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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.

GEORGE A. PETERS, M.B.. F.R.C.S. Eng.

.I.S..O.-,-.,/, l',off^<o,-ojSn,vni '»'■!■ CI ini.o, Sur.j'ry. Vn,- 'y ot Toroii'n : S„,y,o,
To,ni,io <!•„,, nl Uo-i.iUit : N",-;/.r'», no.,,il,il f. r >/■■/.■ Ch:''lf,i ;

TORONTO :

Rei>rintki) 1 ROM Tin; Marih C'ANAD.'. I.AN'CHT

UJO '

-f.

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
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i*')lilia-,'ti- I'a^x-s tliroii'.'li tli(

ira'.nii. ni\iilf<l and lieM apafl n.

U A CASE OF FUSIFORM DILATATION OF THE OESOPHAGUS
WITHOUT INTRINSIC STENOSIS

2. A CASE OF OESOPHAGOTOMY FOR FOREIGN BODY. -

RECOVERY.

By OEOWiE A. PETEU8. M. B., F. B. C. S. Eng.

AMOciate Profemor o( Surgeir and Clinir.1 SurKerj ri.iviT.ity of Toronto; Surifeon, Toronto Cneral Hotpltal

Surgeon, Ho.pital tor Sick Children; Surgeon, National Association for Consuniplnta.

THE case from whom the specimeji which is the basis of this article
was removpd, was a farmer ag.d 35 years, referred to me by Dr. S. T.
Rutherfoid of Listowel, to whose careful observation and clincal acumen,
I am indebted for the following hihtory. The family history is free from
tiint of cancer. There is, however, a history of some degree of neurosis,
'-.rly on the mother's side. The perstmal history is that of a
nearty, well-developed and well-proportioned man, a farmer by
:on and a very hard-working' man. He was always in the habit
.^mg r-nidly, and then going immediately to work. Until the age
of about 3 . years he experienced no trouble in swallowing and the history
of difficulty in deglutition which follows, dates from December, 1890,
when he first came under Dr. Rutherford's care. For a short time pre-
viou8ly,he had noticed tbathehad occasional attacksof regurgitation of food
and liquid after meals. This condition persisted with fluctuations in inten-
sity for four or five years.gradually .however, becoming more marked. He
noticed that the food which regurgitated was not sour in taste but some-
what sweet, apparently due to the fact that it had been acted upon by
the saliva, but had not come in contact with the gastric juicj. The
eructation was not exactly an act of vomiting, but a gulping, regurgitating
act It would .sometimes be accompanied by marked hiccough. He ob-
served that on some occasions after partaking of a solid meal, the ingestion
of a cup full of fluid, such as milk or tea, would carry the whole meal
onwards to the stomach an.l thus obviate the regurgitation. This, in
fact, was his habit of eating for many months. On the contrary, on
some occasions the swallowing of the liquid seemed to stimulate or excite
the act of regurgitation, and the whole meal would then be rejected. The
latter condition grailually became more marked, until finally he found it
impossible to cause the food by any method to reach the lomach. Ke
was sometimes troubled very considerably with hiccough, and the whole
history of U case would appear to point to a spasmodic element in the
disability in regard to swallowing. Recognizing this element, Dr.
Rutherford exhibited the bromides in full doses, and on the further
advice of the late Dr. J. E. Graham, who suspected that there might be
pressure of enlarged mediastinal glands on the oe.sophagus, he also had a
full course of the iodides. The biomide.s, when given in full doses, gave

more relief than any other drug, thus serving to substantiate tiie view
that there was a spasmodic element in the causation. The patient noticed
that while taking the bromides, his hiccough was le^ss marked than under
the iodide treatment.

During the last year and a half he gradually los« tlesh to the total
amount of some 50 or 60 lbs and had, of course, become corres-
pondingly weak. Latterly his weakness had been such that he had found
it 1 .cessary to give up work altogether, and when in that weak condition
in September, 1900, he was prostrated by an attack of typhoid fever.
This still further reduced his condition and swallowing became impossible,
so that had tectal feeding .lot V)een resorted to, he would undoubtedly have
died at that time. On tlie subsidence of the fever he was fed for a time
by the stc-nach through a tube which his physician was able, after some
manipulation, to pass. Dr. Rutherford at that time recognized a dilated
oesophagus, capable of containing nearly a pint of fluid.

As soon as the fever abated, he was placed in the hospital, under
the care of Dr. Howitt. of Guelph, who preformed a gastrostomy, making
an opening near the pyloric end of the stomach (Fig 1 E). but making
no attempt in the then weak condition of the patient to a-scertain the
state of the oesophagus. The gastrostomy was >i.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<l. thou>;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 U<iuid
swallowed remained in the oefophnjjus and never entered the stomach .it
all, as it would after a short interval be returned by an act of easy vom-
iting, or regurfjitation.

