tion the application of a strong solution of nitrate of silver, afford relief by diminishing the extreme sensibility of the diseased surface. Counter irritation may occasionally be applied with advantage, as the tincture of iodine, hot fomentations, cantharides, &c. The improval of health by residence at the sea coast, by cod-liver oil, by preparations of iodine, and of steel, and by the use of such forms of nutritious diet as can be taken by the patient, are the means most likely to be followed by enduring benefit. IV. Spasmodic Stricture of the Esophagus.-The few cases of this kind which have come under my own observation have been in young women of an excitable character, who were suffering from leucorrhoea, or painful menstruation, and impaired digestion. The strongest language was used by these patients to express their inability to swallow, and they showed the greatest unwillingness even to make the attempt. One of them was a young woman about twenty-three years of age, thin and imperfectly nourished. On passing an oesophageal bougie, no obstruction whatever was found; she afterwards swallowed food in small quantities, which was increased day by day until she took the usual amount. Fright, terror and cold are found to produce spasmodic dysphagia, and instances of this kind we have seen after violent storms of thunder and lightning; but in lesser degrees it is not unfrequent in hysterical subjects, and as the symptoms of hysteria are well marked there is no danger of mistaking the complaint for cancerous obstruction, although there may be some difficulty in distinguishing it from perforating ulcer extending into the trachea. Abercrombie gives the case of a lady, æt. 40, in whom stricture of the oesophagus was supposed to exist. The symptoms continued for a year, and were entirely relieved by passing "an egg-shaped silver ball attached to a handle of silver wire." This state, however, is not limited to one sex. Mayo† mentions a remarkable instance of spasmodic stricture of the œsophagus in a gentleman, æt. 60, who had sudden obstruction of the œsophagus whilst at dinner. It was relieved by the passage of a *Abercrombie on 'Diseases of the Stomach.' III. Laryngeal Dysphagia. In acute laryngitis and incroup, it is the exception to find deglutition performed in the normal manner; and sometimes, especially in laryngitis, dysphagia is an urgent symptom. In these cases, however, the dyspnœa and cough are the earlier and the more marked indications of disease. The epiglottis is found to be injected and tumid; and the branches of the superior laryngeal nerve are rendered intensely sensitive. This abnormal sensibility is an explanation of the dysphagia which is generally present, even if the mischief do not spread directly to the pharynx. Diseases of the laryngeal cartilages rarely extend to the pharynx, unless the malady be of a cancerous character; more frequently, as in necrosis, suppuration takes place among the muscles of the neck, and chronic laryngitis of a most intractable form is produced. But although dysphagia is not a prominent symptom of disease when only the cartilages of the larynx are affected, the reverse is the case when the fibro-cartilage, the epiglottis, is also implicated, whether in syphilitic, in strumous, or in the cancerous diseases. In syphilis, both the glossal and laryngeal surfaces of the epiglottis become involved, and sometimes nearly the whole of the fibro-cartilage is destroyed leading to distressing dysphagia ; and in phthisis ulceration of the epiglottis is one of the most trying complications of the complaint, the ulceration extending on its inner surface as far as the margin, which becomes eroded and gradually destroyed, and the contact of food with this irritated surface sometimes leads to the instant rejection of it through the nares. In chronic phthisis I have seen this condition attributed to organic disease of the oesophagus itself, on account of the extreme urgency of the dysphagia, and because the food appeared to have passed below the pharynx before it was forcibly ejected. It sometimes happens that solids are more easily swallowed than fluids; and this is the case in some instances where the dysphagia arises from disease of the larynx; a solid will pass over the diseased epiglottis and fall beyond it, whilst a fluid comes in close contact with it. Laryngeal dysphagia is often greatly mitigated by the inhalation of steam, or of the fumes from conium or stramonium. In less severe cases astringent gargles, and in syphilitic ulcera tion the application of a strong solution of nitrate of silver, afford relief by diminishing the extreme sensibility of the diseased surface. Counter irritation may occasionally be applied with advantage, as the tincture of iodine, hot fomentations, cantharides, &c. The improval of health by residence at the sea coast, by cod-liver oil, by preparations of iodine, and of steel, and by the use of such forms of nutritious diet as can be taken by the patient, are the means most likely to be followed by enduring benefit. IV. Spasmodic Stricture of the Esophagus.-The few cases of this kind which have come under my own observation have been in young women of an excitable character, who were suffering from leucorrhoea, or painful menstruation, and impaired digestion. The strongest language was used by these patients to express their inability to swallow, and they showed the greatest unwillingness even to make the attempt. One of them was a young woman about twenty-three years of age, thin and imperfectly nourished. On passing an oesophageal bougie, no obstruction whatever was found; she afterwards swallowed food in small quantities, which was increased day by day until she took the usual amount. Fright, terror and cold are found to produce spasmodic dysphagia, and instances of this kind we have seen after violent storms of thunder and lightning; but in lesser degrees it is not unfrequent in hysterical subjects, and as the symptoms of hysteria are well marked there is no danger of mistaking the complaint for cancerous