External (Esophagotomy in the Operative Treatment of Cicatricial Stricture of the (Esophagus. With a Proposition for improving the Method of performing fnterna! (Esophaqotomp: I BY * WILLY MEYER, M. D., Professor of Surgery to t1f?-Riew,fCYork Post-Graduats Medical School and Hospital; Attending Surgeon to the German and New York Skin and Cancer Hospitals. REPRINTED FROM THE "Neto York fHeWcal journal for November 19, 1892. Reprinted from the New York Medical Journal for November 19, 1892. EXTERNAL (ESOPHAGOTOMY IN THE OPERATIVE TREATMENT OF CICATRICIAL STRICTURE OF THE (ESOPHAGUS. With a Proposition for improving the Method of performing Internal (Esophagotomy* By WILLY MEYER, M. D., PROFESSOR OF SURGERY TO THE NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL ; ATTENDING SURGEON TO THE GERMAN AND NEW YORK SKIN AND CANCER HOSPITALS. In spite of the immense progress of modern surgical technique and improved operative methods, ably assisted by the antiseptic treatment, the permanent cure of a narrow or impermeable cicatricial stricture of the oesophagus is still one of the most difficult tasks of the surgeon. This will be especially found in children, who naturally look at the doctor who attempts with them any bodily manipula- tion as their torturer, and therefore struggle with all their might against every effort at dilatation of the obstructed canal by the bougie. * Read before the New York Surgical Society. March 9, 1892. (For discussion, see N. Y. Med. Jour., July 2, 1892, Proceedings of New York Surgical Society.) Copyright, 1892, by D. Appleton and Company. 2 EXTERNAL (ESOPHAGOTOMY. Two chief methods are applied in the operative treat- ment of this serious trouble : 1. External oesophagotomy at the spot usually selected for this operation, with consecutive instrumental dilatation from this wound with either bougie or knife, generally with both. 2. Retrograde divulsion, with the help of preliminary gastrostomy. Before endeavoring to bring out and compare the value and advantages of each of these two methods, I want to state first, as briefly as possible, the history of a case of this kind which recently came under my observation and treat- ment : E. B., of Montreal, aged two years and nine months, is the third child of healthy parents. In October, 1890, while being un watched for a moment, she swallowed some caustic lye which was used by the housemaid for cleansing and polishing the bath- tub. The doctor who was immediately sent for ordered a dose of sweet oil, which promptly produced a strong vomiting spell. As far as could be seen, mouth and throat were badly burned, and it could be inferred that the oesophageal canal had suffered also. The little patient was unable to swallow even fluids until two days after the accident. After a week she also par- took of a semi-solid diet. From now on everything went well. The child seemed in apparent health until December, 1890, six weeks after the accident. Then she complained of pain and difficulty in swallowing solid food. Soon all the symptoms of a progressive stricture of the oesophagus were noticed. The doctor who was consulted about it was opposed to local treat- ment as long as deglutition was possible. But when he tried, after a lapse of six more weeks, to push a sound into the stom- ach he did not succeed. From this time on the child passed through the hands of a number of specialists at Montreal and Toronto, to which latter city the parents moved about that time. It was noted by all of these gentlemen that there was a stricture right behind the cricoid cartilage, and a second ob- EXTERNAL G1SOPHAGOTOMY. 3 struction lower clown, commencing at a spot which correspond- ed about to the bifurcation of the trachea. Now and then this latter one was overcome, but the bougie apparently never en- tered the stomach. Whenever it seemed to pass farther down, the child suddenly became very restless and cyanotic, with long- drawn-out croupous inspirations, and vomited. The same symp- toms usually appeared about eight to ten days after the last sounding, which was generally done every twelve days, and were sometimes accompanied by rise of temperature. Then the little sufferer pushed all the five fingers into her mouth, and instinctively tickled the soft palate until she vomited. For the last three months the diet had been entirely fluid. Already in the early summer the doctors had advised an operation, but the parents, unhappily, were opposed to such a treatment, and only saw the absolute necessity of a more heroic interference when the child had nearly died in one of the attacks above described. When 1 saw the child at my office, September 9, 1891, it was thin, pale, restless, and slightly cyanotic. When she cried, the inspiration at once became croupous. I abstained from testing the caliber of the oesophagus at this time, deeming it best to do that once thoroughly under an anaesthetic. Mother and child were admitted to the German Hospital. There fluid diet was partaken of. Small quantities seemed to find no special difficulty in their descent to the stomach. AVeight, twenty- three pounds. Four days later fever set in; no food was or could be taken. On careful general examination, an apparent organic cause for the rise of temperature could not be found. Dr. A. Jacobi, who at this time saw the patient with me, was likewise unable to diagnosticate any disease. Immediate sound- ing of the oesophagus in narcosis was therefore decided upon. Temperature, 102° F. After the first whiff of chloroform the face turned blue; a few sounding inspirations, with spasm of the lower jaw and grinding teeth, followed, and respiration stopped. Immediate lowering of the head and extraction of the toDgue were resorted to. No relief followed. Tracheotomy was just going to be performed when my finger, which I had pushed far down over the base of the tongue in order to give the air free access to the larynx, suddenly produced vomiting. 