DEFINITION.—A chronic inflammation of some of the tissues of the oesophagus.
SYNONYM.—Oesophagitis chronica.
ETIOLOGY.—Chronic oesophagitis is sometimes a sequel of the acute affection. More frequently it is the result of excessive use of strong alcoholic beverages or of very hot drinks. It is said to be sometimes the result of passive congestion in chronic pulmonary and cardiac diseases. It follows the prolonged sojourn of foreign bodies in the oesophagus. It exists in connection with carcinoma of the oesophagus, with dilatation, and with stricture of the oesophagus, and with other diseases obstructing the tube externally or internally. It is sometimes produced by caries of the vertebræ, both scrofulous and syphilitic, and by the pressure of aneurismal and other tumors.
PATHOLOGY AND MORBID ANATOMY.—Hypertrophy of the mucous membrane of the oesophagus, of the submucous connective tissue, and even of the muscular coat, are the processes which take place in chronic oesophagitis, especially when it has been of long continuance. This hypertrophy, when at or near the cardiac extremity, may produce stricture (Rokitansky and others), with subsequent dilatation of the oesophagus from its frequent and prolonged distension by food which should have passed on at once into the stomach.
On post-mortem examination the main evidences of disease are most frequent in the lower third of the organ. Its folds of mucous membrane are thick and prominent, dirty red, brownish-red, or gray, as may be, abraded here and there, and covered with viscid muco-purulent secretions. Abscesses and ulceration are not uncommon in cases due to prolonged pressure or extension of disease from outside the tube. Such ulceration has not uncommonly been the source of serious hemorrhage.
Diffuse inflammation of the peri- or retro-oesophageal connective tissue has been noted as an occasional sequel to the inflammatory process in the walls of the oesophagus.
SYMPTOMATOLOGY, ETC.—The symptoms of simple chronic oesophagitis are similar in the main to those of mild acute oesophagitis, but are often still more moderate, and therefore likely to be overlooked. In severe cases the symptoms are chiefly those of the disease, usually stenotic, which has excited the chronic inflammatory process. The course is prolonged and the duration indefinite. Stricture is a frequent sequel.
DIAGNOSIS.—The diagnosis rests on the same principles and inferences as in acute oesophagitis, the symptoms, however, being of longer duration. The auscultatory signs of arrest or impediment in the descent of the solid or liquid bolus are usually more definite than in acute oesophagitis. The same differentiations are available in excluding spasm, stricture, and malignant diseases. The use of the sound or catheter is much more justifiable than in the acute variety.
PROGNOSIS.—The prognosis is usually unfavorable, on account of the great liability to stricture and occlusion from organization of inflammatory products.
TREATMENT.—Chronic oesophagitis may require both local and constitutional treatment. The constitutional treatment will have to be adapted to the cause of the disease. If due to obstructed circulation in consequence of valvular disease of the heart, digitalis and remedies of its class will be indicated. If due to obstructive pulmonic disease, chloride of ammonium and alkaline remedies will be indicated. Syphilitic inflammation requires the mixed treatment, with mercuric chloride and potassium iodide or their equivalent. Iodides, indeed, are often required in non-specific cases, and are useful particularly in ordinary circumscribed oesophagitis. Under all conditions alcoholic beverages should be interdicted, and so should the deglutition of all irritating food and drink. Mild, bland, and mucilaginous substances should be largely employed in food and drink. The copious use of carbonic-acid waters is also recommended (Oppolzer). Sinapisms and revulsives to the side of the cervical and dorsal vertebræ are also recommended by some writers (Oppolzer).
The topical treatment consists in the systematic use every few days of aqueous solutions of astringents (alum, tannin, ten to thirty grains to the ounce) or alterants (compound solution of iodine, twenty minims to the ounce) passed gently over the diseased surfaces by means of a piece of soft surgical sponge securely attached to a flexible staff.
Severe pain of rather sudden occurrence is usually attributable to circumscribed ulceration, and is best treated by superficial cauterization, as above, with a dilute solution of silver nitrate (ten grains to the ounce). These remedies may be used in the form of ointments of the same strength smeared upon a rather large flexible bougie. To relieve pain and sense of constriction belladonna or stramonium ointment, applied in the same manner, sometimes fulfils a useful indication. Before making these applications attempts should be made by auscultation to locate the seat of disease or obstruction. After subsidence of the disease, occasional catheterization may be practised at intervals of several weeks, in order to detect any recommencing stenosis.
