CHAPTER III.. Diseases of the œsophagus.

DISEASES OF THE ŒSOPHAGUS.

The œsophageal tube is of very simple anatomical construction, and performs an equally simple physiological function; nevertheless, in the ox it is liable to a large number of diseased conditions. These conditions may affect only a circumscribed area of the mucous membrane or the entire extent of the tube. Again, both the muscular and mucous tissues may be affected, as in inflammation of the œsophagus accompanied or followed by contraction, and in the formation of œsophageal abscesses and tumours; or the muscular tissue alone may be affected, as in cases of dilatation. Even where no lesion is apparent the normal rhythm of deglutition may be interfered with, either by the presence of a foreign body (obstruction) or by spasm of the muscular layers (œsophagismus) or by compression due to tissues surrounding the œsophagus (false contractions).

We shall successively study the different forms of œsophagitis, contraction, and dilatation, together with their complications; then obstructions, ruptures of the œsophagus, œsophagismus, and false contractions.

ŒSOPHAGITIS.

Inflammation of the œsophagus may be due to many different causes, and may occur in one of three different degrees of severity. It may be either superficial, i.e., limited to the epithelial layer of the mucous membrane; or deep, affecting the entire thickness of the mucous membrane (epithelium, corium, and œsophageal glands); or, finally, it may attack both the mucous and muscular layers. German authors recognise various divisions, such as erythematous, catarrhal, follicular, and phlegmonous œsophagitis. In reality these are not always different forms, but simply successive stages in the evolution of a single morbid condition. Here we shall only study the ordinary forms of œsophagitis, leaving on one side those which occur symptomatically during foot-and-mouth disease, cattle plague, gangrenous coryza, actinomycosis, etc.

=Causation.= The causes of œsophagitis may be divided into three groups of different character:—(a) Rough fodder (clover containing wrestharrow, thistles, thorns, furze, or splinters of wood, etc.) must be placed in the first rank, for its repeated action abrades and irritates the mucous membrane to such an extent as finally to produce inflammation. This inflammation usually remains superficial and of moderate intensity; its occurrence can be anticipated during years of scarcity, when the animals feed on rough and irritating material like fern, broom, heather, furze, etc.

(b) Hot drinks, whether in the nature of beverages or medicinal draughts, are a frequent cause of œsophagitis if administered by careless or inexperienced persons. The mucous membrane is scalded over a varying area and with different degrees of severity, or is destroyed by the chemical action of such drugs as ammonia, dilute acids, iodine solution, etc.

(c) Rough or clumsy manipulation in withdrawing or displacing foreign bodies, or merely passing the probang, produces that variety of œsophagitis termed traumatic. In clumsy hands œsophageal sounds or catheters may abrade or even tear the mucous membrane and subjacent tissues.

=Symptoms.= These vary to some extent, according to the intensity of the inflammatory phenomena. If the lesions are superficial and only implicate the epithelium, as in catarrhal œsophagitis, the symptoms often pass unnoticed, and only produce difficulty in swallowing. When inflammation has involved the entire thickness of the mucous membrane the immediate consequence is loss of appetite due to pain during swallowing. After the bolus of food has been masticated, and has passed into the pharynx, the animal stretches out its head and neck and seems to be making efforts to force it down the œsophageal canal. The progress of the bolus is slow and clearly difficult.

In œsophagitis due to scalding the blisters are soon broken by the passage of food, the corium is exposed, and the animal has equal difficulty in swallowing either solids or liquids. The reflex action provoked by the passage of the food over these lesions may be so violent that the ingesta never arrive at the stomach, but are violently rejected by a sudden and unexpected antiperistaltic contraction. Even saliva is returned. Moreover, in these cases the history is generally clear, and the animal is feverish or greatly depressed. These objective symptoms are very significant, and when, in addition, an abnormal and exceptional degree of sensibility is detected at some point by palpation, they unmistakably indicate the existence of œsophagitis.