4 EXTE RNAL (ESOPI1AGOTOMY. At the same moment respiration started up again. finite a time elapsed before the vomiting of mucus and partially curdled milk ceased. Then the former cyanotic condition disappeared ; respi- ration was entirely free; the examination could be performed. A medium-sized whalebone bougie (bougie d boule) met with a stricture right behind the cricoid cartilage. By some slight pressure it was overcome. Two inches and a half lower down the sound was again stopped. After some manipulation, which again induced impeded crowing inspirations and cyanosis, I suc- ceeded in making the bougie enter the stricture for about two inches, but then it was firmly caught. The same result was experienced with thinner bougies. I did not venture to enforce any further progress downward, out of fear of perforating the wall of the oesophagus. Repeated attempts to reach the stomach were made with different sized and shaped bougies on subse- quent days without anaesthesia, but likewise failed. Operative interference was clearly indicated. But which operation was the most preferable? In view of the superior stricture, which was directly accessible to the knife, I decided to perform exter- nal oesophagotomy. On account of my absence from the city about that time, the operation had to be deferred until September 30th. Chloroform narcosis was induced, preceded by a hypodermic of three minims of morpho-atropine. This time there was no trouble with the respiration. The incision, about two inches long, split the supe- rior stricture. It was seen that it was caused by a thin, circular, cicatricial, spur-like band, which narrowed the lumen to the size of a lead-pencil. The spur was highest on the side oppo- site the incision. Thus the canal made a sharp curve at that spot, the convexity pointing to the left. This spur was divided with the scissors transversely at two spots, and the small wounds were united longitudinally with a few interrupted catgut stitches, thus imitating the Ileineke-Miculicz method used in pyloroplasty. I now pushed a conical bougie (No. 11 of the French gauge) down toward the stomach, and succeeded in the first attempt, by using some slight pressure, in entering that organ. Bougie No. 12, or a soft-rubber catheter (N61aton) of this size, encoun- tered insuperable resistance. As a French conical catheter was EXTERNAL (ESOPIIAGOTOMY. 5 not at hand, the bougie No. 11 was left in place. After proper disinfection of the wound, narrow strips of iodoform gauze were put into the depth of the wound at both sides of the oesophagus, and its cut surfaces united with those of the skin with a number of catgut sutures. Rectal alimentation was employed. On the following day the child was doing well; the bougie was ex- changed for a catheter (No. 13), and feeding was started from above. Small quantities of water were allowed by the mouth to quench the dry feeling in the throat, but, of course, they appeared at once, as also did the saliva, at the opening in the neck. After three weeks of gradual dilatation, always easily done from the wound in the neck, a Nelaton catheter (No. 26), with a distal opening, passed the stricture. Only the larger sizes, from No. 23 upward, had met with some difficulty—more so whenever the child screamed and resisted. On October 21st the wound had healed, a good lip fistula had been established, and the child had for some time been out of bed. The subsequent history is of some interest and impor- tance. -I will therefore state the different points as briefly as possible, quoting from the history : October 21st.—No. 27 bougie and catheter refused to pass, probably on account of the struggling of the child. Therefore morphine-chloroform narcosis. Recumbent posture (Rose’s), head turned to the right. Irrigation of oesophagus with warm Thiersch’s solution. Divulsion of the entire canal with Powell’s urethral dilator armed with the rubber cap up to No. 30. This procedure was here just as easily done as in a case of urethral stricture. The instrument was caught at its introduction a num- ber of times in a blind canal. It passed at last by bringing the handle far over to the i-ight. There was therefore a curve to the right. Thus the whole oesophagus formed an S-curve. Ir- rigation repeated. A soft-rubber catheter, No. 30, passed into the stomach. Temperature later in the evening, 104°. 22d.—No. 30 was exchanged for 22, whereupon the tempera- ture dropped promptly. Probably small tears inside of the canal had been compressed by the snugly-fitting tube. Their discharge was reabsorbed and caused the rise of temperature. 6 EXTERNAL (ESOPHAGOTOMY. 28th.—Deep narcosis; irrigation as before. Divulsion up to No. 35. No. 25 left in. This time no febrile reaction. November 2d.—Narcosis deep, divulsion up to No. 40 (this number corresponds to the normal caliber of the undilated oesophagus of a grown person at a level with the bifurcation of the trachea*). Slight haemorrhage from upper portion of oesophagus near the lower angle of the fistula. A stout drain- age-tube of 32 was carried down into the stomach stretched over a piece of whalebone and left in situ. It slipped out in the following night and could not be replaced by the house sur- geon. Other sizes of tube and catheter also refused to pass. 3d.