erbations being due to superadded
spasm of the muscular coat and congestion of all the coats. As the
gullet dilates above the stricture, there is an increasing
accumulation of what has been swallowed, and this the patient
regurgitates at intervals; this is usually described as "vomiting,"
but the material ejected shows no signs of gastric digestion. There is
pain referred to the epigastrium or between the shoulder-blades, the
patient suffers from hunger and thirst, and may present an extreme
degree of emaciation.

The _diagnosis_ is suggested by the history, and is confirmed by the
oesophagoscope or by the X-rays after an opaque meal. The use of
bougies has taken a secondary place since the introduction of these
methods of examination, but, when other means are not available, the
passage of bougies having a whalebone shaft and a series of metal
heads shaped like an olive, may give useful information regarding the
site, number, and size of the strictures that require to be dealt
with.

_Treatment._--If the patient is in a critical state from starvation,
gastrostomy must be performed to enable him to be fed; otherwise he is
prepared for treatment of the stricture by rest in bed, sedatives, and
suitable liquid or some solid foods to improve his general condition
and eliminate the muscular spasm and congestion already referred to.
If the passage of bougies with the object of dilating the stricture is
difficult or impossible, it may be made easier or possible by getting
a silk thread through the stricture. The patient swallows several
yards of a reliable silk thread a day or two before the proposed
dilatation is carried out; the thread is expected to pass through the
stricture of the stomach, and to enter for some distance into the
small intestine; the metal head of the bougie, which is canalised in
its long axis, is "threaded" on the silk, and the latter acting as a
guide, the bougie is passed safely and confidently through the
stricture. Larger olive-shaped heads are passed at intervals until the
normal calibre of the gullet is exceeded, after which it is usually
easy to pass an ordinary full-sized instrument at intervals of a month
or so.

In the event of failure, recourse must be had to gastrostomy, and
through the stomach it may be possible to dilate the stricture by the
"retrograde" route. In aggravated cases, the gastrostomy opening must
be retained in order to prevent death from starvation.

#Malignant Strictur