[Footnote 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 (Reid[24]).
[Footnote 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.
{429} Paralysis of the Oesophagus.
DEFINITION.--Loss of motive-force in the muscular tissue of the
oesophagus, whether intrinsic or reflex in origin.
SYNONYMS.--Gulæ imbecillitas, Paralytic dysphagia, Atonic dysphagia.
ETIOLOGY.--Paralysis of the oesophagus may be caused by impairment of
function in one or more of the nervous tracts distributed to the
muscles concerned in dilating the upper orifice of the gullet or in
those concerned in the peristaltic movements which propel the bolus to
the stomach. These impairments of function may be nutritive in origin,
as in softening and atrophy of the nerve-trunk, or, as is more
frequent, they may be pressure-phenomena from extravasations of blood,
purulent accumulations, exostoses, tumors, and the like.
The paralysis may be due to disease or wounds of the nerves themselves
or of their motor roots, or of the cerebro-spinal axis, implicating
their origin, or to pressure and atrophy of a trunk-nerve in some
portion of its tract. It is likewise due to neurasthenia from
hemorrhage or from protracted disease (enteric fever, yellow fever,
cholera), or to systemic poisoning in diphtheria, syphilis, and
plumbism. It may be due to muscular atrophy or intermuscular
proliferations of connective tissue, to dilatation of the oesophagus,
and to disease in the tube. It may be due to mechanical restraint from
external adhesions of the oesophagus to intrathoracic tumors
(Finny[25]). It may result from sudden shock or fright. It may follow
the sudden reaction of cold upon the overheated body. It is one of the
manifestations of hysteria and of the hysteria of pregnancy.
[Footnote 25: _Dub. Journ. Med. Sci._, Oct., 1877.]
SYMPTOMS.--Partial paralysis may give rise to no symptoms at all. The
earliest manifestations are those of impediment to the prompt passage
of the bolus to the stomach, repeated acts of deglutition or additional
swallows of food or drink being necessary. Large masses are swallowed
and propelled onward more readily than small ones, and solids more
readily than fluids. There is often a characteristic gurgling attending
the passage of fluids along the tube. Swallowing is best performed in
the erect posture. These symptoms increase in severity as the paralysis
increases. There is little pain or none at all. In some cases there is
no regurgitation of food; in others, this is more or less frequent.
When the paralysis is complete, deglutition becomes impossible, and the
food attempted to be swallowed is expelled from the mouth and nose in a
paroxysm of cough. Sometimes the food enters the larynx and produces
paroxysms of suffocation or threatens asphyxia.
There is more or less flow of saliva from the mouth in consequence of
the inability to swallow it; and in some cases the losses of material
from the blood are so great as to reduce the patient very rapidly.
PATHOLOGY AND MORBID ANATOMY.--Paralysis of the oesophagus may be
partial or complete. It may be associated with paralysis of the
pharynx, palate, tongue, epiglottis, or larynx; with so-called bulbar
paralysis; with general paralysis; with cerebro-spinal disseminated
sclerosis.
DIAGNOSIS.--The diagnosis rests mainly on the symptoms of dysphagia,
especially when associated with paralyses elsewhere. It is
differentiated {430} from paralysis of the pharynx by the ability to
swallow the bolus and the apparent arrest of the bolus at some portion
of the tube. Auscultation of the oesophagus will determine the locality
of the arrest. It likewise affords presumptive evidence of an
alteration in the usual form of the bolus, which, being subjected to
compression at its upper portion only, assumes the form of an inverted
cone. The remaining auscultatory indications are similar to those of
dilatation.
There is no impediment to the passage of the stomach-tube or
oesophageal sound, or to its free manipulation when within the
oesophagus.
When the symptoms quickly reach a maximum, they indicate a paralysis
due to apoplexy, and so they do when the symptoms are sudden, hysteria
being eliminated. Paralysis due to gumma or other cerebral tumor is
much slower in its course.
PROGNOSIS.--In idiopathic paralysis, the local or special affection to
which it is due being curable, the prognosis is favorable, especially
if the paralysis be confined to the oesophagus. Recovery, however, is
often slow, even in curable cases. In hysterical paralysis the
prognosis is good. In deuteropathic paralysis the prognosis is much
less favorable, and will depend upon the nature of the causal
disease--apoplexy, insanity, cerebral tumor, syphilis, etc.
TREATMENT.--The treatment varies with the nature of the cause as far as
combating the origin of the disease is concerned. With regard to the
intrinsic paralysis of the oesophagus itself, strychnine and its
congeners are indicated, and may be administered hypodermatically if
the difficulty in swallowing be very great. If the paralysis be
partial, it is better to give nux vomica or Ignatia amara by the mouth,
in hopes of getting some beneficial astringent influence on the walls
of the oesophagus.
