TUMORS OF THE THORAX.

Primary tumors of the chest wall constitute less than 1 per cent. of those occurring in general practice; this, of course, not having reference to secondary developments from cancer in the breast, which are somewhat frequent. Of the benign tumors those which most frequently appear upon the surface are the lipomas, which are seen either in circumscribed or diffuse form, as illustrated in Figs. 507 and 508.

They are sometimes multiple and perfectly innocent, save as they may attain large size or ulcerate from surface irritation. The granulomas, especially those of syphilis and tuberculosis, are common, appearing either as superficial tumors which ulcerate, or as deeper ones which may break down in the course of months or years, after perhaps involving the ribs or a considerable portion of the chest wall. Actinomycosis is perhaps as often seen in this region of the body as anywhere.

The fibromas are seen more commonly in the axilla and beneath the thoracic musculature. The chest is a frequent site for those pedunculated fibromas which have been described under the term keloid. A most striking case of neurofibroma of the skin is portrayed in Plate XLIX.

Chondromas of the chest are slow-growing, usually painless, may involve a considerable area, both of bone and cartilage, are not infrequently the seat of cystic changes, and often undergo a final sarcomatous degeneration. All this is true in lesser degree of the osteomas, which are of the cancellous type.

The malignant tumors of the thorax proper are mostly sarcomas which assume various types, according to their cellular characters, the round-cell sarcomas growing rapidly, becoming extremely hemorrhagic and fungous, and tending to kill early, while the larger and more spindle-cell and the giant-cell forms grow relatively more slowly, and may even be successfully removed (Figs. 509 and 510.)

Carcinoma of the chest wall is generally the result of extension from cancer of the breast or of some other epithelial structure. Advancing carcinoma spares nothing, and may not only perforate the chest but involve the lung beneath, with or without later ulceration, and the occurrence of pneumothorax.

While these are the more common forms of tumor of this region there are no known growths which may not occasionally be met here.

Treatment.

—The treatment for all these tumors is extirpation. With benign growths outside of the ribs proper this is usually a simple matter. When the whole or nearly the whole thickness of the chest wall is involved it becomes then a serious problem how far to proceed in the effort to extirpate. This is true alike whether sternum or ribs are involved. The entire sternum may be separated from its surroundings and lifted out of place, and this would be justifiable when dealing with an osseous or cartilaginous growth. If, however, it were distinctly sarcomatous it would be hardly worth while. If in such an operation the pleura be spared and air not admitted to the pleural cavity almost anything is allowable. If, however, it appear that it will be necessary to open the pleural cavity caution should be observed. Of late years, however, less hesitation has been felt in this regard, and Parham and others, including myself, have shown that extensive portions of the thoracic wall may be resected without the necessity for employment of the elaborate operative methods suggested by some recent experimenters. For instance, Sauerbruch has devised a “pneumatic cabinet,” the patient’s head resting outside when the anesthetizer administers the anesthetic. The balance of the body rests within the cabinet, which is sufficiently large to accommodate the operator and two or three assistants, and which, being closed, is subjected to a lowering of atmospheric pressure equivalent to 10 Mm. of mercurial column, or to a difference in atmospheric level of 1000 to 1200 feet. The patient breathing air at external pressure does not suffer the collapse of the lung, thus exposed, which would otherwise take place. The operation being completed within the cabinet, the dressings are applied and hermetically sealed, and the door then opened and pressure equalized. Subsequent dressings can be made in the same way. Thus has been afforded a scientific method of doing that which the experience of many American surgeons has shown to be only theoretically indicated. Sauerbruch’s device is ingenious in theory and complicated in operation.

A simpler method is to apply the Fell-O’Dwyer apparatus over the face and thus keep up artificial respiration. It is not, in theory, so ideal as to open the trachea and practise this procedure as is done in the experimental laboratory, but is much simpler and will usually suffice, should anything of the kind be required.

A malignant tumor of the chest wall whose overlying skin is seriously involved, and whose removal would leave a defect which it would not be possible to cover with integument, should not be disturbed. It might be possible in certain cases to partially transplant the breast in such a manner as to permit closure of a defect thus made. Nevertheless it is questionable if any cancer advanced to the extent of requiring this procedure is to be considered operable.

Nor should any malignant tumor of the chest wall be operated if, in addition to its own presence, there be indication of the involvement of the lymphatics or other structures within the chest, such indications including, for instance, cough, loss of voice, dyspnea, dysphagia, disturbance of pneumogastric control of the heart, displacement of the latter, or great accumulation of fluid in any of the chest cavities. The only exception to this statement is possibly when the lung has attached itself to its interior surface, but yet not so extensively but that removal of a small amount of lung tissue will not interfere with extirpation of the growth. Cases of recurring carcinoma where the chest wall is completely involved rarely justify operation.

