The Inspection op the CEsophagtjs and the Caedia. BY MAX EINHOEN, M. D. REPRINTED PROS! THE TCeto 3Torfe ifHeMcal Sournal for December If 1897. Reprinted from the New York Medical Journal for December 11, 1897. THE INSPECTION OF THE (ESOPHAGUS AND THE CAKDIA.* MAX EIXHORX, M. D. It is well known that the problem of inspecting the oesophagus has been worked at for quite a number of years. The first attempts in this direction were made by Stork,f who introduced some kind of a speculum into the oesophagus and tried to obtain a view of it by means of a laryngeal mirror. Similar attempts had been made by Waldenbnrg,! and later also by Macken- zie.* This method, however, proved to he inadequate, as it is only possible to see a little spot, but not a larger area. In 1881 Mikulicz ]] first succeeded in inserting a * Read before the German Medical Society of the City of New York, October 4, 189 Y. f Stork. Die Untersuchung des Oesophagus mit dem Kehlkopf- spiegel. Wiener med. Wochtmchrift, 1881, No. 8. # Sir Morell Mackenzie. Diseases of the Throat and Nose, vol. ii, 1884, p. 81. tL. Waldenburg. Berl. khn. Wochenschrift, 1810, No. 48, p. 578. | Mikulicz. Ueber Gastroskopie und Oesophagoskopie. Wiener med. Presse, 1881, Nos. 45, 46, 41, 48, 49, 50, 52. CoPTBTGHT, 1807, BT D. APPLETON AND COMPANY. 2 THE INSPECTION OF straight tube into the oesophagus, and was able to look directly into it by means of reflected light. This instru- ment which Mikulicz designed has since undergone but slight and unessential modifications; thus the original method still prevails. Besides Mikulicz, yon Hacker,* of Vienna, has done a great deal of work in oesophagoscopy, and I may say that this investigator deserves almost as much credit as Mikulicz himself. Yon Hacker was the first who examined a great number of patients with the oeso- phagoscope. The valuable papers of this writer were published in the Wiener Idinische Wochenschrift of 1889, 1894 and 1896. Later on, Theodor Eosenheim f also took up the subject of oesophagoscopy and modified Mikulicz’s instrument in such a manner that the ob- turator ended in a blind piece of rubber tubing two inches in length (see Fig. 1, A). The end of the oesophagoscope is in this way flexible and can, accord- ing to Eosenheim, be much more easily inserted. Ido not think that the rubber end of the obturator is of im- portance; it also has the disadvantage that a thorough cleansing or disinfection of the instrument is thereby made materially more difficult. For this reason I have constructed the obturator in such a way that it can serve as a cotton holder by means of a screw arrange- ment. The end of the obturator being wrapped with cotton and the screw tightened, it is inserted into the oesophagoscope, the lower opening of which is then neatly closed by the cotton (Fig. 1, G). Each time the * Yon Hacker. Wiener Min. Wochenschrift, 1889, No. 23, p. 469 ; 1894, Nos. 49 and 50; 1896, Nos. 6 and V. f Th. Rosenheim. Deutsche med. Wochenschrift. 1895, No. 50 ; Berl. Min. Wochenschrift, 1896, Nos. 13, 14, 15. THE (ESOPHAGUS AND THE CARDIA. 3 instrument is used a fresh piece of cotton is wrapped around it. In regard to the modifications of the cesophagoscope. Pig. I.—Mikulicz’s oesophagoscope. A, Rosenheim’s modification, the end made of rubber; B, C, and D, E, flexible oesophagoscope ; C, the flexible oesophagoscope made still by means of the screw ; P, the obturator serving as a cotton holder ; 6, the oesophagoscope, with the obturator F, occluding the opening. 4 THE INSPECTION OF various investigators have tried to construct a metallic tube which would be flexible while it was inserted into the oesophagus, but which could be straightened after- ward by some arrangement. The advantage of such an apparatus would consist in its being more easily in- serted. I myself have also worked considerably in this line, and have made several attempts during the past year to construct a suitable apparatus. J, Eeynders & Co. have made, under my direction, several flexible oesophagoscopes which can be straight- ened after they are inserted. I must state, however, that they are not so serviceable as the ordinary stiff oesophagoscope, as the straightening is frequently not perfect. One is a spiral instrument which becomes straight on the insertion of a stiff obturator (Fig. 1), D and E); there is another which by means of wires and a screw arrangement can be made flexible or stiff at will. Kelling,* to whom, next to Eosenheim, much credit is also due with regard to oesophagoscopy, has just de- vised a new segmented oesophagoscope which can be straightened. Probably Kelling’s instrument will work better than the two instruments of mine constructed by Eeynders. I on my part have abandoned further attempts in this direction, as it is not in reality difficult to intro- duce a stiff tube into the oesophagus. Suppose the flex- ible tube is used, it must be stiffened before looking through it; if the oesophagus occupies such a position that a stiff tube can not be pushed down, even the flex- * Georg Kelling. Boas’s Archiv f. Verdauungskrank., Bd. ii, pp. 321 and 490; Munchen. med. Worhemchrift, 1897, No. 34. THE (ESOPHAGUS AND THE CARDIA. 