may be successfully used, both internally (gr. 1/16 two or three times
a day) and in spray, a drachm or less night and morning (one grain to
four ounces). External counter-irritation by repeated blistering over
the larynx and under the angles of the jaws is useful in some
instances. During treatment the voice should be used as sparingly as
practicable.
In chronic atrophic pharyngitis the treatment, constitutional and
local, should be such as favors secretion from mucous
membranes--internally, cubeb, pyrethrum, calamus, xanthoxylum,
jaborandi, ammonium chloride; topically, sprays, four or more times a
day, of hot water, glycerin and water, ammonium chloride. Patients
sleeping with the mouth open should wear an apparatus, extemporized or
made to order, to keep the lower jaw closed in sleep.
Syphilitic Pharyngitis.
DEFINITION.--A specific inflammation of the mucous membrane of the
pharynx or of the mucous membrane and submucous tissues, the result of
syphilis, and often associated with like disease in contiguous
structures.
SYNONYMS.--Pharyngitis syphilitica, Pharyngitis specifica, Syphilitic
sore throat, Syphilis of the pharynx.
ETIOLOGY.--Contamination by syphilitic virus is the sole cause, whether
by direct inoculation or by systemic poisoning, hereditary or acquired.
Direct inoculation proceeds from primary sores on the lips, tongue,
cheek, and hard palate, themselves the result of actual contact with
sores in other individuals. Initial sores have been seen upon the
tonsils, palatine folds, pharynx, and even the epiglottis. Direct
inoculation from secondary sores may be communicated by the
tooth-brush, blow-pipe, pipe-stem, trumpet, mouth-piece of
feeding-bottle, pap-boat, or similar article previously used by an
infected individual. Uncleansed surgical instruments convey the disease
in like manner.
PATHOLOGY AND MORBID ANATOMY.--Syphilitic pharyngitis--or, more
strictly speaking, syphilitic sore throat--occurs in all varieties,
primary, secondary, tertiary, and hereditary. Secondary manifestations
are the most frequent, and primary sores the most infrequent. The
primary sore is soft in some instances, and hard in others. Phagedænic
ulceration may ensue. Secondary manifestations are usually bilateral,
and often symmetric in configuration and distribution. They appear from
a few weeks to a few months after infection, and are among the most
frequent early manifestations of secondary syphilis. The inflammatory
process begins in erythema, usually diffuse, often punctated, sometimes
in patches. It extends from above downward more frequently than in the
reverse direction, but may spread in any direction. The lesion
commences upon the soft palate and tonsils more frequently than {407}
on the pharynx, but may commence in any portion of the oro-guttural
cavity. Tumefaction ensues, with lividity of the surface. The
epithelial cells become distended; the resulting opalescence, somewhat
characteristic, eventually subsides into a central opacity, the true
mucous patch or condyloma latum. Mucous patches vary in size from mere
specks to large irregular surfaces, often the result of coalescences.
They sometimes become red and granular and covered with purulent
products. Microscopically (Cornil), they consist of thickened
epithelium upon a base of proliferated lymphoid cells, which often
infiltrate the deeper tissues extensively. They may disappear in the
course of a few weeks by resolution and absorption. Sometimes
suppuration occurs in small superficial abscesses which discharge upon
the surface. Several abscesses discharging simultaneously in
coalescence, an extensive ulcer may result, which, in repair, leaves a
cicatricial trace of its site. Flat and circular bluish-white patches,
due to thickening of epithelium, appear after the first year of
constitutional syphilis, and may exist in association with the true
mucous patch. They bleed readily on rough handling, but rarely undergo
ulceration.
Tertiary manifestations may present within a few months after infection
or not until many years. Gummatous infiltration of the connective
tissue, diffused or circumscribed (syphiloma), follows diffuse or
localized erythema, and then the gummata break down, discharge by
ulceration, and leave deep-seated irregular ulcers with undermined
edges and surrounded with inflammatory areolæ. These manifestations are
much more frequent in the palate than in the pharynx, and the
ulcerative process often destroys the uvula and large portions of the
palate and palatine folds. When the pharynx and posterior surface of
the palate are both ulcerated, cicatricial adhesions are sometimes
inevitable, and thus serious stricture of the suprapalatine pharyngeal
canal may ensue. The lesion may be quite limited in extent or may
involve the entire pharynx. The ravages may become sufficiently
extensive to involve the vertebra and the skull or to perforate the
large blood-vessels. Cicatrization in the pharynx is vertical or
stellate as the rule, and the peculiar pallid lustre of the cicatrices
is quite characteristic of the syphilitic lesion. In many instances
secondary and tertiary manifestations commingle. Ulceration is then
more likely to extend superficially than in depth.