TUMORS OF THE LUNG.

Tumors of the lung proper might be made amenable to surgery, in certain instances, if an exact diagnosis could be made. Occasionally this is possible, though but very rarely. Particles of lung tumor have been expectorated and their minute character recognized, so that actual diagnosis has been made. As in the abdomen, cancer of the thoracic viscera will usually lead to an accumulation of serous fluid, and, in both instances, thus obscure rather than simplify recognition. Quincke has shown that the presence in such pleuritic effusions of fat cells (hydrops adiposus) is significant, since they rarely if ever occur in any other exudates.

Primary tumors of the lung are usually sarcomas or endotheliomas. Carcinoma is exceedingly rare, save as secondary to cancer in the breast. Even sarcoma is itself usually secondary to disease in some other part of the body, metastasis having occurred through the blood channels, instead of through the lymphatics, as is the case with carcinoma. Tumors arising in the pleura may be of endotheliomatous type and are usually accompanied by the presence of bloody serum. Extremely rare tumors within the chest are those of dermoid origin, connected more often with the pleura than with the lung proper. These may suppurate and communicate either externally or internally. One known case mentioned by Dennis was that in which such a tumor communicated with a bronchus, so that the patient coughed up hair. Syphilitic gummas are also found in the lung, either in multiple small form or in masses of considerable size. They are slow in development and may give rise to no special disturbance. Dennis has described instances in which these growths have become encapsulated.

Two other forms of tumor are not very rare in this situation: one is that produced by actinomycosis; the other occurs in echinococcus disease and in the formation of hydatid cysts. The former, developing within the lung proper, tends to migrate toward its surface, to include the pleura, and finally to invade the chest wall. Such a tumor when exposed in either location can scarcely be differentiated from a breaking-down sarcoma, except by the recognition in it of the small, calcareous particles which are so pathognomonic of this disease. (See Actinomycosis.) In the living patient the sputum will frequently contain these particles, while under the microscope the peculiar club-end, thread-like fungus formation may be recognized. The disease is usually of slow development, but occasionally, especially when mixed with a secondary infection, may be rapid. Significant tumors may also occur in other parts of the body. Actinomycotic tumors upon the surface may be attacked with curette and cautery. Injections of iodine are also of value. For actinomycosis of the lung proper potassium iodide and Lugol’s solution are indicated as well as copper sulphate.

Hydatid cysts occur within the lungs in about 10 per cent. of cases of echinococcus disease. Their contained fluid is alkaline, of low specific gravity, colorless, and contains the characteristic hooklets which are pathognomonic of this disease. A circumscribed collection of fluid within the chest, shown to be due to this condition, may be tapped or incised and drained. When occurring in the lung it not infrequently leads to secondary pyothorax, while operation for the latter may reveal the existence of the former. Any hydatid cyst of the lung which can be recognized, or be made accessible, may be treated by incision and drainage, the lung, if not already adherent, being first fastened to the chest. Inasmuch as the condition develops in the lower lobe and on the right side this is occasionally a practicable procedure. As the diagnosis is usually made only after the primary cyst has ruptured and small cysts are cast off, producing more or less pleuritic effusion, the attempt may still be made to do this by a free incision of the chest wall, perfecting the diagnosis and completing the procedure at this time.

THE HEART.

There is but little to be said about the heart in addition to that elsewhere stated, where such injuries as gunshot wounds, stab wounds, etc., are considered. Rupture of the heart without external injury is possible under conditions of fatty degeneration or softening produced in consequence of embolus or thrombus. Aneurysms of the heart are also known by which it is weakened and permitted later to give way. The final rupture is usually the consequence of some emotion or extra exertion, although it may occur with injury to some other part of the body, as after a blow upon the abdomen. Death may be instantaneous, or occur more slowly as the result of filling of the pericardial sac and rapidly increasing embarrassment of heart action.

Wounds of the heart produce syncope and shock, restlessness, extreme anxiety, with dyspnea and such disturbance of heart activity as to materially change the sounds heard on auscultation.

The treatment of such cases not primarily fatal should include opium narcosis, but not stimulants intended to excite the heart to extra activity. The operations justified under these conditions are elsewhere described.[50]

Pericarditis, either of idiopathic or traumatic origin, may produce a degree of distention, either hydropericardium or pyopericardium, calling for surgical intervention—in the former case with the aspirating needle, in the latter either with the needle or the knife. When a pericardium is greatly distended with fluid there is marked change in the position of the apex beat, with embarrassment of heart action, accompanied by distress and distention of the veins of the upper part of the body, as well as much alteration of the ordinary physical signs, the area of dulness being correspondingly enlarged and the lung sounds being lost over the area occupied by the distended sac. Great distention, with marked precordial trouble and distress of heart and lung function, always requires paracentesis.

