No. 1856.

MARCH 26, 1859.

UNIVERSITY COLLEGE HOSPITAL.

Practical Clinical Remarks,Delivered at University College

Hospital,

BY JOHN ERICHSEN, ESQ., F. R. C. S.,SURGEON TO THE HOSPITAL.

ON THE SURGICAL DIAGNOSIS OF DIFFICULTDEGLUTITION.

GENTLEMEN,-The case to which I am desirous of directingyour attention to-day is one of stricture of the oesophagus. Of

this the following are a few of the leading points :-Ma,ry Ann B-, aged thirty-three, a native of Hertford-

shire ; for the last ten years a servant in London; unmarried.She has always been well nourished, and we cannot make out,from the history of the case, any constitutional disorder, or anyhereditary tendency to cancerous or other tumours. Three

years ago (in the latter part of 1855), the patient first expe-rienced a little difficulty in swallowing solids. This after a

time subsided, but again recurred, and increased up to thebeginning of last December, when she became quite unable toswallow solid food. This difficulty in deglutition has since ex-tended to soft and even to liquid substances; and she hasnoticed that the thicker the matter to be swallowed, the moredifficulty did she experience, the more liquid slipping downwith greater ease than others. Not only was there this diffi-culty in deglutition, but after she had apparently swallowedthe food, it showed a tendency to return, and, in fact, didreturn into the mouth, by a process, I cannot say of rumi-nation, but of simple regurgitation of the food, which hadreached the point of constriction, but had not passed throughit. This state of things so increased, that when I saw her first,when she was sent to me by my friend, Dr. Henry Bennet, shewas utterly unable to swallow even water; she might, perhaps,get a few drops down, but the greater part, at all events, was IIrejected through the mouth and nostrils. ’

This case is a very interesting and important one. A woman,in the prime of life, is seized with great difficulty in swallowingin December, and before the beginning of January is broughtto such a condition that there seems to be but one result to belooked for-namely, death by starvation-death, in fact, of themost horrible kind, staring her in the face, unless we can suc-ceed in restoring the calibre of the canal, or in bringing theparts into such a condition that the patient may be enabled tonourish herself; for it is impossible that she can go on for anygreat length of time employing the means which we have beenobliged to have recourse to, in order to prevent her from dyingby starvation.Now what is the local state that prevents deglutition in this

poor woman? On examining the oesophagus, we found thatwe could pass nothing larger than a No. 8 gum-elastic catheterthrough the narrow, constricted portion of that tube. Thestricture is close to the commencement of the oesophagus, beingopposite to or just below the cricoid cartilage; and its laterdevelopment, at all events, has been very rapid. On carefulexamination, there is no sign of tumour to be met with in theneck, except some slight enlargement of the left thyroid lobe;and there is no indication, auscultatory or otherwise, of anyintra-thoracic tumour compressing the oesophagus. The faucesalso are natural and healthy in appearance. And, lastly, thereis no expectoration of blood, pus, or muco-pus; nor does anyhaemorrhage follow the use of the catheter. Our diagnosis,therefore, is, that this patient is suffering from simple strictureof the oesophagus.

So far as treatment is concerned, we are enabled, by passinga gum-elastic catheter (6 or 8) to inject, twice daily, goodstrong beef-tea, with eggs, and a certain quantity of port wine,and the patient has evidently much imprcved in condition sinceshe came into the hospital. She suffers no pain, and no incon-venience beyond the difficulty in swallowing. On careful exa-

mination, we can make out no cause for this difficulty, exceptconstriction of the oesophagus. But may not other conditionsbesides this give rise to difficulty in deglutition, or dysphagiaas it is termed? Undoubtedly; and I have brought this casebefore you chiefly in order that I might have an opportunity ofgoing over the different conditions which may give rise to diffi-culty in deglutition, the diagnosis of stricture of the oesophagusfrom the others, and of the various kinds of stricture from eachother.Now, there are at least eight different conditions met with

in the neck and chest capable of giving rise to dysphagia bycompressing the oesophagus, independently of any stricture ofthat canal-which are capable, in other words, of simulatingstricture of the oesophagus, in so far as that they all give rise tothe most prominent symptom of stricture-namely, difficultyin deglutition.The first condition which I shall bring before you capable of

