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.
DISCUSSION.
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.
