CHAPTER II. ON DISEASE OF THE ESOPHAGUS. THE œsophagus is a portion of the alimentary tract more than some others exempt from organic disease, and for these reasons in the first place, its function is of an exceedingly simple character, being merely to conduct the food into the stomach; and, secondly, the transit of the food is very rapid over its mucous membrane. The close contact of the œsophagus with many important structures at the root of the lungs sometimes leads to its becoming involved in disease originating in those parts, although this is not so frequent as primary disease of the œsophagus implicating the latter structures. The pharynx is the organ of deglutition, and disease of any part of it, or of the openings into it, leads to difficulty in the performance of its function, or dysphagia; but the process of swallowing can scarcely be said to be fully completed until the food is lodged in the stomach; and hence dysphagia becomes one of the most prominent symptoms of disease, not only of the pharynx, but also of the œsophagus. The causes of dysphagia are very varied, and are chiefly as follows: I. From disease of the tonsils or palate. II. From diffused inflammation of the cellular tissue of the pharynx or œsophagus, or from local suppuration, sometimes in connexion with disease of the spine. III. From disease of the laryngeal cartilages, or epiglottis. IV. From functional or spasmodic stricture of the œsophagus or pharynx, as in hysteria, hydrophobia, &c. V. From paralysis of the muscles. VI. From acute inflammation of the mucous membrane. VIII. From structural obstruction to the œsophagus, as— 1. Constriction; 2. Ulcerations, sometimes communicating with the larynx ; 3. Cancerous disease; 4. Obstruction from the pressure of aneurismal or other tumours. I. Dysphagia arising from cynanche tonsillaris, as well as from acute inflammation of the throat, from scarlet fever, or from diphtheritic inflammation, from syphilitic ulceration of the soft palate, or the fauces, &c., needs only to be mentioned in connexion with diseases of the œsophagus. II. Inflammation of the cellular tissue of the neck, associated with pyæmia or with erysipelas, is either diffused, as we find in pyæmia or erysipelas; or a defined abscess is formed. The latter produces sudden and urgent dyspnoea, with febrile disturbance; and on examining the throat we observe a projection from the posterior fauces, sometimes on a level with the soft palate, sometimes above or below it; the diagnosis is then sufficiently evident, and, when it is possible, puncturing the abscess relieves the urgent symptoms. When the inflammation is diffused, the patient rapidly passes into a typhoid condition, the dysphagia becomes extreme, the respiration impeded, and, on examining the neck, we find either the erysipelatous redness of the skin, or a fulness and tenseness among the infra-hyoid muscles, impeding the free movement of the parts concerned in deglutition. The examination of the neck will generally enable us to distinguish the dyspnoea arising from this cause from that produced by disease of the larynx, or trachea, or from pressure or injury to the nerves of respiration. In my notes I find the following case, a very interesting one of the kind, occurring in 1847:- CASE I. Diffused Inflammation of the Throat.-Abraham Stanley, æt. 36, a sailor, of intemperate habits, was admitted into Guy's on October 13th, 1847. On the 5th, whilst unloading coals, he received a blow on the back of the hand, and on the following day rigors came on, and pain in the axilla, but the skin of the arm did not become inflamed. On admission, on the 13th, he presented the appearance of a man suffering from typhoid fever; there was delirium at night; pulse very soft, 106; the tongue moist, and the respiration much oppressed; no fluctuation could be found under the pectoral muscle, or any suppuration detected in the neck; and the wound on the hand was dried. Stimulants and opium were administered on the 15th. The respiration was difficult and laboured, 42 per minute; there was evident obstruction of the larynx, and there was some tenderness about it, but scarcely any swelling, and no fluctuation or suppuration could be detected on very careful examination; there was also great difficulty in swallowing. On the 16th, the respiration and deglutition were somewhat easier, but the skin was clammy, and the tongue dry. He died on the following day, after vomiting some blood. On inspection, the whole of the cellular tissue surrounding the muscles of the neck were found infiltrated with pus, but there was none below the pectoral muscles. CASE II. Diffused Inflammation of Throat. Ulceration of Pharynx.— In this case, which was admitted in May, 1847, a woman, aged 66, had sore throat, with pyrexia, quickly followed by typhoid symptoms, and death on the fifth day. On inspection, suppuration was found among the muscles of the neck, which extended round the œsophagus, as low as the root of the lung. In the pharynx there were several superficial ulcers, and one opposite the arytenoid cartilage had extended into the cellular tissue. The disease appeared to be an erysipelatous form of inflammation, and of such an aggravated kind as to be quite beyond the reach of remedial measures. Hot fomentations should be used, and ammonia with stimulants administered; it is rare, however, that the suppuration in these cases is sufficiently localized so as to admit of relief by incisions. III. Disease of the laryngeal cartilages, or epiglottis.