Spontaneous rupture of the esophagus following vomiting

SPONTANEOUS

RUPTURE FOLLOWING LEWIS

VOMITING*

F. SMEAD,

TOLEDO,

T

HE foIIowing case is reported because of its rarity and because it is interesting that serious injury to the esophagus may resuIt from severe vomiting. Moreover, the fact that the marked abdominaI symptoms present Ied, as in many other recorded cases, to Iaparotomy, shouId attract the attention of the abdomina1 surgeon. Most of the cases, in the literature, of actua1 rupture of the esophagus have been in men but Vinson of the Mayo CIinicz7 has reported 9 cases in which, as the resuIt of the vomiting of pregnancy, serious damage has been done to the Iower esophagus. AI1 of his patients who recovered, deveIoped strictures in the Iower third of the esophagus. Two of them died, one from an abscess of the mediastinum and the other from an esophagea1 hemorrhage. StiII another deveIoped a periesophagea1 abscess and recovered foIIowing drainage into the esophagus. The vomiting of a dark, bIoody materia1 was a prominent symptom and most of the patients compIained of a substerna pain. It is certain that Vinson’s cases were the direct resuIt of the vomiting of pregnancy. Two factors seem to have been responsibIe for the troubIe. The first was direct mechanica trauma to the waI1 of the Iower esophagus, which, in the case to be reported ‘in this paper, resuIted more seriousIy in the actua1 rupture of the esophagus. The second factor was described by Zenker48 and Von Ziemsen in 1878 as esophagomaIacia. It was their beIief that as the resuIt of vomiting the Iower esophagus is exposed to the proIonged chemica1 and digestive action of stomach contents and the reaction thus especiaIIy in weakened indiinduced, viduaIs, predisposes to more serious resuIts from infIammation and trauma. * Read at the Forty-third

OF THE ESOPHAGUS M.D.

OHIO

The case which Ied to this report was that of an active business man aged fifty. For ten years this patient had had a11 the usua1 symptoms of duodenal ulcer. The diagnosis had been confirmed by definite x-ray findings. He had aIso had a stricture of the lower esophagus which had caused considerable diffIcuIty in swallowing. In spite of these conditions he had been quite comfortable and had been gaining weight. At seven o’cIock on the morning of February 3, 1928, the patient began to have abdomina1 pain and vomited strenuously for the folIowing two hours but was abIe to bring up onIy a smaI1 amount of blood. SuddenIy at 9.00 A.M. he experienced a very severe pain in his epigastrium and Ieft Iower thorax. He was not reIieved by 45 grain of morphine. When seen at 12.00 noon he was in great distress. The whoIe abdomen was hard and extremeIy tender in the epigastrium. His breathing was di%cuIt and he groaned constantIy. He was Iying doubled up on his Ieft side with his thighs Aexed. His temperature was IOO’F., pulse 120, systoIic bIood pressure 120, diastoIic 75, and respirations 30. The red bIood count was 4,500,00o, hemogIobin 70 per cent white bIood count 8800, with poIymorphonucIear ceIIs 70 per cent. The urine showed albumin 180 mg. per IOO c.c., sugar negative, and acetone positive. Examination of the chest showed no definite pathoIogy except what might be expIained by a recent cold. There was no emphysema of the neck at any time during the iIIness. In the Iight of a definite history of duodena1 uIcer a diagnosis of an intra-abdomina1 perforation was made and the abdomen opened. There was no perforation of the stomach or duodenum. There was, however, a voIvuIus of a Ioop of the Iower iIeum causing an acute obstruction. The pyIorus was markedIy constricted by the oId uIcer and the diIated stomach distended with about 3 qt. of fluid. The following day he was much worse. There

annua1 meeting, American Association of Obstetricians, GynecoIogists Surgeons, heId at Niagara FaIIs, September 15, ,930. 497

