SEQUELÆ.--The main subjective symptoms of oesophagitis are pain and
difficulty in swallowing, with febrile phenomena superadded in severe
cases. In simple oesophagitis of mild character these symptoms may be
so slight as to be attributed to other causes or be disregarded
altogether. In most instances there is a dull, steady pain beneath the
sternum, some sense of impediment to deglutition or absolute pain in
swallowing (odynphagia), and occasional regurgitation of viscid, glairy
mucus, food, or acid products from the stomach. In severe cases the
substernal pain is more acute and more diffused, and is frequently
associated with pain between the scapulæ and to the left side. This
latter pain may be attributable to acid from the stomach. Sometimes the
pain is described as acute, especially during the passage of large
boluses, particularly if they are very hot, or even very cold. The seat
of pain, however, does not always indicate the seat of inflammation,
even though the pain be always referred to the same locality. When the
cervical portion of the tube is implicated, tenderness may sometimes be
detected by external pressure or by special movements of the head and
vertebræ.
The amount and character of the dysphagia vary greatly. Sometimes there
is a sense of impediment to the passage of food, solid or liquid, or
solid only, through and beyond the painful region. This sensation may
be accompanied or be followed at a brief interval by regurgitation of
food or mucus, or food enveloped with mucus, the latter in some
instances tinged with blood. The deglutition or the regurgitation may
be {414} accompanied by spasm of the muscular coat of the oesophagus.
The dysphagia is not always due to tumefaction of the mucous membrane,
but usually in part to coexisting inflammation of the muscular coat or
infiltration between the sheaths of muscular fibres, paralyzing their
efforts at contraction.
There are no subjective symptoms which permit discrimination between
desquamative catarrhal oesophagitis and folliculous oesophagitis. The
only symptom particularly indicating pseudo-membranous oesophagitis is
the expulsion of shreds of the membrane by hawking or by emesis; but a
strong inference is justifiable when the ordinary symptoms of
oesophagitis occur in cases of pseudo-membranous pharyngitis or
croupous pneumonia.
Phlegmonous oesophagitis is indicated by the presence of pus or of dead
mucous membrane in the matter regurgitated or vomited. In severe cases
there is considerable febrile reaction. In children, convulsions may
supervene from reflex irritation conveyed along the pneumogastric
nerve.
The course of acute catarrhal oesophagitis is, as a rule, short, the
pain and dysphagia usually subsiding in a few days, with complete
resolution and no unfavorable sequelæ. When due to obstruction, the
course is indefinitely prolonged. Sometimes it subsides into a mild or
unsuspected chronic oesophagitis. In the symptomatic oesophagitis of
febrile diseases, the course is longer and unequal. In severer forms
and in phlegmonous oesophagitis, the disease may be protracted by
suppuration, abscess, gangrene, perforation of the oesophagus, and
other complications. It often terminates fatally--in three or four days
in some cases--sometimes under symptoms of collapse. Cases may recover
without important sequelæ, but stricture very often results from
cicatricial complications. Chronic oesophagitis is a more frequent
sequel of the phlegmonous variety than of the catarrhal. It, in its
turn, may give rise to dilatation of the oesophagus, annular or
diverticular, from detention of food and consequent pressure.
DIAGNOSIS.--The diagnosis will rest upon the interpretation of the
coexistence of a certain number of the symptoms mentioned. Idiopathic
phlegmonous oesophagitis may readily be mistaken for dorsal myelitis by
the location of the pain--the more so that the spinal disease is
occasionally attended with spasm of the oesophagus, and the myelitis by
difficulty in deglutition; but the differentiation may be determined by
the inability to produce oesophageal pain by pressure made along the
dorsal vertebræ. In deuteropathic or traumatic phlegmonous
oesophagitis, the history of the attack will indicate the probable
nature of the malady, and prevent the mistake. Diffused oesophagitis is
suspected when the general pain or the painful dysphagia appears to
extend along the entire tract of the oesophagus, or at least a large
portion of it.