DEFINITION.—Circumscribed destruction of portions of the mucous membrane of the oesophagus, the result of inflammatory processes.
ETIOLOGY.—Ulceration of the oesophagus occurs as a result of inflammation of the organ, as discussed in connection with Oesophagitis, and the cause varies with the character of the oesophagitis, whether idiopathic, traumatic, or symptomatic of disease elsewhere. Diseases, constitutional or local, provocative of ulceration of the oesophagus, usually implicate some portion of either the alimentary or the respiratory tract.
SYMPTOMATOLOGY.—The symptoms are in the main those described under Acute Oesophagitis, particularly the expulsion of sanguinolent products or of unmixed blood. Perforation into the trachea is indicated by expectoration of food or drink; perforation into the great vessels, by hæmatemesis, usually fatal; and perforation into the mediastinum, by emphysema and purulent cellulitis. When large or extensive ulcerations have cicatrized they occasion symptoms of organic stricture.
PATHOLOGY AND MORBID ANATOMY.—Referring to the corresponding section under Oesophagitis, attention may be directed here to the liability of deep-seated ulcers of the oesophagus to perforate the gullet and establish fistulæ with the trachea, bronchi, mediastinum, aorta, and carotid artery, according to the locality of the lesion. These lesions are usually necessarily fatal.
DIAGNOSIS.—The presence of blood in matters regurgitated or vomited forms the chief diagnostic indication of ulceration of the oesophagus, taken in connection with the usual symptoms of acute or chronic oesophagitis.
PROGNOSIS.—The prognosis is altogether dependent on the nature of the disease which has given rise to the ulceration.
TREATMENT.—The constitutional treatment will depend on the nature of the disease which has occasioned ulceration. Ergot and turpentine are administered in case of hemorrhage—the former best, perhaps, hypodermatically. Attempts are sometimes made to cauterize the ulcer or ulcers with nitrate-of-silver stick conveyed in a covered slotted canula, to be exposed when the fenestrum reaches the ulcerated locality, previously determined by catheterization, or inferred to be reached by the sensations of the patient. The practice is uncertain in its manipulation and questionable in its results.
DEFINITION.—A constriction of the calibre of the oesophagus, whether spasmodic or organic in character. This definition excludes stenosis due to pressure from without.
DEFINITION.—A contraction of the muscles of the oesophagus, of variable duration, causing partial or complete stenosis of the gullet and interfering with the passage of food or of food and drink to the stomach.
SYNONYMS.—Oesophagismus, Spasm of the oesophagus, Cramp of the oesophagus, Convulsive dysphagia, Spasmodic dysphagia, Spasmodic stenosis of the oesophagus, Spastic stricture of the oesophagus.
HISTORY.—On this subject there is little of importance in medical annals previous to the observations of Frederick Hoffmann,15 and little of importance subsequently save the observations of Mondière,16 though numerous personal observations are on record, as well as a number of excellent compilations in various monographs, text-books, encyclopædias, and dictionaries.
15 De spasmo gulæ inferioris, Halæ, 1733; De morbis oesophagi spasmodicis, Opera omnia, vol. iii., Geneva, 1761.
16 "Recherches sur l'Oesophagisme ou Spasme de l'Oesophage," Arch. gén. de Méd., April, 1833.
ETIOLOGY.—Spasmodic stricture of the oesophagus is a neurosis often hysterical. It is much more frequent in females than in males, and, although observed in young subjects and less frequently in old ones, is most common between the ages of twenty and fifty. It is sometimes observed in several members of a neurotic family. It is often associated with other evidences of neurosis, but sometimes constitutes the sole manifestation. Sometimes the cause defies detection. Sometimes it can be traced to a fear of strangulation, induced primarily by some accidental impediment to deglutition or the entrance of a foreign body. Strong mental emotion, such as the dread of hydrophobia after having been bitten by a dog, sometimes produces the affection.
