CHAPTER XXXI DIAGNOSIS OF DISEASES OF THE MOUTH (Part 2)

patient should always be inquired into, particularly as to the swallowing of hot or caustic fluids, the impaction of bones, false teeth, or other foreign bodies, and the existence of nervous phenomena — functional or organic. Whenever possible, an examination with X-rays and bismuth porridge should be made. The dark shadow of the bismuth can be traced as it is swal- lowed, the seat and degree of obstruction noticed, and the presence of a pouch determined. In case of doubt a skiagram should be taken. It will show a mediastinal tumour, and particularly an aortic aneurysm, if either is present. The careful passage of an resoflmgoscofe may enable the surgeon to see a foreign body in or transfixing the gullet, or ulcera- tion, stenosis, growth, or compression of the tube by something outside it. The pidsation of an aneurysm may be seen. An oesophageal sound or bougie should only be used for diagnosis when neither X-rays nor cesophagoscope is available, as its passage is not unattended with danger. In an adult the distance from the upper incisor teeth to the stomach is 16 inches. Dysphagia in the young is often due to con- genital malformation ; in those past middle life it is 442 SURGICAL DIAGNOSIS [chap. usually the result of malignant disease. Hysterical dys- phagia is more cc.mmon in women than in men, but is not limited to the female sex ; malignant stricture is more common in men than in women. A sudden onset of dysphagia indicates either the impaction of a foreign body, a painful laceration, cauterization, or ulceration of the tube, the pressure of an inflam- matory swelling, or muscular spasm. Occasionally the existence of a malignant stricture is first noticed through the impaction of a carelessly masticated bolus in the slightly narrowed part of the gullet. A gradual onset of dysphagia may be caused by slow changes in the wall of the tube — stricture — or by slowly increasing pressure from without from a chronic abscess, aneurysm, or other tumour. Inter- mittent dysphagia may be caused by hysterical spasm, or by the pressure of an intermittently form- ing swelling like a pharyngeal pouch. The amount of matter regurgitated at one time is an index of the existence and size of a pouch or dilatation of the tube. Patients are sometimes able to indicate accurately the level of the obstruction. 1. If a new-born infant is found to suck well but to be unable to swallow, the milk flowing out of his mouth, and if at the same time he rapidly emaciates, there is a congenital stricture of the fharynx at its junction with the a3sophagus. By passing a small flexible metal probe the seat of the stricture can be ascertained. 2. If in a young person there is difliculty of swallowing which comes on and increases in the course of a meal, and is associated with the gradual formation of an ill-defined swellmg deep in the neck, it is due to a fharijngeal potich. Pressure upon this swelling may cause regurgitation of food, and as it is thus emptied, or empties spontaneously, the xxxi] DYSPHAGIA 443 dysphagia passes off. In rare cases the swelling contains only air, and is tympanitic on percussion. If the patient eats some bismuth porridge until the pouch fills out, and is then examined with X-rays and a screen, the pouch is readily seen. There may be some narrowing of the tube opposite the mouth of the pouch. Although this is a congenital con- dition, the patient may not complain until he has reached middle life. 3. Where dysphagia has developed rapidly, the pressure of an abscess should always be suspected. If a soft or fluctuating swelling can be seen or felt behind the pharynx or deep in the neck, bulging beneath the sterno-mastoid muscle, the diagnosis is clear. These abscesses may be acute, from infec- tion, accompanied by fever and severe illness, or chronic, associated with tuberculous disease of the spme ; the presence of rigidity of the cervical spine or of angular curvature of the upper dorsal spine therefore helps the diagnosis. 4. If the dysphagia came on suddenly, and at once became complete, or is complete for certain articles only, and it is found that the oesophagoscope tube or a full-sized bougie can be passed into the stomach without anything pathological being ob- served, it is a case of hysterical dysphagia. 5. Where gradually increasing dysphagia is asso- ciated with an increasing tumour in the neck or mediastinum, it should be attributed to the fressure of the tumour, unless there is strong reason to think that there is intrinsic disease of the part. The com- pressing tumour may be an aneurysm, a benign or malignant bronchocele, malignant growths in other parts, or masses of enlarged glands. There may be a primary malignant stricture of the gullet with secondary enlarged glands in the neck. 444: SURGICAL DIAGNOSIS 6. Gradually increasing and constant dysphagia with correspouding emaciation, where there is no evidence of any swelling pressing upon the part, indicates stricture of the gullet. If there is a history of syphiUs and there are signs of gummatous dis- ease of the pharynx, it is syphilitic. If there is a history of the swallowing of corrosive fluid, and the guUet is seen 1 o be puckered in and the wall is pale, the stricture is cicatricial. Traumatic stricture may follow an rdceration caused by the impaction of a foreign body or by other injury to the part. If there is no history suggesting previous ulceration of the gullet, the disease must be regarded as malignant stricture. The age of the patient, the steady increase of the dysphagia, the rapid emaciation, and the presence of enlarged glands in the neck are confirmatory circumstances. The oesophagoscope will show an altered colour of the part, loss of elasticity, and unevenness or ulceration of the surface. 7. Severe pain and difficulty in deglutition coming on immediately afttr urgent vomiting, or the swallow- ing of a large or too hot bolus or a sharp fragment of bone, is due to a laceration or abrasion of the gullet ; these symptoms may last for some days, but gradually subside if only liquid or soft food is taken. 8. Where, immediately after very m-gent vomiting, the patient becomes intensely collapsed and there is severe pain behind the sternum, rupture of the oesophagus has occurred. If the patient does not die in the collapse, signs of mediastinal suppuration come on. 9. Repeated haemorrhages from the pharynx without obvious cause, such as aneurysm, ulceration, or maUgnant tumour, are probably due to oesophageal noivus. The blue veins can be seen by means of the a^sophagoscope.