The irregularity in deglutition, and therefore also in rumination, sometimes excites moderate tympanites without any very apparent cause. Should the condition still appear doubtful the œsophageal sound may be passed, but with great care. It generally aggravates the pain and produces intense antiperistaltic movements, which the practitioner should not attempt to overcome.

=Complications.= If œsophagitis is moderate, recovery is the rule. The symptoms of pain gradually diminish.

When, on the contrary, inflammation is very intense, as in certain cases of traumatic œsophagitis, the injured spot may become infected and suppuration follow. The existing fever then persists or becomes more marked; the animal is extremely depressed; respiration may be difficult and accelerated, and appetite is entirely lost.

If the œsophageal abscess remains submucous the diagnosis is difficult, but it is often problematical, even when the abscess develops in the cervical region. The jugular furrow (usually on the left side) becomes the seat of a severe diffuse inflammatory swelling, the course of which clearly indicates the development of the symptoms. In exceptional cases fluctuation may be detected.

If from the first the abscess develops around the œsophagus or in the course of suppuration comes to occupy this position, swelling in the jugular furrows is more apparent and easier to detect, and in this case fluctuation may be localised. When the lesions are within the thorax no tangible symptoms can be detected. Death may occur in a few days, when an abscess in the lower cervical region breaks into the anterior mediastinum, or when an abscess in the thoracic region opens into the pleural cavity. In œsophagitis produced by scalding and from swallowing hot or caustic liquids the mucous membrane, and sometimes the muscular tissue, is destroyed, and ulcerations and cicatrices result, or the œsophagus may even be perforated, with rapidly fatal results; even when recovery occurs, cicatrices form and cause very grave contraction.

=Diagnosis.= The diagnosis is generally easy, provided that the symptoms noted are methodically analysed and the history of the case is taken into consideration.

=Prognosis= is favourable in ordinary cases. On the other hand, it may be very grave when general symptoms become marked, when the vital functions are disturbed and a deep-seated abscess appears to be forming.

=Lesions.= In the first degree the lesions are confined to inflammation and desquamation of the epithelium; in the second, to inflammation of the corium and of the mucous membrane; in the third, to infiltration of the submucous layers and of the muscular and periœsophageal tissues. Sloughing and perforation follow the administration of caustic liquids.

=Treatment.= As the direct application of medicines to the inflamed mucous membrane can only be of a momentary character, treatment is confined to administering emollient, anodyne, and slightly astringent drinks, the action of which is assisted by feeding with milk, farinaceous or mucilaginous foods. Under these circumstances recovery occurs in ten to fifteen days. The application of stimulant or blistering ointments along the jugular furrow may have a good effect.

When the general condition of the patient becomes aggravated, and the formation of an abscess appears certain, it is best to recommend slaughter. In the case of a submucous abscess the passage of the probang may, however, predispose or cause the abscess to open into the œsophagus, and thus lead rapidly to recovery, but this is exceptional. The “pointing” of the abscess and its opening towards the jugular furrow may be followed by temporary improvement, but at a later stage is followed by fistula formation, or by contraction of the œsophagus itself. From an economic standpoint it is better to slaughter.

STRICTURE OF THE ŒSOPHAGUS.

Under normal conditions the cavity or lumen of the œsophageal tube is, so to speak, imaginary: the walls of the tube lie flatly together, and the mucous membrane is in folds. During the act of swallowing the tube becomes dilated to a degree varying with the size of the bolus of food, and again retracts as soon as deglutition is effected. Whenever the dilatability of the tube is markedly diminished by changes in its walls, and, in a much higher degree, when this dilatability has disappeared, true stricture exists. In the former case small boluses of food and liquids alone succeed in passing the stricture; in the latter, liquids alone can pass.

=Causation.= Strictures are never primary. They result from intense attacks of œsophagitis, ending in sclerosis of the mucous coat, extensive ulceration consequent on scalding, or interstitial inflammation affecting the muscular coats, which then become thickened or sclerosed.

