Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.

by Alexis Thomson; Alexander Miles

Spasm of the Muscular Coat.—As in other tubular structures containing circular muscular fibres, sudden contraction or spasm may occur in the œsophagus and cause narrowing of the lumen, attended with difficulty in swallowing. This spasmodic dysphagia includes such widely varying conditions as the “globus hystericus” of neurasthenic women, the spasm of chronic alcoholics, and the affection known as cardiospasm or “hiatal œsophagismus.”

In contrast with other affections causing difficulty in swallowing, spasmodic dysphagia usually has a sudden and unexplained onset, the progress of symptoms is irregular and erratic, while the remission of symptoms common to all affections of the œsophagus, and the influence of mental impressions, such as excitement, hurry in the presence of strangers, are exaggerated.

In testing the calibre of the gullet it is found that on one occasion a full-sized bougie may pass easily and be completely arrested at another.

Apart from the treatment of the neurosis underlying the dysphagia, reliance is placed upon dilatation of the portion of gullet affected.

Cardiospasm is the name given to “a recurrent interference with deglutition by spasmodic contraction of the lower end of the œsophagus.” As there is no muscular or nervous mechanism at the cardiac end of the œsophagus forming a true sphincter, the term “œsophagospasm” would be more accurate (D. M. Greig).

According to H. S. Plummer, who has had an experience of 130 cases, there are three stages in the development of this condition. In the initial stage, the first attack occurs suddenly and unexpectedly; a choking sensation is felt at some point in the gullet, usually at its lower end. Attacks of choking with difficulty in swallowing occur chiefly at meals, but they have also been known to occur apart from the taking of food. In this stage the peristalsis of the gullet is sufficient to force the food through the cardia.

In the second stage, the peristalsis of the gullet above being no longer able to overcome the contraction, there is regurgitation of food, which at first is returned to the mouth immediately after being swallowed, but, as the gullet becomes dilated, is retained for longer periods.

In the third stage, the gullet becomes more and more dilated, and the food collects in it and is regurgitated at irregular intervals. The patient complains of a sensation of weight and discomfort in the lower part of the chest, and sometimes of regurgitation of food into the nasal passages during sleep.

Cardiospasm should be suspected as the cause of difficulty in swallowing if a rubber tube cannot be passed into the stomach while a solid one can. When it is impossible to pass a solid instrument in the ordinary way it can always be passed on a silk thread as a guide. The patient is directed to swallow 6 yards of silk thread, half in the afternoon and the remainder on the following morning. The first portion forms a snarl in the gullet or stomach which passes out into the intestine during the night; the proximal end is fixed to the cheek by a strip of plaster. The olive heads of the bougies are drilled for threading from the tip to one side of the base.

The treatment consists in dilating the contracted segments by a bougie. The results are immediate and are most striking, the patients being almost invariably able to take any kind of food at the following meal, and the gain in weight and strength is rapid. In a small proportion of cases, dilatation fails to give relief, and recourse has been had to anastomosing the lower end of the dilated and pouched œsophagus with the stomach.