-Disease of the thyroid or cricoid cartilages rarely, except in cancer, extends to the pharynx, but much more frequently leads, as in necrosis of these parts, to suppuration among the muscles of the neck, or to chronic laryngitis of a most intractable form. We seldom see great difficulty in swallowing from disease of these cartilages, but the reverse is the case when the epiglottis is affected, whether the ulceration arise from syphilitic, phthisical, or cancerous disease. In syphilis both the glossal and laryngeal surfaces of the epiglottis become diseased, and sometimes nearly the whole is destroyed, leading to distressing dysphagia; and in phthisis this ulceration of the epiglottis is one of the most trying complications of the complaint, the ulceration extending on its inner surface as far as the margin, which becomes eroded and gradually destroyed, so that the contact of food, &c., with this irritated surface, leads to its instant rejection, sometimes through the nares. In chronic phthisis I have seen this condition attributed to organic disease of the oesophagus itself, from the extreme urgency of the dysphagia, and from the food appearing to have passed below the pharynx before it was forcibly ejected. It sometimes happens that solids are more easily swallowed than fluids; and this is the case in some instances where the dysphagia arises from diseased larynx-a solid will pass over the diseased surface, falling beyond it, whilst a fluid comes in close contact with it. This condition is often greatly relieved by inhalation of steam, or by the fumes of conium or stramonium; in less severe cases astringent gargles, or the application of a strong solution of nitrate of silver, afford comfort by diminishing the extreme sensibility; or counter irritation may be applied with advantage, -the tincture of iodine, hot fomentations, cantharides, &c. IV. Spasmodic stricture of the œsophagus.-The few cases of this kind which have come under my own observation have been in young women of an excitable nervous system, with leucorrhoea or painful menstruation, and impaired digestion. The strongest language was used by these patients to express their inability to swallow, and they showed the greatest unwillingness even to attempt it. One of these was a young woman about 23 years of age, thin, and imperfectly nourished. No obstruction whatever was found on passing an oesophageal bougie, and she afterwards swallowed food in small quantities, increased day by day until she took the usual amount. Lesser degrees of this condition are not unfrequent in hysterical subjects; and, as the symptoms of hysteria are well marked in them, there is little danger of mistaking the complaint for cancerous obstruction, although there may be greater difficulty in diagnosing it from perforating ulcer extending into the trachea. This state, however, is not limited to one sex, but in great nervous susceptibility may be induced in men. Spasmodic contraction of the œsophagus tends to increase the obstruction arising from organic causes, so that the degrees of dysphagia in the same case, differ exceedingly; even without organic disease the difficulty in swallowing will continue in paroxysms of greater or less severity for several years. The general symptoms and history aid us in the diagnosis of these cases, as the absence of emaciation, the suddenness of the attack after a slight cause, as nervous shock or slight catarrh; the absence of pain; the existence of considerable nervous excitement. Hot fomentations, the use of fluid instead of solid food for a short time, aperient or antispasmodic enemata, as of turpentine or rue, will afford relief in these cases; tonics are often of service, as the compound iron mixture, with decoction of aloes, or the compound steel pill, with aloes and myrrh-quinine, zinc, valerian, vegetable tonics, and with these good air and exercise, and cheerful occupation of the mind. Bougies are often employed, but their use is not generally beneficial, and may be detrimental in tending to perpetuate and aggravate a state of spasmodic irritation and contraction, unless we can in this way introduce nourishing food into the stomach; but in cases where the muscles appear to have lost the power of contraction the introduction of food in this form is absolutely required. In some cases of hysteria, the refusal to swallow arises rather from a disordered will, than from any disease in the oesophagus itself. The most marked true spasm of the pharynx and œsophagus is found in hydrophobia. Two years ago a case of this terrible disease occurred at Guy's. On post-mortem inspection, besides great congestion of the membranes of the brain and spinal cord, the pharynx was the only part affected, and the appearance here was very peculiar. The organ appeared more than twice its natural capacity; the constrictor muscles retracted to the utmost; the fauces exceedingly large, from the rigid contraction of the soft palate; and every part appeared expanded to the utmost. The mucous membrane was injected, and covered with some mucus. The oesophagus, also, was contracted; the lungs intensely congested; the other viscera healthy; but there was emphysema of the neck. The symptoms during life indicated extreme irritability of the nerves supplying the pharynx—in fact, of all the branches of the fifth and pneumogastric nerves. CASE III. Hydrophobia. The patient was a young man, aged 23, who was said to have been bitten by a dog nine years previously. On the day of admission into Guy's, May 15th, 1854, difficulty of swallowing came on, and great mental excitement. He was removed to one of the adjoining workhouses, and afterwards brought to the hospital, about nine o'clock in the C |