

PERFORATION AND RUPTURE OF THE (ESOPHAGUS. 489 

 t 

 when they they are high enough up, they may be reached with the 



finger. 



Cancer of the oesophagus is not easily mistaken. If, in a person 

 of advanced age, particularly in one who has been in the habit of 

 drinking strong liquor, difficulty of swallowing gradually occurs, 

 without any other known cause, and increases slowly till it pro- 

 duces the very painful symptoms described in the second chapter, 

 we may very strongly suspect carcinoma, for we know that this is by 

 far the most frequent cause of stricture of the oesophagus, and that 

 all other forms are proportionately very rare. The presumption 

 that the disease is cancerous increases in probability when there are 

 lancinating pains at various places, particularly between the shoul- 

 der-blades, when the patient emaciates rapidly, and the dirty-yel- 

 low, cachectic appearance of the face, common to cancer-patients, 

 occurs. The diagnosis becomes absolutely certain when we find 

 fragments of cancer in the mucous, sanious, or bloody masses that 

 are vomited or brought up with the cesophageal sound. Subse- 

 quently, when the cancer sloughs, the symptoms of stricture sub- 

 side ; nevertheless, the emaciation continues, the feet swell, coagula 

 often form in the femoral veins, and finally the patient dies from 

 exhaustion, or from perforation of one of the above-named organs. 



TREATMENT. Dilatation of the cancerous stricture by bougies 

 is dangerous, and should never be tried when the diagnosis is cer- 

 tain. In the earlier stages it may hasten the ploughing of the can- 

 cer, and later it may cause perforation of the oesophagus. The 

 treatment must be symptomatic. If there is great pain, we may 

 give opium ; when there is inability to swallow, we may make the 

 almost hopeless attempt to nourish the patient by enemata. 



CHAPTER Y. 



PERFORATION AND RUPTURE OF THE OESOPHAGUS. 



PERFORATION of the oesophagus may take place from within out- 

 ward, or the reverse. The first form most frequently results from 

 the breaking down of cancer, more rarely from ulcers caused by 

 splinters of bone, or from deep sloughs, excited by corrosion with 

 caustic substances. So-called perforating ulcers, such as are found 

 in the stomach and duodenum, are never seen in the oesophagus. 

 The oesophagus may be perforated from without inward by aneu- 

 risms of the aorta, by the breaking down of tuberculous bronchial 

 glands, especially of those located at the bifurcation of the trachea, 



