size of a goose's egg. The pharynx was oedematous; and near its lower partne mucous membrane passed through the fibres of the inferior constrictor muscle, forming a pouch the size of the pharynx itself; the pharynx opened directly into it, instead of into the œsophagus. Some muscular fibres were observed in its walls. The œsophagus was greatly atrophied. Rudolphi speaks of having met with a case of pharyngocele, but he gives no history of it during life, nor any details of the postmortem appearances. Littré (Collect. Academie partie Française) found in a body he examined the pharynx more dilated and its walls thicker than usual; in its inferior part, four cylindriform sacs existed, opening from above. Roennow (Ancien Journal de Med., tom. lxv.) found in a person, who during life had had particularly offensive breath, pouch-like formations containing putrid food. Samuel Cooper (Surgical Dictionary) mentions an instance where a pouch was found in a person who died from dysphagia, filled with apple pips. Mr H. C. Johnson has recorded, in vol i. of the Transactions ej the Pathological Society, the case of a gentleman aged 65, who had for years been unable to swallow but very little food at a time. A considerable quantity of food remained in the oesophagus after each meal, being rejected in the course of an hour or two, in the form of small pellets. He came under Mr Johnson's care for laryngitis, accompanied with dysphagia. He sank under a second attack of laryngitis, pneumonia also existing. In the upper and posterior wall of the oesophagus a pouch existed, having a small valvular opening, on the same level as the cricoid cartilage. De Guise (Dissert sur Anevrisme) observed in a horse the mucus membrane to protrude through the muscular fibres of the upper part of the oesophagus, forming an egg-like sac. to me. Pouch-like Dilatation of the Pharynx. CASE I.-A man æt. 60,1 unable to swallow since the day before he applied Five years ago (1759), while eating cherries, one of the stones lodged in his throat, and was not got rid of until three days after, when it was discharged during a fit of coughing. A sense of soreness remained for some time, and at the end of a year he noticed that from one to two, or even more hours after a meal, a little food was returned unchanged. The quantity returned increased, and the time for its remaining down diminished. He also found that if he drank during a meal, he was in great danger of being suffocated. At last he could not take more than four table spoonfuls of food without its being returned, none entering the stomach. Efforts were made to pass a probangquicksilver was also given him-but in vain, he died 13 days after being seen. A considerable sized muscular bag was found descending between the esophagus and the spine-it was continuous with the pharynx, and was also of the same thickness. CASE II.-Col. D., æt. 69,2 three years before death began to suffer from 1 Ludlow's Medical Observations and Inquiries, vol. vi. 2 Mr Worthington, Medico-Chir. Trans., vol. xx. slight dysphagia, which continued for eighteen months. In the months of January and February 1846, it became more severe, and was accompanied by emaciation. When seen in July solids required the most complete mastication, and the descent of the morsel produced a gulping noise. A fluid like the saliva was constantly secreted, to the amount of 1 or 1 pints in the 24 hours, occasionally it was mixed with food. A probang was arrested opposite the cricoid cartilage; a slender wax bougie seemed to pass beyond the obstruction, but, from the shape it had assumed, this was doubtful. When food was swallowed, it was retained for a short time, and then, regurgitated, unchanged. At last, no food could be made to enter the stomach, and for the last three weeks of life, he was supported by nutritious injections. A pouch, in shape to that of a finger-stole, 3 inches in length, descended from the posterior and lower part of the pharynx, down between the spine and the œsophagus. Two-thirds of it was covered by fasiculi from the inferior construction of the pharynx. The pharynx was much dilated; a free communication existed between it and the pouch. A stricture was found immediately behind the cricoid cartilage, formed by a fold of mucous membrane. A largesized bougie could be passed. Dr Coley observed, when this case was read before the Society, that he had known a medical man who had suffered from dysphagia for ten years; he sank from inanition and thirst, the deglutition of even fluids being impossible. Mr Cline in this case had discovered the existence of a pouch during life. It was found after death to extend from the lower part of the pharynx, and was three inches in length and one in diameter; a stricture existed at the upper part of the oesophagus. A priest, says Burserius, (Inst. Med. Pract., lib. iv.) died in 1782, in a state of extreme emaciation, in consequence of dysphagia, which had existed since early youth. He could eat, but very slowly, and to facilitate the descent of the food, he was obliged to press his throat with his hand. The difficulty was at first confined to solids, but at last extended to fluids, which were rejected. A dilatation existed at the posterior part of the pharynx, which descended six or seven fingers' breadth between the spine and the oesophagus. The upper part of the œsophagus was narrowed. Burserius was indebted for the case to Gianella of Rome, who was present at the post-mortem examination. Marx (Göttingen Anzeigen, 1753) reports the case of