Cardiospasmus represents a condition in which there is a spasmodic contraction of the cardia and the lower part of the oesophagus, causing pain and dysphagia, and not dependent upon an anatomical lesion.

Symptomatology

Although chewing and swallowing food is accomplished without difficulty, as soon as a few mouthfuls have been ingested a feeling of pressure is experienced in the region of the upper and middle portions of the sternum. The patient feels as if something had remained in the oesophagus. At the same time he has also a slight sensation of dyspnoea. Instinctively the inspirations now become much deeper and the expirations are performed with much force. The latter act frequently causes a regurgitation of the oesophageal contents. As soon as the oesophagus has become empty in this way the patient feels better and the symptoms just described disappear. The same phenomena come into play as often as the patient begins to eat.

Cardiospasmus may appear in an acute form and last only a very short time (one to two days), or it may, in rare instances, exist as a chronic affection and last for many years. In the latter instance it must always be considered as a grave trouble. The chronic form, although originally based on the same derangements, manifests itself in a somewhat different way from the acute variety. The same difficulties (dysphagia) are experienced as described above after the swallowing of food. Instead of regurgitating the food, however, the patient instinctively learns to force it down into the stomach, taking a very deep inspiration and compressing the thorax by muscular action while holding his breath. Liquid and semi-liquid foods are easily forced down into the stomach in the manner just described. Most of the patients learn to ingest even coarse substances; they are obliged, however, to take a few mouthfuls of liquid before they can pass the food into the stomach. As a rule, in all these cases of chronic cardiospasmus the upper part of the oesophagus becomes dilated, and can easily hold from 300 to 400 c.c. That is the reason why patients afflicted with this trouble perform the act of forcing the food farther down, not after every one or two mouthfuls, but rather after having already taken quite a considerable quantity, as the food meanwhile can easily lodge within the oesophagus.

As a rule, three or four intermissions are made by the patient during a meal in order to force the food into the stomach.

In some cases the dysphagia is more pronounced on certain days, and less on others. Such patients are occasionally able to take an ordinary meal without the slightest difficulty. As a rule, however, these good days are not numerous. The explanation for this variable condition lies in the assumption that the spasmodic contraction of the cardia alternates with periods of relaxation. These periods of relaxation, however, are found only in cases which are not of long standing. If the condition has lasted for a considerable length of time (one or two years), a dilatation of the oesophagus is often the result. As soon as this has occurred, the dysphagia becomes permanent, no matter whether the cardia be spasmodically contracted or not. The same condition - viz., dilatation of the oesophagus - can also be produced, either by paralysis of the oesophagus or by a lack of reflex relaxation of the cardia (or paralysis of the nervus dilatator car-diae, Oppenchowski). After dilatation of the oesophagus has been established it is generally most difficult to decide whether this is a result of a spasmodic contraction of the cardia or of one of the two conditions just mentioned.

The following case1 well illustrates the latter possibility:

J. W------, 45 years of age, janitor, had typhoid fever twenty-five years ago, since which time he has enjoyed perfect health. In the beginning of March, 1888, the patient fell down in the street, striking his back against a small projection. He arose unaided, and resumed his work without any annoyance. On the following day he had pains in the upper part of his body, especially in his arms; these lasted but a few days and disappeared.

1 Max Einhorn: "A Case of Dysphagia with Dilatation of the (Esophagus," Medical Record, 1888. Similar cases have been described by S. J. Meltzer: Borl. klin. Wochenschr., 1888, No. 8, and J. Maybaum: Archiv fur Vcidauungskrankheiten, Bd. i.. Heft 4. Bee also Max Einhorn: "Idiopathic Dilatation of the Oesophagus." American Journal of the Medical Sciences, September, 1900.

About fourteen days later the patient began to have a feeling of fulness after eating, and had a pressing sensation above the gastric region. Two or three weeks later he noticed some difficulty in taking his food, and tried to assist it by drinking warm water several times during the meal; only in this way did he succeed in enjoying a whole meal.

In May, on account of this pressing sensation, the patient was compelled to leave the table in the middle of a meal and walk up and down the room, making deep inspirations and expirations; he used to press with his hands upon the front of the lower part of his thorax after having made a deep inspiration and closed the glottis. The patient said that these attacks during a meal resembled very much a suffocating condition. The described manipulation usually brought him relief, allowing him to eat again, but then the process repeated itself. In the morning he could eat more easily than at noon-time.

Since June, 1888, the patient has been sleeping very badly (at most three hours during the night). When in bed he had often a sensation as if something would go up and down in the interior of his chest, and when this sensation came on he was forced to cough quite often. From time to time it happened that he awoke, his mouth being full of fluid; also while awake some fluid at times came up into his throat and mouth, this only happening when in the recumbent position. When standing, he was never compelled to empty his throat.

The patient became thin, felt weak and miserable, and soon could partake only of fluid. The sight of Mid food enraged him to such a degree that he threw it away with disgust. Even fluid substances were taken only with great difficulty; he used to throw his arms backward, and. standing erect, his head leaning toward the hack, after a deep inspiration and with closed glottis he would press firmly. The condition of the patient became worse and worse; he lost forty-one pounds during these few months, and went for aid to the German Dispensary on October 23d, 1888.

Present Condition

October 23d, 1888: Patient tall in stature and lean; looks pale. The integument can be lifted in large folds. The physical examination of the thorax and the abdomen cannot detect anything abnormal. The heart sounds are normal. Pulse, 70; respiration, 20; temperature, judging from sensation upon the chest, not increased. The patellar reflex is present, and the patient is able to stand with eyes closed. The urine does not contain any sugar or albumin. The patient complains of not being able to eat any solid food, and of difficulty in taking even fluids, as he cannot get them down. Besides this, he has nearly always a pressing sensation around the chest, coughs very much, and is not able to sleep well.