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Demonstration of oesophageal reflux using live snakes
Clin. Radiol. (1969) 20, 107-109
DEMONSTRATION
OF
OESOPHAGEAL
A. C H A N D R A H A S A N
JOHNSON
REFLUX
USING
and SATYABAMA
LIVE
SNAKES
JOHNSON
From the Departments of Radiodiagnosis and Medicine, Christian Medical College Hospital, Vellore, S. India
T h e a u t h o r describes an I n d i a n r o a d s i d e p e r f o r m e r w h o earns his living b y s w a l l o w i n g a n d r e g u r g i t a t i n g 10 to 15 live snakes a n d fishes. Clinical p h o t o g r a p h s , b a r i u m m e a l r a d i o graphs, a n d o e s o p h a g e a l a n d gastric p r e s s u r e r e c o r d i n g s are p u b l i s h e d . V o l u n t a r y c o n t r o l o f r e g u r g i t a t i o n m a y be learnt. T h e a u t h o r suggests a possible a p p l i c a t i o n o f this action. P a t i e n t s suffering f r o m gastric h y p e r a c i d i t y m a y be able to a v o i d t a k i n g a n t a c i d s b y giving t h e m s e l v e s v o l u n t a r y gastric lavages.
REFLUX i n t o the o e s o p h a g u s is t h o u g h t t o be n o r m a l in a n i m a l s t h a t r u m i n a t e , b o r d e r l i n e a b n o r m a l in infants w i t h c h a l a s i a c a r d i a a n d w i t h o c c a s i o n a l exceptions, definitely p a t h o l o g i c a l in adults. T h i s p a p e r d e m o n s t r a t e s an u n u s u a l case of "reflux". CASE REPORTS The subject, Balu, an Indian circus-type, roadside performer is able to swallow with copious draughts of water 10 to 15 live snakes, each measuring 2 to 3 feet (fig. 1). After a few minutes, on request, he can regurgitate the water and the snakes (Fig. 2). Balu repeated his act under medical supervision. It was found that the snakes had indeed gone into the stomach and their movements were both noticeable and palpable through the abdominal wall. Radiographs confirmed their presence in the stomach (Fig. 3). Subsequently the snakes were force-fed with barium before being swallowed. Their entry, and eventual regurgitation, were studied by cine-radiography and fluoroscopy (Fig. 4). Balu was also given a barium meal to facilitate study of the reflux mechanism. The entire act was cinematographed. Pressure studies were also done. Two unequally long radio-opaque tubes were connected so that one had its open end in the region of the lower oesophageal sphincter and the other in the pylorus_ Simultaneous recordings of the
gastric and oesophageal pressures were made during the various actions involved in the reflux. Complete withdrawal tracings were recorded. INVESTIGATIONS Barium meal: A small sliding hiatus hernia was present. There was no evidence of oesophagitis. The stomach was large; peristalsis was normal. Initial pylorospasm was seen. The duodenum, small and large bowel were normal. When asked to attempt to regurgitate his gastric contents, Balu started contracting his abdomen. This pressure was detected at the pylorus. The cardia opened and reflux took place. -1 At rest the oesophagus pressure was -- mm Hg. and that -9 of the pyloric end of the stomach + 6 mm Hg. The oeso+3 phageal pressure falls with inspiration and rises with expiration while the converse is true in the stomach (Fig. 5). When Balu performs the "Uddiyana Asanam" a Yoga exercise wherein the abdominal wall is retracted, the pressure in the stomach and in the oesophagus falls precipitously (Fig. 6). When he contracts his abdominal muscles in bellydancer fashion the pressure is transmitted to the pylorus. The pyloric pressure increases while the oesophageal pressure is unchanged until reflux occurs (Fig.7).
Fro. 1 FI~. 2 FIG. 1--Swallowing live snakes. FIG. 2--Regurgitating the live snake. 107
108
CLIN1CAL
RADIOLOGY
FIG. 3
FIG. 4
Fio. 3 ~ L i v e snakes and frogs in the s t o m a c h - - p l a i n x-ray a b d o m e n (F = fi'ogs: S = snakes). Fla. 4 - - B a r i u m meal fed to the snakes.
FI6.5 NormM pressure.
FIG. 6
FI6. 7
FIG. 6 - - A b d o m i n a l retraction. FIG. 7 - - C o n t r a c t i o n of the pylorus.
