AFFECTIONS OF THE (ESOPHAGUS. 



swallow. Even when the stricture is near the cardiac orifice of the 

 stomach, they almost always indicate the region beneath the manu- 

 brium sterni as the place where the food sticks ; finally, they cannot 

 even swallow liquids. 



The greater the obstacle, the less the patient succeeds in overcom- 

 ing it by drinking, or by renewed attempts to swallow, and the more 

 frequently the food regurgitates. An antiperistaltic movement, in 

 which the contraction of a lower segment of the oesophagus is followed 

 by the contraction of the segment just above it, has not been physiologi- 

 cally observed, it is true ; on the contrary, the contractions which are 

 voluntarily begun in the pharynx always go from above downward ; 

 but these facts do not exclude the possibility of a morsel of food, which 

 cannot pass downward, being pressed upward by contractions which 

 have proceeded peristaltically from above down to the point of stric- 

 ture, or of a regurgitation in the same way into the mouth of the con- 

 tents of the oesophagus, which has been filled up to a certain point. 

 Occasionally there is no abdominal pressure in this form of vomiting ; 

 in other cases there is spasmodic contraction of the muscles of the ab- 

 domen without any influence on the evacuation of the oesophagus. 

 When the contraction has increased still further, after every attempt 

 to eat or drink often after a few mouthfuls, occasionally not till a 

 good deal has been swallowed (Chapter IIL) there is a feeling of 

 pressure deep in the breast, accompanied with great unpleasantness 

 and anxiety, which increases until, with intentional or instinctive at- 

 tempts to swallow, the food is slowly evacuated from the mouth, little 

 changed, but largely mixed with mucus. The introduction of a bougie 

 affords the best diagnostic sign, as it shows not only the existence of 

 the stricture, but also its grade, locality, and even its form. 



[The common fact that only the morsels first swallowed are re- 

 tained, while subsequently the power of swallowing improves, has 

 raised the supposition that part of the obstruction is due to spasm 

 of the constrictor muscle. 



The diagnosis must not only decide the existence of a stricture, 

 but the original disease on which it depends. In regard to the for- 

 mer, we may sometimes be almost certain of its presence before 

 introducing the cesophageal sound, from the difficulty of swallow- 

 ing and the regurgitation, while the sound may show the seat, 

 grade, character, and extent of the contraction. Skilful and suc- 

 cessful sounding, besides a variety of sounds, requires a certain 

 skill and custom in the examiner ; otherwise slight stenosis may be 

 overlooked, or stricture may be diagnosed from the point of the 

 sound catching before it passes the cricoid cartilage. According to 



