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A Peculiar Case of Oesophageal Stricture Caused by a Benign Tumor.

BY THOS. BROOKS, M. D., DEARBORN, Mo.

ANUARY, 1893, Mr. J., aged seventy, farmer, began to be troubled with vomiting at times. Health had always been perfect, except two very severe injuries from which he never entirely recovered: one, that of having a heavy stone fall against his lower limb, leaving him with irregular attacks of rheumatism. He was again, twelve years ago, struck by a locomotive, leaving him with a partial paralysis of one of his lower extremities.

This vomiting came on almost instantly upon any food being taken. This emesis was without any nausea whatever. He would often make three or four attempts at his meal, but often meet with a total failure of having anything remain in his stomach. Bear in mind there was no nausea whatever, simply a regurgitation of the food swallowed, with a large amount of saliva, and phlegm of a tenaceous character, which was always mixed with large air bubbles.

For the first year these attacks did not occur oftener than every eight or ten days, and would continue through a period of only two or three meals, but the attacks became more frequent and severe, lasting much longer. It was not till August, 1894, that he sought medical advice.

During all this time there seemed to be nothing accomplished by dieting, as some of the most indigestible food gave him less trouble than any other. When any food remained in the stomach he suffered none, and enjoyed his meal as well as at any time during his life. Very often when he would attempt to swallow water, or milk, it would be regurgitated instantly, the same as eructations of gas.

During the entire period of his sickness the vomiting continued periodically, lasting any length of time from one day to two weeks. When first called 1 found the patient very much emaciated, being able to sit up for only a short time. The stomach and bowels were quite empty and hence no trouble to outline the abdominal aorta by inspection. By palpation and percussion nothing was clearly made out. No tumor of any form or size. could be found. No feces in the colon; no gas in the intestines; and no pain to be found about him. By relaxation of the abdominal muscles, I examined the gastric and duodenal region thoroughly, and quite severely, but could find not the slightest tenderness.

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He said he never felt better in his life, and his appetite was ravenous; remarked that he was hungry all the time, as it did not make him the least particle sick to vomit, neither did he suffer any pain.

History was clear of syphilis; no hereditary tendency toward any constitutional disease; pulse 70 strong, bounding and regular; bowels constipated, going eight or ten days without an evacuation; vision clear, pupils. normal; temperature always normal; respiration full and easy, the murmur being very distinct over the entire lungs; tongue clean; no bad taste in his mouth.

He was first examined, August, 1894, by four physicians. Two diagnosing gastric cancer, one gastric ulcer, one gastric catarrh, changing to cancer. I was called November, 1894, and having their diagnoses in view from the first, I was quite guarded in my opinion. There had been no "coffee-ground vomit," no hematemesis, no tarry stool (to indicate haemorrhage of cancerous origin); no diarrhoea (to confirm diagnosis of cancer); no pain; no cachetic appearance; vomiting only when food was taken. He would often go for two days without even a drink of water, during which time there would be no vomiting. No difficulty or pain on deglutition of solid food; no pain referred to the region of the spine or scapulæ.

The diagnosis was difficult: whether a stricture of the oesophagus, gastro-duodenitis, or a combination of the two, there being evidence of each, yet there was no evidence to make up a clear diagnosis of either, but I denied the existence of gastric cancer, or ulcer. That did not seem rational, as I could not see one single symptom as proof of the malady. I could plainly see that the patient was starving, but the most important matter was what to do for him.

The physicians prior to me had him on the following treatment and diet:
B Bismuthii subnitras.

Rhei powder ....

.grm. vi - grm, iii

Misce et fiat capsulæ No. x. Sig:-One capsule t.i.d, also:

Pill aloin, strych., belladon., et cascara, sagrada..No. xx

Sig:-One pill night and morning.

Diet to consist of aqua calcis and milk in limited quantities. I could not agree with this treatment, especially the rheium, and certainly not such enormous doses of bismuth. I put him at once on the following course:

In connection I ordered him to use an unlimited amount of milk, eggs, and broth. I gave this as a test trial for gastro-duodenitis

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Saw him at my office in a few days, doing nicely, eating regular meals, without any restriction of diet, or limit, for he was a very hearty eater. I was astonished at such rapid improvement and began to think I was on the proper course of treatment. This continued about ten weeks when the vomiting again became prominent; no pain, and only a repetition of the disease. The symptoms were much more aggravated.