In March, 1901, 1 made an opening parallel with the margin of the
costal cartilages on the left side, through the rectus muscle, at«d entered the
abdomen. By means of a sound passed through the ga.strost(.my wound,
I very quickly found that my diagno.^i8 of hour-j^lass contraction of the
stomach wa« an error, and that the sac which contained the fluid was
situated a'ocvc t'le diaphragm. The oesophajieal bougie pas.-sed by the
mouth under an anaesthetic.could not be felt with the fingers in the abdo-
men outi^.ide the stomach. Accordingly a small opening was made in the
stomach and the finger introduced. Thestonuvch wall felt smooth, ami it
was onl ' after a prolonged search that the oesopliageal opening was four.d.
It seemed to lie clo^e to the aorta, rather to its right side, and was so
small that only the tip of the index finger could bo made to enter it
With the finger in that position tie aorta seemed to be beating directly
against its left side.and gave me the impression that the oesopliagus passeu
through the same opening in the diaphragm as the aorta l>it 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 <lied within eight hours of the
operation, apparently from exiiaustion ami failure of the circulation.

Post Moktkm Examination.

On opening the chest wall the oesophngus was found lying pouched
towards the right pleural cavity. It still contained some Huid, and looked
as large as the .sigmoid flexure of the colon. On removing the right lung,
it was seen that the dilatation extended from the pharynx to the oesopha-
geal opening in the diaphragm, l» ing considerably larger below than above
and terminating in an abrupt manner just alMJvo the diaphragm. The
diameter of the dilated oesophagus at its uppe*- end (Fig. 1 A) in the recent
state was about two inche.s, while at a point an inch and a hal' abov" the
diaphragm (Fig. 1 B) where the dilatation was greates' the diameter waa
a little less than three inche.s. The coats were exceedingly mu.scular, but
taking into consideration the great dilatation liid not display a thickne.ss
that would indicate hypertrophy. The relation of the oesophagus to the
opening in the diaphragm was of very peculiar interest. Even after death
it was with difficulty that the little finger could be passed through this
opening and the stricture was clearly extni-o"sophngeal and due to the
tight clasping pressure of the pillars of the diaphragm at this point.
The inner lining of the oesophagus w.ia t "fectly .soft and smooth here as
well as throughout its whole length. There was no sign whatever of
intrinsic stricture, either malignant or non -malignant. Nor was there
any scarring. The pillars of the diaphragm, however, were exceedingly
strongly developed. The left crus, supplemented by that portion of the
right which crosses between the oesophaf,'ealHnd aortic openings was par-
ticularly strongly developed (Fig. 1 D.) and was not less than five-eighths
of an inch in thickness at a point opposite the oesophageal opening. It is
quite clear that the tension during contraction of this portion of the
diaphragm, particularly if of spasmodic character, would exert a very
powerful influence in obliterating the lumen of the oesophagus. In fact,
the action of the two crura of the diaphragm upon the oesophagus when
in a state of contraction might be compared to the action of a dull, loose-
jointed pair of scissors on a rubber tul)e, viz., to produce a sudden kink-
ing of the oe.sophagus at the point where it passed between these two
muscular bands. The whole diaphragm was an exceedingly strongly
developed muscle, and, in fact, presented a body of muscular tissue far
in excess of what must be looked upon as normal. One may, perhaps,
even go farther than this. • "i point out that the obstruction was not, at
al! eventa in the later t Js of life, merely spasmoilic but of such a
character that, even in a passive condition, these muscular bands were
such as to produce a marked stenosis of the oesophageal opening (Fig. IC).
This was recognized, as above pointed out, during the operation, when it

was ftMind that it wa* with difficulty thnt the tip of the imlfx Hnf,'*-
could be inserted into it. and moreover, hIho at ptwt mortem examiniition,
when it wai found t ♦. the .itle tinjjer conid scarcely bt; panHed thn)»;;h
this opening. It is, j nr mind, quite cl ar that the xtricturc in thin
case was due to ihe hypertrophied con«lition of the pillarM of the dia-
phra-^m, with or without a tlegree of spatmi in this .uscle. Moreover,
Professor J. J. Mackenzie found on examination of a s ction of the eso-
phagus at the point of constriction that there was no cicatricial tih,sue
whatever, and that the circular muscular fibres seemed to be meclmnically
accumulated but not hypertn»phied. The causative relation of the pillars
of the diaphragm to the stenosis is further attested by the fact that after
their division the index finger could with ease be pa-ssed from the cl-so-
phagus to the stomach, up to the second joint.

Remarks.

