Examination Of The Stomach And Oesophagus

1. October 25tb, 1888, at 8 a.m.: Patient drank coffee one hour before. As soon as a part of the stomach tube was pushed into the oesophagus a coffee-brown liquid was ejected, in which there were some remnants of food and many epithelial cells present. The patient then drank 100 c.c. water. I did not hear any swallowing sound at the ensiform process during the time that the patient drank. On introducing a part of the tube into the oesophagus, water of a neutral reaction came out. Thereupon the tube was pushed farther into the stomach without any resistance, and the patient ejected from his stomach through the tube about 70 c.c. of a coffee-brown liquid. Reaction acid, hydrochloric acid present (phloroglucin-vanillin test), the degree of acidity being 40.

2. November 5th, at 9 a.m.: On account of loss of appetite, the patient had not eaten anything since 2 P.M. of the previous day. The tube was introduced for a length of 46 cm. from the teeth; a pulpy mass (150 c.c.) came out, in which were present small particles of bread; reaction acid, lactic acid present, no hydrochloric acid; acidity = 4. The patient drank 100 c.c. water, the tube was introduced 45 cm., the water came out somewhat turbid by the admixture of mucus and food remnants; microscopically there were many epithelial cells and micrococci. After the water had come out, the tube, without being taken out, was pushed farther and with but a slight resistance it passed into the stomach; the patient was told to empty his stomach, but only a few drops of clear fluid were obtained. This proved that the stomach was empty.

3. November 8th: The patient partook of breakfast, and then drank water; he was examined an hour later. The tube was introduced for a distance of 36 cm., when there appeared a fluid containing no hydrochloric acid; thereupon the tube was pushed, without any further resistance, into the stomach, and by expression a fine chyme was obtained containing hydrochloric acid and peptone.

4. November 13th: The patient took eggs, coffee, and a little softened white bread; then he administered his method of bringing the food down into the stomach by means of pressing (bringing the muscles of expiration into play, after having made a deep inspiration, with closed glottis). An hour later, shortly before the examination, the patient was told to press several times again. The tube was introduced to a distance of 48 cm., and during expiration only 8 c.c. of a turbid liquid were obtained; there were present very minute pieces of bread and many epithelial cells, but no hydrochloric acid; thereupon the tube was pushed, without any resistance, into the stomach; now there came out a chymous fluid with hydrochloric acid. The patient drank 200 c.c. water; the tube was introduced about 40 cm., and the water came out with a gush.

5. November 16th: Patient took breakfast at home and administered his method of forcing down his food. The oesophagus was examined an hour later and found empty. The pharyngeal vault was tickled with the finger to induce vomiting, but without success. Thereupon the tube was introduced into the stomach, and a fine chymous fluid, containing hydrochloric acid, was obtained. The stomach was then filled with air by means of a tube and bulb; the air did not escape along the outside wall of the tube. By keeping the tube open the stomach was emptied of the air; afterwards the lower part of the oesophagus was blown up. A considerable quantity of air could be blown into it without returning, but upon increasing it still more the air began to escape upward through the upper part of the oesophagus, along the outer side of the tube wall. During the inflation of the oesophagus there was observed, at both sides of the vertebrae below the inferior margin of the scapulae, somewhat more tympanitic resonance, but that was not very decided.

It is evident, from the history of this patient, that the difficulty in bringing the food into the stomach slowly developed a few days after the fall, and finally led to complete dysphagia. The examinations showed that the contents of the stomach were normal. The examinations with the stomach tube show, firstly, that the passage through the oesophagus to the stomach is perfectly free, for the thick tube passed into the stomach without any resistance; secondly, that the oesophagus, in its lower third, must be sac-cularly dilated, as the distance from the teeth to the cardia (measured with the tube) is 48 cm.; whereas in the case of this patient, even taking into consideration his large frame, it ought normally to be not more than 40 to 41 cm. In this cavity the tube, leaning on the wall of the oesophagus, was compelled to assume with its lower end the form of a semicircle, and thus produce this high figure. - That the patient is really unable, in swallowing, to bring even liquids down to his stomach, except by the pressing action, is proven by the fact that swallowed water could always be taken out from the oesophagus by means of the tube, whereas immediately afterward the tube, pushed into the stomach, brought up part of the stomach contents containing hydrochloric acid.

Ewald mentions a similar case, in which the tube passed into the stomach without encountering any resistance at the cardia while the food still remained within the oesophagus. He considers this case as one of spasmodic contraction of the cardia and believes that although no resistance was felt with the tube, still the cardia became contracted during deglutition. I do not think it is necessary to assume that the cardia acts differently during insertion of the tube than while taking food. As I remarked above, the symptom of dysphagia exists as soon as dilatation of the oesophagus has been established, no matter whether the cardia be contracted or not, for the dilated oesophagus cannot contract sufficiently to carry the food into the stomach. In order to accomplish this, other means will be necessary, consisting, as mentioned above, in the compression of the thorax, after a deep inspiration.

Diagnosis

The diagnosis of the acute form of cardiospasms is based upon the following points: The existence of dysphagia for a short time, the absence of the swallowing sounds, and the resistance encountared at the cardia on insertion of a tube into the oesophagus - a resistance, however, which can be overcome. It is characteristic of this spasmodic contraction of the cardia that the resistance felt during the introduction of different-sized bougies is the same or rather less for those of large calibre, while in organic strictures of the cardia a thick tube is unable to pass and the thin ones encounter either no resistance at all or glide through with some resistance. The diagnosis of the chronic forms of cardiospasms can be made if the symptom of dysphagia has lasted for long periods of time (three months to two years) and the examination with a bougie reveals the same condition as described in the acute form.

Dilatation of the oesophagus, which is of so frequent occurrence in this affection, and its most important sequelae can be diagnosed in the following way: The patient one to two hours after a meal is examined by means of a tube, which is introduced into the oesophagus, and if there be some contents (in the oesophagus) they are withdrawn. The patient now drinks a glassful of water (200 to 300 c.c.) and is told not to perform the forcing motions. After an interval of about five minutes the tube is again inserted into the oesophagus. If dilatation of the latter exists, the water will now appear through the tube in about the same condition as when drank, i.e., not mixed with food. On pushing the tube farther down through the cardia into the stomach, real gastric contents will now appear, showing that the water the patient drank had remained all the time within the oesophagus and had not mixed with the food.

Prognosis

The prognosis of the acute form is 30 good. That of the chronic form is good quoad vitam and bad quoad valetudinem completam.

Treatment

The acute form is best treated by large doses of bromides and by the introduction of large-sized sounds. Opiates and chloral hydrate have also sometimes a beneficial effect In the chronic form, the treatment will consist in the following: 1. The patient is allowed to take only fluid or semi-fluid foods; 2. After every meal he must perform his pressing action for a long time; 3. Every evening, before going to bed, the oesophagus is emptied and washed by means of the tube; 4. The patient introduces the tube into his stomach once every day, in order to relax the cardia. After a while, when the patient feels better, he can begin to introduce greater variety into his diet, and is allowed to eat even solid substances.