Probably the most common source of obstruction is cicatricial contraction and malignant disease of the oesophagus or cardia. Epithelioma is the most fre quent variety of malignant growth found in this locality.
As already stated under U:soritAGus (volume v), the objective signs are ob tained by passing the oesophageal bougie and by auscultation. Sufficient empha sis can hardly be made upon the fact that the bougie should be soft and flexible, and should he passed with great care, as deaths have been reported from rupture of aneurisms, perforation of the pleura and of the oesophagus itself, even by skilled surgeons. Considerable familiarity with the sounds of degluti tion in normal and diseased conditions is necessary in order that auscultation may prove of any decided help as a means of diagnosis.
Operation.—In the earlier operations the stomach was simply fixed to the ab dominal wall by means of sutures, and was opened directly; but considerable difficulty arose because of the escape of the gastric contents, and the consequent excoriation of the skin. Various meth ods have been devised of late to obviate this difficulty. Whatever method of operation is adopted, the stomach should not be fixed too near the pylorus, other wise the escape of gastric contents into the intestine is hindered.
The Ssabanajew-Frank operation was devised independently by those two sur geons, the technique of both being simi lar. It is generally preferred for the reason that by it the escape of gastric contents is avoided, as well as the neces sity for wearing a tube. In this method an incision is made along the left costal border, and the stomach is seized and drawn out into a cone until the lesser curvature appears. The base of the ' cone is firmly sutured in the incision by deep fixation stitches, and a second in cision two to three centimetres long is made about two or three centimetres above the costal border; the skin be tween the incisions is undermined, the apex of the cone of stomach is passed under this bridge of skin, drawn out of the second incision, and fastened by sutures. The obliquity of the canal and the pressure of the strip of skin prevent leakage, and a tube is inserted only when food is given. The abdominal incision
is closed immediately, and the apex of the cone of stomach is opened. It is very essential that the sutures hold ab solutely tight, in order to prevent infec tion of the peritoneum and to prevent accumulation of secretion and the for mation of a superficial abscess.
Witzers method may be used in ease the stomach is so firmly contracted that it is impossible to draw out a sufficiently long cone to pass under the bridge of skin. According to this method, after opening the abdomen and walling off the field of operation with gauze, a small drainage-tube is laid in a vertical di rection on the anterior surface of the stomach near the cardia. and the stom ach-wall is sewed together from both sides over it, the sutures passing through the serosa and one of the muscular layers. After one and one-half to two centimetres of the tube have been buried in this way a small opening is made through the stomach-wall at the lower end of the tube and the tube is pushed into the stomach a distance of six to eight centimetres. The stomach is se curely sutured about three centimetres beyond the distal end of the tube, and the parietal incision is then closed about the tube. The external end of the tube is then kept closed by a clamp, except at the time of feeding. The mortality from the operation is about 25 per cent. in malignant cases. There can be no doubt that it would be much reduced if the operation were generally undertaken earlier, before the patients were much weakened by the disease.
Feeding by Gastric Fistula.—The food should, at first, be given in small quan tities and should be of such a nature as to be readily absorbed. Peptonized milk or pounded beef may be administered alternately with starchy and fatty food. Half a pint of food given slowly every four hours is a fair average as to quantity and frequency. After feeding by the fistula for some time it may be possible to somewhat increase the quantity and the interval, as too-frequent feeding irri tates the stomach and the fistula.