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but he was restIess and in shock and perspiring profuseIy. He compIained of pain in his chest and of Iabored breathing with inabihty to take fluids by mouth or to cIear mucous from his throat. His temperature was 103%., puIse 140 and respirations 40. There was now a definite pneumothorax on the Ieft side and the heart was displaced to the right. The breath sounds were diminished throughout the Ieft chest and there was ffuid duIIness in the Ieft thorax posteriorIy. He died at 9.00 P.M., thirty-six hours after the onset of his severe pain. A post-mortem examination, fifty minutes after death, showed a greatIy distended smaII bowe1 and a Ioop of gangrenous ileum. The pyIorus was stenosed. The Ieft Iung was coIIapsed and the pIeura1 cavity fiIIed with a thin, brown fluid with a feca1 odor. The pIeura was covered with exudate and greatIy inflamed. There was a stricture of the esophagus 4 cm. above the diaphragm with an interna diameter of 4 mm. Between the stricture and the diaphragm there was a compIete rupture of the esophagus 2 cm. Iong connecting the Iumen of the esophagus with the mediastinum and Ieft pIeura1 cavity. The fluid in the Ieft pIeura contained many gram-negative baciIIi, streptococci, staphyIococci and gram-positive dipIococci. The right Iung was compIeteIy adherent to the chest wall, effectiveIy preventing rupture into the right pleura1 cavity.. The patient aIso had a chronic interstitia1 nephritis and an earIy coronary sclerosis. The esophagus above the stricture was norma1 except for one area of chronic inflammation in the submucosa. Just beIow the stricture there was quite norma stratified squamous epitheIium but stiI1 Iower toward the rupture, a denuded area with a smooth base of dense fibrous tissue showing marked chronic inflammation. Below the rupture the epitheIium showed gIands resembIing those of the stomach but Iess deveIoped. A transverse section taken at the IeveI of the rupture showed a mucosa with glands resembIing gastric gIands. A Iittle away from the edge of the rupture there was an area denuded of epithehum. The mucosa and submucosa and muscuIaris showed a chronic inffammation. At the edge of the rupture there was some necrosis and a deep laceration in the mucosa extending away from the rupture. The outer Iayers of the esophagus and surrounding connective tissue showed an acute infIammation. The cardia and fundus of the stomach

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showed chronic catarrha1 inff ammation and erosion of the mucosa and thickening of the submucosa. The sequence of events is as foIIows: The primary vomiting was initiated by the voIvuIus of the ileum. The distended stomach couId not quickIy empty itseIf because of strictures in the pylorus and esophagus. The fluid from the stomach was therefore forced by vomiting into the Iower esophagus and being unable to pass the stricture, was driven through the chronicaIIy diseased esophagea1 waI1 into the mediastinum and left pIeura1 cavity. The adhesions of the right Iung to the chest waI1 prevented a rupture into the right pIeura. Death was due to shock, intestina1 obstruction, and acute infection ofthe mediastinum and the Ieft pIeura.

The first case of rupture of the esophagus from vomiting was reported in great detaiI in 1724 by Boerhaave” and the second in a miIitary surgeon in 1788 by Dryden,” a case Jamaica. Fitz12 in 1877 reported and reviewed the Iiterature to date. He rejected a number of cases, which were undoubtedIy authentic, on the basis that they were due to post-mortem digestion. It has been rather’ diffIcuIt to disabuse the minds of the profession on this point but the occurrence of some 30 cases, since that time, under such simiIar circumstances and with such uniform symptoms and physica signs, has made the argument of Iess vaIue. Sir More11 Mackenzie2* reported a case in 1886 and f&y discussed the subject, reviewing the cases to date. In Igoo BowIe? and Turner coIIected 18 cases and reported I of their own. In 1914 Irving J. WaIker40 found 22 cases incIuding I of his own. He excIuded IO cases, many of which couId we11 have been accepted. A bibIiography of a11 cases to date is appended to this paper. One must reject from this group cases of rupture of the esophagus from such causes as tubercuIous bronchia gIands, pyogenic mediastinal abscesses, carcinoma, Iues, aneurysms, direct trauma from foreign bodies, diverticuIa, acute gangrenous stomatitis, and chemical burns. The etioIogy of this accident is now cIear and we11 estabIished. A patient with a fuII

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stomach vomits or retches vioIentIy and ejects fluid into the esophagus with such force and such suddenness that the pressure cannot be relieved quickIy as it usuaIIy is by the escape of fluid through The force is therefore the esophagus. exerted against the waIIs of the stomach and esophagus, and a rupture occurs at the weakest point which is the Iower end of the esophagus. Mackenzie removed the esophagus at some 18 post mortems and produced rupture by water pressure and found that rupture occurred in a11 but I in the Iower third under a pressure of from 5 to I I 16. The rent was aIways IongitudinaI, the muscIe giving away first and finaIIy the mucosa. As expIained before, it is not necessary to presuppose any obstruction of the esophagus during vomiting as a cause of rupture. In severa cases, however, rupture occurred whiIe the patient was making a vioIent effort by retching and coughing to disIodge a piece of meat from the guIIet and in 2 cases, incIuding the I reported in this paper, the accident occurred with vomiting in the presence of an esophagea1 stricture. The muscuIature of the Iower esophagus is IargeIy voIuntary and that in the Iower end is invoIuntary. It is probabIe that a spasm of the circuIar voIuntary fibers of the upper esophagus during vomiting or even a Iack of their coordination with the muscIes of the Iower esophagus might cause an obstruction during the act of vomiting. Again, the unyieIding nature of pharyngea1 outIet between the cricoid cartiIage and the sixth cervica1 vertebra may be a point of reIative obstruction during vomiting. Whether an absoIuteIy norma esophagus can be ruptured by vomiting under the conditions just described is diffIcuIt to prove because of the condition of the organ when examined post mortem. NevertheIess, in many of the cases reported there is every reason to beIieve that the esophagea1 waI1 was of norma strength before rupture. It is not unreasonabIe to beIieve that a pressure of from 5 to I I Ib., found neces-

