[Reprint from The St. Louis Medical Gazette, May 15.9.9.] 
A CASE OF DIVHRTICUEUM CESOPHAGI. 
John Zahorsky, M. D., 
Assistant to the Chair of Pediatrics, Missouri Medical College. 
The following case of diverticulum of the oesophagus is 
reported on account of its peculiar location, large size, and 
the difficulties of definite diagnosis. In studying the litera- 
ture I have found very few similar cases reported. Diverticula 
occur almost always opposite the cricoid cartilage, as has been 
shown in the classical article of Zenker and Von Ziemssen. 
Their pathogenesis is not quite clear, but it is probable that 
a congenital weakness at that point in the oesophagus is the 
prime factor. This may be due to a displaced vitelline duct, 
abnormal development of the bronchial clefts, or possibly a 
faulty development of muscular fibers so that a hernia of the 
mucous membrane results. At any rate diverticula do not 
seem to be found in infants and children. We know, there- 
fore, that these pouches are formed gradually during life, and 
the patient is usually full grown before serious symptoms 
develop. The direct cause in their development is retention 
of food and the muscular effort in deglutition which gradually 
distends the sac. At the same time active proliferation of the 
cells in the wall of the diverticulum keeps the thickness 
almost constant and prevents rupture. These have been 
designated pulsion diverticula. 
The so-called traction diverticula occur usually at the 
oifurcation of the trachea, and are caused by an adhesive 
inflammation between the oesophageal wall and some sur- 
rounding structure, as the bronchial glands. The traction 
diverticula are very small and give rise to no symptoms. 
F. W., male, aged 20 years, consulted me in December, 
1895, in reference to a difficulty in deglutition. The family history was unimportant. As far as could 
be ascertained there existed no tendency to tuberculosis or 
cancer in the family. Syphilis was utterly excluded. The 
father died of an operation for inguinal hernia. The mother 
was living and perfectly well. Patient had lost a brother and 
sister, one of typhoid fever and the other of diphtheria. No 
evidence of malformations or structural weakness in the 
ancestors could be elicited, with the exception of the hernia 
in the father. No stigmata of degeneration were discovered. 
The patient had always been free from acute diseases, except 
that he had diphtheria in infancy. Patient had never 
had any disease of the chest, no cough and no glandular 
enlargement of neck. During childhood it was noticed that 
he spit mucus very frequently,and this was made the subject 
of great anxiety by relatives, saying that he would not live 
long. The patient remembers that even in early childhood, at 
times he had a disagreeable sensation during deglutition. He 
positively denies ever having swallowed lye, acids, or corrosive 
poisons. The mother was carefully interrogated on this point 
and not the least evidence could be obtained that patient 
during childhood swallowed anything that might cause a 
traumatic oesophagitis. 
For several years the difficulty in swallowing has been 
growing progressively worse. Regurgitation of food has been 
very common for some time. Among an early 
during childhood was the fact that remnants of food and 
fluid were found on his pillow every morning. This has 
increased to such an extent that he provides himself with a 
cup at bedtime, and on lying down some food soon regurgi- 
tates and he spits it into his cup. This regurgitation of food 
after or during meals and at bed time is the source of nearly 
all his worry. He is unable to attend any dinner outside of 
his home, as he is liable at any time to regurgitate. At 
present this regurgitation is more pronounced than ever 
When patient attempts to eat he swallows several mouthfuls, 
but it all seems to stop somewhere before it reaches his 
stomach, finally he swallows by contracting all the muscles 
of the neck and fixing his respiratory muscles, and by this 
extraordinary effort succeeds in forcing the food into his 
stomach. Patient is fairly well nourished, but rather pale. His intelligence is about the average. Patient has been 
treated by various physicians without success. For over one 
year he has been under the care of one of our leading physi- 
cians, who treated him for stricture of the oesophagus. The 
treatment consisted in passing sounds and bougies. The 
physician had passed large olive-tipped oesophageal dilators- 
The patient himself had been taught to introduce a hard 
rubber bougie, and for nearly one year he passed a bougie 
daily, with the object “to keep the stricture open.” Never- 
theless, there ensued no improvement. Great difficulty in 
swallowing still persisted, and regurgitation was just as 
common. Patient stated that he could introduce his bougie 
at times without any trouble, at other times he seemed to 
strike an obstruction which prevented the bougie from enter- 
ing the stomach. 
The Diagnosis.-—Two facts concerning the patient were 
definite : First, he had great difficulty in swallowing ; second, 
he regurgitated large quantities of food at various intervals. 
What pathological condition of the upper alimentary tract 
could explain these prominent symptoms ? 
The great difficulty in swallowing could only be explained 
by a narrowing of the oesophageal canal. What caused this nar- 
rowing in caliber? A large hard rubber bougie was introduced 
and passed without difficulty into the stomach. The con- 
clusion was inevitable that no organic stricture was present. 
