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 esophagus, 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, reappearing 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 occurred, seemed to corrobate this diagnosis and prognosis. I never 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 esophagus, 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 nervous system, with leucorrhea 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 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.
The first record I have of the principal symptom of this case is on September 8th, 1856. She then told me, that on the previous evening, she had a “choking in the throat,” relieved after taking salt and water. Three days before she had complained of burning in stomach and abdomen, and weakness in stomach and of feeling “nervous.” I had given her Sulph.20 with benefit. Her bowels were quite constipated, as was frequently the case with her. I prescribed Opium2.
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.20, Nux4, Con.20, Puls.20 and Merc30, 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.20 She continued to improve, and on November 2nd, I record: — Can swallow without difficulty; bowels still costive. Gave Opium.2
Has sharp pains in right side of esophagus, 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.30
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.30
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.30 was given. Said she was quite relieved of her old troubles, including constipation and menstrual difficulties.
After nearly a year of good health, on May 22nd, 1858, she called at my office, and said that after dinner her face was flushed and she had head-ache; burning in head and face, bowels costive. I prescribed Nux6, which I have no doubt relieved her, as I did not prescribe for her again till August 12th, when she complained of burning in the pit of stomach; nausea, more after eating; had once or twice vomited bitter and sour matter; constipation; vertigo in morning on rising; burning in face and eyes, with redness of face and suffusion of eyes. Bry.7, a dose morning and evening for a week, was prescribed.
While attending another patient in the family, in the month of October, of the same year, I was requested to prescribe for her. She was under my care from the 13th to the 25th of October, when not being much improved She concluded to try some “bitters” recommended by a kind friend.
On the 13th of October, she had not eaten any thing for several days excepting a very small portion in the morning; at other times, was wholly unable to swallow even water or tea. She would say she felt perfectly well, with this singular exception. She did not have at this time the indications of disorder in regard to the function of digestion, which I have recorded previously, and which occurred subsequently after allopathic treatment. The only symptom besides the difficulty of deglutition, was her old trouble — constipation.
During the period from 13th to 25th October, she improved slightly, a few times being able to swallow a little food at dinner. The bowels were during a portion of this time pretty regular. The remedies prescribed during this period were Opium1, which relieved constipation partially; Bell. 12, with benefit to the throat symptoms; Alum12, Nux0, and Cham.30
On the 13th of November, nearly three weeks after, she sent for me. I found she had been under the care of an old school physician, but had not experienced the slightest benefit. Even the bowels would not yield to the action of Cathartics. She could eat a little more in morning, but none at any other time. I found her in bed; previously she had been up and about. Had this evening, faintness; nausea and palpitation, and sensation as though she could not get her breath. Tongue red anteriorly, but brown posteriorly. Gave her Ign.12 solution, a dose every two hours.
November 21st. Not so well for three or four days. Sour and bitter eructations after eating. Last night had faintness with cold sweat on forehead; hands and feet cold most of the time; menses delayed; should have appeared a week ago; pulse 96. Gave Bell.20 solution, a dose every three hours.
November 26th. Not able to eat; last night after swallowing a little food had sour eructations, which prevented her from eating more; complains of flatulence in abdomen; passes urine quite frequently. Continued Bell.12
November 27th. Sensation of fulness in left iliac region, has had this symptom for a long time; ate at dinner yesterday and this morning at breakfast; took an enema yesterday, of water, with great relief to symptoms. Continued Bell.12
December 1st. Has now, after eating, spitting of thick tenacious matter, appearing like white of an egg beat up; sensation as if there were something which ought to come up; relaxation of joints; last night was awoke with griping in abdomen; tongue dry and stiff; feels much discouraged; pulse 66, of fair size and strength. Gave Nat. mur.30, a dose every three hours.
December 9th. Has been able to eat much better than usual; her broth is made thicker; she also ate half a potatoe, the first in more than two months. Feels rather weaker; tongue clean; pulse 64. Continued Nat. mur.30
December 13th. Today has scarcely swallowed anything, only a little water and a few tea-spoonfuls of weak broth. On endeavouring to swallow had choking. Rumbling in abdomen. It seems to her as though there were wind in abdomen which prevented her from swallowing. Pulse 58. Baryta carb .30 solution, every three hours.
