Stenosis

“ An aortic regurgitant murmur may temporarily disappear if a plug of fibrin closes the orifice, or if the walls of the left ventricle are the seat of extensive fatty degeneration, the aorta being rigid and inelastic.14 When aortic stenosis coexists there will be a double murmur, audible over a very large space, having its maximum intensity at the right edge of the sternum in the second interspace. ”

“ The loose cellular tissue is most frequently concerned in the process rather than the mucosal layer alone. In children the subglottic area is very vascular, and swelling quickly results from trauma or inflammation, so that acute stenosis of the larynx in children commonly has its point of narrowing below the cords. Dyspnea, and croupy, barking, cough with no change in the tone or pitch of the speaking voice are characteristic signs of subglottic stenosis. Edema may accompany inflammation of either the superficial or deep structures of the larynx. ”

“ When the growth extends across the middle line in the anterior commissure, or when a second growth is situated directly opposite on the other side of the larynx, the whole disease must be removed regardless of damage to the tissues which are not affected.
(e) When the operation is performed for stenosis, it is necessary to remove freely all the fibrous tissue without attempting to preserve any part that is diseased. The hæmorrhage is generally severe and necessitates preliminary plugging of the trachea with a Hahn’s canula. ”

“ As a general rule, in aortic stenosis signs of arterial anæmia precede evidences of venous engorgement. The obstruction to the exit of blood is shown in the sphygmographic tracing by a slanting or oblique up-stroke, as seen in the accompanying tracing, or, as Mahomed says, "the influence of percussion is lost." Tracings of the pulse in aortic stenosis sometimes show considerable separation between the percussion and the tidal waves. In some rare instances the pulse is slowed. There may be slight palpitation, and pain in the chest may sometimes occur in paroxysms ”

“ Non-malignant stenosis of the pylorus is of longer duration than cancer of the pylorus. The symptoms of dilatation of the stomach are common to both diseases. Cicatricial stenosis is the most common form of non-malignant pyloric stenosis. This is usually preceded by symptoms of gastric ulcer which may date back for many years. Non-malignant stenosis more frequently occurs under forty years of age than does cancer. The diagnosis between malignant and non-malignant stenosis of the pylorus is in some cases impossible. ”

“ However, as Kehrer insists, it may be one of the greatest difficulties in diagnosis—a difficulty not always to be resolved even when all the attendant circumstances have received the fullest and most painstaking consideration—to determine whether in any individual case an anomaly of the cervix, such as stenosis of the external os or of the whole cervical canal, is or is not to be regarded as a cause of sterility. When stenosis is extreme, there need be no two opinions about the matter ”

“ If the arytenoid motility has been uninjured the repeated pulls on the scar tissue may draw out adventitious bands and develop a loud, useful, though perhaps rough and inflexible voice.
Galvano-cauterization is the best method of treatment for chronic subglottic edema or hyperplasia such as is seen in children following diphtheria, when the stenosis produced prevents extubation or decannulation. The utmost caution should be used to avoid deep cauterizations; they are almost certain to set up perichondritis which will increase the stenosis. ”

“ The stem cell procedure for her stenosis should go forward with only minimal risk. There was every reason to hope he could rejuvenate the tissue in Alexa's left ventricle. It was merely an extrapolation of the kind of heart procedure that had worked such a wonder for Emma Rosen. ”

“ 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. ”

“ Mitral lesions—incompetence or stenosis—are very common causes which act by increasing the resistance in the pulmonary veins and obstructing the free flow of blood in capillaries of the lung. To compensate for this defect the walls of the right ventricle increase in size, and the hypertrophy at first may be unattended with dilatation. ”

“ As a rule, mitral stenosis is accompanied by the loudest as well as the longest cardiac murmur. The murmur is always louder when the patient is erect than when in the recumbent posture. For a few days before death, and at any time when there is great constitutional debility, the murmur may be held in abeyance. A presystolic murmur is never present when auriculo-ventricular narrowing does not exist. When this lesion does exist it is never permanently, and very seldom temporarily, absent. A prolonged murmur and a sharp first sound indicate a funnel-shaped stenosis. ”

“ Here the process may be more local, affecting, for example, the left ventricle chiefly, as in the hypertrophy from aortic valve disease or in association with contracted kidneys, or the right ventricle in chronic lung affections and mitral stenosis. More rarely we find the process confined chiefly to the auricles, but there may be advanced changes of this nature in the hypertrophied left auricle in mitral stenosis. The fatty degeneration of an hypertrophied heart may be induced by any of the general causes above referred to, but there are also special ones to which it is liable. ”

“ Thus in anæmia there are three murmurs, arterial, cardiac, and venous. In aortic disease the murmur has its maximum intensity at the second sterno-costal articulation of the right side, and is not accompanied by a venous hum. There is always more or less cardiac hypertrophy in stenosis, and an increase in the force of the apex-beat, while anæmia is attended by a feeble cardiac impulse. The murmur is soft and blowing in anæmia and harsh and rasping in aortic obstruction. The pulse is characteristic in aortic stenosis; in anæmia it may have a thrill, but is never hard and wiry. ”

