in which there was much disease of the glands in the posterior mediastinum, and a communication between the œsophagus and an abscess in the left lung.* 8... Aneurism of the aorta. I have seen several examples of this affection, and the symptoms had not been such as to excite any apprehension of the disease, until the fatal event took place by rupture into the oesophagus. I have described one remarkable case in which the fatal attack was complicated with ramollissement of the spinal cord. In another, a gentleman, in the vigour of life, there had been for a few weeks difficulty of swallowing, which on some days was considerable, so as to oblige him to stop in the middle of a meal, and on other days was almost gone. There was no other symptom, and in the morning of the day on which he died, he ate his breakfast well, and swal lowed without difficulty. In less than an hour after he was seized with copious vomiting of blood, and died in two hours. Another case has been related to me, in which a probang was passed, under the idea of stricture of the œsophagus; it occasioned rupture of the aneurism, and almost immediate death. 9. Disease of the Cardia. This has been already briefly referred to. 10. Dysphagia appears to exist, assuming all the characters of a fixed disease of the oesophagus but really connected with a morbid irritability, or some degree of inflammatory action, of a part of its mucous membrane. This is, probably, the affection which has been called spasmodic stricture of the œsophagus; but the indefinite doctrine of spasm will certainly not account for it. My attention was first particularly drawn to the disease by the case of a lady 40 years of age, who had been under treatment more • Kunze de Dysphagia. than a year, for what was considered a stricture of the œsophagus, accompanied by all its usual symptoms. Various courses of medicine and the frequent use of bougies had been employed without benefit. I scarcely know what induced me to propose, instead of the bougies, an egg-shaped silver ball, attached to a handle of silver wire, to be passed occasionally through the stricture, which felt to be at the distance of about four inches below the pharynx. To my astonishment, the affection was completely removed, by four or five applications of this instrument. The patient continued well for more than a year, and then had a return of the complaint, which was removed in the same manner; and she had afterwards several slight returns of it, which always yielded readily. The attacks of the affection were generally ascribed to cold, and were preceded by some degree of tenderness of the pharynx, and a feeling of rawness and tenderness a short way down the oesophagus. I have no doubt that they depended upon a superficial disease of the mucous membrane, at a particular spot; but the precise nature of it I cannot determine; and I confess myself unable to explain the speedy removal of the complaint, by the means which I have mentioned, especially in the first attack, when it had continued for more than a year, with all the characters of a severe and permanent stricture. In an interesting case described by Dr. Cumin, the affection came on in connection with dyspeptic symptoms, with vomiting and great derangement of the bowels, produced, in a young woman, by want of exercise in attendance upon a sick relative. Pain was felt behind the cricoid cartilage, and articles swallowed were rejected with a sense of choaking and stricture of the gullet. She derived immediate relief from passing a large elastic gum catheter through the part, the vomiting and the spasms of the gullet having ceased immediately. After some time the symp toms returned, and were again removed in the same manner. She was then sent to the country.* For numerous interesting facts relating to what has been called the spasmodic stricture of the œsophagus, as well as to the whole subject of dysphagia, I refer to the learned work of Dr. Monro.+ 11. Mr. Mayo has described a remarkable case of fatal dysphagia connected with a dilated state of the œsophagus. The affection had existed in a greater or less degree for about ten years, and was at length fatal by gradual exhaustion. Articles that were swallowed lodged for a few minutes and then were brought up again, very small quantities only appearing to reach the stomach. The oesopha gus at the upper part was healthy, but about half an inch below the pharynx it began to enlarge and gradually acquired an extraordinary degree of dilatation. Its greatest enlargement was about four inches above the cardia; it then contracted abruptly, and an inch of the lower extremity was healthy. The inner membrane of the dilated part was opake and thickened, and was marked by numerous longitudinal furrows, and by numerous depressions of various sizes and figures. This singular affection must have been connected with a total loss of the muscular action of the dilated part. Dilatations of a more limited kind have been observed, as in a case by Marx, in which a part of the oesophagus was dilated into a cyst five inches long and three broad. 12. Dislocation of the Os Hyoides. An eminent medical man, now deceased, was liable to this accident, and I have seen him seized with it in an instant, while engaged in conversation. It produced slight difficulty of articulation Trans. of the Med. Chirurgical Society of Edinburgh, yol. iii. and total inability to swallow. He easily relieved himself by a particular movement of the parts with his hand, which had become familiar to him from the frequent occurrence of the accident. A man mentioned by Dr. Mugna,* while swallowing a large morsel of tough beef, suddenly experienced a sensation as if it stuck at the entrance of the œsophagus, and immediately lost all power of deglutition. A sound having passed without difficulty, Dr. Mugna suspected dislocation of the os hyoides. He accordingly introduced the fore and middle fingers of the right hand beyond the root of the tongue, and, on moving the parts a little by the left hand applied to the front of the neck, the affection was speedily removed. SECTION III. DISEASES OF THE DUODENUM. FACTS are wanting on this interesting subject, but it is probable that the duodenum is the seat of several diseases, which are apt to be mistaken for affections of the stomach or the liver. The leading peculiarity of disease of the duodenum, as far as we are at present acquainted with it, seems to be, that the food is taken with relish, and the first stage of digestion is not impeded; but that pain begins about the time when the food is passing out of the stomach, or from two to four hours after a meal. The pain then continues, often with great severity, sometimes for se • Annali Universali, quoted in the Medical Gazette, vol. iv. veral hours, and generally extends obliquely backwards in the direction of the right kidney. In some cases, it gradually subsides after several hours, and, in others, is relieved by vomiting. The peculiar characters of disease of the duodenum are well illustrated by a case related by Dr. Irvine, in the Medical Journal of Philadelphia for August 1824. The patient was liable to attacks of pain and vomiting, which at first occurred at long intervals, but gradually became more frequent, until they occurred regularly every day. His appetite was good, and the functions of his stomach were unimpaired for two, three, or four hours after a meal. He was then seized with violent pain, followed by vomiting, and the pain did not cease till the stomach was completely emptied. He died gradually exhausted, in about six months from the time when the attacks began to occur daily. About three weeks before his death, a tumour was felt in the right hypochondrium, which after eight or ten days subsided. On inspection, the stomach was found distended but healthy, and the liver was sound. The duodenum was enlarged and hardened, and internally showed an extensive surface of ragged ulceration. It was also studded with tubercles, varying in size from that of a hickory nut to a hazel nut. In the largest there was a soft white matter, and the cavity of the duodenum contained about four ounces of pus. In a case by Broussais, the symptoms seem to have been very obscure, or rather are slightly detailed. A man, 63 years of age, had suffered much from dyspeptic symptoms, which were alleviated by a careful diet. He underwent amputation of the arm, after which he had pain in the epigas On the tenth day tric region with a feeling of pulsation. after the operation, he was seized with coldness, paleness, and convulsive movements, and soon died. The intestinal |