ure accounts for the large amount that may be
regurgitated and for the patient describing it as vomiting. Along with
food materials there is abundant saliva, and, if the cancer has
ulcerated, of pus and blood. Contrary to what might be expected, there
is little or no complaint of hunger, in spite of the progressive
starvation and emaciation which inevitably supervene.

Death takes place within a year or so of the onset of symptoms,
usually from starvation, but the fatal issue may be precipitated by
ulceration and perforation of the gullet into a large blood vessel or
into the left pleural sac; in the latter event, there follows a basal
_empyema_ which may contain gas and food materials.

_Diagnosis._--In the majority of cases the history is so
characteristic that there is little doubt regarding the diagnosis; the
most reliable corroboration, with least risk and distress to the
patient, is obtained by radiographic examination after an opaque meal;
the appearance of the dilated gullet is that of an elongated sausage,
parallel with the vertebral column, and terminating abruptly at the
site of stricture (Fig. 285). A filiform, tortuous shadow of the
bismuth may be continued downwards and show up the lumen of the
stricture. The use of the oesophagoscope and of bougies is to be
deprecated as not free from risk.

_Treatment._--The lower end of the gullet is one of the most
inaccessible portions of the body, and although it has been removed by
operation the prospects of success are so small that it is not at
present regarded as justifiable.

Among _palliative measures_, may be mentioned _intubation_ of the
stricture with a view to increasing the amount of food that can be
swallowed; a funnel-shaped tube like that of Symonds or of Hill is
introduced into the lumen of the stricture by means of a bougie or
with the help of the oesophagoscope. The tube is anchored
to a denture, or by means of a silk thread to the cheek by
sticking-plaster. Our experience of intubation is that it merely
serves to tide the patient over a critical period of starvation, so
that he may regain some strength for any other procedure that may be
indicated.

The value of making a fistula in the stomach--_gastrostomy_--in order
to feed the patient, is a question about which widely different
opinions are held both by patients and by surgeons. Many patients
allege that they would prefer to die rather than prolong a precarious
existence by being fed throu