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sary to rupture the norma esophagus, couId resuIt from severe straining and vomiting. UndoubtedIy, the strength of the esophageal waI1 varies in different individuals. The organ, too, may be weakened by scars, strictures, dilatation, uIceration, chronic inflammation, such as that of aIcohoIism and that foIIowing proIonged vomiting and regurgitation. Fitz’2 in 1886 made the foIIowing statement: “There exists the certainty that a previousIy heaIthy oesophagus may be suddenIy ruptured by muscular action.” The rupture of the esophagus may extend onIy into the mediastinum with acute mediastina1 ceIIuIitis or abscess formation. UsuaIIy, the tear extends through the mediastinum and pIeura into one or the other pIeura1 cavities, more frequentIy the Ieft. When this occurs the Iung on the affected side soon coIIapses and the pleura becomes the site of an extensive and viruIent inflammation comparabIe to a genera1 acute peritonitis. Death is IargeIy due to sepsis from this cause. When the rupture is into either pIeura1 cavity the mediastinum is aIways invoIved, as the path of the rupture must pass through the mediastinum. The infection of this space is therefore added to that of the pIeura1 cavity. When the rupture is onIy into the mediastinum both pIeura1 cavities usuaIIy contain bIoody fluid and when the rupture extends into one pleura1 cavity the other shows bIoody ffuid at post mortem. In I case the pericardium contained bIoody serous fluid. The Iaceration in the waI1 of the esophagus has aIways been immediateIy above the diaphragm and IongitudinaI in a11 cases except 2. In that of Boerhaave5 the guIIet was torn entireIy across just above the diaphragm and in that of TZndIer3s the Iaceration was transverse. The Ieft and posterior waIIs of the esophagus have most often given away and the right and anterior, Iess frequently. The tears have been from 3/4 in. to 2 in. Iong. The waIIs of the esophagus near the tears have frequentIy shown signs of chronic infIammation or other pathoIogy but in many cases nothing

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has been found which couId not be expIained by the vioIentIy acute process present in the mediastinum and pIeural cavity. The origin of the emphysema appearing first in the neck above the suprasternal notch has given rise to considerabIe specuIation. It most probabIy arises from air forced into the mediastinum from the stomach at the time of rupture or from the air in the pIeura1 cavity. It is we11 known that vioIent coughing or straining with or without trachea1 obstruction may be foIIowed by subcutaneous emphysema. The pneumothorax itseIf may arise from air in the stomach or from air swaIIowed after the accident and may therefore be deIayed at times for severa hours. The victims of spontaneous rupture of the esophagus have usuaIIy been men of an average of forty-two years, often aIcohoIics, who during the act of vomiting or retching have experienced sudden severe pain in the upper abdomen or Iower chest; most frequentIy in the Ieft Iower chest and back. The vomiting has aIways taken pIace after a fuI1 mea1 or at Ieast when the stomach was fuI1 and nearIy always some bIood has appeared in the vomitus. The pain has been of a severe character unreIieved by Iarge doses of morphine. The patients assume a sitting position stooping forward, or a simiIar position Iying on the invoIved side. They do not want to he ffat on their backs as in abdomina1 perforations. FrequentIy, they reIate that at the onset of their pain they had a feeIing as of something tearing or giving away in the Iower thorax. The patients are found in considerabIe shock with dyspnea and cyanosis as characteristic symptoms. If the rupture takes pIace into the pIeura1 cavity there wiI1 soon be evidence of pneumothorax, displacement of the heart, diminution of the breath sounds, changes in the expansion of the Iower chest and fItrid duIIness. These chest signs and symptoms wiI1 not be characteristic if the rupture extends into the mediastinum onIy and frequentIy not in the first few hours