—Light narcosis. Three inches and a half below the fist- ula there was found an obstacle which seemed at the time im- passable for any instrument with a rounded extremity. When- ever that spot was reached and some pressure exerted on the tube, tbe child coughed hoarsely, yawned, even if fully under the anaesthetic, gagged and vomited, and bit her teeth. Stretch- ing with the dilator created the same symptoms (reflex of the nervus vagus). A conical catheter, No. 21, was at last left in place. Up to this time the child had been fed on strong, nourishing food. About three quarts of peptones, milk, broth, oatmeal and barley water with peptones, etc., besides tbree eggs, had been slowly poured into the stomach at regular intervals pro die. Nevertheless, the weight, which had at first gone up to twenty- five pounds, had lately rather decreased. Scales showed twenty- three pounds on November 6th. Stools smelled very bad. Evi- dently a great proportion of the food was not assimilated and left the intestinal tract undigested (dyspeptones). Bill of fare therefore reduced. Probably also the loss of saliva had some- thing to do with the small degree of assimilation.! 6th.—Soft-rubber catheter with distal end No. 26 put in. * Y. Hacker. Ueber die nach Veratzungcn entstehenden Speiserdhren- verengerungen. Wien, 1889, p. 8. f Cf. Le Fort. Des indications therapeutiques dans les retrecisse- ments cicatriciels et cancereux de l’oesophage. Bull, general de thera- peut., 1890, No. 2, EXTERNAL (ESOPHAGOTOMY. 10th.—Permanent catheter came out during sleep. It was now entirely dispensed with. For every meal the tube attached to tbe glass funnel was introduced into the oesophagus for about two inches and then the food allowed to run in. It easily did so whenever the girl kept quiet, but stopped and was slightly regurgitated at once when she screamed. A cup. of milk or other fluid was even swallowed without leakage at the fistula, if a con- dom slightly blown up with air was carefully pressed with the hands on the fistula or held there in place by a bandage. llfth.—Narcosis (mixed, deep). No. 26, which had passed eight days ago, is stopped three to four inches down. All at- tempts at overcoming the obstruction were futile. The same sensation was experienced as in entering a false urethral pas- sage. Irrigation. After some trying, Powell’s dilator slipped in. The instrument was firmly surrounded by the wall of the oesopha- gus, which thus, four days after the removal of the permanent catheter, had recontracted in its entire lower portion. There was no doubt a tubulous stricture of dense cicatricial tissue about three to four inches long beginning at that often-mentioned spot two inches to two inches and a half from the lower end of the fistula, which corresponded to the bifurcation of the trachea.* Repeated gradual divulsion of the whole tract step by step, from the cardia upward, up to No. 40, found at last great resistance. Marked reflex symptoms as at previous occasions. Irrigation. No subsequent reaction. Feeding without permanent tube as before. Another test, made November 18th, showed again recontrac- tion. I now had treated the little patient for nearly eight weeks. Twice a permanent tube up to No. 27 bad been borne, but a larger size was always pushed out inside of twenty-four hours. Four times the whole cicatricial tube had been divulsed, twice up to No. 40. Each time the stricture had refused to yield for any length of time. The task was of course to give the oesopha- gus a caliber which permitted of swallowing all kinds of food and * I abstained from oesophagoscopy under electric light, as I could not see any advantage in its performance in this case. 8 EXTERNAL OESOPHAGOTOMY. could be preserved bypassing a sound of at least No. 35 through the mouth. Only then the fistula in the neck could be closed by a second operation. Was there hope of coining to a successful end by continued stretching and divulsing? Or had I to apply to some other resource? The only other means which could still he now tried were electrolysis and direct application of the galvanic current for the sake of reabsorption of the cicatricial tissue, gastrostomy with consequent retrograde divulsion, and internal oesophagotomy. I decided and got permission of the parents to attack the long lower stricture also with the knife, being well aware of the great danger of this interference. 23d.—Deep, mixed narcosis, Rose’s posture. Thorough anti- septic irrigation. Stricture only admits No. 20. Otis’s straight urethrotome is held at about three inches below the fistula, but passes after the handle lias been carried far to the right. A strong vomiting spell, which is aggravated by screwing up the instrument. Rough cough, grinding of the teeth, great restless- ness. Deeper narcosis. Urethrotome screwed up to No. 38. Knife points to the front and left. Division of stricture. Second incision in the same way to the front and right. Haemorrhage not abundant; mostly venous. Stopped by irrigating with ice-cold Thiersch’s solution. No permanent catheter. About ten min- utes later another sudden explosion from the stomach. Two large pieces of curdled albumin, by far larger than any ever vom- ited before, are brought up and extracted through the fistula piecemeal. Jf, P. M.—Three hours later, child restless, without fever; rectal alimentation. 9 P. M.—Temperature, 105-2° ; pulse, 148 ; restlessness in- creased, general hyperesthesia. 2Jtth.—Patient struggles when fed. Soft-rubber catheter No. 26 passes without meeting the slightest obstruction or cre- ating hemorrhage. It nearly drops into the stomach. It is left in place. Within the next forty-eight hours the symptoms of a general meningitis appear. Twisting and spasms all over. Sensory, motor, and vaso-motor centers all involved. Abdo- men soft, not tympanitic. No symptoms of lung trouble, pleu- EXTERNAL (ESOPIIAGOTOMY. 9 ritis, or posterior mediastinitis. In spite of very careful nurs- ing, the little patient succumbed on December 2d, nine days after the last operation.* Post-mortem Examination, by Dr. T. Adler.