a man æt. 73, who died after suffering for 20 years from gradually increasing dysphagia. A pouch, five inches in length and three in breadth, descended between the oesophagus and the spine. In the next case, the pouch was unusually broad :— CASE III. A man, æt. 77,1 had suffered since his youth from difficult deglutition. A year ago, in fixing some dental appliance to his upper jaw, force was used; inflammation of the whole alimentary canal was excited, and for some months he was subject to vomiting immediately after meals. This was followed by increased dysphagia, and he was obliged to confine himself entirely to fluids, which descended with difficulty, and with a kind of gurgling noise, and they were immediately afterward returned to the mouth without effort, mixed with mucus. He often had recourse to friction on the neck to assist the descent of the fluid, and to empty a pouch which he fancied existed; the little fluid which did descend, appeared to do so in a thread-like manner. No tumour could be discovered in the neck, or pain, but a sense of burning existed in the stomach, with severe thirst. No instrument was passed. He at last 1 Dr Cassan, read before the Academie de Med., vide Arch. Gén de Méd., 1826. sank from inanition. The lower half of the pharynx was dilated ints a kind of pouch, formed by its posterior and lateral parts. In front and below the dilatation a narrowing, without thickening, of the œsophagus existed for eight lines of its length, it then insensibly enlarged. Affolter, Naumann (Handbuch der Med. Klinik) observes, he found in a case where the commencement of the oesophagus was the seat of a stricture 14 inch in length, that the pharynx formed on each side a large sac-like dilatation. Dr Melville, Monro (Morbid Anatomy of the Stomach and Gullet) states, met with an instance of dilatation where the patient could retain a pint of fluid for ten minutes, conversing the whole of the time with his friends. I have in my possession the pharynx taken from the body of a middle-aged, emaciated man, brought into the Clamart for the purpose of being dissected. The pouch will admit the three fore-fingers as far as their second joints. The œsophagus is the seat of a stricture, rather less than 4th of an inch in length. A large-sized bougie could be easily introduced. I was led to study the best mode of introducing an instrument in this case. It appears that sliding the point of the instrument down the sides of the pharynx will not in every instance succeed; but if it is passed along the posterior part of the larynx, failure is scarcely possible. Spindliform Dilatation of the Esophagus. CASE I.-A man, æt. 24;1 health good up to a year ago, when a sensation was experienced in the centre of the sternum, as if an obstacle existed to the descent of the morsel. The obstruction increased to such an extent that solids would not pass unless large quantities of fluid were taken to wash them down. Regurgitation followed, and then vomiting of all taken, whether solid or liquid. After some irregularities in diet, the affection made great progress, mucous and blood being discharged. Hectic set in, and he sank in a month. For the last three weeks of life he was supported by nourishing enemata. The œsophagus immediately below the pharynx began to dilate. This continued as low as the stomach. Its centre, the most dilated part, was 4 inches in diameter. It contained 2 pints of thick liquid, mixed with mucous and blood. The mucous membrane was ulcerated. The cardia was converted into a hard narrow ring. CASE II.-A man, æt. 24,2 had suffered for four years from vomiting, which was particularly liable to recur after eating indigestable food. His present illness arose from a beer debauch. He sank thirteen days after entering the hospital from diarrhoea. The oesophagus opened into the stomach like the os uteri. Above this, as high as the pharynx, it was largely dilated; near the centre so much so as to admit with ease the arm of a middle-sized man. Its coats were hypertrophied; and from the upper third down to within an inch of the cardia, ulcerations, varying in size from a linseed to a fourpence-piece, existed. CASE III. A female, the mother of children, became, after gastric fever, subject to dysphagia, with oppression and difficulty of breathing; and at the end of a year vomiting was added. A small quantity only of the food swallowed seemed to pass into the stomach, giving rise to convulsive efforts, which 1 Dr Lindlaw. Caspar's Wochenschrift. 1840. were only relieved by vomiting up that which had been taken. She at last sank. The walls of the esophagus were found hypertrophied, the muscular coat greatly developed, the mucus membrane red and thick. It was dilated to eight times its usual diameter. Its lower part was of the natural size. CASE IV. A man, æt. 38, strong and muscular, experienced on taking food a sensation as if it was arrested a little above the stomach, giving rise to the most painful and protracted efforts to swallow. The kind of food taken made but little difference. Immediate relief always followed vomiting. After a debauch, to which he was much addicted, the vomiting occurred spontaneously, and fluids then gave rise to the painful sensations before confined to solids. A probang was passed without difficulty. The difficulty in swallowing had existed since childhood, and was attributed to a blow from a club. Of late he had suffered from difficulty of breathing, particularly on exertion. He was found dead after having eaten and drank to excess. The brain and lungs were found gorged with blood, and the oesophagus was found greatly distended with food, and largely dilated. The dilatation commenced immediately it entered the chest, gradually increasing until it reached its centre, it then diminished until it passed through the diaphragm. When distended it measured 6 inches in diameter. Its walls were thick and strong like leather. No trace of muscular tissue could be observed. CASE V.