Hereditary manifestations pursue much the same course as tertiary
manifestations. They usually occur before puberty, but are occasionally
delayed until after maturity. Deferred tertiary and late hereditary
manifestations sometimes present the characteristic ulceration of the
commingled secondary and tertiary disease; and this form of ulceration
is often incorrectly attributed to scrofulosis and to lupus.
SYMPTOMATOLOGY, COURSE, DURATION, COMPLICATIONS, AND SEQUELÆ.--The
subjective symptoms of syphilitic pharyngitis are those of erythematous
and ulcerative pharyngitis of like grade, except that there is very
little pain. The course is chronic unless specific treatment be
instituted, when prompt repair may be expected unless the general
health has been much undermined. The duration is indefinite. The
manifestations subside under treatment, and recur if it is not
sufficiently prolonged. Complications occur with similar manifestations
of syphilis in adjacent or contiguous or distant structures, as may be.
The most frequent sequel in neglected cases is cicatricial stricture.
{408} DIAGNOSIS.--Bilateral inflammation in symmetric distribution is
very characteristic of syphilis. Irregular ulcers with undermined
borders and surrounded by inflammatory areolæ are similarly
characteristic. Acknowledged history of syphilis or the detection of
syphilitic manifestations elsewhere serves to confirm the diagnosis. In
cases of doubt a few days' treatment with specific remedies in large
doses will almost invariably serve to clear up the diagnosis.
PROGNOSIS.--The prognosis as to life is good unless the ulcerations
have become so extensive as to threaten perforation into blood-vessels
or the patient has become greatly debilitated. The prognosis as to
freedom from cicatricial adhesions and stricture is not good in the
presence of lesions which have destroyed large territories of tissue,
even under very careful management.
TREATMENT.--Specific medicines in positive doses constitute the most
effectual treatment. Mercury is indicated in secondary lesions.
Extensive ulcerative tertiary and hereditary lesions are peculiarly
susceptible to large doses (30 to 90 or more grains daily) of potassium
iodide, under the influence of which they often heal without any local
applications whatever. As soon as a positive impression has been
produced the dose may be diminished. The parts should be kept clean and
comfortable by periodic douching with sprays of alkaline solutions, or,
what is still more serviceable, with a ten-volume solution of hydrogen
peroxide diluted with one or more parts of distilled water. The best
local application to the edges of the pharyngeal syphilitic ulcers is
the solid cupric sulphate. Chromic acid (1:8) is a serviceable local
stimulant to indolent ulcers. Necrosed fragments of bone should be
removed. Should any impediment to respiration take place during
administration of the iodides, oedema of the larynx may be suspected,
and should be looked for. Professional supervision is requisite for
many months after the lesions have healed. Cicatricial sequelæ of
stricture require surgical interference.
{409}
DISEASES OF THE OESOPHAGUS.
BY J. SOLIS COHEN, M.D.
Oesophagitis.
DEFINITION.--Inflammation of the oesophagus.
SYNONYMS.--Inflammatory dysphagia, Inflammation of the gullet.
Oesophagitis may be acute or chronic. Either form may be idiopathic,
deuteropathic, or traumatic.
Acute Oesophagitis.
DEFINITION.--Acute inflammation of the gullet.
SYNONYM.--Oesophagitis acuta.
HISTORY.--Until the publication in 1829 of a thesis by J. T. Mondière
entitled _Recherches sur l'Inflammation de l'Oesophage, et sur quelques
points de l'anatomie pathologique de cet organ_, little study had been
devoted to acute inflammation of the oesophagus; and since that time
Mondière's researches have been largely utilized by subsequent writers.
It has been taken for granted that Galen's mention of pain in the
oesophagus[1] has indicated his recognition of the disease. Fernel[2]
mentions phlegmon of the oesophagus; Honkoop[3] describes inflammation
of the oesophagus; J. P. Frank[4] describes an oesophageal angina; and
Joseph Frank[5] seems to have been the first author to use the term
oesophagitis. Since the publication of Mondière's monograph the
principal systematic descriptions have been those of Hamburger[6] Von
Oppolzer[7] Zenker and Ziemssen[8] Luton,[9] and Bernheim.[10]
[Footnote 1: _De locis affectis_, lib. iv. cap. iii.; lib. v. cap. v.]