Rupture

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when the rupture is into the pleura. Some patients compIain of an increase of pain on swaIIowing or eructating. A peculiar symptom has been the presence of emphysema appearing first above the suprasterna1 notch and spreading to the chest, abdomen, and even scrotum. This symptom has been present in two-thirds of the cases reported. The patients have compIained of more or Iess pain and soreness in the epigastrium or whoIe abdomen and muscIe spasm has usuaIIy been present. These symptoms have Ied in a number of cases to a diagnosis of an intra-abdomina1 perforation and unnecessary surgery. The whoIe clinica picture is one of a serious accident to the thoracic or abdomina1 viscera in which profound shock and sepsis rapidIy deveIop. The onset of this cIinica1 picture with vomiting foIIowed by abdomina1 pain, soreness, and muscIe spasm wiI1 require the ruhng out of such acute abdominal conditions as ruptured peptic uIcer and acute hemorrhagic pancreatitis. However, the pain referred to the Iower thorax, the marked dyspnea and cyanosis shouId Iead immediateIy to a carefuI examination of the chest. The presence of diminished breath sounds, pneumothorax, cardiac dispIacement, and fluid duIIness wiI1 justify a paracentesis of the pIeura1 cavity. If stomach contents are found in the asprrated is assured provided ffuid a diagnosis diaphragmatic hernia can be ruIed out. The x-ray is of vaIue in proving the presence of the pneumothorax, Iung coIIapse, and heart displacement. The diagnosis of the rupture in the esophagus by means of a barium meal, aIthough it might be concIusive, wiI1 not be practica1 because of the condition of the patient. In case the esophagea1 rupture is into the mediastinum onIy, an accurate diagnosis wiI1 be diffrcult. The x-ray with or without a barium mea1 wiI1 be heIpfu1. An examination with the esophagoscope wiI1 suffice if the patient can be controhed. The presence of emphysema in the neck wiI1 lead to at Ieast a suspicion of esophagea1 rupture. The treatment of a case of rupture of the

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esophagus, if one is so fortunate as to make an earIy diagnosis, wilI depend upon whether the rupture has taken pIace onIy into the mediastinum or into the pleural cavity on one side or the other. The rupture into the mediastinum wilI resuh in an extensive ceIIulitis more often than an abscess because of the force with which infected stomach contents is driven into the Ioose celluIar tissue of the mediastinum. An abscess may be diagnosed, opened and treated through an esophagoscope but the drainage of a mediastina1 cehulitis in this way wil1 be entireI\; inadequate. The lower posterior mediastinum has been drained for acute mediastinitis by removing the Iower ribs at the costovertebra1 angle on the right or Ieft side. The operation is known as posterior mediastinotomy. The serious condition of the patient, however, wiI1 make this procedure extremeIy hazardous and of doubtfu1 vaIue. When the rupture takes place into the pIeura1 cavity, free and prompt drainage of the cavity is imperative. In such a case, if the patient survives the infection of the pIeura and the accompanying mediastina1 invoIvement, he wiI1 deveIop an esophageal fistuIa which

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wiI1 probabIy cIose spontaneously. Feeding through a duodena1 tube or gastrostomy wiI1 of course be required. Later, diIation of the esophagus to prevent stricture wiI1 be necessary. RESLJME I. Rupture of the esophagus may foIlow vomiting. 2. Serious damage to the esophagus has folIowed the vomiting of pregnancy. 3. The ruptured esophagus has often been abnorma1 before the rupture. 4. ProbabIy a normal esophagus can be ruptured by vomiting. 3. Rupture of the esophagus from vomiting can occur only when the stomach is fuI1. 6. Abdominal pain, soreness, and muscIe spasm suggest intra-abdomina1 pathoIogy. 7. Thoracic pain, dyspnea, _ cyanosrs, -‘emohvsema of the neck. and ohvsical signs m the chest folIowing vomiti& should suggest esophagea1 rupture. 8. In rupture into the pIeura, thoracotomy is imperative. g. A case of spontaneous rupture of the esophagus following vomiting is reported.