It occurs in connection with organic lesions of the oesophagus, organic lesions of the stomach, organic lesions of the larynx and trachea, and organic lesions of the lungs, heart, large blood-vessels, and perioesophageal tissues, but likewise as a reflex disorder, with lesions of distant organs, as the genito-urinary tract, the intestines, the brain and spinal cord. Even pregnancy may produce reflex oesophagismus. It sometimes occurs as a direct or reflex manifestation of gout and of rheumatism. In a few instances it occurs as one of the manifestations of tetanus and of hydrophobia.
SYMPTOMATOLOGY, COURSE, DURATION, ETC.—The spasm may affect the oesophagus only, or may be associated with spasm of the muscles of the pharynx. It is usually manifested in a sudden inability to swallow or to complete the acts of deglutition. This may be transitory or may continue for a number of hours. The relaxation of the spasm is sometimes followed by the discharge of flatus and the copious secretion of pale urine. The spasm may recur at irregular intervals or be more or less distinctly intermittent. Sometimes it precedes every effort at deglutition. In some instances it occurs only upon attempts to swallow certain kinds of food, and the articles of food vary with different patients. Cold viands sometimes produce spasm when warm and hot food is tolerated. Consciousness of a liability to spasm increases the dysphagia for the time being, or brings it on suddenly when this liability had been forgotten. The spasm is sometimes painless and sometimes painful. In some instances it is associated with partial regurgitation of a mass of air (the globus hystericus).
The dysphagia is rarely complete, instances in which no liquids can be swallowed being infrequent. The aliment swallowed usually passes on into the stomach, upon relaxation of the spasm, after a certain period of detention varying from a number of seconds to many minutes. In cases of prolonged or persistent spasm the aliment is usually rejected, either at once or after a time, according as the contraction takes place at the pharyngeal extremity of the oesophagus or lower down. When rejected after some detention in the gullet, the aliments are usually enveloped with mucus or followed by expulsion of mucus and of flatus.
In some subjects the pain in swallowing is severe. Sometimes it is associated with spasm of the diaphragm (hiccough), spasm of the air-passages, palpitation of the heart, and syncope.
The liability to spasm sometimes continues for years. Sometimes it ceases permanently as suddenly and as unexpectedly as it began.
The seat of the spasm is referred by the patient to different regions, which in their totality comprise the entire extent of the oesophagus. In some patients the seat varies on different occasions. The actual seat of any individual spasm is best determined by exploration with the oesophageal bougie or by auscultating the oesophagus during the passage of a bolus. It is most frequent perhaps at the upper extremity, and then perhaps at the cardiac extremity. When habitually low down, there is some liability to permanent distension of the oesophagus from repeated retentions of food at the same place for hours together. In some instances food is regurgitated from the oesophagus after its retention for a day or even longer. When the spasm is high up, the regurgitation may follow the act of deglutition almost immediately.
PATHOLOGY AND MORBID ANATOMY.—The affection being usually a pure neurosis, there is no oesophageal lesion to be cited. In some of the few autopsies recorded, constriction has been noted without lesion of tissue.
DIAGNOSIS.—The diagnosis is based on the sudden onset of the spasm without assignable cause, its intermittent or recurrent character, its manifestation in advance of the effort at deglutition, the symptoms of regurgitation, the coexistence of some of the affections mentioned in connection with its etiology, and on the satisfactory result of exploration with the oesophageal bougie; which differentiates the affection from organic stricture or mechanical obstruction. In catheterization of the oesophagus in cases of pure spasm, although the sound is usually arrested at the seat of constriction, it passes onward after a few moments by sudden relaxation of the spasm. Sometimes, indeed, the very first manipulation of this kind overcomes the spasm permanently.
In the absence of other indications the differentiation from spasm of organic origin rests, in great measure, on the conservation of nutrition, cases being few in which the spasm is persistent enough to interfere so materially with the ingestion of aliment as to produce emaciation.
PROGNOSIS.—The prognosis is usually favorable in spasm of the oesophagus, except in cases where the underlying malady is itself a grave one. Patients do not die of neurotic spasm of the oesophagus. In the majority of cases it is susceptible of cure within a few weeks, sometimes much more promptly. Even when it continues for months or for years there is little fear of permanent injury to the general health, inasmuch as sufficient nutriment of some kind or other can be ingested to sustain the patient.