I was then the more suprised and astonished, as he had been eating anything common for people in health, without the slightest discomfort. At this time when anything was swallowed it was instantly rejected. This condition continued for about twenty days when our patient died from starvation. I saw him four times during the last two weeks; symptoms remained the same, no variation whatever.

When (from weakness) he could speak only in a whisper, he said to me: "Why must I die? I never felt easier in my life; not a trace of pain anywhere in my body."

He requested me to hold an autopsy after death, which I was exceedingly glad to have the opportunity of doing. At the autopsy I found the stomach entirely empty and very much contracted from atony. The pylorus, duodenum, liver, pancreas, spleen, and bowels were in a perfectly normal and healthy condition. When removing the stomach I found adhesions at the opening in the diaphragm to be very strong. I carefully dissected out the œsophagus at the cardiac opening, and found, to my surprise, a cartilaginous tumor of a benign variety, about 21⁄2 inches in diameter, and extending about 3 inches above the stomach and causing quite a complete stricture at this point. The inability of food to pass through this point caused quite a dilatation of the oesophagus, as shown in cut. There was no tendency toward degeneration, but I am of the opinion that ossification was taking place, and should not this stricture have formed we would have had the formation of bone in a short time.

I have not as yet prepared a specimen for microscopical examination, though I certainly shall in the near future.

Now had I been able to convince the other brethren that there existed no cancer we would have certainly inserted a gastric canula, and had our patient enjoying health today. I was anxious to wash out the stomach. and make the proper test of its contents, but to this they did not agree. Had we tried to insert a tube we would have made a proper diag‐ nosis clearly. Can any one give an explanation of the periodical vomiting, and the existence of such a growth without pain? Would be glad to correspond with any of the readers of the HERALD, either through its columns or privately.

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The Newer Therapeutics; Dosimetric and Specific

A

Medicines.

By W. G. BUCKLEY, M. D., PHILADELPHIA, PA.

STHMA.- Recent and paroxysmal and not complicated, requires aconite (amorphous), lobelia, hydrocyanic acid medicinalis. Give one

granule of the first two remedies named and one drop of the acid every two hours or oftener till better. Where the spasms affect the whole body more or less, with vomiting, give a granule of the arseniate of copper and one of the sulphate of strychnine every hour or two hours till relief is had. When the pulse is full and some bronchitis of an acute form exists, give always the aconite. But if the bronchitis be of a chronic nature, the lobelia, grindelia, antimon. arseniate with strychnine should be given.

In the nervous variety, with convulsive breathing, nausea and vomiting and much stringy mucous, cold sweat on the face, the veratrine with strychnine and hyoscyamine should be employed, one granule of each together, alternately with one of conitine and potassium bichromate.

In the cardiac form, digitaline, strychnine, and (aconine when the pulse is strong) cactenine if the pulse be only moderately strong, if very weak glonoin should be employed with strychnine. Give a granule of each of the selected ones every hour or two till relieved.

In the hysterical variety, give the granules of the valerianate zinc, assafetida, and hyoscyamine, one of each together every hour to three hours, also cannabine and macrotin in alternation with the three, the former when exaltation of spirits, loquacity and incoherent talk predominate, the latter when she thinks she will not recover.

The paludal variety is controlled by hydroferrocyanate of quinine, arseniate of quinine and strychnia sulph. Iodide of cinchonidia may be with advantage given in conjunction with the above, one of each together from two to four hours apart. Syphilitic infection and the scrofulous nature call for the latter. The gouty and rheumatic diathesis require arsenate of strychnine, colchicine and sulphur; in constipation the sulphur composition.

In all cases, to prevent a return of attacks, the usual dose of the seidlitz salt should be administered every morning fasting. The regimen should be that generally recommended for persons of weak digestion. The patient should eat sparingly. A milk and vegetable diet is probably the best for all. The Abbott Alkaloidal Company, of Ravenswood, Chicago, make a pepsin compound, vegetable, which is useful when, by accident, fermentation. should take place from unwittingly taking an improper food. This company also make the granules I employ; they are economical, handy and thoroughly reliable; easy to take and readily dissolved in the juices of the stomach.-Tri-State Medical Journal.