simulating oesophageal stricture is the existence of tumoursof various kinds connected with the pharynx. Putting out ofconsideration tumours of the tonsils, which would always bereadily discovered, we may have polypus of the pharynx hang-ing down and offering obstruction to the passage of food. Inall polypoid growths connected with the pharynx (which, bythe way, are exceedingly rare) you will be able to make outthe nature, connexions, &c., of the growth by drawing thetongue well forward, keeping it fixed with the tongue spatula,and passing the finger well down behind the root of the tongue;you can thus explore the pharynx, even below the root of theepiglottis, without much difficulty. But other conditions mayexist; you may have a post-pharangeal abscess between theposterior wall of the pharynx and the spine, possibly arisingfrom caries of the cervical vertebrse, or a post-pharangealtumour, as; for instance, a carcinomatous tumour, developingfrom the bodies of the vertebrde, and pushing the pharynx for-wards. The eye is often deceived in these cases, failing todetect the existence of an enlargement at the back of the

pharynx; but the finger readily recognises it. In the case ofabscess you will feel fluctuation, and the dysphagia will be re-moved by opening the abscess and letting out the contents, andthe solid or semi-solid and soft, or other feel of a tumour in thissituation will enable you to give a very probable guess as to itsnature. These, then, are the chief conditions connected withthe pharynx, capable of giving rise to dysphagia, and whichare liable to be mistaken for stricture.

Then, secondly, you may have difficult deglutition inducedby some morbid condition of the larynx; as, for instance, oedema.about the back of the epiglottis, or chronic oedema, ulceration,and thickening of mucous membrane there, or oedema aboutthe rima glottidis, giving rise to a tendency for liquids to passinto the air-passages, and thus occasioning a serious impedimentin swallowing, the difficulty in swallowing being attended witha feeling of spasm and suffocation. By passing the finger downbehind the root of the tongue, the state of parts can often befelt; but the combination of dysphagia with a suffocative fit,and these probably associated with laryngeal cough, are thechief points to be attended to in the diagnosis.A third condition, which may give rise to difficult deglutition,

is the existence of tumours in the neck, outside the oesophagus,but compressing it; for example, enlarged glands or a carotidaneurism, developing posteriorly, as has been known to occurwith the internal carotid artery, or a tumour connected withthe thyroid body, tightly bound down by the sterno-mastoidand fascia, and pressing backwards. All such growths may,by pressing on the oesophagus, give rise to dysphagia, and youwill do well in all cases where that symptom is complained ofto examine carefully the neck for tumours, which will generallybe very readily detected, especially where the difficulty hasexisted for some time, and the person has become much ema-ciated from deficient nourishment.A fourth cause of dysphagia is aneurism of the innominate

artery. When this disease has risen into the root of the neckit is easily recognisable, but in certain cases it developes firstin a direction backwards, and then one of the earliest symp-toms is dysphagia. Indeed, the patient may suffer but littlefrom any other symptom, and may apply to the surgeon forrelief from it alone, quite unconscious of the existence of anyserious disease. But, on close inquiry, in all such cases youwill find that the dysphagia has been preceded by, and is ac-companied with, a certain degree of dyspnaea, and usually oflaryngeal irritation. This is owing to the recurrent laryngealnerve, which lies between the artery and the oesophagus, suf-

fering compression before the mucous canal can be influencedby the development of the aneurism. Besides these, there willbe other svmntoms of compression and of obstructed circula-

310

tion ; as, for instance, oedema of the hand and arm, a smallpulse at the right wrist, and pains in the right upper extremity.In such a case, much danger might be incurred by at once put-ting an instrument into the oesophagus, under the impressionthat stricture existed; for the point of the catheter, or what-ever instrument might be used, might perforate the sac of theaneurism, and so give rise to instant death. Examination bythe eye, hand, and stethoscope will generally make out theexistence of bulging of the right sterno-clavicular articulation,perhaps also of the upper part of the sternum and first tworibs, dullness in this region, pulsation, and bruit.

Fifthly, aneurism of the aorta, whether of the fusiform or

sacculated variety, may give rise to difficulty in deglutition bypressure on the gullet. In this case also there is great dangerof the aneurismal sac being pierced by an instrument passeddown for the purpose of ascertaining the existence of stricture.Such a thing has happened to a surgeon; and although theaffection will of course terminate fatally of itself, and may veryprobably burst into the oesophagus, yet for a patient suddenly,while an instrument is being passed, to bring up an enormousquantity of arterial blood, and fall dead in a minute or so, is,to say the least, a very distressing occurrence. In these cases,we shall probably have dyspnoea, from the pressure of theaneurism on the trachea, or bifurcation of the bronchi, dullnesson percussion, the ordinary stethoscopic signs of aneurism, and,especially in the sacculated variety, aching pain between theshoulders, radiating down the arms or round the chest, causedby the pressure of the sac against the spine.Then, as a sixth condition leading to dysphagia, we have