Paracentesis pericardii is performed ordinarily by puncturing (a previously sterilized area) 3 to 5 Cm. to the left of the left border of the sternum, and in the fifth intercostal space, with a sterilized needle. Here are found the internal mammary artery and the pleura. Too rapid withdrawal of fluid may lead to syncope. It should, therefore, be allowed to escape slowly. Should it prove purulent it may be incised, passing the knife-blade along the needle; or the sac may be emptied, when, if fluid re-collect, a free incision should then be made. Roberts has shown that recovery follows in at least 40 per cent. of cases of empyema of the pericardium thus treated. Gauze drainage may be provided, but irrigation of the cavity should not be practised.

Allingham has suggested to open the pericardium from below by an incision three inches in length, carried along the lower margin of the seventh left costal cartilage, to separate the cartilage from the abdominal muscles, pull outward and upward the lower surface of the diaphragm, expose the cellular interval between its attachment to the cartilages and to the tip of the sternum, to expose and enlarge by blunt dissection, until there appears a mass of fat which belongs above the diaphragm in the interval between the pericardium behind, the sternum in front, and the diaphragm below. When this is removed the pericardium is exposed and can here be opened. Throughout the procedure injury to the pericardium which lines the upper surface of the diaphragm should be avoided. By this method the pleura need not be opened and better drainage may be secured. (Dennis.)

Abscess in the heart wall is an exceedingly rare lesion, usually accompanying pyopericardium, but occasionally met without it. It was the writer’s experience in one case, in puncturing for what was supposed to be a pyopericardium, to withdraw pus and give temporary relief. Later postmortem examination showed that this pus came from a large abscess in the wall of the heart, which had been thus entered by the aspirating needle without immediate bad consequences, but, on the contrary, with temporary relief.

THE LUNGS.

In the fact that the lung never completely fills the pleural cavity we find explanation for the kindred fact that small effusions produce little if any compression symptoms. Collapse of one lung after opening the chest is never complete if the other lung be uninjured and functionating. Moreover, a partial collapse on the affected side will be quickly atoned for when the pressure of the external atmosphere is taken off.

Two or three serious pathological conditions of the lung occasionally require surgical intervention.

HYDATIDS OF THE LUNG.

Hydatids of the lung have been mentioned (see above). Seventy-five per cent. of these cases terminate fatally without surgical help, and in reality more prospective benefit can be offered by it than without it. Serious and even fatal collapse has attended the sudden withdrawal of fluid from hydatid cysts in this location. Aspiration may be made, but even this is scarcely less dangerous while it is less satisfactory than free exposure and drainage.

ACTINOMYCOSIS OF THE LUNG.

Actinomycosis of the lung may be recognized by the sputum and also by the pus discharged from any breaking-down cavity within the affected area. (See section on the Pleura.) If a localized focus could be diagnosticated or recognized after exposure the portion of the lung thus involved might be removed.

ABSCESS OF THE LUNG.

Abscess of the lung is always the result of some local or distant infectious process. The mechanism of production of the multiple metastatic abscesses which characterize pyemia has been described in the earlier portion of this work. For such conditions surgery affords no aid. Circumscribed abscess may be the result of the presence of a foreign body—i. e., a bullet or a parasite—or it may result from embolism with infarct, in consequence of such affections as ulcerative endocarditis, puerperal septicemia, sloughing fibroid, an otitis media, or a septic pneumonia produced from any cause. It may be the result of extension from an osteomyelitis of some portion of the bony wall of the thorax, which itself may result either from injury or from local infection. Abscess of the lung is seen not infrequently in connection with empyema, and often results from suppurating tuberculous bronchial nodes. It may be produced, also, by extension of trouble from below the diaphragm, as hepatic abscess, subphrenic abscess, and the like. It is always a secondary rather than a primary affection.

Such abscesses are to be recognized by the character and offensiveness of the sputum, the pus discharged being colored green or brown, containing shreds of tissue, with masses of bacteria and crystals of fat. Some believe the presence of elastic fibers to be pathognomonic. When pulmonary abscess is diagnosticated it is necessary, in addition, to determine whether multiple lesions or a circumscribed collection are to be dealt with. In the former instance it is of little avail to intervene. In the latter the physical signs will usually furnish evidence of adhesions between the lung and the chest wall, by whose presence the operative procedure is simplified.

The term pneumotomy is applied to the exposure and evacuation of pus in the lung, whether it be found in connection with an ordinary abscess or a suppurating hydatid cyst. It is essentially a thoracotomy, plus the added measure of whatever may be done to the lung itself, and will be described in connection with other operations upon the chest.

