_Gastrostomy_ is always indicated as the disease progresses, and it should be done before nutrition is greatly impaired. Surgeons often hesitate thus to "operate on an inoperable case;" but it must be remembered that no one should be allowed to die of hunger and thirst. The operation should be done before inanition has made serious inroads. As in the case of tracheotomy, we always preach doing it early, and always do it late. If postponed too long, water starvation may proceed so far that the patient will not recover, because the water-starved tissues will not take up water put in the stomach. _Radiotherapy_.--Radium and the therapeutic roentgenray are today our only effective means of retarding the progress of esophageal malignant neoplasms. No permanent cures have been reported, but marked temporary improvement in the swallowing function and prolongation of life have been repeatedly observed. The combination of radium treatment applied within the esophageal lumen and the therapeutic roentgenray through the chest wall, has retarded the progress of some cases. The dosage of radium or the therapeutic ray must be determined by the radiologist for the particular individual case; its method of application should be decided by consultation of the radiologist and the endoscopist. Two fundamental points are to be considered, however. The radium capsule, if applied within the esophagus, should be so screened that the soft, irritating, beta rays, and the secondary rays, are both filtered out to prevent sloughing of the esophageal mucosa. The dose should be large enough to have a lethal effect upon the cancer cells at the periphery of the growth as well as in the center. If the dose be insufficient, development of the cells at the outside of the growth is stimulated rather than inhibited. It is essential that the radium capsule be accurately placed in the center of the malignant strictured area and this can be done only by visual control through the esophagoscope (Fig. 95) Drs. Henry K. Pancoast, George E. Pfahler and William S. Newcomet have obtained very satisfactory palliative effects from the use of radium in esophageal cancer. [221] CHAPTER XXVIII--DIRECT LARYNGOSCOPY IN DISEASES OF THE LARYNX