RUPTURE OF THE ESOPHAGUS.
Rupture of the esophagus has been known to occur in consequence of severe vomiting, there being some twenty-five cases of this character now on record. (Dennis.) A tear is rarely complete, but it may be followed by hernia and formation of a diverticulum. The accident will be indicated by violent pain following severe vomiting in connection with an effort to dislodge a foreign body. There will be more or less shock and perhaps collapse, with escape of blood. Emphysema of the neck and upper part of the chest may result and the injury prove fatal. The condition being suspected, it would be advisable to do an external esophagotomy or else to carefully introduce a stomach tube and leave it in situ.
PERFORATION OF THE ESOPHAGUS.
Perforation—i. e., rupture without traumatism—may result from the existence of ulcers or from the advance of malignant disease. It may occur in either direction. Thus while the mediastinum may be infected from entrance of septic material into it the direction may be reversed and an abscess or other lesion of the surrounding tissues may evacuate itself into the esophagus. Should this prove to be an aneurysm the patient will die with uncontrollable escape of blood. The treatment of such a case, if any be permitted, will depend entirely on the nature of the exciting cause. Perforation has also followed injudicious use of bougies when exploring or treating strictures (especially cancerous) of the esophagus.
ESOPHAGISMUS.
Esophagismus, or spasmodic contraction of the esophagus, is usually an expression of hysteria, or else is a reflex spasmodic effect due to the presence of some neighboring irritation. In the esophagus, as in the urethra, there may be spasmodic stricture, which will afford considerable obstruction. Thus I have seen it as a functional neurosis, absolutely without explanation, in an apparently healthy workingman. It is noticed also in connection with hemorrhoids and with hepatic lesions. It is seen in pregnancy, and a certain degree of it will complicate many cases of gastric ulcer, gastritis, or esophagitis such as is produced by swallowing mild caustics. While producing dysphagia and obstructive phenomena it is intermittent and interposes little real obstacle to the passage of a full-sized bougie or tube. It is frequently accompanied in the hysterical by globus hystericus, and by regurgitation of whatever food the patient attempts to swallow.
The local treatment consists of dilatation by the passage of full-sized instruments at frequent intervals. If a neurosis the patient may require other treatment, addressed either to the nervous system or to any well-marked constitutional condition.
STRICTURE OF THE ESOPHAGUS.
Stricture of the esophagus has an etiology practically identical with that which pertains to stricture of any other passage of the body. It may be due to extrinsic or intrinsic influence. Among the former may be mentioned the presence of tumors, either benign or malignant, or of cicatricial tissue, while among the latter should be mentioned the injuries resulting from the presence of foreign bodies, the extensive ulcerations due to the swallowing of various caustic fluids, and the cicatricial contraction which may follow other lesions like ulceration. Those cases which are due to serious congenital defects will usually die early. Of the ulcerative lesions which lead to stricture the most common are the cancerous. Syphilitic and tuberculous ulcerations may occasionally produce the same effect. By far the most common causes are the traumatic, which are connected either with foreign bodies or with the unfortunate accidental use of caustics.
Esophageal strictures are recognized by the difficulty in swallowing which they produce and the later dilatation of the esophagus above, which is the frequent result of their long existence. The degree of difficulty experienced by the patient in deglutition is to a considerable degree a measure of the extent of contraction. It may be nearly always assumed that such a stricture as is produced by the swallowing of caustic fluids will leave a tortuously contracted passage-way, and the instrument passed for its recognition, while arrested in its upper portion, may give little or no correct idea as to the arrangement below. In some instances it may be possible here, as in the case of diverticula, to introduce sufficient bismuth emulsion into the esophagus to make it cause a shadow in an x-ray picture, and in this way to give pictorial information not otherwise attainable.