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.).
SYMPTOMATOLOGY, COURSE, DURATION, TERMINATION, COMPLICATIONS, AND 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 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 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.