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extended between his shoulders, but there was no tenderness in the back. December 4th the pain at the left nipple became more fixed, and there was a slight systolic bruit. January 1st, Dr. Hughes noticed that the radial pulse was weaker on the right side, and he was found to have difficulty in swallowing solids. This dysphagia increased in severity and his dyspnoea became more distressing. January 20th he was unable to swallow food; his face was livid, dyspnoea urgent, and his pain severe. He died on the 25th. On examining the chest, the lungs were emphysematous, pale, but moderately collapsed. There was acute inflammation of the pericardium, and considerable injection of the pleura on both sides. On turning aside the lungs, an aneurismal tumour, about the size of a large orange, was found at the termination of the arch of the aorta; its walls were thin; the posterior part of the vessel was entirely destroyed, and communicated with a cavity in front of the vertebræ, one of which was absorbed. There was scarcely any fibrin in the sac. The aneurismal tumour had pressed upon the œsophagus, and quite obliterated its canal; the whole of its walls were of a greenish colour, very offensive, and in a sloughing condition. Still no perforation had taken place. Both bronchi were compressed. Two other aneurismal tumours were found connected with the ascending and transverse portions of the arch of the aorta. Other viscera were healthy.

CASE XXIV.-Aneurism of ascending aorta rupturing into pericardium. Communication of œsophagus with left bronchus.—Frederick K—, æt. 23, admitted under Dr. Gull's care, January 23rd, and died April 26th, 1856. He was a hawker, and had been living in the Old Kent-road; he had enjoyed good health till five months ago, when he struck his chest against a box hanging from a crane; a fortnight afterwards he experienced pain at the part; this gradually increased till three weeks before admission, when he was obliged to give up work. On admission, he complained of pain in the chest, a distinct pulsation could be felt between the second and third ribs on the right side, and a jar with the second sound of the heart. There was pain at the seat of pulsation, and along the border of the pectoralis major, and down the inner side of the arm. The pain continued severe, and a systolic bruit became audible at the seat of the tumour. He could obtain no rest at night. On April 19th, he had difficulty in swallowing, and this increased much in severity. On the 28th, after talking with his friends, he died very suddenly. On removing the sternum, an aneurism of the ascending aorta was opened, it had extended to the sternum on the right side. On further opening the pericardium, it was discovered to be full of blood, and a small irregular opening was found at its upper part into the aorta. The heart was of normal size; the left ventricle not hypertrophied; the valves healthy. The ascending aorta formed an aneurismal sac, about two inches and a half in diameter, principally on the right side. The lung was adherent, and it was nearly perforated. The aneurism extended as far as the left carotid; below the left subclavian was another small dilatation. At the centre of the œsophagus

where it is near the left bronchus, was a slough, and an opening into the bronchus, with considerable inflammatory tissue; no communication, however, with the vessel. The remaining viscera were healthy. Although it appeared that the greater pressure from the aneurism was on the right rather than the left side, we can find no other explanation for this sloughing condition of the oesophagus, and its communication with the bronchus, beside the pressure which all these parts suffered from the distended aneurismal sac.

Cases of this kind should render, us exceedingly cautious in the use of œsophageal bougies, lest they lead to the sudden rupture of an aneurism, and the death of the patient.

Gastric Solution.-In studying the diseases of the œsophagus, gastric solution of its lower extremity must be borne in mind. This subject has been very clearly brought forward in the communications to the "Guy's Reports," by Mr. Wilkinson King, in the years 1842 and 1843. It is exceedingly frequent to find the mucous membrane of the oesophagus abruptly terminating at the cardiac extremity of the stomach, from the solvent action of the gastric juice having extended to that line; but on opening the canal of the œsophagus itself for several inches near its lower extremity, the upper margins of the rugæ are often found deprived of mucous membrane, and long shreds are observed on stretching out the tube, these portions having escaped digestion. This solution extends into the mediastinum, as found in cases mentioned in the communication just referred to, or into the pleura itself, the contents of the stomach escaping into the left pleural cavity, that which is in closer relation with the œsophagus.

Only two cases of this perforation of the œsophagus have occurred at Guy's during the last three years-one in a case of fever, another hydrocephalus-so that it is a circumstance of unfrequent occurrence. The causes which lead to solution of the stomach are more clearly understood than formerly. Dr. Budd has very lucidly, in his work on "Diseases of the Stomach," brought forward all that is known on the subject. The position of the body, the development of gases in the intestines pressing upon the contents of the stomach, the noncontracted state of the oesophagus itself, are causes which produce the passage of the gastric juice into the œsophagus. Sometimes, indeed, this pressure, forces the contents into the

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pharynx, and we find them gravitating into the trachea and bronchi.

Ecchymosis. Hæmorrhage from the œsophagus generally arises from the rupture of aneurismal tumours, or from cancerous disease; but in cases of fatal purpura, we sometimes find the whole mucous membrane covered by points of effused blood, and blood is also effused into the surrounding cellular tissue. This part, however, is affected only in common with the whole mucous surface of the alimentary canal, as well as with other membranes and gland-structures.

