TREATMENT OF 
CEsophageal/Stricture 
BY PERMANENT TUBAGE 
BY 
WALTER F. CHAPPELL, M.D., M.R.C.S., Eng. 
Attending Physician to the Chest and Throat Department (out-door), Pres- 
byterian Hospital, Assistant Surgeon Throat Department Manhattan 
Eye and Ear Hospital, New York. 
Reprinted from the Neuu York Medical Record. TREATMENT OF 
CEsophageal Stricture 
BY PERMANENT TUBAGE 
BY 
WALTER F. CHAPPELL, M.D., M.R.C.S., Eng. 
Attending Physician to the Chest and Throat Department (out-door), Pres- 
byterian Hospital, Assistant Surgeon Throat Department Manhattan 
Eye and Ear Hospital, New York. 
Reprinted from the New York Medical Record. TREATMENT OF (ESOPHAGEAL STRICTURE BY 
PERMANENT TUBAGE. 
Walter F. Chappell, M.D., M.R.C.S. Eng. 
Stricture of the (Esophagus, however produced, causes so 
much distress, that any suggestions for its relief, or to benefit 
the condition of the sufferer, must be acceptable to every 
practitioner. In every case of organic stricture, we have to 
decide on the best manner of nourishing and sustaining the 
patient in the later stages of the disease. 
Gastrotomy has been most relied upon to effect this end, 
but owing to the seriousness of the operation, and the usual 
weakened condition of the patient when it is performed, the 
result obtained cannot be considered a success, in fact, the 
operation itself often proves fatal, and is therefore only resort- 
ed to that the patient may escape the horrors of starvation. 
The use of a short tube for feeding was advocated by Sir 
Morrell MacKenzie many years ago. In 1884, Dr. Charters 
Symonds exhibited a short tube before the Clinical Society of 
London very similar in design and for the same purpose as 
that recommended by Dr. MacKenzie. This tube was an im- 
provement in shape and manufacture on MacKenzie's, and was 
intended for permanent retention, while MacKenzie only 
allowed his to remain in position a few days at the most. 4 
The possibility of keeping the tube in the oesophagus, for 
from one to six months, as has been reported by several 
observers, greatly increases its usefulness, until at the present 
time, most cases of malignant stricture, if seen moderately 
early, can be so managed as to render gastrotomy unnecessary; 
indeed, in very advanced cases we can frequently introduce a 
small tube, and sustain the patient until the disease has pro- 
gressed to a further degree and implicated some other organ, 
which terminates life, and spares the patient a gastrotomy or 
the trials of slow starvation. 
When the disease ulcerates through into the trachea, the 
short tube cannot be retained in the oesophagus. As this con- 
dition occurs only very late in the case, the oesophageal open- 
ing rarely closes completely, if a short tube has been used, and 
the patient can be nourished with a long feeding tube for the 
time which he needs it. The use of the short tube has been 
confined chiefly to cases of malignant stricture, and has there- 
fore been only palliative in its usefulness, but I have found it 
of great service as a curative agent in other forms of stricture. 
In recent and slight cases of traumatic stenosis of the gullet, 
where we may expect a good result from gentle dilatation, the 
presence of a short, silk, gum-elastic tube, at the seat of stric- 
ture, in the interval between the passing of the bougies, will 
hasten the restoration of the calibre of the oesophagus. When 
used for this purpose, we need a set of tubes each a little 
smaller in diameter than the corresponding bougie to be em- 
ployed. After passing the bougie into the oesophagus and 
allowing it to remain ten or fifteen minutes, it is removed,jand 
a suitable short tube introduced and kept in position four or 
five days until the next sized bougie is passed. This method 5 
of dilatation prevents contraction of the stricture in the in- 
terval between the passing of the bougies. We also get the 
dilating effect of the mere presence of the tube in the stric- 
ture. In some cases of nervous or hysterical strictures, it is 
also of service when they have resisted the continuous passing 
of the bougie for some time, or have recurred. In one case, I 
employed a soft rubber tube and allowed it to remain in posi- 
tion two weeks. After its removal, the patient swallowed 
perfectly for a month, when the attack recurred. The tube 
was re-introduced and allowed to remain a week, when re- 
covery was complete and remained so. The moral effect of 
the presence of the tube was no doubt the chief element in re- 
covery. 
It seems to me that a similar use of the tube might be made 
after internal cesophagotomy. After this operation, we rely 
upon the passing of bougies to maintain the calibre of the 
tube, and while I have not had an opportunity of testing it, 
it seems, from our experience with short tubes in gradual dila- 
tation, that we have every reason to expect that an introduc- 
tion of a silk gum-elastic tube, say four or five days after an 
internal cesophagotomy, and used in conjunction with the 
bougies, would be a great assistance to us in restoring the 
oesophagus to a more normal condition. Of course, better 
success may be expected, when only a short part of the oeso- 
phagus is implicated in the stricture. 
