Methods of Examination.—It is sometimes possible to detect an impacted foreign body, a distended diverticulum, or a new growth in the cervical portion of the œsophagus by palpation.
Auscultation while the patient is drinking sometimes aids in the diagnosis of stricture; the stethoscope is placed at various points along the left side of the dorsal spine, and abnormal sounds may be heard as the fluid impinges against the stricture or trickles through it.
Introduction of Bougies.—Œsophageal bougies or probangs are used for diagnostic purposes in cases of suspected stricture, and to aid in the detection of foreign bodies. Various forms are employed, of which the most generally useful are the round-pointed gum-elastic or silk-web bougie, and the olive-headed metal bougie, consisting of a flexible whalebone stem, to which one of a graduated series of aluminium or steel bulbs is screwed. For some purposes, such as pushing onward an impacted bolus of food, the sponge probang—which consists of a small round sponge fixed on a whalebone stem—is to be preferred.
Before passing bougies, it is necessary to make certain that the symptoms are not due to the pressure of an aneurysm on the œsophagus, as cases have been recorded in which a thin-walled aneurysm has been perforated by a bougie. The existence of ulceration or of an abscess pressing on the gullet also contra-indicates the use of bougies.
For the passage of a bougie the patient should be seated on a chair with the head thrown back and supported from behind by an assistant, and he is directed to take full deep breaths rapidly. The bougie, lubricated with butter or glycerine, and held like a pen, is guided with the left forefinger. As soon as the instrument engages in the opening of the œsophagus, the chin is brought down towards the chest, and if the patient is now directed to swallow, the instrument may be carried down the œsophagus, or can be passed on by gentle pressure. Great gentleness must be exercised, and no attempt should be made to force the instrument past any obstruction. The instrument may catch against the hyoid bone, and this may be mistaken for an obstruction.
It is to be borne in mind that in some cases the passage of a bougie may be attended with a considerable degree of shock, and cases are on record in which this has proved fatal without any gross lesion being found after death.
Intubation, or the passage of a cannula through a stricture, is referred to later.
Œsophagoscopy.—The œsophagoscope—a form of speculum which enables the œsophagus to be illuminated by an electric lamp—is employed for the detection and removal of foreign bodies, for the examination of ulcers, diverticula, and strictures of the tube, and with its aid it is possible to remove a portion of a growth for microscopic examination. The mouth, pharynx, and entrance to the œsophagus having been cleansed and cocainised, the patient is placed in the recumbent or sitting posture, and the tube introduced. For prolonged examinations a general anæsthetic is preferred.
The mouth of the œsophagus is closed by the sphincter-like action of the lower fibres of the inferior constrictor muscle, and the cervical part of the tube appears as a transverse slit, due to the backward pressure of the trachea. The thoracic portion is more open and may contain air, so that it is possible to see down to the lower end, the closed cardiac orifice appearing as an oblique cleft surrounded by a rosette-like cushion of mucous membrane. The pulsation of the aorta can be seen just above the prominence formed by the left bronchus.
Radiography.—Opaque foreign bodies can be detected by the screen or in a radiogram; and the position of a stricture by making the patient swallow capsules containing bismuth and examining with the screen. To determine the position and size of a diverticulum, a radiogram is taken after the patient has swallowed some food, such as porridge mixed with bismuth.