[Footnote 2: _De partium mortis et sympt._, lib. vi. p. 277.]
[Footnote 3: _Specimen inaugurale de morbo oesophagi inflammatorie_,
Lugd. Batav., 1774.]
[Footnote 4: _De curandis hominem morbis, Epitome prælectionibus
academicis dicata_, Mannheim, Stuttgardt, and Vienna, 1792-1820.]
[Footnote 5: _Praxeous medica præcepta universa_, Lipsiæ, 1826-32.]
[Footnote 6: _Klinik der Oesophaguskrankheiten_, Erlangen, 1871.]
[Footnote 7: _Vorlesungen über specielle Pathologie und Therapie_,
Erlangen, 1872; Englished in abstract by the writer in _Philada. Med.
Times_, 1872.]
[Footnote 8: _Handbuch der speciellen Pathologie und Therapie_, 1877;
English translation, New York, 1878, vol. viii.]
[Footnote 9: _Dictionnaire de Médecine et de Chirurgie pratiques_,
Paris, 1877, vol. xxiv.]
[Footnote 10: _Dict. Encyclopediques des Sciences médicales_, Paris,
1880, vol. xiv.]
ETIOLOGY.--Acute oesophagitis is quite a rare disease. It occurs
idiopathically, deuteropathically, and traumatically--traumatically far
the most {410} frequently, and idiopathically least frequently. It is
doubtful whether any special predisposing causes of oesophagitis can be
indicated. Nevertheless, infancy has been so cited by some authors
(Mondière, Billard, Behier, and Steffan). Slight idiopathic
catarrhal--or rather erythematous--oesophagitis occasionally ensues in
the adult from sudden or prolonged exposure to cold and moisture, and
under such circumstances may sometimes be regarded as rheumatic in
origin, subsiding after a few hours' continuance, to be immediately
succeeded by manifestations of articular rheumatism, acute or subacute,
as in some analogous examples of rheumatic pharyngitis. Exceptionally,
severe oesophagitis may follow a simple cold (Noveene, cited by
Bernheim), or presents as an extension of sore throat, the result of
cold (Graves[11]). It is induced also by the habitual use of very hot
drinks and food, and occasionally by the opposite extremes, the use of
very cold articles of food and drink (Mondière, Bourguet, Hamburger).
The abuse of tobacco and alcohol is alleged as quite a frequent cause
of mild oesophagitis, usually occurring, however, in association with
pharyngitis from the same causes.
[Footnote 11: _Lon. Med. and Surg. Journ._, 1836-37, No. 172, and
_Clinical Lectures_, Dublin, 1864, p. 592.]
Oesophagitis sometimes follows the deglutition of irritating medicines
or moderately caustic poisonous substances not sufficiently acid to
produce veritable traumatic oesophagitis. Mercury, codeina, and
particularly tartar emetic, are cited as capable of exciting
oesophagitis.
Large doses of tartar emetic, as formerly administered in pneumonia
(Laennec[12]), sometimes produced a peculiar form of pustulous
oesophagitis, not unlike the pustulous oesophagitis sometimes occurring
as part of the local manifestations of small-pox.
[Footnote 12: _Traité de l'Auscultation médicale, etc._, Paris, 1837,
vol. iii. p. 560, illustrated; Laboulbène, _Anatomie pathologique_, and
_Nouveau Dict. de Méd. et de Chir._, vol. xxiv. p. 370, illustrated;
Von Oppolzer, _op. cit._, p. 109.]
Deuteropathic catarrhal oesophagitis occurs sometimes as an extension
of catarrhal pharyngitis on the one hand, and of catarrhal gastritis on
the other. It also occurs in scarlet fever, measles, and typhus fever.
It is likewise consecutive to the various diseases and surgical lesions
of the tube itself. Parasitic oesophagitis occurs as an extension of
parasitic stomatitis or thrush. Deuteropathic circumscribed phlegmonous
oesophagitis is sometimes produced by extension of inflammation from
softened caseous bronchial glands at the bifurcation of the trachea,
and by pressure from mediastinal tumors, aneurism of the aorta, etc.
