The operative method carried out in the case described below may be of interest, and perhaps also of some practical value. History.\p=m-\R.M., a woman, aged 47, sick for fifteen years with typical symptoms of cardiospasm, with frequent regurgitation, became worse gradually; she was treated by a number of physicians, but the cardia was never dilated; of late the patient had been unable to swallow anything. The patient entered the medical division of the German Hospital (Dr. M. Einhorn). Neither

more »

... ounds nor dilator could be made to pass into the stomach; they evidently slipped sideways into an esophageal pouch, which rested on the diaphragm. Metal sounds passed down a distance of 17% inches from the teeth before they met resistance (14 inches being the normal distance in grown persons) ; flexible tubes could be made to pass 1\ m=1/ 2\ inch further down. Rectal feeding had to be resorted to, but soon had to give way to a gastrostomy according to Kader's method (Dr. M. Rehling). Operation was well borne, and the patient was instructed to chew her food, but instead of swallowing it, to spit it into a receptacle partially filled with some kind of nourishing fluid, from which it was then poured into the stomach. In spite of this she did not gain and asked to be relieved by operation. The proposition made to her to let me try first to pass the contracted cardia with the help of the esophagoscope was refused, and was not particularly pressed in view of the unfavorable results obtained by others in cases of such long standing. An attempt was made, however, to pass the cardia from below, for which purpose the stomach was washed clean and direct gastroscopy performed with the electric cystoscope introduced through the gastric fistula. Owing to the lack of proper landmarks I did not succeed in definitely locating the cardia, an experience I had frequently had before in similar cases; nor was I able to pass a ureter catheter by means of the ureter catheterizing cystoscope, although at one time a metal probe had been introduced through her mouth down to the obstruction, and this, as well as the ureter cystoscope, had been made visible with the help of the fluoroscope, the oe-ray tube being placed at the back of the patient for the purpose of locating the cardia. The failure was evidently due to the fact that the cardia proper could not be pressed forward by the sound. After consultation with Dr. Einhorn I decided to perform thoracotomy under differential pressure and, if the diffuse esophageal pouch demonstrated by the ¡r-rays should be found to be due to cardiospasm and not to a carcinoma which might have developed on the_ basis of an old ulcération, I would then try to reduce its diameter by esophagoplication. Excision of a large ellipsoid piece of the entire length of the esophageal wall with immediate suture would have been a more radical step. However, such an operation would have involved" greater risk than it seemed wise to take in view of the patient's greatly reduced condition ; she weighed 87 pounds. Operation.-May 31, 1910, operation was performed under positive differential pressure by means of the positive chamber in use at the German Hospital since April, 1909. Stomach lavage was first performed, the gastric tube removed and the fistula packed with iodoform gauze and covered with zinc adhesive plaster. The patient was given a hypodermic injec¬ tion of morphin % gr., atropin 1/100, and, by hypodermoclysis, 1,000 c.c. saline solution. Anesthol anesthesia was employed, with two narcotizers in the chamber, with oxygen tank and esophageal sounds. The thorax was put on the stretch by means of the new operating-table for thoracic surgery else¬ where described,1 a curved incision was made over the sixth to the tenth ribs, exactly corresponding in direction with the 1. Ann. Surg., July, 1910, p. 40. lower part of the typical Schede incision, and a skin and muscle flap raised. An incision was then made in the eighth intercostal space. The lung was superficially injured on divid¬ ing the pleura because of a total adherence of the lung to the costal pleura. Careful blunt dissection was done and the incision lengthened anteriorly and posteriorly. The wound was then gently separated and the rib-spreader inserted, but, in order to avoid rib fracture, wide separation was not forced. Separation of the lung from the costal and diaphragmatic pleura posteriorly proved easily feasible. A number of double ligatures, with divisions between, were needed for firm ligamentous bands. When the lung was pushed off from the anterior mediastinum it tore at two places, which were tem¬ porarily covered with moist gauze sponge. When the loosened lung (which remained adherent inwardly) was pushed upward and inward, away from the diaphragm and aorta, a large pearshaped swelling was seen, corresponding to the lower end of the esophagus. This evidently was the sac in which the instruments had been caught. The overlying pleura was split, the pneumogastric nerves made out and thoroughly separated from the esophagus on either side for fully five inches. The sac was loosened all around with both hands until the finger¬ tips met posteriorly at the spinal column. The cardia was palpated through the diaphragm and found not infiltrated and could be pulled into the thorax for a distance of about one inch without opening the abdominal cavity, a phenomenon also observed in previous cases. The cardia was surrounded by the finger, then by a piece of twisted gauze, the ends of which were clamped. This gave a good hold. The tip of a long flexi¬ ble sound now introduced into the esophagus was felt in the pouch posteriorly and laterally over the spinal column. It was lifted by the left hand, which rested behind the esophagus, and met by the right in front which guided it toward the car¬ dia, the latter resting on the gauze handle. The sound passed the cardia nicely, its upper end being gently pushed by the narcotizer. This proved conclusively that the cardia was permeable to instruments. The sound being withdrawn, a double esophagoplication was done, the same as is done when performing gastrotomy accord¬ ing to Kader. Interrupted silk sutures, flat curved needles and the indispensable "Krister's swan" were used,1 care being taken not to penetrate the esophagèal wall and not to include the pneumogastric nerves. Meanwhile an intravenous injec¬ tion of saline with 20 mm. of adrenalin had become necessary. The esophagus was then dropped back into its normal place and the initial lung incisions and tears stitched with a straight round needle threaded with fine silk, grasping just enough of the pleura to close the wound. Suture of the rents near the mediastinum were technically difficult or impossible and a small flap of parietal pleura just hanging handy was stitched on to the lung to cover one of the rents. Air was thought to be heard passing out of the lung now and then. Closure of the thoracic wound was then undertaken. Two pericostal silk sutures, tied, held the ribs in proper apposition until three double chromicized catgut retention sutures, made to pass through drill-holes in the middle of the lower rib and sur¬ rounding the upper one were tightened. Then the silk sutures were cut and removed. The external wound was closed with continuous catgut sutures and the dressing applied. The patient was removed from cabinet and returned to bed; pulse was 108; stimulation was employed. Postoperative History.-On the following day at noon there was cyanosis and dyspnea, a pulse of 140 and increased respira¬ tion. Diagnosis: compression of lung by fluid or air, which latter, it was thought, might have escaped through the pul¬ monary tear that could not be sutured. To make sure of this, the patient was brought back to the cabinet and the pressure turned on, with everything ready to reopen the wound in case of increase of dyspnea, which would indicate the presence of a pressure pneumothorax. Fortunately, this did not happen, and, as the patient felt comfortable under differential pressure and complained of difficulty in breathing the moment it was stopped, she was left in the apparatus for almost ten hours, food being given frequently through the tribe which had been reintroduced through the gastric fistula. When the head was removed from the chamber at 9 p. m. and the patient placed