Internal injuries due to attempts to withdraw or propel foreign bodies along the œsophagus may also cause strictures.

=Lesions.= In simple strictures the lesions are confined to the development in the depths of the mucous membrane and in the muscular layers of inflammatory tissue, which becomes denser with lapse of time. This alters the character of the walls and the structure of the tissues, and causes them to lose their elasticity. After extensive ulceration the tissue of the cicatrix contracts and hardens to a very varying degree.

=Symptoms.= The apparent symptoms are very clearly marked; the appetite is good, and the animal masticates as usual, but in the act of deglutition is seen to extend the head on the neck, and to make efforts to swallow, which prove unavailing when the contraction is too marked. A reflex antiperistaltic movement often causes the substances ingested to be at once rejected. These violent efforts, however, in time provoke dilatation above the stricture. A quantity of food accumulates in this dilatation, and the symptom so characteristic of œsophageal stricture then appears—viz., regular regurgitation. The second constant symptom associated with compression or obstruction of the œsophagus is tympanites after feeding, however trifling may be the amount swallowed. Rumination is suspended, and even eructation of gas is difficult. Finally, the characteristic sign of stricture is noted on passing the probang, which reveals the existence of the condition, indicates its position, and suggests its degree of development.

=Diagnosis.= Strictures only develop progressively and slowly, a fact which enables them to be differentiated from œsophagitis. It is more difficult to differentiate them from dilatations, because the stricture always ends by becoming complicated with dilatation; but this distinction is of little practical importance, the consequences being identical.

=Prognosis.= The prognosis is very grave, and there is no economic reason for attempting treatment except in special cases; the indications are in the direction of slaughter.

From the economic standpoint there is no treatment. Basing their actions on human practice, the Germans have recommended progressive dilatation of the lumen of the œsophagus by passing a series of catheters of gradually increasing size. What, however, is justifiable in human medicine, where the only object is to keep the patient alive at any cost, may be highly objectionable in veterinary practice; and in the present instance this is the case. Except in very rare instances, which the practitioner alone can appreciate, dilatation is contra-indicated, and the owner’s interest lies in slaughtering the animal before it has lost much condition.

DILATATION OF THE ŒSOPHAGUS.

Dilatations are more frequent than strictures. Their mode of origin is easily understood. When the muscular tissue has lost its tonicity and contractile power at a given point, or when, as a consequence of any form of inflammation, it has begun to undergo atrophy, the mucous membrane becomes herniated, because its circumference is not supported regularly during deglutition. The ectasia, which at first is of small size, becomes more marked in consequence of the tendency that exists for the food to accumulate in the dilated region. Dilatation is thus set up.

Localised attacks of œsophagitis, accidental injuries and fissuring of the œsophageal muscular tissue, produced by clumsy efforts to displace foreign bodies with the probang, are the principal causes of dilatation. When the probang is imprudently or clumsily manipulated, it may press excessively at any point where the œsophagus makes a slight bend, and thus split the contracted muscular coat without injuring the lax mucous membrane.

Œsophageal contractions, as we have seen, may form the point of origin of dilatations, but in this case the dilatations are more regular in form, and affect the entire circumference of the tube. The muscular tissue is still everywhere normal, and becomes dilated in consequence of equally-applied eccentric pressure.

=Symptoms.= When the dilatation develops slowly and progressively, as a consequence of muscular atrophy, the symptoms remain unnoticed for a long time, and the owner only begins to be anxious when the animal loses condition, or when the driver or cowman detects masses of half-chewed food mixed with the saliva in the manger.