Circumscribed oesophagitis is usually indicated by odynphagia at a
certain point of the tube after completing the act of deglutition. The
location of the inflammation can sometimes be determined by
auscultation of the descent of the alimentary bolus or of a swallow of
water (Hamburger), which may yield evidence to the ear of arrest or
impediment to its passage. Auscultation of the oesophagus, however, is
less useful in acute oesophagitis than in stenosis, stricture, and
mechanical obstruction. When available in oesophagitis, the normal
sound of the passage of water down {415} the gullet becomes masked, and
accompanied by that of regurgitative ascent of small bubbles of air.
Sometimes there is a slight friction sound during the act of
deglutition itself. In circumscribed oesophagitis, especially when
annular, as is most frequently the case, sounds are heard attributable
to marked obstruction to the descent of the bolus. Abscess cannot be
positively diagnosticated until after its rupture and the appearance of
pus in the matters regurgitated or otherwise expelled from the
oesophagus.
Catheterism of the oesophagus is hardly justifiable as a method of
diagnosticating oesophagitis, though proper enough when it becomes
important to determine the locality of attendant obstruction.
It is important that inflammation of the oesophagus be differentiated
from spasm, stricture, stenosis, carcinoma, and other oesophageal
maladies; nearly all of which present the same main subjective
symptoms--pain and impediment to deglutition. The history of the case
is in itself a guide of great diagnostic value, often quite sufficient
for the purpose; but in its absence or retention other data must be
gathered.
Spasm of the oesophagus is most frequent in neurotic subjects. Its
manifestations are often sudden. It is evanescent or intermittent. It
is not a febrile affection. It is often overcome in a moment by
catheterization.
Stricture presents often an additional symptom of oesophagitis, the
regurgitation of mucus and food. The differentiation is made, in cases
of doubt, by the passage of the bougie or catheter.
Carcinoma of the oesophagus, while recent, may present much similitude
to oesophagitis, but as the case advances, the glandular involvements,
the cachexia, the expulsion of cancerous fragments, and the vomiting of
blood seem sufficient to prevent further confusion.
PROGNOSIS.--The prognosis is favorable in acute catarrhal oesophagitis,
the manifestations often subsiding within a few days; sometimes,
indeed, within a few hours, and that, too, without special medication.
It is therefore largely dependent on the cause of the oesophagitis and
the severity and extent of the malady. The only unfavorable
prognostications arise from the impediment to nourishment and the
complications which may ensue.
In presumptive pustulous oesophagitis from the use of preparations of
antimony, the manifestations usually subside within a few days upon
suspension of the remedy. Sometimes, however, these cases terminate
fatally.
Pseudo-membranous oesophagitis is usually fatal in its significance,
and the same may be said of the pustulous or ulcero-papular
oesophagitis of small-pox.
Phlegmonous oesophagitis is of grave augury, though many cases recover.
It may prove fatal within two or three days, though life is usually
prolonged for several days, even in fatal cases. When not fatal,
abscesses are apt to form, which, discharging internally or externally,
are followed by stricture or fistulæ.
Both ulcerative oesophagitis and intense catarrhal oesophagitis may
terminate in chronic thickening of the walls of the oesophagus and in
cicatricial adhesions more or less extensive.
TREATMENT.--Mild oesophagitis requires no special treatment. The
patient should be kept within doors, and be fed on rice-water, {416}
barley-water, and other mucilaginous articles of diet, so as to avoid
all sources of local irritation. These drinks are usually better borne
hot than cold, but sometimes cold is quite agreeable. When cold can be
well borne the frequent deglutition of pellets of ice is useful as well
as agreeable, and ice-cream becomes a medicinal article of diet.
In severe cases the measures indicated become still more requisite, and
the use of the voice should be restrained in addition. All unnecessary
efforts at deglutition should be avoided, and anodyne medicaments
(opium, hyoscyamus, belladonna) should be added to the demulcent food
or beverages. When swallowing is impracticable or very painful,
nutriment should be given by the bowel, and medicines by the bowel or
by the skin. Thirst may be allayed by retaining fragments of ice in the
mouth from time to time, by rinsing the mouth with simple or acidulated
water, by sucking the juice of acid fruits, or by allowing compressed
effervescent lozenges to dissolve slowly in the mouth.
The external application of cold compresses, continuously or in
frequent renewals, is also indicated.
Febrile phenomena require ordinary antiphlogistic medication. When this
is impracticable, the indications may be met by using the cold bath or
the wet sheet, and by administering antipyretics hypodermatically.