Pseudo-membranous oesophagitis is almost always deuteropathic. It has
been encountered chiefly in association with pseudo-membranous
pharyngitis or diphtheria, and with croupous pneumonia, but likewise in
enteric and typhus fever, in cholera and in dysentery, in measles,
scarlatina, and small-pox, in nephritis, tuberculosis, carcinoma, and
pyæmia.
In a case of hysteria, to be mentioned later, the entire epithelial
coat of two-thirds of the oesophagus was discharged by emesis. In this
respect the local disease--in that instance at least--resembles
pseudo-membranous enteritis.
Traumatic oesophagitis is produced by the deglutition of corrosive
substances, which destroy portions of the mucous membrane in their
passage or excite a suppurative inflammatory process, or is produced by
the {411} passage of foreign bodies of sharp and irregular contour, or
by the passage of surgical appliances, whether used for actual
operations or for explorations merely.
In rare cases traumatic oesophagitis is the result of wounds with
firearms or other weapons.
Phlegmonous oesophagitis may be the result of disease or injury of the
interior of the oesophagus, or of its external coat by extension of
disease from tissues surrounding it. Foreign bodies, arrested in the
oesophagus or wounding it in their passage to the stomach; injuries
from surgical appliances, exploratory or operative, employed in
treatment for foreign bodies in the tube or in cases of stricture and
morbid growth; and chemical irritants swallowed by accident or
design,--are the chief causes in the former class of cases; but
pustulous and pseudo-membranous oesophagitis must likewise be regarded
as occasional causes. The causes operating upon the exterior of the
tube primarily are suppurative laryngitis and tracheitis, tumefaction
and softening of bronchial and tracheal lymphatic glands, and caries of
the spine. Isolated cases have been attributed to emboli in connection
with valvular diseases of the heart (Parenski, cited by Daton), and to
fits of anger (J. Frank and Rigal, cited by Daton). In certain cases
the cause is unassignable, and is then usually attributed to some
dyscrasia, syphilis in particular.
PATHOLOGY AND MORBID ANATOMY.--Acute oesophagitis presents both as a
diffused inflammation and a circumscribed process, annular or irregular
in contour. It does not appear from the post-mortem records consulted
that any special portion of the tube is particularly liable to
circumscribed inflammation, though the lower fourth appears most
frequently affected. The inflammatory process may be simply superficial
or erythematous, catarrhal or desquamative (Zenker and Ziemssen), or it
may be phlegmonous, and thus interest the submucous tissues as well as
the mucous membrane. This may terminate in abscess or in diffuse
suppuration with ulcerations. In occasional instances gangrene ensues.
Both in diphtheria and in croupous pneumonia, pseudo-membranous
oesophagitis is an occasional complication; and the same process is
said to have been observed in typhus fever, measles, scarlatina,
cholera, pyæmia, dysentery, tuberculosis, and carcinoma (Von Oppolzer
and others).
Pustulous oesophagitis occurs in small-pox, and occasionally follows
the use of tartar emetic in large doses.
The morbid anatomy of acute idiopathic oesophagitis, though usually
detailed in descriptions of the disease, must be known by theory much
more than by demonstration, few examples coming under the inspection of
the pathologist in time to distinguish the progressive stages of the
inflammatory process, and still fewer being revealed by oesophagoscopy
during life. The lesions most frequently observed post-mortem are
thickening, softening, and desquamation of the epithelium, with very
scanty accumulations of viscid mucus here and there upon the mucous
membrane. The mucous membrane is seen to have suffered numbers of
pinhead or slightly larger superficial circumscribed erosions, rounded
or longitudinal, and likewise a few actual ulcerations. The follicles
of the mucous membrane are often both swollen and hypertrophied,
reaching the size of peas, especially in the upper portion of the tube.
The desquamation of the epithelium usually takes place in small {412}
patches. One case, however, has been recorded (Birch-Hirschfeld[13]) in
which a young hysterical woman, after suffering three days with acute
oesophagitis without assignable cause, ejected by emesis a membranous
tube two-thirds of the entire length of the oesophagus, and shown under
examination to have been the completely detached epithelial coat of the
oesophagus, wholly normal in its upper layers and infiltrated with
agglomerated round cells in its lower layers. It was supposed that the
mass had been detached in consequence of acute subepithelial
suppuration.
