safety? Is there something in consumptive diseases that grants the debilitated sufferers perfect immunity from the bad consequences of exciting poisons? A large portion of them are much distressed by gastric disorder. For weeks or months before death they suffer from pain and tenderness of the epigastrium, loss of appetite, thirst, frequent vomiting of acid matters. These symptoms often cause more difficulty than pulmonary disease; and after death, M. Louis found the stomach in about one-fifth of the cases who died of this disease, softened or partially destroyed in texture, and he supposed this change to be the result of inflammation. It is probable that he was mistaken in his opinion on this point, and that the solution of the coats of the stomach is effected by the action of the gastric fluid which has retained its digestive power after death; but can it be possible that burning, irritating draughts of alcohol, even largely diluted, can exert any soothing or invigorating influence upon a patient affected with any of the symptoms just enumerated? In all the commonest forms of pthisis in every stage, the liver is in a state of torpor and congestion; the blood which should flow rapidly through it from the stomach is obstructed; the capillaries of the mucous membrame of the latter organ are congested; the appetite, though sufficiently craving, is capricious, morbid. If strong brandy can be taken without sensible and immediate injury, it is because the case is not a bad one. If it be long continued, it must undermine the last pillar of hope. If in large doses it does not intoxicate, it can only be that our patient has reached that wretched condition already alluded to in which "it is impossible to get drunk;" if it does intoxicate, it shows that the patient has entered upon that downward course of physical and moral degradation in which recovery of health is impossible; and, if it could be restored, life itself would be of little value.

Here we leave the subject; not because we have exhausted it, or can hope to have set any disputed question at rest, for the subject is inexhaustible and constitutes a troubled ocean that will never rest. We have condensed the more important

of the well-established facts which have a practical bearing on the cure of disease; we have kept within the line of safe experience, and have seen beyond it the dangers of reckless attempts to disregard the lessons furnished by all past obser

vation.

A SINGULAR CASE OF

SPASMODIC STRICTURE OF THE ESOPHAGUS,

BY B. F. JOSLIN, JR., M. D., NEW YORK.

The case which I now report possesses considerable interest from the peculiar nature of the disease, as well as from the fact that a nearly complete history of it can be given as from the earliest signs of disease, until the final termination (with the exception of a few weeks) the patient was under my care. The post mortem examination, which revealed the probable cause of the symptoms, will also be published.

Although not in the final result successful, it still illustrates the truest method of palliation—that of relieving the disease as far as possible by appropriate medicines. During its progress it afforded many illustrations of the efficacy of attenuated medicines, administered according to the plan of allowing the symptoms to indicate the remedy. Now that we have the whole case in review, it is difficult to surmise what other plan of treatment could have been adopted, or what better course, could have been pursued if any one had been in possession of all the information elicited by the post mortem examination.

The prominent symptom of the case was difficulty of deglutition, not constant as from permanent stricture of the œsophagus, but variable in its degree and time of occurrence. First appearing about three years and a half since and continuing several weeks, then apparently giving way to treatment, and after the lapse of nearly three years, during which

period she enjoyed good health most of the time, re-appearing and continuing with intermissions of only a few days at a time, until the patient died of inanition.

Such is a general outline of the case; and before proceeding further I wish to say something in regard to the diagnosis. At the time of the first appearance of the disease three years since, I considered it as purely nervous and not of serious importance; the temporary recovery which shortly after ocurred, seemed to corrobate this diagnosis and prognosis. Inever saw any reason to change my diagnosis, but after I had treated her for sometime, subsequently to the re-appearance of the symptoms, I came to the knowledge of certain facts which together with the additional fact that my patient was not improving, led me to think more seriously of the case.

I learned that the father of this patient died with apparently the same disease-inability to swallow, accompanied, in his case, with some indications of insanity. He died quite suddenly after only a few weeks continuance of the disorder; while she lingered out a painful existence for months.