Certain signs are pathognomonic; others may be regarded as of secondary importance. By carefully watching an animal which is feeding the following symptoms may be noted: As a general rule hunger is very marked, and the animal chews its food and swallows the first few mouthfuls in a perfectly normal way. Three, five, eight, or even ten mouthfuls may be swallowed; then the animal suddenly stops, appears a little anxious, extends its head and neck, an antiperistaltic contraction occurs, and one or two masses of food are rejected and fall into the manger. The discomfort being thus momentarily relieved, the animal, which is dying of hunger, although faced with food which it is unable to swallow, returns to its meal, swallows one, two, or three boluses of food, regurgitation again occurs, and the whole process is repeated.

What is going on under these circumstances is easy to explain.

At the commencement of the meal the dilatation is usually empty, or nearly empty. A mouthful of food is swallowed. It descends the œsophagus until it arrives at the diverticulum, into which it partially or wholly passes, the peristaltic wave of contraction ceasing at this point. The second mouthful follows with the same result, then a third, a fourth, etc. The diverticulum soon becomes filled to repletion, and no more food can enter it. The food therefore accumulates in the upper portion of the œsophageal tube until the latter becomes nearly filled; but as this tube, provided its innervation is intact, is intolerant of the presence of any foreign body, and as efforts to swallow prove fruitless, a sudden antiperistaltic wave of contraction occurs, with the result that all the material contained in the tube above the dilatation is ejected into the mouth, whence it falls into the manger. The same result follows any further attempts to swallow during a particular feeding time. From this it will be seen that the animal can ingest at a given time only as much as the dilatation will contain.

In the intervals between meal times and under the action of the saliva and warmth, the food collected in the dilatation becomes softened, breaks down, and slowly moves onward towards the rumen. When the next feeding time arrives the dilatation is almost empty, and the same set of symptoms recurs.

If, instead of forage, the animal begins by taking gruel or very fluid material, deglutition appears normal, or at least fairly easy; but if drinking is deferred until after taking hard food, it becomes almost impossible, because the passage is obstructed. These symptoms are, so to speak, pathognomonic. Under any circumstances they are so significant that error in diagnosis is unlikely.

By careful examination œsophageal regurgitation can very easily be distinguished from true vomiting; the character of the rejected material shows that it has not come from the stomach, while the boluses of food preserve their cylindrical form, and are still saturated with saliva.

Some secondary signs also deserve to be mentioned, such as the animal’s anxiety and restlessness whilst its neighbours are feeding, the existence of trifling and intermittent tympanites due to suppressed eructation, suppression or irregularity of rumination, constipation, etc. At a later stage there is rapid wasting and disordered appetite, and finally the patients die slowly of hunger, whatever efforts are made to feed them.

When the seat of dilatation is in the cervical portion of the œsophagus, there are other symptoms which leave no doubt as to the condition. When empty the pouch cannot be detected; but during a meal the accumulation of food causes it to assume the appearance of a doughy, diffuse, indolent swelling, which alters the outline of the jugular furrow, yields to pressure, and sometimes produces respiratory disturbance by pressing on the trachea, the pneumo-gastric and inferior laryngeal nerves, etc.

When the dilatation is intra-thoracic and the above-described symptoms have been observed, the dilated spot can only be detected and localised by using the probang. The greatest possible prudence, however, is required in manipulating the instrument, in order to avoid rupturing the thin walls of the dilated portion.

=The diagnosis= is not always easy; when food is regurgitated, and one finds by auscultation that the sound usually produced by the passage of solids or liquids into the rumen is absent, there need be no hesitation in diagnosing either a dilatation or a stricture. The clinical consequences being the same, the possible error would be of little importance.

=Prognosis.= The animal’s life is rarely in immediate danger, but from the economic point of view the prognosis is extremely grave, and it is in the owner’s interest to slaughter the animal as soon as possible in order to avoid loss. Even in cases of dilatation in the cervical region, surgical interference is not advisable.

=Treatment.= As foreshadowed by what has been said, there is no rational economic treatment. When the dilatation is in the cervical region, one might in exceptional cases attempt to restore the regular calibre of the œsophagus by removing an elliptical portion of mucous membrane, and bringing the muscular tissue together with sutures; that is to say, when the rupture or fissuring of the muscular coat has been accidental. But as one is usually unable to remove the primary cause, to which the change in the muscular tissue is essentially due, the dilatation would recur without the operation having conferred any benefit.

