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AUSCULTATION OF THE (ESOPHAGUS. 
BY 
LOUIS ELSBERG, M.D., 
PROFESSOR OF LARYNGOLOGY AND DISEASES OF THE THROAT IN THE 
UNIVERSITY OF NEW YORK. 
EXTRACTED FROM THE 
TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION, 
PHILADELPHIA: 
COLLINS, PRINTER, 105 JAYNE STREET. 
1815. ON AUSCULTATION OF THE (ESOPHAGUS. 
An addition has been made to our means of diagnosis in case of 
disease of the oesophagus, which consists in making the patient go- 
through the process of swallowing, the physician listening to the 
sounds thereby produced. This method of auscultation of the 
oesophagus is so easy, and its results so instructive and valuable,- 
that it cannot be made too. widely known. It was first introduced 
less than five years ago by Dr. W. Hamburger, a practitioner in 
Bohemia, and has proved of incalculable importance to all who 
use it. But, although exceedingly easy, it requires, as Dr. Morell 
Mackenzie, in a clinical lecture at the London Hospital, has recently 
justly said, considerable practice and much patience: “practice, 
because it is requisite to get the ear well accustomed to the oeso- 
phageal sound in health; patience, because in each case of disease7 
it is necessary to apply the stethoscope successively down the 
whole length of the oesophagus, and to listen attentively at each 
spot.” You know the oesophagus is about 9 inches long, and 
situated behind the windpipe and in front of the vertebral column 
partly in the neck and partly in the chest. It extends from the 
pharynx, on a level with the lower border of the cricoid cartilage, 
opposite to the 5th cervical vertebra, to the cardiac orifice of the 
stomach, on a level with the 9th dorsal vertebra. It makes two 
curvatures to the left side, one at the root of the neck and the other 
as it passes forward to the opening in the diaphragm. Its diameter 
is nearly an inch, when fully distended; but in the quiet condition, 
it is disposed of in rugae or folds. In order to locate it for the 
purpose of auscultating it, you must remember that it commences 
about an inch above the so-called vertebra prominens (the 7th 
cervical), and terminates a little below the level of the lower border 
of the scapula. (See Figure.) You must auscultate it both in the ON AUSCULTATION OF THE (ESOPHAGUS. 
neck and in the thorax: in the neck by means of the stethoscope; 
ii\ the thorax either with or without the stethoscope, but the sounds 
are heard more distinctly if the ear be pressed directly against the 
naked back. 
The patient being ready, direct him to take, and hold in his 
mouth, a good mouthful of liquid, plain water or fluid a little 
thickened, such as gruel or arrowroot; apply the stethoscope or 
ear over the portion of the oesophagus to be examined; make a 
sign to the patient to swallow; and listen. 
On the side of the neck, a loud gurgling noise, a metallic “gloo- 
gloo” sound is heard, the so-called “ pharyngeal sound,” which is 
due to the commingling of air with the swallowed liquid, and 
which is sometimes so loud as to drown every other sound even 
much lower down. But usually in the whole of the thorax, the 
true “oesophageal sound” becomes audible. This is distinctly the 
sound of the rapid descent of a small spindle-shaped body of soft 
consistence. Dr. Hamburger goes further; he describes the sound 
as characteristic of an egg-shaped body, about an inch in length 
and half an inch in breadth, the small end of the egg directed up- 
ward and the large end downward; this is a refinement of percep- 
tion to which few will attain, but this refinement is not needed to 
gain valuable information from the practice of the auscultation. I 
have said that sometimes the pharyngeal sound is so loud that it 
obscures every other sound; but, generally, the oesophageal sound 
can be distinctly made out even high up over the oesophagus, 
more plainly, it is true, lower down, say on the left side of the first 
dorsal vertebra and below. The relative intensity of the pharyn- 
geal over the oesophageal sound is diminished by the patient taking 
a continuous draught of water. 
There are four points to which attention is to be directed in clini- 
cal auscultation of the oesophagus: viz., the character of the oeso- 
phageal sound; the rapidity of the descent of the bolus; the direc- 
tion which the bolus takes; and the shape of the bolus. 
L The character of the oesophageal sound is the point most 
readily appreciated. We may find in a patient, that the sound, at 
a particular point, becomes feeble, is modified or stops; while it 
is distinct enough above that point. This may come from, 1, stric- 
ture; 2, impacted foreign body; 3, retention of the bolus in the 
pouch of a diverticulum; 4, organic dilatation; 5, paralysis, and 6, 
rupture. I could cite a number of cases from my own practice ip ON AUSCULTATION OF THE (ESOPHAGUS. 
which the precise seat of one of the first four of these pathological 
conditions was revealed by the method of auscultation. I have 
not met with any case of paralysis confined to a definite portion of 
the oesophagus, nor of rupture. 
There may be a grating or friction sound, which indicates 
roughness of the inner surface of the oesophagus, such as might 
accompany croup, large ulcers with ragged edges, polypous excres- 
cences, etc. 
II. The rapidity of descent of the bolus. As the larynx ascends 
at the commencement of the act of swallowing, it is very easy to 
ascertain the precise moment of this commencement, by placing 
the thumb and index finger upon the upper edge of the thyroid 
cartilage. The time which elapses between the rising upward of 
the thyroid cartilage and the arrival of the bolus at the portion of 
the oesophagus auscultated can then be determined. We find that 
in disease the normal rapidity is diminished, but accurate detailed 
observations are still wanting on this point. 
III. The direction which the bolus takes. Instead of passing 
vertically downward, the bolus may descend in an oblique direc- 
tion toward the left or the right side, or rise up again. The 
oblique deviation may be due to aneurism of the aorta or to 
exostosis of the vertebrae; the mode in which the rising upward 
or regurgitation takes place, sometimes enables us to distinguish 
between a spasmodic and an organic stricture: for, in an organic 
stricture, an appreciable time elapses before the food is forced 
upward, in spasmodic stricture the regurgitation is instantaneous. 
IY. The shape of the bolus. I have stated that Dr. Hamburger 
goes so far as to describe the precise shape and size of the bolus 
as revealed by the normal oesophageal sound. He also describes 
alterations of the normal sound indicative of differences in the 
shape. He says,/.i., that the lower end of the egg-shaped bolus 
is more and more blunted or truncated in proportion to the feeble- 
ness of the muscular contraction of the walls of the oesophagus; 
that in case of stricture at the cardiac orifice, the shape becomes 
funnel-shaped with the small end downward with frequent regur- 
gitation, and that these deviations from the normal shape can 
positively be determined by the variation of sounds heard. 
Whether this refinement of perception can be acquired or not, 
it is certain that auscultation of the oesophagus is a valuable addi- 
tion to our means of diagnosis in the diseases of ah organ which* ON AUSCULTATION OF THE (ESOPHAGUS. 
until recently, has evaded all efforts at physicahexamination except 
the single one by the bougie or sound. 
In the neck the oesophagus is a little to the left of the trachea, 
and the stethoscope should be placed upon the left side of the neck. 
To assist in determining the proper place for auscultation on the 
back, I have had this diagram made from a wood-cut published by 
Dr. Morell Mackenzie in the London Lancet of May 30,1874. 
а. Inferior curved line of occipital bone, about five-eighths of an inch below the occipital protu- 
berance. 
б. Pharynx. 
c. Vertebra prominens (seventh cervical vertebra). 
d. Termination of oscephagus, opposite the ninth dorsal vertebra. 
In conclusion, I beg leave to recommend to this Section the 
appointment of a special committee to report, at the next annual 
meeting of the Association, on the Means of Diagnosis at our com- 
mand in diseases of the oesophagus.