—No mediasti- nitis, no peritonitis, no pleuritis. Suppurative meningitis, espe- cially on the right side. Brain soft and pultaceous; nowhere else a suppurative focus. All organs in perfect condition. The oesophagus specimen is of great interest (Fig. 1). The posterior wall of the canal having been split in its entire length, it appears that the upper stricture is entirely cured. Surface smooth. No ridge (Fig. 2, a). Lip fistula in the side well established (Fig. 2, l). The lumen of the canal below the superior stricture in the length of fully two inches dilated at least to double the size of the upper portion. Mucous membrane here unchanged. Mus- cularis thin. In the right half a superficial, nearly healed in- cision an inch long. (This is the only spot where the second cut, made with the urethrotome, took effect.) The lower strict- ure, three inches long, begins right behind the bifurcation of the trachea and ends about an inch above the cardia at a spot which corresponds to the hiatus cesophageus of the diaphragm. Mu- cous membrane of this last-mentioned portion (above cardia) perfectly normal; muscularis and peri-oesophageal tissue not thickened. An inch and a half below entrance to inferior stricture (and three inches and a half below the lower angle of the fistula in the neck), on the right side of the oesophagus, a false passage three quarters of an inch long (Fig. 2, c). Its en- trance is marked by deep, irregular wrinkles of cicatricial tissue. A tongue-like process of normal mucous membrane extends downward within half an inch from this spot as a direct con- tinuation of the upper normal mucous lining. The entire other surface of the stricture is covered with cicatrix. Out resulting from internal oesophagotomy in the left half of the canal (first incision), three inches long and a quarter of an * The constant presence of the oesophageal tube proved of the great- est benefit in this serious illness. Feeding could be kept up with excel- lent regularity. Digestion and assimilation went on uninterrupted, as demonstrated by the normal defecation and micturition. 10 EXTEKXAL GO SOP 11 AG 0 T 0 M Y. inch deep, gaping, smooth, without surrounding inflammatory symptoms, entering the muscularis, nowhere penetrating (Fig. 2. d). Its direction points toward the tissue in front of the aorta. It has thoroughly divided the convex side of the stricture in its entire length * and swelled the caliber of the latter to at least No. 40 French. (Circumference nowhere less than an inch and a half, measured on the specimen which is hardened in alcohol.) Mucous membrane of the stomach appears normal in all its parts. There is no doubt that the remote cause of death was in- ternal oesopliagotomy, and the immediate, pyaemia, with the only one local inflammatory manifestation—“ suppurative meningitis.” Streptococci had entered the circulation in the oesophageal wound where venous bleeding at the time of operation had been especially marked, passed the capil- laries of the pulmonary arteries which are the widest in our system, and were carried into the smaller ones of the brain as infectious emboli. Could this result have been avoided ? Was there any other way to cure the patient ? In other words, had inter- nal oesophagotomy been clearly indicated ? * This fact refutes von Hacker’s statement (l. c., p. 117): “Longer strictures can not be fully divided with the help of internal oesopha- gotomy neither from above downward nor in the opposite direction. The post-mortem examination showed in all these cases an incision in the upper or lower half of the stricture only.” The use of the urethro- tome—which, when screwed up, brings the wall of the oesophagus on the stretch—enables an incision of the entire stenosed portion. That this be true is well demonstrated by my case. The depth of this in- cision will, of course, vary at different spots if the course of the strict- ure is curved. It will be deepest at the greatest convexity, provided the knife was turned to this side first, and this, I believe, should always be done. A thorough incision on one side alone seems to me to be suf- ficient. A second one can have effect only if the stricture is cut 1 arger size with this second incision. EXTERNAL (ESOPIIAGOTOMY. 11 In trying to give a satisfactory answer to this, here vital, point three questions ought to be considered : 1. Could the former treatment, with the additional use of electrolysis or direct application of the galvanic current, have effected a cure if it had been carried out longer ? 2. Was death due to the mode of carrying out the in- ternal division of the stricture ? 3. Would gastrostomy with retrograde divulsion have promised a permanent, quicker, and safer result ? With reference to the first question, the assumption will probably find little opposition that a longer-continued divul- sion would, in this case at least, not have promised any fur- ther improvement. The stricture was long, cylindrical, and dense; it had to recontract after simple stretching.* More rapid and forced divulsion seemed to me too dangerous and not indicated. At one or the other spot the (esophageal wall might have ruptured and septic mediastinitis set up. Rapid divulsion, moreover, gives an unfavorable prognosis with reference to the permanency of the obtained result. Perhaps the application of the ordinary galvanic cur- rent (one to two elements), cathode inside of the stricture, might have reabsorbed some of the cicatricial tissue. But a constant improvement was not to be expected by it. Electrolysis, although having proved of use in the hands of others,f also promised very little in this case in view of the length and the tubulous character of the stricture. The stricture therefore had to he divided with the * A glance at the specimen also proves this view to be correct. The oesophageal wall, with the thickened peri-cesophageal tissue, is at the seat of the lower stricture at least four times as thick as at other normal spots. f F. Hjort. Die Behandlung der Speiserohrenverengerungen. Achte Sitzung d. Intern, med. Cong, zu Kopenhagen, 1884. Rep. in Ctrlbl. f. Chirargie, 1886, p. 69. Electrolysis was here carried out after gastros- tomy in a retrograde manner in one case with a most satisfactory result. 