When an exact diagnosis has been made, the only useful indication is to confine the animal to very fluid food, which will not obstruct the œsophagus. Ordinary forage should be withheld.

ŒSOPHAGEAL OBSTRUCTIONS.

In this chapter we shall only consider such obstructions as occur in consequence of the animal having attempted to swallow without sufficiently chewing objects which become arrested in the œsophagus.

Obstruction is termed “total” or “partial,” according as the obstructing body fills the entire calibre of the œsophagus at the point of obstruction, or only occupies a part of the space. Partial obstructions produced by beet and turnip tops, etc., are usually but momentary; liquids and saliva are still able to pass between the obstruction and the walls of the tube, and as soon as the arrested food becomes a little softened it is displaced and the œsophagus again becomes patent.

=Causation.= The circumstances under which this accident occurs are extremely easy to understand. Obstructions are produced by apples, potatoes, turnips, carrots, cabbage-stalks, beetroots, etc., which, whether sliced or not, are swallowed gluttonously. Not having been sufficiently comminuted, and being of larger size than the œsophagus can readily accommodate, they become arrested at some point between the commencement of the œsophagus or a few inches behind the pharynx, or just in front of the point of entry of the gullet into the stomach. The latter is the commonest position, though not infrequently the obstruction occurs in the intra-thoracic portion.

It may occur in the stable, but is commoner in animals which, having broken loose, have entered orchards, gardens or potato or turnip fields and attempted to swallow apples, cabbages, potatoes, etc., found there.

In sheep, obstruction of the œsophagus is due to similar causes, but in their case the above-mentioned objects are replaced by small wild apples, turnip shells, Jerusalem artichokes, horse-chestnuts, carrots, etc.

The symptoms may be divided into general and local.

=General symptoms.= As soon as the foreign body becomes fixed in position, the animal begins to make exceptional efforts to swallow. The head is extended on the neck, and the œsophagus and the muscles surrounding the trachea are violently contracted. These efforts proving fruitless, feeding is necessarily stopped, and the animal at once appears slightly anxious.

Very soon afterwards salivation sets in, saliva being continuously secreted. If the obstruction is total, the saliva cannot be swallowed, and is either returned in quantities by antiperistaltic movements or escapes in frothy filaments from the mouth.

Tympanites is not long in appearing. It is progressive, and results both from arrest of eructation and from continued fermentation in the rumen. It may eventually come to a standstill, or may continue and threaten to produce asphyxia.

=Local symptoms.= The local symptoms are difficult to appreciate, except in cases of cervical obstruction. Sometimes the foreign body produces a local swelling, which changes the outline of the jugular furrow, most frequently on the left side. In many cases it can only be detected by manipulating the parts between the trachea and the lower surface of the cervical vertebræ. When the obstruction is within the thorax, the probang alone can detect its position.

=Diagnosis.= The diagnosis is usually easy. The history and the observed symptoms are often very clear, and the suddenness with which the obstruction has made its appearance prevent the condition from being confused with dilatation or stricture.

=The prognosis= is very variable. It is often easy to remove the obstacle; in other cases intervention is difficult, and death may occur rapidly.

=Treatment= is confined to one essential point—removal of the obstruction. The chief difficulty lies in choosing the mode of intervention. Moreover, success depends on several factors, which, in the order of their importance, are as follows: the size of the obstructing body; the time which has elapsed since the accident occurred; the bodily condition of the animal—i.e., whether it be fat or thin—and the extent to which tympanites has developed.

The first thing to do (and in favourable cases all that is required) is to puncture the rumen and leave the canula for some time in position. The onward progress of the foreign body, especially when the obstruction is in the intra-thoracic portion of the tube, is often impeded by the tympanites, which tends to thrust the object towards the pharynx, or at least to fix it in position. In consequence of a sudden change in the conditions of pressure the foreign body may move and pass into the rumen; all danger is then at an end.

