REPRINTED FROM <Ije ^ojfton Metrical anti Surgical journal APRIL 25. 1889. A PECULIAR FORM OF OESOPHAGISMUS. BY HAMILTON OSGOOD, M.D. & l^urti, Algonquin A PECULIAR EORM OF CESOPHAGISMUS.1 BY HAMILTON OSGOOD, M.D. The affection considered in this paper is called " peculiar " because in several respects it seems unlike other oesophageal disturbances which are described in the books and which are suggestive of the malady in question. It would be an easy mat- ter to dismiss the subject with the off-hand diag- nosis of globus hystericus or simple oesophagismus, that is, stricture of the oesophagus not dependent upon pathological growths in, or trauma of, this tube; but the many writers whom I have consulted, consider globus hystericus as pathognomonic of hysteria; and in ordinary oesophagismus, which is also pronounced an hysterical affection, there exists either a simple impossibility of deglutition, or a, difficulty so marked as invariably to arrest a probang, or even fluids, at some point in the oesophagus, and there occurs regurgitation both of food and liquids. Whereas, in the cases which I am about to call in witness, there was no evidence of hysteria, and one- half my patients were males, while, with the excep- tion of an abnormal condition of the mucous mem- brane, the females were otherwise in sound health. With reference to ordinary oesophagismus there was in my patients at no time an insuperable diffi- culty in swallowing either solids or liquids. Still, there was one symptom which is common to the three lesions, viz., a sense of oppression in the ceso_ 1 Read before the Boston Society for Medical Improvement, March 11, 1889. 2 phagus. In globus this is compared to a ball rolling upward and downward in the gullet. In ordinary cesophagismus, accompanying the more or less stub- born dysphagia with regurgitation, there is a sudden, painful, and absolute closure of the oesophagus. In my patients the symptoms were the same sud- den, often intense, pain and sense of constriction in the epigastrium; radiation of the pain; slight regur- gitation if the attack occurred at table, with an ar- rest of food at the cardiac orifice and perfect con- sciousness on the part of the patient of this arrest, the food, however, after an instant's delay, passing- on into the stomach. My notes contain details of six cases, which, in their symptoms, very closely resembled each other, their unlikeness being shown in a difference in the intensity, frequency, and duration of the attacks ; some of them occurring often during a period of years and lasting but a few moments, others appear- ing less frequently but exhibiting a larger degree of obstinacy and severity. In its character, the affection, as I have seen it, seems largely sympathetic and reflex, for invariably there has existed some chronic form of disturbance in the mucous membrane at some point more or less distantly removed from the locality to which the sensations of pain were chiefly referred. So far as I am aware the ailment does not affect children. The ages of my patients varied between twenty and fifty years. The attacks in question, as to the time of day and other circumstances, occur in a perfectly irreg- ular manner and the intervals between them are equally unmethodical. The degree of their inten- sity varies as widely as do their other peculiarities, being sometimes slight, sometimes excessive. Although cesophagismus occurs in catarrhal con- 3 ditions of the stomach I should not admit dyspep- tic symptoms on the part of my patients, there being no indigestion, no pyrosis, in brief, no disturb- ance of that nature. In no case have I found this organ tender on pressure. The distress was always located beneath the xiphoid cartilage as high as its union with the gladiolus, and here tenderness on pressure is usual. From its point of origin the dis- comfort, which is very peculiar in character, may radi- ate up to the pharynx and from that locality pass into one or both of the ears. This aural pain is probably located in the mucous membrane of the Eustachian tubes, but is said to terminate in the tympanum in what is declared to be a sharp point. When the entire tract of the oesophagus is thus involved the distress is very annoying and is apt to alarm the patient. The salivary glands secrete abundantly, a symptom, so far as I have been able to discover, mentioned only by Luschka.2 There is a sense of impending- suffocation, in some cases of death, for a prolonged attack seems to carry the sensation by the route of the vagus nerve to the heart. Sometimes the dis- tress appears at the right of the median line and gradually involves the right chest as far as the outer border of the mamma, being sharply felt in the nipple. In extreme cases pain is felt in the back, and when leaning against a chair the patient experiences a soreness in the spinal column at a point opposite the original seat of pain. This may indicate that the intercostal nerves also become, sensitive. In my patients at all times there existed a difficulty in swallowing beer, champagne, apolli- naris water, and other gaseous drinks. So soon as the fluid reached the lower end of the oesophagus a spasmodic, but only momentary, constriction fol- lowed. 