ens our patients from so many sources, how-
ever, with more scientific remedies and
better facilities the prognosis should be
more favorable. In some epidemics nearly
all get well, while in other epidemics nearly
all die. The treatment of diphtheria has
been a grave question, and is still one of
fearful moment to the medical profession.
Specific after specific has been discovered,
and still they die.

Now, gentlemen, I want to tell you not
how other physicians treat the trouble, but



how I treat it, and if my experience and
observation are worth anything to you you
are welcome to it : When called to see a
patient suffering from suspicious symptoms
I examine with care both the inside and
outside of throat, and also all abrasions
upon the skin should there be any. If I
find a reddened irritated condition and con-
gestion of the throat with a thick film of
a catarrhal nature beginning to form on
tonsils and surrounding parts difficulty of
deglutition, with some glandular swelling,
said condition as described attended with
elevation of temperature, I give my patient
the benefit of a doubt, and put him imme-
diately upon diphtheritic treatment. The
treatment is both local and constitutional.
The local treatment consists of gargles, in-
halation of steam, and the topical applica-
tion of medicines to the diseased parts.
What shall we do with the false membrane
in the throat ; should there be any force used
in its removal? No, not unless by its me-
chanical presence it threatens life.

Dr. William C. . Wile, of Mississippi,
several years ago began the use of sulpho-
calcin as a solvent of the exudate that
formed in the throats of his diphtheritic
patients and was much gratified at the suc-
cess that attended the topical application
of the remedy. Bishop says he confirms
Dr. Wile's statement of the solvent pro-
perties of the remedy. I think the medi-
cine is worthy of an honest trial. Unless
the topical application of some medicine
will dissolve the exudate, and thereby cause
its removal, it had better remain undis-
turbed, as it will in a very short time re-
turn.

There are two reasons to my mind why
the false membrane should not be inter-
ferred with. Tlie first is, when any force
is used in its removal you will have a fresh
bleeding surface, which will invite the
diphtheritic germs at once. The second
reason is that the bacilii do not reside in
contact with the mucous membrans, but in
the upper strata of the exudation, and hence
away from the greatest point of danger to
patient. The inhalation of steam from
boiling water with the addition of a few
drops of turpentine will be quite soothing
to patients from diphtheria. Shaved ice
will come in for its part of comfort to dis-
eased throats.

I often use as a local application to out-
side of throat equal parts of sweet oil, spt's.
camphor, and about 1-4 as much of turpen-
tine, and always remember not to produce"
any abrasion of skin, as diphtheria might
follow.

I want now to consider the constitutional
treatment, and notice the indications us



20



THE CHARLOTTE MEDICAL JOURNAL



they present themselves. We are met in
the very beginning of the disease with great
anemia. Millions of red blood cells are at-
tacked by the germs of diphtheria, and ut-
terly destroyed, and to meet and success-
fully overcome this invasion upon human
blood, I know of nothing better than to
saturate the life fluid with iron and quinine.
For a child, say from 3 to 5 years old I give
the following :
Rx.



n-



Quinia sul. grs.
Mur. tinct. iron,
Chlor. pot.,
Syr. simplex,
sig — teaspoonful



XXX.

3j

3i

3iv

every 2



hours.



well,
held



This Rx. has always served me
aiid has met the anemic conditions
up my patients better than anything else I
have ever tried. We must remember how
apt the heart is to suffer from the infection,
and guard its muscular structure with great
care. The toxic infection spends its greatest
force upon the heart muscle, thereby pro-
ducing degeneration and great weakness,
so that heart tonics are called for from the
very inception of the disease. This indi-
cation is best met with strychnine and digi-
talis. Some prescribe some form of alco-
hol, but for my life I cannot see the pro-
priety or the necessity for so doing, since
science has demonstrated the fact that alco-
hol is neither food nor medicine ; and hence
it cannot occupy any place in the economy
except that of an irritant and paralysant.
I have no quarrel for those who prescribe
it, but for my own use I would not give
one grain of strychnine for a car load of the
stuff.

