ion is not uncommon.

_Symptoms_.--Malignant disease of the esophagus is rarely seen early,
because of the absence, or mildness, of the symptoms. Dysphagia, the
one common symptom of all esophageal disease, is often ignored by the
patient until it becomes so marked as to prevent the taking of solid
food; therefore, the onset may have the similitude of abruptness. Any
well masticated solid food can be swallowed through a lumen 5
millimeters in diameter. The inability to maintain the nutrition is
evidenced by loss of weight and the rapid development of cachexia.
When the stenosis becomes so severe that the fluid intake is limited,
rapid decline occurs from water starvation. Pain is usually a late
symptom of the disease. It may be of an aching character and referred
to the vertebral region or to the neck; or it may only accompany the
act of swallowing. Blood-streaked, regurgitated material, and the
presence of odor, are late manifestations of ulceration and secondary
infection. In some cases, constant oozing of blood from the ulcerated
area adds greatly to the cachexia. If the recurrent laryngeal nerves
are involved, unilateral or bilateral paralysis of the larynx may
complicate the symptoms by cough, dyspnea, aphonia, and possibly
septic pneumonia.

_Diagnosis_.--It has been estimated that 70 per cent of stenoses of
the esophagus in adults are malignant in nature. This should stimulate
the early and careful investigation of every case of dysphagia. When
all cases of persistent dysphagia, however slight, are endoscopically
studied, precancerous lesions may be discovered and treated, and the
limited malignancy of the early stages may be afforded surgical
treatment while yet there is hope of complete removal. Luetic and
tuberculous ulceration of the esophagus are to be eliminated by
suitable tests, supplemented in rare instances by biopsy. Aneurysm of
the aorta must in all cases of dysphagia be excluded, for the dilated
aorta may be the sole cause of the condition, and its presence
contraindicates esophagoscopy because of the liability of rupture.
Foreign body is to be excluded by history and roentgenographic study.
Spasmodic stenosis of the esophagus may or may not have a malignant
origin. Esophagoscopy and removal of a specimen for biopsy renders the
diagnosis certain. It is to be especially remembered, however, that it
is very unwise to bite through normal mucosa for the purpose of taking
a specimen from a periesophagea