The duration of the affection depends upon the surroundings of the patient, his amenability to treatment, and the existence or absence of disease in the oesophagus or elsewhere. In cases dependent upon diseased conditions in the oesophagus or elsewhere the character of the disease controls the prognosis, both immediate and ultimate. Thus, aneurism of the aorta, tuberculosis, ulceration of the larynx and trachea, carcinoma of the stomach, tetanus, and hydrophobia present the highest unfavorable indications. Purely neurotic cases are extremely prone to recurrence.
TREATMENT.—The treatment to be pursued will depend upon the nature of the case. If due to organic lesion in the oesophagus or in some other organ, the treatment will be directed to that affection, whatever it may be. If due to emotional disturbance, therapeutic efforts will be directed to their suppression or removal. If purely hysterical, appropriate constitutional remedies for that condition will be prescribed. These comprise asafoetida, valerian, camphor, musk, oxide of zinc, bromides, belladonna, conium, and so on, best administered in small doses at frequent intervals.
Local treatment is almost always necessary, both for its beneficial mechanical effects and for its emotional influence. This consists in the systematic passage of the bougie; and it is by far the best practice to insist upon the patient's submission to it without an anæsthetic. In cases of intense hyperæsthesia, which are rare, and in the initial exploratory passage of the instrument in highly excitable or uncontrollable subjects, anæsthesia may be resorted to if there be no contraindication. The mere passage of the bougie will often effect immediate relaxation of the spasm. When required, the manipulation may be repeated a few times at intervals of several days. Should the passage of the bougie determine the stricture to be purely spasmodic, the patient should be made to partake of food in the physician's presence at first, and afterward under the supervision of an efficient attendant, until it becomes evident that there is no absolute impediment to the passage of food. The presence of the physician during early attempts at taking ordinary food imparts such confidence in the patient that he soon overcomes his dread of strangling and learns to eat again as he should do. Meantime, it may be necessary from time to time to pass the bougie just before food is taken. In such cases it is well to smear the instrument with ointment of belladonna, so as to deposit it more or less along the entire tract of the oesophagus. Failing by these methods, success may follow the occasional passage, at intervals of a few days, of a sponge probang saturated with a very weak solution of iodine or of silver nitrate.
Counter-irritation along the course of the pneumogastric nerve or along the spine is sometimes useful.
Electricity is sometimes employed to overcome the spasm; but intra-oesophageal electrization of every kind is risky from the danger of exciting fatal syncope from irritation of the pneumogastric nerve. This objection is not applicable to percutaneous electrization, save in a much more limited degree. Caution is requisite even with external manipulations along the tract of the pneumogastric nerve; and such manipulations, therefore, should not be undertaken without sufficient familiarity with the effects of electric currents in that situation.
Taken all in all, the best results seem to follow the systematic use of the bougie and enforced deglutition under the eye of an attendant in whom the patient feels reliance can be placed in case the food should "go the wrong way" or become impacted in the gullet.
DEFINITION.—Diminution in the calibre of the oesophagus in consequence of organic alterations in its walls, whether interstitial, cicatricial, or malignant.
SYNONYM.—Stenosis of the oesophagus.
HISTORY.—As mentioned in connection with other affections of the oesophagus, so with organic stricture: though much more has been written on the subject, it is to the observations and publications of Mondière, so frequently cited, that we must credit medical literature with a due appreciation of this topic. The last thirty years especially have been prolific in the record of cases, and their study has been further stimulated by the attention directed to the operation of gastrostomy as a means of prolonging life in cases otherwise hopelessly fatal.
ETIOLOGY.—Organic stricture of the oesophagus is occasionally congenital. As a rule, life is rarely prolonged under such conditions, but cases are on record in which it has been preserved to quite advanced age. Thus, in a female who died from inanition at fifty-nine years of age, after lifelong symptoms of stricture (Everard Homes17), there was an annular stricture behind the first ring of the trachea; and in a male subject who died with pneumonia at seventy-four years of age, after lifelong symptoms of stricture,18 the stricture was found at the cardiac extremity of the oesophagus, which was enormously dilated its entire length above the constriction.
17 Biblioth. méd., t. viii. p. 260; Michel, Dict. Encyclopedique, t. xiv. p. 466.
18 Wilks, Path. Trans. London, xvii. p. 130; Holmes, The Surgical Treatment of the Diseases of Infancy and Childhood, 2d ed., p. 137.