In all instances the feeding of the patient is an important element in
treatment. Masses of food arrested in the tube should be forced onward
with the sound. In some cases nourishment must be habitually introduced
through the stomach-tube and nutritive enemata be resorted to.
Electricity, though sometimes successful, is a risky agent to employ,
because, as announced by Duchenne, the use of an oesophageal electrode
is attended with some risk of unduly exciting the pneumogastric nerve
and thereby inducing syncope.
Dilatation of the Oesophagus.
DEFINITION.--An abnormal distension of a portion of the oesophagus or
of the entire tube, whether general, annular, or pouched.
SYNONYMS.--Oesophagocele, Hernia of the oesophagus, Diverticulum of the
oesophagus.
ETIOLOGY.--Dilatation of the oesophagus is occasionally met as a
congenital affection (Hanney,[26] Grisolle,[27] and others). The cause
under these circumstances is obscure. Usually, however, dilatation of
the oesophagus is of mechanical origin, due to distension by food or
water above a stricture or an impacted foreign body. Presumptive
paralysis of the muscular coat in chronic oesophagitis is alleged as a
source of similar distension.
[Footnote 26: _Edinb. Med. and Surg. Journ._, July, 1883.]
[Footnote 27: _Traité Élément. de Path. int._, Paris, 1883, ii. p.
358.]
{431} General dilatation is presumed to be the mechanical result of
constriction of the cardiac extremity, leading to distension of the
oesophagus by the accumulation of large quantities of liquids.
Sometimes it is due to paralysis of the muscular coat, permitting its
distension by food.
Annular dilatation is sometimes due to distension just above the seat
of a stricture. Sometimes it is due to impaction of a foreign body;
sometimes there is no mechanical impediment; occasionally it is
observed as a congenital anomaly.
Pouched dilatation (diverticulum) is usually due to retention of food
immediately above an impacted foreign body or some obstruction of
another character. Some of the muscular fibres of the oesophageal wall
become separated and spread asunder, allowing the mucous membrane to be
gradually forced through them by repeated efforts of deglutition upon
retained masses of food or drink, until finally a pouch is formed,
hernia-like, outside of the tube. Another mode of production is said
(Rokitansky[28]) to consist in the subsidence of tumefied glands
outside the oesophagus, after adhesions had been contracted with the
oesophagus during the inflammatory process. The shrinking of these
enlarged glands to their normal volume sometimes draws the tube outward
into a funnel-shaped sac constricted at its margin by the muscular
coat, which has receded from the pouch or has been stripped loose. The
same form of dilatation is likewise an occasional result of rupture of
the muscular coat sustained in blows or falls. It occasionally exists,
too, as a congenital defect, and this has been attributed (Bardeleben
and Billroth[29]) to partial closing of one of the branchial fissures
externally, while the internal opening has remained patent.
[Footnote 28: _Archiv. gén. de Méd._, 1840, p. 329.]
[Footnote 29: _Trans. Clin. Soc. London_, 1881, p. 130.]
SYMPTOMATOLOGY.--The symptoms, at first, are usually those of
obstruction to the passage of food, but before this obstruction occurs
dilatation may have existed without symptoms. In some cases of
diverticulum high up, there is a tumor, usually on the left side of the
neck. Rokitansky has reported one the size of the fist situated on the
right side of the neck, and Hankel[30] and others a tumor upon each
side. The tumor varies in bulk from time to time according as it may be
empty or may be distended with food, drink, or gas.
[Footnote 30: _Rust's Mag._, 1833; _Dict. Encycl._, _loc. cit._]
Food caught in the pouch can often be forced out into the pharynx by
external pressure over the tumor in the neck. The retention of food
above a constriction or in a sac is usually accompanied by some
distress after indulgence in too much food. This uneasiness becomes
relieved upon regurgitation or vomiting. Deglutition is impeded to a
less extent when the disease does not implicate the upper portion of
the gut.
Complete dilatation is sometimes indicated by long addiction to habits
of rumination. In some instances this rumination is an agreeable
sensuous process. In pouched dilatation it is very often disagreeable,
the regurgitated matters being acrid, owing to acid fermentation of the
contents of the sac.
While the dilatation remains moderate there may be little dysphagia or
none at all, the muscles continuing sufficiently vigorous to propel the
food; but after the muscles become paralyzed by distension the
dysphagia gradually increases and may culminate in complete aphagia.
One {432} of the special indications of diverticulum is that the
regurgitation does not take place until several hours after a meal. As
the sac enlarges there may be less and less complaint of dysphagia,
because it becomes able to contain larger quantities of food. At the
same time it may so compress the main tube as to occlude its calibre
and prevent access of food to the stomach.
