STRICTURE OF THE ESOPHAGUS.

BY D. W. HARTSHORN, M.D.

All diseases of the oesophagus have a tendency to constrict, and ultimately to occlude its passage. Hence the condition which we term stricture; and the causes that lead to it become of great interest both to the surgeon and physician.

It is rarely an idiopathic affection, being usually the result of some preceding condition.

Occasionally, the constriction is of a nervous or spasmodic character. And while this form comprises a small part, by far the majority of cases result from an organic change, either of a fibrous or cancerous degeneration of its walls.

The prominent symptom of oesophageal stricture is difficult deglutition, but there are several conditions besides stricture of the œsophagus that give rise to dysphagia, and it needs only a glance at these and its anatomical relations to enable us to understand this. The oesophagus is a continuation, so to speak, of the pharynx, beginning on a level with the lower border of the cricoid cartilage, opposite the fifth cervical vertebræ, and ending at the cardiac orifice of the stomach, on a level with the ninth dorsal vertebra.

The passage of food to the oesophagus may be obstructed, by polypoid growth projecting from the pharnyx, or from a postpharyngeal tumor, or an abscess, arising perhaps from caries of the vertebræ, pushing the pharynx forward. Chronic oedema, ulceration and thickening of the mucous membrane of the epiglottis, or oedema about the rima glottidis, may give rise to a tendency for liquids to pass into the air passages, occasioning a serious impediment in swallowing, from the spasm and feeling of suffocation that results.

In the neck, the oesophagus is in relation posteriorly with the vertebral column. Abscess from any cause, or tumors connected with the spine may compress it. Anteriorly it is in relation with

the thyroid gland; tumors, or great enlargement of this gland, or other enlarged glands of the neck, tightly bound down by the sterno-mastoid muscle and cervical fascia, may press upon and obstruct it.

Its close relation with the carotid arteries, innominate artery, and also with the aorta, make it liable to be pressed upon in aneurism of these vessels.

Enlargement of the bronchial glands, especially those of the left bronchus, with which it is in relation, or cancerous and other tumors, developed from the thoracic spine into the posterior mediastinum, through which the oesophagus passes, may press upon it, giving rise to dysphagia.

Excessive curvature of the spine; backward dislocation of the sternal end of the clavicle; impaction of a foreign body in the œesophagus, any of these may give rise to difficult deglutition though no stricture exist.

Recognizing these facts, when a case of difficult deglutition presents itself, we should pay attention to certain points, for they will enable us to differentiate between the conditions above referred to and stricture. If it be due to conditions of the pharynx, or larynx, or adjacent structures, it will be revealed by an ocular and digital exploration, which should always be made. Careful examination of the neck will determine the existence of tumors outside of the œsophagus.

The existence or non-existence of aneurism, may be ascertained by the well known symptoms of that affection, and if found to exist, and to be the probable cause of the dysphagia, we should desist from an exploration of the oesophagus with instruments, else we might pierce or rupture the aneurismal sac.

It is a very difficult matter to diagnose a post-mediastinal tumor arising from the spine, or an enlarged bronchial gland compressing the œsophagus, and it is a much more difficult one to distinguish it from an aneurism undergoing consolidation; but the constant pain in the spine, or on one side of it, the neuralgic pain up the side of the head, or down one arm, the dyspnoea and dysphagia and the varicose condition of the superficial veins of the side, may be looked upon as diagnostic of tumor.

Obstruction from backward dislocation of the clavicle, or excessive curvature of the spine, will be readily recognized without any exploration of the canal ; so also in case of impaction of a foreign body, the fact of the accident, and by a careful examination with instruments we will readily detect it. Still cases have occurred in which very competent surgeons have been foiled though the foreign body was still impacted.

Having decided, by a process of exclusion, that the cause of the difficult deglutition can arise from no other source than stricture, it becomes necessary to ascertain whether it is of a spasmodic or organic character, and if it is of the organic form, whether it is due to a fibrous or cancerous change, as this will enable us to decide upon the proper treatment and the ultimate result.

Purely nervous or spasmodic stricture may exist without evident disease or change of any kind; but in the majority of cases it is associated with, and dependent upon, some local change of structure of a simple kind, as chronic inflammation, or ulcerative abrasion of the mucous membrane of the pharynx, or follicular imflammation about the epiglottis and larynx, or the patient may have swallowed at some time a foreign body, as a fish bone, or other hard irregular substance, which acted as the starting point of the inflammatory or ulcerative action, and caused the dysphagia which still continues, though the cause has disappeared. In these cases the dysphagia is intermittent. If the patient's mind be directed to, or allowed to dwell upon the affection, the dysphagia is increased, while if it is diverted food passes easily.

