Etiology.—Stricture of the oesophagus may be congenital, hut it occurs, in the majority of cases, as a result of lesions produced either by the ingestion of corrosive liquids or by ulceration oc curring as complication of infectious diseases, particularly typhoid fever. Syphilitic ulceration of the oesophagus, though, is usually followed by stricture varying in degree with the location of the ulceration and the area involved. Impacted foreign bodies, masses of thrush-fungus, local tuberculosis, in juries—i.e., all conditions capable of causing severe acute cesophagitis—may act as primary causes. A greatly-en larged thyroid, an aneurism, an in tramural abscess, enlarged lymphatic glands, growths of the mediastinum, etc., may also, by pressure upon the oesopha gus, reduce its lumen. Cancer of the oesophagus is not an uncommon cause.
A comparatively frequent cause of stricture is squamous epithelioma: al most the only form of neoplasm encoun tered in the oesophagus. It is usually met with in men, and after the fortieth year.
Pathology.—The pathology of strict ure varies with the cause, but in prac tically all cases due to local lesions, ex cepting cancer, the prevailing feature is the presence of cicatricial tissue. In cases originating from the ingestion of corrosive fluids the stricture is usually high, spasm of the oesophagus generally preventing gravitation of the liquid to the lower part of the organ. In all others, even syphilis, the chances are that the stricture—there is generally but one—will not be far from the lower third, or lower down. The extent of tissue involved varies frequently, and occasionally the whole lumen of the oesophagus is more or less involved and distorted. In the majority of cases in which the stricture is low, there is sac culation or dilatation of the portion above the stenosis.
Prognosis.—In cases of cicatricial stenosis the prognosis is quite favorable under appropriate treatment. Without treatment the contraction usually re duces the lumen sufficiently to prevent alimentation, and the patient dies of slow starvation. Cases due to cancer are naturally hopeless, while the prog nosis of cases resulting from the press ure of surrounding growths, aneurisms, etc., depends upon the degree of cura bility of the latter.
Treatment.—The aim of the treat ment is obviously to restore the lumen of the oesophagus to its normal dimen sions as nearly as possible, but in can cerous stricture this is hardly indicated, the neoplasm itself involving complica tions that bring on a fatal issue. For this reason a distinct line should be drawn between cases of stricture due to cicatricial lesions—i.e., injuries, syphi lis, tuberculosis, etc.—and those due to a malignant neoplasm. In all of the former dilatation with the boogie may be said to be required as soon as a strict ure has been recognized; in cancerous stricture the procedure should not be re sorted to. It but inflicts severe suffer ing upon the patient and involves ad ditional risk.
Cicatricial stricture may be expected in all serious injuries of the oesophagus.
Hence, after an accident or a local dis order known to be followed by cicatriza tion, stenosis should be prevented by dilatation with bougies employed in the manner indicated under DIAGNOSIS. Dilatation should be begun as soon as there is a reasonable evidence that an ulcerative process no longer exists, and be repeated daily, beginning with a medium-sized tube and ending with one representing the normal diameter of the oesophagus. The surgeon should not wait until symptoms of stenosis appear, since this often occurs only after con siderable narrowing of the lumen. In some cases stenosis returns as soon as the bougies are not introduced, and the patient is required to personally use the instrument during the rest of his life. Whether begun early in the history of the case or late, the procedure is gener ally effective, but in old cases the tissues yield with difficulty and sometimes greatly tax the patience of surgeon and patient. It is sometimes necessary to begin with catgut, which can be left in situ until the following visit, when the smallest bougie can often be introduced. The catgut does not prevent the passage of liquids and the patient can be fed as usual. As large a bougie as the stricture will admit is then introduced every day, and a larger one substituted every few days until the largest number is easily passed and retained several hours daily.
Permanent tubage of the (esophagus, introduced by Symonds, of London, has won much favor. The tubes are "from four to six inches in length and are made of gum elastic upon a silk web, the outside and inside being as smooth as possible. The upper end is funnel shaped so as to rest upon the face of the stricture, and slightly flattened on one side (that it may not press unduly against the back of the cricoid) and the margin is perforated in two places for the attachment of a silk thread. The other end is hollow, with a lateral open ing. The tube can be introduced upon a bougie, but it is more easily managed with a proper whalebone guide set in a suitable handle. The exact site of the stricture is ascertained first and marked upon the guide; the greatest gentleness must be used, and as soon as the point .enters the narrowed part the tube is slowly pushed onward until the resist ance to the funnel is felt; the guide is then withdrawn and the silk thread at tached to the tube tied around the ear or fastened with strapping. A tube of this kind can be left for two or three months without being changed, the pa tient swallowing liquid food through it. As a rule, however, it is necessary to remove the first after three or four days, as the stricture always dilates to some extent, and sometimes this must be re peated. Even if it should slip through, it will pass per al121711 or remain lodged in the stomach without inconvenience" (Mansell-Moullin). This method is said to be devoid of risk to life, and a suffi cient amount of food can readily be in gested.