cisions than any other Rabbi in Chicago. I found that he met with almost uniformly good results. The method was very much. like that described by the essayist. He seized the prepuce with the thumb and finger, placed over it a little shield made from a silver half dollar that someone had given him with a slit extending two-thirds the way through it. With the scalpel a downward sweep was made along this shield, amputating the prepuce. He then laid the shield aside and, taking the two sides of the cut surface between his fingers and thumbs, he retracted the mucous lining with the ring fingers, holding the integument tightly. A little alum water was then applied and a little tape wrapped around to retain in position the reduplicated tissue. That was wet with alum water and then a piece of cloth or gauze with a hole in the middle was applied in such a way as to hold this dressing in place. There was no such thing as sutures, and the cases all did well. I immediately adopted the method, using a little surgeon's adhesive tissue. I never saw a case fail to do well in any child too young to interfere with the dressings with his hands. I do not, however, recommend the operation as I used to.

DR. WILSON (closing discussion).-The operation may be carried out with the greatest simplicity by using a pair of surgeon's scissors. The advisability of using the knife is debatable. I had a very disagreeable experience which led to my adopting the scissors. Unfortunately, I was using a sharp scalpel, and just as I made the incision the nurse's attention was diverted and she neglected to hold the child's legs, which were brought suddenly and forcibly together and the point of the scalpel severed the left femoral artery. Fortunately, the circumcision was completed, as I was able to enlarge the incision over the femoral artery, introducing forceps and catching the proximal end of the vessel and afterward ligating. It was that experience that induced me to use the more simple method.

CONGENITAL HYPERTROPHIC STENOSIS OF THE

PYLORUS IN AN INFANT.-REPORT

OF A CASE.

BY JOHN DORNING, M.D.,
New York.

The following case of congenital hypertrophic stenosis of the pylorus is reported merely because it presents the typical clinical features of this now generally recognized disorder and hence may, with propriety, be added to the growing list of recorded cases of this interesting malady.

On May 29, 1905, I saw, in consultation with Dr. M. E. O'Donovan, of New York, Baby McG., seven weeks old, whose history is as follows: The baby was healthy and well developed at birth and weighed between nine and ten pounds. He had vomited since birth, usually after each nursing. On several occasions he did not vomit for a half day, but would afterward regurgitate a large quantity of sour material. He generally smelled sour. On the supposition that the maternal milk was the cause of the stomach disturbance, artificial feeding, consisting of the various infant foods, gruels and milk combinations, was substituted. For five days prior to my visit there had been less vomiting than usual. During these days the food was composed of arrowroot, I teaspoonful; whole milk, 3 teaspoonfuls, and hot water, 6 ounces, alternating with a weak solution of gelatin in water. During the past four weeks the vomited matter has been mixed with mucus. He never vomited bile. The stools have always been green, but there has never been any diarrhea. There has been progressive loss of flesh and increasing weakness.

Examination showed a very pale and greatly emaciated baby. The skin of face wrinkled and expression apathetic. The epigastrium was slightly distended. At short intervals a peristaltic wave, from left to right, was observed in the epigastrium. The abdomen was soft and there was no distention or muscular resistance. On deep palpation a nodule, about the size of a large bean, was felt in the epigastric region, just to the right of the

DORNING: Congenital Hypertrophic Stenosis of the Pylorus. 85

median line. Examination of the chest was negative. With such a history and physical signs it was clearly a case of congenital hypertrophic stenosis of the pylorus. An operation was advised and emphatically declined. I then suggested irrigation of the stomach and a food mixture of whey, dextrinized gruel and cream. I did not again see the child, but the subsequent history obtained from the doctor was, that he was not permitted to irrigate the stomach; that the food suggested seemed to agree and was for the most part retained. There had been much less vomiting since our consultation. The child seemed to improve for about ten days and then gradually failed and died on June 16th. An autopsy was not allowed.

While hypertrophic stenosis of the pylorus in infancy is a condition not frequently observed, still, in view of the many cases reported during the past ten or twelve years, it cannot be said to be a rare affection. It is well, however, to keep the malady in mind, so that an early diagnosis may be made and the little. patient given the benefit of an operation before his vitality becomes exhausted. For with our present knowledge of this condition an operation is really the only measure that offers any hope of recovery in the majority of cases.

In an article, illustrated with a photo-micrograph of a section of an hypertrophied pylorus, published by the writer in the ARCHIVES OF PEDIATRICS, 1904, may be found a bibliography of the subject.