Traumatic oesophagitis from a foreign body requires removal of the
object if still in the oesophagus; that from swallowing alkalies is met
by the use of acidulated beverages (vinegar and water, Orfila); that
from swallowing acids, by the use of alkaline drinks, of which the
handiest is usually soap and water. As soon as they can be procured
this may be changed for lime-water and calcined magnesia.
Theoretically, the carbonates of the alkalies are indicated likewise,
but it is contended (Hamburger, Oppolzer) that the extrication of the
carbonic acid gas renders mechanical rupture of the corroded oesophagus
imminent. Subsequently, fresh water should be freely drunk, or be
injected into the oesophagus when swallowing is impracticable. The
subsequent treatment is to be instituted upon general principles.
Chronic Oesophagitis.
DEFINITION.--A chronic inflammation of some of the tissues of the
oesophagus.
SYNONYM.--Oesophagitis chronica.
ETIOLOGY.--Chronic oesophagitis is sometimes a sequel of the acute
affection. More frequently it is the result of excessive use of strong
alcoholic beverages or of very hot drinks. It is said to be sometimes
the result of passive congestion in chronic pulmonary and cardiac
diseases. It follows the prolonged sojourn of foreign bodies in the
oesophagus. It exists in connection with carcinoma of the oesophagus,
with dilatation, and with stricture of the oesophagus, and with other
diseases obstructing the tube externally or internally. It is sometimes
produced by caries of the vertebræ, both scrofulous and syphilitic, and
by the pressure of aneurismal and other tumors.
PATHOLOGY AND MORBID ANATOMY.--Hypertrophy of the mucous membrane of
the oesophagus, of the submucous connective tissue, and {417} even of
the muscular coat, are the processes which take place in chronic
oesophagitis, especially when it has been of long continuance. This
hypertrophy, when at or near the cardiac extremity, may produce
stricture (Rokitansky and others), with subsequent dilatation of the
oesophagus from its frequent and prolonged distension by food which
should have passed on at once into the stomach.
On post-mortem examination the main evidences of disease are most
frequent in the lower third of the organ. Its folds of mucous membrane
are thick and prominent, dirty red, brownish-red, or gray, as may be,
abraded here and there, and covered with viscid muco-purulent
secretions. Abscesses and ulceration are not uncommon in cases due to
prolonged pressure or extension of disease from outside the tube. Such
ulceration has not uncommonly been the source of serious hemorrhage.
Diffuse inflammation of the peri- or retro-oesophageal connective
tissue has been noted as an occasional sequel to the inflammatory
process in the walls of the oesophagus.
SYMPTOMATOLOGY, ETC.--The symptoms of simple chronic oesophagitis are
similar in the main to those of mild acute oesophagitis, but are often
still more moderate, and therefore likely to be overlooked. In severe
cases the symptoms are chiefly those of the disease, usually stenotic,
which has excited the chronic inflammatory process. The course is
prolonged and the duration indefinite. Stricture is a frequent sequel.
DIAGNOSIS.--The diagnosis rests on the same principles and inferences
as in acute oesophagitis, the symptoms, however, being of longer
duration. The auscultatory signs of arrest or impediment in the descent
of the solid or liquid bolus are usually more definite than in acute
oesophagitis. The same differentiations are available in excluding
spasm, stricture, and malignant diseases. The use of the sound or
catheter is much more justifiable than in the acute variety.
PROGNOSIS.--The prognosis is usually unfavorable, on account of the
great liability to stricture and occlusion from organization of
inflammatory products.
TREATMENT.--Chronic oesophagitis may require both local and
constitutional treatment. The constitutional treatment will have to be
adapted to the cause of the disease. If due to obstructed circulation
in consequence of valvular disease of the heart, digitalis and remedies
of its class will be indicated. If due to obstructive pulmonic disease,
chloride of ammonium and alkaline remedies will be indicated.
Syphilitic inflammation requires the mixed treatment, with mercuric
chloride and potassium iodide or their equivalent. Iodides, indeed, are
often required in non-specific cases, and are useful particularly in
ordinary circumscribed oesophagitis. Under all conditions alcoholic
beverages should be interdicted, and so should the deglutition of all
irritating food and drink. Mild, bland, and mucilaginous substances
should be largely employed in food and drink. The copious use of
carbonic-acid waters is also recommended (Oppolzer). Sinapisms and
revulsives to the side of the cervical and dorsal vertebræ are also
recommended by some writers (Oppolzer).
