Since reporting, two years ago,1 a series of ten cases of cardiospasm with sacculation of the esophagus, we have had the opportunity of studying four additional cases and of observing the after-results in eight of the fourteen cases treated. The clinical and x-ray observations of the results in these cases have ranged over periods of from one to four years after the cessation of treatment. It is to these observations especially that we wish to call attention here. When our original paper on

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... subject was presented, insufficient time had elapsed following the treatment of the cases tojustify any absolute statements as to the ultimate results, but based on the pathologic findings we ventured the statement that while a fairly complete symptomatic cure was possible, an anatomic cure seemed most, improbable in those cases' in which sacculation existed to any marked degree. We believed that even after c ompl et e stretching and paralyzing of the cardia, it was questionable whether any of these patients in whom saccùlatiÔri existed would be found entirely free from symptoms; that they would always have to exert more or less care in the amount and character of food taken, and the manner of ingesting if; furthermore, that tlie more marked Ihe distcntion of the esophagus the less complete would he the cure and the more pronounced the after-symptoms. Since that time we have been able lo ob.-erve three of our patients for période of four years or inore, and five for période ranging from one to three years, and have been able fo verify in them the belief expressed at that time. We may accept as a fair example of these, patients those who received treatment, four years ago and who to all intents and purposes are well, are experiencing little or no difficulty in swallowing, aiid yet are made 'to realize that they are not normal individuals. Without exception they stale Ilia!, their condition is so much befiel-than prior to the treatment that they pay little or no attention to the existing minor ailments, yet they must exert care in eating and must not eat rapidly or swallow their food in large masses, some finding it best to avoid very cold Huid and solid articles of diet. Some of these patients have observed that the foods which are light enough to float on water cause more difficulty than those which are heavier, a fact which is to be rqpd"ily accounted for through our observation that fluid secretions collect in the sac as the result of the negative pressure which exists there, and that very light articles of food are kept afloat within the sac. in spite of the brilliant results obtained through the forcible divulsion of the cardia through hydrostatic pressure, we have been unable to find a single case of advanced cardio-pasin with sacculation in which fliese mild symptoms did not exist, and we believe fhaf others who may later report ihe after-results.in their cases will have met with practically the same experience. PERSISTENCE OF THE SAC APTIClt CUKIC OF ('AliniOSI'ASM The reason for the persistence of the symptoms has been clearly shown by us to be due to the persistence Of (he sacculation. which seems to undergo but little shrinkage after the spasm has been overcome, and fo the consequent loss of the norma] peristalsis of the lower third or two-thirds of the esophagus. In our al tempts to demónstrate the persistence of the sac in all of the cases that we were able fo keep under observation, we resorted first to the introduction into the esophagus of a stomach-tube with an intragastrie, thin rubber bag attached, somewhat similar to thai which has been described by others. Into this the wafer was gradually injected by means of a large glass-metal syringe until the patient experienced great discomfort as a result of the"distention. It was found invariably that almost as much fluid could be injected into the sac four years following the "cure" as could be introduced just prior to the commencement of the treatment. In other words, we could introduce into the sacculation that persisted as long as four years after the treatment, from ¿00 to 400 c.c. of fluid. This led to the observation of these cases before the fliioroscopic screen, using bismuth suspension in soured milk. . Figuré 1 shows the radiograph of Patient 4 of our original series taken with over 300 c.c. of bismuth suspension injected into the bag. This patient subjectively and objectively seems perfectly well, and carries on his work as bank clerk with practically no discomfort. His weight is now 168 pounds as compared with 138 pounds prior to his treatment four years ago. He experiences no obstruction whatever, but has learned by expérience that he is most comfortable if he eats slowly and avoids coarse foods and cold drinks. He finds, too, finit a small quantity of fluid secretion collects in the sac, and he is made aware of ifs presence through its regurgitating into bis mouth and nose during the night. To avoid this he empties the sac at night by bending forward with his head low and forces this fluid out through an expulsive.movement. The expelled fluid never contains food particles, but is composed of a frothy, rnuçold solution, evidently largely saliva. figure 2 is the radiograph of Patient 5 of our original series. This patient though well, manifests similar minor symptoms, but the sac easily contains 35Ó e.e. of bismuth suspension. These are fair examples of Ihe a/-ray observai ions made in all the cases we have been able to follow. The persistence of the sac was demonstrable in every case, the only variation being in the size of the sac. In order to determine to .what extent the normal esophagus can be stretched, a series of normal persons were observed in a similar manner, and in nö case were we able lo inject into the intragastrie bag within the esophagus more than 40 to (iO c.c. of fluid without causing the patient the most intense discomfort. Figure 3 represents the radiograph of the normal esophagus si retched to (lie utmost. The technic of this work Í3 perfectly simple, the tube with intragastrie hag being readily introduced either with or without a mandrin. The fluid is then injected by means of a large glass-metal syringe. If these patients be placed before the screen and be given bismuth-pap mixture, it is seen to drop rapidly to the cardia, where it halts for a second and then enters tiie stomach. In other words there is no food relent ion in the sac as is the cuse prior to treatment. In spite of flic rcicnl excellent literature on the subject of cardiospasm, it is evident that the condition