Auscultation of the oesophagus may sometimes be employed with advantage; provided, however, the examination be conducted in a very quiet room. The stethoscope is usually employed, but di rect application of the ear along the left of the spine—while the patient brings his shoulders as close together anteriorly as possible—is far more satisfactory. A peculiar irregular wave-like bruit is heard when liquid is swallowed, followed by a second splashing sound as the fluid reaches the stomach. When a stricture is present the wave-bruit and the splash ing sound are varied in proportion, the latter being absent in some cases of ad vanced constriction or replaced by re peated splashes following one another more or less in rapid succession.
Far more precise, however, is the infor mation acquired by means of the oesoph ageal sound—especially the graded, olive-tipped, flexible boogie. The pa tient being placed upon an ordinary chair (avoiding one with a high back), the physician stands behind him. He should use his left hand as guide for the instrument, by placing it on the pa tient's face so as to bring the index and middle fingers over and parallel with the patient's mouth. The patient's head being thrown back, the boogie (warmed and lubricated with glycerin) should first be passed between the fingers and then introduced into the mouth per pendicularly—much as a sword-swal lower introduces the weapon. The olive tip, however, should not penetrate the oesophageal canal by passing °rev the larynx, but into the pyriform sinus on either side of the larynx. Each sinus affords a funnel-like aperture which allows the bougie to glide easily into the oesophagus, without encountering the bodies of the cervical vertebra or the cricoid cartilage. The instrument should not be forced down, but allowed to drop into the cavity by reason of its own weight.
[The present method of introducing the instrument over the middle portion of the pharyngeal wall, and therefore over the centre of the epiglottis and the posterior surface of the larynx, is de fective, and accounts for the resistance usually encountered while introducing the instrument.
I have found the procedure herein described far more effective, and, when gentleness is used, far safer than that recommended in text-books. CHARLES E. DE M. SAJOUS.] Frequently a spasm of the muscles causes the instrument to suddenly be arrested; but after a few seconds this ceases and arrest only occurs at the seat of the stricture. When this happens the
instrument should be allowed to remain in situ; after a few moments it often suddenly drops lower down. In some cases it is advisable to first anasthetize the pharynx and that portion of the oesophagus within reach with a cent. solution of cocaine. When perma nent arrest occurs below the larynx, the spot (ganged by length of bougie troduced) should be estimated and a slightly smaller bougie then tried. This is repeated until one is obtained that penetrates the opening—of which it affords an approximate diameter for future comparison. In some cases only narrow catgut will pass. Gum-elastic stomach-tubes may be used, but they do not afford the exact information ob tained from the olive bougie. It should not be used, however, when an aneurism is known to cause the stricture.
Great care and gentleness should in variably prevail. The procedure is not devoid of danger even in the hands of an expert, softening of the tissues, espe cially in the low strictures, readily yield ing to the pressure of the instrument.
[I have witnessed a ease in which a pint of milk was thus introduced into the mediastinum, as shown by the autopsy. CHARLES E. DE M. SAJOUS.] The presence of stricture having been determined, the history almost in variably points to its original cause. The case should be completely examined, how ever; a history of syphilis with tertiary pharyngeal symptoms may be obtained, for instance, and the stricture be as cribed to cicatricial stenosis, while in reality the true cause may be an aneu rism. All the etiological factors should be borne in mind and the prevailing one determined by elimination.
In stricture due to cancer the stenosis is usually situated where the left bron chus forms a ridge in the esophageal mucous membrane, but no portion of the canal can be said to be exempt. The vomited matter is often tinged with blood and the cancerous facies soon serves to establish the diagnosis. Ema ciation is generally very rapid. The possibility that a stricture may be can cerous imposes additional care in the use of the bougie, the friability of the can cerous tissues being such as to easily yield to even slight pressure. A strict ure occurring after the fortieth year in a man whose history does not present strong evidence of syphilis, tuberculo sis, or local injury is usually cancerous.