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 {421} 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. {422} 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.
Organic Stricture of the Oesophagus.
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 Homes[17]),
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.
[Footnote 17: _Biblioth. méd._, t. viii. p. 260; Michel, _Dict.
Encyclopedique_, t. xiv. p. 466.]
[Footnote 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, {423} 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.
[Footnote 19: _The Lancet_, 1872.]
[Footnote 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.
{424} 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 {425} 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
{426} 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 reported[21] 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.
[Footnote 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.
Carcinoma of the Oesophagus.
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.
{427} 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 (Newman[22]). 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 {428} may be involvement of the pneumogastric
nerve, with reflex influence on the spinal nerves and the sympathetic
(Gurmay[23]).