WITH THE REPORT OF A CASE.*

BY J. P. CROZER GRIFFITH, M.D.,

Clinical Professor of Diseases of Children in the University of Pennsylvania,

AND

R. S. LAVENSON, M.D.,

Assistant Physician to the Philadelphia Hospital; Assistant Pathologist to the Hospital of the University of Pennsylvania, Philadelphia.

Although malformations of the esophagus have been reported with considerable frequency on account of the striking symptoms presented, they are, in fact, comparatively uncommon. Careful study of the matter has been made by Mackenzie, Kraus, Marsh, Phillips and others. Mackenzie could collect but 63 cases, and Dickie, writing in 1906, found but 13 additional ones. He fails, however, to mention these by name. The most valuable contribution of recent date is that of Happich, in which, as well as in Mackenzie's text-book, will be found the bibliography for reported cases not specifically mentioned by us.

Malformations may be of various forms. Ignoring bronchial clefts which belong rather to another category, these may be:

(1) Total Absence of the Esophagus.-This is a very rare condition associated generally with other serious malformations, such as seen in acephalous monsters with defects in the thoracic and abdominal viscera. Happich collects 7 cases of this anomaly, viz., those of Sonderland, Tiedemann, Cooper, Mondière, Lozach, Heath, and Mackenzie. Kraus adds none to the list; and we have found no records elsewhere.

(2) Partial or Complete Doubling of the Esophagus.—This also is an extremely rare disorder, there being in Happich's list only the 2 cases reported by Blasius. To this we may add the case of Kathe, published in 1907, in which a narrow supplemental lumen appeared to exist in the wall of the tube.

(3) Tracheoesophageal Fistula without other Lesion of the Esophagus. Like the others this is also very rarely seen. Happich quotes but 4 cases, those of Pinard Tarnier, Richter, and von de Water; and reference to the original communication shows that the reports of Pinard and Tarnier were upon the same case, so that the number is actually but 3. Kraus mentions the 3 cases of Vrolick, Lamb and Eppinger.

(4) Stenosis.-The cause of this may be either a fold of

From the Children's Medical Ward and the Pepper Clinical Laboratory of the University of Pennsylvania.

mucous membrane, as is the cases of Rossi, Tenon, Kraus, and others, or a narrowing involving the entire wall of the esophagus, as in the case of Hirschsprung. In certain instances of stenosis recorded, viz., those of Home, Cassan and Berg, and Follin, it is far from sure that the condition was congenital in origin. Very probably carcinoma may have been the cause. Omitting these we have found the records of but 20 cases, viz., Rossi, Tenon, Bauernfeind, Gianella, Siegert, Worthington, Brenner, Zenker, Mayer, Hirschsprung. Schneider, Cruveilhier, Blasius, Fagge, Wilks, Turner, Crary, Baillie, Wadstein, and Demme.

(5) Congenital Dilatation.-This is limited to the portion of the esophagus just above the diaphragm. The condition was first described by Arnold and by Luschka, the latter of whom applied to it the appropriate term "Vormagen." The case described by Rotch appears to be a very typical instance. The condition may lead to a secondary diffuse dilatation involving the entire length of the esophagus. Although Vigot, it is true, described funnel-shaped diverticula arising from the anterior wall of the esophagus, it is doubtful whether these are ever really congenital. It is claimed by some that the foundation for the development of pulsion diverticula is laid in a congenital weakness of the muscular elements of the esophageal wall.

(6) Obliteration of the Esophagus in only a Portion of its Extent, Unaccompanied by Fistula.-This, too, is very uncommon. There are several varieties. Only the upper portion of the esophagus may be normal, the position and extent of the lower obliterated fragment varying with the case. This was true in the cases of Brodie, Durston, Schoeller and others, that of Durston being the first case of congenital malformation of the esophagus recorded by anyone. In other instances both upper and lower fragments of the esophagus are patulous, and a more or less distinct muscular or connective tissue cord or band united them, as in the cases of Marsh, Weill and Pehu, Steel, and Shattock. Whatever the form, the degree of preservation of the obliterated portion is subject to great variation. In some cases the esophagus is described as entirely absent. In others, the cord-like character was distinctly present. In some, as in the case of Phillips, there seemed to be an absolute disappearance of the intervening portion of the esophagus, but microscopical examination showed remains of the esophageal tissues. In all, of course, the lumen of the affected portion was completely obliterated. The term "obliteration" is, indeed, only used here to describe the condition of the lumen, whatever the state of the walls might be.