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This Item is filmed at the reduction ratio checked below/ Ce document est filme au taux de rMuctlon indlque ci-dessous. 10X 14X 18X 22X 26 X 30X y 1 12X 1SX 20X 24 X 28X 22 1 Th« copy filmad h«r« has been reproduced thanks to the generosity of: L'exemplaire film* fut reproduit grice A la g4nArosit4 de: University of Toronto Archives University of Toronto Archives The Images appearing here are the best quality possible considering the condition and legibility of the original copy and in keeping with the filming contract specifications. Original copies in printed paper covers are filmed beginning with the front cover and ending on the last page with a printed or illustrated impres- sion, or the back cover when appropriate. All other original copies are filmed beginning on the first page with a printed or illustrated impres- sion, and ending on the last page with a printed or illustrated impression. The last recorded frame on each microfiche shall contain the symbol — »■ (meaning "CON- TINUED"), or the symbol V (meaning "END"), whichever applies. Mdps, plates, charts, etc., may be filmed at different reduction ratios. Those too large to be entirely included in one exposure are filmed beginning in the upper left hand corner, left to right and top to bottom, as many frames gi required. The following diagrams illustrate the method: Les images suivantes ont At* reproduites avec le plus grand soin, compte tenu de la condition et de la nettet* de l'exemplaire film*, et en conformity avec les conditions du contrat de filmage. Les exemplaires originaux dont la couverture en papier est imprimte sont film*s en commenpant par le premier plat et en terminant soit par la derniAre page qui comporte une empreinte d'impression ou d'illustration, soit par le second plat, salon le cas. Tous ies autres exemplaires originaux sont filmis en commengant par la premiere page qui comporte une empreinte d'impression ou d'illustration et en terminant par la derniire page qui comporte une telle empreinte. Un des symboles suivants apparaftra sur la derniire image de cheque microfiche, selon le cas: le symbole — ^ signifie "A SUIVRE", le symbols V signifie "FIN". Les cartes, planches, tableaux, etc., peuvent *tre filmis * des taux de reduction diff^rents. Lorsque le document est trop grand pour h*re reproduit en un seul clich*, il est film* A partir de I'angie sup*rieur gauche, de gauche * droite, et de haut en bas, en prenant le nombre d'images n*cessaira. -Les diagrammes suivants illustrent ie m*thode. 1 2 3 1 2 3 4 6 6 Vi/j{ML^2a^fcafcgr>>cf^t^^^ 1. A Case of Fusiform Dilatation of the (Esophagus without Intrinsic Stenosis. 2. A Case of CEsophagotomy r Foreign Body. — Rccvcyy. ll!us.trat-d. BV GEORGE A. PETERS, M.B.. F.R.C.S. Eng. .I.S..O.-,-.,/, l',off^/■■/.■ Ch:''lf,i ; TORONTO : Rei>rintki) 1 ROM Tin; Marih C'ANAD.'. I.AN'CHT UJO ' In -f. "1 Tilt: 14NAPA 1.4 MKT. DILATED OESOPHAGUS. (ILLUSTRATING DR. PETERS' PAPER. A. Ipper i«.iliiiii. al."'U tin rc-ioii ..f tin- ■ ricoi.l lai'l nptii. ('. i» yhiiiii just :i1«M' tlio ii'iiiil whin- Hi ilialiliraL'm. I>. The li\ pirtroi.hiiril c ins ..( ttic ili.i| ' - .1 ;;1.,-^ r„(i. K. Tiu' :.-;i-.r'-!"l ,ih.l, altila:;! . I!. Tin- iviMi-t | i*')lilia-,'ti- I'a^x-s tliroii'.'li tli( ira'.nii. ni\iilfi.owed by most gratifying success. He could take food by the fi>tu us opening and retain it well in the stomach. It seemed to digest perfectly, and in the course of some three or four months he increased in flesh up to his original weight. After being fed through the gastrostomy opening for .some six months, he began again to go down hill, and became nervous and extremely anxious to have something dot>e to allow him to partake of food in the natural way. With this purpose in view, he, on Dr. Howitt's suggestion, placed himself under my care in the Toronto General Ho.spital. On passing an CEsophageal bougie no obstruction was found until the bulb had pa.ssed some 16 inches from the front teeth. Here the passage was abruptly interrupte;h the bulb wa' not grasped to any extent whatever. Occasionally, however, the bulb could be made to pass onwards to a distance of nineteen inches, apparently entering the stomach. But I was never able to feel the bulb of the bougie by means of a sound passed through the gastrostomy wound. 'J'his must have been, a-i I found out later, due simply to the fact of accidentally missitig the bulb, for it is quite clear that the two instruments must have been in the same cavity. The stomach was fairly large, and this probably accounted for the ease with which the two instruments mi,s.sed one another. Before operation my conception of the condition was that there was an hour-glass contraction of the stomach, the oesophagus communicating witli the left compartment, while the ga.st!oat-omy wound conunnnicated with the right. This view seemed to be substantiated by tht- fact that liquid coloured with methylene blue to the amount of more thai-, a pint could be swallowed and y-t could not Iw recovered thronnh the gaHtn.s- tomy wound. It turned out afterwards, of course, thai the blue Uit to the right of that vessel. This was subsequently disproved so far as the common opening was coricerned,by post mortem e.xamination, as it was found that the right nus of the diaphragm parsed between these two tnbes in the normal manner, b.'^ that the oeM>nl.ageal opening had been dragged quite to the right o. th3 middle line by the weight of the oesophageal sac pouching into the right plerral cavity. An oesophageal bougie was now passed by the mouth, hut could not be felt to come in contact with the finger in the cardiac oponing of the oesophagus. On withdrawing the finger from this opening, however, and exp?oring the neighborhood, the end of ^he Ik agie could be felt dis- tinctly tc the rij^ht of this opening through the stomach wall and the diaphragm. After considerable manipulation the bougie was directed to- wards the oesophageal opening, and passed on into the stomach. The bougie was now directed by the finger across the stomach cavity towards the gastrostomy wound and made to emerge there. A .silk ihread was tied'to it, and to this in turn a length of small rubber tubing, which was thus withdrawn across the stomach through the cardiac opening and so upwards to the mouth. My intention was to endeavour to dilate the stricture by slow traction by means of this rubber tube, adopting to some extent the string-saw method of Abbe. The operation wound in the stomacl; wa.