A description of the tubes used and the methods of intro- 
duction, with suggestions as to the management of the cases, 
will, I think, be valuable. 
The tubes are made of gum-elastic on silk webb, or of soft 
rubber with thickened walls. The former are the most use- 6 
ful, as in fact it is only in a few cases that the soft rubber can 
be used. The length of the tube varies from four to seven 
inches, according to the length of the stricture, or if there are 
two strictures close together, the tube may be long enough to 
include both. The soft rubber tube rarely requires to be 
more than four inches long, as it is only applicable to stric- 
tures at the upper extremity of the oesophagus, and can easily 
be introduced and so nicely adjusted in position that a tube of 
this length is usually quite sufficient. The superior extremity 
is funnel-shaped and rests on the top of the stricture. The 
small end is rounded and has an eye about half an inch from 
the extremity. The bore of the tube is as large as possible, 
consistent with the strength of the tube, and extends past the 
eye to the inferior extremity. This allows the whalebone in- 
troduced to be carried to the bottom and then easily removed. 
According to my experience, however, it is just as well, if not 
better, to have the small end of the tube open, as it is not so 
likely to get filled with food. A stout silk thread of requi- 
site length is then passed through the tube on either side of the 
funnel-shaped extremity. The tube is then washed in a car- 
bolic solution and the outside coated with vaseline. The 
position and size of the stricture have of course been ascer- 
tained by bougies. 
The oesophagus is disinfected as much as possible by direct- 
ing the patient to swallow a solution for that purpose ; I then 
give two or three teaspoonsful of a one per cent, solution of 
olive oil and cocaine. This not only facilitates the passing of 
the tube by its lubricating properties, but also shrinks the tis- 
sues and increases the calibre of the stricture to a small de- 
gree. 7 
When the stricture is at the upper extremity of the oesopha- 
gus, the tube can be introduced by simply engaging a bougie 
in its funnel end ; but when it is further down we have to 
guard against the tube coiling up during introduction. For 
this purpose Dr. Symonds recommends a whalebone intro- 
ducer, which is passed to the bottom of the tube, and outside 
of this a gum elastic sheath which is engaged in the funnel 
extremity. The whalebone will keep the tube stiff, and pres- 
sure may be made on the sheath from the top of the tube. 
Plenty of time must be taken and only the gentlest manipula- 
tions employed. If the stricture is not too narrow, you can 
get some assistance by directing the patient to swallow while 
you exert gentle pressure. The silk thread which is fastened 
to the tube keeps it under control, and is usually brought out 
of the mouth and fastened on the cheek. I have found this a 
very troublesome procedure, as a good deal of mucous always 
accumulates in the pharynx and mouth, and the presence of a 
thread in the mouth increases this to such a degree that it is 
almost unbearable to some patients. To obviate this, I passed 
a very small soft-rubber catheter through the nose into the 
mouth and secured the thread to it, and then drew it up 
through the nose, removed the catheter, and left the thread in 
one of the nasal passages ; the thread was then fastened to the 
cheek with plaster. By this means the thread is kept in the 
back of the pharynx, and well out of the way of the fauces. 
In two cases in which I employed this method, the patients 
said they had very little discomfort. 
The soft rubber tube is prepared for introduction in the 
same way as the silk elastic, and when the case is suitable for 
its employment can be easily introduced with the finger and a 8 
bougie. If the case is progressing favorably under the tub- 
age treatment, it is advisable to remove the tube once in two 
weeks, and after cleaning, re-introduce it. In cases of malig- 
nant stricture, it is necessary at first to remove the tube more 
frequently than this, owing to the dilation which often follows 
the first introduction. 
The following are short histories of a few cases treated with 
the tubes:- 
Mrs. V., age 51, came under my care in June 2d, 1890. 
She had an excellent family history. Sixteen years before the 
present illness began she had some difficulty in swallowing 
solids. The physician who attended her at the time diag- 
nosed it as nervous stricture of the oesophagus. He blistered her 
back and throat and gave her tonics. She did not lose flesh 
or strength, and after about eighteen months was so much im- 
proved that she discontinued the treatment. Since that time, 
however, and up to the beginning of the present illness, she 
was obliged to swallow solids with care, as she found they 
would stick in her throat, and if she drank quickly she chok- 
ed. Soon after Christmas, 1889, she found the slight difficul- 
ty in swallowing was increasing, and two weeks later, it was 
very pronounced. From this time she rapidly grew worse, 
and by the 1st of April was reduced to fluid diet. Her voice 
began to grow hoarse about this time. These symptoms pro- 
gressed until June 2d, when she came under my observation. 
