In all dietaries, proper mastication and insalivation should be practiced, even milk requiring such admixture of saliva to insure against its coagulation in too large curds, and the food intended for introduction through a gastric or intestinal fistula, being more easily digested if thus prepared. Moreover, mastication and insalivation, in addition to their direct value in modifying the bolus to be swallowed, reflexly stimulate the inferior digestive juices.

The various functions fulfilled by mastication and insalivation are as follows: 1. The comminution and softening of food;

2. The introduction of ptyalin, of some though not great importance in the digestion of cooked starches;

3. More or less perfect insurance against accidental swallowing of foreign bodies, poisons and tainted or fermented foods;

4. Prevention of oesophageal and gastric neuroses such as hiccough, delayed peristalsis, spasm due to a dry bolus or one that is too large, air swallowing, spasm or relaxation of the cardia, etc.;

5. Diminution of the tendency to swallow undue quantities of liquid to wash down solid food;

6. Reflex stimulation, in advance, of the gastric and even pancreatic and intestinal secretions;

7. Satisfaction with reasonable quantities of food, the feeling of satiety not occurring if the food is hastily bolted, till an excess has been taken.

It is unwise to make a cult of chewing but the food should be masticated till it becomes almost tasteless, when deglutition will occur reflexly. This is the gist of the so-called Fletcher method, which has been found by Prof. Irving Fisher to reduce the ingestion, especially of meats, and to increase the oeconomic utilization of ingesta so that the body is well nourished on considerably less than the ordinary excessive ration.

The alternate use of hot and cold ingesta tends to crack the enamel of the teeth and to produce catarrhal inflammation of the mouth, tongue, pharynx and even of the oesophagus and stomach. As in the case of corrosive poisoning, the protection of the oesophagus with dense, ropy mucus and the brief sojourn of the ingesta in this tube, may protect it although the stomach suffers.

The continuous use of ice held in the mouth, may produce stomatitis, especially glossitis, and hence increase the thirst for which the ice was prescribed.

The mouth and teeth should be cleaned or at least rinsed before eating - especially in fevers and in cases of gastro-intestinal fermentation or putrefaction, but also in health - to minimize the number of microroganism swallowed and after eating, to protect the teeth against caries. Neutral soap and water, waxed shoe-thread to remove particles between the teeth, soda and borax solutions for rinsing, are better than volatile organic or strong mineral antiseptics.

In various forms of stomatitis, especially with ulceration of the gums as in mercurial poisoning, or with gangrene as in noma, as well as in diphtheria and septic inflammations of the throat, parotitis etc,,, nutrition may be interfered with on account of the sensitiveness of the parts. In all such cases, the nourishment should be liquid or pultaceous, consisting mainly of milk, eggs and cereals, with expressed meat and fruit juices, if necessary. The diseased part should be cleansed and disinfected, using hydrogen peroxid or even strong antiseptics, before feeding. Occasionally, gavage may be easier for the patient as well as preventive of infection for the stomach.

In fracture of the jaw, after splinting, in tetanus etc., it may be mechanically impracticable to separate the teeth. If milk etc., can not be sucked through or behind the teeth, it may be necessary to pull one or two to allow the introduction of a tube or intubation may be practiced through the nose.

Various obstacles in the pharynx or oesophagus or abutting upon them, may prevent the swallowing of food. Spasmodic obstruction may usually be overcome by bougies and, while it may delay, it seldom prevents deglutition. Very rarely is oesophageal intubation required and still more rarely is the spasm sufficient to prevent the passage of a tube, especially if the bougie is first introduced.

Cicatricial obstruction, usually requires intermittent dilatation with bougies. Unless it develops as the immediate consequence of corrosion or ulceration, or the case has been neglected, the oesophagus will usually allow at least the passage of liquids.

Oesophageal dilatation and diverticula, present many individual peculiarities. They do not usually prevent swallowing although they may delay it and may call for the use of bougies, and tubes. In some cases tubes may be permanently retained, issuing either from the mouth or nose, or reaching only to the pharynx, being retained by a thread or other device.

Syphilitic obstructions usually yield promptly enough to general medication so that by using liquids or by intubating or dilating, gastrostomy is unnecessary. Tuberculous, other ulcerative and inflammatory, including corrosive lesions, are less certainly relieved.

When the malignant nature of an oesophageal obstruction has been pretty positively established, further instrumentation should be avoided as tending to stimulate growth. In the majority of cases, radical operation is impossible. In a surprisingly large number, liquid or even semi-solid food can be swallowed to the end. Purpetrol (pure mineral oil, not the ordinary commercial products used by laryngologists) is of value as a lubricant for the passage of food.

Instrumentation in obstruction due to aneurysm is especially to be avoided, on account of the conspicuously prompt result of rupture and the equally marked responsibility of the physician, rather than because of the mathematic probability of rupture by a blunt bougie or soft tube.

A malignant or other obstruction which is absolute or practically so requires prompt decision on the part of physician and patient, syphilis alone offering any reasonable hope of sufficiently speedy relief of an obstruction of a degree threatening death by starvation. Radical local operation should first be considered but, even so, gastrostohiy is often indicated as a preliminary to build up the patient's strength. If the patient is in a hopeless condition on account of old age, or disease or if the obstruction is a rapidly growing malignant tumor or advanced aneurysm, it is better to maintain life as long as possible - usually not more than 40 days dating from the time at which nutrition becomes seriously impaired - by rectal and hypodermic nutrition and inunction. In cases in which there is no immediate danger of death except on account of the imminence of starvation - including slowly growing malignant tumors - a gastric or superior intestinal fistula should be made. If the stomach is not invaded by the growth and is otherwise in fairly good functional power, the former should be preferred, otherwise the latter, in spite of the trouble from digestion of tissues by escape of activated pancreatic ferments. (See special discussion of fistulae.)