In the majority of cases the stricture is due to cicatricial obliteration of more or less of the calibre of the oesophagus, the result of losses of substance following scalds produced by caustic substances swallowed, mostly by accident and sometimes by design. Wounds of all kinds, whether from the interior, as in the case of foreign bodies and instruments of extraction, or from the exterior, as in the case of surgical operations, wounds from firearms, and the like, are apt in their cicatrization to give rise to this form of stricture.
Though denied by some authorities, syphilitic disease of the oesophagus is an undoubted cause of stricture. Setting aside disputed records of older authorities, we may cite recent cases reported by Lancereaux, West,19 Wilks, Virchow, and Lublinski,20 the latter-named going deeply into the bibliography, pathology, and therapeutics of stricture from syphilis. The author could add his personal testimony were it requisite.
19 The Lancet, 1872.
20 Berlin. klin. Woch., Aug. 20, 1883; London Medical Record, Nov. 15, 1883, p. 489.
Stricture of the oesophagus is likewise occasioned by the presence of papillomatous, fibroid, and other morbid growths. Carcinoma is quite a frequent cause.
The frequent deglutition of undiluted spirituous liquors is said to give occasion at times to stricture of the oesophagus, but in these instances this result is usually due to precedent chronic oesophagitis thereby excited, and terminating in infiltration and hyperplasia of the submucous connective tissue, and sometimes great thickening of the epithelium as well.
Males are more frequently the subjects of stricture of the oesophagus, and early adult life the most frequent period for its occurrence, though it may present at any age.
SYMPTOMATOLOGY.—Except in traumatic cases, the earliest symptoms, preceded in some instances by indications of mild oesophagitis, perhaps unnoticed or unrecognized, are occasional impediments to deglutition of large and firm boluses, or rather a mechanical obstacle to completion of the act of glutition occurring at intervals of a few meals or a few days. After a while the swallowing of a large solid bolus becomes permanently impracticable. Then, sometimes, repeated efforts become necessary to swallow small masses of solid food; and even to do this may require external manipulation, or at least the additional pressure of liquids swallowed immediately after the solid bolus. These efforts are sometimes attended with spasm, regurgitation, and pain, and may be accompanied in addition with tracheal dyspnoea, and with nervousness in consequence. As the disease progresses it becomes impossible to swallow solid food, and subsequently even fluid food in extreme cases. The bolus is then often regurgitated immediately after its deglutition, and may be covered with mucus, blood, pus, or fragments or detritus of ulcerated malignant growth, according to the nature of the case. Pain and sensations of rawness are often felt at the point of constriction, whence the pain often radiates toward one or both scapulæ. If the tube is much dilated above the stricture, the food may be detained in the sac for several hours, and then be regurgitated in a softened, partially-decomposed condition. Should the mass be so situated as to compress the trachea, suffocative symptoms may be produced.
In stricture due to organic disease there may be dysphonia from pressure or injury to the recurrent laryngeal nerve producing paralysis of the vocal band. The anatomical relations of the left recurrent nerve renders it the much more liable of the two to become implicated. Moderate dyspnoea may result from this paralysis by reason of the reduced space of the glottis.
PATHOLOGY AND MORBID ANATOMY.—Organic stricture of the oesophagus is usually due to disease or structural change involving the mucous membrane and submucous connective tissue; but the muscular structure may become involved likewise. It may, however, be due to abnormal laxity of the mucous membrane, permitting a fold to occupy a position impeding the passage of the bolus.
In cases which are not carcinomatous the diminution in the actual calibre of the tube is usually due to submucous proliferation of connective tissue and to thickening of the mucous membrane. The encroachment on the calibre of the tube may be quite slight, or may be so great as to amount to almost complete occlusion.
The seat of stricture is at the upper portion of the oesophagus most frequently, then at the cardiac extremity, at the point of crossing by the left bronchus, and at the point of passage through the diaphragm—all localities slightly constricted normally—but it may occur at any portion.
In most instances the stricture is single. There may, however, be two, three, or even four strictures. Multiple strictures are most common after deglutition of caustic substances which have made their way clear down into the stomach.
