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DYSPHAGIA
1058 The
treatment of intussusception is surgical, and operation should be carried out as soon as possible after the diagnosis has been established.
.
DYSPHAGIA (MR. STANFORD CADE) I AM concerned in this lecture with some practical considerations of the common conditions producing dysphagia. From an academic point of view it is no doubt interesting to argue whether some case of difficulty in swallowing is due to spasm of a sphincter or to failure of relaxation of the same sphincter ; from the practical point of view it matters chiefly to discover whether the difficulty in swallowing is due to a malignant growth or to some other cause. The only way of differentiating the various cases is by submitting them all to a complete investigation at the earliest possible moment. Age, sex, mode of onset should not be used as an excuse to postpone investigation. In cases of dysphagia there is no justification for " expectant " treatment. The erroneous impression gained from the literature that dysphagia is not uncommonly due to spasm, aneurysm, cicatricial contraction, or diverticula is due to the fact that such cases are often reported, being interesting and presenting some special feature. In reality they do not account for more than 6 to 8 per cent. of all cases, the vast majority being due to a malignant growth. This being the case it is of the greatest
importance not to delay diagnosis. A systematic investigation should consist of the following steps :1. History of the case.-This should be taken in detail; it will throw a great deal of light on the case. Direct inquiry should be made for trauma, foreign bodies, burns. A statement by the patient that dysphagia has been present for years, that it is intermittent, that it occurred often under emotional strain with certain foods only should not be allowed to detract attention from the graver possibilities and must not encourage the practitioner to prescribe belladonna and hope for the best. It must be remembered that a long history of slight or intermittent dysphagia does not infrequently precede the development of a neoplasm and that the " text-book picture " of fairly rapid and relentlessly progressive difficulty in swallowing is not always obtained. With equal caution must be received the statement that dysphagia occurred as " a bolt from the blue " in the middle of a meal and the first indication was sudden but complete and temporary inability to swallow. Direct inquiry should be made about : (a) vomiting, its quality, quantity, and relation to swallowing ; (b) increased salivation and presence of mucus in the throat ; (c) occasional streaks of blood in the sputum ; (d) change of voice, however slight. A carefully obtained history often helps to establish or
of the rarer causes of dysphagia, but it be forgotten that by far the commonest cause is a malignant growth somewhere between the pharynx and the cardia and deliberate search is to be made for it. 2. Clinical examination should consist in a systematic examination of the mouth, pharynx, and larynx. The lateral walls of the pharynx, the pyriform fossae, and upper aperture of the larynx should be scrutinised. A pool of mucus behind the arytenoids, or frothy saliva in one pyriform fossa should arouse the gravest suspicion. The presence of cedema or an ulcer make the diagnosis nearly a certainty. A routine examination of the neck, chest, and abdomen should always follow. And lastly, the patient should be given a tumbler of water and swallowing observed. The accidental discovery of an unsuspected lesion elsewhere should not deter one from a complete examination. The greatest injustice to the patient is a diagnosis of " functional " dysphagia without the fullest possible examination. 3. X ray examination should consist of : (a) A preliminary skiagraphy of the chest with special attention to the mediastinum. (b) Screening of the eesophagus with an opaque meal of fluid, semisolid and thick barium. The clinician interested in the welfare of his patient will be present at this examination. The meal should be visualised from the mouth down to the stomach both in the antero-posterior and oblique positions. (c) Films should be taken as they may reveal beyond the actual narrowing of the lumen of the cesophagus, extramural extension of the disease, its size and position. 4. (Esophagoscopy.-In careful hands this is a minor procedure. It should never be omitted ; it should follow and not precede X ray examination, and it can give details of the type, size, and extent of the lesion unobtainable by other methods of examination. The three following points require emphasis : (a) Bougies are dangerous and of doubtful usefulness, and should never be used unless under direct vision through the oesophagoscope. (b) A positive Wassermann reaction does not signify that the patient is free from all other diseases and time must not be wasted in protracted antisyphilitic treatment. (c) A negative result of a biopsy is of little value and should not outweigh clinical evidence. Success or failure of treatment depends upon early diagnosis. If the lesion is benign, appropriate surgical treatment gives satisfactory results. Early diagnosis offers the only hope in malignant cases. The pharynx offers possibilities for the exercise of surgical skill in a minority of cases. Radiation by radium or X rays is applicable to a larger group of cases and by modern methods has given encouraging results. The aesophagus is still the realm of experimental surgery and for all practical purposes beyond the range of successful radiation. a
diagnosis
must
never
THE SERVICES Col. H. R. Bateman, late R.A.M.C., having attained the age for retirement, is placed on retd. pay. Lt.-Col. J. P. Lynch, from R.A.M.C., to be Col.
Maj.
O’Shaughnessy
Supernumerary for
INDIAN MEDICAL SERVICE Lt.-Col. R. T. Wells retires. Lt. P. L. O’Neill to be Capt. Lt. F. W. Whiteman is restd. to the estabmt.
ROYAL ARMY MEDICAL CORPS J. W. Lane to be Lt.-Col. TERRITORIAL ARMY
Lt. G. Lyon-Smith to be Capt. F. A. Edwards (late Cadet Serjt., Dulwich Coll. Jun. Div., O.T.C.) to be Lt.
to be Lt. service with a.T.G.-Lt. S. Andrews to be Capt. supern., for serv. with Med. Unit, Queen’s Univ., Belfast Contgt., Sen. Div., O.T.C.
L. F.
ARMY MEDICAL SERVICES
Contgt.,
ROYAL AIR FORCE Officer J. F. Sandow is granted Flying commission in this rank.
a
permanent
treatment of intussusception is surgical, and operation should be carried out as soon as possible after the diagnosis has been established.
