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GENERAL CONSIDERATIONS.THE most unsatisfactory chapter in the surgery of to-day is that of the treatinent of oesophageal obstruction. The grave discomfort of being unable to swallow, the frequency with which the obstruction is due to carcinoma, the inaccessibility of the oesophagus, and the consequent unsatisfactory results of surgical treatment, make this the most dreaded of all diseases. Fortunately therc is quite a definite proportion of cases where the obstruction is not due to carcinoma and can be completely cured if recognized. Since, however. these cases also are fatal if overlooked, it becomes of extreme importance to recognize and to treat them as early as possible.The most important of these non-malignant obstructions is that curious condition most often described as cardiospasm. It has also been known as idiopathic dilatation of the ccsophagus, achalasia of the cardia, hiatal esophagismus, arid ccsophagectasia. This lesion, which appears to have been first described by Ziemssen and Zenker in 1874, has excited much interest since attention was more i'ully directed to it by Mikulicz in 1581. In the many accounts, often of few or isolated cases, which have since followed tlicre is 110 doubt that a considerable number of different lesions have bcen described.It is thus essential that some clear definition of the condition should be gi\-en ; all the cases would be included under the following : " A condition of dilatation and hypertrophy of the ccsophagus where, on post-mortem examination, no obstruction can be found distal to the dilatation." This will exclude all cases of hysterical spasm in young men and women : these do not show any hypertrophy and dilatation, and yet it is evident from the literature that they are often confused with cardiospasm, which is a discase more cornmonly of middle or advanced age.The hypertrophy and dilatation which is not infrequently scen with carcinoma or other obstruction of the lower end of the esophagus clearly docs not come into this category, but it is not so generally realized that obstruction at the pylorns may also be associated with dilatation of the esophagus. Cases ha\-c. for instance, bcen reported by EhlcrslO where there was eimrmous hypertrophy of the cesophagus with congenital pyloric obstruction, and by Pritchard a~i t l Hillier47 where there was a similar pyloric lesion and also coiistrictiori a't the ilcocxcal d v c . It is vevy possible that in both these cases the msophageal lesion was secoritlary to the pyloric obst,ruction, for Hutchison27 demonstrated that with congenital pyloric stenosis the hypertrophy and dilatation not uncommonly exteiidcd to the cesopha,gus. This is clearly shown by an investigation of post-morteni specimens. The records of the London Hospital postmortems have heen carefully iiir-estigated for mc by Mr. Hamilton Hailey,

OUR experience of the nature and frequency of gastrojejunal ulceration is of necessity short, for the first gastro-enterostomy was performed by Wolfler, at the suggestion of his assistant Nicoladoni, as recently as the year 1881. Possibly because the earlier operations were generally performed for carcinoma of the pylorus, the first case of gastrojejunal ulcer was not reported by Braung until 1899, this being one in which a fatal perforation took place. In the short period of thirty-five years that has ensued since this date our knowledge has been steadily increasing. At first only single cases were reported at long intervals, the first in France being reported by QuCnu in 1902, and the first in this countiy by Mayo Robson in 1904. After this they were found in rapidly increasing numbers, Pater~on,"~ in his epic paper in 1909, first directing widespread attention to the subject, although he found that BrodnitzlS in 1903 was able to collect 15 cases, GossettI7 in 1906 31 cases, and Einer Kay13 a year later added 6 examples. Paterson in his own paper collected 52 certain and I I doubtful cases, 2 of which were from his own practice.Of later years so many examples have been reported that it is no longer practical to collect individual cases but only to consider general statistics. So many indeed have been reported that a keen controversy has arisen as to the actual frequency of the condition. On the one hand, LewisohnZs in 1925 published a series of 68 cases of gastro-enterostomy where 23, or 34 per cent, developed gastrojejunal ulceration after having been watched for a period of not less than five years. Hurst and StewartZ4 believe that it is a dangerous and frequent sequel of gastro-enterostomy. They cast doubt upon the accuracy of many of the figures reported by various surgeons, and claim that the number of anastomotic ulcers slowly but steadily multiplies as the cases of gastro-enterostomy are watched over increasing periods. They give pathological statistics showing a 7.3 per cent incidence in 42 cases examined at Leeds, ten days to two months after operation, and a 52 per cent incidence in 42 cases examined nine months to nineteen years after operation.These, however, must be considered as very selected cases, for the examinations were carried out on patients who had died, and therefore took no cognisance of those who had recovered and might have formed a high percentage of the total operated upon. These extreme views as to the frequency of this dangerous complication are held by a considerable number of surgeons of wide experience. This is especially so on the European continent, where many have abandoned the routine use of gastro-enterostomy and have replaced it by some form of partial gastrectomy. Among those who hold these views may be quoted Finsterer,14 von Habere1-,4~ Hohlbaum,22 von Ei~elsberg:~ and in this country Pannett.38On the other hand, many surgeons, and especially those in this country and the United States, have found that recurring ulceration of this type, although VOL. XXI1.-NO. 85 SURGEO...

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