The topical treatment consists in the systematic use every few days of
aqueous solutions of astringents (alum, tannin, ten to thirty grains to
the ounce) or alterants (compound solution of iodine, twenty minims to
the {418} ounce) passed gently over the diseased surfaces by means of a
piece of soft surgical sponge securely attached to a flexible staff.
Severe pain of rather sudden occurrence is usually attributable to
circumscribed ulceration, and is best treated by superficial
cauterization, as above, with a dilute solution of silver nitrate (ten
grains to the ounce). These remedies may be used in the form of
ointments of the same strength smeared upon a rather large flexible
bougie. To relieve pain and sense of constriction belladonna or
stramonium ointment, applied in the same manner, sometimes fulfils a
useful indication. Before making these applications attempts should be
made by auscultation to locate the seat of disease or obstruction.
After subsidence of the disease, occasional catheterization may be
practised at intervals of several weeks, in order to detect any
recommencing stenosis.
Ulcerations of the Oesophagus.
DEFINITION.--Circumscribed destruction of portions of the mucous
membrane of the oesophagus, the result of inflammatory processes.
ETIOLOGY.--Ulceration of the oesophagus occurs as a result of
inflammation of the organ, as discussed in connection with
Oesophagitis, and the cause varies with the character of the
oesophagitis, whether idiopathic, traumatic, or symptomatic of disease
elsewhere. Diseases, constitutional or local, provocative of ulceration
of the oesophagus, usually implicate some portion of either the
alimentary or the respiratory tract.
SYMPTOMATOLOGY.--The symptoms are in the main those described under
Acute Oesophagitis, particularly the expulsion of sanguinolent products
or of unmixed blood. Perforation into the trachea is indicated by
expectoration of food or drink; perforation into the great vessels, by
hæmatemesis, usually fatal; and perforation into the mediastinum, by
emphysema and purulent cellulitis. When large or extensive ulcerations
have cicatrized they occasion symptoms of organic stricture.
PATHOLOGY AND MORBID ANATOMY.--Referring to the corresponding section
under Oesophagitis, attention may be directed here to the liability of
deep-seated ulcers of the oesophagus to perforate the gullet and
establish fistulæ with the trachea, bronchi, mediastinum, aorta, and
carotid artery, according to the locality of the lesion. These lesions
are usually necessarily fatal.
DIAGNOSIS.--The presence of blood in matters regurgitated or vomited
forms the chief diagnostic indication of ulceration of the oesophagus,
taken in connection with the usual symptoms of acute or chronic
oesophagitis.
PROGNOSIS.--The prognosis is altogether dependent on the nature of the
disease which has given rise to the ulceration.
TREATMENT.--The constitutional treatment will depend on the nature of
the disease which has occasioned ulceration. Ergot and turpentine are
administered in case of hemorrhage--the former best, perhaps,
hypodermatically. Attempts are sometimes made to cauterize the ulcer or
ulcers with nitrate-of-silver stick conveyed in a covered slotted
canula, to be exposed when the fenestrum reaches the ulcerated
locality, previously {419} determined by catheterization, or inferred
to be reached by the sensations of the patient. The practice is
uncertain in its manipulation and questionable in its results.
Stricture of the Oesophagus.
DEFINITION.--A constriction of the calibre of the oesophagus, whether
spasmodic or organic in character. This definition excludes stenosis
due to pressure from without.
Spasmodic Stricture of the Oesophagus.
DEFINITION.--A contraction of the muscles of the oesophagus, of
variable duration, causing partial or complete stenosis of the gullet
and interfering with the passage of food or of food and drink to the
stomach.
SYNONYMS.--Oesophagismus, Spasm of the oesophagus, Cramp of the
oesophagus, Convulsive dysphagia, Spasmodic dysphagia, Spasmodic
stenosis of the oesophagus, Spastic stricture of the oesophagus.
HISTORY.--On this subject there is little of importance in medical
annals previous to the observations of Frederick Hoffmann,[15] and
little of importance subsequently save the observations of
Mondière,[16] though numerous personal observations are on record, as
well as a number of excellent compilations in various monographs,
text-books, encyclopædias, and dictionaries.
