In cancer of the stomach, prolongation of the patient's life and personal comfort depends more upon the dietetic than any other form of treatment. Nourishment should be given in a concentrated and predigested form, and where pyloric obstruction exists, in a condition which admits of direct absorption from the stomach wall. It is necessary to avoid food that is liable to remain long in the stomach and excite nausea and vomiting, which may in turn develop severe pain or fatal haemorshage, and to prohibit anything which by undue fermentation might cause distention and stretch an already thinned gastric wall to the point of perforation.

Osier mentions that in organic disease of the stomach pain usually begins soon after eating and continues until its digestion is over or vomiting occurs, but sometimes the pain of carcinoma may be relieved by ingestion of food.

Aside from the local difficulties of digestion in gastric carcinoma in the immediate vicinity of the stomach wall, the gastric juice is either deficient in amount or altered in composition, and the hydrochloric acid may be totally absent. Hence stomach digestion cannot be counted upon at all, and it is important to digest all food by artificial processes.

In nearly all cases nutrient enemata will sooner or later be required either as an adjunct to stomach feeding or to replace it entirely. Owing to the importance of this subject, it will be separately discussed. (See p. 414).

If much pain follows the ingestion of any food, or if there is a tendency to haemorrhage, stomach feeding should be entirely replaced in this manner. In no other disease can life be supported for so long a time and so comfortably upon exclusive rectal alimentation. After a few days of rest secured by substitution of enemata the stomach may become less intolerant and food can again be swallowed.

The exact nature and site of a carcinomatous lesion cannot always be determined, especially in its early stages, and each case requires special study. Patients soon find by experience what gives them most distress and learn to avoid it. In general, saccharine and farinaceous foods should be proscribed because they are normally not digested in the stomach, and in carcinoma they linger and, aided by the catarrh which is usually also present, undergo abnormal fermentation with production of gas, nausea, and vomiting. It is usually the case that predigested albuminous food is better assimilated.

Digestion in such cases should be watched from day to day, and when patients can tolerate a little simple farinaceous food without its producing eructations or increasing the gastric pain and discomfort, it may be added.

If the new growth causes stricture of the cardiac end of the stomach, only fluid food can be taken, and the act of swallowing should be studied to make sure that dilatation of the oesophagus is not developing. If, on the other hand, it constricts the pyloric end, food cannot pass on into the intestine and gastric dilatation may result. It then becomes highly important to put into the stomach only that which can be absorbed from its wall. Such substances, besides water, include peptones, albumoses, and alcoholic stimulants (champagne, whisky, and brandy), all which may be taken up by the circulation of the gastric wall in considerable quantity. Albumoses would theoretically constitute a most useful food, being entirely pre-digested and ready for immediate absorption; but practically patients soon weary of such a diet, and food of that nature will not long support life when given alone. In complete pyloric obstruction albumoses may be prescribed, and in advanced gastric dilatation they are needed.

They may be sometimes alternated with other foods with advantage.

If much dilatation exists without nausea or vomiting, fluid foods will sometimes lie unabsorbed in the stomach for one or two days, and then several quarts of fluid will be unexpectedly ejected. It is consequently advisable to examine and percuss the stomach from time to time, to make sure that nourishment swallowed is not accumulating there.

. Exceptionally, if the disease has not progressed too far, patients do best on a dry diet, and finally chopped steak, tender rare beef, chicken, scraped beef, soft-cooked or raw eggs may be given, and digestion is facilitated by the use of pepsin and hydrochloric acid or papoid. If there is no pyloric obstruction, and if it does not produce nausea or pain, simple forms of starchy food may be added, such as dry bread, toast, or crackers.

In advanced cases the diet must be fluid and concentrated; food should be given only in very small quantities - not over one or two teaspoonfuls at one time, frequently repeated. Meat extracts, albumoses, buttermilk, pancreatinised milk, koumiss, and prepared egg albumin may be retained. The yolks of eggs are not absorbed from the stomach on account of the fat which they contain. When possible, the diet should consist almost wholly of predi-gested milk.

Oppolzer advises the use of sour milk in cases of carcinoma of the stomach in which there is more or less constant tendency to vomiting, and in which ordinary milk coagulates in the stomach in large curds. Sour milk is much less apt to form large tough coagulse. It is usually better, however, in such cases to pancreatinise the milk or give it in the form of koumiss.

For the control of vomiting there may be also tried iced carbonated water, champagne, bismuth, and counter-irritation. For indigestion, eructations, or gaseous distention, antacids and antifer-mentatives are indicated, or pepsin with dilute hydrochloric acid.

Ewald says: "A diet of starches and vegetables is more easily borne than that of meat, since the diminution in the secretion of hydrochloric acid causes the digestion of albumin and meat to be incomplete. In most cases milk is also poorly borne, on account of the absence of rennet." When milk is tolerated, however, he advises the addition of a few drops of Cognac to each tablespoonful, or the use of kefir or peptonised milk.

Many special systems of diet have been exploited for the treatment of cancer of the stomach, some of which have proved of occasional value, and have at least the merit of being based upon scientific reasoning, whereas others are pure quackery. It is almost needless to say that no such thing as a dietetic "cure " for cancer exists. The most that can be expected of any dietetic system for this fatal disease is that it may make the patient somewhat more comfortable, and prolong his life perhaps for a few weeks or months by maintaining better general nutrition.

Lavage is sometimes employed as an adjunct to dietetic treatment where much catarrh of the stomach or dilatation is present. It may relieve some of the symptoms in the early stages of the disease, but it should be performed with great care, for it is uncertain to what extent the stomach wall may be eroded. I have known of at least one case in which a fatal result followed the false passage of an oesophageal tube.