ion as to its extent,
especially with regard to involvement of the larynx.

_Oesophagectomy_, or resection of the cancerous segment of the gullet,
in suitable cases, even if it does not yield a permanent cure, not
only prolongs life but relieves the patient of her most distressing
symptoms. It is rarely possible to secure an end-to-end anastomosis,
but the feeding by means of a tube introduced into the open end of the
gullet is more satisfactory and the laryngeal symptoms are more
efficiently relieved, than by either of the purely palliative
operations. In the majority of cases, however, only the palliative
measures of _oesophagostomy_ or _gastrostomy_ can be adopted.
Oesophagostomy presents the advantage, that by exposing the cervical
portion of the gullet, the operator is enabled to investigate the
extent of the disease and to revise his opinion on the feasability of
its removal if necessary. In advanced cases, when the disease has
spread widely in the neck and involved, it may be, the thyreoid and
the larynx, it may only be possible to relieve the urgent distress of
the patient by gastrostomy. _Tracheotomy_ may also become necessary
because of the spread of the cancer to the interior of the larynx.

#Cancer of the Lower End of the Gullet.#--The remarkable preference of
this location of oesophageal cancer for the male sex has already been
referred to; it affects the same type of male patients as are subject
to squamous epithelioma in other parts of the body. So far as we have
observed, its association with chronic irritation of the mucous
membrane in which it takes origin, or with any pre-cancerous
condition, has not been demonstrated.

The _clinical features_ resemble those of cicatricial stricture; the
difficulty of swallowing is usually of gradual onset, it concerns
solids in the first instance, then semi-solids like porridge or bread
and milk, and finally fluids. As in other forms of oesophageal
obstruction, the difficulty of swallowing varies quite remarkably from
time to time, presumably from variations in the degree of congestion
of the mucous membrane and of spasm of the muscular coat, but also
from mere nervousness, the patient having greater difficulty when in a
hurry, as in a railway refreshment room, or embarrassed by the
presence of strangers.

As the lumen of the gullet becomes narrower, the food materials
accumulate above the obstruction, and the consequent dilatation of the
gullet above the strict