Permit me to send the following case to you for insertion in the
Gazette.
Mary Blores, æt. 33, was admitted into the Middlesex Hospital on
the 16th of November. She was in a state of extreme feebleness and
emaciation. Those who brought her said that during the preceding
month she had appeared to swallow nothing: what she took as food
seemed to her to stop in the gullet, and after a few minutes
returned. I found, however, that a large œsophagus-bougie passed
readily into the stomach, meeting with no obstruction beyond a
spasmodic resistance in the pharynx. A draught of milk and water
was given her--she swallowed it without much effort, but it quickly
returned. In the course of the afternoon a pint of beef tea was
injected through an elastic tube into the stomach--it was thrown up
directly.
I now learnt from her that she could swallow liquids much more
readily than solid food; that when she took a small quantity,
it seemed to her not to reach the stomach, and in three or four
minutes was invariably thrown up; that on taking a large draught
she had an impression that it reached the stomach--in this case
vomiting did not follow so soon, and some part of the draught was
permanently retained; that she craved food and drink, and was
literally dying of hunger and thirst; that the vomiting which took
place was not preceded by nausea, although in its progress it had
all the appearance of ordinary retching; that the matter vomited
was not thrown up at once, but by successive efforts; it consisted
of the food she had last taken, mixed with colourless mucus. The
belly was so shrunk that the umbilicus was not more than an inch
distant from the spine, upon which the pulsations of the aorta
were readily felt: there was no enlargement or hardness about the
stomach, no particular tenderness on pressing the epigastrium, no
sensation of pain or heat now or formerly.
The complaint had began ten years ago, during pregnancy, since when
she had never been free from it, although at times her sufferings
had been less, and she had been able to retain some portion of her
meals. She had borne in this period three children; the vomiting
had lasted during the whole period of her pregnancies, and during
her confinement. The principal remedies which had been used for her
relief were a succession of blisters on the pit of the stomach--but
they had produced no benefit. Latterly her symptoms had been
greatly aggravated.
This patient was attended by Dr. Watson and myself. But the means
which we tried to enable her to retain her food, and to support her
expiring strength, had scarcely a temporary effect. She died on the
2d Dec. sixteen days after her admission. The body was carefully
examined, at the expressed wish of her relatives.
The unusual appearances found in the abdomen were--1. the smallness
of the first part of the duodenum, which was but half the ordinary
size of the ileum; 2. the capaciousness and fulness of the gall
bladder,--from which, however, on compressing it, the bile flowed
readily into the intestine; 3. a contraction of the middle of
the stomach of the length of two inches, for which extent the
peritoneal coat was thickened and opaque, and the inner membranes
folded in deep longitudinal rugæ, the mucous surface of which was
partially suffused with circular spots of red. The breadth of the
contracted part of the stomach, as it lay collapsed, was an inch
and a half.
[Illustration]
[Illustration]
But it was in the chest that the most remarkable circumstance
presented itself. The œsophagus gradually enlarged from the
pharynx, which was perhaps rather narrower than usual, to an
extraordinary degree of dilatation; the greatest breadth which it
attained was situated about four inches above the cardia: the tube
then contracted more abruptly, so as to render the termination
of the œsophagus, like its commencement, of nearly the usual
dimensions. The structure likewise of the cardiac extremity for
about an inch, and of the pharyngeal end for about half an inch,
was healthy. The intermediate part presented, when inverted, the
following curious appearance:--The inner membrane was thickened
and opaque, and had _the appearance_ of having partially yielded
from dilatation; at the upper part the furrows or thinner parts of
the membrane followed in some degree a longitudinal direction; at
the lower part the surface was pitted with shallow depressions of
various figures. I have represented in the adjoined sketches these
appearances, which on the middle of the œsophagus passed from one
into the other; at the furrows or depressions the membrane seemed
of the natural thickness and colour; the intermediate raised and
thickened part was opaque and whitish. The muscular fibres of the
œsophagus were of the natural colour and thickness.
I remain, Mr. Editor,
Your obedient servant,