2 Anatomie des Hals. 4 In describing this lesion it will perhaps suffice if, without giving details of individual cases, I bor- row from each of them. In none of my patients were the attacks confined to meal hours. The distress appeared in the most capricious manner at any waking hour of day or night and under all circumstances ; as, for example, during a change from an upright to a stooping pos- ture, as in lacing the boots ; on turning in bed; on rising from a prone to a sitting position; during a rapid walk; after a hearty laugh, or sudden cough, or sneeze or hiccough; on inhaling a bit of food into the larynx; while sitting, lying, or standing in perfect quietude; on waking from a dreamless sleep without bodily movement. No patient has ever- been able to give me a reason for the onset, which is electric in its suddenness, coming like a grip upon the lower end of the oesophagus and at once causing radiation of pain. It is during the existence of an obstinate attack that the sufferer complains of the strange sensation of pain in one ear, very rarely in both ears, and not at all in some cases. This sensation extends in an unbroken line from the lower end of the oesophagus (or subjectively from beneath the xiphoid cartilage) through the pharynx and on into the tympanum. It is described as suggesting a fine wire dragging painfully upon the cardiac end of the gullet, being sharply felt throughout the .entire length of this tube, as if the wire were hot, and ending in the tympanum in the acute point already mentioned. In other cases lancinating pains are felt in the chest, neck, and throat, as if they darted about indifferent as to which nerve-fibres they followed. Sometimes the sensation rises to the level of the larynx and there halts in the form of a hot lump. Or, the entire inner surface of the oesophagus feels as if the 5 tube were lined with heated metal. In all cases, however, the original seat of the distress is invari- ably connected by sensation with the most distant locality which may be involved. So that radiation of the pain simply means that a larger district is included in the feeling of distress. a There being no nerve," according to Yeo,3 which can be compared to the pneumogastric in the variety of spasms in which it participates," it is probably to this nerve that we must look for an ex- planation of the wide dissemination of distress in the malady under consideration. Arnold's nerve, the auricular branch of the pneu- mogastric, is joined soon after its origin by a fila- ment from the glosso-pharyngeal and later gives off an ascending and a descending branch to the facial nerve. The tympanic branch from the petrous ganglion of the glosso-pharyngeal perhaps also par- ticipates in the sensation in the tympanum. In short, as Vulpian4 has shown, the various anasto- moses of the vagus with the accessory, glosso-pharyn- geal, facial, and sympathetic nerves are largely accountable for the pain in oesophagismus beginning at the lower end of the oesophagus, terminating in the tympanum and involving the intermediate space. In attempting to solve the problem as to which nerves preside over the oesophagus, Vulpian4 placed especial importance upon the separate origin of the accessory and pneumogastric, because in his experi- ments he made a particular point of irritating both nerves at their place of origin. He finally decided that the manifold anastomoses, even before leaving the cranial cavity, of the vagus with the accessory (these inosculations continuing in the later course of 3 Manual of Phys. < Med. Jahresberichte, 1866, vol. i. p. 116^ 6 these nerves), and that the numerous anastomoses also of the pneumogastric with the glosso-pharyn- geal, facial, and sympathetic, made it impracticable, from an anatomical standpoint, to decide as to which of these nerves, the vagus or accessory, were really the motor nerve of the oesophagus, although, a priori, it is impossible to deny a functional partici- pation of every one of the five nerves