[Reprinted from The Philadelphia Monthly Medical Journal, 
September, 1899.] 
SPASMODIC STRICTURE OF THE ESOPH- 
AGUS, WITH A REPORT OF A CASE 
OF UNUSUAL DURATION. 
LOUIS GROSS, M.D., 
of San Francisco, Cal. 
Spasmodic stricture of the esophagus, or esopha- 
gismus, is a condition which may be described as a 
clonic, spastic contraction of the muscular coat of the 
esophagus, usually of hysteric or hypochondriac origin, 
or from reflex stimuli. 
This affection, in its lighter forms, is comparatively 
frequent; in fact, the so-called “ globus hystericus,” 
a common stigma of hysteria, is naught else but a 
spasmodic contraction of the muscles of the esopha- 
gus, although this involvement of the musculature of 
the esophagus is, as a rule, unattended by any diffi- 
culty in deglutition. 
Spasm of the esophagus may be a mere psychic or 
hysteric phenomenon ; it may occur in the course of 
certain nervous disorders, such as epilepsy, chorea, 
and especially hydrophobia ; or it may result from the 
strain of violent retching. Of the psychic causation, 
the most striking example is to be seen in the case of 
patients who imagine they are suffering from hydro- 
phobia. Then, again, it may come on in hysteric in- 
dividuals without any demonstrable cause. In tetanus 
and epilepsy, the esophagus sometimes participates 
in the spasm which affects so many of the other so- 
matic muscular structures. In chorea, spasm of the 
gullet is less frequent. In true hydrophobia, the 
muscles of the pharynx and esophagus are specially 
involved. 
Among the reflex causes acting at a distance, dis- 
eases of the stomach and affections -wt-jtii%u,tqTu 
be mentioned. Howship’ rscord-l^sl man was treated with bougies for four months, on ac- 
count of stricture of the middle third of the esopha- 
gus. After death, no stricture was found, but the 
stomach was in a state of fungous ulceration. Shaw2 
also reports a case, in which he had treated a patient 
for organic stricture of the esophagus. After death, 
the dysphagia was found to have been caused by ul- 
ceration of the larynx. Mackenzie3 had two patients, 
who always suffered from esophageal spasm, when 
pregnant, but were relieved immediately after par- 
turition. 
The affection consists essentially of a spasm of the 
circular fibers of the esophageal muscle. The more 
frequent occurrence at the extremities of the tube is 
explained by the greater abundance and higher devel- 
opment of the circular fibers in those situations. 
It is found in connection with hysteric and other 
nervous disorders from the fact that there is, doubt- 
less, a perverted condition of the nervous centers 
necessary for its production. Morbid changes of 
structure have not hitherto been observed. 
In diagnosis, the first essential is to demonstrate 
that we are really dealing with a purely functional 
affection. Here we must remember that the sudden 
onset of the attack, its occurrence in a neurotic sub- 
ject, and the use of the esophageal sound make, as a 
rule, the diagnosis easy. It is, however, with the use 
of the sound that the greatest accuracy in diagnosis 
is attained, sometimes a single introduction affecting 
a cure. In spasmodic stricture one can by gentle, 
careful, persistent pressure cause the spasm to give 
way and reveal its true nature; yet there are cases 
which require complete anesthetization before we are 
able to say positively that we are dealing with a stric- 
ture of spasmodic and not organic origin. 'ln paral- 
ysis of the gullet, the dysphagia is constant, while in 
malignant disease it is nearly always progressive. 
The symptoms of stricture of the gullet are quite 
distinct. There is inability to swallow ordinary food 
and in extreme cases even liquids are rejected. In 
some slight and recent cases solids and semisolids 
are swallowed more easily than liquids, but as the 
disease becomes more advanced warm drinks can be taken with less trouble than cold ones. The dys- 
phagia may be paroxysmal, occasionally coming on in 
the middle of a meal. Sometimes the patient ex- 
presses the well-known feeling of a “ball rising in 
the throat.” Hamburger4 believes that “globus 
hystericus ” consists in a wave of spasm affecting 
successive segments of the gullet from below up- 
wards. 
Regurgitation, when it occurs, comes on instan- 
taneously with every attempt to take food. If the 
regurgitated matter be of alkaline reaction, the in- 
dication is that it has not reached the stomach. Pain 
is a symptom of slight practical value. It may or 
may not be present. 
Auscultation often affords valuable information. 
Thus the point of obstruction may vary in situation. 
The first morsel may be arrested or retarded at the 
upper part of the esophagus, while the second or third 
morsel is stopped two or three inches lower down ; or 
while the act of deglutition is arrested or delayed one 
moment it may be performed perfectly the next. This 
is an absolute proof of the spasmodic character of the 
affection. 
