e development of this condition. In the
initial stage, the first attack occurs suddenly and unexpectedly; a
choking sensation is felt at some point in the gullet, usually at its
lower end. Attacks of choking with difficulty in swallowing occur
chiefly at meals, but they have also been known to occur apart from
the taking of food. In this stage the peristalsis of the gullet is
sufficient to force the food through the cardia.

In the second stage, the peristalsis of the gullet above being no
longer able to overcome the contraction, there is regurgitation of
food, which at first is returned to the mouth immediately after being
swallowed, but, as the gullet becomes dilated, is retained for longer
periods.

In the third stage, the gullet becomes more and more dilated, and the
food collects in it and is regurgitated at irregular intervals. The
patient complains of a sensation of weight and discomfort in the lower
part of the chest, and sometimes of regurgitation of food into the
nasal passages during sleep.

Cardiospasm should be suspected as the cause of difficulty in
swallowing if a rubber tube cannot be passed into the stomach while a
solid one can. When it is impossible to pass a solid instrument in the
ordinary way it can always be passed on a silk thread as a guide. The
patient is directed to swallow 6 yards of silk thread, half in the
afternoon and the remainder on the following morning. The first
portion forms a snarl in the gullet or stomach which passes out into
the intestine during the night; the proximal end is fixed to the cheek
by a strip of plaster. The olive heads of the bougies are drilled for
threading from the tip to one side of the base.

The _treatment_ consists in dilating the contracted segments by a
bougie. The results are immediate and are most striking, the patients
being almost invariably able to take any kind of food at the following
meal, and the gain in weight and strength is rapid. In a small
proportion of cases, dilatation fails to give relief, and recourse has
been had to anastomosing the lower end of the dilated and pouched
oesophagus with the stomach.

#Paralysis of the Gullet.#--As the passage of the food along the
gullet is entirely dependent upon muscular peristalsis, when the
muscular coat is paralysed, as it may be after diphtheria, for
example, the patient is unable to swallow and the food materials are
regurgitated, with consequent loss of flesh and strength. The
difficulty may