A suitable management of diet adds greatly to the comfort and helps to prolong the life of those who have malignant growths in the stomach.

It is not practicable to prescribe a fixed regimen in these cases. The diet must be adapted to the degree of obstruction that exists at the cardia or pylorus, to the motor power of the stomach, and to its ability to digest and absorb nourishment.

When the tumor is at the cardia and produces a progressive interference with deglutition, liquid food only can be taken. The case must be watched closely to prevent distention of the esophagus above the stricture. As the obstruction becomes greater the amount of liquid food swallowed at a time must be lessened.

When the tumor is at the pylorus, which is thus partly or wholly obstructed, care must be taken that the stomach does not become distended and that food does not remain in it long enough to undergo abnormal fermentation. In most instances gastrectasis exists when the patient first comes under treatment. The diet and care of the patient must then be directed toward a relief of gastric dilatation along the lines already described. Under the caption of Gastric Dilatation I have already alluded to the good results that can be obtained in such cases, and described the details of treatment.

In malignant disease of the stomach there is, almost without exception, either a diminished formation of gastric juice or an entire absence of it. The character of food adapted to these cases is the same as for those of chronic gastritis in which there is atrophy of the glands and absence of free hydrochloric acid.

The food should be small in amount and easy to digest; often it is even best that it should be partly digested before it is eaten. It should not be bulky or heavy. If the motor power of the stomach is good or may be restored, a variety of food may be given in small portions. Digestion will be performed fairly well in the duodenum. As the stomach cannot be expected to do its usual work of digesting and disintegrating the food, it is necessary to administer pepsin or papain and hydrochloric acid after albuminous, and taka-diastase or pancreatin after farinaceous, articles. It is also important that all food be finely divided when it is swallowed, or capable of quickly crumbling to pieces afterward. The stomach must be kept clean by daily or frequent lavage. By attention to these points the comfort and the strength of those in whom there is no obstruction or only moderate obstruction at the pylorus can be preserved.

A patient recently under treatment had a moderately distended stomach producing pain and discomfort which was from time to time temporarily relieved by vomiting. When about three ounces of peptonized milk were administered every two and one-half hours during the waking part of the day and his bowels were moved by enemata instead of laxatives the distention and pain ceased. In a few days a few spoonfuls of gelatin jelly were given instead of one or two of the milk meals as a styptic and for variety. It soon became evident that he could take other things without discomfort, such as a soft cooked egg or meat juice or a little scraped meat, though these as often happens were not especially relished or craved, and a small saucer of cornstarch or tapioca or a little of crackers or stale bread instead of two or three of the portions of milk. As feeding in this case had to be kept up for weeks in small portions at the intervals named, it was a great comfort to the patient to have such foods as crackers which he could chew before swallowing. In this case, as in many others which I have observed, laxatives to relieve constipation produced pyloric contraction and painful peristalsis. In other cases not thus affected by them they are a help to prevent gastric distention.

The best foods for the cases in which duodenal digestion must be relied upon are finely chopped meats, such as steak, roast beef, chicken, and squab, also soft-cooked and raw eggs, Zwieback, pulled bread, farina, starch, Mellin's food, Robinson's barley, and similar preparations. Milk is often well tolerated. In other cases it cannot be used because of the large clot of cheese into which it is transformed in the stomach. In such cases sour milk, buttermilk, matzoon, and kumiss are better than sweet milk. Often the addition of lime-water or of a little cooked flour will prevent the curdling of sweet milk.

Antiseptics, and such digesters as papain, taka-diastase, pepsin, and hydrochloric acid are useful sometimes.

In that large group of cases in which there is great, or practically complete, obstruction at the pylorus, predigested foods only can be used with success, and what is not absorbed must be washed out at least once daily. To prolong life, rectal alimentation, which is particularly successful in these cases, must be employed. The slow but persistent loss of flesh and strength characteristic of the malady causes the tissues to adapt themselves to a meager supply of nourishment. Better results are, therefore, obtained from the seemingly minute quantity of food that is utilized than in most other maladies. Pancre-atinized milk, peptones, albumoses, somatose, and water may be given by the mouth. Occasionally, perhaps once or twice daily, the patient may be permitted to chew the juice out of meat or to take a little broth or fruit-juice. This will often satisfy a craving for the taste of food and partly compensate for the less agreeable foods upon which more dependence is placed. Preferably, they should be given an hour or two before the stomach is to be washed, in order that they may not remain in it long enough to spoil.

The diet that has just been described and that has proved most useful in my hands is not recommended by Beneke. He argues that because of its chemical composition the morbid growth will be checked by diminishing the quantity of albuminous food and of phosphoric acid taken, and recommends therefore the following diet:

"Breakfast: A strong infusion of black tea with sugar and cream. A little bread with plenty of butter, and potatoes cooked in their skins, with butter. Cocoa may be substituted for tea.

"Lunch: Fruit, raw or cooked. English biscuits, or a little bread and butter, and a glass of wine.

"Dinner: Fruit soup or wine soup with sago or Indian corn meal, or potato soup. Not more than fifty grams of meat. Fresh minced potatoes in the form of puree, mashed, or plain boiled. Any kind of vegetable roots. Stewed fruit. Apples or prunes with rice, or rice with wine. Salads and fruit ices. Light Moselle, Rhine wines, or champagnes are allowed. Beer, however, is to be permitted only in small quantities on account of its large percentage of alkaline phosphates.

"Afternoon: Black tea with sugar and cream, and a little bread and butter, and perhaps also some raw fruit and biscuit.

"Supper: Soup as at dinner. Rice and fruit. Boiled potatoes with butter or potato salad. Small quantities of sardines in oil. Anchovies or fresh herrings. Buckwheat gruel with wine and sugar. Light wines."

When malignant tumors develop in the stomach hematemesis is of frequent occurrence. It must be treated as in ulcer of the stomach. As in that malady, lavage is for a time coun-terindicated. It must be practised with great caution after hemorrhage, both because it is liable to excite fresh bleeding, and because there is danger of causing perforation of the stomach at the point of ulceration.