The dynamics of swallowing in a case ' f thi'^k.nU sfibrds an inter-
esting subject for .speculation. Ordimiri! , in i ease where a muscular
effort is opposed by mechanical • Sstrtieti' n, HtHjrtrophy of the muscle
takes place, and thus the efiPect . ^e obsLruc'ion may be entirely over-
come. But here the hypertrophy is unefjuai to the task, dilatation takes
place, and when that stage has been reached the problem is an entirely
different one. because the muscular contraction, taking the form in this
instance of a peristaltic wave, is unable even at its height to entirely
obli erate the lumen of the viscu.s. Accordingly, in tead of Torciiig the
colunm of food and liquid ahead of itself, the peristaltic wave now merely
travels upon the surface of this column which, at the moment of pa.ssage
of the wave, is of course lessened in diameter. The result is, that the
Tood and ii(juid instead of being forced strongly against the obstruction
merely rush strongly backwards, or re<>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 ha<l passed onwards to
the stomach Its continued presence, however, was detected by means of
an X-ray photograph, which showed tlie plate lying slightly obliquely
in the position indicated, at a short distance above the sternal notch.

It thus became evident that no less an operation than an open oeso-
phagotomy would suffice to dislodge the body, and with that end in view
Dr. Baines placed the patient in my charge. Accordingly on tlie 22nd
July, assisted by Drs. Baines and Wishart, the following operation was
undertaken.

The patient was placed in position, with the shoulders well raised
and a sandbag under the neck so as to throw the head somewhat back-
wards and thus increase the area for operative measures An incision
about three inches long was made on the left side of the middle line, cor-
responding with the anterior margin of the sterno niasttiid muscle. The
incision was rapidly deepened, largely by blunt dissection, until the anter-
ior belly of the one-hyoid muscle was reached. This muscle, and the
sterno-th} roid and sterno-hyoid muscles were drawn inwards. The lateral
border of the trachea could then be felt, and on stretching the wound
open the oesophagus could be located immediately behind this. (Jreat
assistance in locating the gullet was rendered by an oesophageal bougie
with a large bulb, passed into its interior and pressed towaids the wound.
The foreign body, however, could not be felt. The gullet was separated
from its connections to a considerable extent, both anteriorly and poster-

iorly, by blunt dissection, and in this way it became possible to bring its
lateral wall almost to the level of the skin before making the opening. The
remainder of the wounl was then packed clasely with iodoform gauze, so
as to prevent any discharge which might escape when the oesophagus
was opened, from infecting the deep portion of the wound. These two
measures, viz.: the free dissection of the oesophagus from its suiTOundings
and the packing of the wound, we regarded as very important measures
in preserving asepsis of the wound. An incision was now made upon the
bulb in the oesophagus, and the lateral margin of the wound was helii hy
a pair of forceps on each side. The finger was then inserted, and the
plate was felt to occupy the position already described, viz. : just below
the level of the cricoid cartilag.*, and so firmly and deeply imbedded in
the oesophageal wall that the finger could easily be passed in front of it.
This accounted fully for the inability to feel it with the oesophageal bou-
gie, or with forceps passed down from the mouth. A pair of curved for-
ceps were then passed along the finger, and the body grapsed and remov-
ed, though not without very considerable difficulty. Great care was
taken to catch all the mucos that escaped from the wound in sponges.
The wound in the oesophagus was then closed accurately by means of a
double row of catgut sutures, the outer row being in the form of Lembert
sutures. Having sponged this portion of the wound dry, and disinfected
with carbolic acid solution 1-20, the gauze was removed from the main
body of the wound and the oesophagus allowed to fall back to its place.
The whole wound was then sutured up with deep sutures, applied in such
a way as to bring all the deep parts of the wound together und yet allow
of their subsequent removal by passing the ends through the skin at each
end of the wound and tying them over pledgets of gauze. The skin edjres
were approximated by a continuous horse-hair suture, and a dry dressing
arplied after dusting the wound freely with bismuth formic iodide.

The patient was given no food by the mouth for two days, and the
wound healed kindly without any swelling or inflam nation. In the
meantime the patient was well sustained by rectal feeding.

The sutures were removed on the fifth day, when the wound appear-
ed to be perfectly healed. A day or two afterwards, however, a small
area of fluctuation was observed under the wound, ami on making a
minute opening in the scar a small quantity of purulent fluid e.scaped.
This left a cavity, which however did not communicate with the oe.sopha-
gus. The abscess discharged for about a week but ultimately closed,
leaving but a slight scar.

The patient was allowed liijuid food on the fifth day, and shortly
afterwar.18 solid fo«)d was permitted. He had some slight difliculty in
swallowing at first, and a slight degree of hoarseness was present for a
short time, but he has subscjuently fully recovered the u>e 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.