I found her much emaciated, pale and haggard in appearance, 
and she had swallowed nothing for thirty-six hours. Not hav- 
ing a suitable long tube at hand, I tried to pass a No. 7 Eng- 
lish gum-elastic catheter, but was not successful. A hypo- 
dermic of morphine was then administered and the patient 9 
directed to swallow half a grain of cocaine dissolved in water. 
In twenty minutes, I passed the catheter without difficulty, 
and gave her some milk. A few hours later, a tube was in- 
troduced and food again given. The following day, I passed 
a No. 6 bougie and found the stricture was sixteen inches 
from the upper incisor teeth, which is the usual point from 
which measurement is made. 
From the history, appearance of the patient, and great 
salivation present, there could be no doubt a malignant growth 
had to be dealt with. 
On the 6th of June, I improvised a short tube by taking 
sufficient of the upper extremity of a long feeding tube which 
has a funnel-shaped end, and introduced it at the seat of the 
stricture. The first day it caused some coughing, but after 
that she swallowed without difficulty, providing she did so 
slowly. A week later I removed the tube, and put in a new 
one which I had had made. This she wore continuously un- 
til July 14th, when she began to feel nauseated, and I was 
obliged to remove the tube. From the 10th of June till the 
14th of July she had gained seven pounds in weight, and was 
much stronger and very comfortable. After the removal of 
the tube she swallowed liquids, but the vomiting and cough- 
ing was so great that she did not retain anything, and a thin, 
dark-brown, grumous fluid began to appear in the vomit ; on 
the 17th she had a violent chill, followed by fever, the tem- 
perature going up to 103 F. ; she was delirious and como- 
tose, and died the following day. 
On post mortem examination, a malignant growth was found 
in the lower part of the oesophagus. It implicated about four 
inches of oesophagus and nearly destroyed its walls to that ex- 10 
tent. It had also extended to the trachea and perforated it 
just above the right bronchus. The neighboring lung tissue 
on both sides was implicated, and also the walls of the aorta. 
A carcenomatous mass, about the size of a hen's egg, was 
found in the walls of the stomach, near the oesophageal open- 
ing. It protuded into the cavity of the stomach and was very 
vascular. Its surface showed signs of erosion and recent 
hemorrhage. The heart walls were thin and pale, and the 
pericardium contained two ounces of pus. 
Miss C., Age 27, never had any special illness, but was 
always nervous. Had been in a house during the summer 
was undergoing repairs, and thought she caught malaria. 
While eating supper about two weeks befor consulting me, 
found she was suddenly unable to swallow anything solid ; 
taking liquids also made her choke. When I saw her she was 
thin, pale, and weak, extremely nervous about her condition, 
as she was sure she felt a lump rise in her throat and choke 
her every time she attempted to swallow. After spraying the 
fauces with cocaine, I passed a No. 10 oesophagus bougie with 
little effort, and the following day a No. 13, which was about full 
size for her. Mixed bromides and quinine were prescribed, 
and the patient told she could now swallow any food she wish- 
ed. She returned in a week and reported that for a few days 
after her visit she was all right, but she now felt the lump in 
her throat and could not swallow. I again passed a full-sized 
bougie and sent her home, only to have her return ten days 
later with another attack. These recurrences were repeated 
several times until she became quite despondent. I then in- 
troduced a soft-rubber short-tube, about No. 10 in size, and let 
it remain for two weeks. During this time she took plenty of 11 
fluids and called to tell me that she was quite sure she could 
now take solids. 
A few days later, I removed the tube and she was able to 
swallow perfectly for a month, when, after some excitement, 
the old trouble returned. The tube was again resorted to, and 
after four (bays she was quite well and remained so. I have 
no doubt that in this case, the tube hung free in the 
oesophagus soon after its introduction, and that the patient 
swallowed outside of it as well as through it. 
I have employed the tube in two other cases, one of hysteri- 
cal stricture, where it was only a partial success, owing to 
nausea ; the other, a mild traumatic stricture, where it was 
used as an aid to gradual dilatation with marked success. Not 
having any notes of these two cases, I am unable to present 
them in detail. 
It seems remarkable in case No. 1, which I have reported, 
that so large a growth should be found in the stomach without 
causing any distress or symptoms which would draw atten- 
tion to its presence. I only discovered it two or three days 
before death, when the vomiting came on. Up to that time, 
there had not been the slightest complaint of distress in the 
stomach. Dr. S. J. Mixter, of Boston, has suggested a new 
instrument for introducing the short tube. I have not used 
it, but Dr. Robert F. Weir, who has had considerable experi- 
ence with it, tells me that he prefers it to any other.