Esophagus

“ The facts brought out experimentally in studies on lower animals are doubtless true also of man. Not very infrequently, because of the accidental swallowing of corrosive substances, the esophagus is so injured that, when it heals, the sides grow together and the tube is closed. Under these circumstances an opening has to be made into the stomach through the side of the body and then the individual chews his food in the usual manner, but ejects it from his mouth into a tube which is passed through the gastric opening. ”

“ 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. ”

“ 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. ”

“ The Stomach.—The stomach is a pear-shaped dilatation of the alimentary canal, lying under the liver and diaphragm in the epigastrium and left hypochondrium and connecting the esophagus with the small intestine. It lies largely behind the ribs, but the greater curvature is only two fingers’ breadth above the umbilicus and can be manipulated through the skin. The cardiac end, into which the esophagus enters, is the larger and points upward to the left. The lesser and lower end, known as the pylorus, is at the right and its opening into the small intestine is guarded by the pyloric sphincter. ”

“ It is at this time that the contractions of the stomach wall, which we recognize as hunger, begin to come on. There is a sphincter muscle between the esophagus and stomach which closes the opening tightly and so prevents the pressure within the stomach from forcing gas or liquid back up into the esophagus. This sphincter opens automatically only in connection with the act of swallowing. Every time we make a swallowing movement a sort of wave passes down the esophagus, and when this wave arrives at the stomach the sphincter relaxes, allowing whatever was moving down the esophagus to enter. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ This, however, does not mean that esophageal foreign bodies should be pushed into the stomach by blind methods, or by esophagoscopy, because a swallowed object lodged in the esophagus can always be returned through the mouth. Foreign bodies in the stomach and intestines should be fluoroscopically watched each second day. If an object is seen to lodge five days in one location in the intestines, it should be removed by laparotomy, since it will almost certainly perforate. Certain objects reaching the stomach may be judged too large to pass the pylorus and intestinal angles. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ If it is in the esophagus, Aëtius suggests that the patient should be made to swallow a sponge dipped in grease, or a piece of fat meat, to either of which a string has been attached, in order that the foreign body may be caught and drawn out. If it seems preferable to carry the body on into the stomach, the swallowing of large mouthfuls of fresh bread or other such material is recommended. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ It then descends, through the oesophagus, into the stomach, where it becomes digested, and, in a great measure, dissolved, by the gastric juice, which is secreted by the arteries of the stomach. It is then pushed through the pylorus, or right orifice of the stomach into the duodenum, where it becomes mixed with the bile from the gall bladder and liver, and the pancreatic juice from the pancreas. These fluids seem to complete the digestion: after this, the food is continually moved forwards by the peristaltic motion of the intestines. ”

“ The oesophagus expands into a curious gizzard, which is armed internally with large horny processes, some broad and thick, others spinous, fitted to act as crushing instruments. From this we pass to a stomach and a coil of intestine embedded in the lobes of a voluminous liver; a caecum of large size is given off near the commencement of the intestine. The liver opens by two ducts into the digestive tract. ”

“ 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. ”

“ By severance of the vagus and splanchnic nerves, the lower esophagus, the stomach and the small intestine can be wholly separated from the central nervous system. Animals thus operated upon nevertheless eat food placed before them, and may indeed manifest some eagerness for it. ”

“ CHAPTER XXXV—GASTROSCOPY The stomach of any individual having a normal esophagus and normal spine can be explored with an open-tube gastroscope. The adult size esophagoscope being 53 cm. long will reach the stomach of the average individual. ”

“ Digestive System.—The mouth leads through a short vertical oesophagus into an enlarged stomach, which lies horizontally curved around the axis of the calyx. The stomach is succeeded by a short intestine, which leads into the anal papilla. Both oesophagus and stomach are ciliated, and the food consists of minute organisms, swept into the mouth by the current produced by the cilia covering the ambulacral grooves and podia; the ten arms may indeed be compared to a net spread out in the water to catch swimming prey. ”

“ The oesophagus leaves the branchial sac in the dorsal middle line, near the posterior end of the dorsal lamina. It is a short curved tube which leads ventrally to the large fusiform thick-walled stomach, ridged internally. The intestine emerges from the ventral end of the stomach and soon turns anteriorly, then dorsally, and then posteriorly, so as to form a curve, the intestinal loop, in which the ovary lies, open posteriorly. ”

“ Traction diverticula of the oesophagus not uncommonly occur as sequels to suppurative inflammation of cervical lymphatic glands. More frequently dilatation of a section is met with, due as a rule to the presence of a stricture. The stomach often diverges from the normal in size, shape and position. Normally capable in the adult of containing from fifty to sixty ounces, either by reason of organic disease, or as the result of functional disturbance, its capacity may vary enormously. ”

“ The labrum is large, and forms a chamber above the mouth, into which food is driven by the limbs, as in the Phyllopoda, food being taken while the animal swims or lies on its back. The oesophagus runs vertically to join a small stomach, which bends sharply backwards and passes gradually into an intestine. In the last segment of the abdomen the intestine joins a short, thin-walled rectum, provided with radial muscles, by means of which it can be dilated. The dilatation of the rectum leads to an inhalation of water through the anus, which may possibly serve as a means of respiration. ”

“ The mucous and serous membranes of the canal and the glandular elements of the associated organs are the parts most subject to inflammatory affections. Among the several sections of the digestive tract itself, the oesophagus and jejunum are singularly exempt from inflammatory processes; the fauces, stomach, caecum and appendix, ileum, mouth and duodenum (including the opening of the common bile-duct) , are more commonly involved. Stomatitis, or inflammation of the mouth, Inflammatory lesions. ”

“ Circumscribed oesophagitis is usually indicated by odynphagia at a certain point of the tube after completing the act of deglutition. The location of the inflammation can sometimes be determined by auscultation of the descent of the alimentary bolus or of a swallow of water (Hamburger) , which may yield evidence to the ear of arrest or impediment to its passage. Auscultation of the oesophagus, however, is less useful in acute oesophagitis than in stenosis, stricture, and mechanical obstruction. ”