REFERENCES I. ADAMS, W. Rupture of the oesophagus caused by vomiting. Trans. Path. Sot., 29: I 13, 1878. 2. ALLEN. Rupture of the oesophagus caused by vomiting. Am. J. M. SC., 73: 17-22, 1877. 3. BAILEY. Rupture. N. York M. J., 18: 5 17, 1873. Pbila. M. Times, 3: 460, 1873. 4. BENEKE, R. Oesophagusruptur und Oesophagomalacia. Deutscbe med. Wscbr., 30: 1489, 1904. 5. BOERHAAVE. Rupture of the oesophagus caused by vomiting. Lisaband, Hist. Anatom. Medica., 2: 311, 1767. Atrocis net. descripti prius Morbi Historia secundem Artes Leges Conscripta, Ludg. Batav., 1724. 6. BOWLES, R. L., and TURNER, G. R. Case of rupture of the oesophagus with table of 17 other cases. Med. Cbir. Trans. 83: 240-255, 1900. Abst., Lancet, I: 930, 1900. Brit. M. J., I: 763, 1900. 7. BOYD, S. Rupture of the oesophagus caused by vomiting. Trans. Path. Sot., 33: 125, 1882. 8. CHARLES. Dublin Quart. J. M. SC., I : 3 I I, I 870. 9. CHRISTIE, G. W. Perforation of ulcer of the oesophagus foIIowing vomiting. Lancet, 2: 17, 1915. IO. COHN, F. Beitrag Zur Kasuistic der Spontanen Oesophagusruptur 8”, Jcna, 19. Frommannsche Buchdruckereie, 1907.

I I. DRYDEN, J. Rupture from vomiting. Med. Comment, Edinb., 3: 308-12, 1788. 12. FITZ. Rupture of the healthy oesophagus. Am. J. M. SC., n. s., 73: 17-36, 1877. 13. FOSTER, T. W. Med. c+ySurg. Rep., PhiIa., 3: 5 13, 1859. 14. GRAMATZICI. Inaugural Dissertation, Konigsberg, 1867. Ueber die Rupturen der Speiserohre. 15. GRIFFIN, J. Rupture of the Oesophagus caused by vomiting. Lancet, 2: 337, 1869. 16. GUERSENT. Bull. Fat. de Med. de Paris, I : 73, 1812. 17. HABERSHON.Diseases of the Abdomen. Rupture of the Oesophagus caused by vomiting. Ed. 2, Chicago, Chicago Med. Bk. Co., 1862. 18. HARRISON, C. E. A case of rupture of the oesophagus. Lancet, I : 784, 1893. 19. HEATH. Rupture of the oesophagus caused by vomiting. Reported by Stanley Boyd. Trans. Patb. Sot., 33: 1882. 20. HEINTZE. Freie Vereinigung der Chirurgen Bert. Sitzung vom Feb. 12, 1900. 21. HEYFELDER. Tr. Path. Sot., London, 33: 123, 1837. 22. HOWSE. Rupture of the oesophagus caused by vomiting. Lancet, I : I 13, 1884. 23. KING. Guy’s Hospital Rep., S. 2, I : 113, 1843. [For Remainder of References see p. 516.1

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operatively in all cases. Three patients are Iiving and report to the cIinic reguIarIy for periodic examinations. Results: Three patients are Iiving and three are dead. The average Iength of life after operation was six years. The three living patients report reguIarIy to the cIinic for periodica examinations.

Breast

Cancer

SEPYEMBER, rpj1

In our opinion the x-ray therapy administered foIIowing operation hindered the further growth of the disease and heIped proIong the life of the three Iiving patients. From our observation in these cases, we beIieve it is equaIIy advisabIe to irradiate carcinoma of the breast in the maIe, as it is in the femaIe.

REFERENCES BLODGETT, A. N. Cancer of the breast in a child. Boston M. ti S. J., 136: 611, 1897. BRYAN, R. C. Cancer of the breast in a boy fifteen years otd. Surg., Gynec. Obst., 18: 545-546, 1914. DEAVER, J. B., and MCFARLAND, J. The Breast: Its Anomalies, Its Disease and Their Treatment. Phila., Blakiston, 1917, p. 484. ELBOGEN, G. A. Zur Kenntnis Von Paget’s Disease Of The NippIe, Festchr Hans Chiari Seines 25 Jahrige. Professoren-Jubilaums Gewidmet Von Seinen SchuIern. Leipsic, WiIheIm BraumuIIer, rgo8, pp. 143-156. FORREST, R. W. Case of cancer of the mamma in the male preceded by a so-called eczema of the mammary areoIa: Paget’s disease of the nipple. Glasgow M. J., 14: 457, 1880. JONAS, E. Paget’s disease of the nipple: report of an interesting case. Interstate M. J., 17: 647, 1910.

