Ephah

“ The œsophagus is a slightly flexuous canal, inclining to the left in the neck, to the right in the upper part of the thorax; it commences at the termination of the pharynx, which is a musculo-membranous sac, about four inches in length, and communicating with the cavity of the nose and mouth; the œsophagus then passes behind the arch of the aorta to the œsophagal opening in the diaphragm, where it enters the abdomen, and terminates into the stomach.
The stomach in man is an oblong, membranous bag, placed obliquely across the abdomen and just below the diaphragm ”

“ Symptoms.—Dysphagia is the most frequent complaint in cases of esophageally lodged foreign bodies. A very small object may excite sufficient spasm to cause aphagia, while a relatively large foreign body may be tolerated, after a time, so that the swallowing function may seem normal. Intermittent dysphagia suggests the tilting or shifting of a foreign body in a valve-like fashion; but may be due to occlusion of the by-passages by food arrested by the foreign body. Dyspnea may be present if the foreign body is large enough to compress the trachea. ”

“ Small food masses often lodge above the foreign body and are best removed with forceps. The folds of the esophagus are to be carefully searched with the aid of the lip of the esophagoscope. If the mucosa of the esophagus is lacerated with the forceps all further work is greatly hampered by the oozing; if the laceration involve the esophageal wall the accident may be fatal: and at best the tendency of the tube-mouth to enter the laceration and create a false passage is very great. ”

“ Great care must be exercised, however, that it be not overridden or pushed upon, as either accident might result in perforation of the esophagus by the pin point. The coiled spring is to be sought, and when found, seized with the rotation forceps and the pin thus drawn into the esophagoscope to effect closure. An open safety-pin lodged point upward in the esophagus is one of the most difficult and dangerous problems. A roentgenogram should always be made in the plane showing the widest spread of the pin. ”

“ On the left side, the œsophagus, inclining from the median line, presents itself in the antero-inferior triangle. It only half emerges from behind the trachea (which still covers its right portion) , and closely lies on the vertebræ: it continues the canal of the pharynx, from a line of abrupt distinction opposite the lower edge of the cricoid cartilage, downward. It is at its commencement that this tube most frequently interests the surgeon, by becoming the seat of stricture, or by arresting and fixing foreign bodies. To this space the operation of œsophagotomy belongs ”

“ It is this resiliency and movability that make bronchoscopy possible. The inspiratory enlargement of lumen opens up the forceps spaces, and the facile bronchoscopist avails himself of the opportunity to seize the foreign body.
THE ESOPHAGUS A few of the anatomical details must be kept especially in mind when it is desired to introduce straight and rigid instruments down the lumen of the gullet. First and most important is the fact that the esophageal walls are exceedingly thin and delicate and require the most careful manipulation. ”

“ This is explained by the trickling of liquified food from the esophageal reservoir into the stomach as the spasm intermittently relaxes, this occurring usually before a serious state of inanition supervenes. At times the hiatal spasms are extremely violent and painful, the pain being referred from the xiphoid region to the back, or upward into the neck. Patients are often conscious of the times of patulency of the esophagus; they will know the esophagus to be open and will eat without hesitation, or will refuse food with the certain knowledge that it will not pass into the stomach. ”

“ Strictural lumina are much more apt to be concentric as approached from below because there has been no distortion by pressure dilatation due to stagnation of the food operating through a long period of time. At retrograde esophagoscopy there seems to be no abdominal esophagus and no cardia. The esophagoscope encounters only the diaphragmatic pinchcock which seems to be at the top of the stomach like the puckering string at the top of a bag. ”

“ Dysphagia after recent diphtheria should suggest paralysis of the esophagus. The larynx, lips, tongue, and pharynx also, are usually paralyzed in esophageal paralysis of bulbar origin. The absence of the cricopharyngeal resistance to the esophagoscope passed without anesthesia, general or local, is diagnostic.
Treatment.—The internist and neurologist should govern the basic treatment. Nutrition can be maintained by feeding with the stomach-tube, which meets no resistance to its passage. Should this be contraindicated by ulceration of the esophagus, gastrostomy should be done. ”

“ 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. ”

“ An esophagoscopy may be needed in a bronchoscopic case, or a bronchoscopy in an esophageal case. In every case both kinds of tubes should be sterile and ready before starting. It is the unexpected that happens in foreign body endoscopy. 13. Do not pull on a foreign body unless it is properly grasped to come away readily without trauma. Then do not pull hard. 14. Do no harm, if you cannot remove the foreign body. 15. Full-curved hooks are to be used in the bronchi with greatest caution, if used at all, lest they catch inextricably in branch bronchi. ”

“ 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 oesophagus is usually congested as may be also the pharynx and the larynx.
Next to the peripheral nerve degenerations, to be later considered, the most important lesions are found in connection with the heart. All chambers of the heart show a dilatation with hypertrophy as well as dilatation of the right ventricle in cases that have lasted for some time. The heart muscle has the faded-leaf appearance indicative of fatty degeneration. Microscopically there are segmentation and vacuolation of the fibres. The lungs show congestion and at times present the characteristics of pulmonary oedema. ”

“ In no other manner can the landmarks and endoscopic anatomy be studied so thoroughly and practically, and in no other way can the pupil be taught to avoid killing his patient. The danger-points in esophagoscopy are not demonstrable on the living without actually incurring mortality. Laryngeal growths may be simulated, foreign body problems created and their mechanical difficulties solved and practice work with the forceps and tube perfected. ”