12 EXTERNAL (ESOPHAGOTOMY knife unless I combined gastrostomy with retrograde slow divulsion first as a trial. Which method of internal cutting was, under the circumstances, the most preferable ? Incis- ion wdth a blunt-pointed and long-handled bistoury or with a herniotome which had to be introduced alongside a grooved director,* or alongside a small rubber bougie (as used for cutting an anterior urethral stricture) was here im- possible on account of the curve of the narrow stricture. A special oesophagotome, according to Trelat, Collin, or others, was not at hand.f A urethrotome—which, as I afterward found in perusing the literature, had only once been used be- fore in this operation J—seemed to otfer the best advantages. The choice of the proper instrument, however, was not the main point at issue. It was that to every case of in- ternal oesophagotomy, even to-day, one immense danger is attached—namely, impossibility of previous disinfection. If there had been a way of thoroughly disinfecting the oesophagus before cutting the stricture, as wre are accus- tomed and bound to do in the urethra before internal urethrotomy, I am sure my little patient would not have * C. Gussenbauer. Ueber kombinirte Oesophagotomie. Zeitschrift fur Heilkunde, vol. iv, p. 33. f If gastrostomy had been done, the small triangular knives recom- mended by F. Lange, of this city, which are pulled through the stricture on a thread from below, would have come into consideration. \ Of. K. G. Lennander. Narbenstrictur des Oes. bei einem zwei- jahrigen Kinde. Aeussere Oesophagotomie. Genesung. Rep. Ctrlbl. f. Chir., 1890, p. 148. Lennander used Maisonneuve’s urethrotome, which cuts from anteriorly backward. This is especially dangerous. It may thus happen that the instrument is introduced into a false pas. sage and the knife divides the Avail of the latter (cf. v. Hacker, l. c., p. 66 and following pages). The internal cesophagotomy should always be done retrograde, the knife having first passed beyond the stricture. Gradual blunt dilatation, therefore, has to precede the internal cutting if the stenosis is very tight. In a number of cases a guide pushed up from the stomach will lead the way. (See below.) EXTERNAL (ESOPHAGOTOMY. 13 died, but probably be cured to-day; for that only a free division of the contracted long cicatricial tube does really “ cure ” such a stricture which does not yield to stretching, where false passages have been bored by the frequent at- tempts at sounding from the mouth, I am fully satisfied. I would put the radical treatment of these contractions on ex- actly the same basis as that of urethral strictures. Unhappily, the surgery of the posterior mediastinum has not yet advanced so far as to enable us to attack the lower oesophageal stricture as we do the upper ones—from outside. Perhaps surgery will never attempt as much, and, if it would, such an undertaking would perhaps be unwise and impracti- cable. There are no soft tissues around which in cicatrizing with the oesophageal wound would pull its cut surfaces out- ward in the shape of a funnel, as the perinseum does after ex- ternal urethrotomy, thus partially guarding against a recur- rence of the trouble. I therefore believe that rebellious strictures of the oesophagus in its intrathoracic portion must always be divided from the inside, provided they are divided at all. Such a thorough operation, with the help of a deep incision, is here of course accompanied, besides the proba- ble septic infection, as emphasized before, by another great danger—perforation of the oesophageal wall by the knife, with subsequent posterior mediastinitis, pleuritis, or arterial fatal haemorrhage from the aorta or common carotid. The latter accident can partially be avoided by not carrying the incision so deep as to penetrate the oesophageal wall in its entire thickness. It will be a matter of personal tact and judgment to avoid such an accident as much as possible. A number of shallow cuts with subsequent dilatation, if necessary repeated, might in some cases prove of perma- nent benefit.* Still we have a right to presume that a * Von Bergmann (Ueber Operationen am Schlundrohre, Deutsche med, Wochenschr., 1883, No. 42 ii. 43) wants internal cesophagotomy EXTERNAL (ESOPHAGOTOMY. good deep cut which thoroughly divides the cicatricial mass in its entire length, as it had been done in my case, promises a real radical cure, without necessitating further or continued regular sounding for many years, perhaps for life. It will then be sufficient to test the caliber once or twice a year, as is the rule in strictures of the urethra which have been cut.* Reabsorption of septic material can of course take place as well from a superficial as from a deep wound. This scar tissue, after some time, generally is quite vascular, espe- cially if irritated by instrumental manipulations. This also would be my answer to any one who might say that the fatal result in my case had been due to the depth of the in- cision, which, as mentioned above, implicated the muscular part of the canal. I firmly believe that, the same hard luck being imminent, a more superficial wound in that spot could just as well have given entrance to the streptococci which caused the fatal blood poisoning. I still have to answer the third question put above: Would gastrostomy with retrograde divulsion have given a better result in this case ? I believe decidedly not. Besides the necessity which presented itself in my patient to attack the superior constricting ring with the knife, which for etfect- done only in cases where a cicatricial, very short, still permeable, valve- like stricture refuses to yield to gradual dilatation. He advocates a “ superficial, multiple debridement.''' In a case similar to the one de- scribed before, I would, in the future, probably also first satisfy myself with one or two more superficial incisions, and repeat them if necessary, protected by the method proposed below, after having tried retrograde divulsion. I would then first perform internal oesophagotomy on a tubulous stricture, without screwing up the urethrotome to the desired caliber at once—rather proceed gradually. * But the deep, thorough division of the stricture, made as in urethrotomy, should in all these cases be the very last resort, in view of its manifold dangerous consequences. EXTERNAL CESOPHAGOTOMY. 