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.
The malignant form of constriction is of the most serious character and the one in which we have less hope of doing anything to permanently relieve the patient. The treatment must necessarily be palliative. The dilatation must be cautiously carried on to a greater or less extent, depending upon the progress that the disease has made upon the passage. In the primary stage of the development of cancer of the oesophagus it will be difficult to recognize the difference between it an organic stricture by the touch or by the amount of pressure of the bougie necessary to open the passage.
In such a case we depend upon the character of the touch and the general appearance of the patient to decide. In such cases our success will depend much upon the judicious use of the bougie and the proper treatment immediately following, whether or not we give relief to the patient, prolong his existence, or by injury or perforation hasten a fatal termination. We suggest that immediately after the dilatation has been accomplished that a suppository of Hydrastis canadensis should be carried into the dilated stricture, and left to melt and flow down over the diseased part. Any other remedy that the physician may desire can be applied in the same manner.
We believe that these local applications following so soon the use of the bougie will be likely to have a healing effect and thus prevent as rapid a degeneration of the tissues as would other wise occur with out their use. It will also leave the passage in a better condition for a subsequent dilatation. If the disease has progressed so far that the tissues have begun to soften and break down, the appropriateness of the local treatment will only appear the more reasonable.
As we have before stated, we do not undertake the treatment of these cases with any hope of permanent relief, but with the hope of making the patient more comfortable. The following remedies may aid us in thus doing:.
Arsenicum album will be called for by the totality of the symptoms more than almost any other remedy during the progress of the disease. The characteristic symptoms which call for its use are excessive pains in the cardiac region of the stomach, extending up into the oesophagus, of a burning character, causing nausea. Great thirst for cold water and acidulated drinks, a small quantity of which satisfies. Vomiting of food soon after eating.
Hydrastis canadensis is indicated when there is a sense of great prostration and sinking at the epigastric region, wit palpitation of the heart. Empty, gone feeling in the stomach. Acute, distressing pain in the region of the pit of the stomach.
Kreosotum for nausea and vomiting, with a painful sensation of tightness at the pit of the stomach. Painful, hard place in the region of the stomach.
Lycopodium, painful pressure in the it of the stomach and lower part of the chest. Contraction and spasm of the stomach when breathing.
Phosphorus; the region of the stomach is painful to the touch. Painfulness of the stomach when walking. Violent pain in the stomach. Burning of the stomach, extending up into the throat.
A word in regard to the feeling of patients comes within the scope of this paper. We do not propose to refer to old methods of feeding, but to suggest a new one. Neither does the author purpose to ignore any other method. We suggest that good tender beef or mutton be finely minced and slightly moistened, salted and frozen in appropriate moulds, with hollow centres, of proper size and form, and carried down by the same instrument that carries the suppository through the dilated stricture to the stomach, and there be dropped and the introducer removed.
By this means something more than a liquid diet could be given until the patient would be able to swallow solid food himself. It might be well, after the dilation is made, to carry a few beef-balls into the stomach before carrying down the medicated suppository to remain in the constricted portion. Of course this same method of introducing solid food into the stomach in other forms of stricture when necessary is equally as feasible.
The instrument above referred to, called the introducer, is a very simple invention of the author. It consists of a slightly tapering, left-hand screw, with a hollow shank, with a thread out in it to correspond to the screw-thread on the whale-bone red, upon which the bougies are introduced for the purpose of dilatation. When the dilatation is accomplished, the bougie is removed from the whalebone red, and the introducer screwed in its place.
The size of the introduce is as follows: whole length one inch and a half, length of shank half an inch, breadth of same one-quarter of an inch; length of coarse, left-handed screw one inch, and size of same one-eight of an inch, and slightly tapering. It is made of metal and silver-plated.
The suppository is another invention of the author, and is designed to go with the introducer. It is nothing more or less than a rectal suppository made with a hollow centre of appropriate size to receive the screw, which is screwed into each one before the suppository is cold, and before it is removed from the mould. These are kept in a cold place until needed for use.
When medicated ice could be in any way serviceable in the treatment of disease of the oesophagus, medicated water might be put into the suppository-moulds and frozen, with the hollow centre for the introducer, and the be passed down and up the gullet as many times as necessary, or be lodged at any point in the cardiac region of the stomach.
The operation of introduction is quite simple. The suppository is screwed on to the introducer, and the introducer is screwed onto the whale-bone red, and carried down the oesophagus to the dilated portion near the cardiac orifice of the stomach, when the whale-bone rod is turned several turns to the right, when the suppository will be detached, and the introducer must be removed. If the stricture be located at the upper portion of the oesophagus, then the suppository should be carried down and up several times when a sufficient amount of the remedy will have been applied to the dilated portion.
It is self evident that suppository could not be lodged very well at the upper portion of the oesophagus, without great inconvenience to the patient.