REFERENCES

JUDD, E. S., and MORSE, H. D. Carcinoma of the maIe breast. Surg., Gynec., Obst., 42: 15, 1926. LUNN, J. R. A case of cancer of the breast in a man aged 91. Tr. Path. Sac., London, 48: 247, r896I 897. PAGET, J. Disease of the mammary areoIa preceding cancer of the mammary gland. St. Bartholomew’s Hosp. Rep., IO: 87, 1874. RUBENSTEIN, M. W. Paget’s disease of the male nipple and areoIa. Arch. Dermat. t?ySypbil., 22: 281, 1930. SEKIGUCHI, S. Studies on Paget’s disease of the nipple and its extra-mammary occurrence. Ann. Surg., 65: 175, 1917. WARFIELD, L. M. Carcinoma of the maIe breast. Butt. Johns Hopkins Hosp., 12: 305-310, 1901. WILLIAMS, W. R. Cancer of the male breast, based on the records of one hundred cases, with remarks. Lancet, 2: 261-263, 310-312, 1889.

OF DR.

37. 24. LEYDEN. Rupture of the oesophagus caused by vomiting. Gramatzki, Ueber die Rupturen der 38. Speiserohre. 25. LINDERMAN. Miincber.. med. Wcbnscbr., No. 26, p. 493, JuIy 28, 1887. 26. LINDSAY and SMITH. Tr. Roy. Acad. M., Dublin, 39. 17: 53, 1899. 27. Mayo CIinic. Stricture of the oesophagus following the vomiting of pregnancy. 13: 6, 1921. 40. 28. MCKENZIE. Diseases of the Nose and Throat. New York, W. Wood Co., 1884, vol. 2. 41. 29. MCREYNOLDS, J. 0. Laryngoscope, 17: 633, 1907, 30. MCWEENEY, E. J. Rupture of the oesophagus. Lancet, I: 940, 1900. Spontaneous rupture. Tr. Royal AC. M., Ireland: 8: 393-415, 1899. Also, 42. Lancet, 2: 158-64, 1900. 43. MENNE, F., and MOORE, C. Rupture of the 31. oesophagus. Arch. Ped., 38: 672, 1921. 32. MEYER. Rupture of the oesophagus caused by 44. vomiting. Med. verein Zeitung in Preussen. Nos. 45. 30, 29-41, 1858. 33. MILLER, G. I. LJnexpIained rupture of the Oesophagus. Post Graduate, N. Y., 26: 312-17, 1911. 34, OPPOLZER. Rupture of the oesophagus caused by 46. vomiting. Wien. med. Wcbnscbr., I : 65, 1851. 35. PINTO DE MAGALHAES, A. C. As Rupturus Espontaneas do Esophago. Med. con.temp., Lisb., 29: 47. 129, 177. 1911. 36. RAESTRUP. Spontane Zerreissung der Speiserohre. Deutscbe Ztscbr. j. d. ges gericbtl. med., I I: 37348. 379, 1928. * Cant inued from

SMEAD*

ROY, D. W. A case of ruptured oesophagus. Lancet, 2: 1765, 1911. SCHULTZ, 0. H. A case of traumatic rupture of the cardiac orifice of the oesouhaeus. orobabIv caused by vioIent vomiting. Proc. New York Path. Sot., 7: 138, 1907-8. TKNDLER. Rupture of the oesophagus caused by vomiting. Deutscbe Ztscbr. j. prakkt. Med., 5: 613, 1878. WALKER, I. J. Spontaneous rupture of the heaIthy oesophagus, J. A. M. A., 62: 1952-1955, 1914. WATKINS, R. W. A case of spontaneous rupture of the oesophagus. Tr. Chicago Patb. Sot., I I : 23, 1919. WATSON. &it. M. J., 2: 1182, 1912. WEST, S., and ANDREWS, F. W. Rupture of a healthy oesophagus by the act of vomiting. Tr. Path. Sot., Lond., 48: 73-77, 1896-7. WHIPMAN. L,ancet, 2: 749, 1903. WILLIAMS, C. J. B. Rupture of the oesophagus and diaphragm induced by vioIent vomiting. Tr. Path. Sot., Lond., I: 151. 1846-8. WILLIAMS, T. H., and BOYD, W. Spontaneous rupture of the oesophagus. Surg. Gynec. Obst., 42: 57-60, 1926. WOLFF, L. Two cases of rupture of the oesophagus. Med. News Phila., 64: 516-518, 1894. Med. News, London, 64: 516, 1894. ZENKER. Cases. Cycl. Prat. M., N. Y., 8: go, 1878. p. 501