nor obviate the necessity for its ultimate
performance. The Charters-Symonds or Guisez esophageal intubation tube
is readily inserted after drawing the larynx forward with the
laryngoscope. The tube must be changed every week or two for cleaning,
and duplicate tubes must be ready for immediate reinsertion.
Eventually, a smaller, and then a still smaller tube are needed, until
finally none can be introduced; though in some cases the tube can be
kept in the soft mass of fungations until the patient has died of
hemorrhage, exhaustion, complications or intercurrent disease.

_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 cen