Syphilitic strictures are usually single, and so, as a rule, are strictures of malignant origin. The latter are much larger in extent.
Cicatricial strictures from caustic substances may be in the form of bands, rings, or longitudinal stripes or folds. Sometimes they are quite extensive, and have been known to interest fully one-third of the length of the oesophagus. The circumference, length, calibre, and thickness of the stricture, however, vary within the most extreme limits. Occasionally occlusion of the tube is complete.
The detention of food above the stricture usually dilates the oesophagus, producing hypertrophy of the mucous membrane and submucous connective tissue, followed in its turn by fatty degeneration. Atrophy of the oesophagus may ensue below the stricture if at all tight, and the mucous membrane becomes thrown into longitudinal folds.
DIAGNOSIS.—The diagnosis of organic stricture of the oesophagus rarely presents difficulty. Dysphagia, spasm, and regurgitation are quite characteristic of stricture. When the constriction is high up, the vomiting or regurgitation of food may closely follow its deglutition; when low down, this act may be delayed ten or fifteen minutes, in some cases for hours. Alkaline reaction of the vomited matters is indicative of their having failed to reach the stomach. The presence of blood-cells, pus-cells, and cancer-cells indicates ulceration, suppuration, and malignant disease, respectively.
Auscultation of the oesophagus during deglutition of water will indicate the seat of stricture by revealing the ascent of consecutive air-bubbles even when palpation with bougies fails. The passage of oesophageal bougies or the stomach-tube into the oesophagus will often reveal the point of stricture. Its length is estimated by the distance of the resistance offered to the passage of the instrument; its diameter, by the size of the largest instrument which can be passed through it; and its consistence, by the character of the resistance. Care is requisite in manipulating with these instruments, lest by undue exertion of force they be passed through an ulcerated portion of the wall of the tube or a diverticulum. The character of the resistance is sometimes the sole means of differentiating stricture from stenosis due to compression of the oesophageal wall from its outside.
It sometimes happens, in individuals with impaired sensitiveness of the epiglottis or vestibule of the larynx, that the exploratory bougie is introduced into the air-passage instead of the gullet. The usual premonitory phenomena of suffocation will indicate the mistake. There is some likelihood, too, of entering the larynx in individuals with unusually prominent cervical vertebræ and in cases of stricture at the extreme upper portion of the oesophagus. In introducing these instruments into the oesophagus, therefore, it is well that they be guided along the fore finger of the disengaged hand, and passed deeply into the throat, either to the side of the larynx or behind it. By keeping to the side and reaching the oesophagus by way of the laryngo-pharyngeal sinus the risk of entering the larynx may be avoided. Before introducing the tube the case should be carefully examined for aneurism, which by pressure sometimes gives rise to the ordinary subjective symptoms of stricture. Should aneurism be detected, passage of the tube would be hazardous.
PROGNOSIS.—The prognosis is in most instances unfavorable. It is comparatively favorable in cases of moderate stricture due to causes apparently remediable. The extent and volume of the stricture progress more or less slowly according to the nature of its cause, and in non-malignant cases, such as are due to the action of caustic substances, it may last for years before the patient, if not relieved, succumbs, as he does, from gradual inanition. In the earlier stages, before the hypertrophied muscles above the stricture undergo fatty metamorphosis, the increased muscular power is sufficient to force nourishment through the stricture; but when this becomes no longer possible progressive marasmus must ensue. Meantime, abscess may become developed in consequence of the pressure of retained food, and tuberculous degeneration of the lung and local gangrene may take place in consequence of the malnutrition.
TREATMENT.—The treatment of organic stricture of the oesophagus resolves itself into maintenance of the general health, the administration of the iodides to promote absorption of effusions into the connective tissue or the muscles, mechanical and operative measures for removal of the causes of the constriction or the strictured tissues themselves, and operations for securing artificial openings below the point of stricture for the introduction of nourishment (oesophagostomy and gastrostomy). Nourishment by enema is of great value.
In carcinomatous stricture local measures are in the main unjustifiable, as they usually entail injury which may prove very serious. Arsenic internally is thought to retard the progress of malignant disease when administered early and persistently. Morphine is used hypodermically to assuage pain.