Even though the obstruction does not immediately cease, puncture of the rumen, by removing the danger of asphyxia, allows one at least to wait for several hours, sometimes until next day, during which time the object may pass into the rumen without further extraneous assistance. The other methods may be grouped into four series:

I. =External taxis.= This is directed towards loosening the foreign body and thrusting it towards the pharynx and buccal cavity. It can only be used against obstructions in the cervical region. Two methods, although very ancient, are still practised.

(a) The first is carried out in the following way: the animal is fixed to a post or tree so that it cannot struggle, its head being drawn up as high as possible. The operator stands on the left side, with his back turned towards the patient’s head, his left hand is pressed into the right jugular furrow, his right hand is placed on the left jugular furrow immediately below the foreign body. By using the fingers the foreign body is moved, and is progressively thrust towards the pharynx, in spite of the animal’s efforts to swallow. In carrying out this manipulation it is absolutely indispensable not to let slip the obstructing body for a single instant, otherwise the peristaltic action will immediately return it to its former place. When it has been raised as far as the pharynx, an assistant passes his hand into the back of the mouth, as indicated in a former chapter, seizes the object and withdraws it; or, instead, the assistant takes over the operator’s duties, while the latter himself extracts the foreign body.

(b) In the second method the animal is fixed in a different position, the head being held about 10 to 12 inches from the ground, with the neck lowered and inclined towards the earth. As in this position the œsophagus is longitudinally relaxed, and can be dilated to its fullest extent transversely, the difficulty of displacing the obstacle should be very much less. In this case the operator always stands on the left side of the neck, but with his back towards the animal’s body. The right arm is passed around the neck and the right hand pressed into the right jugular furrow, the left hand being similarly engaged in the left jugular furrow. The method of employing the fingers is identical, or instead of the fingers the thumbs may be used.

When the obstructing object has been lifted as far as the pharynx it has a tendency to fall out of the mouth, and if it fail to do so it can be fixed in position and removed as in the preceding case.

II. =Extraction.= These methods are applicable to cases where the foreign body has become fixed in the cervical region, but more especially to obstructions in the intra-thoracic part of the œsophagus. In the majority of cases they are dangerous, and may lead to pinching, rupture, or perforation of the œsophageal mucous membrane. They should therefore be regarded as exceptional measures. Theoretically, the instruments described are perfect, but practically they do not secure the results anticipated, because one can never prevent displacement, wrinkling, and involution of the œsophageal mucous membrane.

The forceps probang has the drawback of seldom grasping smooth foreign bodies with sufficient firmness to permit of their extraction.

The corkscrew sound exposes one to the great danger of completely piercing the œsophagus, because it has to be managed blindly, and because one never knows at what depth the corkscrew portion should be protruded in order to obtain a proper hold of a foreign body.

III. =Passage of the probang.= When taxis fails or is inapplicable, we are forced to attempt thrusting the foreign body onwards. The method is much safer than the preceding, but, nevertheless, demands great tact, prudence, and gentleness. Suitable œsophageal sounds are made with cupped extremities, though in cases of emergency an instrument can often be successfully improvised from a cane, whip handle, or flexible stick, about 4½ to 5 feet in length, securely wrapped at one end with cloth or tow and freely coated with some greasy material such as lard, vaseline, or oil.

The end of the sound having arrived in contact with the obstacle, the operator exercises moderate but permanent pressure. The obstacle may not move immediately, because of spasm of the œsophagus, which grasps it. It is therefore necessary to wait and to take advantage of a moment when the resistance is less, and even then the obstacle may not move.

Rough manipulation with improvised sounds may tear, fissure, or perforate the muscular and mucous coats, producing the gravest consequences.