I want to in conclusion pay my re-
spects to the serum therapy. This is quite
a change from the old way of treating diph-
theria, but the scientific elements developed
and brought out in the new planhave un-
dergone the most crucial tests, and the wis-
dom of the departure from the old plan is
impressing the medical profession every-
where. Since the introduction of anti-
toxin the mortality of diphtheria has been
greatly reduced. The German physicians
claim great success with antitoxin when
used early in the disease. The antitoxin
treatment is destined to become more pop-
ular, and will be more generally adopted
by the medical fraturnity, since it offers the
greatest hope to diphtheritic patients of any
remedy known to our profession.



Esophageal Stenosis and Its Surgical

Treatment, witli a Report of a

Number of Cases.*

By James G. Hunt, M. D., Utica, N. Y.
Attending Surg-eon Faxton Hospital ; Division
Surgeon N. Y. O. & W. R. R. ; Vice-Presi-
dent N. Y. State Medical Association.



"Say, pa!"

"Well, what?"

"What did the Dead Sea die of?'



The line which separates health from dis-
ease is not always to be determined when
certain tissues or organs have increased in
size or have undergone structural changes
disproportioned to the rest of the body.
The exclusive study of morbid growths,
according as they affect internal or external
parts, has led to limited views of the sub-
ject. Exercise within certain limits may
cause the size of particular parts to be rela-
tively increased, as the arms of the prize
fighter or the legs of a circus performer.
In these cases, however, such enlargement
is consistent with health.

We recognize that the departure from the
normal type is absolutely necessary, for the
purpose it is required to carry out ; and
when this is accomplished, it returns to the
natural condition.

In like manner other hollow viscera en-
large when they have an obstruction to
overcome. No tissue or organ of the body
is exempt from more or less increase of its
extent or magnitude, and there are none
consequently, which may not occasionally
present morbid or excessive growth.

Increased growth of tissues may assume
various forms.

The organ or structure may gradually be-
come enlarged in whole or in part, still
maintaining more or less of its original tex-
ture, shape and function constituting hyper-
trophy. Membranes may become preter-
naturally thickened, causing more or less
induration, whereby the movements of the
parts may be affected, or the calibre of
tubes and ducts may be diminished, pro-
ducing stricture.

The results of the healing process may
give rise to new tissues, exactly resembling
those previously existing in other parts of
the body, as in cicatrices, callus, etc. ; such
growths may assume the form of a tumor.
Narrowings are the most frequent and
clinically the most important of the affec-
tions of the esophagus.

Under the head of stricture belongs all
those stenoses which are caused by such a
change in the wall of the esophagus, as en-



*Read at the Annual Meeting of the New York
State Medical Association, New York, October
24, 25 aud 26. 1S9(J.



THE CHARLOTTE MEDICAL JOURNAL.



tirely destroys or greatly limits its power
of distention. Here the stiffness of the
wall during the act of deglutition has an
effect as if an unyielding hand surrounded
it, and so in this wise is practically a stric-
ture, whether any contraction has occurred
or not. Changes of this nature may be
either contracting, cicatrices or cancerous
degeneration, and the consecutive muscular
hypertrophy which may accompany steno-
sis arising from any cause whatever.

Strictures pure and simple are best repre-
sented by the cicatricial, i. e., those which
remain after healing of a loss of substance
or solution of continuity arising from any
cause, when the cicatrix has undergone
contraction.

Relatively the most frequent and also the
most severe are those strictures which some-
times remain after the destructive action of
corrosive substances, such as the concen-
trated mineral acids, particularly sulphuric
acid and caustic alkalies.

And yet, since these substances usually
cause death, even strictures from this cause
are very rare, and these vary in their char-
acter according to the depth to which the
loss of substance has extended. If the mus-
cular layer is partially or totally destroyed,
we then shall have a dense callous, cicatri-
cial tissue, the contraction of which pro-
duces the most obstinate strictures, (callous
stricture).

Even when the muscular layer is pre-
served, the quickly developed hypertrophy
serves greatly to increase the stiffness of the
wall, to make it unyielding, and so increase
the stenosis.

With the exception of the pharynx (be-
hind the cricoid cartilage) these strictures,
according to the best of authority, occur
most frequently in the vicinity of the car-
diac orifice, or even in the muscles which
guard that opening itself.

The signs and symptoms, therefore, man-
ifested with any deviation from the normal
standard peculiar to each individual at once
suggest of an abnormal change which may
point to both organic as well as functional,
but not strictly so.

