Philip Kramer

Dysphagia Produced by a Contractile Ring in the Lower Esophagus

Summary 1.In six male patients complaining of dysphagia, the responsible disorder appeared to be an annular esophageal constriction situated 0.5-2.5 cm. above the diaphragm. The constriction did not produce dysphagia unless it happened to trap a solid morsel of food, thereby occluding the esophageal lumen. 2.Anamnestic, radiologic, physiologic and pathologic evidence indicated that the annular constriction was not caused by a fibrous band, inflammatory stricture, cardiospasm (or achalasia), or diaphragmatic hernia. 3.If the claim of several anatomists is correct that a physiologic sphincter exists in the esophagus 1-2 cm. above the diaphragmatic hiatus, the constriction ring may be identified tentatively as an overactive inferior esophageal sphincter.

The Effect of Specific Foods and Water Loading on the Ileal Excreta of Ileostomized Human Subjects

Summary 1.The effect on ileal excreta of 12 selected foods and liquids fed in normal quantities was studied in 7 healthy ileostomized persons. These foods were chosen for investigations because they are either forbidden or advocated in the treatment of many intestinal disorders. Only prune juice consistently increased the wet weight and many other characteristics of ileal effluent. Cooked cabbage augmented the output of wet and dry weight per day of ileal excreta, whereas baked beans increased only the dry weight output per day. 2.Water loads in approximate amounts of 1400, 2500, and 3500 gm. per day above control intake did not alter Real excreta significantly. The excess water seemed to be excreted mainly in the urine. 3.The wet weight of ileal excreta per day averaged 507 gm. It was semi-liquid to mushy, had an average pH of 6.3, and contained 92.1 per cent water on the average. Fat and nitrogen output per day were normal. An average of 60.3 mEq of sodium, 3.6 mEq of potassium, 86.2 mg. of bilirubin and 17.8 mg. of urobilinogen were excreted per day. 4.If these characteristics of ileal effluent and those of normal feces are compared, certain inferences as to colonic function can be made. The colon seems to absorb approximately 58 to 60 mEq of sodium and 400 ml. of water per day, excretes potassium, and is the main site where urobilinogen is formed.

II. Cardiospasm, a generalized disorder of esophageal motility

Abstract In four patients with cardiospasm the esophageal motility as studied by balloonkymograph records presented the following deviations from normal: decreased tone, lack of propulsion and irregular phasic activity of variable intensity. These abnormalities involved the lower two-thirds of the esophagus. Administration of acetylbetamethylcholine chloride to patients with cardiospasm produced a violent tonic contraction of the lower half of the esophagus. This contraction obliterated even a considerably dilated lumen. The esophageal motility pattern and the hypersensitive response to acetylbetamethylcholine chloride differentiated the esophageal motility of cardiospasm from that recorded in control subjects and in patients with scleroderma, mechanical obstruction of the esophagus and transient spasms of the esophagus. The diffuse derangement of esophageal motility found in the patients with cardiospasm suggests that this disorder affects not only the cardia but nearly the entire esophagus. The hypersensitive response to a parasympathicomimetic agent, when viewed in light of Cannons law of denervation, supports the hypothesis that disruption of the esophageal parasympathetic innervation plays a role in the pathogenesis of cardiospasm. The observations made do not elucidate the ultimate cause of cardiospasm. They indicate, however, that cardiospasm should be more precisely defined and should not be confused with other disorders of esophageal motility. They furthermore indicate that some of the arguments which have been advanced in favor of the view that cardiospasm is a psychogenic disorder must be accepted with some reservation.

I. Motility of the human esophagus in control subjects and in patients with esophageal disorders

Abstract Balloon-kymograph records of esophageal motility were obtained in subjects with and without clinical disorders of the esophagus. The motility recorded was that stimulated by inflating and maintaining a relatively large balloon in fixed positions of the esophagus. In subjects without esophageal disorders a characteristic motility pattern was recorded in the upper, middle and lower esophagus, the middle and lower positions presenting a regular sequence of large peristaltic waves. In patients with cardiospasm the motility records demonstrated decreased tone and irregular phasic activity of variable intensity. Propulsion of the balloon along the esophagus did not occur. In patients with scleroderma both tone and phasic activity were markedly diminished. Propulsion of the balloon was diminished but occasionally was present. Esophageal motility in the presence of mechanical obstruction evidenced a mild decrease in tone and augmented regular phasic activity.

Gastric Acid Secretion in Chronic Obstructive Pulmonary Emphysema

A number of published reports have implied a greater than normal incidence of peptic ulcer in patients with chronic obstructive pulmonary emphysema. Thus, in several clinical and/or autopsy stUdies, approximately 15 to 28 per cent of emphysema patients had suffered at some time from an acute or chronic peptic ulcer.!-5 Weber and Gregg6 analyzed the relationship of thes3 two diseases from another point of view: they found that of 70 patients with gastric ulcer, 30 (43 per cent) had pulmonary emphysema. The actual incidence of peptic ulcer in the general obstructive emphysema population cannot be ascertained from these reports. In most instances the emphysema patients were hospitalized or came under medical observation because of severe pulmonary disease. It would seem, therefore, that the patients in the various series cited were specially, although not deliberately, selected. Nevertheless, peptic ulcer seemed to be associated more commonly with obstructive emphysema than with many other chronic diseases.! Mechanisms responsible for the increased incidence of peptic ulcers were considered, but no author presented experimental evidence to account for the association of

Antimotility activity of equitoxic doses of anticholinergic agents

SummaryUsing 100 mg. of Banthine as a standard of reference, the doses of atropine, Bellafoline, Pamine, Elorine, and Pathilon that gave similar side effects (the equitoxic dose) were determined. This dose was found to be 2–8 times the amount usually used clinically or experimentally. The small-intestine antimotility activity of this dose was then measured by balloon kymography in the same subject. Considerable variation in degree of side effects, dose required to produce side effects, and antimotor response to a particular dosage of drug was observed from subject to subject.If an equitoxic rather than an arbitrarily predetermined dose is used, then atropine appears to be the most active of the drugs tested.

Reactivation of ulcerative colitis following closure of an ileostomy of 27 years' duration.

SummaryA case of ulcerative colitis is reported in which restoration of intestinal continuity 27 yr. after an ileostomy led to flare-up of the disease. Ileostomy and colectomy were necessary to control the disease. This case seems to emphasize the opinion expressed already in 1932 that “ileostomy for ulcerative colitis should be permanent.”3 While on steroid therapy without antibiotics, this patient developed oral moniliasis. This complication was observed in 2 additional patients with ulcerative colitis treated with steroids alone.

Present concepts of the nature of direct and indirect bilirubin

SummaryPresent evidence would indicate that two or possibly more types of bilirubin, known historically as direct and indirect bilirubin, exist. The differences reside in the chemical nature of each bilirubin and not in the nature of the protein linkage. Direct bilirubin is a water-soluble compound probably in the form of a conjugated bilirubin-glucuronide11; because of its solubility, direct bilirubin is excreted in the urine. Both types of bilirubin are associated with serum albumin which probably acts simply as a vehicle for carrying the pigment. The van den Bergh test measures two types of bilirubin; at the pH at which the reaction is conducted each type is dissociated from its protein molecule. The role of alcohol in the van den Bergh is unknown and is not that of separating bilirubin from protein.