-A blacksmith, æt. 43,2 had, when a lad, received a severe blow on the sternum. It was almost immediately afterwards followed by difficulty in swallowing. For the last 20 years he has suffered severely from attacks of dysphagia, sometimes for three weeks no food entering the stomach. Occasionally he has, however, by great force, been able to propel food into the stomach. Of late he has allowed the food to remain for hours, sometimes days, to become somewhat digested before he attempted to do this. No food would pass into the stomach until the oesophagus was quite full. After death the oesophagus was found capable of containing 2 quarts of fluid; about 2 inches of it above the cardia was contracted. Mr Mayo (Outlines of Pathology) found in a female, æt. 33, who died after suffering 10 years, that the oesophagus began to dilate immediately below the pharynx, at 4 inches above the cardia it was 2 inches broad, it then narrowed to its natural dimensions. Sacciform Dilatation.-I opened the body of a man, Portal (Anatomie Médicale) observes, in whom the oesophagus formed a dilatation much larger than the stomach, which last was only the size of that of a child 2 years of age. The cardiac orifice was so narrowed that a quill would not pass. Dumas (Recueil Periodique) also found the lower part of the œsophagus dilated into a kind of second stomach. Blasius (Adversar. Medica Obs. ix.) found in the body of a man the lower part of the oesophagus dilated into a kind of second stomach; below this the canal was narrowed. Dr Huss of Stockholm found in the body of a female, æt. 43, a large dilatation of the lower part of the left side of the oesophagus; the canal above this as high as the pharynx was also dilated. Grashuis (Acta Nat. Curios. lib. vi.) mentions the case of a single female, æt. 31, who, after a troublesome catarrhal affection, began I Dr Hannay, Edin. Med. and Surg. Jour., vol. xl. to suffer from slight pain in the chest and in the back, under the left scapula, at last pain in the left side of the chest was also added, severe, but occurring only after eating, and gradually subsiding at times; it was accompanied by great anxiety and oppression of breath. In June of the same year (1733) fulness was observed in the left side of the chest. By the end of August great difficulty in swallowing, both liquids and solids, was experienced. She was seen by Boerrhaave and by Schuck. Regurgitation of food in from 12 to more hours after it was taken set in, mixed with large quantities of viscid tenacious mucus. After this had taken place the passage of food into the stomach became free for a short time. Emaciation set in; she had night fever, and cough, with mucus expectoration streaked with blood. She sunk from disease of the chest and the loss of a little blood, on the 8th of July. On raising the left lung a preternatural enlargement of the oesophagus was found in the centre of the chest, which, when laid open, was found to contain blood and ichorous matter; some hard fleshy tubercles existed on its internal wall, and on one side a dilatation capable of holding a goose's egg, communicating with the canal by an opening capable of admitting the finger. Esophogocele.-The following is, I believe, the only instance recorded. A person, observes De Guise (Dissert. sur l'Anévrysme) had suffered for 15 years from regurgitation of food after eating; at last deglutition became very difficult, and death from inanition ensued. A membraneous sac was found at the side of the oesophagus, which, from its position when distended with food, prevented the morsel from entering the stomach. ARTICLE V.-Case of Chronic Cerebral Abscess. By JAMES I was first summoned to see Mr A. B. on the 22d of February 1854, when I found him labouring under general debility, with a little occasional pain of chest, with severe cough, and dark-coloured expectoration, which had been of long standing, his attention being mainly directed to the idea that he was labouring under a syphilitic taint of the system. On inquiry, I found that about ten years before he had contracted syphilis; but on examination I ascertained that he now enjoyed perfect immunity from this disease, of which fact many medical men had previously tried to persuade him, but without effect. He persisted in swallowing mercury contrary to my most rigorous injunctions, thinking that by this, he would overcome the supposed "impurity of blood" -an idea he had got from Davies' book on Syphilis. I endeavoured to direct his attention to the state of the chest, which appeared to be the main seat of his disease; all, however, proved ineffectual, and I accordingly advised him to consult Dr Christison, which he did, the result being a confirmation of my opinion of his case, that the system was free from syphilitic taint. Dr C. prescribed pills of the ammoniated citrate of iron, and the fluid extract of teraxicum, along with a little laxative medicine; by the continual use of which for some weeks, his health was greatly improved, and continued so till the end of September, when he only still complained of a little |