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venience, when but slight weight will be felt; but retain the weight for some time in the same position, and the feeling of weight will gradually intensify, but will never attain to the same degree of intensity as in the first experiment. The expenditure of force by friction, before reaching the condyles, sufficiently accounting for such diminution; and its more tardy recognition is equally satisfactorily accounted for, from the force, in this instance, having to travel obliquely, and also at a greater distance from the seat of perception than in the former case. Such a contrast, under circumstances so similar, can, I think, only be accounted for by an hypothesis, either similar or identical with that here maintained.
Expeb. HI.—Let the same weight be placed on the upper lip, immediately below the nose, the countenance looking upwards—in this position the amount of weight experienced will be little different to that in the last experiment; but it will be much sooner felt, since it has a much shorter course to run along the zygomatic arch to the occipital condyles, but, from the narrowness of the bridge or arch, much of the force must be expended in other parts ere it reaches, if it ever does, the desired point; hence the weight felt, though a shorter course to run than in the second, is not increased by taking such a course. Of course, experiments can be tried at any point between the 1st and 3d experiments; but it will be observed, that the quickness with which weight is felt will bear a strict relation to the distance the gravitating body is placed from the occipital condyles, and also the intensity of weight experienced from any given body placed upon any of these parts, cceteris paribus.
The transit from the last experiment, where the superior maxillary bone was the resting point, to the inferior, is natural and easy. This bone, the inferior maxillary, articulates with the temporal bone in the glenoid fossa: between the head of the inferior maxillary bone and the fossa is placed an articular fibro-cartilage, on either surface of which is a synovial sac; but, as age advances,the fibro-cartilage mostly becomes absorbed towards its centre, and the synovial membranes are almost defaced at this point. The thinness and hardness of the fibro-cartilaginous disc makes this structure capable of transmitting force to the synovial membranes, without much interruption to their natural course. Moreover, if it did not so act, one membrane is always free to receive impressions from force channelling along the osseous tissue: since it is placed between two synovial membranes, both of which are placed in juxta position with the bony articular surfaces; hence any heavy body is felt when balanced on the chin, as well as elsewhere.
But it will be asked, why, if this bone has articular surfaces adapted to take cognisance of weight, do we not feel weight, of a greater or less degree, at all times when masticating food 1 It has been before stated, that a feeling of strength was the normal or uncounterpoised state of this sense, and that weight was the result of gravity counterpoising muscular force; now, the very end of mastication implies, a priori, that the thing acted upon is inferior, or in subjection, to the masticating power, or else why attempt to subject it to such a process? And, if subject to it, it cannot be upon a parity with it, or a counterpoise, but, so far as gravity at least is concerned, it must needs be considerably plus; and hence all feeling induced by, or connected with, counterpoise, must necessarily be wanting under such circumstances, and therefore, in partaking of food, vigour and strength ought (as they are), to be experienced, and not weight and labour.
I might remark that, in experimenting upon the chin, if a weight of 3 or 4 ounces be placed upon the chin, its weight will be quickly felt, but not to the same degree when the countenance is but slightly elevated above the natural erect position; but, if it is made to look directly upwards, the same weight will be felt much more intensely. This evidently arises from the same weight channelling its force onwards to the occipital condyles, whereby, by increased sentient surfaces presenting themselves, increased feeling of weight is experienced. Such incidental peculiarities are not to be altogether despised and rejected!
I shall pass over in silence the articulations of the clavicle, not from not having experimented upon them, and that satisfactorily; but any one who has carefully examined their synovial membranes, and also the very variable degrees of mobility different individuals possess in this articulation, will agree with me, that, from ordinary grounds of doubt, in articulations so variable as are these, experiments, as a test of correctness, or contrariwise, of any assumed hypothesis, are better avoided than pursued.
The shoulder-joint has already been examined and dismissed— the next in order, therefore, will be the elbow-joint. This joint is a compound one, the articulation of the ulna with the humerus being as perfect an example of a ginglymoid joint as the skeleton supplies; whilst the articulation of the radius with the humerus more closely resembles the enarthrodial order of articulation than any of the orders of articulation usually given in anatomical works.
