Diagnosis.—Progressive stenosis is a feature of all cases of stricture; hence the diagnosis must be based upon other symptoms. When the facies of the pa tient, a family history of cancer, and absence of local injury, syphilis, or tuber culosis can be recorded in a patient aged over 40 years, the likelihood that cancer is present is very great. Ejecta of por tions of the mass will then reveal the characteristic histological features of cancer.
In the majority of cases, however, such clear signs cannot be obtained. Then pressure from a growth external to the oesophagus must be excluded; an aneu rism, an enlarged gland, etc., may, as shown, cause stricture. If the stenosis is near the larynx it is rarely cancer, but a cicatricial stricture or an impacted foreign body. The auscultation test de scribed may be employed and also the oesophageal bougie, but the latter must be used with extreme care. (See STRICT URE.) Etiology and Pathology.—Almost all cases of cancer encountered in the oesophagus are of the squamous-epitheli oma variety, the growth starting from the pavement-epithelium of the mucous membrane, most frequently in that of the lower third of the organ. It gradually invades the mucous membrane, and, progressing laterally, the lumen of the cavity is soon reduced by a ring-like neoplasm. Later, the deep tissues be come involved and the epithelioma, if the patient lives long enough, may ex tend to any of the important organs of the thoracic cavity.
Cancer occurs especially in males over 40 years of age. An inherited predis position and an exciting cause—such as the prolonged use of alcohol, strong condiments, or an ulcer—are thought to afford the necessary conditions for its development.
Treatment.—This has been considered under the head of STRICTURE.
Neuroses.
Spasm of the CEsophagus (CEsophagis mus).—SYMPTOMS.—Spasmodic contrac tion of the muscles of the oesophagus comes on suddenly, several attacks oc curring in quick succession or intermit tently, efforts to suppress them by swal lowing saliva or food usually bringing them on. Deep-seated cramp-like pain is experienced during the spasm in the majority of cases. Food on its way down to the oesophagus may be regurgitated if still near the larynx; if below this it is retained in situ, until the spasm has passed. The attacks may last but a few hours and recur only after months' in tervals; again, they may be persistent and render proper alimentation of the patient impossible without recourse to auxiliary means. Solids can, as a rule,
be swallowed.
DIAGNosts.—The constriction usually occurs near one of the extremities of the oesophagus, hut it may not be limited to these regions in succeeding attacks. Hys teria and other neuroses can usually be detected, especially in females, for whom the disease shows a predilection. The bougie may be used advantageously to distinguish cesophagismus from the or ganic lesions already described. In spasm the instrument will encounter a stenosis during the active stage and pass down freely while no spasm is present.
ETIOLOGY.—Spasm of the cesophagus is the manifestation of a general neuro sis, particularly hysteria, and is therefore observed in young females. It may oc cur as a symptom of tetanus, rabies, epi lepsy, chorea. and other neuroses, and as a result of violent emotions,—fright, joy, etc. It may also be associated re flexly with pregnancy, and with dis orders of the genital system, or of other organs, especially the neighboring ones, —the pharynx and the stomach. It often attends the various organic dis eases of the organ itself.
TREATMENT.—Cessation of an attack is easily effected, in the majority of cases of hysterical cesophagismus, by means of antispasmodics,—the bromides, valerian, asafoetida, etc.,—but the first of these should only be used temporarily. The mere passage of the sound in these cases is often sufficient to arrest an attack. In all other forms the same remedies, with, in severe cases, hypodermic use of ether, atropine grain), or morphine, if pain is present, are indicated during the access, constitutional treatment being instituted to counteract the causative disorder. In persistent cases the patient may require alimentation through the tube, and other measures outlined under STRICTURE.
Paralysis of the CEsophagus.—SYMP TOMS.—Paralysis of the cesophagus is rarely met with. There is functional inactivity of the muscular coat of the oesophagus and great difficulty is experi enced in swallowing, the bolus remain ing in situ if at all large. Liquids pass down with case and are used by the pa tient to "wash down" small masses of solid food. The accumulation of food in the oesophagus often engenders dila tation, and the symptoms of the latter disorder are the predominating ones.