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rynx, between it and the cervical vertebræ. It is not a frequent, but is nevertheless an important complaint. When behind the upper part of the pharynx, it may be known by a projection in the back of the fauces, visible to the eye when the jaws can be sufficiently opened, and sensible to the finger, which at the same time detects fluctuation. When lower down, it is not so easily recognized. Deep-seated pain in the region of the pharynx, tenderness upon pressure from without, stiffness of the neck, great difficulty of deglutition followed by absolute inability to swallow, suppression of the voice, and the most distressing dyspnoea, attended with laborious efforts to inspire, are symptoms which should lead the physician to suspect its existence, and, if it be invisible, to attempt by the careful introduction of a stomach tube to ascertain whether the passage is closed. The danger arises partly from inanition, but chiefly from pressure upon the larynx, producing suffocation. Several fatal cases are on record; and it is probable that others have occurred, which have been mistaken for laryngeal disease. The chief diagnostic symptoms are the seat of pain, and the inability to swallow. There is usually considerable fever, and sometimes cephalic symptoms, which tend to direct attention away from the real danger. The abscess is more dangerous in the lower than the upper part of the pharynx.

This affection may attend the advanced stage of certain fevers, or may result simply from inflammation of the pharynx. It may also be produced by disease of the cervical vertebræ. As hitherto observed, it has been most common in children under four years; but it may occur at any age.

The treatment consists simply in opening the abscess; and the chief cautions requisite are to avoid making too deep an incision, and to strike as nearly as may be the middle line, so as to avoid any considerable artery. Dr. Abercrombie relates three cases of children, who were apparently rescued from suffocation in this way. Should the abscess be out of sight, and beyond the reach of the finger, the cutting instrument should be sheathed in a tube, until in contact with the tumour.*

Article IV.

INFLAMMATION OF THE ESOPHAGUS, or ESOPHAGITIS.

This is a very rare affection, unless originating from the direct application of irritating substances, or from mechanical violence.

Symptoms, &c.—A sense of heat and of pain, increased by swallowing, and frequently referred to the lower extremity of the pharynx, or to the cardiac orifice of the stomach, no matter what part of the tube may be affected, is the earliest symptom. Sometimes the pain is felt between the shoulders, or is referred to the larynx. Tenderness upon strong pressure from without is experienced, if the disease is seated in the upper part of the oesophagus. Deglutition is usually more or less difficult, and sometimes impossible. The complaint is said to be frequently attended with hiccough, and sometimes with the eructation of a glairy mucus, and with vomiting. There is usually little or no fever. The inflammation generally terminates by resolution, though suppuration sometimes takes place, and an abscess may form between the mucous membrane and the muscular coat. Ulcers occasionally result. The inflammation may also be of the pseudo-membranous character, in which case

For an elaborate account of this affection, the reader is referred to an article by Dr. Charles M. Allin, in the New York Journal of Medicine (N. S., vii. 307).

it is usually propagated from the fauces or larynx, though it does occasionally originate in the oesophagus, and has been known to occupy its whole extent. The vomiting of flakes, or a tube of false membrane, would lead to the suspicion of its character. In some cases of oesophagitis, the mucous follicles are exclusively affected; but this cannot be ascertained during life. The disease occasionally becomes chronic, in which case we have the ordinary symptoms of the acute in a moderated form, and especially a copious discharge of mucus by the mouth.

Causes. The usual causes are acrid, corrosive, or very hot substances swallowed, and mechanical violence from sharp, rough, or hard bodies introduced into the oesophagus, or from undue efforts by the surgeon in the use of the stomach tube, the bougie, or the probang. The disease may also be propagated downward from the fauces, or upwards from the stomach. It has been ascribed, in some instances, to the retrocession of cutaneous eruptions, and of rheumatism. There is little doubt that the muscular coat sometimes becomes the seat of the latter affection.

Treatment.-Venesection when the pulse is strong and excited, saline cathartics, stimulating pediluvia, a liquid farinaceous diet, repeated leeching or cupping, emollient poultices, and, in the advanced stages, blisters upon the neck or between the shoulders, constitute the chief remedies. In chronic cases, revulsion should be sustained by a perpetual blister, by pustulation with croton oil or tartar emetic, or by a seton. Should the case not yield to other measures, mercury should be resorted to; and this should be employed early, if there is reason to believe that the inflammation is pseudo-membranous. When inability to swallow exists, attempts may be made to support the patient by nourishing liquids injected into the bowels.

Article V.

STRICTURE OF THE ESOPHAGUS.