In attempting to perform any experiment upon this joint, it will be well to remember the distinctive kinds of articulation the radius and ulna have with the humerus. With reference to the ulna, it is difficult to conceive how gravitating force would channel, if a weight were placed over the coronoid process, and how far it would affect the sigmoid notch, much less, if it were carefully analysed, would it be easy to describe the same: neither, again, is it an easy matter to place any weight over this part. Though, then, the writer has tried several experiments upon this articulation, with apparent success, yet, from the above reasons, he deems it wise to avoid giving any of them in details, and will consequently direct attention to the radial articulation. This articulation being very simple, affords great facilities for retaining distinct the antagonising forces, muscular and gravitation.
One experiment will be sufficient for all practical purposes. Let the experimenter extend the arm and forearm, but not to perfect straightness or rigidity; at the same time let the hand be supinated, or in that position in which a large flat book would be balanced on the surface of the hand. In this position, place a book upon one of its angles, or any other suitable object, of 1 lb. to 2 lbs. weight, immediately over the radio-humeral articulation. This articulation in the extended arm is not just under the bend of the elbow, but about two-thirds of an inch in advance of it; and if this little point be not borne in mind an error in performing the experiment is very likely to occur. Supposing, then, the weight has been carefully adjusted, so that its gravitating force shall pass through the articulation, considerable weight will be felt; but if the same weight be placed one or two inches anterior to this point, whereby, from increased leverage, much greaterweight ought to be felt, scarcely any will be felt, the same thing happens if it is placed posterior to this point; but this is what might be inferred as a natural consequence of diminished leverage. In the former position this objection cannot be urged. If, therefore, weight is felt more intensely over the articulation, than over that part where leverage gives such a decided advantage to the weight, it tenders to the fulcrum against which it rests, what is it but that, at the point over the articulation, the counterpoising forces can be brought into play where their resultant can best have applied, to sentient nerves there distributed, the stimulus their function naturally demands; which function, when thus stimulated, namely, by receiving the diagonal of two antagonizing forces, is manifested in the recognition of weight?
(7b be continued.)
Article IV.—Case of Pharyngocele, with notices of similar Lesions of the Pharynx and (Esopliagus. By Evans Reeves, M.D., London.
A Tall, somewhat emaciated man, set. 65, by trade a shoemaker, came under my care in August 185-1, suffering from dysphagia. The affection had commenced about ten years before, with a sense of uneasiness in the throat, which impelled him to constant efforts to dislodge something which seemed arrested there, but without any further effect than to bring up a little frothy phlegm. This continued for about three years. Then he began to bring up every ten or fifteen days some yellow mucus, at first about a teaspoonful each time, but the quantity increased, as also did the frequency of its occurrence. He continued in this state for about four years, when, after eating some dried currants, the uneasiness in the throat became very severe, accompanied by constant efforts to bring something up, and inability to swallow any solid food. After suffering for nearly a week relief was obtained by bringing up a number of currants, distended and mixed with mucous. From this time food was brought up, at first in small, but later in larger quantities. He wa3 seldom free from uneasiness in the throat, except for a short time after the food had been brought up. He observed," I can take solid food very well directly after I have got rid of the stuff, but the difficulty soon returns, and on the second or third day I can only get liquids down, but even these, if the uneasiness is very great, sometimes return." Bougies had been frequently introduced, sometime they descended with ease, while at others they could not be made to pass. During the last four months, from the increased difficulty, none had been passed.
On examining his neck, by pressing the finger deep under the sterno mastoid muscle, a soft swelling could be felt, extending down from the cricoid cartilage, behind the oesophagus. It was much more prominent on the right than on the left side.
By pressing on both sides of it at the same time, about three tablespoonfuls of pultaceous matters were suddenly ejected into the mouth. Immediately after this he swallowed without difficulty a piece of soft bread of the size of a large hazel-nut. His voice was hoarse ; and he had cough with expectoration. The upper part of the larynx was swollen, but the pharynx presented no particular change.
A large sized bougie could be easily introduced, if its point was made to glide down the left side of the pharynx. But if attempted to be passed otherwise, it passed into a sac, and its point could be distinctly felt close to the spine, about two fingers' breadth below the cricoid cartilage. By the use of enemata of strong beef tea—the nutriment taken by the mouth being confined to milk, with cod-liver oil—occasionally mopping the larynx with a solution of nitrate of silver, he has gained flesh, and his state has become more comfortable. He is now able, by pressing on the lower part of the pharynx, on the right side, while swallowing fluids, nearly to prevent the entrance of any into the sac; and as soon as he experiences uneasiness, he can, by pressing on each side of the throat, evacuate the contents of the sac, and obtain immediate relief.