The symptoms of annular dilatation are similar to those of stricture
with retention of food above it, the regurgitation usually following
deglutition more quickly.
In some cases of dilatation, circumscribed and general, food is
sometimes retained for an entire day or more before it is ejected. The
decomposition of the retained food usually produces a more or less
continuous foul odor from the mouth.
The course of the affection is progressively from bad to worse, and
entails ultimate emaciation. Some patients succumb early, and some live
to advanced age. Perforation of the oesophagus ensues in some
instances, and death results in consequence of the injuries sustained
by perioesophageal structures by the escape of the contents of the
oesophagus. Perforation is indicated by sudden collapse and by
emphysema from swallowed air.
PATHOLOGY AND MORBID ANATOMY.--Dilatation of the oesophagus is either
general or partial, according as it takes place in the whole or greater
portion of the oesophagus or in a circumscribed portion. Partial
dilatation may involve the entire circumference of the canal (annular
dilatation), or it may implicate but a portion of the wall, which
becomes pouched into a sac externally (diverticulum or saccular
dilatation).
General dilatation, though sometimes congenital, is, as mentioned under
Etiology, more frequently the mechanical result of distension of the
oesophagus by food or drink prevented from ready entrance into the
stomach by a constriction at the cardiac orifice. This form of
dilatation is sometimes discovered as a post-mortem curiosity. The
muscles have usually undergone great hypertrophy, and the mucous
membrane some thickening and congestion, with erosions and sometimes
ulcerations, indicative of chronic oesophagitis. In some instances all
the coats of the oesophagus have undergone hypertrophy. The dilatation
may vary from slight enlargement to the thickness of an ordinary man's
arm or larger (Rokitansky[31]); in rare cases, even a capacity nearly
equal to that of the stomach (Luschka[32] and others). (See Fig. 19.)
[Footnote 31: _Path. Anat._]
[Footnote 32: _Arch. für Anat., etc._, March, 1868, p. 473.]
[Illustration: FIG. 19. Fusiform Dilatation of Oesophagus (Luschka). A,
Larynx; B, Thyroid gland; C, Trachea; D, Oesophagus; E, Stomach.]
The oesophagus is usually fusiform or spindle-shaped, being constricted
at those portions at which it is normally slightly constricted.
Sometimes the dilatation takes place between the lobes of the lungs
(Raymond[33]).
[Footnote 33: _Gaz. méd. de Paris_, 1869, No. 7, p. 91.]
Annular dilatation is usually due to circumferential distension just
above a stricture. When not due to stricture its seat is usually just
above the diaphragm, where the oesophagus is normally liable to
constriction. The upper portion of the dilatation is larger than the
lower portion, and the muscular walls are usually hypertrophied.
Pouched dilatation (diverticulum) is usually formed chiefly of mucous
membrane and submucous tissue pushed through gaps in the fibres of the
{433} muscular coat, produced by distension. It sometimes involves the
entire coat in cases in which the oesophageal wall has become adherent
to enlarged lymphatic glands, which subsequently undergo subsidence in
volume and drag the adherent portion of the wall after them
(Rokitansky). The muscular walls are then usually hypertrophied, the
mucous membrane sometimes hypertrophied, sometimes atrophied. The
diverticulum is usually located in the upper portion of the oesophagus,
just below the inferior constrictor muscle of the pharynx. It may thus
be, in part, a pharyngocele also. It may be located behind the point of
bifurcation of the trachea or where the oesophagus is crossed by the
left bronchus. Its direction may be to the left side in the upper
portion of the oesophagus, to the right side, or upon both sides; but
when situated lower down it is usually directed backward, between the
posterior wall of the tube and the spinal column. Hence its distension
with food completely blocks up the calibre of the oesophagus. The
orifice by which the oesophageal wall remains in communication with the
pouch is round or elliptic in shape and variable in size, sometimes
being about an inch in its long diameter, sometimes much smaller. The
size of the diverticulum varies; a common size is that of a duck egg,
but the size of a fist has been attained. Sometimes the diverticulum
drags the oesophagus out of position and forms a sort of blind pouch in
the direct line of its axis, so that it becomes filled with food which
fails to reach the stomach. Sometimes there are several dilatations.
The dilatations become enlarged by retention of food, and are liable to
undergo inflammation, ulceration, and perforation.
DIAGNOSIS.--The diagnosis will depend upon the symptoms of dysphagia,
regurgitation, and so on, and upon the evidence furnished by
auscultatory indications, palpation with the oesophageal sound, and, in
some instances, the existence of a tumor in the neck, enlarging after
meals, and {434} from which food or mucus can be forced up into the
pharynx by pressure externally.
