Samuel J. Stabins

Idiopathic eosinophilic infiltration of the gastrointestinal tract, diffuse and circumscribed; a proposed classification and review of the literature, with two additional cases.

Abstract A classification is proposed for idiopathic eosinophilic infiltrations of the gastrointestinal tract, based on pathologic, clinical and laboratory features. Two relevant cases are added to the literature. In general, patients with a long-standing history of upper gastrointestinal complaints, with or without overt allergies, a roentgenographic picture of a constricting antrum or pylorus, and/or segmental narrowing and dilatation of the small bowel, associated with eosinophilia and leukocytosis, have diffuse eosinophilic gastroenteritis of the monoenteric or polyenteric type. The evidence suggests that these patients can be treated successfully with adrenocortical steroids and that surgery may be avoided. The regional type of this disease is confined for the most part to the pyloric area, causing obstruction in the absence of peptic ulcer, with little in the peripheral blood to aid in the diagnosis. Circumscribed eosinophilic infiltrated granulomas are well demarcated lesions of the regional or polypoid type, occurring anywhere in the gastrointestinal tract, giving local signs, and easily confused with neoplasm.

Spinal anesthesia in the treatment of megacolon and obstinate constipation

P RIOR to 1927, the treatment of idiopathic megacoIon was varied and extremeIy unsatisfactory. The conservative treatment consisted of diet, catharsis and repeated enemas. The resuhs were far from encouraging and after a Iong tria1, many of these cases were treated surgicaIIy. The surgica1 treatment was attended with radica1 procedures and high mortaIity. The more radica1 procedures varied from coIostomy, partia1 coIectomy to tota extirpation of the coIon. Even after such formidabIe procedures, the resu1t.s were often poor. Various theories have been advanced as to the cause of idiopathic megacoIon ranging from adhesions on the outside of the bowe1 to vaIve formation within. Briefly, some of these theories wiI1 be mentioned. An abnormaIIy Iong mesentery, chronic coIitis, increased Iength of the coIon, actua1 mechanica obstruction and congenita1 aplasia of the muscuIar tunics, were the outstanding theories unti1 rgoo. At that time Fenwick considered the possibiIity of spasm of the sphincter ani associated with fissures in the ana margin. In rgo7, Bing considered a neuropathic diIatation and hypertrophy of the coIon, probabIy a segmenta defect associated with changes in the sympathetic nerves. The true definition of idiopathic megacoIon infers a diIatation of the bowe1 without any obvious mechanica obstruction inside or outside of the bowe1. If we are to adhere to this definition, many of the theories, by the nature of their expression inferring some mechanica obstruction, cannot be considered in a discussion of idiopathic megacoIon. In 1895, Langley and Anderson showed that stimuIation of the Iumbar sympathetic gangIia caused an inhibition of peristaIsis with diIatation of the coIon and contraction of the interna sphincter of the anus. GaskeII feIt that impuIses inhibitory to the muscuIature of the Iarge bowe1 and motor to the interna sphincter of the anus pass through the Iumbar sympathetics. Learmouth and Markowitz have since substantiated this opinion by pIacing a buIb against the interna sphincter and recording contractions foIIowing stimuIation of the gangIia. In 1924, RoyIe and Hunter removed the Iumbar sympathetics for reIief of spastic paraIysis of the Iower extremities. They noted that one of the benefits of the operation was the striking reIief of the obstinate constipation that had been present in these patients. It was not unti1 1926, however, that a practica1 appIication of these observations was made when Wade and RoyIe performed a Iumbar sympathectomy for Hirschsprung’s disease (idiopathic megacoIon). The child made a fine recovery with exceIIent cIinica1 improvement and reIief of the constipation. In 1928, Judd and Adson reported 2 cases and in 1930, Scott and Morton reported one case. Since then numerous cases have been reported with varying degrees of success. The next step in the treatment of the disease was the introduction of spina anesthesia as a preoperative test to determine whether sympathectomy wouId be of benefit. This test was used prior to sympathectomy in the case reported by Scott and Morton. The resuIts were striking.

Bleeding duodenal ulcer in infancy: Asurgical problem

Summary 1. Two cases in female infants under 1 year of age are reported successfully treated by surgery during acute hemorrhage. 2. Bleeding duodenal ulcer should always be seriously considered in thedifferential diagnosis of gastrointestinal hemorrhage in infancy. 3. Hematemesis is not a necessary criterion to establish the diagnosis. 4. The margin of safety in conservative treatment of this condition of the infant is considerably reduced in contrast to that of the adult. 5. The advances in preoperative and postoperative care combined with modern surgical technique remove this condition from the hopeless field of therapy.

CHANGES IN THE VASOMOTOR REACTION ASSOCIATED WITH GLOMUS TUMORS

The interesting clinical syndrome produced by tumors of the glomic structures in the extremities was first described by Masson in 1924 (1) and called by hlim, gloiinus tumors. WVe lhave collected from the literature seventy-four cases of this condition (Table I). This condition is easily