which have been named in the innervation of this tube. The results of Vulpian's experiments were briefly these: 1. In dogs (a) irritation of the roots of the pneumogastric, within the cranial cavity, causes violent movements of the pharynx and oesophagus in their entire length. These roots, therefore, supply fibres which are in part strictly motor and partly reflex. (&) Irritation of the glosso-pharyngeal within the cranium causes in the oesophagus move- ments which are wholly reflex, (c) Irritation of the accessorius creates a doubtful effect. At any rate, the motor peculiarities of this nerve can be at- tributed only to the upper root-fibres which lie nearest the pneumogastric. (d) Of all the nerves which anastomose with the vagus, the facial is the only one which possesses an undoubted motor influ- ence upon the oesophagus, and this is decidedly con- fined to the upper half of the tube. 2. In cats, according to all probability, it is chiefly the fibres of the accessory in the course of the vagus, at least it is not exclusively the actual fibres of the pneumogastric, which produce motion in the oesoph- agus. 3. In rabbits the share taken by the vagus and accessorius in the innervation of the muscular tissue of the oesophagus is apparently nearly the same in both nerves. Evidently, then, it would be a difficult matter, with justice, to accuse any special one of these 7 nerves as the offender in the peculiar radiating dis- tress, which in the various forms of oesophagismus (Hamburger including globus hystericus as the first stage) involves nearly the whole of the chest, the neck, the throat, ^nd even the tympanum. Probably, however, notwithstanding the importance of the glosso-pharyngeal as an exciter of reflex movements and in spite of its undoubted share in creating oesophagismus during the existence of a granular condition of the pharynx, it is with the pneumogas- tric that the odium of blame would chiefly rest. Luschka 5 makes the interesting statement that the auricular branch of the vagus admits a remark- able sympathy between the ear, the lungs, and the stomach, which, formerly a perfect enigma, was ex- plained by Rahn in 1771. This sympathy makes clear why it is that in many individuals,, tickling the external meatus will cause vomiting and a more or less severe, sometimes convulsive, cough. Luschka mentions cases in which a foreign body, or hardened wax, in the ear caused signs of phthisis which disappeared on the removal of the offending body. The aural symptom in oesophagismus interests me especially, because I find mention of it in only two cases. One is noticed'by Zenker and Von Ziemssen,6 in regard to which these writers merely allude to abnormal sensations in the auricular branch of the pneumogastric. The other allusion is made by Lincoln7 in the report of a case of can- cerous stricture of the oesophagus in which "pain extended up into the ears." Zenker and Von Ziemssen say that, according to Goltz, irritation of the terminal branches of the sensitive nerves in the oesophageal mucous mem- s Anatomie des Hals. 6 V. Ziemssen's Cyclop., vol. viii. p. 210. 7 New York Med. Jour., 1884, xl, 8 brane; by their inosculations with the ganglionic plexuses (demonstrated by Meissner, Auerbach and others) in the walls of the oesophagus, causes a contraction in the irritated portion of the gullet, and that inactivity in the medulla oblongata may be largely responsible for persistence of these contractions. From the researches of these experimenters, Zen- ker and Von Ziemssen8 conclude that obstinate spasm of the oesophagus may result from direct irritation of its walls, from manifold lesions of innervation in the roots and branches of the vagus and in the medulla oblongata, and finally from severe irritations which affect other peripheral and sensitive regions. Luschka9 says he never suc- ceeded in finding ganglionic cells in the submu- cous tissue of the oesophagus. The vagrant and complicated course of the nerves which are involved might be made to explain still further the curious routes of pain in cesophagismus, but enough has been said on this point. Comparing my experience with that of the various writers, I find but one, Niemeyer,10 who says that many cases considered as spasm of the oesoph- agus are merely a sensation of compression. This, he remarks, is common after dog-bite and arises from fear. He thinks the origin of oesophagis- mus is frequently reflex, proceeding from the uterus, sometimes of central origin and symptomatic of disease of the brain or upper portion of the spinal cord. Attacks, he says, generally occur at meal times and are accompanied by regurgitation of food. Globus he considers hysterical. Eichhorst11 accredits cesophagismus to hysteria, 8 Loc. cit., Art. " (Esophagismus." 