The contraction in the lumen must, therefore, arise from 
some tumor pressing on the gullet or, as has been shown in 
at least one instance, an angular flexure of the oesophagus. 
Finally spasm of the cardiac orifice must be considered. 
In regard to the regurgitation or vomiting of food the 
question of its source presented itself. If this food came from 
the stomach the diagnosis of rumination seemed probable. 
A chemical examination of the regurgitated food revealed 
the following: Starch well digested; entire absence of hydro- 
chloric acid ; pepsin not demonstrable; lactic acid showed a 
marked reaction by Uffelman’s test; peptones absent. 
Microscopically starch granules numerous, but meat fibers 
totally undigested. This showed that either it did not come 
from the stomach or that organ secretes no true gastric juice. 
The physical examination revealed no abnormally in the lungs, heart and abdominal organs. Posterially over the chest 
in the left infra scapular region a small area of dullness 
was discovered. Over this there existed an absence of the 
respiratory murmur. Kidneys as revealed by urinary exam- 
ination were absolutely healthy. 
By clapotement a loud splashing sound was heard over 
the epigastrium, so that gastrictasia seemed possible. On 
auscultation over the oesophagus during the act of swallowing 
the deglutition murmur was not audible. 
Kwald’s test breakfast was given, and one hour afterward 
the stomach tube was passed. To my surprise it did not 
enter the stomach, but at a distence of 40 cm. it struck an 
obstruction. Nevertheless, nearly one pint of fluid and food 
was withdrawn. This fluid seemed to contain the ingredients 
of the test breakfast. Also a piece of coagulated egg albumin 
which the patient assured me he had, ingested the day before. 
Clearly it seemed that a diverticulum existed immediately 
above the diaphragm. One peculiarity seems important to 
notice that while the rigid bougie could pass into the stomach, 
the soft, flexible tube could not be induced to enter. More 
experiments with the bougie demonstrated that at times it 
seemed to meet with some obstruction, at other times it would 
enter the stomach. I was unable to procure a rigid stomach 
tube, consequently after many trials I gave up the attempt to 
introduce the soft rubber tube into the stomach. After each 
meal nearly one pint of fluid could be emptied from the sac. 
After emptying the sac, the dullness in the left infra-scapular 
region constantly disappeared. 
The patient was given a soft rubber stomach tube and 
instructed to introduce it and empty the diverticulum after 
each meal. A few days afterward he came to me with the 
surprising information that he had pushed the tube into his 
stomach. I was incredulous, but he offered to demonstrate 
it. After several failures he finally pushed the tube to 
52 cm. I immediately expressed some contents and was 
able at once to demonstrate the presence of true gastric con- 
tents. Hydrochloric acid, by Boas’ test a marked reaction; 
the biuret reaction showed the presence of peptones, and 
pepsin was also demonstrated. This was in marked con- trast to the many examinations which had never shown 
either hydrochloric acid, pepsin, or albumoses. 
A great many other tests were made. A capsule of po- 
tassium iodid was swallowed on an empty sac. Twenty-five 
minutes later no trace could be found in the saliva by nitric 
acid and starch paper. One dram each of tartaric acid and 
bicarbonate of soda injested in solution separately did not 
distend the stomach, but repeated eructations ensued. It was 
obvious that it entered the sac, the orifice of which was too 
large to prevent the escape of the carbon dioxid formed. 
These examinations very clearly demonstrated the ex- 
istence of a pulsion diverticulum of the oesophagus situated 
immediately above the diaphragm. Its size was larger than 
any of which I was able to find a record; it held about 400 
cc. Diverticula at this location are very rare, according to 
Zenker. 
Prognosis seemed rather unfavorable. The danger lay 
in the possibility of ulceration and subsequent perforation. 
Another danger lay in the continued enlargement of the sac 
and a consequent complete stenosis of the gullet. Food en- 
tered this dilatation first and, being full, pressed on the 
sides of the oesophagus, and thus occluded the lumen below 
the mouth of the sac. This last mentioned danger is almost 
sure to arise in time. Surgical intervention, on account of 
the peculiar location, being surrounded by important struc- 
tures, seemed impossible, and in consultation Prof. Tuholske 
advised against an operation. 
The treatment consisted in evacuating the sac with the 
stomach tube after each meal. Thus the patient regurgi- 
tated no more food in the interval between meals and at 
night and felt very well. 
A few months later he presented himself one evening to 
me saying he had been cured. He had visited Schrader, 
the healer, in Illinois. He felt so much stimulated that he 
ate his supper without much distress, and he believed him- 
self healed. A few days later he acknowledged that he was 
still the same. 
Three years have elapsed. The condition is about the 
same. He still continues to withdraw the fluid from the sac 
after meals. He has grown somewhat melancholic lately, the depressing effect of his helpless condition is telling forci- 
bly on his intellect. 
He still has great difficulty in swallowing, but he man- 
ages to eat very well at home. But he avoids company and 
never takes a meal away from his mother’s table. 
[1635 S. Grand Ave.]