If a tuberculous abscess could be located it also might be treated upon the same general principles. Thus Lane and others have suggested early operations for relief of tuberculous lesions. For obvious reasons, however, the method has not found general acceptance.

GANGRENE OF THE LUNG.

Gangrene of the lung is the terminal stage of a local infection, and unless relieved may prove fatal to the patient. It is due to the causes above mentioned as producing abscess in the lung, while to them may perhaps be added a few others, especially expressions of embolism or thrombus of the pulmonary circulation by which, the blood supply being cut off, death of tissue occurs before there is time for phlegmonous development. Thus it is met with occasionally after the acute exanthems and the infectious fevers and after violent pertussis. When diffuse it is of the miliary type. When circumscribed it may be due to more localized causes. In any event it is more frequent in the lower portions of the lung.

Pulmonary gangrene may be recognized by the extreme condition of the patient, offensive odor of the breath, and expectoration of sputum which may at first be frothy and bloody, but becomes rapidly purulent and finally necrotic in type. Meantime, the function of the lung being materially interfered with, respiration is rapid and there will be more or less cough, pain, and finally collapse. When the sputum is allowed to stand in a test tube there will form an upper layer, opaque and frothy; a middle, more frothy layer; while the lower and denser portion will be of a dirty green color and contain shreds of dead tissue with bacteria, crystals of triple phosphates, fat debris, and pus. According to the nature of the case the cavity or the area of dead lung may be outlined by physical signs. There is a form of fetid bronchitis which has been mistaken for pulmonary gangrene, but the character of the sputum and the progress of the case will be quite different.

Gangrenous areas of limited size have in certain favorable cases cleared up and the patients have recovered, but ordinarily for this condition surgery affords the only prospect of relief, the operation being begun with a thoracotomy and completed by the removal of the gangrenous lung tissue. The operative procedure is essentially the same as that for abscess and above described.

Septic pneumonia is the term applied to those forms of pneumonitis which occur in connection with septic lesions in other parts of the body, or with the less typical forms—e. g., aspiration pneumonia, due to the passage into the finer bronchioles of material from the mouth or nose. It gives rise to the same physical signs, though it is perhaps more often irregularly located than is the consolidation of the ordinary lobar pneumonia. Viewed in this way it will be regarded as a serious complication of various other conditions, many of which are surgical, and it is frequently a primary expression of infection. The physical signs by which it may be recognized are scarcely different from those of ordinary pneumonia, except that, in addition to the latter, there may be distinct expressions of general septic infection and of profound toxemia, and that the disease may progress to the point of producing pulmonary abscess or gangrene. While the milder types of septic pneumonia are not necessarily fatal, it is always a serious complication, and, as such, dreaded by the surgeon. It is not, however, essentially a surgical complication, but calls for the treatment generally given to pneumonia, plus whatever may be needed for the primary condition behind it.

CHYLOTHORAX.

This implies a collection in one of the pleural cavities, usually the left, of fluid which is practically unchanged chyle, which has probably escaped from the thoracic duct. The number of cases on record is not over fifty, of which about one-third have followed unrecognized injury with probable rupture of the duct. Most of these cases have occurred in connection with fracture of the spine. The duct may be opened by the progress of ulcerative disease, and carcinoma is often the predecessor of chylothorax. Rupture may also occur in connection with tuberculous lymphatics about the course of the duct, and when the condition occurs in children this is the usual explanation. It should be differentiated from so-called chyloid effusions into the pleural cavity, which are more often seen in connection with cancer than tuberculosis, the fluid in this case being mixed with fat and degenerated leukocytes or cells. Pure chyle contains sugar, while chyloid fluid contains but a trace of it. The former also is thicker, and compares with the latter as does cream with skimmed milk.

The prognosis is not usually favorable. Nevertheless recovery has ensued without operation. Mere pressure of the effusion may occlude the opening through which it occurs until the latter shall heal. When the fluid gives rise to severe symptoms the chest should be aspirated.

HYDROTHORAX; HEMOTHORAX; PYOTHORAX.

Under these terms are included the presence of fluid in the pleural cavity, between the lung and the chest wall; this fluid, in the first instance, being serum, which may be slightly admixed with pus and blood; in the second, blood; and in the third, pus.

Hydrothorax may be a primary condition, the result of pleurisy with effusion, or of pleuropneumonia. It may also occur as does a similar collection in the abdomen, as the result of disease of the chest wall, the lung itself, or in consequence of serious cardiac or renal disease, with tendency to dropsical accumulations in various parts of the body. Thus it is seen in connection with tuberculous disease or cancer of the lung, as well as cancer of the chest wall. There is, moreover, a miliary expression of tuberculous pleuritis in which hydrothorax is always a complication.