15 ing a radical cure could of course only be done correctly by external oesophagotoiny, it can be taken for granted that stretching from below would have likewise been followed by recontraction, even if a larger size of tubes or bougies could have been passed and left in situ. Of course not all strict- ures of the lower portion of the oesophagus present the same difficulties of treatment. Many can be stretched by long-continued sounding and kept patent if tested now and then. The sooner this treatment is started, the oftener sub- sequent trouble and operative treatment can be avoided. In fact, as the stricture is bound to come in the majority of cases, sounding should always be started about two to four weeks after the accident, and kept up at regular intervals with increasing sizes of the bougies, if possible, for many years, perhaps for life.* The majority of these patients will, of course, not listen to such urgent medical advice, and the family physician, who mostly gets these cases first in hand, will often neglect to submit his resisting client to this clearly indicated prophylactic but painful treatment. Thus, after some time surgical help is generally called for. Should, then, gastrostomy or oesophagotomy be performed ? It would be absurd to draw definite con- clusions in this direction from the experience in one single case. Still, I should venture to say that, in children at least, external oesophagotomy and subsequent stretching from above seems to me to be the preferable operation—the one which should be first tried. IIow easily and often also in older patients the so called impermeable stricture of the oesophagus in its thoracic * Maydl (Die Magen-Chirurgie der letzten fiinf Jahre, Internal. Min. Rundschau, 188*7) proposes to perform gastrostomy at once, right after the cauterization of the oesophagus, and von Hacker (foe. cit., p. 121) adds to this proposition the one to start sounding of the oesophagus with the help of this gastric fistula two or three weeks later. 16 EXTERNAL (ESOPHAGOTOMY. portion can be successfully overcome and widened from a wound in the neck, has only very lately been again em- phasized by Graser, of Erlangen.* lie stated how easily a sound would glide through a strictured oesophagus into the stomach from an opening in the neck, which had persistently refused to enter and pass the stricture from the mouth. From a fistula in the neck the sound lias to pass a straight way downward to the stenosis, whereas from the mouth this way is curved. The entrance to the stricture is thus easier found. The bougie or tube, if left in place, causes no annoyance and can soon be exchanged for a larger size. It took, in some cases, only one week before the largest size met the stricture without difficulty. The lip fistula in the neck is closed as soon as the sound can also be passed with equal ease from the mouth down into the stomach. In children, where it is especially important, we can avoid by the oesophageal operation the annoying constant gagging and vomiting which the presence of a tube in the throat and mouth or in nasopharynx and nose drawn up through the gastric fistula necessarily produces, for some time, more so if it is left in situ. And this again is ad- visable, because it is well known that rapid dilatation is best done by permanent catheterism.f On the other hand, gastrostomy is also a comparatively easy and safe operation. If carried out according to von Hacker (that is, by splitting the left rectus muscle longi- tudinally and using its belly as an artificial constrictor),J * Zur Behandlung der Oesophagus-Stenosen. Verhandlungen der deutschen Gesellschaft fur Chirurgie, XIX. Congress, 1890, p. 136. •)• The loss of saliva, which mostly passes through the wound in the neck and seems not to be insignificant for nutrition, can partially be avoided by tying a blown-up rubber bulb on the fistula, jj. Wiener med. Wochensclirift, 1886, Nos. 31 and 32. EXTERNAL (ESOPHAGOTOMY. 17 the leakage can with certainty be avoided; and, if the von Hacker-Scheimpflug* cannula is put in, feeding with semi- solid and solid diet may he at once begun. This is a very important factor in patients who have become greatly ema- ciated. After external oesophagotomy, only fluid diet can in the beginning be given, on account of the narrow' caliber of the permanent catheter. I have brought along here this cannula, as it was made for me by the W. F. Ford Surgical Instrument Company. I wanted to use it in a patient of mine, seventy-one years old, who had been operated upon by me according to von Hacker’s method for cancerous stricture of the oesophagus, and had an excellent, perfectly patent fistula through the rectus muscle still, after nine months.f In this fistula he was wearing a stout rubber tube. Three days before I re- ceived the cannula from the instrument company the pa- tient suddenly died from an intercurrent pneumonia inside of two days. As is shown in the accompanying cut (Fig. 4, which represents schematically the cannula in position), this can- nula, made of silver, is constructed according to the prin- ciple as represented in Trendelenburg’s tampon-cannula for the trachea. It can be easily made in different dimensions, according to the width and depth of the gastric fistula, by any instrument maker. A double rubber balloon of hour- glass shape, each part of which can