In cancerous and tuberculous disease great caution is requisite in determining upon mechanical or surgical procedures. In cicatricial stenosis from the effects of caustic substances, such measures may be undertaken with much less consideration.
The local treatment consists in systematic mechanical dilatation with bougies or mechanical dilators properly constructed. These are employed daily, every other day, or at more prolonged intervals, according to the tolerance of the parts and the progressive improvement. They are retained several moments at each introduction, and followed by the passage and immediate withdrawal of an instrument of larger size. It is often advisable that the final dilatation of each series be made with a stomach-tube, so that liquid food may be poured through it from a syphon or a small-lipped vessel, that there may be no necessity for swallowing food for some hours thereafter. This method is continued until it becomes evident that nothing further is to be gained by its continuance. In cases that have been at all successful, the introduction of the instrument should be repeated every week or two for a long time, to prevent or retard recurrence of the constriction, which is very liable to take place. M. Krishaber has reported21 cases in which a tube passed through the nose was retained from forty to three hundred and five days; and from this success he deduces the practicability of continuous dilatation in this manner. Billroth and Rokitansky have encountered cases in which frequent dilatation had set up inflammation of the surrounding connective tissue, which had caused fatal pleurisy by continuity.
21 Trans. Internat. Med. Congress, London, 1881, vol. ii.
Forcible dilatation by mechanical separation of the sides of a double metallic sound has been employed with success in some instances. It is a risky procedure.
Destruction of cicatricial tissue by caustics has been attempted, and, though successes occasionally attend the practice, it is hardly considered sufficiently promising.
Division of the stricture by internal oesophagotomy, with subsequent dilatation, has been practised of late years, and offers some chances of success. Oesophagostomy and gastrostomy have been performed in some cases of impassable stricture, and the latter operation is gaining in favor. For surgical details, however, we must refer to works on surgery.
DEFINITION.—Carcinomatous degeneration of the oesophagus, whatever the variety.
SYNONYM.—Cancer of the oesophagus.
ETIOLOGY.—Carcinoma is the most frequent disease of the oesophagus that comes under professional observation. The most frequent variety is the squamous-celled (53 out of 57, Butlin). Spheroidal-celled and glandular-celled varieties are much less frequent. In some instances the morbid product is a combination of the two. Colloid degeneration is occasionally met with. Carcinoma is usually primitive. Its cause is undetermined, but, as it is most frequent at the constricted portions of the tube, pressure is supposed to be the exciting cause. It does not always give rise to secondary infection. Sometimes it is an extension from the tongue, epiglottis, or larynx, or from the stomach. It is most frequent in males, and more so in the intemperate than in the abstinent.
The immediate exciting cause is often attributed to local injury from retention of foreign bodies or the deglutition of hot, acrid, or indigestible substances.
There appears to be some disposition to carcinoma of the oesophagus in tuberculous subjects (Hamburger), while the children of tuberculous parents may have carcinoma of the oesophagus, and their offspring, again, tuberculosis.
SYMPTOMS.—The earliest local symptom is slight dysphagia, with impediment to completion of the act of glutition—an evidence of commencing stricture. Subsequently, inverted peristaltic action is added, an evidence of dilatation above the stricture, with partial retention of food. At a later stage vomiting will occur, with admixtures of pus and sanguinolent fragments of cancerous tissue.
Progressive emaciation and impaired physical endurance usually precede these local symptoms, but actual cachectic depression may come on quite tardily. At first there is no pain; subsequently there comes on considerable uneasiness at some portion of the tube. Finally, there may be severe local burning or lancinating pains, particularly after meals. If the disease be high up, there may be pain between the shoulders, along the neck, and even in the head, with radiating pains toward either shoulder and along the arm. If low down, there may be intense cardialgia and even cardiac spasm. If the trachea or larynx be compressed or displaced, dyspnoea will be produced. If the recurrent laryngeal nerve be compressed, there will be dysphonia or aphonia. Perforation of the larynx will be indicated by cough, expectoration, hoarseness, or loss of voice; of the trachea, by paroxysmal cough, dyspnoea, or suffocative spasm; of the lungs, by acute pneumonitis, especially if food shall have escaped, and expectoration of blood, pus, and matters swallowed, as may be; of the pleura, by pneumothorax; of the mediastinum, by emphysema; of the pericardium, by pericarditis; of the large vessels, by hemorrhage. Perforation of the aorta or pulmonary artery is often followed by sudden death from hemorrhage, and of the lungs by rapid death from pneumonitis.
