When these short tubes cannot be used or when they cause cough during deglu tition Krishaber's or Morell Mackenzie's long tubes, or, better still, a long, cath eter-like rubber tube can be employed and left in situ several days at a time.
Operative procedures are sometimes resorted to.
Internal cesophagotomy, an operation based on that of urethrotomy, wherein the cicatricial bands are cut, has not given the satisfactory results claimed for it. It is only warranted in cases of an nular stricture. CEsophagostomy is pre ferred when the stricture is high enough to be reached through the side of the neck, the incision being made between the pharynx and larynx on the left side, toward which the cesophagus leans in this region. The trachea then finds itself on one side of the incision and the carotid sheath on the other. The loca tion of the stenosis having been deter mined, it is as nearly as possible made to correspond with the upper part of the incision, which should also include the cesophagus. Sometimes the omo-hyoid must also be incised. A rubber tube is then introduced, and the permanent fistula formed serves for its easy intro duction and withdrawal. The patient can thus be easily fed, the tube passing under the stenosis. The operation is not an easy one. owing to the proximity of large vessels and other easily-wounded structures.
In cancerous stricture it is inadvisable to pass boogies, as already stated; but a soft-rubber catheter with large fenestra, passed every other day or oftener, often serves to keep the passage open. It may also be left in situ and serve for the in troduction of liquid food. Rectal feed ing should be resorted to when oesoph ageal alimentation becomes impossible, but when rectal feeding in turn becomes insufficient—which often happens when continued several weeks — gastrotomy should be resorted to. Through the opening thus obtained to the interior of the stomach it is possible to very satis factorily supply the patient with all the food he requires. The improvement is usually rapid, and comparative comfort is insured until the toxic effects of the neoplasm bring on death. (See STOM ACH, SURGERY OF, for the details of the operation.) Dilatation of the Esophagus.
Etiology and Symptoms.—Dilatation of the oesophagus may be congenital, as stated, but in the majority of cases it occurs as the result of stenosis of the lower end of the tube, which, by its re sistance to the passage of food, causes its accumulation in the oesophageal canal. To compensate for this the walls become greatly hypertrophied. This condition
is followed, as elsewhere, by softening, which in turn causes the canal to yield to the pressure of its contents, and to become greatly enlarged.
Generally, small quantities of food are passed into the stomach at a time, and the pouch-like cavity becomes grad ually emptied between meals. But re gurgitation occurs when this process is too slowly performed, and the frequent invasion of the larynx by the food thus brought up causes strangling and cough, besides the dysphagia experienced.
The bougie may be used to advantage, the large dimensions of the cavity and the narrow orifice met below being char acteristic. Side-pouches may cause the sound to be arrested if it is not intro duced perpendicularly or if distension of the canal is present.
Treatment.— Contraction of the di lated organ may sometimes be facili tated by introducing a long rubber tube or bougie and using it as the only avenue for the introduction of food into the stomach. Symond's tubes are too short for this purpose, and an arrange ment based on the principle of the stom ach-tube or a large rubber catheter is necessary. These may be introduced with the bougie or after the stricture has been enlarged. Galvanism and strychnine tend to cause contraction in incipient cases. The main object in all, however, should be to insure adequate alimentation. In advanced cases gas trostomy has proved of great value.
Tumors of the Esophagus.
Carcinoma.
Symptoms.—Cancer of the oesophagus is rather frequently met with, and is at tended by progressive stenosis, as already stated under the head of STRICTURE OF THE (ESOPHAGUS. In some cases, how ever, the facies of the patient and ca chectic symptoms denoting the involve ment of other organs are first to appear. Pain is marked early in the cases; later on the tissue-destruction involves the nervous supply, and the pain is no longer experienced. Slight hcemorrhages may occur at this stage, though streaks of blood may have already been noted in the vomited matter. The cancerous process is then apt to invade the sur rounding organs,—the larynx, the tra chea, the bronchi and lung, the pleura, the pericardium, and the larger vessels,— causing fatal haemorrhage. The cervical glands are often enlarged. The verte brT may be included in the destructive process and involvement of the cord, with paralytic symptoms, appear. Pa ralysis of the larynx may also occur through pressure on the recurrent laryn geal. Progressive emaciation begins early in the history of the case and death from exhaustion finally supervenes.