be blown up with the help of the small tube running inside the larger one (Fig. 4, t), is pushed over the cannula and fastened there in shal- low grooves (Fig. 4, g) with silk threads (Fig. 4, s). The rubber tube in the middle, which connects the two balloons, is best tied on the cannula, in the length of about a quarter of an inch, by simply running a silk thread around it a * Wiener klin. Wochenschrift, 1888, pp. 491, 517. f Cf, New York Medical Journal, 1891, p. 521, 18 EXTERNAL (ESOPHAGOTOMY. number of times. Thus a free space is formed between the two blown-up balloons which will not press upon the borders of the fistulous tract. If the latter is still sore, a piece of iodoform gauze, dry or spread with a salve, can Fig. 4. be conveniently rolled around this spot. It is firmly field in place by the two balloons. The latter, when distended, must take the shape of air-pillows, which fit water-tight all around and should not press the borders of the fistula (Fig. 4, b). This point is especially important with reference to the lower one. To put the whole into working order, a drainage-tube of any desirable length is fastened to the outer end of the large cannula (Fig. 4, di) and closed by a EXTERNAL (ESOPHAGOTOMY. 19 clamp. Through it the food is poured into the stomach (Fig. 3). Another rubber drainage-tube is tied on the small funnel-shaped silver tube to facilitate proper filling of the balloons (Fig. 4, sdt). The sounding from below itself has been greatly facili- tated by the method published by Ilagenbach,* advised for strictures which are still permeable. A shot on a long- thread is swallowed. The one end of the thread is held in front of the mouth and the other end drawn out of the stomach through the gastric fistula. A strong silk thread is then tied to the lower end of the first one outside of the abdominal wall and pulled through the stricture and out of the mouth. Both ends are then tied together. Every day a sound is tied to the thread outside of the stomach and drawn through fistula, cardia, and oesophagus upward. The size can be rapidly increased. The thread is constantly left in situ, and does not cause any inconvenience. If the stricture is impermeable from above, the cardia must be searched for through the gastric fistula. The tube and electric light, as used in urethroscopy, may there often be of great service to detect the sometimes greatly drawn aside and constricted lumen. If found, a thin bougie is pushed up through into the mouth. This retrograde treatment is con- tinued so long until the same large-sized tube passes the stricture from above just as easily as it is pulled through with the help of the guide from below upward. Then the opening in the stomach and the abdominal wound are closed by special suture. Of course, this second operation is more difficult and serious than that done for closing the lateral opening in the oesophagus at the neck.j In order to esti- * Kasuistische Beitriige zur retrograden Dilatation von Oesophagus- stricturen (aus der chirnrg. Klinik zur Basel). Korrespondenzblatt f. schweizer Aerzte, 1889, No. 5. f If gastrostomy was done through the belly of the left rectus mus- cle, the gastric fistula might eventually close without further operating 20 EXTERNAL (ESOrHAGOTOMY. mate the real value of retrograde dilatation without an in- ternal cutting operation, the result obtained should be re- examined after one to three years. In a number of these cases internal oesophagotomy had, and will still have, to be added, with, of course, not less danger than in any other case. We always are forced to resort to it if the stricture does not yield to larger sizes of the bougie, or if it rapidly recontracts. Among the one hundred clinical cases of cicatricial stricture of the oesophagus selected and reported by von Hacker (l. c.), I find internal oesophagotomy performed fourteen times* (in one case it had to be done twice). In five it had been combined with the external incision (Cases I, XI, XIII [2], LII, XCIX of the tabula; Case XIII is the one just referred to; both operations were done here twice, combined, by Gussenbauer). Of these five cases, three were cured, one died of haemorrhage fifteen days after the operation; one of mediastinitis, pleuritis, and peritoni- tis on the third day after the operation. (Sands’s patient, mentioned in foot-note, died of shock twelve hours after the operation.) Of the remaining eight, where internal oesopha- gotomy alone had been done, six are reported as cured, one died three months after the operation of suppurative pleu- ritis and pneumonia, another of mediastinitis and pleuritis. Meningitis as a sequela to the operation in question, as ob- served in my case, I found nowhere reported. But even one single case of such a kind gives sufficient proof that, with internal oesophagotomy as heretofore performed, we may well escape the dangers which often, sooner or later, as soon as the tube, which passed through it into the stomach, had been removed. The fistula in the neck may now and then also heal in this way. * In looking up a few of the reported cases in the original, I find that one case of combined oesophagotomy done by Sands (JV. Y. Med, Jour., 1884 p. 534) has not been included in the tabula. (Boy.) EXTERNAL (ESOFIIAGOTOMY. 