[Footnote 13: _Lehrbuch der pathologische Anatomie_, Ziemssen, 1877, p.
818; English translation, vol. viii. p. 140.]
In addition to swollen and hypertrophied follicles there may be some
evidence of ulcerative destruction of these follicles. Mondière and
others declare that this folliculous inflammation and ulceration may
exist without any other change whatever in the remaining constituents
of the mucous membrane; and therefore this form of oesophagitis was
termed folliculeuse by Mondière (folliculous oesophagitis). This form
of the disease has been observed in typhus fever, in croup (Mondière),
and in tuberculosis. Ulceration of the oesophagus occurs, likewise, in
carcinoma and in oesophagitis from corrosive fluids, wounds, and other
injuries.
In pseudo-membranous oesophagitis the exudation occurs usually in small
circumscribed gray-yellow or brownish flakes or stripes distributed
over different portions of the surface, more closely, however, at the
upper portion of the tube. Superficial erosions are sometimes observed
beneath these deposits, and occasionally ulcerations, at times
sufficient to give rise to severe hemorrhage (Zenker and Ziemssen).
Usually the mucous membrane is but slightly hyperæmic. In some
instances pseudo-membrane is so massed in plugs as to occlude the
cavity of the tube, as with obturators. In cases associated with
pseudo-membranous gastritis the oesophageal manifestations are greatest
in the vicinity of the cardiac extremity. Somewhat allied to
pseudo-membranous oesophagitis, and apt to be confounded therewith, is
the parasitic deposit of the Oïdium albicans in cases of thrush; in
connection with which subject this point has already received
attention.
The pustules of small-pox may interest any portion of the mucous
membrane, but are most numerous at the upper portion of the tube. They
may be discrete or confluent. The pustules from tartar-emetic poisoning
are most numerous at the two extremities of the canal. It is contended
that the so-called pustules of variolous oesophagitis are really
superficial variolous ulcers, the antecedent specific lesions having
been lenticular papules merely, with abrasion of the softened
epithelial layer.[14] Variolous oesophagitis may excite an accompanying
catarrhal or pseudo-membranous oesophagitis. The local lesions, be they
pustular or ulcerous, heal without cicatrices.
[Footnote 14: _Virchow's Deutsche Klinik_, 1858, No. 31, p. 306; Zenker
and Ziemssen, _op. cit._, p. 146.]
Phlegmonous oesophagitis presents both as a diffuse and as a
circumscribed inflammation. Examined after death, there is abundant
purulent infiltration into the submucous connective tissue, which has
undergone destruction in portions of its extent. The infiltration
pushes the folds of mucous membrane outward to the interior of the
tube, and thus diminishes its calibre considerably when the
infiltration is annular. {413} The mucous membrane is congested,
ecchymosed, and covered with mucus, and has usually suffered
desquamation of portions of its epithelium. Ulcerations through the
mucous membrane will have taken place in some instances. Cicatrices
mark the location of ulcers which have healed.
In the diffuse variety the oesophagus is inflamed and swollen, as a
whole, in proportion to the extent of the disease. In the circumscribed
variety the morbid appearances are circumscribed. It has been known to
continue into the stomach (Belfrage and Hederius, cited by Zenker and
Ziemssen), and to extend therefrom (Ackermann, _idem_).
As described by Zenker and Ziemssen, chiefly from ten autopsies by
themselves and one by Belfrage and Hederius, phlegmonous oesophagitis
begins with a submucous purulent infiltration, transforming the areolar
tissue into an apparent layer of pus, although microscopic examination
shows the bundles of connective tissue to be intact at first. At a
later period they become really destroyed, leaving mere crevices filled
with pus. The mucous membrane, but little involved, may remain normal
or may present the evidence of catarrhal inflammation, desquamation of
epithelium, congestion, and slight deposits of mucus. The muscular
coat, intact to the unaided eye, under the microscope gives some
evidence of purulent infiltrations. The pus may finally escape through
the mucous membrane, in extensive infiltrations, at several points,
which give the parts a sieve-like appearance when the perforations are
closely grouped.
Gangrene sometimes occurs as a result of intense phlegmonous
oesophagitis, but this is far more rare than the gangrene supervening
after injuries by caustic substances. Sometimes it results from
capillary embolism (Rokitansky, Virchow, cited by Luton, _op. cit._).