“ If the external parietes of the digestive tube be excited by any stimulus, by touching it with the finger, by a puncture, or by the galvanic fluid, there is in the œsophagus a sudden contraction of the longitudinal and circular fibres, which narrows the organ and shortens it at the same time; the relaxation takes place instantaneously and in as striking a manner. In the stomach, no motion is perceived in the direction of its length; we see only an annular contraction, which is developed slowly at the excited point, and which is usually not transmitted to the neighbouring parts. ”

“ The window can be replaced by a rubber diaphragm with a perforation for forceps if desired. It will be noted that none of the endoscopic tubes are fitted with mandrins. They are to be introduced under the direct guidance of the eye only. Mandrins are obtainable, but their use is objectionable for a number of reasons, chief of which is the danger of overriding a foreign body or a lesion, or of perforating a lesion, or even the normal esophageal wall. The slanted end on the esophagoscope obviates the necessity of a mandrin for introduction. ”

“ PARALYSIS OF THE ESOPHAGUS The passage of liquids and solids through the esophagus is a purely muscular act, controlled, after the propulsive usually voluntary start given to the bolus by the inferior constrictor, by a reflex arc having connection with the central nervous system through the vagus nerve. ”

“ The air distal to the impacted foreign body is soon absorbed, and the negative pressure thus produced increases the impaction. A ring of edematous mucosa quickly forms and covers the presenting part of the object, leaving visible only a small surface in the center of an acute edematous stenosis. A forceps with narrow, stiff, expansive-spring jaws may press back a portion of the edema and may allow a grasp on the sides of the foreign body ”

“ He made the discovery that the œsophagus is of equal importance with the trachea in carrying on the process of respiration and [Pg 19] in exercising the faculty of vocal expression; that for these purposes œsophagus and trachea are to an equal degree directly amenable to the influence of the atmospheric air; that the dual nature of organic beings in general, and of man in particular, is represented by the hemispheres of the thorax and the abdomen; that the former in its entirety represents spiritual and the latter in its entirety material issues ”

“ At this point the esophagus lies centrally and above the trachea. Figure 40 shows a transverse anterior section through the thoracic region at 14 of Fig. 34. At this point the esophagus is slightly to the right of and is superior to the trachea. At this level the apex of the lung is sectioned. This is in the region of the cervical air-sac. Figure 41 shows a posterior section at 12 of Fig. 33. The 162esophagus here is above and to the right of the inferior larynx, and directly below and between the lungs. The inferior larynx is above the base of the heart. ”

“ No. 1049 presents the tongue, pharynx, and larynx of a man who had swallowed a tea-cupful of nitric acid. The epithelium of the œsophagus is for the most part wanting, and hangs in shreds; the dorsum of the tongue, in front of the circumvallate papillæ, is excavated, and over its central part superficially ulcerated; in other places the tongue is encrusted with a thick, loose, fawn-coloured layer, formed probably of desquamated epithelium. ”

“ This may be done by way of the œsophagus or the trachea, i. e., from the side of the hemisphere of the abdomen, or from that of the thorax. The outward movement of the abdomen during respiration, therefore, is not caused by a pressure brought to bear on its contents by the diaphragm, but it advances and recedes in conformity with a direct process of inspiration and expiration by way of the œsophagus and the trachea; the œsophagus and trachea sustaining each other and acting reciprocally and in conjunction. ”

“ The skull and branchial basket complete their development. At the same time the pharynx loses its connection with the rest of the alimentary canal and remains as the branchial canal. The so-called oesophagus of the adult is apparently a new formation which grows forwards and acquires a connection with the mouth. It is probable that it represents a hyperpharyngeal groove constricted off from the dorsal wall of the pharynx. ”

“ When small, the sac is in the midline, but with increase in size, it presents either to the right or the left side, commonly the latter. The sac may be very small, or it may be sufficiently large to hold a pint or more, and to cause the neck to bulge when filled. When large, the pouch extends into the mediastinum. It will be seen that anatomically the pulsion diverticulum has its origin in the pharynx; the symptoms, however, are referable to the esophagus and the subdiverticular esophagus is stenosed by compression of the pouch; therefore, it is properly classified as an esophageal disease. ”

“ The oesophagus or gullet is thick and muscular, extending through the whole of the neck of the animal; its cavity, as well as the opening from the pharynx, is triradiate like a leech-bite, but can be dilated by the action of the muscular walls, inserted into a firm external cuticle ”

“ The esophagus is located above the heart. Showing the relations of the visceral organs back of the heart girdle, photograph number 44, gives an anterior section made at 12, Fig. 33. The lungs are spread out occupying the posterior thoracic region and below at No. 10 is the diaphragm. The diaphragm does not appear to have that rigidity and firmness of position as in mammals. It is rather rudimentary. Below the left lung and above the left lobe of the liver is the proventriculus. Note that the viscus is empty and that the mucous membrane is thrown into folds. ”

“ The mouth and pharynx can be studied to better advantage later with the dissection of portions of the vascular system.
The oesophagus can be seen above the liver, by pressing that organ aside, as a somewhat constricted tube entering the anterior end of the abdominal cavity. It immediately joins the stomach, which is more or less expanded according to the amount of food contained in it. ”