“ During the necrotic stage the symptoms of laryngeal stenosis sometimes persist, and sometimes cease with the expectoration of quantities of pus containing possibly a part, and occasionally the altered whole, of the affected cartilage: with continued purulent expectoration the patient's strength fails, the breath becomes very fetid, and hectic fever and death may supervene. ”

“ 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. ”

“ Painstaking after-care is essential to success. When dilatation and healing have taken place, the laryngostomy wound in the neck is closed by a plastic operation to convert the trough into a trachea by supplying an anterior wall.
Intubational treatment of chronic laryngeal stenosis may be tried in certain forms of stenosis in which the cicatrices do not seem very thick. The tube is a silver-plated brass one of large size (Fig. 110) . A post which screws into the anterior surface of the tube prevents its expulsion. Over the post is slipped a block which serves to keep open the tracheal fistula. ”

“ Accurate timing of the murmurs in relation to the heart sounds enables us to judge whether the murmur is due to stenosis or incompetence of the valve affected.
If the valvular lesion is severe, it is essential for the proper maintenance of the circulation that certain changes should take place in the heart to compensate for or neutralize the effects of the regurgitation or obstruction, as the case may be. In affections of the aortic valve, the extra work falls on the left ventricle, which enlarges proportionately and undergoes hypertrophy. ”

“ The characteristic signs are inspiratory indrawing of the supraclavicular fossae, the suprasternal notch, the epigastrium, and the lower sternum and ribs. Cyanosis is seen at first, later giving place to pallid asphyxia when cardiac failure occurs. Little air is heard to enter the lungs, during respiratory efforts and the infant, becoming exhausted by the great muscular exertion, soon ceases to breathe. Paralytic stenosis of the larynx sometimes follows difficult forceps deliveries during which stretching or compression of the recurrent nerves occur. ”

“ 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 ”

“ Symptoms.—When compensation is gone, diminished blood in the brain causes dizziness and faintness.
MITRAL INSUFFICIENCY OR INCOMPETENCY.—This is the most common valvular disease. The segments of the valve may be shortened and deformed. There is often stenosis (narrowing) caused by this deformity. The effects are regurgitation, flowing back of blood from the left ventricle into the left auricle, which is also receiving blood from the lungs, causing dilatation of the auricle and its enlargement to expel the extra blood ”

“ As to how your procedure might differ from your mother's, I guess the main area of concern is simply the scale." He laid her files on the steel table. "Your heart has reached the stage of aortic valve stenosis where cardiac output no longer can keep up proportionately with vigorous exercise. And that has put an even larger strain on an already weakened condition. What we are about to undertake here corresponds to what might almost be considered an aortic valve replacement, though it is done at the cellular level. We call it regenerative medicine. ”

“ If there be any obstruction to breathing, the larynx is inspected and the projecting granulations are removed by intralaryngeal forceps. The remainder of the mass generally shrinks and disappears. If the stenosis be troublesome (chiefly in syphilitic cases) , the prolonged use of a laryngo-tracheal canula (p. 540) , or of an intubation tube, or dilatation with bougies, may be necessary. In rare instances a permanent tracheotomy tube is required, with a valve to encourage expiration through the mouth. ”

“ Excessive polypoid tissue hypertrophy should be excised. The less redundant cases subside under galvanocaustic treatment, which may be preceded by tracheotomy and extubation, or the intubation tube may be replaced after the application of the cautery. The former method is preferable since the patient is far safer with a tracheotomic cannula and, further, the constant irritation of the intubation tube is avoided. Subglottic hypertrophic stenosis consists in symmetrical turbinal-like swellings encroaching on the lumen from either side. ”

“ 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. ”

“ The mucous membrane of the larynx may be the seat of mucous patches or of catarrh, and as a result the child's cry is hoarse.
_Affections of the Bones._--Swellings at the ends of the long bones, due to inflammation at the epiphysial junctions, are most often observed at the upper end of the humerus and in the bones in the region of the elbow. Partial displacement and mobility at the ossifying junction may be observed. The infant cries when the part is touched; and as it does not move the limb voluntarily, the condition is spoken of as _the pseudo-paralysis of syphilis_. ”

“ Exterior to the vena innominata are the sterno-thyroideus and sterno-hyoideus muscles, some strong fascia covering the vein at its upper part, and the first bone of the sternum. The arteria innominata may ascend higher in the neck before it divides, in which case its pulsation will be perceptible in front of the trachea, and the subclavian artery will cross higher in the neck, which is one reason for not continuing the external incision down to the sterno-clavicular articulation in the operation on the right carotid. ”

“ The symptoms and consequences of inflammation of the vein have been already detailed. The affection is attended with great pain, and with swelling from effusion into the cellular tissue around the course of the vessel; the integuments are inflamed and tense; sero-purulent secretion soon takes place in the infiltrated cellular tissue, both deep and subcutaneous, followed by sloughing, and separation of the skin from its subjacent connexions; even death of the muscular structure sometimes ensues—the pectoral muscles have been found black and soft. The local treatment must be active. ”