[Footnote 15: _De spasmo gulæ inferioris_, Halæ, 1733; _De morbis
oesophagi spasmodicis_, Opera omnia, vol. iii., Geneva, 1761.]
[Footnote 16: "Recherches sur l'Oesophagisme ou Spasme de l'Oesophage,"
_Arch. gén. de Méd._, April, 1833.]
ETIOLOGY.--Spasmodic stricture of the oesophagus is a neurosis often
hysterical. It is much more frequent in females than in males, and,
although observed in young subjects and less frequently in old ones, is
most common between the ages of twenty and fifty. It is sometimes
observed in several members of a neurotic family. It is often
associated with other evidences of neurosis, but sometimes constitutes
the sole manifestation. Sometimes the cause defies detection. Sometimes
it can be traced to a fear of strangulation, induced primarily by some
accidental impediment to deglutition or the entrance of a foreign body.
Strong mental emotion, such as the dread of hydrophobia after having
been bitten by a dog, sometimes produces the affection.
It occurs in connection with organic lesions of the oesophagus, organic
lesions of the stomach, organic lesions of the larynx and trachea, and
organic lesions of the lungs, heart, large blood-vessels, and
perioesophageal tissues, but likewise as a reflex disorder, with
lesions of distant organs, as the genito-urinary tract, the intestines,
the brain and spinal cord. Even pregnancy may produce reflex
oesophagismus. It sometimes occurs as a direct or reflex manifestation
of gout and of rheumatism. In a few instances it occurs as one of the
manifestations of tetanus and of hydrophobia.
SYMPTOMATOLOGY, COURSE, DURATION, ETC.--The spasm may affect {420} the
oesophagus only, or may be associated with spasm of the muscles of the
pharynx. It is usually manifested in a sudden inability to swallow or
to complete the acts of deglutition. This may be transitory or may
continue for a number of hours. The relaxation of the spasm is
sometimes followed by the discharge of flatus and the copious secretion
of pale urine. The spasm may recur at irregular intervals or be more or
less distinctly intermittent. Sometimes it precedes every effort at
deglutition. In some instances it occurs only upon attempts to swallow
certain kinds of food, and the articles of food vary with different
patients. Cold viands sometimes produce spasm when warm and hot food is
tolerated. Consciousness of a liability to spasm increases the
dysphagia for the time being, or brings it on suddenly when this
liability had been forgotten. The spasm is sometimes painless and
sometimes painful. In some instances it is associated with partial
regurgitation of a mass of air (the globus hystericus).
The dysphagia is rarely complete, instances in which no liquids can be
swallowed being infrequent. The aliment swallowed usually passes on
into the stomach, upon relaxation of the spasm, after a certain period
of detention varying from a number of seconds to many minutes. In cases
of prolonged or persistent spasm the aliment is usually rejected,
either at once or after a time, according as the contraction takes
place at the pharyngeal extremity of the oesophagus or lower down. When
rejected after some detention in the gullet, the aliments are usually
enveloped with mucus or followed by expulsion of mucus and of flatus.
In some subjects the pain in swallowing is severe. Sometimes it is
associated with spasm of the diaphragm (hiccough), spasm of the
air-passages, palpitation of the heart, and syncope.
The liability to spasm sometimes continues for years. Sometimes it
ceases permanently as suddenly and as unexpectedly as it began.
The seat of the spasm is referred by the patient to different regions,
which in their totality comprise the entire extent of the oesophagus.
In some patients the seat varies on different occasions. The actual
seat of any individual spasm is best determined by exploration with the
oesophageal bougie or by auscultating the oesophagus during the passage
of a bolus. It is most frequent perhaps at the upper extremity, and
then perhaps at the cardiac extremity. When habitually low down, there
is some liability to permanent distension of the oesophagus from
repeated retentions of food at the same place for hours together. In
some instances food is regurgitated from the oesophagus after its
retention for a day or even longer. When the spasm is high up, the
regurgitation may follow the act of deglutition almost immediately.
PATHOLOGY AND MORBID ANATOMY.--The affection being usually a pure
neurosis, there is no oesophageal lesion to be cited. In some of the
few autopsies recorded, constriction has been noted without lesion of
tissue.