ULCER, CANCER, STRICTURE, PARALYSIS, RUPTURE OF ESOPHAGUS 259 hæmorrhage, or may bleed to death without giving evidence of the hamorrhage. The blood in such cases may be swallowed and retained in the stomach and intestines, or there may be slight hæmorrhage and vomiting of the blood, and it will be a difficult matter to decide whether it is an œsophageal or a gastric hæmorrhage. Again, the blood may be swallowed and pass per rectum and this be the only evidence of the hæmorrhage. The use of the esophagoscope is a help in such conditions, especially if there are old ulcers, but it must be used with the greatest care. Cancer. Cancer of the oesophagus is usually of the epithelioma type and may or may not ulcerate early, due to the mechanical irritation of the food. If the growth causes much stenosis, we get a gradual dilatation of the tube above the tumor due to accumulation of food distending it. This food may later be swallowed, but is usually regurgitated. As the cancerous growth advances it in volves the neighboring organs and may thus perforate into the trachea, pericardium, aorta, or pleura or even erode the vertebræ. SYMPTOMS.-Cancer of the esophagus is more frequent in men over fifty, and it is accompanied with progressive dysphagia, first for solids and then for liquids, and rapid emaciation. Regurgitation may occur early or late. Pain may be a constant feature or occur only after eating food. Enlargement of the cervical glands may occur. Three conditions simulate malignant disease-senile dysphagia, nervous dysphagia, and an oesophageal pouch. Spasmodic stricture may be caused by dyspepsia. DIAGNOSIS. The diagnosis is made by the passage of the bougie and from the symptoms enumerated. PROGNOSIS.-The prognosis is hopeless, and the usual mode of death is from asthenia or sudden perforation of some vital organ. TREATMENT.-The treatment is to relieve the suffering, resorting to morphine, codeine, and cocaine without hesitation. Analgetics dissolved or suspended in mucilage give relief. Gastrostomy is advisable, if done eaaly, before asthenia is too pronounced. The use of the x-ray or radium has not been successful, though one case can be vouched for by the author where the stricture has been relieved and life apparently prolonged after a course of x-ray exposures. Radium as a cancer cure has not given satisfactory results. In every case of malignant disease the patient should have the benefit of the doubt and receive antisyphilitic treatment. STRICTURE, PARALYSIS, RUPTURE, ETC. Stricture of the oesophagus may be: 1. Congenital. 2. Due to cicatricial contraction following ulcers due to corrosives, syphilis, or typhoid. 3. A result of tumors, benign or malignant, in the wall, narrowing the lumen. 4. Caused by pressure from without, as of aneurysms, swollen lymph glands, enlarged thyreoid, pericardial effusion, and tumors not involving the wall itself. Diagnosis. The diagnosis of the true condition will depend upon a close study of the history and physical signs. From the history we may learn of the occurrence or non-occurrence of any previous traumatism, or inflammatory condition, with or without a general or constitutional disease. The rapidity of the increasing severity of the symptoms is an important point. Symptoms. Concomitant symptoms in other organs should be noted especially. If regurgitation is present, the time of its occurrence with respect to the ingestion of food is a fair indication of the position of the stricture. Regurgitation immediately after swallowing indicates a high position of the stricture, but, if it is delayed, a low position. The fact that the food is regurgitated, and not vomited, can be discovered by the odor, the absence of hydrochloric acid, and the unchanged condition. Auscultation for a delayed second swallowing sound also helps. Then, lastly, we may try the passing of bougies, beginning with the largest size of the olive tipped. Gentleness in manipulating a bougie is imperative, because of our ignorance of the actual condition and the possibility of rupturing the œsophagus and puncturing an important viscus. FOREIGN BODIES IN THE ESOPHAGUS 261 Spasm or spasmodic stricture may occur in hysteria, hypochondriasis, chorea, epilepsy, idiocy, or hydrophobia and after irritation by foreign bodies. It may be a very painful condition, especially if some sharp body has been swallowed, and persist for a day or so, or even continue for weeks. The actual damage may be very trivial, but the nervous spasm and sensation of pain will persist. THE TREATMENT of such a condition is that of the general constitution. Sometimes a cure may follow the passing of a bougie, especially in neurotic conditions, if done with demonstrative formality. The bougie may or may not be arrested at the site of the stricture. Organic stricture of a non-malignant character requires dilatation by means of flexible bougies or it must be overcome by surgical means. A low down lesion can be reached by opening the thorax under negative pressure. Paralysis of the Esophagus Paralysis of the oesophagus is very rare and usually of central origin, as in bulbar paralysis. Following diphtheria, there may be a peripheral paralysis. Prognosis. The prognosis in the first would be hopeless, while in the second it would be good, unless the paralysis extended and involved some vital organ. Rupture of the Esophagus Rupture of the oesophagus from violence or in the course of cancerous softening has a fatal termination. Foreign Bodies in the Esophagus Foreign bodies in the oesophagus can be located by means of the bougie and by the use of x rays. The use of the Röntgen ray in the diagnosis of foreign bodies in the esophagus is of the greatest value only when those bodies are metallic, as we then obtain a definite outline of them and their location. If the body is of some other material, we must use the greatest care in forming an opinion of the importance of the shadows on the plate. In such