IV. =Crushing.= The crushing of an obstruction in the cervical region was long ago suggested, and is still greatly commended by empirics and farriers. It is performed by means of a little mallet and a piece of board. The method is barbarous, and exposes the animal to such grave complications as crushing of the œsophageal walls, followed by necrosis, laceration of the connective tissue, and interstitial hæmorrhage, injuries of the superficial or deep-seated jugulars, of the carotid artery, pneumo-gastric nerve, etc. It should never be practised, even although attempts have been made to improve it by replacing the mallet and board by specially formed forceps intended for crushing potatoes or roots. Only in the rare cases where one is certain that the foreign body consists of a very ripe fruit could crushing be justified, and in this case there is no need to have recourse to special instruments, for the hands alone suffice.

=Injection of alkaloids.= The practitioner occasionally finds himself in the embarrassing position of having vainly tried all the above methods. Before adopting the last resource, viz., œsophagotomy, it is then worth while to test the action of certain alkaloids, injected subcutaneously, after having punctured the rumen.

We know that pilocarpine and eserine stimulate secretion and the action of the bowels. Injected under the skin they cause frequent swallowing efforts, and intense peristalsis extending throughout the length of the digestive tract. Doses of 1½ to 2 grains of pilocarpine and 1 to 1½ grains of eserine, according to the size of the animal, sometimes produce excellent results, and rapidly remove obstructions.

Apomorphine, the effects of which are, so to speak, inverse, because they tend to produce anti-peristalsis and vomiting, may be tried in doses of 2 or 3 grains.

=Œsophagotomy.= The last resource is œsophagotomy, which, however, is only applicable in cases of obstruction of the cervical portion of the œsophagus. It should be performed as described in the section hereafter on operative manipulation. (See also Möller and Dollar’s “Regional Surgery,” p. 166.)

The point selected is necessarily governed by the position of the obstacle. There is no need to enter into full details. We may remark that it is not always necessary to perform the complete operation, and the third and fourth stages can sometimes be avoided by substituting for them attempts to break down the foreign body by submucous manipulation. The œsophagus, having been exposed and isolated, is punctured with a straight tenotome immediately below the obstacle. A curved tenotome is then introduced, and the root, potato, or fruit divided. As a rule, a little pressure from the outside then causes one or other of the fragments to move onwards and deglutition becomes normal.

Attempts have also been made to divide the obstructing body directly without previous incision and without isolating the œsophagus. It is much more difficult, for the least movement of the patient changes the relationships of the superposed layers and introduces obstacles to the manipulation of the blunt-pointed tenotome which is employed. More success often attends attempts to puncture the object with a fine trocar.

RUPTURES AND PERFORATIONS OF THE ŒSOPHAGUS.

=Causation.= Wounds of the œsophagus caused by external violence are rare, or at least secondary; lacerations produced from within, on the contrary, as a result of clumsy manipulation are relatively frequent. They may extend throughout the length of the tube, but in a far greater number of cases are found near the entrance to the stomach at the point where the œsophagus turns towards the left.

The passage of the œsophageal sound or probang is apt to exaggerate this curvature, and if pushed violently the instrument may produce first a flexure, then a partial rupture or even a perforation of the tube.

In other cases a rough, irregular, infected foreign body may when swallowed penetrate the wall and cause inflammation, necrosis and perforation of the œsophagus.

=The symptoms= are always very grave, and of rapid development. They consist in local œdematous swelling, sero-sanguineous infiltration at the entrance to the chest, in the pretracheal region and along the jugular furrows.

The pneumo-gastric and inferior laryngeal nerves being compressed, dyspnœa results. If the œsophagus is perforated in the thoracic cavity septic pleurisy at once sets in.

=Diagnosis.= The diagnosis is easy, provided the history point to perforation of the œsophagus.

=The prognosis= is fatal whenever the perforation is within the thorax. It is sometimes possible to intervene in cases of perforation in the cervical region, but from the economic standpoint such intervention is of little value.