THE following observations are based on a series of IOO personal cases of carcinoma of the esophagus which have been examined and treated during the past seven years. Post-cricoid and gastro-esophageal neoplasms have not been included, and the series is confined entirely to growths affecting the esophagus proper.The analysis of the case histories was instigated by the considerable literature which has accumulated within recent years on the actual, experimental, and theoretical methods of surgical removal of malignant tumours of the gullet, and the feature that became manifest from this analysis was the large number of cases which showed evidence of spread of the growth at or about the time of the first examination.Apart from the inaccessibility of the oesophagus, its intimate relationship to other vital structures, and its poor response to surgical trauma, the possibility of radical surgical treatment of esophageal neoplasms would appear to depend upon two debatable but related factors-namely, early diagnosis and virulence of the growth.
DIAGNOSISDiagnosis invariably is late, as it is dependent upon the onset of symptoms ; and it is well recognized that unfortunately the early symptomatology of cancer of the oesophagus is vague, and its manifestations are apt to be regarded as trivial and unimportant. There is of necessity a latent period between the earliest carcinomatous formation and the patient's awareness of something amiss, and the duration of this period at present cannot be estimated, although serological methods may in the near future yield information on this point.The most common complaint that causes patients to seek advice is difficulty in swallowing. Of the present series of IOO cases, 91 came complaining of dysphagia, 4 of pain, I of hoarseness, 2 of impaction of foreign body, I of glands in the neck, and I of hiccup. Watson' states that of a series of 506 patients suffering from carcinoma of the esophagus who were admitted to the Memorial Hospital, New York, in 64 per cent dysphagia was the first symptom ; and Chevalier Jackson? records that of 671 such cases, in 649 difficulty in swallowing first drew attention to the disease. The dysphagia is caused by an actual narrowing of the esophageal lumen by tumour formation with or without a superadded muscular spasm, and so by the time this symptom appears the growth must have extended into the lumen sufficiently to interfere with the passage of food down the gullet, and it is reasonable to assume that it has spread also in other directions. As a rule the onset and