The serious features of hydrothorax result from the compression which it may make upon a lung with consequent embarrassment of lung function and from the possibility of infection by pyogenic organisms and the consequent conversion of a hydrothorax into a pyothorax.

Collections of serum within the pleural cavity which manifest a kindly tendency to disappear by resorption do not require surgical intervention, but all such accumulations which do not quickly evince this tendency should be removed by the operation of paracentesis, which, applied to the thorax, is called thoracentesis, i. e., aspiration through the hollow needle. No lung should be allowed to have its capacity long reduced by compression.

Hemothorax may be idiopathic or traumatic. In the former case it is an expression of malignant disease, or of advanced septic lesions which have permitted erosion of bloodvessels and escape of blood. It may also result from rupture of an aneurysm, and will then prove fatal. It is seen in surgical cases in connection with injuries to the chest wall or its contents, as in compound fracture of a rib or perforation of a rib fragment into the chest, with injury to the lung.

In case of the sudden escape of fluid into the chest, with symptoms of collapse and lung compression, it may be assumed that an acute hemothorax affords the explanation. Fluid accumulating rapidly under any circumstance is more likely to be blood than serum. The exploring needle may be relied on to furnish the deciding test, in addition to the ordinary physical signs afforded by auscultation and percussion.

Pyothorax is frequently referred to as empyema, the latter term indicating a collection of pus in a previously existing cavity, and, by common consent, made to refer to the pleural cavity unless some other be mentioned. Empyema is seldom a primary condition. Generally it is the result of a hydrothorax, which has become contaminated either by direct or by indirect access of germs. Under these circumstances it indicates the conversion of a relatively innocent collection of serum into a collection of pus, with all its attendant dangers. It may be looked for in cases of perforating injury of the chest, e. g., compound fracture of the ribs, gunshot wounds, and the like.

While returning the ordinary physical signs met with in fluid collections in this location, and being discoverable with the exploring needle, empyema has this additional feature, that the pus may, when long retained or accumulated in large amount, burrow and attempt to escape through whatever path may offer least resistance. In this way strange freaks will occur, as when it escapes behind a mammary gland and pushes the latter forward, thus forming a large retromammary abscess, which requires not merely the ordinary incision, but a thoracotomy and ample drainage as well. It may penetrate at other points and thus escape. The most remarkable illustration that the writer personally has known of this travelling of pus was in a colored man, in whom it perforated the diaphragm, then separated the peritoneum from the abdominal wall over a large area, collected in large amounts between the peritoneum and the abdomen in front, and even extended down into the pelvis. This man had such a peculiar abdomen that he was supposed to have dropsy. When the trocar was inserted there was a discharge of over a pailful of almost pure pus.

In addition to the ordinary embarrassment which a considerable amount of pus thus collected causes, there should be reckoned the peculiar septic and toxic features, which can be easily accounted for by the nature of the contained fluid. Pyothorax will nearly always have septicemic in addition to local features, which give it an individuality of its own.

The operations practised for relief of these conditions are discussed at the conclusion of this chapter.

THE ESOPHAGUS.

Anatomically, the esophagus is a musculomembranous tube with downward projection into the thorax, its uppermost portion blending with the lower constrictor of the pharynx, the tube proper beginning at the level of the cricoid cartilage, and opposite the sixth cervical vertebra. Its conclusion opposite the tenth dorsal vertebra marks the cardiac orifice of the stomach. In its upper portion it is placed centrally, then inclines a little to the left, and, at the level of the third dorsal, lies about half an inch to the left of the middle line. This furnishes the reason for approaching it upon the left side in doing external esophagotomy. From here it passes to the middle line again until opposite the ninth vertebra, where it once more inclines a little to the left. It has an anteroposterior curve corresponding to the shape of the spine. Between it and the trachea, in the neck, lies the recurrent laryngeal nerve. Its nervous supply is derived from the sympathetic and the pneumogastric, and its lymphatics connect with the mediastinal nodes, the latter point being of importance in connection with cancer of the esophagus. Its average caliber is about three-quarters of an inch, save where it is crossed by the left bronchus and at the diaphragmatic opening. There is also a slight constriction at its upper opening.

CONGENITAL MALFORMATIONS OF THE ESOPHAGUS.

Congenital malformations include its absence, at least throughout some of its course. Communication between it and the treachea, so-called tracheo-esophageal fistula, has been noted. Its upper portions, into which may open the incompletely closed branchial clefts, are also subject to malformations with incomplete obliteration of the latter and consequent diverticula. Irregular dilatation is also occasionally of congenital origin, as well as acquired, in the latter case being due to fatty degeneration of muscle fibers. These dilatations should be differentiated from those which are mostly found on the proximal side of any constricted tubular passage, and which are produced by accumulation and distention from behind of whatever should be passed through it.