Since I have limited my paper to organic,
cicatricial stricture of the esophagus, and
purely to cases which came undc" my med-
ical observation, I shall not dwell upon the
neurotic form, excepting from a diagnostic
standpoint.

Only one case in all has been reported by
Dr. Wilks as a supposed congenital stric-
ture of the esophagus (Guy's Hospital Re-
port, 1871-72, Vol. 17).

The hysterical esophageal stenosis is
purely of a neurotic nature, and is differen-



tiated from the organic form without diffi-
culty.

Now in order to demonstrate the most
common seat of an esophageal stenosis, and
the accompanying symptoms, a brief des-
cription of the topography appears to be
inevitable.

The esophagus is a hollow musculo-mem-
branous canal, about nine inches long, join-
ing the pharynx above and the cardiac end
of the stomach below. It commences at the
lower border of the cricoid cartilage, pass-
ing through the esophageal opening of the
diaphragm, to terminate at the cardia, op-
posite the ninth dorsal vertebra; in the
neck it lies between the trachea and the
spinal column and longus colli muscles, at
the lower part inclining to the left, having
on either side the common carotid artery,
with the lateral lobes of the thyroid gland,
the recurrent laryngeal nerves ascend be-
tween it and the trachea.

A very important point to be remembered
is that the esophagus belongs to both the
respiratory and the digestive tracts, although
it is commonly described as a part of the
latter; its upper portion is exclusively con-
nected in the act of respiration, while the
lower region participates in both functions.

Cicatricial stricture of the esophagus may
result from any disease or injury in which
ulceration is followed by healing.

The most common cause of such contrac-
tions is probably to be found in the swal-
lowing of weak alkaline solutions.

Leroux, of Paris, mentions a case in
which the stricture was caused by the swal-
lowing of a very hot liquid containing a
piece of leek.

A very interesting case was reported by
Dr. Kendall Franks, in the "Medical Press
and Circular of London," a number of years
ago, in which the stricture was produced
by a hard piece of bread crust. When the
patient was first seen, who was a young
lady of about twenty years of age, the con-
dition had existed for over four years and a
half ; there was no evidence of hysteria ;
and he was of the opinion that it was due
to cicatricial thickening where the parts
were injured by the ragged edge of the
bread crust at the time of the accident.

Stricture also very frequently results from
the inflammation following mechanical irri-
tation ; or scalds received in swallowing hot
fluids, or hot solid food; or caustic sub-
stances.

The most common seat of this form of
stricture is at the upper part of the esopha-
gus, this being the narrowest portion of the
tube in its normal condition : or it may form
at the lowest portion of the pharynx, just
behind the cricoid cartilage, because these



THE CHARLOTTE MEDICAL JOURNAL.



are the areas most accessible to mechanical
injury, burns and scalds.

Occasionally the stricture is the result of
acute or chronic inflammation of a spontan-
eous origin.

It may also be produced after the exist-
ence of some of the infectious fevers, such
as variola, diphtheria, etc.

The stricture is not infrequently due to
disease involving the submucous connective
tissue, sometimes even the muscular portion
of the tube.

In cases which are not cancerous the
diminution of the calibre of the tube is
usually due to submucous fibrinous deposit
and subsequent organization, thus causing
thickening or contraction of the mucous
membrane.

Stricture of the esophagus is occasionally
congenital, as before mentioned, and under
such circumstances would be necessarily
fatal. Sometimes the immediate cause of
the stricture is unknown, and it is, there-
fore, ascribed to a neurotic origin.

Another variety of esophageal stricture
is due to varicose veins. Dr. Janeway re-
ports a case to the Practitioner's Society of
a man of fifty years of age, who had several
attacks of hfematemxesis and also hemorrhage
from the bowels. It was supposed that he
had an ulcer of the stomach.

Death from exhaustion and sepsis at the
end of two weeks, and at the autopsy vari-
cose veins as large as a man's finger were
found in the esophagus, extending four in-
ches above cardiac orifice of stomach. An
opening into one of these veins, large enough
to admit a number ten sound, was found
and it contained a septic clot. Stomach
normal. No cirrhosis of liver. There were
twelve cases at the time of this autopsy.

The symptoms of cicatricial stricture :

in cicatricial stricture of the esophagus
the characteristic symptom is dysphagia;
it varies in degree according to the narrow-
ing of the canal.

