THE PHYSIOLOGICAL BASIS OF REFLUX OESOPHAGITIS IN SLIDING HIATAL DIAPHRAGMATIC HERNIA BY

The rational treatment of each patient with ulceration of the oesophagus above a diaphragm-atic hernia of the stomach would be easier if more was known about the aetiology of this complex condition. Experimentally the squamous epithelium of the oesophagus shows no real resistance to peptic digestion (Selye, 1938), but clinically, when valvu-lar function at the cardia is lost, the damage to the oesophagus which follows varies widely in different individuals and may be completely absent. A bed-side experiment has been designed to clarify the obvious difference between some patients with hernia and reflux who, in a few months, develop obstruction from peptic stenosis of the oesophagus, and others who, for 30 years with an unblemished gu'let, suffer only mild social embarrassment after dinner. Between these extremes there is a large group in whom mild oesophagitis with occasional aggravation has been present for years without a stricture forming; yet in all three groups there is no gross difference in the sliding hernia. As this variable damage has prognostic importance in the management of such a common condition, it calls for an explanation of how and why it arises. In the last two years 50 patients from these dis-similar groups (Table 1) have been studied tunde