The prognosis is usually favorable, especially in 
recent cases, although if of very long standing, like 
many other nervous affections, it becomes intractable. 
Mackenzie3 thinks it may lead to narrowing of the 
esophagus and thus predispose to carcinomatous de- 
velopment. Even when the disease is of only mod- 
erately long duration, the cure is often protracted 
and relapses are apt to occur. 
Cases of unconquerable spasm of the gullet have 
ended in death, but they are very rare. In fact, in 
these cases, on postmortem examination, no disease 
could be found. Power5 has related an instance 
of death from inanition following esophagismus, and 
yet after death no organic lesion whatever, in or 
around the gullet, could be detected. Hamburger4 
thinks, from the few cases he has examined, that 
esophagismus is a forerunner of carcinoma. 
The following case is cited as an example of esoph- 
agismus of long standing: 4 
Mrs. 8., aged 55, previous health excellent. She awakened 
one morning in a state of profuse perspiration and demanded her 
usual breakfast, consisting of a cup of coffee' and two slices of 
toast, which she was able to swallow without difficulty. Three 
hours later, on attempting to swallow a glass of water, she found 
to her consternation she was not able to do so. Dr. Albert 
Abrams, of this city, was summoned to the case in consultation, 
and the following objective signs were obtained. Edema of the 
glottis, dyspnea, and absolute dysphagia. There was hemianes- 
thesia on the left side of the body, with hemiparesis. For 36 
hours, the patient was unable to swallow anything. At the end 
of this time, finding that the spasm of the esophagus did not 
yield, food was introduced into the stomach by means of the 
stomach-tube. The procedure was persisted in for 5 weeks—the 
actual duration of the esophageal spasm. During the second 
week, in order to more thoroughly confirm the diagnosis, the pa- 
tient was anesthetized. It resulted in a complete removal of the 
stricture. On coming out of the anesthetic, her voice was less 
husky. The patient was then referred to Dr. Wilber M. Swett, 
of this city, for laryngologic examination, the report of which is 
herewith appended. 
April 21, 1899.—Examination. Entire immobility of the right 
half of the larynx and vocal cords. Some secretion in the rima 
glottidis, and the part is anesthetic. Velum palati anesthetic. 
Considerable difficulty in swallowing saliva. 
April 24, 1899.—In phonation, the right cord fails to approxi- 
mate the left. Left moves perfectly. Case appears to be one of 
hysteria. Electric massage applied, also electricity to the larynx 
externally. 
April 25, 1899.—Two applications to the larynx did not affect 
the patient. Laryngeal reflexes absent. Optic disc normal. 
April 26, 1899.—Electric massage continued. 
R.V.=-M L. V. = fg 
+ 2.5 Rt. and Left= jjg 
4.0 Rt. and Left Snell 2. 
Larynx moves much better, and the right cord approximates, 
leaving only a small central chink. 
May 4, 1899.—Considerable improvement in the voice and mo- 
bility of the right cord, and is able to swallow a little hard food. 
Patient went to the country. 
July 20, 1899.—Patient returned. Right half of larynx moves 
slightly. Left half and cord have excessive motion, and taking 
up the loss of the right side, thus giving a fair voice. 
The patient left for the country, during which time, a period 
of 4 weeks, the spasm gradually subsided, so that she was able 
to take food of any kind. She is now perfectly well, as far as 
her dysphagia is concerned, only there still remains a slight 
hoarseness. 
The treatment consisted in a daily introduction of 
the sound, the intraesophageal application of elec- 
tricity, electric massage externally, the use of cold 
water in its manifold applications, the bromids through 5 
the stomach-tube to their physiologic effect, viz., 
abolition of the palatal reflexes and the ataxic gait. 
Hypnotism, recommended so highly by Brothers,6 
was employed without any effect. The application of 
a refrigerating spray to the superior laryngeal nerves 
at their entrance into the larynx alone succeeded in 
effecting a cure. The effect of the cold may have 
been purely psychical. 
1 “ Practical Remarks on Indigestion,” London, 1825. 
2 London Medical and Physical Journal, vol. 48, p. 185. 
3 “ Esophagus, Nose, and Naso pharynx,” 1884. 
4 “ Klinik der Esophagus Krankheiten, Erlangen, 4. art, p. 494. 
5 Lancet, 1866, vol. 1, p. 252. 
6 Brothers (S.l: ‘‘Hypnotism and Suggestion, with a Case of Spasmodic 
Stricture of the Esophagus,’ Medical Record, New York, August 29, 1896. 
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