Sometimes the actual constriction may be
slight, however, deglutition is rendered dif-
ficult or impossible by superinduced spasm.

When the contraction results from the
swallowing of a weak caustic or irritant
solution, there is generally at the primary
stage an acute inflammatory period during
which there is painful deglutition.

These symptoms persist as long as the
ulceration continues, but when the ulcer
heals the patient can usually swallow with
ease and for some time may consider him-
self cured.

At the end of a few months, however,
owing to the increasing contraction of the
tissues forming a cicatrix, difficulty in swal-
lowing is again experienced.



From this period the dysphagia grows
steadily worse; and if not relieved, is most
likely to prove fatal.

DIAGNOSIS.

As to diagnosis : The location of the
stricture may be determined by the passage
of a bougie or by auscultation.

On placing your ear or stethoscope over
the course of the esophagus posteriorly it
will be noticed that fluids pass at the ordi-
nary rate and give rise to the normal sound
till they reach the upper part of the stric-
ture, when the fluid is partially arrested,
and a gurgling or trickling noise is heard
below the point of obstruction.

The latter may be observed to continue
for four or five minutes after a mouthful of
fluid has been swallowed.

In introducing the bougie, the instrument
is either arrested at the point of obstruction
or is passed beyond it with difficulty, some-
times a second stricture may be found lower
down. A number of cases have been re-
ported where even three strictures were
present.

The topography of the esophagus is of
considerable practical interest to the at-
tending surgeon from a diagnostic stand-
point, as he is required in a large number
of cases to dilate the canal by a bougie
when it becomes of importance to know
exactly the direction of the esophagus, and
its relation to the surrounding parts should
be remembered.

In cases of malignant disease of the eso-
phagus, where its tissues have become soften-
ed from infiltration of the morbid deposit,
the greatest care is requisite in directing
the bougie through the strictured part, as a
false passage may easily be made, and the
instrument may pass into the mediastinum,
or into one or the other pleural cavity, or
even into the pericardium.

The surgeon should also bear in mind
that permanent contraction of the esopha-
gus and consequent symptoms of stricture,
are occasionally produced by an aneurism
of some part of the aorta pressing upon the
tube.

In such cases the passage of a bougie
could only hasten the fatal issue.

Inflammation of that portion of the
pharynx which cannot be seen when the
tongue is depressed is rare.

It is quite certain to exist if there be pain
and an impediment in the act of swallowing
when the food arrives at that point opposite
the superior and posterior border of the
larynx ; while the respiration remains free
and the voice not affected.

The esophagus is not very often the seat
of disease. We sometimes meet with acute



THE CHARLOTTE MEDICAL JOURNAL.



23



inflammation of this division of the alimen-
tary canal produced by the swallowing of
boiling water or corrosive poi.ons, especial-
ly nitric, sulphuric and muriatic acid, or
strong alkaline solutions such as ammonia.
There is very little trouble in diagnosing
a cicatricial stricture of the esophagus; the
patient will complain of more or less diffi-
culty of deglutition, which in severe cases
amounts to complete inability to swallow.
This is sometimes attended by spasm,
regurgitation of food, oppression of the re-
spiratory organs, pain in the parts, and
more or less nervous distress.

There will be more or less general ill-
health from insufficient nourishment, and
oftentimes there are more or less severe
pain complained of in the region of the
sternum, stomach or cervical vertebrae.

The diagnosis is confirmed or disproved
by the passage into the stomach of gum
elastic bougies, or esophageal probes con-
sisting of olive shaped masses of gutta-per-
cha, ivory or steel, and affixed to stout
whalebone or steel rods.

, Commencing with one of the smallest
bulbs, the instrument is carried through the
stricture, if possible, and the length of the
constriction is judged of by the distance
along which the resistance to the passage
is felt, the size of the largest bulb which
can be employed ; and its consistence by
the amount of resistance offered to the pas-
sage of the exploring instrument.

The instrument after passing a stricture
should always be carried down into the
stomach in order to ascertain whether there
be any more strictures further down the
esophagus.

It is necessary that great care should be
taken in the passage of these instruments,
on account of the probable existence of a
pouched condition of the adjacent parts im-
mediately below the seat of the stricture,
into which the instrument may glide.