9 Loc. cit. 30 Path. u. Therap.,Bd. i. p. 523, 8te Auflage. 11 Spec. Path, unci Therap., Bd. ii. p. 66. 9 hypochondriasis, epilepsy, chorea, and tetanus. A symptom also of rabies. Says it is caused by phys- ical excitement, by disease of stomach and intestines, by injury of the oesophagus, in many cases by affections of the throat (quoting Seney's case in which relief was given by excision of the tonsils), and adds that it occurs during pregnancy and lactation and sometimes in gout. He claims that attacks commonly occur during meals. Lennox Browne12 thinks imperfect mastication of food a cause of oesophagismus, and says the spasm appears in gout. Also that it is sometimes caused only by cold, or equally only by hot food or drink, which is then regurgitated. Strumpell13 considers oesophagismus a rare affec- tion, occurring especially in hysterical individuals, no anatomical change being present. Thinks it may be reflex from the uterus or from an ulcer in the oesophagus. He deems globus of similar nature. Zenker and Von Ziemssen 14 suppose the source of the spasm may be traced to powerful physical af- fections and as a result of hysteria and the psycho- ses, think it resembles functional disturbance of the respiratory organs, and that it might be referred to lesions of the gray matter in the medulla oblon- gata. They agree that the spasm may be reflex from abdominal organs or be caused by anger, fright, dread, but think the customary division of the malady into symptomatic and idiopathic cannot be carried out, and add that the differential diagnosis of oesophagismus depends chiefly upon the inter- mittent character of the dysphagia coincident with spasm of the glottis, neuralgia, palpitation, and pre- disposition to spasms in general, and finally is to be decided with the sound. 12 Diseases of the Throat. 13 Spec. Path. u. Therap., Bd. i. p. 561. ** Loc. cit. 10 Henna15 reports a case in which he not only ex- cludes hysteria, tetanus, hydrophobia, etc., but thinks the disease extremely rare. In this opinion he con- tines himself strictly to idiopathic oesophagismus. The case was one of actual constriction, lasting eight days, nearly causing starvation of the patient, a man of seventy years. The stenosis was overcome by a sound and did not return. The writer thinks the case a neurosis, the exact nature of which may not be demonstrable, and quotes Valleix's 16 defini- tion of the condition, viz., " A convulsive constric- tion of the oesophagus whose explanation cannot be found in that or neighboring organs," as perhaps the' best yet proposed. Ogsten17 says that pain at the lower end of the (esophagus generally means cancer. In the matter of diagnosis of spasm of the gullet he rightly con- siders auscultation of great value. He found that in eleven individuals two andahalf to eight seconds, or an average of four seconds, was the time required for food to reach the stomach. If a stricture exist liquids will create a churning sound at the site of it. Ogsten explains that at the moment in which fluids leave the mouth thepomum Adami rises. At this point of time the fluid passes from the pharynx into the oesophagus, and it is then that the ear placed three inches below the left scapula will hear an "am- phoric gurgle " or an " amphoric rushing sound and Hamburger is quoted to the effect that the ear can recognize the sound of deglutition as being pro- duced by the egg-shaped form in which the sub- stance is swallowed, the broad end going first; and that when the stricture is reached the egg-shape is broken and the change can be heard. Ogsten 15 Hosp. Gazette, Oct. IS, 1879. 16 Guide du Practician, 5th ed., tome lii. p. 584. 17 Manch. Med. Chron., 1886. 11 naively adds, " My ear cannot recognize an egg- shaped sound." B. W. Richardson18 reports a patient who could swallow cold foods and liquids but in whom hot substances created pain and were often regurgitated. Richardson thinks that heated foods are likely to produce contraction of the circular fibres of the oesophagus, "while cold," he says, "has a tendency to relax them. Heat irritates, cold soothes. It is better and easier to introduce a cold than a warm tube or sound." My experience would teach me the exact opposite of this advice. Albert,19 after an excellent and instructive diag- nosis by exclusion, says that spasm of the oesopha- gus arises through a disturbance of the innervation of this tube, which causes spastic contraction of a portion of