In these cases the obstruction is high up, the inferior constrictor muscle of the pharynx, its lower fibers being continuous with those of the oesophagus, is often involved in the contraction.

We recognize two forms of organic stricture, the fibrous and the cancerous, and it is often very difficult to differentiate between them; sometimes a stricture that was originally fibrous degenerates into the cancerous or malignant form, then others will remain fibrous, never changing their character.

The etiology is a very important element in the diagnosis; fibrous stricture is rarely idiopathic, it almost invariably results from cauterization of the oesophagus from swallowing concentrated

acids, or caustic alkaline solutions, either accidentally or with suicidal intent.

The effects vary with the nature, quantity and strength of the fluid swallowed. If the poison, whether acid or alkaline, be very concentrated, and taken in large quantity, more or less complete destruction of the mucous membrane of the pharynx, oesophagus and stomach commonly results.

The stomach in these cases, especially if it be empty, may be perforated, the patient usually dying in a few hours.

If the poison be more dilute, violent inflammation of the mucous membrane of the pharynx and oesophagus is excited, lymph is effused on the surface and into the sub-mucous areolar tissue. Ulceration often sets in, followed by thickening of the walls of the œsophagus, and constriction of its calibre.

Although we are confident from the history and symptoms that stricture has occurred, still it is necessary to make an instrumental examination, as this will establish or dispel the fact of its existence, and if it exist, by it we can determine its location and character.

The best instrument for the examination is the oesophageal probang, of which there are several sizes, varying from one-quarter of an inch to one inch in diameter; each consists of a cocoon shaped piece of ivory on the end of a whalebone stick.

If the stricture be simple or fibrous the probang passes smoothly, there is no feeling of roughness, or that it is lacerating its way, no blood follows its withdrawal, and the patient does not raise pus, or blood and pus, and shreds of tissue, though there is frequently a copious discharge of mucus, neither are we able to detect any material enlargement of the neck.

In the malignant or cancerous form, the instrument imparts the sensation as though it were passing over a rough and ulcerated surface, and upon withdrawing it the patient coughs up blood, or blood and pus, often mixed with shreds of tissue; we are also generally able to detect an elongated swelling at the root of the neck, the burning lancinating pains common to cancer are always present, and there may be cancerous tumor elsewhere, or the neighboring glands may be affected, and the symptoms of the cancerous cachexia may be manifest.

The treatment of stricture varies with its nature. If it is the spasmodic variety, and the conditions that gave rise to it still exist, as those mentioned of the pharynx, or larynx, our selection of remedies should be made with a view to removing them.

If they have passed away, and it is due to a purely nervous or hysterical state, the mind should be diverted, and the general health improved, by attention to hygienic and dietetic laws. The internal remedies for this form of stricture are, Arsenicum, Asafoetida, Belladonna, Hyoscyamus. Great benefit will also be obtained in these cases, by the occasional passage of a full sized ivory tipped œsophageal probang.

The treatment of organic stricture is more difficult. If a person has swallowed either a strong acid or caustic alkaline solution, we know that if the patient recover from the immediate effects, he is still liable to suffer from other conditions more or less remote, as inflammation, ulceration, the effusion of lymph, and contraction.

During the inflammatory stage, food should be given very sparingly or not at all for a short time, the more perfectly at rest the injured parts are kept the better; demulcent drinks and ice may be given in small quantities to allay thirst, the patient being supported by nutrient enemata.

As soon as the first inflammatory symptoms have subsided, an œsophageal probang should be passed, even before symptoms of dysphagia appear, and if the œsophagus has been severely injured, the occasional passage of the probang should be kept up long after there seems to be any need, for experience has shown, that stricture of the œsophagus is almost certain to occur, sooner or later, in such cases, sometimes in a very slow and insidious manner, and by such a course we can generally avert it.

If the means have not been used to prevent its occurrence, and symptoms arise to indicate its existence, an examination should be had at the earliest possible moment, and the proper treatment adopted without delay; this consists in passing a probang, the ivory tip of which will just enter the stricture, and retaining it there from five to fifteen minutes, or even longer if it can be borne.

If the stricture be so tight that the smallest sized probang will not pass, we can begin the treatment with a urethral catheter or bougie, gradually increasing the size until the probang will pass.