ctional
character. Under deep general anesthesia, however, it is impossible to
differentiate between the normal reflex and a spasmodic condition,
since both are abolished. Many cases of intermittent esophageal
stenosis supposed to be spasmodic are due to organic narrowness of
lumen plus lodgement of food, obstructive in itself and in the
esophagitis resulting from its presence. The organic narrowing,
congenital or pathologic, is readily recognizable esophagoscopically.

_Treatment_.--The fundamental cause of the disturbance of the reflex
should be searched for, and treated according to its nature. Purely
functional cases are often cured by the passage of a large
esophagoscope. Recurrences may require similar treatment.

[247] FUNCTIONAL HIATAL STENOSIS. HIATAL ESOPHAGISMUS. PHRENOSPASM,
DIAPHRAGMATIC PINCHCOCK STENOSIS. (SO-CALLED CARDIOSPASM)

There is no sphincteric muscular arrangement at the cardiac orifice of
the esophagus, so that spasmodic stenosis at this level is not
possible and the term cardiospasm is, therefore, a misnomer. It was
first demonstrated by the author that in so-called cardiospasm the
functional closure of the esophagus occurred at the diaphragmatic
level, and that it was due to the "diaphragmatic pinchcock."
Anatomical studies have corroborated this finding by demonstrating a
definite sphincteric mechanism consisting of muscle bands springing
from the crura of the diaphragm and surrounding the esophagus at the
under surface of the hiatus. An inspection of the cadaveric diaphragm
from below will demonstrate an arrangement like double shears
admirably adapted to this "pinchcock" action. Further confirmation is
the fact that all dilatation of the esophagus incident to spasm at its
lower extremity is situated above the diaphragm. In passing it may be
stated that the pinchcock action, plus the kinking of the esophagus
normally prevents regurgitation when a man with a full stomach "stands
on his head" or inverts his body. For the upward escape of food from
the stomach an involuntary co-ordinated antiperistaltic cycle is
necessary. The dilatation resulting from phrenospasm may reach great
size (Fig. 96a), and the capacity of the sac may be as much as two
liters. While the esophagus is usually dilated, the stomach on the
other hand is often contracted, largely from lack of distention by
food, but possibly also because of a spastic state due to the same
causes as the phrenospasm. Recently Mosher has d