the same and hence the changes which occur in the symptoms. The oesophagus is now open, now closed. He compares the spasms to similar strictures of the urethra occurring especially in hysterical individuals, and cites a purely neurotic case in which the patient could swallow nothing but liquids for two years. Mere mention of the trouble brought on a spasm. Lewis20 mentions the case of a man who could swallow one mouthful of water, two with difficulty, while the third was regurgitated. A sound was passed without meeting the slightest resistance, but the patient could not afterward retain fluid with any better success. An anodyne mixture was fol- lowed in two hours by a sensation of - "something giving way inside," and the trouble did not recur. This case suggests Ogsten's statement 21 that some- times the oesophageal sound must be forced on I8Asclepiad, 1886, iii. p. 65. ^Allg. Wien. Zeitg., 1884, xxix. p. IS. 20New York Med. Rec., 1886, xxx. p. 516. 21 Loc. cit. 12 until its outer encl is in the mouth before the stricture is reached. In Lewis's case an obstinate stricture apparently existed, and his sound probably did not go far enough to reach it. Burrall22 mentions an attack which he relieved with ether. Bamberger28 includes affections of the heart, lungs, and aorta among the reflex causes of oesoph- agismus. Debove24 alludes to a patient in whom the pain radiated from the epigastrium and eighth dorsal vertebra toward the shoulder, not naming which. There was in this case an oesophageal cicatrix, and I cite it simply because Debove is the only writer I have met who found in oesophagismus pain in the dorsal region. Pain in the dorsal vertebrae, and soreness beside, were marked in two of my patients. As a mere recapitulation and with reference to the symptoms mentioned by the writers whom 1 have quoted, it may be said that in my cases the attacks were not confined, nor were they peculiar to, meal-times; they were caused neither by fear, anxiety, nor hysteria, nor were they a sequel of ner- vous ailments and other forms of spasm. The patients were not affected, nor were the attacks caused, by the temperature of food or drinks. Re- gurgitation, when it did appear at table, was so infrequent, and so mild in character, as never to interfere with a continuation of eating, notwith- standing persistence of the feeling of constriction and severe pain. The act was rarely more than half accomplished, and the sudden sensation of spasm which was its cause did not prevent degluti- tion of the mouthful of water taken with the hope of relieving the condition. There was only tempo- 32 Phys, und Pharm., 1879, p. 46. 23 Virchow's Path, und Ther., Bd. vi. Ite Abthg. p. 24. Gazette Hebdom., 1885, p. 676. 13 rary difficulty in swallowing solid food, and I was not obliged to use a sound in any case. Moreover, it should be repeated that the seizures rarely occurred at table. It should not be forgotten, however, that when an attack came on during a meal, food was arrested in the lower end of the (esophagus, and after a moment's delay passed on. This completion of the act of deglutition, however, did not in any case relieve the pain, which not only remained but often increased, and so long as it lasted, although swallowing was possible, the patient nat- urally refused to eat. Valleix's definition25 of oesophagismus I hold to be unsound, because I unfailingly found a distant cause. The auscultatory symptoms of Hamburger did not occur in my cases. Ogsten's26 opinion that pain in the lower end of the oesophagus generally means cancer seems to me unfounded. In spite of distress I was never obliged to admin- ister ether. In short, as I remarked at the outset, my cases seem peculiar in the absence of the absolute steno- sis which generally is the striking feature of oesoph- agismus. In my patients the chief symptom was a localized distress, a sense of clutch, weight, com- pression, all distinctive of spasmodic stricture, the pain, which was entirely unlike gastrodynia, radiating capriciously and causing great discomfort not only in and of itself, but by its reflex effects upon respiration and the heart, and yet at no time complicated, except in a mild degree, by either dys- phagia or regurgitation. I have, therefore, considered the lesion, as I have seen it, a localized sensation of constriction without actual contraction of the 2s Loc. cit. 26 Ogsten's paper, loc. cit. 14 oesophagus. It is, I think, a form of hypersesthesia of high degree, a reflex irritability of the nerves of sensation which does not extend to, or at any rate causes only a slight contraction of, the muscular