Albers (PatfioL Anatomie) considers dilatation of the oesophagus to be a congenital disease. I do not think this the case, for it never once fell under my observation during the two years I attended the Hopital des Enfans; and all the cases which I have been able to collect from Continental and English sources, show that it is a disease of the prime and decline of life rather than of the earliest period.
In 21 cases the following were the ages and the duration of the disease :—Males present a greater liability to this disease than females; in 19 cases, 3 were females and 16 males. The same preponderance I have observed to exist on the part of the male sex in cancer and simple ulceration of this part of the digestive canal.
Males—aged 54, the disease commenced then; 66, begun when 18; 65, suffered several years; 60, five years before death; 69, three years before death; 77, suffered since youth; 73, suffered twenty years; 24, one year before death; 24, four years; 55, ten years (still living); 38, since boyhood, from a blow; 43, since boyhood, from a blow; 43, fifteen years; 43, ten years; 43, a few years; 43, since early youth.
Females—aged 33, ten years before death; 30, time not stated; (mother of children) time and age not stated.
Situation and Forms.—1st, In the pharynx, where it is met with under three forms: a, as pharyngocele, the mucous membrane protruding through the fibres of the inferior constrictor muscle of the pharynx; b, as & pouch-like dilatation of all the coats—the jabot of Vic-d'Azyr; c, as a sacular dilatation. All the coats as in the last being affected.—2d, In the oesophagus, where it is met with: a, as a spindliform dilatation, which appears to be the most frequent, all the coats being affected; b, as a sacciform dilatation; e, as cesophoffocele, the mucous membrane protruding between the muscular fibres of the canal.
Case II.—A gentleman1 had suffered for some time from uneasiness in the throat, with occasional difficulty in swallowing, which was always relieved by the introduction of a bougie. Some ineffectual attempts had now been made to pass one. At last after many attempts by giving the instrument a lateral twist so as to cause the point to glide along the side of the throat, it passed without difficulty. The instrument was introduced once a fortnight up to his death, one year from being first seen. A bag formed entirely by the mucous membrane was found projecting from the posterior and inferior part of the pharynx, and descended between the oesophagus and the spine.
Case III.—A merchant, set. 64 2 (had enjoyed good health up to this time), began to suffer from pain in the throat when swallowing, as if something had stuck there. The pain increased in severity, and at last cough and suffocation set in with regurgitation of the food taken, which he was obliged to remasticate before it would descend. Astringent gargles and other remedial measures were ordered, without benefit. An attempt was made to pass a bougie, but it met with an obstruction, which it was found impossible to surmount. His appetite continued good, and he eat largely, but most of the food taken was almost immediately rejected. After death, a pouch was found at the lower part of the pharynx, three inches and nine lines in length, and one and a half inches in diameter; it descended as low as the 14th ring of the trachea, and contained several ounces of fluid. It opened between the lower fibres of the inferior constrictor of the pharynx, the aperture being somewhat narrower than the opening of the oesophagus. The pouch had externally a cellular coat; in it, near the opening, large muscular fibres were observed; internally, it had a vascular coat, thicker than that of the oesophagus or pharynx, also an epithelial one.
Case IV.—A man, ret. 66,* of robust form, entered the hospital in August 1837. When 18 years of age, an enlargement was observed on the right side of the neck, about three fingers' breadth below the jaw. It gradually increased in size, and at last became as large as a pigeon's egg. He had difficulty in swallowing, and felt a constant sense of uneasiness in the upper part of the oesophagus, as if something was lodged there; it was relieved by vomiting up some alimentary matters. Once the sensation lasted three days, relief being obtained by the vomiting up of some indigestible substance taken some days before. When 40 years of age, the difficulty in swallowing greatly increased, and he was obliged to confine himself to fluids, but at last even the passage of these was attended with great difficulty. The vomiting became more frequent, but it was always followed by relief. He was now suffering under pneumonia, and was greatly emaciated. On the right side of the neck an elastic tumour existed of the size of the fist, implicating the right lobe of the thyroid gland. On the left side, another of the size of a pigeon's egg, which subsided on his vomiting up that which he had drunk. The vomiting was easily produced—by lying back and pressing on the tumor. After death, the right lobe of the thyroid gland was found to contain a cyst the
1 Sir Charles Bell's Surgical Works.
2 Kuhne Rusts Mag., fur die Gesammt Heilkunde, Bd. xxxix.
3 Rokitansky Oestreich Med. Jahrbucher, Bd. xxii.
NEW SERIES NO. UL MARCH 1855. 2 F