I). Water-tight closure of the pylorus. This may be diagnosed by the non-appearance of charcoal, berry juice, peppermint or, better yet, purpetrol, in the faeces. It occurs mainly in cancer of the pylorus or, at any rate, this is the only condition - barring extremely depressed general states - in which immediate operation of a radical nature should not be insisted on. Even cancerous obstruction to this degree, unless as a final stage of type C, is usually due to a slowly growing scirrhus mass and should be considered to indicate radical operation or if that is not feasible, the establishment of a superior enterostomy. Some surgeons advise gastrostomy plus gastroenterostomy which, of course, should not be allowed unless there is some peculiar contraindication to superior enterostomy.

Granting that operation has been set aside, we have, in addition to the meagre assistance of hypodermic nutrition and inunction the choice of introducing nutriment for a short distance into either the upper or the lower end of the alimentary canal and, for physiologic reasons neither method is efficient. Excepting the small quantities of fat present in milk and other selected foods, the entire fat ration, say 60 grams of cocoanut butter - which is softer and apparently better absorbed than cacao butter - should be introduced by inunction daily. Peptonized milk, dextrose and perhaps cereal gruels and white of egg and milk with digest-ants should be used for gastric feeding, in amounts as nearly as possible approaching the standard minimum ration or about 1500 calories, should be given in two or three daily feedings. Minute feedings with various liquid foods will give a false sense of satisfaction but fermentation and usually putrefaction will occur and vomiting will necessarily ensue after a few days at most, unless the patient is so much depressed that even this conservative reflex is absent. Lavage must be practiced every day or two. As in the previous type, an alternation of rectal and gastric nutrition must be followed.

So-called Idiopathic Hypertrophy of the Pylorus occurs mainly in infants. It is scarcely amenable to dietetic treatment, since the food is already as bland and soft as possible. However, before resorting to operation, the maternal milk or substitute should be examined with reference to curdling in large masses and a brief change to some prepared, non-starchy food, to white of egg water etc., and lavage of stagnated food, may be practiced.

Microgastria develops from prolonged lack of appetite, as from solitary life or eating in unpleasant surroundings, from ulcer or various other painful gastric conditions or from fibroid degeneration of the stomach without tendencies to cause dilatation. Antipathy to water, without addiction to other beverages also causes it. Once established, a vicious cycle exists. The primary indication is to administer food as concentrated as possible, to aid digestion and to increase the frequency of meals. Water should be given three or four hours after meals. Later, the endeavor should be made to stimulate the appetite by change of environment and general hygienic measures and gradually to increase the bulk of food so as to enlarge the stomach. Unfortunately, many cases coexist with anadenia.

Gastric Cancer interferes with digestion and requires dietetic management for the following reasons:

1. Prevention of entry of food through the cardia.

2. Prevention of exit of chyme through the pylorus.

3. Infiltration or weighting of the gastric wall, preventing proper motility.

4. Early and rather infrequent stimulation of motility or secretion or both, by irritation. A few cases of hyperchlorhydria subsequently prove to be cancerous. It is difficult, however, to establish the date at which the cancer begins and many such cases are probably primarily of ulcer with hyperchlorhydria, the ulcer later becoming cancerous.

5. Usually and practically always ultimately, depression of motion or secretion or both by general asthenia or local repression of function. While cancer almost always produces hypo- or aohlorhydria in advanced stages, it should be remembered that the groat majority of hypochlorhydric cases are not cancerous. This fact renders the prompt diagnosis of cancer exceedingly difficult.

6. On account of the depression of secretion, interference with motility and destruction at the pylorus, saprophytosis is favored. Lactic acid fermentation has been considered pathognomic of cancer but it always occurs to some degree under ordinary diet and it is, at most, diagnostic of stagnation which, in ex-troino degree and with other circumstances favoring saprophytosis, is usually due to cancer.

7. After the cancer has become exposed, ulceration due to digestion or gangrene develops, according to the relative strength of secretion, the failure of nutrition of the mass and the development of proteolytic bacteria.

Ktiologically considered, cancer has been ascribed to the excessive consumption of meat, of raw vegetables conveying the putative germs of cancer, of salt, of raw eggs implanting living epithelial cells, and from the local standpoint, of various dietetic errors unduly fatiguing the stomach, causing chemic irritation by products of fermentation, mechanic irritation by foreign bodies and dense masses swallowed, or indirectly favoring hyperchlorhydria and ulcer which subsequently becomes cancerous. None of these factors has any practical bearing in a statistic sense, although the local one may have some influence.

In the early stage, cancer is scarcely diagnosticable and, if it were, no particular dietetic indication is present. The indications for operation requiring feeding by fistulae and the indications derived from the various mechanic, digestive and saprophytic complications have been discussed under appropriate headings. It may be emphasized that, unless the tumor involves nervous structures, pain and discomfort are largely amenable to dietetic management. The ordinary painful gastric cancer is so mainly because the stomach contents are allowed to remain in an excessively acid state, rarely on account of hyperchlorhydria, usually on account of fermentative acidity. The dietetic management described and lavage, will almost entirely relieve this pain.