An experience that I have often met with
and through which it may be thrust by the
employment of an undue amount of muscu-
lar force.

In case the stricture is quite small and
pouched at its side, the use of a conical
wax bougie with the tip bent forward
is recommended as more likely to pass the
stricture than a straight bougie, which
would be apt to be caught in the sac.

The symptoms of acute esophagitis are
usually confounded with those of inflamma-
tion of the pharynx or of the stomach.

We may be quite sure of its presence if
difficulty and pain in deglutition exists for
which nothing in the throat can be found
to account, and if these symptoms be asso-
ciated with a hiccough and a burning sen-



sation between the shoulders and in the
course of the tube.

Stricture is, beyond doubt, the most com-
mon of the chronic diseases of the eso-
phagus.

The narrowing may take place at any
part of its length.

The constriction results from preceding
inflammation or ulceration, from cancerous
degeneration of the walls of the tube, or
from the pressure of a tumor or an aneurism.
The disease manifests itself by a difficulty
in swallowing, even liquid food cannot pass
without great distress; and if the stricture
goes on increasing the death of the patient
by starvation is certain to follow.

Together with the obstruction of the pas-
sage of the food, we may have very severe
pain complained of and occurring at a par-
ticular part of the tube, and also raising
clots of blood without cough or vomiting.
The matter ejected in the attempts at
deglutition consists of masticated food to-
gether with some mucous.

If on the introduction of a small bougie,
resistance is met with, and dysphagia is
present, there is nothing more certain about
it than an organic stricture exists.

The narrowing may be simply spasmodic,
yet give rise to all the symptoms of an or-
ganic constriction ; but they are not per-
manent as I remarked above, and at times
nourishment is readily swallowed, and a
full sized bougie passes the constriction with
the greatest ease.

This singular disorder is occasionally suf-
ficient to be accompanied by ulceration of
the larynx; this is chiefly met with in
hypochondriacs and hysterical women.

In traumatic cases the diagnosis presents
but little or no difficulty ; the history of a
caustic or irritant solution having been
swallowed, or any form of trauma produced
by mechanical irritation at once removes all
doubt; in very rare mstances where the
temporary lodgment of a foreign body, or
the fact of an irritant having been swallow-
ed months ago has been forgotten, or when
an insane person is the subject of the stric-
ture that any doubt can arise.

Under all circumstances it will be neces-
sary first to determine whether the difficulty
of swallowing be due to stricture or com-
pression of the esophagus; and, secondly,
in the event of the affection being intra-
esophageal, to eliminate the various other
diseases of that portion of the canal.

In cases of compression, the difficulty ot
swallowing, though considerable, is seldom
so marked as in cicatricial stricture, except
in certain rare instances of excessive fibrous
or cancerous enlargements of the thyroid



24



THE CHARLOTTE MEDICAL JOURNAL.



gland or of a tumor in the posterior medi-
astinum.

In aneurism of tiie aorta and enlargement
of the cervical or bronchial glands, as well
as in peri-esophageal abscess, <^he difficulty
in swallowing is seldom so constant or
severe.

The only diseases of the esophagus which
require to be differentiated from cicatricial
contraction are cancer and simple stenosis.

Cancer may be diagnosed by its occur-
rence in persons over forty years of age,
and by its progressive character.

The special characteristic of true cicatri-
cial stricture, on the other hand, is the
peculiar nature of the dysphagia, that is to
say, its primary occurrence, its disappear-
ance, and its subsequent return in a more
severe and intractable form.

In cases of si?nple stenosis there is a his-
tory of difficulty in swallowing from an
early period of life, and the symptoms are
not progressive where the cicatricial stric-
ture results from the healing of an ulcer
caused by disease, a clear history of the
previous existence of the complaint is in it-
self enough to establish the diagnosis.

PATHOLOGY.

Cicatricial stricture is most often found
at the junction of the inferior end of the
pharynx, or near the cardia. This may be
explained by the fact that both locations
are controlled by entrance orifices, the up-
per one by striped muscular fibres, and the
inferior by the circular fibres forming the
orifice of the cardiac end of the stomach ;
though it may occur anywhere in the tube;
a point at a level with the diaphragm being
a favorite intermediate position.

The single form is most common, but