DEMONSTRATION OF OESOPHAGEAL REFLUX U S I N G LIVE SNAKES
109
Fro. 9 FIG. 8 ipontaneous vomiting. Fro. 9--Vomiting followed by retching. Fro. 8--Soontaneot
DISCUSSION Balu learned in one day to swallow fishes and regurgitate them. There are at least four other persons locally who perform a similar act to earn their livelihood. It is generally accepted that frequent regurgitation may cause oesophagitis. But Balu feels his frequent stomach lavage keeps his stomach and oesophagus h e a l t h y - despite the fact that when 5 to 6 snakes get coiled up during reflux the oesophagus may stretch to a diameter of 5 inches. Unwittingly, by voluntary relaxation o f the pharyngo-oesophageal sphincter he prevents the intra-oesophageal pressure from building up to the point of rupture. During reflux there is a sudden sharp rise in intra-oesophageal pressure which may be immediately preceded by an equally sudden rise in the intragastric pressure. The intragastric pressure drops immediately. The intra-oesophageal pressure takes some time to come down to normal. The sharp rise in oesophageal pressure noted during reflux then falls slightly and is sustained in a state
of minimally increased pressure until the oesophagus empties itself either through the mouth or into the stomach (Fig. 9). It is possible for an adult to train himself to regurgitate his gastric contents at will. The possibility of using this capacity in medicine has been seriously considered and is being tried at t h i s institution. Two subjects have been studied to date and both show remarkable healthy upper gastrointestinal tracts. When a patient with high gastric acid content can give himself a gastric lavage once or twice a day he enjoys multiple advantages. Antacids can be eliminated thus saving this continual expense. The side effects of the various antacid and antispasmodics commonly used are also eliminated. Even the need for vagotomy or other surgical procedures could be avoided. Aeknowledgement.--I am greatly indebted to Dr. A. M. Jelliffe for his help in rewriting the manuscript, Mr. Nagarajan
the typist, Messrs. Victor and Verghis radiographers, Messrs. Eddy and Prakash who helped in recording the oesophageal pressure studies. Above all, I am indebted to Balu.
NOTICE T•E European Association of Radiology will hold its 2nd Congress from 14 to 18 June 197l in the Netherlands Congress Centre at The Hague, the Netherlands. The organization has been entrusted to the Netherlands Ass ~ciation of Radiology. Professor J. R. van Ronnen of Leiden University will be president of the Congress. Approximately 2000 participants are expected to attend. For all further information please apply to the local secretariat c/o Holland Organizing Centre, 16 Lange Voorhout, The Hague, the Netherlands.
DEMONSTRATION
OF
OESOPHAGEAL
A. C H A N D R A H A S A N
JOHNSON
REFLUX
USING
and SATYABAMA
LIVE
SNAKES
JOHNSON
From the Departments of Radiodiagnosis and Medicine, Christian Medical College Hospital, Vellore, S. India
T h e a u t h o r describes an I n d i a n r o a d s i d e p e r f o r m e r w h o earns his living b y s w a l l o w i n g a n d r e g u r g i t a t i n g 10 to 15 live snakes a n d fishes. Clinical p h o t o g r a p h s , b a r i u m m e a l r a d i o graphs, a n d o e s o p h a g e a l a n d gastric p r e s s u r e r e c o r d i n g s are p u b l i s h e d . V o l u n t a r y c o n t r o l o f r e g u r g i t a t i o n m a y be learnt. T h e a u t h o r suggests a possible a p p l i c a t i o n o f this action. P a t i e n t s suffering f r o m gastric h y p e r a c i d i t y m a y be able to a v o i d t a k i n g a n t a c i d s b y giving t h e m s e l v e s v o l u n t a r y gastric lavages.
