cicatrices.

_The diagnosis_ of luetic lesions of the esophagus, therefore, depends
upon the history, presence of luetic lesions elsewhere, the serologic
reaction, therapeutic test, examination of tissue, and the
demonstration of the treponema pallidum. The therapeutic test by
prolonged saturation of the system with mercury is imperative in all
suspected cases and no other negative result should be deemed
sufficient.

_The treatment_ of luetic esophagitis is systemic, not local. Luetic
cicatrices contract strongly, and are very resistant to treatment, so
that esophagoscopic bouginage should be begun as early as possible
after the healing of a luetic ulceration, in order to prevent
stenosis. A silk-woven endoscopic bougie placed in position by ocular
guidance, and left _in situ_ for from half to one hour daily, may
prevent severe contraction, if used early in the stage of
cicatrization. Prolonged treatment is required for the cure of
established luetic cicatricial stenosis. If gastrostomy has been done
retrograde bouginage (Fig. 35) may be used.

TUBERCULOSIS OF THE ESOPHAGUS

_Esophageal tuberculosis_ is not commonly met, but is probably not
infrequently associated with the dysphagia of tuberculous laryngitis.
It may rarely occur as a primary infection, but usually the esophagus
is involved in an extension from a tuberculous process in the larynx,
mediastinal lymphatics, pleura, bronchi, or lungs.

Primary lesions appear as superficial erosions or ulcerations, with a
surrounding yellowish granular zone, or the granules may alone be
present. The mucosa in tuberculous lesions is usually pallid, the
absence of vascularity being marked. Invasion from the periesophageal
organs produces more or less localized compression and fixation of the
esophagus. The character of open ulceration is modified by the mixed
infections. Healed tuberculous lesions, sometimes resulting from the
evacuation of tuberculous mediastinal lymph nodes into the esophagus
may be encountered. The local fixation and cicatricial contraction may
be the site of a traction diverticulum. Tuberculous esophago-bronchial
fistulae are occasionally seen.

_Diagnosis_, to be certain, requires the demonstration of the
tubercule bacilli and the characteristic cell accumulation of the
tubercle in a specimen of tissue removed from the lesion.
Actinomycosis must be excluded, and the possibility of mixed luetic
and tuberculous lesions is to be kept in mind. Post-