I PROPOSE to speak of three forms of constriction of the oesophagus, viz., spasmodic, organic, and constriction from malignant disease of the passage.
The first variety belongs to the nervous, and is found most frequently a among debilitated women whose nervous systems have been wrecked to a greater or less extent by the habits and customs of the present generation, or by having inherited a constitutions without any vital stamina. Then general appearance of the patients is pale, anaemia, nervous, leaving a poor appetite for proper food, or a capricious one for unnatural articles. This form of stricture is not wholly confined to women, but sometimes occurs among men. When it does occur among females it is more likely to the near the menopause.
The constriction commences with a very slight difficulty in swallowing solids, accompanied with a sensation that some thing has lodged in the gullet, and necessitates the use of some kind of liquid to remove it. The difficulty develops more or less rapidly until there is a sense of dread at the thought of swallowing anything of a solid character. We have known persons afflicted with this complaint to spend nearly two hours in eating a meal. The result is such cases could be nothing less than extreme emaciation, or in other words, show starvation. Under such circumstances, the patient realizes that there is a necessity of getting relief in some way or other, and most naturally applies to her family physicians to obtain relief.
When, however, she is informed what is necessary to have done, in order to overcome the difficulty, she naturally shrinks from the operation of dilatation. The patient concludes to postpone the operation, hoping that the difficulty, if nervous, may after a while pass away. The expectation of the patient is however hardly ever realized in this regard; she is obliged sooner or later to submit to the operation.
When this is successfully done she feels that she has a new lease of life, until there are sings of its reappearance, which is most likely to occur. This state of affairs fills the mind of the patient with fear of choking and a dread of another operation. However being familiar with the relief received by the dilatation she does not shrink from the second as she did from the first; but has it repeated; this is, however, not so in all cases, for there are those that put it off until starvation stares them in the face, before they will submit.
The cause of this form of constriction, we believe to be a deficiency in the nerve supply to the muscle of the oesophagus at a particular point, which suggests some diseased condition of the base of the brain. The extent of this diseased condition determining whether it is a spasmodic or a permanent constriction.
The extent of time covering a spasmodic constriction according to recent authorities may be from a few moments to several hundred days.
The treatment of spasmodic stricture of the oesophagus requires the use of the cone or olive-shaped bougie. It is well always to begin the dilatation with the smallest size, and not to hurry the operation, when there is a decided resistance. We are well satisfied from experience that the presence of the bougie will sometimes occasion a decided spasm, either of the constricted parts or those in close proximity, which may continue for an indefinite period. The evidence of this possibility being in the fact, that the bougie may pass down comparatively easy; when the attempt to withdraw it is made, it can only be accomplished with great difficulty.
In such cases patience is of the greatest importance in making a success of passing the bougie. It should be covered with some oleaginous substance like cosmoline or sweet oil. It is important that the operator shall have acquired such a sense of touch in the use of the probe that he may be able to recognize the condition of the parts as to readily determine the difference between the constriction and a pocket of mucous membrane.
When the point of constriction is reached by the bougie and the resistance is decided, the pressure should be gentle at first, but increasingly firm, but not harsh, accompanied by a rotary movement of the bougie in the hands of the operator; and if the parts do not yield to a proper among of pressure, the instrument should be removed, and the patient allowed to rest, and then after thoroughly anointing the bougie it may be again introduced and the pressure applied as before. This operation may be repeated several times, or until the stricture is overcome, provided the condition of the patient will allow. Strictures of this class are not as difficult to overcome by means of bougies as those where the muscular tissues have becomes more permanently thickened, called organic.
The following remedies used internally, we have found useful in the treatment of spasmodic stricture of the oesophagus:.
Belladonna is indicated by pressing pain, like contraction and a feeling as though a foreign body had lodged fast in the oesophagus; a feeling during deglutition that the throat is too narrow or drawn together too lightly for food to pass properly.
Gelsemium semp. has afforded relief in some cases of spasmodic constriction, where there seems to be great prostration of the nervous and muscular systems.
Hyoscyamus nig. is called for in that class of cases where the patient has a great deal of twitching of the muscles; spasmodic constriction of the oesophagus from a variety of causes; solid and warm food an be swallowed best; liquids cause spasms in the oesophagus, stop respiration and talking.
Hydrophobinum is spoken of by some authorities as being indicated in periodical spasms of the oesophagus, with painful urging to swallow, but impossibility of doing it; abhorrence of fluids, especially water.
Phosphorous, stricture of the oesophagus, regurgitation of all fool; food reaches the cardia and is immediately rejected.
Veratrum alb. is useful in spasmodic constriction of the oesophagus, resulting in paralysis of the tube.
The organic form of stricture is the more difficult to treat by means of the bougie or internal medication. The deposit of fibrinous material into the submucous and muscular tissues, followed by thickening and contraction of the muscular tissue gives rise to a condition of muscular resistance which sometimes is most difficult successfully to overcome. This the result of various causes which are not always understood, stare one in the face with a sort of defiance which is certainly very discouraging. It is a fact, however, that we have stricture occurring from mechanical causes, such as drinking hot water and corrosive substances.
The treatment of what is denominated organic stricture of the oesophagus may be divided into general and local, or systemic and local. We find the general system much depressed from want of food. The patient has become much emaciated, very much discouraged and hardly cares to make any further effort to live; in fact a release many times would be welcomed. The importance of getting nutrition into the system in such a manner as to give the patient strength as son as possible cannot be over-estimated. If the patient is much reduced physically, injections of beef tea by the rectum should be given until she is sufficiently strong to bear the operation of dilation with the hard rubber or ivory bougie.
This operation, as before suggested in the treatment of spasmodic stricture, should be practiced in this case with even more care if possible than the other. We have found that it require much patience and care to work the bougie through this form of stricture; but when it is accomplished there should be two or three larger sizes passed through at one sitting. In some cases of bad stricture there will be more or less of haemorrhage form slight laceration of the tissues. When this is the case, the dilatation should not be pushed too far at one sitting. If any haemorrhage occurs a Hamamelin suppository of appropriate size should be carried down into the partially dilated stricture and left there, which will soon melt and operate on the lacerated part as a local styptic.
If the lacerated tissue does not give rise to haemorrhage, there should be a Calendula suppository applied which will have a most beneficial effect. There can be no doubt that this new method is applying remedial agents directly to the diseased part where dilatations is necessary may prove of great value in the treatment of constriction of the oesophagus. After one, two or three days as the case may require, the operation of dilatation may be repeated, beginning again with the smallest size bougie and increasing the number and size until finally the passage is fully dilated, following each time of dilatation with the local application of medicine by means of the medicated suppositories as the case may require. In fact any remedy which the operator may desire may be applied locally in the form of a suppository.
The internal administration of remedial agents may be practiced as they may be indicated by the totality of the symptoms.