The most common malformations of the esophagus which are not of the stenotic character are so-called diverticula, which appear in two forms—namely, distention and traction, these being both acquired forms, while congenital formations of this character are also occasionally met.

Congenital diverticula may appear anywhere along the course of the tube, but are probably more common in its upper portion. They constitute more or less irregular tubular sacs which lie alongside of and parallel to the main tube. The openings by which they connect may be large or small. These saccular defects, always small at first, may assume increasing proportions, because of the entrance therein of food and their consequent distention by foreign material, as well as by products of decomposition of the same. Thus slowly and insensibly a very mild form of such defect may in time assume serious proportions.

The acquired diverticula of the distention type are usually met with in the upper part, and are practically hernial protrusions of at least the mucosa through the fibers constituting the muscular portion of the tube, and cannot occur save by some preceding pathological change. Traction diverticula are the results of adhesions to breaking down lymph nodes or other pathological conditions, by which the esophageal wall is first pulled out of position, then gradually sacculated, and the condition still further aggravated by accumulation therein of foreign material. The acquired diverticula attain considerable size, and when emptied one may be astonished at the accumulation which has occurred. Such a tube having been completely emptied may be again filled by the first food which is subsequently taken. After being filled, the balance of the food may then pass into the stomach, with partial or complete comfort or satisfaction to the patient.

The principal indication of an esophageal diverticulum, beside dysphagia, is regurgitation or vomiting of food. When food which has undergone decomposition is occasionally rejected, and when, at the same time, the stomach is shown to be not dilated and not at fault, the suspicion of a diverticulum may be considered well founded. Its opening into the esophagus may be so placed as to always engage the instrument which may be passed down for examination, either bougie or stomach tube. Should this be a constant phenomenon the diagnosis may be easily established. In such a case it may be possible to first empty and then distend the sac with food mixed with bismuth subnitrate, or perhaps to inject it with an emulsion of the same. If this can be done, the fluoroscope or a good radiograph will show a distinct shadow, and in this way a pictorial outline of the condition may be obtained.

Treatment.

—The treatment of these diverticula is of great difficulty, especially when the sac has attained a size which permits of retention of material. Sacs which contain decomposing matter should be emptied by the stomach tube and washed out at frequent intervals. If it be then possible to pass the tube beyond them the patient should be fed through it, or it may be possible to place the patient in the recumbent position, with the head lower than the body, and cause food or fluid to be swallowed in this attitude. It will then probably enter the stomach instead of the sac. Such measures as these failing, and nothing else affording relief, operations are occasionally undertaken. Much will depend upon the location of the sac, especially its height. A diverticulum in the neck may be more easily reached than one in the chest, and Richardson and myself have had remarkable success in the relief of aggravated cases of this kind. Cushing has shown the advantage of the administration of atropine before these operations, in order to limit the flow of saliva and keep the parts dry. The sac having been exposed by a long incision in front of the sternomastoid, it may be filled with a solution containing methyl blue, by which it may be identified, or it may be filled with paraffin, which, solidifying, will serve admirably for its identification. It then may be attacked as would be any solid tumor. The sac having been identified and extirpated its opening into the esophagus is then closed by sutures and the neck wound cared for as usual, with provision for drainage (Figs. 511 and 512).

Traction diverticula may be amenable to surgical intervention. Should the esophagus be diverted by adhesion to an advancing aneurysm nothing should be attempted. Among the operations which may be practised upon the thorax there may be mentioned a method of posterior exposure and attack upon some of these conditions which may or may not afford advantages, according to the nature and location of the various conditions.

Cardiospasm (see chapter on the Stomach) produces a sacculation of the gullet often mistaken for diverticulum, and requiring to be differentiated from it.

FOREIGN BODIES IN THE ESOPHAGUS.

Foreign bodies may be lodged in any portion of the esophageal tube and cause a variety of troubles, according to their size, shape, location, and nature. There is scarcely any conceivable object which may be introduced into the mouth which has not been known to be impacted in the esophagus and produce more or less serious symptoms. Young children, imbeciles, and the insane may suffer unwittingly in this way, while the condition is usually accidental and unintentional.

The accompanying figures (Figs. 513 and 514), portraying in one case a jackstone lodged in the esophagus, a coin in the other, a case of my own, will furnish illustrations of what has just been said. (See also page 674.) The young and the insane may make no statement which will furnish a clue for the distress caused in attempts to swallow or the actual impossibilities of the act. In most instances, however, a history of impaction and a statement as to the nature of the foreign body may be obtained. The symptoms produced are those of partial or complete inability to swallow, of more or less pain accompanying the act, and of the regurgitation often of blood or of bloody mucus. The object may be sufficiently large to produce dyspnea and suffocative symptoms, e. g., a plate with false teeth.

