The Hospital Bulletin, Vol. V, No. 3, May 15, 1909

Lecturer on Laryngology in the University of Maryland, Surgeon to the Presbyterian Hospital, Baltimore.

The esophagoscope has passed the experimental stage in the diagnosis and treatment of esophageal lesions. Its usefulness has been demonstrated so often that it would seem superfluous to dilate upon its value. Its use, however, is not as general as it should be. There are still those who consider esophagoscopy unnecessary or impracticable. At the Presbyterian Hospital we have had numerous instances of its practicability, and with us it has become the routine practice to examine all patients complaining of obscure esophageal symptoms. Dr. Chevalier Jackson records the case of a patient whose only symptom was a lump on swallowing. She appeared to be a neurasthenic, and his advice to have the esophagus examined was ignored by the family physician. Two months later, with the patient etherized for a radical antrum operation, he passed the esophagoscope and found a malignant growth.

Three interesting cases have recently come under my observation, and they illustrate so well the value of the esophagoscope I shall report them somewhat in detail. The first patient was seen with Dr. E. B. Freeman; she was 67 years old. The morning before she came to the hospital, while eating ham, she swallowed a large piece that had not been sufficiently masticated. It lodged in the introitus esophagi and remained there. When she came to the hospital she had swallowed neither solid nor liquid food for nearly thirty-six hours. A half hour before examining the esophagus she was given a hypodermic of morphia and atropia. With the patient in the sitting position the throat and upper end of the esophagus were anesthetized with 10 per cent solution of cocaine. Jackson's laryngeal speculum was introduced and the larynx pulled forward. A large mass resembling somewhat an ulcerative epithelioma was seen, and proved to be the piece of ham. Dr. Freeman and I removed it piecemeal with Pfau's foreign body forceps. It required about forty-five minutes to remove it entirely. The patient stood the ordeal well, and was able to go home the same afternoon. For about a week she had temperature, cough and expectoration, but ultimately made a good recovery. In this case the esophagoscope probably saved the patient an esophagotomy. The second patient was a female, thirty-three years old, referred to me by Dr. J. F. Chisolm, of Savannah. While at an oyster supper she attempted to swallow a large oyster, with the result that she choked for a few seconds and then had a sense of fulness in the region of the larynx. The next day she had some difficulty in swallowing, so that she took only liquids. The second day afterward swallowing was decidedly painful; she grew rapidly worse, until the fourth day her condition was serious. She reached this city the morning of the fifth day, with a temperature of 100 degrees and extreme prostration. The examination of the esophagus was made under ether with the head in the extended position. No foreign body was found, but the upper end of the esophagus was red, swollen and edematous, and seemed to be closed. The patient was given cold milk and ice bags to the throat. For two days she suffered excruciating pain on swallowing, and it looked as if we would have to resort to rectal feeding. The next day there was slight amelioration of the pain, which gradually disappeared. In this case the esophagoscope enabled us to see at once that a foreign body was not present, and that the symptoms were due to a severe, acute inflammation, probably caused by a piece of shell attached to the oyster.

I was asked by Dr. A. M. Shipley to examine a patient who had been referred to him for probable cancer of the stomach. The man was sixty years old and had had some trouble in swallowing for about two months. Attempts to pass the stomach tube were unsuccessful. The patient was examined in the sitting position after cocaine anesthetization. No difficulty was experienced in passing the esophagoscope. About three inches below the cricoid cartilage the progress of the instrument was arrested by a tumor partially closing the esophageal lumen. The esophagoscope showed that the tumor was too low for removal. In this case the patient can be dilated through the esophagoscope and made more comfortable for the short time he has to live.

919 North Charles street.

SYPHILITIC OSTEO-PERIOSTITIS.

BY C. G. MOORE, '09.

Senior Medical Student.

The bony manifestations of syphilis occur as secondary and tertiary lesions, and as Keyes, of New York, has pointed out, these so-called “nodes” are simply local periosteal congestions, accompanied by serious effusions without cell hyperplesia. Any bone in the body may be affected by syphilis, but certain of them suffer by preference, such as the thin bones of the nose and pharynx—that is, those exposed to climatic changes and injuries, such as the bones of the skull, ulna, tibia, etc.

We must call special attention to injury as a powerful pre-disposing cause of bone syphilis, for, when we consider that bone lesions may be the only manifestations of existing syphilis, with the presence of a bone lesion before us, with an antecedent history of an injury, we must not forget that we may overlook the true nature of the disease, and hence must be constantly on the alert for the syphilitic taint.