CASE XXV.-Rupture of the oesophagus.-The following case warrants the belief that sometimes rupture of the coats of the œsophagus takes place during life; the specimen is in the Museum of Guy's (No. 1799 46).

M. Curtis, æt. 24, a cabinet maker, of intemperate habits, attended a public supper in September 1842: during supper he felt sick and left the table; he vomited slightly, and returned home with assistance. He then took a dose of castor oil; at 2 in the morning he complained of severe pain across the epigastrium and great difficulty in breathing; the abdominal muscles were rigid, the respiration laborious; the patient was found sitting up in bed, leaning forwards on his hands; his countenance was anxious, the pulse soft, the bowels had not acted; an emetic of antimony and ipecacuanha was administered, but without effect; at 7.30 a.m. there was less pain, but increased dyspnoea, and there was emphysema of the face and throat. The stomach-pump was used, but without effect, and he died at noon. On inspection a large rent was found in the œsophagus at its lower part, filled with ingesta, which were also extravasated into the left pleura; the pleura also contained castor oil. The stomach and intestines were exceedingly distended with flatus; and the stomach partially dissolved by gastric juice. The rent in the oesophagus appears in the preparation to extend into the stomach, but was perhaps increased after death. It is probable that the œsophagus was much dilated with food, and that its coats were softened either by previous disease, or by digestion from gastric juice regurgitated into it from the stomach, and there remaining sufficiently long to corrode its walls. There is no evidence that the stomachpump increased the rent, for the castor oil which was found in the pleura was taken several hours before the stomach-pump was used; still, if it had been known that such a rent had existed, such a remedy would not have been applied; the severity of the symptoms rendered it probable that some poisonous substance might have been taken with the food, and the emetic failed to act; under the circumstances which existed the use of the stomachpump probably tended to relieve rather than aggravate the symptoms.

CHAPTER III.

ORGANIC DISEASES OF THE STOMACH.

THE greater number of cases of ordinary gastric disease are generally described as functional, or as those in which no structural change is believed to exist; but the increase of science, due to an advanced chemical, anatomical, and physiological knowledge, has already done much to throw light upon this heterogeneous mass.

ATROPHY OF THE MUCOUS MEMBRANE OF THE STOMACH.

Dr. Handfield Jones has drawn particular attention to the microscopical appearances of diseased conditions of the stomach; to degeneration of the mucous membrane; and especially to hypertrophy or atrophy of its follicles and glands.

The follicles of the stomach are easily observed under a low magnifying power; and appear to constitute a great part of the mucous membrane itself. On the surface of the mucous membrane are numerous minute pits, and the follicles open into them. At their lower extremity they rest on a stratum of cellular tissue of varying thickness, but containing a very large quantity of elastic fibre. The blood-vessels may be seen in sections of a portion of congested membrane, to extend between these gastric follicles, nearly in a straight course, and immediately beneath the surface of the membrane, and around the minute crypts upon it to form a beautiful plexus of vessels. The sympathetic nerve may be observed, in microscopical sections, at the base of the mucous membrane, sometimes upon the capillary vessels, and at other times leaving them; but its ultimate division I have not been able to trace. There is no doubt that it forms an important element in the structure of the membrane. The surface presents columnar

epithelium and mucus, and the follicles contain spheroidal epithelium and nuclei. It is these follicles and the surrounding tissue which undergo degenerative changes. As in every other gland, these minute and simple ones appear to have varying degrees of functional activity. Thus in many cases of fatal disease, with gradually increasing exhaustion, only a small quantity of food is taken for many days before death, whilst, in other instances, the appetite is maintained to the last; we consequently often observe, in the one case, the follicles full of secreting cells and nuclei; in the other, perhaps it is not an easy thing to observe them at all.

The microscope has done much to increase our knowledge of pathology and our means of investigation; but, with this increase of power we must add equal caution to remove all causes liable to mislead us. The mode which I have adopted in preparing sections, and which will generally be found a successful one, is to stretch the membrane over or between the fingers, and then, by means of Valentin's knife, make a section of the required depth and thickness. This is afterwards removed by scissors, and spread out in water by needle points. I have examined with great care a considerable number of stomachs from the post-mortem table of Guy's Hospital; but it is not necessary to mention the cases in which the membrane appeared in a healthy condition. In many of these examinations I have observed appearances precisely corresponding to the descriptions and drawings of Dr. Handfield Jones; but I think very great attention must be given to the manner in which many of these appearances may be produced by the mode of making the preparation, or by changes after death. I refer to wasting of the follicles, nuclear deposit around them, and the development of cysts. The gastric follicles change very rapidly, and in a short space of time nothing can be observed but the termination of the follicle itself upon the submucous areolar tissue, and above this an irregular aggregation of granules and nuclei. The basement membrane also rapidly becomes dissolved; and this condition will be found, on microscopical examination, before the ordinary appearances of gastric solution are observable on the stomach. The greater curvature of the stomach is in this way generally too much changed to allow us to place

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