Paralysis of the Gullet.—As the passage of the food along the gullet is entirely dependent upon muscular peristalsis, when the muscular coat is paralysed, as it may be after diphtheria, for example, the patient is unable to swallow and the food materials are regurgitated, with consequent loss of flesh and strength. The difficulty may be tided over for a time by feeding through a rubber tube, but it is to be remembered that, in children, struggling in resisting the passage of the tube may seriously strain a heart that is already threatened by the toxins of diphtheria.
Diverticula or Pouches of the Gullet.—A diverticulum consists in the protrusion of the mucous and submucous coats through a defect or weak part in the muscular tunic; it is therefore of the nature of a hernia and not a localised dilatation of the tube as a whole. Anatomically, there is such a weak spot in the posterior wall opposite the cricoid cartilage, known as the pharyngeal dimple, between the circular and oblique fibres of the crico-pharyngeus muscle. As the pouch increases in size by pressure from within, it usually extends downwards and to the left. This pouch is described as a pressure or pulsion diverticulum because the hernial protrusion is ascribed to increased pressure within the pharynx, not only the normal increase caused by the act of swallowing, but an abnormal pressure from the too rapid swallowing or bolting of imperfectly masticated food materials.
Fig. 285.—Radiogram, after swallowing an opaque meal, in a man suffering from malignant stricture of lower end of Gullet.
The clinical features are not so characteristic of difficulty in swallowing as might be expected. The patient, usually a man over forty years of age, complains of dryness in the throat and of a sensation as of a foreign body; later there is regurgitation of saliva and of food with occasional choking. In about one-third of the cases, there is a fullness, or a palpable tumour in the neck, about three times more often on the left than on the right side, which may increase in size after a meal, and pressure on which may cause a gurgling sound and, it may be, regurgitation of food.
It is suggestive of a pouch, if the patient regurgitates food materials which can be identified as having been swallowed several days before, currants perhaps being those most easily recognised and remembered.
Diverticula are also met with at a lower level, springing from the gullet at or below the upper opening of the thorax; the distension of the pouch with food materials presses upon the gullet with more serious effect, even to the extent of complete obstruction and consequent rapid emaciation. In men over fifty, the resemblance to carcinoma may be very close.
In this, as in all cases of difficulty in swallowing, chief stress should be laid on the X-ray appearances after the administration of an opaque meal; a pouch shows as a uniform, spherical shadow of from one to two inches in circumference.
Treatment is influenced by the manner in which the patient may have learned to overcome the difficulty of getting food into his stomach—Lord Jeffrey, who was the possessor of the pharyngeal pouch shown in [Fig. 286], was in the habit of emptying it, after a meal, by means of a long silver spoon. Some patients learn to feed themselves through a soft rubber tube.