various other intra-thoracic tumours, such as enlarged bron-chial glands, cancerous and other tumours developing from thethoracic spine into the posterior mediastinum, and so compress-ing the oesophagus. In such cases the diagnosis is very diffi-cult. It is difficult enough to determine the existence of atumour, but still more difficult to distinguish it from an aneu-rism undergoing consolidation; but dullness on percussion, anddyspnoea with dysphagia, together with fixed pain in or to oneside of the spine, with neuralgia down the arms or up the sideof the head, and a varicose condition of the superficial veins ofthe chest, are the signs on which we place our chief reliance indiagnosing the existence of a tumour. Indeed, in the diagnosisof aneurism of the aorta and of mediastinal tumour, I look uponthe combination of dyspnaea with dysphagia, and fixed, wearingpain between the shoulders, as of the greatest importance.A seventh cause for difficulty of deglutition is, dislocation of

the sternal end of the clavicle backwards, whether merely asimple dislocation, or produced in consequence of excessive cur.vature of the spine. Of the latter kind there is at least one caseon record, which is narrated by Sir Astley Cooper, in which the z,sternal end of the clavicle by its pressure so obstructed thepassage of food, that the patient was brought into a conditionof extreme danger. The surgeon under whose care the patientwas, very skilfully and creditably sawed through and detachedthe sternal end of the clavicle, and thus relieved his patientfrom the imminent danger in which she was placed.The eighth and last class of cases are those in which deglu-

tition is obstructed in consequence of the impaction of someforeign body in the gullet. Now, of course, if a man swallowssuch a thing as a piece of mutton bone, or the settings of arti-ficial teeth, it generally lies across the gullet in such a manneras to be easily felt by the surgeon on passing a probang; butthere are other cases in which a foreign body becomes lodgedin such a way as to escape detection and removal. Some yearsago I was requested to see a patient who was said to haveswallowed a piece of gutta percha. He had, it appeared, inconsequence of having lost several teeth, endeavoured to con-struct an artificial masticatory apparatus for himself, whichhad become loose, and he had accidentally swallowed it. Afew days afterwards, finding that deglutition continued diffi-cult, he consulted a very able surgeon, who carefully examinedhim; but not detecting any foreign body, he considered that thepiece of gutta percha had passed into the stomach, and thatthe cesophagus had been scraped by it in its passage down.Inability to swallow solids came on. I saw him six monthsafterwards. The question then was whether the foreign bodywas still impacted in the oesophagus, or whether the symptomsarose from damage inflicted on that tube. I examined the

oesophagus most carefully, but failed, as other surgeons had

previously done, to discover the existence of any foreign body.I thought, I confess, that the oesophagus had been injured insome way, and that probably epithelioma was developing itself,and would, sooner or later, prove fatal. At all events, the casedid end fatally; for one day, while at dinner, the patient sud-denly vomited a large quantity of blood, and fell down dead.

On examination after death, we found that the piece ofgutta percha had formed for itself a bed in the wall of thexsophagus, lying parallel with the inside of the tube, and thatthe ulceration of the mucous membrane caused by its presencehad opened some cesophageal vessels-which, we could notascertain (it was not, however, either the carotid artery orjugular vein); thus giving rise to the copious and suddenhaemorrhage which had caused the patient’s death. ’J he sur-face of the gutta percha which looked into the oesophagus beingconstantly covered and smoothed over by mucus, and beingprotected, as it were, by a rim of swollen mucous membraneall around it, had allowed the probang to pass easily withoutits presence being detected.

These, so far as my experience goes, are the eight conditionswhich are likely to simulate stricture of the oesophagus; andsuch are the points to be attended to in the diagnosis of theseaffections from each other. With regard to their diagnosisfioni stricture, the process is rather a negative than an affirma-tive one, proving the absence of tumour, aneurism, &c. Youcome by a process of exclusion to the conclusion that the diffi-culty in deglutition can arise from no other cause than stric-ture, and finally ascertain the situation and extent of this-by exploration with a gum-elastic catheter or bougie. But,having ascertained the existence of a stricture, there are stillthree forms of that affection which it is necessary to distinguishfrom each other, inasmuch as they differ greatly in the modeof treatment, and in the ultimate result. These are-

