This section is from the book "Diseases Of The Stomach", by Max Einhorn. Also available from Amazon: Diseases of the Stomach.
The swallowing sound, if not absent, is frequently retarded, and heard about twenty seconds after swallowing of water, while normally it should be heard after seven. This sign, however, is not pathognomonic; for, on the one hand, I have seen cancer of the cardia with the appearance of the swallowing sound at the normal time of seven seconds; and, on the other hand, I have observed cases in which there was no organic trouble and still the swallowing sound was not heard for a long time.
It is best to examine the patient with silkworm tubes or olive-shaped bougies of different sizes. For the sake of convenience the latter may be made in a divisible form, thus enabling them to be carried in the physician's pocket (Fig. 63). The examination should be directed with the following objects in view:
It is of the utmost importance to introduce the tube through the oesophagus into the stomach, and to pay attention to the fact whether there be no resistance at any place of the passage. If a resistance is felt, mark at what distance from the mouth it is situated, and also whether it can be overcome without the application of much force. Much force should never be exerted; if a tube of a certain thickness has met with resistance within the oesophagus, then try a tube of thinner calibre. In this way the degree of stenosis can be estimated.
Fig. 63. - Einhorn's Divisible Oesophageal Bougie.
When withdrawing the tube from the oesophagus, it is always necessary to close the opening with the thumb, and then empty the contents into a porcelain dish. Sometimes small particles of the neoplasm are then found, which, when examined under the microscope, will frequently reveal the nature of the trouble, and assist us in making a positive diagnosis of cancer.
The tube sometimes contains either fresh clear blood, not smelling badly, or blackish-looking and decomposed blood mixed with mucus, with a very disagreeable, sometimes fetid odor. The latter condition is very frequently found in malignant strictures of the cardia, and is sometimes pathognomonic of cancer. Fresh, clear blood, appearing constantly at the examination of the tube, is suggestive of malignant trouble at the cardia, even when no stricture has yet been found. This symptom, however, is not a positive one, as there are other conditions that may produce it. The following case well illustrates the importance of the detection of blood at the lower end of the oesophagus:
Patient, about 45 years old, had complained of a burning sensation and pains in the epigastric region for over a year. He had no difficulty whatsoever in the partaking of food. He was not emaciated and presented a healthy, good color. On examination, the gastric region was found to be somewhat tender, but not painful to pressure. The outlines of the stomach were not enlarged. The swallowing sound was heard seven seconds after the deglutition of water. The examination with the tube one hour after test breakfast revealed no abnormal conditions whatever. The tube passed into the stomach without the slightest resistance. The chemical analysis of the gastric contents showed the presence of free hydrochloric acid, the absence of lactic acid, and a degree of acidity of 99. On washing out the stomach of the patient in the fasting condition, it was found that it contained no food from the previous day, and the water returned pretty clear. When, however, the water stopped running and the tube was partly withdrawn, so that its end was in the neighborhood of the cardia, a small quantity of clear blood, mixed with some water, usually ran out. When the upper opening of the tube was closed and the instrument entirely withdrawn, it was found to contain pretty clear blood.
Numerous examinations during a period of about two months showed the presence of the same condition, especially with regard to the appearance of blood at the end of the washing procedure or when withdrawing the tube. The characteristic rest treatment for ulcer did not benefit the patient in the least. The probable diagnosis of cancer of the cardia was made, and the patient died one year afterward in a well-known sanitarium in Germany, in which the -diagnosis of cancer had been confirmed.
 
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