The anatomical variations of the Plummer-Vinson stricture in the cervical oesophagus. An X-ray atlas.

The radiologists of the Royal Victoria Hospital have kindly allowed this compilation to be made from the ample collection of their x-ray records. The purpose is to improve diagnosis of the Plummer-Vinson stricture, a lesion often not identified, even when the patient complains of difficulty in swallowing. If there has been too often a failure on the part of our profession to understand the obstructive nature of this dysphagia, and to have insight into the patient's description of her symptoms, it is because this lesion cannot be examined by any physical method, or by pharyngoscopy, or by laryngoscopy. Because there is no way for him to experience it, the lesion has not taken form in the mind of the doctor. It has not achieved perception and cognition, and so it has not entered his diagnostic repertoire. Only a minority diagnose the stricture promptly from the history alone. Clinical descriptions have not been sufficiently educative, and it seems they never will. There is one way in which the stricture can take form in the doctor's mind, and that is by him making himself familiar with the x-ray appearances. A further advantage of x-ray study is that it disposes of old theories of "hysteria", "spasm", "nervousness" and "globus hystericus". It shows the stricture, and shows it unchanged and unchanging, unless and until it is dilated, or unhappily becomes carcinomatous. The stricture is the precursor of the postcricoid carcinoma. Endoscopy and endoscopic reports, valuable though they are, are not so constructive of a mental form for the lesion as is radiology. Only the endoscopist, and no one else, sees the endoscopic appearance. There is no photographic record. Even for the endoscopist the vision is transitory. The lesion is modified as the instrument passes. Comparison of one stricture with another is difficult or impossible. Moreover, the endoscopic sensation of tightness has helped to perpetuate false ideas of "spasm". Endoscopy and dilatation are the essential treatment of the stricture (Bingham and Logan, 1953), and endoscopy is of great diagnostic value in confirming or excluding obstruction, or carcinoma, but for studying the pathology these are not sufficient methods. The x-ray plates are available to everyone, are a permanent record, efficiently demonstrate the morbid anatomy and can be compared one with the other. The stricture takes the form of a single web, or of two webs, or of a long stricture of cuff or sleeve type, or of web and cuff combined, or, less frequently, of a general contraction of the cervical oesophagus or of a segment of it. The