-^ now stitched up by a double row of Lembert sutures, t> stomach dropped back, and the ab- dominal wound closed after disiulection, without dniinagc. %^ The operation waa a prolonged and s mewhat severe one, and the patient suffered greatly from Hhock. He ur/:''tate, beneath the peristaltic wave h id ro accumulate in the upper part of the dilatation. Taking the instance before us, it is quite clear that this must have been the case, otherwise f o d must have entered the stomach, since there was really no absolute obstruction, as the tip of the finger or a bougie properly directed could at all times be passed through the opening from the oesophagus to the stomach. Practically, then, after a certain stage of dilatation has been reached, the condition appears to perpetuate itself, and the increasing weight of the colunm of food and liquid which may be contained in the dilated portion merely tends the more strongly to bring about a passive dilatation. Moreover, it must >ot be forgotten that there is a negative pressure in the thoracic cavity through which this portion of the oesoph-gus passes and this still further nds to favour the dilata- tion. Again, in the case above cited, it was perfectly evident that the presence of the heart and pericardium crowded the dilated oesophagus towards the right pleural cavity and caused a distinct curve of the tube in that direction This again would still further increase the stenosis at the point of passage of the esophagus through the diaphragm by tending to cause a sharp kink of the tube at that point. The literature of (he subie-t has been comprehensivt ly reviewed in an article by Dr. H. Strauss, of Berlin, Germany, which formed the sub- ject of a lecture and demonstration at the Nineteenth Congress of Inter- nal Medicine at Berlin. Among the theories given to account for the condition may I e mentioned the following: — 1. Congential weakness of the oesophageal wall as urged by Striimpel. 2. Abnormal relaxation or elasticity of a Mehnai t'.i oesophageal entro- mere. 3. Pressure of the aorta upon the lower portion oi the oesophagus, leading to a slight degree of stagnation which, it is argued, sets up re- peated irritations of the mucous membrane which lead to spasms of the cardiac region of the oeso[)hagus. 4. Strlinip"! considered that in his case a bend of the oesophagus in its lower portion hai impeded the passage of the oesophageal contents. In the transactions of the Pathological Society of London, Vol. 39, p. 103, Handford reports a case of dilatation of the oesophagus without stricture. The history given is similar to that givtn above as regards the difficulty of swjiUowing and the regurgitation of food, but differs in regard to the cardiac symptoms and the mode of death. The seat of obstruction in this case was exactly at the point where the oesophagus pHSses through the diaphragm, and it is noted that there was no intrinsic stricture of the oesophagus, since the opening would readily admit thefin- gi r. There was no induration or thickening which could point to a cicatrical condition or new growth. It is noted, however, that the aorta was dilated to some extent, and the cause of the obstruction is attributed to the pressure of the oesophagus against the unyielding central tendon of the diaphragm by the dilated aorta. The condition of the diaphragm itself is not noted, nor is there history of hiccough, as was present in my case, but it seems to me possible that the fault here may have been pri- marily in the diaphragm, since it is difficult to understand how simple dilatation of the aorta could produce such an effect upon the oesophageal opening through the diaphragm. I have above given my reasons for holding the diaphragm responsi- ble, in this case, for producing an extrinsic stenosis of the oesophagus, pro- bably primarily as a spasmodic condition but subsequently pa.ssing on to an organic lesion die largely, if not altogether, to hypertrophy of the pillars of the diaphragm. 2. A Case of Oesophagotomt fob Foreign Body. — Recovery. The case about to be described is that of a patient referred to me by Dr Allen Baines, who furnishes the following history : — Mr. Q. D., aged twenty-six, while swallowing a raw egg dislodged and swallowed a small vulcanite plate bearing one front tooth. This occurred on the 18th July, 1901. The plate lodged just below the level of the cricoid cartilage. The pitient experienced great pain and was quite unable to swallow any si)lid food. A throat speciali-it, who was called in, mad>i an attempt to withdraw the plate by means of a coin catcher. He was able to locate the plate but not to withdraw it. This was explained afterwards at the time of the operation by the fact that the two lateral horns of the plate, which was an inch and a half in length transversely and fortified at the points by gold tips, became entangled, as it were, in the mucous ;i ^mbraiie and muscular coats of the oesophagus, so that any efforts made to draw the foreign body upwards merely re- sulted in imbedding it more firmly in the oesophageal walls Moreover, the frequent contractions of the oesophagus in efforts to swallow, still further served to imbed the horns. The plate thus came to occupy an oblique position across the oesophagus in such a way that its concavity looked forward, and thus an oesophageal bougie pas^ed readily down- wards and failed to locate the foreign body. Had itnot been for the patient's sensation one might have thought that the plate hae of his voice and of his powers of deglutition. There i.s no evidence of any stricture having followed the operation. 102 OollfK" St., Toronto.