The patient was a lady, twenty-eight years of age at the time of her death. She was of rather nervous temperament. Her menses were usually scanty, and bowels inclined to constipation. She mentioned to me during her last sickness that for some months previously, she had been in the habit of taking quite strong coffee, which I have no doubt increased her nervous irritability.

To show the distinction between this case and one of ordinary spasmodic stricture of the oesophagus, I will quote a few lines from Habershon on Diseases of the Alimentary Canal. He says, "The few cases of this kind which have come under my own observation, have been in young women of an excitable rervous system, with leucorrhoea or painful menstruation and impared digestion. The strongest language was used by these patients to express their inability to swallow, and they showed the greatest unwillingness even to attempt it. * The general symptoms and history aid us in the diagnosis of these

*

*

cases, as the absence of emaciation, the suddenness of the attack after a slight cause, as nervous shock or slight catarrh; the absence of pain; the existence of considerable nervous excitement." In the case which I report, emaciation was regularly progressive during the last four months of the patient's life.

principal symptom of this She then told me, that on "choking in the throat," reThree days before she

The first record I have of the case is on September 8th, 1856. the previous evening, she had a lieved after taking salt and water. had complained of burning in stomach and abdomen, and weakness in stomach and of feeling "nervous." I had given her Sulph." with benefit. Her bowels were quite constipated, as was frequently the case with her. I prescribed Opium3.

She continued to be troubled with the choking sensation in throat on attempting to swallow any thing solid, until the 26th instant. During this period I gave her Carb. an.", Nux, Con.", Puls." and Merc.", under the last mentioned of which remedies improvement took place. On making an effort to cough, about this time, to remove the obstruction in the throat she raised blood. During this period, I have

also recorded the following symptoms :

Sensation of a lump in throat; constant sour taste in mouth, and sometimes sour eructations; oppression at pit of stomach; heaviness and fulness in head; vertigo in morning; easily excited; ulcers on tongue, for a day or two; sharp pain in left iliac region extending to thigh, increased by motion; menses scanty and delayed.

On the evening of the 26th, she was able to eat solid food after an enforced abstinence of many days. On the 27th, I gave her Plumb.30 She continued to improve, and on November 2nd, I record:-Can swallow without difficulty; bowels still costive. Gave Opium.'

November 6th. Bowels less costive; about 4, p.m., daily, has congestion in the head; face red, with sensation of fulness in head attended with nervous excitability. Prescribed, Bell."

November 22nd. Return of pain in throat. Bell."

November 24th. Sensation of choking in throat, with oppression in upper part of chest; feels unwilling to take solid food for fear it would choke her. Rhus."

November 26th. Better. Continued Rhus.

December 4th. Fulness in head; wild feeling. This morning palpitation and sensation of heat rising upward in chest. Bell.10

December 13th. Throat more troublesome than ever. Complaint returned on the 6th instant. Head relieved by Bell." She has observed the affections of head and throat to alternate.

Has sharp pains in right side of œsophagus, about an inch below the lower jaw. Thinks she cannot swallow solid food; has not taken any for a week; lives on soft toast. Has at times fluttering palpitation, with faintness and sharp pain in one spot of chest. Puls."

December 16th. Better. Puls."

December 20th.

Menses on 17th and 18th instants were very slight as usual. Complains of pain and oppression in chest, more on left side; pains extend to neck, and to left arm, and to thumb. Sensation in neck and upper extremities as of drawing. No trouble in throat, except that after eating a sensation of rising; has fluttering in left chest; feels quite low spirited; imagines she has disease of heart; horrible dreams; tongue brown; constipation. 2 Sulph."

December 23rd. Better. Sach. lact.

December 29th. Soreness and aching in left hypochondrium, extending to abdomen; sour eructations and sour taste in mouth; after eating, salivation. 1 Nux." and Sulph."

After this I was not called upon to prescribed for her, until after an interval of six months, that is, July 6th of the following year, 1857. She then had neuralgic pains in the face, for which Puls." was given. Said she was quite relieved of her old troubles, including constipation and menstrual difficulties.

I may as well mention, that I had occasionally seen her