Internist Wilhelm His (1863-1934) was born as one of six children to the renowned anatomist and physiologist of the same name. Several significant discoveries, particularly related to the cardiac conduction system, have been named after him.
He also dedicated his work to the question of reflux. He observed that the stomach, when viewed from the front and with an intact diaphragm, always expands at an acute angle to the esophagus under the dome of the diaphragm. This angle, which varies between approximately 20 to 70 degrees depending on the curvature of the diaphragm.
During autopsies, the Professor observed that in reflux patients with a hiatal hernia, the stomach had shifted upwards, altering the angle: the higher the stomach rose, the flatter the angle became.
Even back then, the medical community was puzzled by the closure system between the stomach and the esophagus that protects us from reflux. Both at that time and now, no signs of a sphincter or closure muscle were found at the esophagus or stomach, nor any signs of muscle weakness or pathological changes. The organs were healthy but simply misaligned.
The only anatomically noticeable change that was recognized remained this altered angle. Could this angle perhaps be significant for reflux control? Was the flattening not merely a consequence of organ displacement but did it actually influence reflux control?
No one knew. But the name was born: His Angle. Yet, discussions and debates intensified, as they often do when knowledge is lacking. Soon, the first research papers began to appear. Initially contradictory, but later increasingly unanimous, the conclusions from the previous century concerning the influence of reflux function unfortunately could not be confirmed. Although, Professor His was very close to the solution already.
Then, Allison et al. highlighted a crucial point in their research: the importance of the diaphragm! Allison described that the stable and healthy left crus of the diaphragm forms a sturdy pillar that maintains order. However, when the diaphragm ruptures, this important anchor is lost. The stomach slides upwards into the thorax, resulting in a flattened His angle.
We can confirm the fundamental importance of this finding through our own research today: the left crus is indeed the critical anchor of the diaphragm! However, he related this discovered function only to the stomach in the frontal plane. He overlooked the crucial anchoring function for the esophagus in the sagittal plane, and thus for its function!
How close the colleagues were to the truth back then, and they could have spared medicine a century of misdirection and many patients the need for esophageal surgery with fundoplication! But in those times were no cardio-MRIs or imaging techniques for the beating heart available to them. They could not find it.
Today, we know that the His angle has nothing to do with natural reflux control. It simply indicates that the organs are misaligned.
It is much more crucial to capture and correct the arrangement and cooperation of the organs in three-dimensional space across different planes, rather than focusing on just one plane! Humans are three-dimensional beings! When the organs are returned to their proper anatomical positions, their function returns as well. Naturally, the His angle will also return to normal because everything is in its rightful place.
Sincerely,
PD Dr. med. Eckhard Löhde