1st- The hvsterical or snasmodic stricture-2nd. The fibrous stricture.3rd. The carcinomatous stricture.The hysterical or spasmodic stricture is met with chiefly in

young females under twenty-five, though it may occur in mucholder persons of the hysterical temperament. One great pointto be attended to is, that the stricture is generally high up, in.the pharynx, rather than in the cesophagus, being produced bythe contraction of the constrictor muscles of the pharynx.Another point is, that the dysphagia is intermittent-that isto say, when the patient’s mind is allowed to dwell long on theaffection, and she gets anxious about it, then the difficulty isgreatly increased; whilst at other times, when her thoughts.are diverted from it, food passes easily. You will find also, in-these cases, that on attempting to pass a probang or largebougie, you will at first find its progress resisted, but bypatiently and gently pressing down upon the stricture, the,instrument will soon pass easily. These points, taken in con-junction with the age and temperament of the individual, will-leave no doubt as to the nature of the affection.But there are two kinds of organic stricture of the cesophagus

-namely, the simple and the malignant-between which thediagnosis is often very difficult; because strictures originallyfibrous sometimes degenerate into or assume a malignant form; qbut others continue fibrous from the first, and others, again,carcinomatous. Generally, on passing an instrument, we shallfind that in the simple or fibrous stricture it passes smoothly,and gives no sensation of roughness, no feeling of lacerating it&way, or as if it were passing over an ulcerated surface; no,blood follows its withdrawal, and the patient does not bringup pus, or pus and blood, though there may be copious mucous.discharge. There is no material enlargement in the neck, noswelling of the cervical glands, no sign of the cancerous

cachexia.In the malignant or carcinomatous stricture, on the other

hand, the instrument seems to pass over a rough and ulcerated,surface, its introduction is followed by blood, and the patientcoughs up blood, or blood and pus, mixed often with shreds oftissue-conditions all indicating a loss of substance. There isalso, generally, an ovoid or elongated swelling at the root ofthe neck; the neighbouring glands may be affected; there maybe cancerous tumours elsewhere, and the symptoms of the can-cerous cachexia may be present. Bear in mind, however, thata fibrous stricture may degenerate into a malignant one-into->epithelioma, though, perhaps, not into scirrhus or encephaloid.The treatment of stricture of the oesophagus will depend

, upon its nature. In the hysterical variety, the occasional in-troduction of a full-sized oesophagus bougie, the application of

, belladonna to the neck, and anti-hysterical treatment gene-! rally, iron, aloetics, douches, and diverting the patient’s mindfrom her malady, are the means to be employed. In such cases

Dr. Garrod, as you may have seen in an instance at present inL the hospital, has very advantageously employed large doses of, assafcetida.! The treatment of organic stricture is more difficult. In the. fibrous stricture, the only chance of benefit lies in dilatation by

gradually increasing bougies, and by this means great good may

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be effected. We may vary the mode of dilatation. Thus we

may adopt the plan of M. Trousseau, who coats the end of acatheter with sealing-wax, so as to be just small enough topass through the stricture, and by increasing the thickness of thecoating of sealing-wax from day to day so dilate the stricture.Another plan is that of Dr. Arnott, which consists in dilatationby means of fluid pressure. This method promises very bene-ficial results, at least more so than any other (though I havetried it in one or two cases without much benefit), and I intendto employ it in this case. In cancerous stricture, there is littleto be done beyond keeping the patient comfortable, and sustain- I,ing life as long as possible.There is only one other point of treatment which I have to

mention, and that is the proposition lately made to open thestomach in cases of confirmed stricture of the oesophagus, andfeed the patient in that ’way. But this is one of those ex-tremely heroic measures which are more easily proposed thancarried into practice. In ninety-nine cases out of a hundred itwould probably at once put the patient out of his misery in avery summary, though a perfectly surgical, manner ; and if herecovered the immediate effect of the operation, his life would,probably, be a burden to him;’ irritation of the stomach would,doubtless, soon be set up, and where the stricture is of can-cerous nature, life would soon be destroyed by the cancer itself.Should the stricture at last become so tight as no longer to

allow the catheter to be passed, and food thus injected into thestomach, the patient must inevitably die of inanition, unlesskept alive by nutritive enemata. By these means I have knownlife prolonged, by a frail tenure it is true, for many weeks. Insuch cases it is an interesting physiological fact, that althoughthe patients may continue to be moderately well nourished,and do not feel the pangs of hunger, they suffer excessivelyfrom thirst.

ON THE

SHAPE OF TRANSVERSE WOUNDS OF THEBLOODVESSELS

IN

RELATION TO THEIR PHYSIOLOGY.

BY W. S. SAVORY, F.R.S.,DEMONSTRATOR OF ANATOMY AND OF OPERATIVE SURGERY AT

ST. BARTHOLOMEW’S HOSPITAL.