The condition being suspected or made known, the location of the foreign body may be determined by the esophageal bougie and by the use of the x-rays. With certain irregularly shaped objects the latter prove a desirable help, especially when irregular plates containing false teeth, or toys have been passed into the esophagus. They afford an indication not only as to their exact situation and emplacement, but also as to the best method of attack, that is, whether from without or within. Considerable distress may be produced by even small particles, as chips from an oyster-shell, small pieces of glass, and the like.

Treatment.

—A foreign body which produces the slightest discomfort or recognizable symptoms should be removed. Only occasionally can this be done by making the patient endeavor to swallow something else, this being too uncertain a method of procedure; although I have known a peach-stone impacted in the esophagus to be pushed into the stomach by the passage of an esophageal bougie. The situation and the nature of the object being known, one then decides how best to proceed. The available methods of operation are:

• 1. The introduction of a bougie and the enforced passage of the object into the stomach (questionable).
• 2. The use of the esophageal snare.
• 3. The use of the esophageal forceps or similar means of extraction.
• 4. The more directly operative methods by external incision.

The esophagoscope is an instrument of comparatively recent device and perfection. We owe it largely to the ingenuity of Mikulicz. It is to the esophagus what the endoscope is to the urethra, and may be regarded as essentially an enlarged endoscope. Its introduction is comparatively easy, but its retention is distressing to the patient, so that opportunity may thus not be afforded for profiting by its use. The employment of cocaine anesthesia, and perhaps of morphine hypodermically, will sometimes enable it to be used satisfactorily. It may also be used for exploratory purposes previous to commencing a formal operation under general anesthesia. There are furnished with the instrument itself forceps and extractors, by which it may be possible, when the object is once seen, to grasp and withdraw it. The use of the esophagoscope is, moreover, not limited to these lesions, since it can be used in revealing the character of strictures, small wounds, diverticular openings, and the like. Endeavors may be first made to locate the body by those possessing such an instrument and expert in its use.

The esophageal snare is a simple instrument which, after being introduced, is shortened in such a way as to cause to protrude a basket-like meshwork of bristles in which, as the instrument is withdrawn, a small object may be entangled and so withdrawn. In the same way an ingeniously made coin catcher is furnished, which, in cases of impacted coins or similar shaped objects in the esophagus, may be introduced beyond them and then withdrawn, the object being caught in a miniature cradle, from which it cannot escape until brought up into the pharynx. Esophageal forceps are made with long blades, curved like all the instruments used within the pharynx, and serving admirably for grasping objects impacted high in the tube (Figs. 515 and 516).

Dislodgement being impossible by either of the above-mentioned expedients, recourse may be had to the operation of external esophagotomy. This may require to be done as an emergency measure, but is practically always indicated when an impacted object cannot be otherwise removed. A dangerous location for a foreign body in the esophagus is at a distance of about nine inches from the upper incisor tooth, at which point it will be located directly behind the arch of the aorta, at which level ulceration would perhaps result disastrously, as Richardson has shown. The operation was devised by Goursault, in 1773, and has proved a satisfactory surgical measure. It is performed upon the left side of the neck. The incision is made along the anterior margin of the sternocleidomastoid from the middle of the neck downward. The larynx and trachea are separated to the inner side, the muscles and the large vessels to the outer side, the omohyoid divided, the descendens noni and the recurrent laryngeal nerves, which lie in the groove between the trachea and the gullet, are protected from injury, and the esophageal tube thus exposed. The surgeon will feel more secure in opening it if he now pass downward through the mouth a bougie or instrument upon whose beak or tip he may cut down. The esophagus being opened, the margins of the wound are secured by sutures which serve as retractors, and the interior of the tube is then subjected to the necessary manipulation. Even now it may not be an easy matter to dislodge a pointed object, which may have become partially impacted. Thus it may be dislodged at first by pushing it down a short distance and turning it, the direction having been already indicated by an x-ray picture. The manipulation should be as gentle as possible. Extraction having been accomplished, the esophageal wound is closed by the sutures introduced for traction purposes. Over this the external wound is closed, with suitable provision for drainage, as it is almost certain to have been infected during the procedure. In rare cases it has been necessary to combine a gastrotomy with this operation, in order that by combined manipulation a peculiarly shaped object may be dislodged.

Gastrotomy will be necessary in but few instances, as, for instance, when an object known to be one which cannot pass through the pylorus has been dislodged into the stomach by pressure from above—as plates containing false teeth, and various similar objects. It will probably be safer to open the stomach and remove the object than to leave a patient to his otherwise uncertain fate. On the other hand objects which are sure to be in time dissolved or disintegrated by the stomach juices may be allowed to remain to await this event.

