causing pneumothorax, or may spread to the neck and even to the entire body. The treatment is entirely symptomatic.

MEDIASTINAL HÆMATOMA.

Hemorrhage into the mediastinal tissues occurs in hemorrhagic conditions, from erosion or rupture of blood-vessels or from rupture of an aneurysm.

The symptoms are those of hemorrhage and mediastinal pressure, while ecchymoses may appear after a few days in the lumbar region.

DISEASES OF THE THYMUS GLAND.

Hypertrophy is occasionally met with in children; it may cause spasm of the glottis (thymic asthma) or sudden death.

Abscess may develop in syphilitic children.

Sarcoma and carcinoma may originate in the thymus. gland and may give the regular symptoms of tumor in the mediastinum. The gland may be enlarged during the course of leukæmia or of Hodgkin's disease.

Hemorrhages in the gland-tissue are not uncommon during scurvy and purpura hæmorrhagica.

IV. DISEASES OF THE DIGESTIVE

SYSTEM.

I. DISEASES OF THE ESOPHAGUS.

ACUTE ESOPHAGITIS.

Etiology. The oesophagus may be inflamed-(1) by the spread of inflammation from the pharynx or the stomach; (2) by mechanical or chemical irritants or corrosives; (3) by pseudo-membranous inflammation secondary to diphtheria or to some acute infections; (4) by the pustules of variola; (5) in rare cases œsophagitis may develop in sucklings without known cause.

Lesions. The inflammation may be diffuse or localized, and either catarrhal, pseudo-membranous, or phlegmonous. The pustules of variola result in ulcerations. There may be a mycotic inflammation secondary to thrush and resembling it in its pathological features. The swallowing of corrosives is followed by sloughing and ulceration.

Symptoms.--Pain on swallowing is a nearly constant symptom, and a continuous substernal ache is frequently observed. Food may be regurgitated; if coated with blood or with pus, ulceration is indicated.

In cases of caustic poisoning the lips, the mouth, and the pharynx exhibit evidences of corrosion, and the symptoms of toxic gastritis are present, usually with some associated shock. Rupture of the oesophagus may occur. Patients recovering from the acute symptoms ultimately develop œsophageal stenosis.

Some cases of acute oesophagitis, even if severe, occasion but a trifling amount of discomfort.

The treatment of acute œsophagitis consists in the administration of the proper antidote in case of corrosive mineral poisons. Demulcent drinks and cracked ice are of service in diminishing the pain and the inflammation. The nourishment should be bland and unirritating. Fluids alone should be given during the acute stages, while in severe cases rectal alimentation should be insisted upon.

A chronic catarrhal inflammation of the mucous membrane lining the œsophagus is produced by improper and irritating food and by the presence of tumors or stricture of the oesophagus itself; or the chronic form may result from an acute attack.

The symptoms consist chiefly in the raising of mucuscoated regurgitated or vomited food.

The treatment is that of the underlying cause.

STENOSIS OF THE ESOPHAGUS.

Synonym.-Stricture of the oesophagus.

Stenosis may result-(1) From compression from without by tumor of the neck or the mediastinum, by aneurysm, by retropharyngeal abscess, or by a large pressure-diverticulum. (2) From obstruction of the lumen by foreign bodies, and rarely by tumors and polypi. (3) From contraction of the wall. (a) There may be cicatricial contraction following the healing of ulcers due either to corrosive poisons or to diphtheria, small-pox, or, more rarely, to syphilis or to tubercular disease. A rare form of ulceration, the "round ulcer," is seen at the lower end of the œsophagus. This ulcer is produced by self-digestion by regurgitated gastric juice, after the manner in which ulcer of the stomach is caused. (b) There

may be malignant growth of the wall, usually epithelioma. (c) There may be spasmodic contraction or (d) congenital narrowing at some part.

Symptoms. In all cases of stenosis of the oesophagus these cardinal symptoms are present-difficulty in swallowing, pain, and the regurgitation of food. The cases may, however, conveniently be described in three groups.

CICATRICIAL STENOSIS.

The stricture may occur at any part of the oesophagus, but it is most frequent in the lower third.

The whole

length may be involved. The stenosis may reach such a degree that liquids can barely trickle through. The œsophagus above the stricture is usually much dilated, and its walls are thickened.

After the history of antecedent ulceration the patient complains of increasing difficulty in swallowing, the food being cut finer and finer and washed down with water. In severe cases liquids alone are taken. The food seems to stick, and after a time it is regurgitated. The lower down the stricture is, and the more dilated the œsophagus above it, the longer the time after eating before regurgitation occurs. The ejected food may be macerated and mixed with mucus, but that it has not reached the stomach is proved by the absence of gastric odor and by the alkaline reaction of the food. The latter test, however, is not infallible if the food be retained some hours before being regurgitated, because of the formation of fatty acids in it. Pain is not a marked feature except at the time of swallowing the first bolus.

The diagnosis is made by the passage of the œsophageal bougie. A conical bougie on an elastic whalebone stem should be employed, but the soft-rubber stomach-tube may be used. It is of the utmost importance, before passing the

bougie, to exclude aortic aneurysm producing stenosis by compression, because of the danger of causing rupture of the aneurysmal sac. The tube should never be passed when ulceration of the oesophagus from any cause is suspected. Auscultation is frequently serviceable in cases where the bougie cannot be employed. The auscultator, listening to the left of the dorsal spine while the patient swallows a mouthful of water, hears a loud splashing, gurgling sound at the site of the stricture, below which the sound is absent or only slightly audible after a pause.

The prognosis depends upon the degree of stenosis and upon its dilatability. In advanced grades death may ensue from inanition or from rupture of the dilated œsophagus above the stricture; or, should the regurgitated food enter the larynx, suffocation or aspiration-pneumonia may result.

Treatment.-Gradual dilatation by the persistent use of the œsophageal bougie should be employed, and in many cases the results are remarkably good. The diet should. be compact and nourishing, and rectal alimentation may be resorted to. In advanced cases the stricture may be cut, or an opening may be made into the esophagus below the stricture (œsophagostomy), or into the stomach (gastrostomy).

CANCEROUS STRICTURE.

This form of œsophageal stricture is usually primary. Epithelioma is most common; scirrhus and encephaloid. are rare. The growth usually occurs in the lower third, next in frequency in the upper third, of the œsophagus. Beginning in the mucous membrane, it extends to form an annular constriction, usually involving one or two inches. of the tube. Ulceration of the growth may occur, so that the stenosis becomes less marked, but the ulceration may extend and perforate the lung, the trachea, a bronchus, the