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 patches. One case, however, has been recorded (Birch-Hirschfeld13) 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.
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.
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. 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.