emonstrated that
hepatic abnormality may furnish an organic cause in many cases
formerly considered spasmodic.

The _symptoms of hiatal esophagismus_ are variable in degree.
Substernal distress, with a feeling of fullness and pressure followed
by eructations of gas and regurgitation of food within a period of a
quarter of an hour to several hours after eating, are present. If the
esophageal dilatation be great, regurgitation may occur only after an
accumulation of several days, when large quantities of stale food will
be expelled. The general nutrition is impaired, and there is usually
the history of weight loss to a certain level at which it is
maintained with but slight variation. This is explained by the
trickling of liquified food from the esophageal reservoir into the
stomach as the spasm intermittently relaxes, this occurring usually
before a serious state of inanition supervenes. At times the hiatal
spasms are extremely violent and painful, the pain being referred from
the xiphoid region to the back, or upward into the neck. Patients are
often conscious of the times of patulency of the esophagus; they will
know the esophagus to be open and will eat without hesitation, or will
refuse food with the certain knowledge that it will not pass into the
stomach. Periods of remission of symptoms for months and years are
noted. The neurotic character of the lesion in some cases is evidenced
by the occasionally sudden and startling cures following a single
dilatation, as well as by the tendency to relapse when the individual
is subject to what is for him undue nervous tension. In a very few
cases, with patients of rather a stolid type, all neurotic tendencies
seem to be absent.

The _diagnosis of hiatal esophagismus_ requires the exclusion of local
organic esophageal lesions. In the typical case with marked
dilatation, the esophagoscopic findings are diagnostic. A white,
pasty, macerated mucosa, and normally contracted hiatus esophageus
which when found permits the large esophagoscope to pass into the
stomach, will be recognized as characteristic by anyone who has seen
the condition. In the cases with but little esophageal distension the
diagnosis is confirmed by the constancy of the obstruction to a barium
mixture at the phrenic level, while at esophagoscopy the usual
resistance at the hiatus esophageus is found not to be increased, and
no other local lesion is found as the esophagoscope enters the
stomach. It is the fai