"Pythagoras," said Socrates, "wrote that the ancient Phoenicians cooked eggs by placing them in slings and whirling them about their heads. Nevertheless, we observe that today, although we have eggs and slings and strong men to whirl them, the eggs do not cook. On the contrary, if the eggs start out hot, whirling quickly cools them. Obviously this is because we are not ancient Phoenicians!"
The literature of the esophagus is vast, but a large amount of it is devoted to shoring up the misconceptions of internationally recognized authorities - as though Socrates' students had missed his irony. This book is different. My intention is to refute the errors and place the field on a logical, not authoritarian, foundation.
Its substance evolved from a single insight: a lower esophageal ring and the dysphagia it caused cleared after the patient's stomach was pulled down and anchored to the abdominal wall. It seemed that the cure could only be explained by postulating that the ring was an accordion pleat of redundant mucosa formed when contraction of the longitudinal muscle shortened the esophagus. Further observations bore out this assumption in elaborate detail and aroused my interest in the function of the longitudinal muscle itself.
The LM could interact with the other muscular components of the esophagus in many ways to accomplish its several functions. To create some order in the bewildering array of possibilities, a Boolean logical approach was used. The states of the organ could be related to the vertices of a 3-cube according to the joint contraction or relaxation of its three components. This had the advantage of forcing my thinking into systematic channels and eventually proved a veritable secret weapon for producing hypotheses for subsequent verification or, more commonly, rejection. With few exceptions, my testing facility was the daily observation of patients in a radiology practice.
With two tools - a logical model and a reliable method of deciding when the LM was contracted - the rest of the work became the task of integrating the LM into esophageal physiology. That this had not been done earlier in any systematic way is due to the 2-dimensional outlook of the instruments of the physiologist: they see only the circular muscle and the sphincter. Of 500+ references cited here, I could find only 2% that were concerned with longitudinal muscle function.
There in an incalculable gain in insight when an extra dimension is embraced. Boyle would have faced an impossible task in formulating his gas law if, despite sophisticated instrumentation for measuring temperature and volume, he was deprived of any measure of pressure. Even worse, if he could not comprehend the idea of pressure. Imagine a Flatlander imprisoned by a circumscribed line because he could not conceive of the vertical dimension. What a liberating revelation it would be if he were given that ability. If we were given the ability to function in 5 dimensions, who knows what understanding and power might be ours.
Unlike statistics, Boolean methods can spell out the answers. Because they employ digital logic to test for truth or falsity, a wrong hypothesis can be rejected on the basis of one counter example. On the other hand, one can often learn more from a single case report than from a multi-university population study. My approach, therefore, has been logical and phenomenological.
I have tried to tell the story twice: the logic in the text and the lore in the illustrations. The latter are the shortest route to understanding the concepts. The reader may note that I have not presented statistical studies. I have, of course, relied on those of others and sought to rationalize them with each other. However, confronted with a group of similar but not identical cases, my penchant was to analyze the differences rather than tabulate the similarities.
Flashes of insight can also be blinding. I fear that, with considerable territory
to cover, I may have overlooked the obvious or gone overboard. I have no hope
that all of the concepts put forth here will survive the scrutiny, not only
my radiological peers, but of interested parties in the fields of gastroenterology,
physiology, surgery and laboratory investigation. I will be content if the work
is successful in attracting their interest to the third dimension of esophageal
O. Arthur Stiennon, M.D.
2812 Marshall Court
Madison, WI 53705