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nothing but a nervous element can be given as the etiologic factor. After mentioning 3 cases of pyloric spasm, he continues as follows: Instead of attacking the pylorus, the spasms may attack the cardia or esophagus. This is exceptional. Comby, in his "Treatise on the Diseases of Childhood," does not mention the occurrence of esophagism before the seventh to tenth years. The case now to be described is that of a little girl ten months of age, breastfed for the first three months. No trace of nervous manifestations in the parents. In the fourth month, without previous digestive infection, the child was taken with an attack of asphyxia of great severity, nutrition became bad and during the interval of five months, from September to February, the increase in weight was only 500 grams. Three developed attacks of forcible vomiting, following immediately the ingestion of fluids, accompanied by slight laryngeal stridor and some hiccough. During this time the child slept well, the stools were normal and she had no fever. Glairy mucus streaked with blood, was occasionally rejected with the milk. Various diets and therapeutic agents were tried without avail.

After giving the child milk of bismuth, radioscopy showed a black mass above the stomach, and in about thirty seconds part of it could be seen entering the stomach, and the remainder would be rejected. By introducing a rigid sound gavage was attempted, but the stomach contracted so on the eye of the instrument that it was necessary to use a syringe and considerable force to inject the milk. The child was isolated, taken from its mother, and put under the care of a nurse. It soon developed a general edema, spasms of the glottis and convulsive twitchings of the right side attributed to edema of the brain, but ultimately recovered. Méry considers the esophageal spasm as possibly attributable to the ingestion of air while sucking the thumb, a habit to which the child was addicted. He thought that the attacks of esophageal spasm decreased in frequency when the infant was prevented from sucking its thumb.

Although Méry's case resembles in some respects my own nevertheless, one must conclude, from his description of it, that it is a good picture of laryngismus stridulus in a rachitic infant.

The infant in my case used the cotton-plugged nipple as a pacifier and the father says that I suggested that it might have had something to do with the attacks, so they stopped using it.

I Dupont Circle.

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DR. ADAMS. AUGUSTUS CAILLÉ, M.D., New York. In connection with Dr. Adams' case, I would report a somewhat similar one; a lad of ten, who is now under my observation, the son of a physician, has had a spasmodic stricture for five years. Five years ago careful examination elicited the fact that there was no diverticulum—it was purely spasmodic. The stricture came on gradually and the inability to swallow was such that the boy was moribund from starvation. There was no difficulty in introducing the usual calibre tube and he was fed in that way. After some time he became able to swallow and was taken home. The father is still compelled once or twice a week to use the tube for feeding him.

This lad had hydrocephalus in his infancy and I imagine the irritation is of central origin, and I doubt if it will ever get entirely well.

In this connection I would sound a note of warning regarding the examination of the esophagus by means of the sound or esophagoscope. I have recently seen a young girl, who had some difficulty in swallowing, who was examined with the esophagoscope by an expert stomach specialist. He ran the instrument into the left pleural cavity, a pneumothorax developed and she was dead in two days.

C. P. PUTNAM, M.D., Boston.--I should like to mention a case similar to Dr. Griffith's; a boy twelve days old, with the history of not having swallowed anything since birth, was brought to the Massachusetts Infant Asylum. A solid obstruction having been found four inches from inside the lips, a gastrostomy was performed successfully by Dr. J. S. Stone. The baby rallied well after the operation and received a little milk with a tube through the wound. The stomach had plainly been empty up to that time. Doubt was thrown upon the diagnosis of obstructed esophagus when next day the baby vomited some milk, but this was explained by the autopsy. On the second day it failed and died.

The autopsy by Dr. Robertson showed that the esophagus ended in a blind pouch a little above the bifurcation of the trachea. The milk introduced into the stomach had been vomited up through the trachea. The child had some consolidation in the bases of both lungs.

THOMAS MORGAN ROTCH, M.D., Boston.—This opens up a rather important point in regard to the differential diagnosis in these cases, especially since we have had in late years much added information in regard to pyloric stenosis. Some of these cases of constriction of the esophagus simulate very closely pyloric stenosis. It is rather curious that they are almost identical so far as the rational signs are concerned. The food will sometimes be kept down for a day or forty-eight hours and then vomited. There is danger in passing the sound because sometimes at the lower part of the esophagus there is a thinning of the wall in these

cases. I have had a careful autopsy made on one where there was congenital stenosis just at the entrance to the stomach and above that a ballooning of the esophagus from stretching. In the lower part of the sac there was a very thin place about i cm. in diameter which was about to rupture into the trachea. The least mechanical interference would have ruptured it before death. We know that in a certain number of these cases we do not find anything on physical examination, although our recent examinations, especially with the Roentgen ray, have aided very much. These cases also simulate closely cases of chronic gastric indigestion, so that the greatest care should be used, before employing any other method, to carefully regulate the diet so as to determine whether or not they are cases of indigestion.

A. JACOBI, M.D., New York.—What was the exact site of the constriction in Dr. Griffith's case ?

DR. GRIFFITH.-Just above the bifurcation.