Lancereaux classified the bone lesions under three heads, viz.:

(a) Inflammatory osteo-periostitis.

(b) Gummy tumor of bone.

(c) Dry caries, atrophic form.

(1) Inflammatory osteo-periostitis is the most frequent form, and is characterized by inflammatory phenomena, vascularization and exudation of a serio-glutinous material. It may be either diffuse or circumscribed, and located, as its name implies, in the area of contact with the osseous and periosteal surfaces. The pain is aching, acute, throbbing or boring in character, while tenderness upon pressure and percussion is most exquisitely excruciating. The diagnosis of inflammatory osteo-periostitis is comparatively easy, if we remember the characteristics, viz., an oval, painful, boggy or even hard bony lesion, accompanied by nocturnal exacerbations of pain, with a concomitant or antecedent history of syphilis. Ostitis with parenchymatous thickening is somewhat less positive in its character, but with nocturnal pains which are usually constant.

(2) Gummy tumor of bone develops either under the periostum, in the substance of bone, or in the medullary canal. It is simply an intensification of the process found in the inflammatory form just described, the difference being that the cell hyperplasia is more abundant. Much of the new material collects in a circumscribed space, and being more rapidly formed and less capable of organization, it entails more profound lesions by its retrograde metamorphosis. Generally tumor of the bone is, therefore, a much more serious form of disease than osteo-periostitis.

In the long bones the medullary canal is the usual seat of deposit. The bone becomes hypertrophied in a porous manner, the Haversian canals and canaliculi become enlarged and filled with a gummy material which resembles a solution of gum arabic. In the flat bones, especially the cranial bones, the cancellar tissue is attacked, and may cause a separation of the two tables, and often necrosis of one or the other plates results. If it happens to be the inner one which undergoes carious degeneration, brain symptoms will develop.

(3) Dry Caries.—According to Virchow, dry caries is always due to syphilis. This affection is a miniature gummy ostitis. Around one of the vascular canals the gummy material is deposited, this gummy material being later absorbed, leaving a stellate induration. This goes on leaving a funnel-shaped depression, its point leading into the diploe, which may be plainly appreciated by palpation. The essential features of this caries is the fact that no sequestra are formed, no pus extruded, nor is the skin but rarely involved.

The following is a case of syphilis in which osteo-periostitis developed:

On January 22nd, 1909, R. B., age 35, white, a housewife, applied to the Medical Department of the University Hospital Dispensary for treatment, complaining of rheumatism in her back and a sore shin. The patient has been married 14 years and has had four children; the two eldest are the only ones now living. Three years ago she gave birth to a full-term child which only lived a few minutes after expulsion.

One year later she gave birth to another child, which was not at full term, but about six months advanced. She says two days previous to this birth she fell down stairs and struck on her abdomen. When the child was born its thigh was fractured, and the physician who attended her said the fracture was caused by the fall.

Her father died nine years ago, at the age of 68 years, of apoplexy; her mother was killed a few years ago in an accident. She has two brothers and three sisters, all living and in good health, as far as she knows. She is at present living with her husband, and says he is apparently well and sound, but drinks heavily, and when under the influence of liquor abuses her a great deal. Patient denies ever having had tuberculosis, syphilis, diphtheria, typhoid, scarlet fever, malaria, grippe, gonorrhoea, or any of the nervous or malignant diseases. She sometimes has a sore throat when she takes cold, but it only lasts a few days. She has complained of rheumatism in her back and limbs for the past three or four years, and thinks it is worse at night.

Patient never complained of any trouble other than those mentioned until three years ago, when her third child was born. She says that at that time her hair fell out, and an eruption, which itched slightly, broke out all over her body, including her face, but only extended down her arms as far as her wrists. This lasted a few weeks, then seemed to subside, but never entirely disappeared, and when she gave birth to the still-born child, one year later, it broke out again worse than before. She went to Dr. McElfresh, who treated her for about three weeks, giving her some medicine to take internally, also some sulphur ointment. She for a time got some better, but owing to her circumstances was unable to continue treatment with Dr. McElfresh, and has done nothing for her condition until the present time. For the past four months she has been suffering with a pain in her right shin; this has been gradually getting worse, and one week ago began to swell and cause her considerable pain, being worse at night, and sometimes hurting her so much that she is unable to sleep, hence her reason for coming to the dispensary.

Upon questioning her in regard to her general health, she says she feels as well as she ever did, with the exception of the previously mentioned pain.

Her appetite and digestion are good, and her bowels are regular, and she has no lung, heart or kidney trouble. She has had no headaches, nausea, or vomiting, and her menstrual periods have always been regular and painless.