PATHOLOGY AND MORBID ANATOMY.—Primitive carcinoma is usually circumscribed. It is most frequent at the cardiac extremity, but often occurs where the oesophagus is crossed by the left bronchus, and sometimes occupies the entire length of the tube. The greater proclivity of the lower third of the oesophagus has been attributed to mechanical pressure where it passes through the diaphragm; that of the middle third, to pressure of its anterior wall against the left bronchus by the bolus. It begins, either nodulated or diffuse, in the submucous connective tissue, implicates the mucous membrane, encroaches upon the calibre of the tube, undergoes softening and ulceration, and becomes covered with exuberant granulations. When the entire circumference of the oesophagus is involved stricture results, sometimes amounting eventually to complete obstruction. Ulceration taking place, the calibre again becomes permeable. The oesophagus becomes dilated above the constriction and collapsed below it.
As the disease progresses the adjoining tissues become involved. Adhesions may take place with trachea, bronchi, bronchial glands, lungs, diaphragm, or even the spinal column (Newman22). Perforation may take place into the trachea, usually just above the bifurcation, or into the lungs, pleura, mediastinum, pericardium, aorta, or pulmonary artery. Abscesses are formed, the contents of which undergo putrefaction. There may be involvement of the pneumogastric nerve, with reflex influence on the spinal nerves and the sympathetic (Gurmay23).
22 N.Y. Med. Journ., Aug., 1879, p. 158.
23 Bull. méd. de l'Aisne, 1869; Gaz. méd. Paris, April, 1872.
DIAGNOSIS.—The diagnosis will rest on due appreciation of the symptoms enumerated and the ultimate evidence of the cancerous cachexia. Auscultation will often reveal the location of the disease. This may be further confirmed by palpation with the bougie, but the manipulation should be made without using any appreciable force. Laryngoscopic inspection and digital exploration are sufficient when the entrance into the oesophagus is involved.
Differential diagnosis is difficult at an early stage, and often to be based solely on negative phenomena. At a later stage it is easy, especially when cancerous fragments are expelled. In some instances a tumor can be felt externally. Such a tumor, however, has been known to have been the head of the pancreas (Reid24).
24 N.Y. Med. Journ., Oct., 1877, p. 404.
Cancer of the oesophagus is liable to be confounded with chronic oesophagitis, cicatricial stenosis, diverticulum, extraneous compression, abscess, and non-malignant morbid growths.
PROGNOSIS.—The prognosis is unfavorable, the disease incurable. Death may be expected in from one to two years, though sometimes delayed for longer periods. Inanition or marasmus is the usual cause of death in uncomplicated cases. Sometimes it takes place by hæmatemesis, sometimes following involvement of the stomach, and sometimes wholly unassociated with any direct disease of the walls of the stomach. Death takes place not infrequently from perforation into adjoining organs, and sometimes from secondary inflammation of other vital organs, as the brain and the lungs.
TREATMENT.—There is little to be done in the way of treatment apart from the constitutional measures indicated in carcinoma generally and in chronic diseases of the oesophagus. The cautious use of the stomach-tube to convey nourishment into the stomach is allowable during the earlier stages of the disease only. It is dangerous after ulceration has taken place, from the risk of perforating the walls of the oesophagus, and thus hurrying on the fatal issue by injury to the intrathoracic tissues.
When deglutition becomes impracticable or the passage of the oesophagus absolutely impermeable to nutriment, food and alcoholic stimuli should be administered by enema. Indeed, it is good practice to begin to give nourishment occasionally by the bowel before it becomes absolutely necessary, so as to accustom the part and the patient to the manipulation. Narcotics to relieve pain are best administered hypodermatically, so as to avoid unnecessary irritation of the rectum.
The passage of dilators, as in stricture of cicatricial origin, is very hazardous. They produce irritation, which hastens the softening of the tissues, and are open to the risk of penetrating the softened tissues and passing through the walls of the oesophagus into the pleura, lung, or mediastinum. Fatal accidents of this nature are on record.
Gastrostomy is sometimes performed to prolong life.