DR. JACOBI.—It is that position which gives rise to a great deal of difficulty in the adult. Carcinomata of the esophagus are apt to be found in just that position. The cause, I think, must be looked for in embryonal conditions. It is with the esophagus just as with the rectum; there may be just such overlapping. The parts are formed separately and as a rule will meet one another and so the tube is formed, but in this neighborhood there is always a narrowest part. We find that when we introduce a large sound into the esophagus of a healthy person, there is apt to be some constriction and it must be explained by the nature of its embryonal development. In the rectum we find it more frequently perhaps, so frequently, that every one of us may have found such a deformity of the rectum that when you mean to open such an imperforate rectum in a newborn by operation it may happen that you find these parts improperly developed so that the trochar runs into the peritoneal cavity in place of into the upper part of the rectum. It is the seat of predilection for cancer even in late life. Such a case of unsuccessful operation for imperforate rectum I published in the American Medical Journal of 1861.

As to the diverticuli they may be explained by something that happens a good many times. The muscular layers of the intestinal tract are not uniformly developed. Defects of these layers are quite common. That is the case in the sigmoid. Diverticuli formed below the constriction must be explained in that way. The muscular layers in these places are incompletely developed. Certain places imperfectly developed are found throughout the whole intestinal tract and the upper part of the apparatus is no exception.

SAMUEL S. ADAMS, M.D., Washington. I would state that there was no fluid found outside of the esophagus in the surrounding tissue, nor was there anything in the bronchial tubes, and yet I believe the pneumonia was probably the result of inhalation of some of the food that the child had been trying to take.

REPORT OF A CASE OF CONGENITAL HEART DIS

EASE.DEFECT OF THE VENTRICULAR SEPTUM
AND ABSENCE OF THE PULMONARY ARTERY-
SYMPTOMS OF ANGINA PECTORIS.

BY ALFRED HAND, JR., M.D.

of Philadelphia.

A few unusual features in the clinical symptoms and pathological findings induce me to make the following report. As an introduction I quote from Hochsinger's article on "Congenital Heart Disease" in Pfaundler and Schlossmann's The Diseases of Children, in which he states that while pulmonary stenosis is very frequent, comprising three-fifths of all congenital cardiac anomalies, and, with a defective septum, allowing of longer life than other forms of congenital heart disease, yet complete obliteration of the pulmonary artery is rare. If the stenosis occurs early in fetal life, then complete partition of the heart is prevented and those portions of the septum which are normally formed under the aortic valves are usually absent. Other authorities state that septal defects are more common in the anterior muscular part than in the membranous part, which is just below the aortic valves, the so-called undefended space.

My own experience is limited to 2 cases, the first one showing a defect in the muscular part, the second, the case under consideration, having a defect primarily of the membranous, but also involving the muscular portion.

The notes of the case are as follows:

S. J., male, colored, three years old, was admitted to the Children's Hospital on July 10, 1907, for “spells,” which began three months ago, the first occurring in April, one in May, two in June, one daily for the first five days of July, and two daily for the five days before admission. The mother described these spells as something like convulsions, starting with a scream, but without biting of the tongue or falling and bruising himself; the child seemed to have pain during the attacks and the breathing was

deep, rapid and noisy; the duration of each attack was about an hour, after which the child would go to sleep. The family and personal history obtained on admission was negative, but it was subsequently learned that the doctor who was present at his birth said that he was a "blue baby."

The notes made by the resident physician, Dr. Vail, on admission were: A fairly well-developed boy; head of fair shape; anterior fontanel open the size of a five-cent piece; eyes and ears normal; throat hyperemic; boy walks properly. Lungs everywhere resonant; large râles at both bases; sounds are rough and friction-like at the left base. The heart is rapid and regular. Abdomen not sunken; liver extends 2 cm. below the ribs; spleen is not palpable. Extremities are negative except that the legs and thighs appear under-developed. Kernig's and Babinski's signs are negative; no ankle clonus; no tache. A convulsive or dyspneic attack occurred on July 11, from 7:45 to 9:40 A.M., with much cyanosis, great relaxation, dyspnea, weak and rapid pulse; the child could be aroused; there were no tonic or clonic movements.

When I saw the patient a few hours later physical examination was negative, except for soft breathing over the base of the right lung posteriorly with slight impairment of percussionresonance at the angle of the scapula, and also marked dullness over the upper part of the sternum. The idea was therefore entertained of an enlarged thymus with attacks of thymic asthma.

On July 12 there was an attack lasting from 12:30 to 3:45 A.M., with dyspnea, cyanosis and suprasternal recession. Examination later showed the lungs to be perfectly clear, but a striking phenomenon was found in the loudness and clearness of the heart sounds, which were heard all over the precordium, to the right of the sternum and up to the second interspace; the sounds seemed close to the ear of the listener, but there was no murmur to account for the clubbing of the fingers; the apex beat was not displaced, but the cardiac dullness extended nearly one cm. to the right of the right border of the sternum. The possibility of enlarged posterior mediastinal glands pushing the heart forward was considered, but Eustace Smith's sign was negative.

On the following day, July 13, I had my first opportunity of seeing him in an attack; he was lying on the right side with his hands pressed against the precordium; his face bore an expression of pain and there was an audible groan with each expiration, the respirations being slow and labored. On auscultation the

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