safely and confidently through the stricture. Larger olive-shaped heads are pa.s.sed at intervals until the normal calibre of the gullet is exceeded, after which it is usually easy to pa.s.s 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, hoa.r.s.eness, 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-sophageal 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 sophagoscope may be preferred. A portion of the growth may be removed for microscopical examination.

The use of the sophageal 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.

_sophagectomy_, 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 _sophagostomy_ or _gastrostomy_ can be adopted.

sophagostomy 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 sophageal cancer for the male s.e.x 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 a.s.sociation 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 sophageal 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 embarra.s.sed by the presence of strangers.

As the lumen of the gullet becomes narrower, the food materials acc.u.mulate 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 bis.m.u.th may be continued downwards and show up the lumen of the stricture. The use of the sophagoscope 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 sophagoscope. The tube is anch.o.r.ed 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 pa.s.sed beyond the experimental stage.

CHAPTER XXIX

THE LARYNX, TRACHEA, AND BRONCHI[7]

Examination of the larynx--CARDINAL SYMPTOMS OF LARYNGEAL AFFECTIONS: (1) Interference with the voice: _Hoa.r.s.eness_; _Aphonia_--(2) Dysphagia--(3) Interference with respiration: _Diphtheritic laryngitis_; _Acute dema of the larynx_; _Intubation of the larynx_; _Tracheotomy_; _Bilateral abductor paralysis_; _Syphilitic affections_; _Tuberculosis_--Tumours: _Papilloma_; _Epithelioma_; _Sarcoma_--Foreign bodies in the air-pa.s.sages: _In the pharynx_, _larynx_, _trachea_, _bronchi_.

[7] Revised by Dr. Logan Turner.

#Examination of the Larynx.#--For this purpose the examiner requires a laryngeal reflector with forehead attachment, one or two sizes of laryngeal mirror, a tongue cloth, and the means of obtaining good illumination. The source of light should be by preference placed opposite to and on the same horizontal plane as the patient's left ear. The forehead reflector is placed over the observer's right eye so that he may look through the central aperture, while at the same time he throws a good circle of light into the patient's mouth. The patient should be seated with the head thrown slightly back; the tongue is protruded and covered with the cloth, and held lightly but firmly between the finger and thumb of the left hand. A full-sized mirror, warmed so as to prevent the condensation of the breath upon it, is inserted with the reflecting surface turned downwards, and pressed gently against the soft palate so as to push that structure upwards.

The handle of the instrument is carried towards the left angle of the mouth, and by slightly altering the plane of the reflecting surface of the mirror the different parts of the larynx are in turn brought into view. The movements of the vocal cords should be observed during both respiration and phonation, and for the latter purpose the patient should be directed to phonate the vowel sound "eh."

In the upper part of the mirror the epiglottis usually comes first into view: it is of a pinkish yellow colour, and presents a thin, sharply defined free margin. In front of the epiglottis are the median and lateral glosso-epiglottic folds pa.s.sing forwards to the base of the tongue, and enclosing the two valleculae. Extending backwards and downwards from the lateral margins of the epiglottis are the two ary-epiglottic folds which reach the arytenoid cartilages posteriorly.

Between the two layers of mucous membrane of which the ary-epiglottic folds are composed are the cartilages of Wrisberg and Santorini. In the interval between the two arytenoid cartilages is the inter-arytenoid fold of mucous membrane, which forms the upper margin of the posterior wall of the larynx. The upper aperture of the larynx is bounded by the epiglottis in front, the ary-epiglottic folds laterally, and the inter-arytenoid fold behind. In the interior of the larynx the vocal folds (true vocal cords) form the most prominent features, being conspicuous as two flat white bands, which form the boundary of the rima glottidis or glottic c.h.i.n.k. Above each true cord, and parallel with it, the ventricular fold or false cord is evident as a pink fold of mucous membrane. Between the ventricular fold and the vocal fold on each side is a linear interval, which indicates the entrance to the ventricle of the larynx.

_Direct Laryngoscopy._--The larynx may also be examined by the direct method by means of Jackson's or Killian's spatulae. After cocainisation of the base of the tongue, the soft palate, and the posterior surface of the epiglottis, the patient is seated upon a low stool and his head supported by an a.s.sistant. The light is obtained from a small lamp in the handle of the instrument or reflected from a forehead mirror. The spatula is warmed and introduced under the guidance of the eye, its end being pa.s.sed over the epiglottis, and pressure exerted so as to draw the latter structure forward. In children a general anaesthetic is required, and the examination is made with the head hanging over the end of the table. Killian's "suspension laryngoscopy" affords the best method of examining the larynx in young children.

_Tracheoscopy and Bronchoscopy._--Direct examination of the trachea and larger bronchi may be carried out in a similar way, by pa.s.sing through the mouth and larynx metal tubes, after the method devised by Killian. This procedure is described as direct upper tracheoscopy and bronchoscopy. The examination may also be made through a tracheotomy wound--direct lower tracheoscopy. These procedures have proved of great service in the recognition of foreign bodies in the lower air-pa.s.sages, and in their extraction; in the diagnosis of stenosis of the trachea, and of aneurysm pressing on the trachea.

CARDINAL SYMPTOMS OF LARYNGEAL AFFECTIONS

The cardinal symptoms of laryngeal affections are interference with the voice and with respiration, and pain on swallowing. Laryngeal cough of a croupy or barking character may be present, and is usually a.s.sociated with a lesion of the posterior wall or inter-arytenoid fold. Haemoptysis is seldom of laryngeal origin, and unless the bleeding spot is visible in the mirror, the source of the bleeding is much more likely to be in the bronchi or lungs.

#Interference with the Voice.#--_Hoa.r.s.eness_ results from some affection of the vocal cords: it may be simple laryngitis, some specific cause such as tuberculosis or syphilis, or some condition which prevents the proper approximation of the cords, as in tumours and certain forms of paralysis. Huskiness of voice occurring in a middle-aged person, lasting for a considerable period, and unattended by any other local or const.i.tutional symptom, should always arouse suspicion of malignant disease, and calls for an examination of the larynx. Should this reveal a congested condition of one vocal cord, a.s.sociated with some infiltration, and should the mobility of the cord be impaired, suspicion of the malignant character of the affection is still further increased. The hoa.r.s.eness in these cases is sometimes greater than the local appearances would seem to account for.

_Aphonia_, or loss of voice, sudden in origin, and sometimes transient, occurs more often in women, and is usually functional or hysterical in nature. Although the patient is unable to speak, she is quite able to cough. In these cases there is a bilateral paralysis of the adductor muscles, so that the cords do not approximate on attempted phonation; or the internal tensors may be paretic, leaving an elliptical s.p.a.ce between the cords on attempted phonation. If the arytenoideus muscle alone is paralysed, a triangular interval is left between the cords posteriorly. There is no inflammation or other evidence of local disease.

The _treatment_ of functional aphonia should be general and local; tonics such as strychnin, iron, and a.r.s.enic should be administered; the intra-laryngeal application of electricity usually effects a sudden cure. In obstinate cases the use of the shower-bath and cold douching, the administration of chloroform, and even hypnotism may be tried.