l growth. Fungations and polypoid
protuberances afford safe opportunities for the removal of specimens
of tissue.

_The esophagoscopic appearances of malignant disease_, varying with
the stage and site of origin of the growth, may present as follows:--
1. Submucosal infiltration covered by perfectly normal membrane,
usually associated with more or less bulging of the esophageal wall,
and very often with hardness and infiltration.
2. Leucoplakia.
3. Ulceration projecting but little above the surface at the edges.
4. Rounded nodular masses grouped in mulberry-like form, either dark
or light red in color.
5. Polypoid masses.
6. Cauliflower fungations.

In considering the esophagoscopic appearances of cancer, it is
necessary to remember that after ulceration has set in, the cancerous
process may have engrafted upon it, and upon its neighborhood, the
results of inflammation due to the mixed infections. Cancer invading
the wall from without may for a long time be covered with perfectly
normal mucous membrane. The significant signs at this early stage are:
1. Absence of one or more of the normal radial creases between the
folds.
2. Asymmetry of the inspiratory enlargement of lumen.
3. Sensation of hardness of the wall on palpation with the tube.
4. The involved wall will not readily be made to wrinkle when pushed
upon with the tube mouth.

In all the later forms of lesions the two characteristics are (a) the
readiness with which oozing of blood occurs; and (b) the sense of
rigidity, or fixation, of the involved area as palpated with the
esophagoscope, in contrast to the normally supple esophageal wall.
Esophageal dilatation above a malignant lesion is rarely great,
because the stenosis is seldom severely obstructive until late in the
course of the disease.

_Treatment_.--The present 100 per cent mortality in cancer of the
esophagus will be lowered and a certain percentage of surgical cures
will be obtained when patients with esophageal symptoms are given the
benefit of early esophagoscopic study. The relief or circumvention of
the dysphagia requires early measures to prevent food and water
starvation. _Bouginage_ of a malignant esophagus to increase
temporarily the size of the stenosed lumen is of questionable
advisability, and is attended with the great risk of perforating the
weakened esophageal wall.

_Esophageal intubation_ may serve for a time to delay gastrostomy but
it cannot supplant it,