I called on the 16th, but learned she had concluded to return to her old school physician. She continued under his care until a few days before her death, which took place February 25th, 1860. As I understood from mutual friends that she had expressed a desire to see me, and that her physician had given up all hopes of curing her, I made a friendly call on the 21st of February. The physician had left several days before, saying that it was useless to give her any more medicine as she was dying. On the 16th, she had taken about two drops of beef tea but had not taken a particle of any thing since. She was as much emaciated as any one could be and so weak that she was unable to turn herself in bed, but her voice wag clear and distinct; had at times been unable to speak. As she wished me to give her something to relieve a burning in throat and extreme dryness in mouth of which she complained, I gave her some pellets of Ars.30
On the 23rd, I was called in haste at half-past six o'clock, a.m. She had been suffering extremely severe pains in abdomen, since 11, p.m.; her pulse was very small and rapid; several remedies were given but appearing not to relieve her I allowed her to inhale Sulphuric Ether, which very greatly relieved her pain. This was occasionally repeated and a few pellets of Nux6 placed in her mouth. Death finally came and relieved her of her sufferings, but the access to it was extremely gradual. When I saw her on the morning of the 23rd, I did not suppose she could live out the day: her hands and feet were cold, and her pulse too frequent to be counted, notwithstanding which, her voice was quite distinct. She retained her consciousness till the last, but for thirty-six hours before her death could not speak.
As some may wonder why the esophageal bougie was not introduced and so afford means of getting food into the stomach, I will state that I had thought of it before my attendance ceased, in December 1859, but the symptoms were scarcely severe enough to warrant it. When I saw her a few days before her death, she was altogether too far gone to give any chance for her recovery. I should have tried it as an experiment without having any confidence in its success, as it was evident, during the latter part of her sickness, that the stomach did not perform its functions for the small amount of food which was swallowed.
Emaciation extreme; pectoral muscles much wasted; lungs pale but healthy; no tubercles; coats of stomach seemed thicker than is usual; peritoneum unusually thick and tough so as to be torn with difficulty; liver large but normal; spleen small; kidneys normal; the veins of the intestines were full, as were also those on external surface of uterus. A number of small lumps of feces were found in bowels.
We then proceeded to examine the esophagus, for which purposes we removed both clavicles. On dissecting about the lower part of trachea, a small hard tumour was discovered, which proved to be osseous in its character. It was about an inch long and a half inch in breadth and thickness, it was hard and solid with numerous spiculae of bone projecting from it. It was situated just above the bifurcation of trachea, inclined to the right side; a nerve was seen to be very intimately connected with the tumour, being on its anterior surface, this I considered to be a cardiac branch of the pneumogastric nerve. By the interference with the functions of this nerve was probably the peculiar difficulty of deglutition produced, as also the symptoms of disorder in the digestive apparatus.
The tumour did not press on the esophagus and was only loosely attached to trachea; it was firmly adherent to the posterior portion of the vena cava superior; it could only be implicated in the production of the symptoms by its relations with the pneumogastric nerve.
In conclusion, I will state that the only remedies which produced a marked effect upon the difficulty of deglutition, were Mercurius, Pulsatilla, Ignatia, Belladonna and Natrum muriaticum, From the larger edition of Jahr's Manual I extract the following symptoms of the pathogenesis of these drugs*[The Italics and other Distinctive Marks are from Jahr.]
* When swallowing he feels as if the throat were swollen, Difficulty of swallowing as if from paralysis of the muscles of deglutition. Choking pain in the pharynx as if from swallowing too large a morsel.
NATRUM MURIATICUM. — Sensation as if a plug had lodged in the throat. Spasms in the pharynx; when swallowing she found it very difficult to get the food down or to bring it up again, so that she came near suffocating. Constriction of right side of throat, the pain extending to neck.
While engaged in writing out this case, a young woman came under my care at the Central Homoeopathic Dispensary, whose case presents some points of resemblance to it. She has had extreme difficulty in the deglutition of solids for a year or more, with progressive loss of strength and emaciation. She has been so far slightly benefited. Should she remain under my care, I shall report the result at some future time.
|Source:||The American Homoeopathic Review Vol. 02 No. 07, 1860, pages 314-324|
|Description:||a Singular Case of Spasmodic Stricture of The Esophagus.|
|Remedies:||Mercurius, Pulsatilla, Ignatia, Belladonna, Natrium muriaticum|
|Editing:||errors only; interlinks; formatting|