.
DYSPHAGIA (MR. STANFORD CADE) I AM concerned in this lecture with some practical considerations of the common conditions producing dysphagia. From an academic point of view it is no doubt interesting to argue whether some case of difficulty in swallowing is due to spasm of a sphincter or to failure of relaxation of the same sphincter ; from the practical point of view it matters chiefly to discover whether the difficulty in swallowing is due to a malignant growth or to some other cause. The only way of differentiating the various cases is by submitting them all to a complete investigation at the earliest possible moment. Age, sex, mode of onset should not be used as an excuse to postpone investigation. In cases of dysphagia there is no justification for " expectant " treatment. The erroneous impression gained from the literature that dysphagia is not uncommonly due to spasm, aneurysm, cicatricial contraction, or diverticula is due to the fact that such cases are often reported, being interesting and presenting some special feature. In reality they do not account for more than 6 to 8 per cent. of all cases, the vast majority being due to a malignant growth. This being the case it is of the greatest
importance not to delay diagnosis. A systematic investigation should consist of the following steps :1. History of the case.-This should be taken in detail; it will throw a great deal of light on the case. Direct inquiry should be made for trauma, foreign bodies, burns. A statement by the patient that dysphagia has been present for years, that it is intermittent, that it occurred often under emotional strain with certain foods only should not be allowed to detract attention from the graver possibilities and must not encourage the practitioner to prescribe belladonna and hope for the best. It must be remembered that a long history of slight or intermittent dysphagia does not infrequently precede the development of a neoplasm and that the " text-book picture " of fairly rapid and relentlessly progressive difficulty in swallowing is not always obtained. With equal caution must be received the statement that dysphagia occurred as " a bolt from the blue " in the middle of a meal and the first indication was sudden but complete and temporary inability to swallow. Direct inquiry should be made about : (a) vomiting, its quality, quantity, and relation to swallowing ; (b) increased salivation and presence of mucus in the throat ; (c) occasional streaks of blood in the sputum ; (d) change of voice, however slight. A carefully obtained history often helps to establish or
of the rarer causes of dysphagia, but it be forgotten that by far the commonest cause is a malignant growth somewhere between the pharynx and the cardia and deliberate search is to be made for it. 2. Clinical examination should consist in a systematic examination of the mouth, pharynx, and larynx. The lateral walls of the pharynx, the pyriform fossae, and upper aperture of the larynx should be scrutinised. A pool of mucus behind the arytenoids, or frothy saliva in one pyriform fossa should arouse the gravest suspicion. The presence of cedema or an ulcer make the diagnosis nearly a certainty. A routine examination of the neck, chest, and abdomen should always follow. And lastly, the patient should be given a tumbler of water and swallowing observed. The accidental discovery of an unsuspected lesion elsewhere should not deter one from a complete examination. The greatest injustice to the patient is a diagnosis of " functional " dysphagia without the fullest possible examination. 3. X ray examination should consist of : (a) A preliminary skiagraphy of the chest with special attention to the mediastinum. (b) Screening of the eesophagus with an opaque meal of fluid, semisolid and thick barium. The clinician interested in the welfare of his patient will be present at this examination. The meal should be visualised from the mouth down to the stomach both in the antero-posterior and oblique positions. (c) Films should be taken as they may reveal beyond the actual narrowing of the lumen of the cesophagus, extramural extension of the disease, its size and position. 4. (Esophagoscopy.-In careful hands this is a minor procedure. It should never be omitted ; it should follow and not precede X ray examination, and it can give details of the type, size, and extent of the lesion unobtainable by other methods of examination. The three following points require emphasis : (a) Bougies are dangerous and of doubtful usefulness, and should never be used unless under direct vision through the oesophagoscope. (b) A positive Wassermann reaction does not signify that the patient is free from all other diseases and time must not be wasted in protracted antisyphilitic treatment. (c) A negative result of a biopsy is of little value and should not outweigh clinical evidence. Success or failure of treatment depends upon early diagnosis. If the lesion is benign, appropriate surgical treatment gives satisfactory results. Early diagnosis offers the only hope in malignant cases. The pharynx offers possibilities for the exercise of surgical skill in a minority of cases. Radiation by radium or X rays is applicable to a larger group of cases and by modern methods has given encouraging results. The aesophagus is still the realm of experimental surgery and for all practical purposes beyond the range of successful radiation. a
diagnosis
must
never
THE SERVICES Col. H. R. Bateman, late R.A.M.C., having attained the age for retirement, is placed on retd. pay. Lt.-Col. J. P. Lynch, from R.A.M.C., to be Col.
Maj.
O’Shaughnessy
Supernumerary for
INDIAN MEDICAL SERVICE Lt.-Col. R. T. Wells retires. Lt. P. L. O’Neill to be Capt. Lt. F. W. Whiteman is restd. to the estabmt.
ROYAL ARMY MEDICAL CORPS J. W. Lane to be Lt.-Col. TERRITORIAL ARMY
Lt. G. Lyon-Smith to be Capt. F. A. Edwards (late Cadet Serjt., Dulwich Coll. Jun. Div., O.T.C.) to be Lt.
to be Lt. service with a.T.G.-Lt. S. Andrews to be Capt. supern., for serv. with Med. Unit, Queen’s Univ., Belfast Contgt., Sen. Div., O.T.C.
L. F.
ARMY MEDICAL SERVICES
Contgt.,
ROYAL AIR FORCE Officer J. F. Sandow is granted Flying commission in this rank.
a
permanent