rate, when they would have been very much less. In fact the risk attending the performance of Bottini's operation in the early stages of this disease is very little indeed, and one which I am confident I shall incline to advise patients to assume more frequently and at an earlier stage of the malady in the future, than has been my custom in the past. My position as to the choice of methods is practically the same as expressed by Dr. Thorndike.

The performance of the perineal enucleation of the gland is, in cases in which it is appropriate, usually very easy. The essential factors in the readiness with which it is done, are fixation of the gland, and the bringing of it as far down as possible onto the perineum. These may be secured by downward pressure from above the symphysis by the hand of an assistant upon the empty bladder, and by drawing it in the same direction by the tips of two fingers resting upon its upper border in the rectum, or probably better by means of such an instrument as that of Dr. Young, which Dr. Thorndike has just shown. I have not used the latter, and am therefore unable to speak more postively of it.

It is remarkable how easy the perineal operation may be in some cases—in one case I removed the whole gland in four minutes-and how difficult in others.

The choice of methods seems to me to be easily divided. In cases in which the cystoscope has shown it to be appropriate and adequate, the Bottini operation, though my personal experience with it is limited, is, upon the evidence in our possession, that of choice. In other cases the best plan to follow is, I believe, as I have frequently stated before, to open the perineal urethra by the usual incision, explore the condition of the gland with the finger, and then to remove it or its obstructing portions through the perineal incision when that is feasible, and when it is not to proceed at once to the suprapubic operation.

One word with regard to the use of the cystoscope in these cases. It has one undoubted and great value, which is that it is capable of determining beforehand as a rule, whether the case is appropriate for a Bottini operation or not, although it is possible to be misled even in this respect because of the inability to gauge the extent of the parts of the gland, and the degree of obstruction for which they may be responsible, which are not visible from within the bladder.

ARTICLE XXVI.

A BRIEF SUMMARY OF THE SURGERY

OF THE ESOPHAGUS.

BY SAMUEL J. MIXTER, M.D.

OF BOSTON.

READ JUNE 9, 1903.

A BRIEF SUMMARY OF THE SURGERY

OF THE ESOPHAGUS.

THROUGHOUT a considerable part of its course, the œsophagus is more difficult of access than any other part of the alimentary canal, and hence the surgical procedures resorted to in other situations for the relief and cure of malignant and other growths, are not available here. the neck, however, its upper part is easily reached, and through the stomach something may be done to its lower part.

In

The chief causes calling for surgical interference are, 1. Congenital malformations, such as double œsophagus or pouches.

2. Impacted foreign bodies.

3. Malignant disease.

4. Syphilis.

5. Cicatricial stricture.

In the above list is not included spasm of the oesophagus, really a medical rather than a surgical condition, although it is almost always cured by mechanical means, the passage of a full sized probang. It should be mentioned, however, that Mickulicz, in a paper read before the American Surgical Association at its recent meeting in Washington, describes an exaggerated form which he calls "Cardiospasm," causing a very considerable fusiform dilatation of the lower part of the œsophagus, for which he has performed gastrotomy, and through the opening forcibly dilated the cardiac orifice. He also suggests that this might be done by means of a suitable dilator, introduced from above.

1. Congenital malformations are perhaps the most interesting and puzzling conditions met with. They may exist for years, and only suddenly be called to the attention of the patient by an inability to swallow, caused by some irritation produced by a rough, ingested body, or they may be the cause of difficulty for years, and simply give the patient great discomfort and annoyance without endangering his life.

The case of a boy of ten years of age in my service at the Massachusetts General Hospital well illustrates an exaggerated form of this condition. He was brought in in the last stages of starvation, having had difficulty in swallowing for some years, the trouble being thought due to a small metal disc that he had swallowed when about four years old. He died soon after a gastrostomy had been performed under cocoaine anesthesia, and on autopsy it was found that there were two tubes, one reaching from the pharynx nearly to the stomach, the other from the stomach nearly to the pharynx, with only a very small opening between them about three inches from the stomach.

Such a case might, I am sure, have been relieved, if not cured, in the manner to be spoken of later in connection with cicatricial contraction.

Congenital pouches are much more common, I have found, than is generally supposed. I have seen a considerable number of them, having seen three of them in my office in a month. They are usually small at first, and it is often late in life when they cause serious inconvenience. In these cases there is usually a history of a "small throat” since childhood, and finally regurgitation of food. These pouches are found in all parts of the œsophagus, but fortunately are most often situated in the neck or behind the clavicles.

When the pouch becomes dilated it is almost impossible for the patient to swallow enough food of any kind to keep