tissue of its locality. The sensation suggests a mechanical condition which probably does not actually exist. Romberg27 mentions a patient who suffered such intense pain in the pharynx that she thought it pro- ceeded from a tumor in that locality. There was a tumor, but it was connected with the pituitary body. It is a common thing for patients to complain that there is so large a swelling in the fauces as makes deglutition impossible. The physician finds a small ulcer or a slightly enlarged and painful follicle and nothing more.. Stone in the bladder causes pain in the glans penis, but stricture of the urethra does not coexist. These examples in proof of my theory might be multiplied. In my patients the affection was invariably reflex in character. I have never failed to discover the coexistence of follicular hy- pertrophy of the pharynx, accompanied in two cases by intestinal catarrh. Sympathy between distant localities of the mucous membrane is a constant and interesting phenomenon. In a recent case of chronic pharyngitis I found there were large haemorrhoids; in another similar case there was chronic conjunc- tivitis. In neither case did I treat the secondary ailment. In the one, the haemorrhoids, in the other, the conjunctivitis, disappeared upon the return of normal conditions' to the throat. Upon this principle my treatment of the form of cesophagismus under consideration has given relief. Attention to the pharynx has deprived the oesopha- gus of its habit of spasmodic pain so long as the throat remained in good condition. Intestinal Nerv. Krankheiten, 2te Aufl. i. p. 18. 15 catarrh lias been relieved by means of nitrate of silver, one-tenth of a grain three times daily, together with electricity. When called upon to treat the oesophagismus I have found that the secondary current gave relief. In treating chronic cases the application of the current to the epigastrium for ten minutes, twice or three times weekly, has accomplished much in break- ing up the liability of the patient to a return of the distress. But there is another useful method of alle- viation. If the patient takes carbonic acid gas in any form, as in' a small quantity of seidlitz powder fre- quently repeated, or any strongly effervescing drink, the eructations which are sure to follow will relieve the sense of constriction. In two cases the patients had learned to swallow air by means of a spasmodic jerk of the diaphragm. The air could be heard rumbling downwards along the course of the gullet. The trick is similar to the act called "sucking air" in cribbing horses. After air has thus been swallowed twelve to twenty times, or after a sufficiency of effervescing drink has been taken, the stomach experiences a feeling of disten- tion. Under this condition a sudden change of pos- ture from sitting to lying, from standing to stoop- ing, or the reverse, a quick spring to the feet, a lateral or antero-posterior rocking movement of the body, or a blow upon the sternum with the hand, will cause the air or gas to burst upward from the stomach with force and in considerable quantity, and the oesophageal distress is relieved. Sometimes these eructations will occur spontaneously from mere over-distention of the stomach. Having once disappeared, the pain may not return for months. It may reappear within five minutes; or, momentary relief may leave behind a dull memory of the feel- ing of constriction beneath the xiphoid 'cartilage, 16 and the pain then gradually returns in lesser or even in greater degree, again to be displaced by the use of air or gas, together with one of the muscular move- ments ; the efficacy of which experience has taught the patient. Relief by this means does not neces- sarily prove the existence of a muscular stricture in the oesophagus, but it shows, I think, that the forced and sudden distention of the gullet has broken a possible deadlock in the nerve currents of this tube, or has overcome what may have been a localized vaso-motor spasm. It is a curious and efficacious remedy, and generally terminates the trouble in a particular instance. If it fail it has only to be re- peated. The help afforded by the galvanic current seems also to make it evident that arrested nerve- currents have again been set in motion. The anti- spasmodics, belladonna, musk, opium, etc., have proved beneficial on some occasions, but I have seldom used them. THE BOSTON Medical and Surgical Journal. A First-class Weekly Medical Newspaper. This Journal has now nearly reached its sixtieth year as a weekly Journal under its present title. 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