The writer has used these suppositories by means of the introducer herein described a limited extent successfully; but the cases to which they are applicable occur so seldom in one’s practice that it may take some time before the results could be definitely known. We therefore through it best to publish the facts, and thus give to the profession an opportunity to test, criticise, or improve on the suggestion for the benefit of humanity.
WILLIAM R.KING, M.D.: I have seen not more than eight cases of oesophageal constriction of any variety in the post fifteen years. I have treated not more than four of these, and not to any extent whatever, by constant or continuous dilatation. Those that have been under my care were mainly those in the first division of Dr. Woodvine’s paper, viz., spasmodic cases, and all these cases were women of decidedly nervous temperament. One of them I have never treated continuously, but have been called twice in consultation when she was seemingly choking from a particle of solid food tightly and spasmodically constricted in the oesophagus.
In this case, after relief was obtained by inducing vomiting through the use of hypodermic injections of Apomorphin, the case was left in the hands of her family physician, from whom she has received strictly Homoeopathic treatment-no local measures whatever except when strangling-and her condition is improved decidedly; the attacks are much less frequent, and she enjoys more of the freedom of the table.
Another case, an elderly, lady, suffered continuously from inability to swallow food. It would regurgitate and often stick fast in the oesophagus. She has been much relieved, though not cured, by a rather brief course of electricity applied along the oesophagus from above downwards and across the tube.
The third case is that of a lady just coming under my observation -a less severe case though quite annoying to her, she spasmodic constrictions of the oesophagus just below the upper orifice. She is very nervous and fidgety, with many symptoms of Zincum phosph., which remedy I have just placed her upon. What the result will be I cannot, of course, with accuracy say.
The fourth case was of organic stricture in a man, whether of malignant nature or not I cannot surely say, as he passed out of my hands before I could with certainty determine. In his case I resorted to the old form of graduated bougies for a time, with applications of the galvanic current through the gullet at the point of constriction, together with the indicated remedies, which included at different times Ars. alb., Tabacum, Phosph., Nux vom., etc. He improved somewhat, though so slowly that he probably became discouraged, as he passed from sight, and I have seen or heard nothing from him since.
After this confession of the extremely small amount of experience in this class of disease possessed by the subscriber, I will proceed to pass comment upon Dr. Woodvine’s paper, with its new ideas and novel methods.
The division of the subject into three classes of constriction is a very natural one, and simplifies the handling of the subject. In the first class, viz., spasmodic constriction, we have almost invariably to deal with a so-called nervous individual. I doubt whether, in many cases, any organic cause for the constrictive spasms can be demonstrated; that is, any actual disease at the seat of the nerve centres from whence co-ordinate motion is controlled.
I am equally unable to demonstrate the absence of such organic lesion, but I believe functional conditions, as, for instance, nerve anaemia, if I may call it so, might easily be a causative factor, as also might its opposite, viz., congestion of the central nerve seat or along its track. Except in the more aggravated cases, where absolute starvation or at least decided emaciation is progressing, I am inclined to be content with the Homoeopathic remedy as I can find it indicated, abetted, perhaps, by the faradic current of electricity applied at intervals. f the cause is central, or at least away from the actual seat of constriction, it appears fair to suppose that remedies might prove more efficacious than local dilatation.
In the use of the improved comes or olive-shaped bougies described by Dr. Woodvine, I should dread very much the possibility of a severe constriction occurring after its passage; and this being then above the butt of the bougie, would make it extremely difficult of removal, perhaps even causing a separation of the whalebone screw-thread, leaving our bougie to deep down to the stomach beyond our reach. This may be an unnecessarily suspected bugaboo, but it would present itself more in such cases then where a fixed organic stricture occurs. There, care should be taken to avoid passing a come too large to readily return. In the spasmodic case this cannot be done, as the extent of the sudden constriction cannot be anticipated.
The treatment by means of bougies is, of course, the rational treatment for organic constriction, especially when nutrition is gravely interfered with.
I contended that in such cases none but an experienced hand should officiate, especially in the inflammatory or malignant cases, owing to the case with which serious damage may be done, aggravating the patient’s discomfort and often shortening his life.
The novel method of applying locally the suitable remedy, as well as for inserting solid food balls by means of the so-called “introducer,” is quite interesting, and I believe in the suitable cases will prove of great value. The instrument, from its description, seems a very ingenious one, and well adapted for its designed use.
In many cases, though I feel we can more readily and with more comfort to our patient apply our local remedy in liquid form, though of course in small quantities, where the constriction is high up in the oesophagus, I doubt whether the suppository would be any better borne than the liquid remedy; and when lower down I am more decidedly inclined to doubt it-of course admitting that the suppository is capable of holding the remedy in contact for a much longer period, if that should be a desideratum.