1. ORGANIC STRICTURE.-The consideration of this subject belongs proper ly to the surgeon; as it is by surgical means that relief is to be afforded. A few remarks, therefore, will be sufficient. The complaint is indicated by difficulty of deglutition, at first moderate, but gradually increasing so that the patient can at length swallow nothing but liquids, or ceases to swallow even these, and dies of inanition. Sometimes, however, the stricture continues many years without perceptible increase. It may arise from thickening of the coats consequent upon inflammation, from contraction produced by the healing of an ulcer, from excrescences growing out of the mucous membrane, from cancer, from cartilaginous or osseous degeneration of the tube, or from the pressure of exterior tumours. Among its effects is a dilatation of the oesophagus above the place of stricture, sometimes to a very great extent. When there is much pain, leeching, blistering, and narcotics may be employed. When it originates in inflammation, some advantage may be hoped from a careful course of mercury, or the internal and local use of iodine. Caustic to the strictured part has been employed by some English surgeons; but the only means upon which much reliance can be placed is the use of the bougie. 2. SPASM OF THE ESOPHAGUS.-This is a morbid muscular contraction of the tube producing more or less difficulty of swallowing.

Symptoms.-The spasm generally comes on suddenly, often, for the first time, during a meal. Upon an attempt to swallow, the food is arrested, and is either rejected immediately and with force, or is retained for a time, and

then rises by regurgitation. The former event is apt to occur when the stricture is near the upper extremity, the latter when it is near the lower. Occasionally, after the food has been a short time in contact with the stricture, this gives way and allows it to pass into the stomach. In some instances, solids can be swallowed better than liquids, and the reverse is sometimes the case; but in general any sort of food is sufficient to excite the spasm when the morbid susceptibility exists. Severe pain often attends the spasmodic action, and the irritation occasionally extends to the larynx or lungs, producing much embarrassment of respiration, with a feeling of impending suffocation. Even where no effort at deglutition is made, there is frequently present a sense of constriction, and, in some cases, a feeling as of a ball ascending in the throat, or moving from one part to the other. This is the globus hystericus of older writers. Hiccough and vomiting sometimes accompany the affection. Its duration is exceedingly various. An attack may consist of a single paroxysm, lasting only a few hours, or the spasmodic action may continue with exacerbations and remissions, and occasional complete intermissions, for months or years. Like most other nervous affections, it sometimes assumes the regular intermittent form.

From organic stricture, the only complaint with which it can be confounded, it may in general be readily distinguished by the suddenness of the attack, by the occasional absence of all the symptoms, so that the patient can swallow easily, and by the other evidences of nervous disorder with which it is frequently attended. A large bougie can also be passed with facility in periods of relaxation, and, even when arrested by the spasm, if held for some time against the stricture, will often be allowed to enter.

Causes. Irritation of the mucous coat, from whatever cause, may produce the spasm when a predisposition to it exists. It is sometimes excited by inflammation of the oesophagus. Among the causes may be mentioned acrid substances swallowed, cold drinks during perspiration, partial exposure to cold air, violent and depressing emotions, the operation of the imagination, and the influence of disease existing elsewhere, as of dentition, organic affections of the larynx, stomach, and uterus, and inflammation of the upper part of the spinal marrow. The predisposition usually consists in an excitable state of the nervous system, such as exists in hysteria, hypochondriasis, and generally in a debilitated and anemic condition of body.

Treatment. The indications of cure are first to relieve the local affection, and secondly to correct the predisposition. The first is answered by remedies suited to relax the spasm directly, and to diminish the nervous excitability of the part, so as to prevent the disposition to its recurrence. If inflammation exist, it should be removed by the means already indicated. If the affection be purely nervous, recourse may be had to narcotic cataplasms, as of tobacco, henbane, or hemlock, to acetate or sulphate of morphia upon a blistered surface, to rubefacients, epispastics, pustulating substances, or a seton applied to the back of the neck, and to the internal use of antispasmodies and narcotics, such as assafetida, valerian, Hoffmann's anodyne, camphor, opium, henbane, and hemlock. Much good is said to have resulted from very cold drinks, and even ice swallowed by the patient.

To meet the second indication, remedies must be employed calculated to remove the disease of other organs with which the spasm may be associated, and to correct any existing morbid state of system. These remedies are detailed elsewhere. It is sufficient here to mention that it is usually desirable to invigorate the general health by chalybeates or other tonics, exercise, fresh air, a nutritious diet, the avoidance of coffee, tea, and tobacco as habitual luxuries, and attention to the bowels and the various secretions. Strychnia

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has been employed successfully in one severe case by M. Mathieu. plete cure was effected in six weeks. (Journ. de Pharm., 3e sér., xxii. 390.) In the regularly intermittent form of the complaint, sulphate of quinia will prove effectual.

SUBSECTION III.

DISEASES OF THE STOMACH.

Article I.

INFLAMMATION OF THE STOMACH, or GASTRITIS.

The inflammation in this disease is usually seated in the mucous membrane, and the submucous cellular tissue; though it sometimes extends to the other coats, and may even involve the whole stomach. The peritoneal coat is seldom exclusively affected, unless in cases of general peritonitis, to which disease, therefore, inflammation of that coat properly belongs. Gastritis exists under the two forms of acute and chronic. Some make an intermediate grade which they call subacute; but there is scarcely sufficient ground for this distinction in any peculiarity of character, or precise degree of violence. Acute Gastritis.-This is not common as an independent affection, though frequently associated with other diseases, of which it may be either an effect, or a mere attendant, having its origin in the same cause. Few organs resist so firmly the ordinary direct causes of inflammation as the stomach, and few are so readily affected through the sympathies. The object of this provision is evident. An organ so important in its functions, and so much exposed to irritant influences from without, would be constantly suffering, and causing the system to suffer, if readily excited into inflammation by such influences; while, if undisturbed by inflammation, or morbid excitement in other organs, it would continue to furnish, through the function of digestion, materials to the blood calculated to sustain the discase.

