The prescription of a suitable diet in carcinoma of the stomach presents great difficulties and no one dietary will suit all cases. But there are certain general principles which should be observed. In the first place it must be confessed that we are dealing with an incurable disease, and consequently great freedom of choice should be allowed to the patient. The fancies and cravings of the patient should be gratified as far as possible. It is curious how, even in an advanced stage, a patient may ask for and digest some article of food which one would have thought was beyond his power. In the second place when the clinical picture is one of pyloric obstruction (cp. obstructive dilatation), we can only aim at ensuring the greatest absorption of nutritive material from the stomach itself, and this is always of small value. Gastroenterostomy or other surgical measure should be undertaken at once. If this is refused or from any cause is impossible, lavage is the only alternative. Though nutritive material is wasted by lavage, it is better to introduce new absorbable food into a clean stomach than to continually add fresh portions to a fermenting mass. The articles which may be found useful in such cases are : thin toast or rusks, peptonized milk, plasmon and plasmon preparations, somatose, Fairchild's panopepton, Benger's peptonized beef-jelly, Brand's nutrient powder, Carnrick's peptonoids Leube-Rosenthal meat solution, Valentine's meat-juice, kefir or koumiss, Benger's food, Grape-nuts, the "Allenbury" food, maltine, honey, Biedert's cream mixture (4 oz. of cream with 90 grains of lactose) and raw meat-juice. Alcohol should be given if possible, preferably as brandy. A diet can be constructed from these materials which shall allow of some choice on the part of the patient.

In the third place when the pylorus is patent, the conditions are the same as in chronic gastritis, but they are of greater severity and do not contain the same prospect of improvement. In fact some gastritis is commonly associated with carcinoma. Free acid is absent and there is often some motor insufficiency. Though attention may be paid to providing such predigested food-stuffs (mentioned above) as may be most readily absorbed from the stomach, we must realize that gastric digestion is a thing of the past. The administration of hydrochloric acid, pepsin, and gastric stimulants is singularly inefficient. Consequently we must rely chiefly on intestinal digestion and our object is not so much to increase gastric absorption as to ensure by a suitable diet a quick emptying of the stomach. Here also help may often be obtained from gastroenterostomy. Reference may be made to the diets suggested under the headings of dilatation and chronic gastritis. Alcohol should be added. A mixed protein and carbohydrate diet should be maintained as long as possible.

The following diet giving 1,260 calories may be quoted as recommended by Wegele in cases of carcinoma without pyloric obstruction : -

Morning .... Malto-leguminose cocoa, 150 grms.

Forenoon. . . . Kefir, 200 grms.

Noon .... Malto-leguminose soup, 150 grms.

Scraped beef-steak, 100 grms. Afternoon . . . Malto-leguminose cocoa, 150 grms. Evening .... Scraped ham, 100 grms.

Tapioca, 150 grms.

10 p.m..... Kefir, 200 grms.

During the day . Toast, 50 grms.

With the cocoa honey, 30 grms.

With the kefir cognac, 20 grms.

As an outline of a diet supplying 2,300 calories, which is possible in an early stage of carcinoma, Biedert recommends : -

6 a.m.....Milk, 250 c.c.; toast, 30 grms.

8 a.m.....2 eggs; toast, 20 grms.

10 a.m.....Cream, 125 c.c.; 2 zwieback.

Noon . . . . . Meat, 140 grms.; toast, 40 grms.; soda-cake, cinnamon-cake, coffee-cake, biscuit, 25 grms. 4 p.m.....Milk-cocoa, 250 c.c.; 3 zwieback with fruit-jelly.

7 p.m. . . . . Rice-mush, 2 zwieback.

10 p.m.....Milk, 250 c.c.; 2 zwieback.

Finally, in some cases of highly cellular carcinoma with rapid ulceration, from the dietetic point of view the characters are those of gastric ulcer, and haemorrhage may be a prominent feature. As in gastric ulcer we are compelled to employ rest to the stomach and rectal feeding.

In cases of carcinoma of the cardiac end of the stomach or of the oesophagus, if operation is refused or impossible; it is necessary to depend entirely on rectal feeding. Subcutaneous feeding may be combined with this, but its value is very small. Sterilized olive oil (or sesame oil) 30-40 c.c. may be injected subcutaneously or into muscle with a 10 c.c. syringe at various spots once a day.