21 followed its performance—namely, pleuritis, mediastinitis, peritonitis, and pneumonia—but still can be shipwrecked on the rock which so far was in our way in every one of these cases : the necessity of doing a cutting operation in a field which could not be disinfected either before or after its performance. Have we, then, no means to guard against blood poison- ing in this operation ? Can not a method be found which lets us operate in a thoroughly disinfected field ? I believe it can, and 1 should propose to proceed in the following manner: If external cesophagotomy had been primarily performed, gastrostomy has to be added, and vice versa. Thus that portion of the oesophagus which presents the operating field is temporarily excluded from the digestive tract. Before starting the internal incision, irrigate the oesophagus from the fistula in the neck downward with Thiersch’s solution, or a solution of permanganate of potassium, allowing the water to pass out of the gastric opening, and during a suffi- ciently long time to be sure that this portion of the canal is thoroughly disinfected. Also carefully wash the stomach from below. (This preparatory treatment may be repeated during a number of days.) Push an iodoformized sponge, or a ball of iodoform gauze on a thread, into the upper por- tion of the oesophagus, between the opening in the neck and pharynx, so as to guard against the descent of the se- cretions of the mouth. Then do internal cesophagotomy, under constant irrigation, from the wound in the neck downward. Continue same after the operation is finished. The water will run into the stomach and readily escape through the gastric fistula. At last pull an iodoformized sponge or a ball of iodoform gauze, with the help of a bougie and thread, through the gastric opening and the cardia into the lower end of the oesophagus. This will prevent regur- 22 EXTERNAL (ESOPHAGOTOMY. gitation of the contents of the stomach in the subsequent direct feeding through the abdominal opening. Of course, also rectal alimentation could be resorted to in the first four to five days. But that would seem to be a rather unneces- sary precaution. If desired, frequent antiseptic irrigation of that portion of the oesophagus between the two plugs, by way of the wound in the neck, could be added, the patient being in the recumbent posture. I trust that this my proposition with reference to inter- nal oesopliagotomy according to antiseptic principles would render it just as safe, in this respect at least, as internal urethrotomy. It can then be carried out with the instru- ments as used in urethral surgery. If Gerster’s urethro- tome can be passed through the stricture, it will deserve pref- erence, as it stretches the stricture transversely over the in- strument. The dividing knife will then less easily cut through the oesophageal wall. For older children and grown persons these instruments, then, have to be made in a larger size, or rather longer, which, no doubt, can be quite easily done. In conclusion, I offer the following propositions : 1. After swallowing acids, etc., sounding should be be- gun as soon as it can be made out that the internal wounds have healed, certainly not later than two to four weeks after the accident. This prophylactic treatment has to be con- tinued at regular intervals for a long period—if necessary, for life. Gastrostomy can be primarily performed for this purpose (Maydl, von Hacker). 2. If a stricture of the oesophagus has developed and is impermeable from the mouth, the patient should be sub- mitted to an operation as early as possible. No forcible dilatation or boring with the sound should be permitted. If the latter is done, the formation of a false passage is favored. The oesophagus has thus often been perforated. EXTERNAL (ESOPHAGOTOMY. 3. External oesophagotomy for the establishment of a temporary fistula in the neck (cesophagostomy) will be found useful and sufficient in many of these cases, espe- cially in children. The stricture can be generally passed quite easily from this opening. A tube can be left in situ without the annoyances which are caused by passing it through the nose and pharynx. This operation is always indicated if, besides an impermeable stricture in the lower portion of the oesophagus or behind the bifurcation of the trachea, a second (or third) one is present at a level with, or not far below, the cricoid cartilage. 4. In grown patients and those who are emaciated and require immediate forcible nutrition, primary gastrostomy, with subsequent retrograde sounding, may be preferable. 5. If the stricture has been successfully stretched, and if the same sound which passed from the wound in the neck can also be pushed down through the mouth, the fistula has to be closed. If gastrostomy had been performed, this second operation generally requires laparotomy and separate suture of stomach and abdominal wound. 6. In a number of cases there is a limit to stretching and divulsion, or the repeatedly widened stricture rapidly recontracts. Then internal oesophagotomy is indicated as the only means to cure the patient. 7. Internal oesophagotomy, if performed under these circumstances, is a very dangerous operation, especially on account of our present lack of means to render the oper- ating field free of infectious material. 8. A thorough disinfection of the intrathoracic portion of the oesophagus seems feasible by first adding gastrosto- my to external oesophagotomy, and vice versa. Then the operating field and the stomach can be cleansed by antisep- tic irrigation before and after the operation. Through tem- porary antiseptic tamponade of the cardiac portion of the 24 EXTERNAL (ESOPHAGOTOMY. oesophagus and of that between the fistula in the neck and pharynx we may hope to guard against contamination of the wound. 9. From a wound in the neck internal oesophagotomy can be carried out in the same way and with the same in- struments as used for dividing strictures of the anterior urethra from within. The division should be made in a retrograde way only, the knife having been first passed be- yond the stricture. A guide pushed up from the gastric fistula will help to accomplish this, even in obstinate cases. It may become necessary, especially in adults, to have an instrument of a special length, and sometimes also curve, constructed for this purpose. THE NEW YORK MEDICAL JOURNAL, NOVEMBER 19, 1892. Fig. 2. Fig. 1. Fig. 3. 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