Symptoms. In severe cases of acute gastritis, there is usually a burning pain in the epigastrium, with incessant nausea and vomiting, commencing with the attack, and continuing, with greater or less intensity, till near the close. The pain is increased by pressure from without, and by a deep inspiration, and is sometimes excruciating in the act of vomiting. The substances thrown up from the stomach are at first the food or chyme, and afterwards bile or mucus, and whatever may be swallowed, and are sometimes more or less deeply tinged with blood. There is occasionally considerable difficulty of deglutition, in consequence of spasm of the oesophagus or cardiac orifice. The thirst is intense, and the patient is constantly calling for cold water, although, if taken freely, it produces uneasiness and oppression by the distension of the stomach, and is often immediately rejected. The tongue is at first usually covered in the middle and posterior part with a whitish fur, while its tip and edges are red, and red papillæ are visible through the coating; but sometimes it is red, smooth, dryish, and without fur, from the commencement. The bowels are almost always constipated, unless they partici pate in the inflammation, in which case they are looser than in health. The patient lies on his back, is apt to be low spirited, is restless and wakeful, and has a feeling of great debility, with an expression of face indicating anxiety and distress. The pulse is frequent and sometimes full, but usually smalland corded; the respiration often short and hurried; the skin hot and dry;

and the urine high coloured. A hard, dry cough, occasionally paroxysmal, is also mentioned among the symptoms.

Should the disease now take a favourable turn, the pain and vomiting abate; the tongue becomes paler and moister, the pulse slower, fuller, and less corded, the skin cooler and softer; and sometimes a general moisture of the surface, or relaxation of the bowels, evinces that the crisis is passed. But, should it advance unfavourably, the tongue, if before coated, becomes smooth, red, and dry, and towards the close is occasionally covered, as well as the inside of the cheek, with a thrush-like exudation; the skin becomes cool and pale, and the pulse more frequent, feeble, and thread-like; the body emaciates rapidly; debility and restlessness increase; delirium frequently occurs; hiccough harasses the patient; active vomiting is succeeded by mere regurgitation; instead of mucus or bile, a black matter like coffee grounds is sometimes ejected; the tenderness on pressure diminishes, and pain sometimes ceases entirely; the countenance sinks, and assumes a haggard aspect; and death occurs, preceded by cold extremities, a scarcely perceptible pulse, and other evidences of extreme exhaustion. The complete suspension of pain, without amelioration in other respects, is an unfavourable sign. In some rare instances, in the latter stage, the pain suddenly increases and becomes more diffused, and extreme tenderness upon pressure is felt over the whole abdomen, which swells and assumes a tympanitic condition. In such cases, the stomach has been perforated, and peritoneal inflammation has been produced by the fluids which have escaped through the opening. Inevitable death speedily follows this event. When the stomach has been disorganized from the commencement by the violence of the cause, as when one of the concentrated mineral acids has been swallowed, great prostration comes on almost immediately, with a cold, clammy skin, and a very feeble pulse; and death soon takes place.

In milder forms of the disease, the symptoms above enumerated as characterizing the earlier stages, are experienced in a less degree. Sometimes, instead of severe pain, there is merely a feeling of oppression, weight, or constriction; instead of obstinate and incessant vomiting, merely a slight nausea, or a disposition to vomit ingesta. The pulse, too, in such cases, is usually more full and developed. Epigastric tenderness is seldom absent. Occasionally, even in severe gastritis, there is a want of all the characteristic symptoms; so that the first evidence of the nature of the complaint is afforded by dissection. This is sometimes attributable to the fact, that secondary or sympathetic affections, such as severe headache or delirium, pains in the back or limbs, or irritation of some portion of the pulmonary apparatus, become so prominent as to act revulsively in relation to the gastric sensibilities, and thus to mask the real disease. When gastritis attends other diseases, it is peculiarly liable to be thus concealed, as in the delirium of drunkards which immediately follows an occasional debauch, and in which it is highly important that it should be recognized. (Stokes.) The duration of acute gastritis is very variable. In violent cases, as from corrosive poison, death, in some instances, takes place in less than twenty-four hours; while in others, the disease continues from two to six weeks, and then, if not fatal, ends in a slow convalescence, or subsides into chronic gastritis of indefinite duration. Milder cases often yield speedily to appropriate treatment; but, if not taken in time, may run on for weeks, and at last assume the chronic form.

Anatomical Characters.-The stomach is more or less contracted, sometimes so as not to exceed the transverse colon in size. The mucous membrane is often much wrinkled, and sometimes covered with a viscid or puruloid mucus, upon the removal of which it exhibits the usual marks of inflammation. The colour is either bright-red, brownish, or livid-red, or blackish-brown, and

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