obstruction, although there may be some difficulty in distinguishing it from perforating ulcer extending into the trachea. Abercrombie gives the case of a lady, æt. 40, in whom stricture of the oesophagus was supposed to exist. The symptoms continued for a year, and were entirely relieved by passing "an egg-shaped silver ball attached to a handle of silver wire." This state, however, is not limited to one sex. Mayo† mentions a remarkable instance of spasmodic stricture of the oesophagus in a gentleman, æt. 60, who had sudden obstruction of the œsophagus whilst at dinner. It was relieved by the passage of a bougie. The brother of the patient, who had suffered from gout, had had a similar seizure. The same author narrates a case of spasmodic stricture in a young man, produced by ulceration of the interior of the larynx. It must be borne in mind also, that spasmodic contraction of the oesophagus tends to increase the obstruction arising from organic causes, so that the degrees of dysphagia in the same case differ exceedingly. The general symptoms and history aid us in the diagnosis of these cases thus, there is an absence of emaciation; the attack comes on suddenly after a slight cause, as from nervous shock or slight catarrh; there is freedom from pain, but nervous excitement is always present. Hot fomentations, the use of fluid, instead of solid food for a short time, aperient or antispasmodic enemata as of turpentine or rue, will afford relief in these cases. Tonics are often of service, as the compound iron mixture with decoction of aloes, or the compound steel pill, with aloes and myrrh; so also quinine, zinc, valerian, vegetable tonics may be used; and the shower bath, good air and exercise, and cheerful occupation of the mind will greatly assist in the restoration to health. Bougies are often employed, but their use is not generally beneficial, and may be detrimental by tending to perpetuate and aggravate a state of spasmodic irritation and contraction; but in cases where the muscles of the pharynx have lost their contractile power, the direct introduction of food is absolutely required. In some hysterical patients, the refusal to swallow arises from a disordered will, rather than from any disease in the œsophagus itself. In Hydrophobia true spasm of the pharynx and oesophagus is present in a most marked degree. A few years ago a case of this terrible disease occurred at Guy's Hospital, and on inspection the appearance of the pharynx was very peculiar, its cavity appeared more than twice its natural size; the constrictor muscles were retracted to the utmost, and the fauces were exceedingly large from the rigid contraction of the soft palate; the spasmodic condition of the muscles rendered every part of the pharynx as dilated as possible; whilst from similar muscular spasm the oesophagus was contracted. The mucous membrane of these parts was injected and covered with tenacious mucus. There was great congestion of the membranes of the brain and spinal cord; and the lungs were in a similar state of engorgement. The other viscera were healthy; but there was emphysema of the cellular tissue of the neck. The symptoms during life indicated extreme irritability of the nerves supplying the pharynx, as, indeed, of all the branches of the fifth and pneumogastric nerves. CASE III. Hydrophobia. The patient was a young man, æt. 23, who was said to have been bitten by a dog nine years previously. On the day of admission into Guy's, May 15th, 1854, difficulty of swallowing came on, with great mental excitement. He was removed to one of the adjoining workhouses, and afterwards brought to the hospital, about nine o'clock in the evening. He was a strong muscular man, and at first sight appeared to be affected with acute mania, or delirium tremens; but there was a sudden starting, especially when a draught of cold air came in contact with his face, which clearly indicated the character of the disease. This starting evidently resulted from spasmodic action of the muscles of the face and pharynx; his countenance had a wild and excited aspect; he thought that he was being murdered, that boiling water was dropping upon his face, and he said, that he felt "choked." The pulse at nine o'clock was 90, and at eleven, it was 120; the tongue was clean; the pupils were widely dilated; the face was bathed with perspiration; and the hands clammy; he would not attempt to drink, but dashed the cup away from him with a violent spasmodic action, but he ate a small portion of bread; and he was frequently spitting out saliva. Restraint was required, for in his terror, which was fearful to witness, he rushed at the window, and would have seriously injured himself. I remained with Dr. Gull for several hours during the night with this patient, a witness of one of the most fearful spectacles of misery and disease I have ever seen. About 12:30, an injection, containing 10 grains of cannabis indica, was administered; but the whole of the enema was at once returned. At one o'clock a longer tube was passed, and the same quantity again injected; the paroxysms had then become very violent and frequent, and the pulse exceedingly small, irregular, and occasionally intermittent, 120 to 130 per minute. At 2:15, he was still more violent, calling out as loudly as his strength would permit. It was then determined to administer chloroform. During the inhalation, intense congestion of the eyes and face came on; the pupils became much smaller, and the pulse a little more perceptible; the respiration, which had been catching and accompanied with gasping and sighing, became more regular. In four or five minutes after leaving off the chloroform the paroxysms began to return; the face, however, did not at once become sensible to impressions. Chloroform was administered three times during the hour, and on leaving it off the same return of paroxysm took place; the pulse became almost imperceptible, and the respiration more stertorous. About 3 a.m., whilst under the influence of chloroform, 10 grains of cannabis indica were placed in his mouth; it became |