Stethoscopic auscultation of the oesophagus during the deglutition of
water indicates an alteration in the usual form of the gulp, which
seems to trickle rapidly in a larger or smaller stream according to the
degree of dilatation. If the dilatation be annular and located high up,
auscultation is said to give the impression of a general sprinkling of
fluid deflected from its course. The peculiar gurgle is often audible
without the aid of stethoscopy. Palpation with the oesophageal bougie
is competent to reveal the existence of a large sac by the facility
with which the terminal extremity of the sound can be moved in the
cavity. In the case of a diverticulum, however, the sound may glide
past the mouth of the pouch without entering it, although arrested at
the bottom of the sac in most instances.
In annular dilatation any constriction below it is usually perceptible
to the touch through the sound; but, on the other hand, the ready
passage of the bougie into the stomach, while excluding stricture, does
not positively disprove the existence of a circumscribed dilatation. If
high up, the dilatation may be detected externally by its enlargement
when filled with food after a meal, and the subsidence of tumefaction
when the sac is emptied by pressure from without, or by regurgitation.
If the dilatation occupy a position which exercises compression of the
trachea, dyspnoea will ensue when it is distended. The intermittence of
the tumefaction serves to differentiate the swelling from abscess or
morbid growth. From aneurism of the aorta, which it may simulate
(Davy[34]), it is to be discriminated by absence of the usual
stethoscopic and circulatory manifestations. The diagnosis of
congenital dilatation is based upon a history of difficulty in
deglutition dating from the earliest period of recollection.
[Footnote 34: _Irish Hosp. Gaz._, 1874, p. 129; _Med. Press and
Circular_, May, 1874.]
PROGNOSIS.--The prognosis is not favorable in any given case unless the
cause can be removed, and not even then unless food can be prevented
from accumulating in the distended portion of the tube. Nevertheless,
cases sometimes go on into advanced age. On the other hand, they may
terminate fatally within a year (Lindau[35]). The danger of perforation
adds additional gravity to the prognosis, for life may be suddenly lost
by this accident. Death usually takes place by inanition. A case of
death by suffocation has been recorded, attributed to the pressure of
the distended oesophagus upon the intrathoracic vessels (Hannay[36]).
[Footnote 35: _Casper's Wochenschrift_, 1840, No. 22; _Arch. gén. de
Méd._, 1841, p. 498; _Dict. de Méd et de Chir._, xxiv. p. 410.]
[Footnote 36: _Edinb. Med. and Surg. Journ._, July 1, 1833.]
TREATMENT.--If the dilatation be due to stricture or to an impacted
foreign body, the treatment should be directed to overcoming the one
and removing the other.
General dilatation from chronic oesophagitis requires treatment for
that disease.
Much depends upon preventing the accumulation of food in a sac or
diverticle; the best means of accomplishing which is the systematic
administration of all nutriment by means of the stomach-tube. When this
is not advisable, care must be exercised in the selection of such food
as is least likely to irritate the parts if detained in the pouch.
{435} As far as general treatment is concerned, stimulants are usually
indicated, as the patients become much reduced. If paralysis of the
muscular coat of the oesophagus is believed to exist, the
administration of preparations of phosphorus and of strychnine are
indicated on general principles of therapeutics. Stimulation of
muscular contractility by the oesophageal electrode has been
recommended, but the prospects of success hardly justify the risks of
serious injury in the domain of the pneumogastric nerve.
It has not yet been determined whether surgical procedures are
competent to relieve dilatation. In cases of pouched dilatation high up
it would not be difficult, as suggested by Michel,[37] to expose the
sac and excise it in such a manner that the sutures uniting the walls
of the oesophagus shall occupy the site of the mouth of the
diverticulum, and, thus obliterating it by cicatrization, restore the
normal path of the food from the pharynx to the oesophagus.
Gastrostomy, too, should hold out some hope of rescue, no matter what
portion of the oesophagus be dilated.
[Footnote 37: _Dict. Encyclop._, xiv. p. 465.]
{436}
FUNCTIONAL AND INFLAMMATORY DISEASES OF THE STOMACH.
BY SAMUEL G. ARMOR, M.D., LL.D.
Functional Dyspepsia (Atonic Dyspepsia, Indigestion).
To difficulty in the physiological process of digestion the familiar
name of dyspepsia has been given, while to a merely disturbed condition
of the function the term indigestion is more frequently applied. This
distinction, difficult at all times to make, may appear more arbitrary
than real; and inasmuch as it involves no important practical point,
the author of the present article will use the terms interchangeably as
indicating functional disturbance of the stomach--_i.e._ disturbance of
the digestive process not associated with changes of an inflammatory
character, so far as we know.