Reply to Giri and Sarkar Free

We would like to thank Giri and Sarkar [1] from Sheffield for their interest in our images case. Medical eponymous for post emetic rupture of the oesophagus scarcely represents the tremendous heritage of Herman Boerhaave (1668 Voorhout–1738 Leiden) on contemporary human science. In 1724, printed by Officine Boutesteniana in Lugdunum Batavorum (the Roman appellation of the city of Leiden in Netherlands, not to be confused with Lugdunum ‘Gallorum’ city of Lyon in France), H. Boerhaave reported ‘Atrocis, nec descripti prius, morbis historia. Secundum medicae artis leges conscripta’ that could be translated as ‘History of an atrocious disease not previously described. Written in the rules of medical science’. The complete English translation of this interesting document of the history of medicine exists in free access at the PubMed Central, thanks to the work of Derbes and Mitchell [2]. As a curiosity, Cirocco [3] has postulated that on the basis of clinical presentation, Alexander the Great could have died from a post emetic oesophageal rupture, unless it seems unconvincing that Alexander could have survived 14 days with such an atrocious disease.

In his time H. Boerhaave concluded that there was no means of treating this disease and interestingly he was nihilistic about the possibility of performing a thoracic paracentesis (paracentesis est sectio, per quam fit vulnus penetrans in corporis cavitatem) because of suffocation caused by secondary pneumothorax (i.e., fuga vacui). His pessimism was justified as it was not until two century later that a successful treatment was reported. In this sense, we found E.A. Graham at the University of Washington to be the first author to report a successful treatment of the disease, however, we could not obtain the correlated document that appeared as editorial comment in the Yearbook of General Surgery in 1944. Apparently, like N.R. Barrett, also A.M. Olsen and O.T. Clagett reported in 1947 in Postgraduate Medicine Journal, a case of survival treated by left thoracotomy and direct suture of the oesophageal tear.

Indirect radiological signs of oesophageal perforation are almost always present in chest X-ray such as pneumomediastinum and left-sided hydro-pneumothorax; other much rarer reported signs on chest X-ray have been the ‘continuous diaphragm’, and the ‘V sign’ of Naclerio. No doubt the radiological demonstration of pleural extravasated contrast medium during oesophagography leads to diagnostic certainty, but false-negative results have been reported and in this sense CT-scan would be much more sensitive in demonstrating the presence of extra-oesophageal air [4]. A dye (methylene blue) swallowed with a previously positioned pleural drain could also be a very fast and sensitive method to confirm the diagnosis of oesophageal perforation.

Since the end of World War II various methods of treatment have been proposed and more recently the endoscopic insertion of a self expandable metal stent [5]; unless this latter technique could be considered as efficacious for oesophageal fistula exclusion, we believe that to arrest the ongoing contamination of mediastinum and pleura a complete removal of the ‘last meal’ is firmly opportune.

References