This group represents the largest number of cases in which artificial nutrition is employed. It may be advantageously split into two subdivisions: (a) Organic stenosis of a high degree (including malignant stricture even of a minor degree); (6) medium-sized benign organic stenoses and spastic strictures.

(a) Difficulty in the passage of food caused by marked stenoses of the esophagus, cardia, pylorus, duodenum, or small intestine demands rectal alimentation. The same obtains if the difficult passage along the above localities is caused by pronounced obstacles compressing the digestive tube from without or by malignant stenoses of any degree.

Similar stenoses along the colon require subcutaneous alimentation.

In all these cases artificial nutrition is but a temporary adjuvant and the stricture requires separate treatment, whenever possible. Thus in benign stenoses, when feasible, stretching should be performed; in malignant strictures, or in benign stenoses either not yielding or not accessible to stretching, likewise in tumors pressing from without an operation for the radical removal of the trouble should be undertaken.

In case the latter is impossible one must be satisfied with the surgical reëstablishment of a food passage, making nutrition possible. Thus in obstacles along the esophagus and cardia a gastric fistula, in those of the pylorus and duodenum a gastro-enterostomy, in those of the small intestine and colon - according to the location of the obstacle - an entero-enterostomy or enterocolostomy, or colocolostomy, or ultimately an anus præter-naturalis should be established.

In case an operation for some reason or other is unfeasible, artificial nutrition will naturally have to be carried on as long as life persists.

In these instances subcutaneous and rectal alimentation can be to advantage conjointly employed, or, if necessary, used alternately.

(6) Medium-sized Benign Organic Stenoses and Spastic Strictures of the Digestive Tract. In obstacles to the food passage due either to benign organic stenoses of a moderate degree or to spastic conditions - the selection of the special mode of nutrition will depend upon the location of the difficulty.

In spastic states of the esophagus and cardia - provided they are of such a high degree that the usual mode of nutrition be entirely impossible - and in moderate-sized stenoses of the same regions, gastral nutrition by means of a somewhat thin stomach-tube will be employed. In moderate benign strictures of the pylorus, or duodenum or in spasm of the pylorus, duodenal alimentation will be resorted to. If the latter for some reason or other fails, rectal alimentation will be used instead.

Stenoses of the small intestine - interfering with the prochoresis to such a degree that complications endangering life begin to appear - require rectal alimentation. If the affected area is situated in the colon, subcutaneous alimentation should be instituted.

In the whole subdivison (b) the separate treatment of the principal lesion should, likewise, never be lost sight of. The artificial nutrition is but a temporary adjuvant, and should be employed until the obstacles - if this be possible - have been removed or the natural mode of nutrition reestablished.