EVERYONE knows that the shape which wounds of arteriesassume mainly depends upon their direction; that while a

longitudinal wound remains as a mere slit, a transverse woundgapes widely, its edges separating in proportion to its extent;and that wounds in other directions gape more or less accord-

ing to their obliquity. But although these facts are familiarones, they have yet attracted very little attention. In manyworks on surgery they are not even mentioned; in none arethey explained. Amongst modern authors, Uuthrie and Listonare conspicuous for the description they give of them. Liston,and Miller after him, have in their works introduced sketchesof the various shapes of different wounds of arteries.

In these and in other works in which the fact is noticed, thelongitudinal wound is described as remaining a mere fissure,the oblique wound as becoming fusiform, and the transversewound as becoming circular or oval according to its extent.

" The longitudinal appears to produce the slightest possible,or perhaps scarcely any, separation; the oblique occasions aseparation proportioned to its extent; and the transverse, how-ever small, seems to produce a circular aperture in the parietesof the artery.

’’This circular appearance of transverse wounds will, ofcourse, be lost if the wound is very considerable. It appearsto have been a very old observation, that wounds of arteriesare circular; it has been noticed by Wiseman, Petit, Monro,and Haller; but I believe that the appearance is confined topunctures or small transverse wounds of the artery, and de-pends chiefly on the retraction of the divided fibres." *" When an artery is cut transversely, in man, to one-third

or one fourth of its circumference, it forms the same circularopening as in animals." t"The degree of gaping in transverse wounds depends upon

the extent to which the parietes are cut; an incision, for in-3bnce, involving a third of thé canal, will be seen to give rise

* Jones on Haemorrhage, pp. 114,115, and 186.t Guthrie on Diseases and Injuries of Arteries, p. 213. 1830.

to a round opening; one involving two-thirds causes a largeoval opening." *The description given of transverse wounds is not quite

accurate. I do not think the angles of the wound, under anycircumstances, entirely disappear. In none of my experimentshave I failed to discover them upon a careful examination.Where the wound is very extensive, they become widened andobscured, but even then they are still visible. They are, ofcourse, much more plainly marked in the larger vessels; and inthe smaller ones they can scarcely be discerned with the nakedeye, although with the aid of a lens they will be at once de-tected. At the same time, the edges of the wound towardsthe centre become raised, and perhaps slightly everted. Infact, it is more accurate to describe these transverse woundsas becoming wedge-shaped rather than circular (Figs. 1 and 2).This is important in relation to the structure and properties ofthe arterial coats.

I What is the cause of the various shapes thus assumed bydifferent wounds ?

If an artery be simply exposed, without any disturbance, ina living animal, and a tranverse wound be made in it, the edgeswill immediately separate. The wound will gape, and assumethe shape just now described. If at the expiration of somehours the animal be killed, and the wound carefully examined,it will be seen to have undergone no change of shape. Even ifthe animal be allowed to bleed to death, that the muscularfibres of the artery may have the greatest "stimulus" to con.-’tracts although the artery will be more than usually diminishedin its calibre, the characters of the wound will remain unaltered.If the wound be examined some days after death, no change inits shape will be detected.

If the portion of artery containing the wound be dissectedout and removed, the wound will at once close; its edges willcome into contact; it will appear as a simple fissure, like alongitudinal wound.

If the same operation be repeated upon an artery of an animalor of the human subject which has been dead for three or fourdays or more, the wound will still assume the same shape; nodifference in this respect can be detected. If dissected out asin the last case, the wound will close at the instant of division.

If a portion of artery, some two or three inches long, be dis-sected out and removed from an animal or the human subject,and a transverse wound be made in it, the edges will remain incontact. It will appear as a mere slit. If now the artery bestretched, the wound will gape, and assume the shape of awound made in the living or dead artery in sit2. As the arteryis allowed to recoil again, the wound closes.

Before I draw any conclusions from these experiments, Iwould notice an objection which has been raised by Guthrieand some other surgeons to experiments on the arteries ofanimals as applicable to the physiology of the arteries of man.The difference between them has been very much exaggerated.§But admitting the fact that they differ somewhat in their struc-ture and properties, it is a difference of degree merely, not ofkind. All examinations and experiments tend to prove this.Therefore, although in certain delicate questions, such as thoserelating to secondary haemorrhage, it is not perhaps safe todraw direct conclusions from experiments on animals as to whatoccurs in the human subject; yet, in relation to the broaderand more general facts, I do not think that the applicability ofsuch experiments can be denied.

I conclude, then, from these experiments, that wounds assumethe same shape in the dead as in the living artery, and that it

* Liston’s Practical Surgery, p. 151. 1837.t Hunter’s Works, vol. iii. p. 166.t See Hunter on the Duration of Muscular Power in the Arteries after

Death. Works, vol. iii. pp. 157-8-9.S See Gnthrm cm eit - n 9ftQ