The intent in this exploration is to determine the distance from the upper incisor teeth of the obstruction, as well as its caliber. When the instrument is withdrawn the surgeon marks the location of the teeth by grasping it at this point with the thumb, and the distance is measured off afterward so that it may be read in inches if desired. The caliber is determined by the success or non-success met with in passing an instrument of given diameter. The size with which the attempt should be made may be determined largely by the history and statement of the patient. With a patient who cannot swallow no ordinary bougie should be expected to pass, while a small solid instrument might produce a perforation. Flexible bougies are also provided by the instrument makers, made as are the silk catheters, some of them being loaded with small shot in order to give them a certain degree of weight. A small, soft, flexible instrument may be thus passed when the ordinary probang would fail. Here, as in the urethra, an olivary bougie may pass, after which the same sort of resistance will be offered upon its withdrawal. In this case the stricture is passed twice, going and coming. A slight degree of constriction is met opposite the cricoid cartilage at the entrance to the esophagus. This should not be mistaken for a pathological condition. Information may be afforded by material brought up by the instrument, such as shreds of tissue, blood, etc. A small bougie coated with sponge may be used for the purpose of retaining and bringing back such material as it may engage.

It will be of assistance to let the patients dissolve in the mouth a tablet containing a little cocaine and swallow it, or to spray or gargle the pharynx with a weak solution. It prevents the gagging and discomfort of an operation which otherwise is almost painless.

ESOPHAGEAL HEMORRHAGE.

Esophageal hemorrhage occurs especially in connection with cirrhosis of the liver. Stockton and others have called attention to a peculiar varicose condition of the esophageal veins in certain of these cases, and the possibility of repeated hemorrhages which may terminate fatally. The same is true of obstructive jaundice with Riedel liver.

CANCER OF THE ESOPHAGUS.

Cancer of the esophagus may be either primary or secondary, and may be either sarcoma or carcinoma. Its first expression will be ulcerative or stenotic, according as it originates on the inner surface or not. Sooner or later it will produce stricture, with the ordinary evidences thereof, and is to be detected in the same way. Cancer is usually of the carcinomatous type or squamous epithelioma. The disease is more common near the lower than the upper end of the canal. The disease spreads and involves the adjoining lymphatics, as well as various other structures. In addition to the ordinary evidences of stricture it is accompanied by a certain degree of pain, which is likely to be referred to the interscapular region or the back of the neck. The emaciation which always accompanies it is not merely an expression of the disease itself, but of the starvation which stricture in time produces. Frequent expulsion of bloody mucus or shreds is extremely indicative.

Esophageal cancer admits only of esophagectomy, as a very unusual method of relief, or gastrostomy, which is a palliative measure intended to prevent death from starvation, but not affording exemption from the advance of the disease.

OPERATIONS UPON THE ESOPHAGUS.

Operations upon the esophageal canal include: