As the lumen of the gullet becomes narrower, the food materials accumulate above the obstruction, and the consequent dilatation of the gullet above the stricture accounts for the large amount that may be regurgitated and for the patient describing it as vomiting. Along with food materials there is abundant saliva, and, if the cancer has ulcerated, of pus and blood. Contrary to what might be expected, there is little or no complaint of hunger, in spite of the progressive starvation and emaciation which inevitably supervene.

Death takes place within a year or so of the onset of symptoms, usually from starvation, but the fatal issue may be precipitated by ulceration and perforation of the gullet into a large blood vessel or into the left pleural sac; in the latter event, there follows a basal empyema which may contain gas and food materials.

Diagnosis.—In the majority of cases the history is so characteristic that there is little doubt regarding the diagnosis; the most reliable corroboration, with least risk and distress to the patient, is obtained by radiographic examination after an opaque meal; the appearance of the dilated gullet is that of an elongated sausage, parallel with the vertebral column, and terminating abruptly at the site of stricture ([Fig. 285]). A filiform, tortuous shadow of the bismuth may be continued downwards and show up the lumen of the stricture. The use of the œsophagoscope and of bougies is to be deprecated as not free from risk.

Treatment.—The lower end of the gullet is one of the most inaccessible portions of the body, and although it has been removed by operation the prospects of success are so small that it is not at present regarded as justifiable.

Among palliative measures, may be mentioned intubation of the stricture with a view to increasing the amount of food that can be swallowed; a funnel-shaped tube like that of Symonds or of Hill is introduced into the lumen of the stricture by means of a bougie or with the help of the œsophagoscope. The tube is anchored to a denture, or by means of a silk thread to the cheek by sticking-plaster. Our experience of intubation is that it merely serves to tide the patient over a critical period of starvation, so that he may regain some strength for any other procedure that may be indicated.

The value of making a fistula in the stomach—gastrostomy—in order to feed the patient, is a question about which widely different opinions are held both by patients and by surgeons. Many patients allege that they would prefer to die rather than prolong a precarious existence by being fed through a tube; some surgeons look upon the operation with disfavour because they doubt whether it even prolongs life, and it is often followed by a pneumonia which rapidly proves fatal. Variation in the results of gastrostomy observed by different surgeons is partly due to differences in the stage of the disease at which the operation is performed, and probably to a greater extent to the confusion between cases of slowly growing squamous epithelioma of the lower end of the gullet and cases of glandular carcinoma of the cardiac end of the stomach, these being grouped together under the clinical heading of “malignant stricture of the lower end of the gullet.” In our experience cases of epithelioma of the gullet (in the strict sense of the term) benefit greatly if subjected to gastrostomy as soon as the condition is recognised. In a case operated upon by Thomas Annandale the patient survived the operation for three years and some months.

Radiation.—The introduction of a tube of radium into the stricture and its retention there, the silk thread attached to the tube being secured to the cheek by a strip of plaster, is described by Hill and Finzi as the most valuable palliative measure that has so far been employed in cancer of the gullet; the capacity of swallowing may be regained to a considerable extent. The employment of radium is rendered easier and more efficient if it is preceded by gastrostomy.

The Roux-operation.—This consists in making a new gullet to replace that which is obstructed; the abdomen is opened and a loop of jejunum is isolated; its lower end is anastomosed—end to side—to the stomach; the intestine is brought upwards through a tunnel made for it between the skin and the sternum, and the upper end is brought out and fixed to the skin, in the supra-sternal notch. It has scarcely passed beyond the experimental stage.

CHAPTER XXIX
THE LARYNX, TRACHEA, AND BRONCHI[7]