This variety has chiefly to be distinguished from cicatricial stricture and spasm of the cardiac orifice. Of the three, the malignant affection is by far the most common, for, out of every hundred cases of obstruction at the lower end of the oesophagus, about ninety are due to cancer, seven to simple stricture, and three to cardiospasm. Carcinoma is rather more frequent in men than women, and seldom develops before fifty years of age. Cicatricial contraction is usually the result of corrosive poisoning, and its symptoms supervene gradually after the subsidence of those arising from inflammation of the oesophagus and stomach. Very rarely it results from a simple ulcer. Chronic cardio-spasm is almost entirely confined to men, although a less severe form is sometimes encountered in anaemic and neurotic women. In each dysphagia is the first and most prominent symptom. In carcinoma and cicatricial stenosis this increases in severity, until regurgitation occurs after every attempt to swallow food; but in cardio-spasm it is apt to vary from time to time, and regurgitation is rare. Carcinoma is accompanied by rapid emaciation, cachexia, and sometimes by pain at the chest, and in spite of all treatment terminates fatally within nine months. The fibrous stricture is more amenable to local treatment, and if gastrostomy is performed life may be prolonged for many years; while cardio-spasm progresses very slowly and may persist for a long time without exercising any serious influence upon the general nutrition. In each complaint the second deglutition sound is greatly delayed or entirely abolished, and a tube inserted into the oesophagus encounters resistance at sixteen to eighteen inches from the incisor teeth. In the organic varieties the stricture gradually becomes impermeable, but in the functional disorder careful manipulation will often effect the passage of the instrument into the stomach. Dilatation of the oesophagus above the stricture may occur in each instance, and a small quantity of undigested food mixed with saliva may be evacuated by the tube. If the stricture is due to a malignant growth, the extract is often fetid, tinged with blood, and may contain minute particles of the morbid growth, but in the non-malignant cases these evidences of ulceration are usually lacking.

If the malignant growth also affects the fundus, a palpable tumour may be detected in the left hypochondrium, which requires to be distinguished from an enlargement of the spleen, a movable kidney, a growth in the tail of the pancreas, and from a tumour of the colon (fig. 45, p. 173).

(1) An enlarged spleen presents a sharp edge, a smooth surface, and a dull note upon percussion. Tenderness is usually absent, and if the organ continues to grow the long axis of the tumour points towards the opposite iliac fossa rather than in the direction of the umbilicus. Gastric symptoms are absent, and leuchaemia may often be detected.

(2) A movable kidney can be displaced by pressure to a much greater extent than a cancerous fundus. Its surface is smooth and non-tender, its outlines well defined, and the percussion-note is resonant, owing to interposition of the colon. Gastric symptoms are wanting, and the other kidney may also be loose.

(3) In carcinoma of the tail of the pancreas the tumour is fixed, hard, tender, tympanitic on light percussion, and rarely accompanied by special gastric symptoms, unless it happens to compress the cardiac orifice or involve the stomach. (4) A palpable tumour of the colon due to a malignant growth is rare, and usually consists of a faecal accumulation above the stricture. The mass is consequently somewhat ill-defined in outline, of softish consistence, and may often be indented by pressure with the finger. It is more movable in a lateral direction than a tumour of the fundus, increases very slowly in size, and may completely disappear after a thorough evacuation of the bowels. The symptoms that accompany it are those of chronic intestinal obstruction rather than of malignant disease of the stomach.

Table 31.-Showing The Principal Points Of Distinction Between The Three Varieties Of Stricture Of The Cardiac Orifice