REFLUX i n t o the o e s o p h a g u s is t h o u g h t t o be n o r m a l in a n i m a l s t h a t r u m i n a t e , b o r d e r l i n e a b n o r m a l in infants w i t h c h a l a s i a c a r d i a a n d w i t h o c c a s i o n a l exceptions, definitely p a t h o l o g i c a l in adults. T h i s p a p e r d e m o n s t r a t e s an u n u s u a l case of "reflux". CASE REPORTS The subject, Balu, an Indian circus-type, roadside performer is able to swallow with copious draughts of water 10 to 15 live snakes, each measuring 2 to 3 feet (fig. 1). After a few minutes, on request, he can regurgitate the water and the snakes (Fig. 2). Balu repeated his act under medical supervision. It was found that the snakes had indeed gone into the stomach and their movements were both noticeable and palpable through the abdominal wall. Radiographs confirmed their presence in the stomach (Fig. 3). Subsequently the snakes were force-fed with barium before being swallowed. Their entry, and eventual regurgitation, were studied by cine-radiography and fluoroscopy (Fig. 4). Balu was also given a barium meal to facilitate study of the reflux mechanism. The entire act was cinematographed. Pressure studies were also done. Two unequally long radio-opaque tubes were connected so that one had its open end in the region of the lower oesophageal sphincter and the other in the pylorus_ Simultaneous recordings of the
gastric and oesophageal pressures were made during the various actions involved in the reflux. Complete withdrawal tracings were recorded. INVESTIGATIONS Barium meal: A small sliding hiatus hernia was present. There was no evidence of oesophagitis. The stomach was large; peristalsis was normal. Initial pylorospasm was seen. The duodenum, small and large bowel were normal. When asked to attempt to regurgitate his gastric contents, Balu started contracting his abdomen. This pressure was detected at the pylorus. The cardia opened and reflux took place. -1 At rest the oesophagus pressure was -- mm Hg. and that -9 of the pyloric end of the stomach + 6 mm Hg. The oeso+3 phageal pressure falls with inspiration and rises with expiration while the converse is true in the stomach (Fig. 5). When Balu performs the "Uddiyana Asanam" a Yoga exercise wherein the abdominal wall is retracted, the pressure in the stomach and in the oesophagus falls precipitously (Fig. 6). When he contracts his abdominal muscles in bellydancer fashion the pressure is transmitted to the pylorus. The pyloric pressure increases while the oesophageal pressure is unchanged until reflux occurs (Fig.7).
Fro. 1 FI~. 2 FIG. 1--Swallowing live snakes. FIG. 2--Regurgitating the live snake. 107
108
CLIN1CAL
RADIOLOGY
FIG. 3
FIG. 4
Fio. 3 ~ L i v e snakes and frogs in the s t o m a c h - - p l a i n x-ray a b d o m e n (F = fi'ogs: S = snakes). Fla. 4 - - B a r i u m meal fed to the snakes.
FI6.5 NormM pressure.
FIG. 6
FI6. 7
FIG. 6 - - A b d o m i n a l retraction. FIG. 7 - - C o n t r a c t i o n of the pylorus.
DEMONSTRATION OF OESOPHAGEAL REFLUX U S I N G LIVE SNAKES
109
Fro. 9 FIG. 8 ipontaneous vomiting. Fro. 9--Vomiting followed by retching. Fro. 8--Soontaneot
DISCUSSION Balu learned in one day to swallow fishes and regurgitate them. There are at least four other persons locally who perform a similar act to earn their livelihood. It is generally accepted that frequent regurgitation may cause oesophagitis. But Balu feels his frequent stomach lavage keeps his stomach and oesophagus h e a l t h y - despite the fact that when 5 to 6 snakes get coiled up during reflux the oesophagus may stretch to a diameter of 5 inches. Unwittingly, by voluntary relaxation o f the pharyngo-oesophageal sphincter he prevents the intra-oesophageal pressure from building up to the point of rupture. During reflux there is a sudden sharp rise in intra-oesophageal pressure which may be immediately preceded by an equally sudden rise in the intragastric pressure. The intragastric pressure drops immediately. The intra-oesophageal pressure takes some time to come down to normal. The sharp rise in oesophageal pressure noted during reflux then falls slightly and is sustained in a state
of minimally increased pressure until the oesophagus empties itself either through the mouth or into the stomach (Fig. 9). It is possible for an adult to train himself to regurgitate his gastric contents at will. The possibility of using this capacity in medicine has been seriously considered and is being tried at t h i s institution. Two subjects have been studied to date and both show remarkable healthy upper gastrointestinal tracts. When a patient with high gastric acid content can give himself a gastric lavage once or twice a day he enjoys multiple advantages. Antacids can be eliminated thus saving this continual expense. The side effects of the various antacid and antispasmodics commonly used are also eliminated. Even the need for vagotomy or other surgical procedures could be avoided. Aeknowledgement.--I am greatly indebted to Dr. A. M. Jelliffe for his help in rewriting the manuscript, Mr. Nagarajan
the typist, Messrs. Victor and Verghis radiographers, Messrs. Eddy and Prakash who helped in recording the oesophageal pressure studies. Above all, I am indebted to Balu.
NOTICE T•E European Association of Radiology will hold its 2nd Congress from 14 to 18 June 197l in the Netherlands Congress Centre at The Hague, the Netherlands. The organization has been entrusted to the Netherlands Ass ~ciation of Radiology. Professor J. R. van Ronnen of Leiden University will be president of the Congress. Approximately 2000 participants are expected to attend. For all further information please apply to the local secretariat c/o Holland Organizing Centre, 16 Lange Voorhout, The Hague, the Netherlands.