5 ible instrument can not then be straightened without eventually causing some lesion. On this account Ido not deem all these modifications essential, and believe Pig. 2.—Photograph of a patient during examination with the oesophagoscope, showing the instrument in position. The panelectroscope having been at- tached to the oesophagoscope, the physician is enabled to inspect the gullet. During the withdrawal of the oesophagoscope the entire oesophagus can be viewed. 6 THE INSPECTION OF that we can efficiently make use of the original instru- ment of Mikulicz and yon Hacker. It has been suggested by Eosenheim and von Hacker to cocainize the pharynx if necessary—Kelling employs even chloroform-ether narcosis in many cases—and to examine the patient in a recumbent posture. In my opinion this posture does not much facilitate the pro- cedure. I usually examine the patient with the oeso- phagoscope in a sitting posture, the head reclining con- siderably backward. (See accompanying photograph. Fig. 2, for which I am indebted to Dr. Carl Gold- mark.) In exceptional instances chloroform-ether narcosis will be necessary. In most cases even the cocainization of the pharynx will not be essential; I, at least, have been able to do without it. [The author then demon- strated on two patients the examination with the oeso- phagoscope.] I do not find oesophagoscopy difficult of execution. In almost all cases in which I have at- tempted to introduce the cesophagoscope I have suc- ceeded. It is self-evident, however, that we may meet now and again with patients who are unwilling to sub- mit to an oesophagoscopical examination. With regard to the value of oesophagoscopy, I must say that it is diagnostically and therapeutically of great importance. Notwithstanding my meagre experience in this field, I have already met with cases in which the diagnosis of a neoplasm could be more easily made with the ceso- phagoscope. Thus, I have recently examined a patient with dysphagia in whom the cesophagoscope revealed several spots at the cardia which were dark red and intermingled with white tissue. This at once gave the THE (ESOPHAGUS AND THE CARDIA. 7 impression of being foreign, of a tissue that ought not to be there. Normally the cardia appears somewhat red- dish, while the oesophagus presents a whitish-gray hue. In another case in which there was likewise the suspi- cion of a cancer of the cardia, the latter did not show anything abnormal. Instead of my seeing, however, above the cardia the oesophageal wall, there appeared here suddenly an empty space. This seemed to point to a dilatation of the oesophagus without a stricture. This diagnosis could also have been arrived at from a study of other symptoms. At any rate a cancer of the cardia could be positively excluded by the oesophagoscopical examination. I fully coincide with the following remarks of von Hacker with regard to cesophagoscopy: “ The experience at hand with regard to the utiliza- tion of cesophagoscopy may still be expanded and the method improved. By means of cesophagoscopy, our knowledge of the appearance and the physiological con- dition of the inner coat of the oesophagus, which until recently was invisible to the eye, has been enlarged, and our views on the morbid conditions of this organ and their course have been materially advanced. . . . “ It is certain that the oesophagoscope is already of aid in the early recognition or exclusion of cancer of the oesophagus or of the cardia of the stomach. It aids us also in discovering foreign bodies in the healthy as well as the diseased gullet and in quickly and delicately re- moving such bodies without a bloody operation. Thus, it is diagnostically and therapeutically of the highest importance.” In conclusion, let me emphasize the statement that cesophagoscopy will undoubtedly prove of great value 8 THE (ESOPHAGUS AND THE CARDIA. in diagnosis as well as therapeusis, and I firmly believe that this method will become popular. It may, per- haps, still take some time, but there is no doubt that the oesophagoscope will have a lasting place in medi- cine. 20 East Sixty-third Street. The New York Medical Journal. A WEEKLY REVIEW QF MEDICINE, EDITED BY FRANK P. FOSTER, M.D. THE PHYSICIAN who would keep abreast with the advances in medical science must read a live weekly medical Journal, in which scientific facts are presented in a clear manner; one for which the articles are written by men of learning, and by those who are good and accurate observers ; a journal that is stripped of every feature irrelevant to medical science, and gives evidence of being carefully and conscien- tiously edited ; one that bears upon every page the stamp of desire to elevate the standard of the profession of medicine. 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