1917 Journal of the American Medical Association  
well open into the duodenum. 2. When a gallbladder fistula is established with the surface, all observers have noticed that the bile flows more freely during the night or during intervals of digestion than during digestion. In other words, the bile flows into the gall¬ bladder during the intervals of digestion. The gall¬ bladder seems to serve as an elastic safety reservoir which takes off the pressure from the bile duct during certain times of the day. It seems likely that this may be
more » ... his may be explained on the basis that during active digestion peristaltic waves are intermittently passing down the intestine. In the wake of these waves there follows a diminution of the intra-intestinal pressure, which permits the temporary flow of bile from the duct. As soon as the wave has ceased, the normal intraintestinal pressure is resumed and the valve is closed. During long intervals of digestion, and particularly during the night, the peristaltic waves are few. The intra-intestinal pressure is more nearly constant, and the bile is forced out into the gallbladder, or out through a gallbladder fistula as the case may be (Fig. 14 A and B). If the gallbladder has been removed or destroyed, an equilibrium of pressure in the gall ducts and intestines is established in the long inter¬ vals between peristaltic contractions, with the result that the full degree of intra-intestinal pressure in the bile ducts during the intervals of digestion produces permanent dilatation of the duct (Fig. 15 A and B ). In connection with this problem, it is well to mention the fact that the urine coming into the bladder through the normal valve is seen to come in jets of several drops at a time, while it passes through a ureteral catheter with a steady drip. Is it, therefore, not prob¬ able that the jets seen in the first case are due, partially at least, to the rhythmic contraction of the bladder which at certain intervals increases the intravesical pressure and temporarily closes the valves, while, when the catheter is passed up into the ureter, the bladder contraction is not operative on the flow? ABSTRACT OF DISCUSSION Dr. Edward Martin, Philadelphia : As to the statement in regard to inelasticity of the belly wall, it is one of the most elastic of all structures, to wit : the circum¬ ference changes before and after dinner, as shown by the relative bigness of your garments. As to intraabdominal pressure, on operation, with the first admission of air there is a cavity, hence a negative pressure. The pressure is constantly varying ; at times it is life-threatening from its effect on the circulation and the respiration. Every vital process and every reparative process depends on the freedom and rapidity of the blood supply, and probably the underlying reason for abnormal abdominal conditions asso¬ ciated with ptosis is a circulatory interference and not a mechanical interference with the progression of the intestinal contents. Of all deceiving factors, the roentgenogram ranks among the first. Ochsner has shown that any viscus may be in any position and function normally if the blood supply is not interfered with. Concerning the mechanism of the valves, going back to fun¬ damental principles, the law of sphincters is that when irri¬ tated they contract. Flaccidity is almost unknown ; the anal, the pyloric, the cardiac, urethral sphincters give us trouble only by contracting. In the first few months of life the car¬ diac valve is normally incompetent, a period for quantitative errors of judgment. Later, if abnormal, it becomes perma¬ nently tight. Any neighboring pathologic condition may cause it to grip tight, the sphincter having its own centers which respond in only one way. An incontinent ileosphincter is extremely Tare. They all yield to continued abnormal back pressure. The cecum is usually empty and the stimulus to the cecum to contract is a sudden, violent gush from the ileum. A slow ooze, as through a spasmodically contracted sphincter, will not give this stimulus. I cannot see the mechanism of a vacuum formed in an absolutely soft gut. It is probable that the beneficial effects of operation are not from tightening a loose sphincter, but from loosening a spas¬ modically tight sphincter. We are cursed by pylorospasm. How do we cure pylorospasm? Usually by curing the lesion reflexly responsible for it, and sometimes by paralyzing and putting out of service the muscle. The rule of the sphincters is that they are always tight. Why is a patient with chronic appendicitis constipated and toxic? Because he has a loose sphincter? No; because he has a tight sphincter. The lower ileum is the portion where the intestinal contents remain longer than in any other part of the intestinal canal. With a teasing chronic appendix the reflex spasm prevents that rapid distention of the cecum which excites cecal contraction. Why do these patients get well of their constipation by the taking out of a fibrosed appendix? And why do so many of them suffer from pylorospasm? Because the sphincters work together ; that is, the ileocolic and the pyloric. We have had no success in implanting the ureters, and we have done it very carefully; no success because there always occurs a narrowing at the point of implantation and an ascending infection. Sweet has attempted it many times. In only two reputed cases has it been done successfully without a segment of the bladder wall. I agree that the mechanism of the vesical sphincter of the ureter is, in part, a mechanical one.
doi:10.1001/jama.1917.02590360009003 fatcat:opmanybq5vcfjkhjvsdrpevkhq