WOUNDS OF THE ESOPHAGUS.

Wounds of the esophagus occurring in other ways than those above indicated may be the result of gunshot and various perforating injuries. The tube may be also partially cut across in so-called cut-throat.

Any external wound of the esophagus which can be recognized should be closed with sutures, and the parts brought together, if possible, with provision for drainage. Those lacerated wounds constituting some forms of cut-throat, however, permit of very little in this direction, for when seen they are too infected. Through an esophageal opening thus inflicted the patient may be fed for a time by a tube, the wound being left to close later by granulation or by a secondary operation. When the esophagus has been anywise injured it would be better to abstain from feeding or else to introduce food through an esophageal tube.

RUPTURE OF THE ESOPHAGUS.

Rupture of the esophagus has been known to occur in consequence of severe vomiting, there being some twenty-five cases of this character now on record. (Dennis.) A tear is rarely complete, but it may be followed by hernia and formation of a diverticulum. The accident will be indicated by violent pain following severe vomiting in connection with an effort to dislodge a foreign body. There will be more or less shock and perhaps collapse, with escape of blood. Emphysema of the neck and upper part of the chest may result and the injury prove fatal. The condition being suspected, it would be advisable to do an external esophagotomy or else to carefully introduce a stomach tube and leave it in situ.

PERFORATION OF THE ESOPHAGUS.

Perforation—i. e., rupture without traumatism—may result from the existence of ulcers or from the advance of malignant disease. It may occur in either direction. Thus while the mediastinum may be infected from entrance of septic material into it the direction may be reversed and an abscess or other lesion of the surrounding tissues may evacuate itself into the esophagus. Should this prove to be an aneurysm the patient will die with uncontrollable escape of blood. The treatment of such a case, if any be permitted, will depend entirely on the nature of the exciting cause. Perforation has also followed injudicious use of bougies when exploring or treating strictures (especially cancerous) of the esophagus.

ESOPHAGISMUS.

Esophagismus, or spasmodic contraction of the esophagus, is usually an expression of hysteria, or else is a reflex spasmodic effect due to the presence of some neighboring irritation. In the esophagus, as in the urethra, there may be spasmodic stricture, which will afford considerable obstruction. Thus I have seen it as a functional neurosis, absolutely without explanation, in an apparently healthy workingman. It is noticed also in connection with hemorrhoids and with hepatic lesions. It is seen in pregnancy, and a certain degree of it will complicate many cases of gastric ulcer, gastritis, or esophagitis such as is produced by swallowing mild caustics. While producing dysphagia and obstructive phenomena it is intermittent and interposes little real obstacle to the passage of a full-sized bougie or tube. It is frequently accompanied in the hysterical by globus hystericus, and by regurgitation of whatever food the patient attempts to swallow.

The local treatment consists of dilatation by the passage of full-sized instruments at frequent intervals. If a neurosis the patient may require other treatment, addressed either to the nervous system or to any well-marked constitutional condition.

STRICTURE OF THE ESOPHAGUS.

Stricture of the esophagus has an etiology practically identical with that which pertains to stricture of any other passage of the body. It may be due to extrinsic or intrinsic influence. Among the former may be mentioned the presence of tumors, either benign or malignant, or of cicatricial tissue, while among the latter should be mentioned the injuries resulting from the presence of foreign bodies, the extensive ulcerations due to the swallowing of various caustic fluids, and the cicatricial contraction which may follow other lesions like ulceration. Those cases which are due to serious congenital defects will usually die early. Of the ulcerative lesions which lead to stricture the most common are the cancerous. Syphilitic and tuberculous ulcerations may occasionally produce the same effect. By far the most common causes are the traumatic, which are connected either with foreign bodies or with the unfortunate accidental use of caustics.

Esophageal strictures are recognized by the difficulty in swallowing which they produce and the later dilatation of the esophagus above, which is the frequent result of their long existence. The degree of difficulty experienced by the patient in deglutition is to a considerable degree a measure of the extent of contraction. It may be nearly always assumed that such a stricture as is produced by the swallowing of caustic fluids will leave a tortuously contracted passage-way, and the instrument passed for its recognition, while arrested in its upper portion, may give little or no correct idea as to the arrangement below. In some instances it may be possible here, as in the case of diverticula, to introduce sufficient bismuth emulsion into the esophagus to make it cause a shadow in an x-ray picture, and in this way to give pictorial information not otherwise attainable.

The surgeon should distinguish between hysterical spasm or esophagismus and cicatricial stenosis. The former will offer but little obstacle to the passage of a full-sized bougie. In fact it will be frequently benefited, usually cured by it, while in the latter instance this is almost impossible.