cases it is best to make two or more plates at intervals of some days, and compare them carefully. Even with the most careful comparison the x ray is not a positive factor in such diagnosis. One case has been recently recorded of an eminent surgeon who depended upon the x ray for the diagnosis of the position of a tooth plate said to have been swallowed by a patient. It was apparently located at the cardia, but when gastrotomy was performed nothing was found. The next day the tooth plate was found in a crevice of the bed. Fish bones and other small foreign bodies can sometimes be extracted by means of the bristle probang; coins and tin whistles by the coin catcher. When a foreign body is located and cannot be removed by such means or cannot be pushed into the stomach, surgical methods of removal must be adopted. CHAPTER VII THE DIGESTIVE SYSTEM-Continued CLINICAL PATHOLOGY OF THE STOMACH AND INTESTINE AND DIAGnostic teCHNIQUE SYNOPSIS: Clinical Pathology of the Stomach, Motor Phenomena, Sensory Phenomena of the Stomach.-Secretory Phenomena of the Stomach.-Hydrochloric Acid in the Stomach, Digestive Ferments.-Diagnostic Technique.-Transillumination with Fluorescein. Remarks on the Clinical Pathology of the Intestine.-Motor, Sensory and Secretory Phenomena of the Intestines.-Diagnostic Technique.-Examination of Fæces. Conclusions. REMARKS ON THE CLINICAL PATHOLOGY OF THE STOMACH A healthy stomach mechanically and chemically prepares the food for the intestines, and very little absorption takes place in the stomach proper. The normal motor function of the stomach is fairly understood. The fundus has a peristaltic action with little interior tension; the pyloric antrum has a strong muscular action with high interior pressure. A sphincterlike arrangement closes this segment against the fundus and permits the gastric contents to flow through the relaxed sphincter at the pylorus into the intestine. A very slow transfer of contents may be followed by a dilatation of the stomach and an undue formation of gas and fatty acids. Motor Phenomena and Neuroses Regurgitation and Vomiting; Singultus.-The cardia of the stomach. will open during the act of swallowing. Regurgitation and eructation of gases, air, and fluids may take place from the œsophagus or stomach. If they are from the latter, hydrochloric acid and fatty acids will give an acid taste in the mouth (pyrosis, water brash). Vomiting is due to a complex muscular action of the stomach and diaphragm combined. The impulse takes its origin in the medulla, near the respiratory centre, and may be due to local brain irritation or to a reflex from the abdominal vagus nerve, and the salivary glands also participate in the act. We speak of nervous, paroxysmal, and reflex vomiting; cerebral or toxic vomiting from alcohol, apomorphine, chloroform, ether, sewer gas, bacterial poisons, sepsis, and uræmia. Reflex vomiting, if cerebral, is usually projectile and unattended with nausea or pain. It may be a premonitory symptom of apoplexy or associated with meningitis, hydrocephalus, brain concussion, etc. SECRETORY PHENOMENA OF THE STOMACH 263 Spasms of the stomach, pylorus, or cardia are frequently observed, also peristaltic unrest and peristaltic atony. Dilatation of the Stomach.-A dilated stomach acts like a dilated heart -its cavity does not empty itself. Pyloric stenosis is accompanied by dilatation of the stomach and is often compensated by hypertrophy of the gastric muscularis with subsequent degeneration of the muscular elements. Anomalies of form and position favor such changes, and then we speak of motor insufficiency. A dilatation without pyloric stenosis is found in connection with supersecretion, hyperacidity, and neurasthenia. Atony of the stomach may be due to undue fermentation and may cause undue fermentation or putrefaction. Speaking generally, we may affirm that in atony without dilatation the stomach is empty if examined in the morning before breakfast. This denotes weak peristalsis. In atonic dilatation the stomach is not obstructed, but is unable to empty itself, and food is found in washing the stomach in the morning. In dilatation due to pyloric obstruction we speak of secondary dilatation as we find it in cancerous, fibrous, or cicatricial obstruction. The wash water will show food in all stages of putrefaction. Sensory Phenomena of the Stomach In health we feel the stomach when we are hungry or when we overload it, and a sick stomach will show the overloaded feeling after a small quantity of food has been taken. Actual pain in the stomach (gastralgia) is constant in ulcers and cancer from irritation of HCl and organic acids. Clonic muscular contraction in the walls of the stomach and intestine also produces pain. Neuralgia of the stomach is observed in stomach neurasthenics and in tabetic subjects. Many phenomena in various parts of the body are of gastric origin, such as epileptoid and tetanic seizures, vasomotor phenomena, paræsthesias, and neuralgias of various parts, also migraine, vertigo, cardiac irregularities, and asthmatic complaints. Disorders of the Appetite.-Anorexia is a simple loss of appetite often observed in old people, in nervous people, and in persons who are under great mental strain (anorexia mentalis). Polyphagia, or bulimia, may be permanent or paroxysmal. It is an inordinate craving for food in convalescence from febrile disease and in some insanities and hysteria, etc. Akoria is a feeling of emptiness. Pica is a craving for unusual substances, observed in hysteria, idiots, and children. Thirst may be increased or annulled in fever, in diabetes, or from a dry mouth. Idiosyncrasies are aversion to certain foods. Other sensory phenomena are anesthesia, hyperæsthesia, parasthesia, nausea, and abnormalities of appetite. Secretory Phenomena of the Stomach Gastric Juice.-Healthy individuals may have a small quantity of gastric juice in an empty stomach. When this quantity is increased, we |
