taking of food or vomiting is apt to open the wound, the food should be given by the rectum until all danger of vomiting is past and until the patient can masticate or swallow without fear of injuring the part. It should be remembered that wounds about the mouth are often very easily pulled apart.

Diet after Harelip or Cleft-palate Operations.-Following these operations especial attention to the diet is necessary. The child should be sent to the hospital several days or even weeks before the operation, in order to accustom him to the attendants, to the hospital feeding, and to teach him to take nourishment from a spoon or by means of a long medicinedropper. If the patient is an infant, it should receive the diet on which it is increasing in weight. If breast milk is to be given, it should be taken from the breast with a breast-pump and fed to the infant with a spoon. The greatest cleanliness should be observed, and the technic of preparing and preserving the milk should be carefully carried out. The infant should not be allowed to suck too soon, for fear of breaking open the wound.

In all mouth operations the diet should consist of cold sterilized milk or modifications of milk until solid food can be taken. Rectal feeding or feeding by means of a nasal tube may be used as a temporary expedient.

Diet after Esophageal Operations. Following esophagotomy rectal feeding may be employed, or the patient may be fed with a nasal or a stomach-tube until he is able to swallow without pain. The food should be of liquid or semisolid consistence until the wound has healed, except when the patient may be trusted to masticate all food very thoroughly. If the food is regurgitated through the wound or if it passes out on swallowing, the feeding had better be accomplished by means of a tube, or rectal feeding may be instituted for several days.

Diet after Excision of the Larynx. The diet after this operation is a matter of great importance. Formerly great difficulties were encountered, and gastrotomy was often resorted to as a means of furnishing food to the patient. With improvement in technic this may now usually be dispensed with. (The student is referred to the text-books on surgery for an account of the improved technic.)

The length of time that must be allowed to elapse after the operation before the patient can be permitted to swallow is dependent upon the patient's condition. Graf operated upon a patient who was able to swallow on the day following the opera

tion. The length of time varies ordinarily from four days to eight weeks or longer. During this time rectal feeding may be employed at the outset, or the nasal or the stomach-tube may be used. Some operators insert a tube in the esophagus and allow it to remain there for days. It may be passed through the mouth or the nose. This method has been strongly condemned and is not in general use.

Diet after Operations about the Gall-bladder or Liver. Following operations upon the gall-bladder, where a fistula has been made, the food should consist largely of the proteins and carbohydrates. The fats are not well borne, and for this reason it is well to eliminate them so far as possible from the dietary. Water is the first thing of importance and should be forced. It has been demonstrated that if a patient suffering with gall-bladder disease does not void at least 500 c.c. of urine in twenty-four hours mental symptoms are almost certain to develop.

Diet after Operations about the Pancreas.-The functions of the pancreas, with the exception of furnishing a fat-splitting enzyme, can be assumed and carried on by the other glands. The diet does not differ from that advised for other abdominal operations, but it may be well to limit the consumption of fats. The use of artificially pancreatized food has been suggested. This is a subject that requires further investigation.

Diet after Operations about the Kidney. In all operations about the kidney the diet should be so arranged as to make the work of elimination as easy as possible for the organ. This may be accomplished by a diet such as has been prescribed in chronic or even in acute nephritis. All irritating substances, in particular, should be avoided.

Diet after Operations on the Stomach.-In preparing patients for operations on the stomach the fact that such individuals are often emaciated and weakened by longcontinued illness must constantly be borne in mind; on this account such patients should, wherever possible, be "built up" for at least a week before operation. In order to accomplish this result as much digestible food as the patient can consume should be given him. It should be offered to him in as appetizing and in as concentrated a form as possible; as a rule, only small quantities at frequent intervals should be given.

If necessary, rectal alimentation should be practised; in individuals who are anemic and very weak, the use of a salt infu

sion the day previous to the operation is advisable. In all operations on the stomach it is most important that the organ be as sterile as possible, and also entirely empty before the operation. Since the noteworthy experiments of Cushing and Livingood,' by which these investigators established the fact that an amicrobic state can be produced in the stomach and small intestine, Finney, as well as other surgeons, has taken advantage of this fact in his surgical procedures on the stomach.

By washing out the stomach thoroughly with sterile water twice daily and feeding the patient on a sterile diet the stomach may be kept free from micro-organisms. Finney advises the following procedure:

"For three to four days preceding the operation the patient is fed on sterile liquid food at intervals of two hours. The food is served in sterile dishes. Always before taking nourishment the mouth is thoroughly cleansed with a 1 per cent. solution of carbolic acid. The stomach is washed twice daily with sterile water and always two hours before operation, and nothing injected after this.

"For four to five days after the operation nourishment is administered only by means of rectal alimentation. Normal salt solution enemata are alternated with the nutrient enemata at intervals of every four hours.

"On the fifth day after the operation egg-albumin is given in teaspoonful doses, gradually increased to one-half ounce every two hours, if well borne, and finally to one ounce every two hours on the sixth day, and two ounces on the seventh day, and four ounces every three hours on the tenth day.

"On the twelfth to the fourteenth day the patient is given a soft-boiled egg, and the following day soft food, and on the eighteenth day light solid food."

Surgeons differ markedly in their views regarding the time that should be allowed to elapse after operations on the stomach before mouth-feeding is begun. Some, as Czerny, allow eight days to elapse, whereas others, as von Eiselsberg, give very light food, such as milk, the day following the operation. According to Kehr, the following regulations as to diet should be maintained after operations on the stomach:

"1. After operation, the diet should be regulated at first from hour to hour, then from day to day.

"2. Strong, healthy individuals may be allowed to go without food as long as their general condition warrants it.

1 Johns Hopkins Hospital Reports, vol. ix.

Leyden's Handbuch der Ernährungs-Therapie, 2d edition, vol. ii., p. 555.

"3. The more extensive the operation, the more care should be exercised with the diet.

"4. Patients weakened by cancerous growths may be allowed liquid food as soon as the effect of the anesthetic has worn off. "5. An exact knowledge of the motor as well as the secretory functions of the stomach will indicate the proper method of feeding in these cases."

Diet after Operations on the Intestine. In operations on the upper portion of the intestine the dietetic regulations are similar to those previously described under Operations on the Stomach; food may, however, be given by the mouth earlier than after operations on the stomach. The food should be of such a nature as will not leave too solid a residue in the bowels; it must also vary according to the pathologic condition present, as well as according to the extent of the surgical procedure.

After an ordinary appendix operation the patient may be given liquid food on the second day after operation; on the third day a soft diet may be allowed, and on the fifth or sixth day solid food may be taken; on the other hand, if the operation has been a serious one, with pus-formation and a gangrenous appendix, he may be required to be fed exclusively by rectal enemata for five or six days or more.

The cause of death after gastric and intestinal operations, according to F. Ehrlich,' is not so much shock as exhaustion, brought on by starvation before and after the operation. To prevent this he feeds his patients immediately after the ether nausea has worn off, and he feeds them well.

He feeds his patients by a routine method in the following manner: So soon as the nausea from the anesthetic has worn off, the patient gets tea, red wine or gruel; on the day after the operation he is given sweetbread in bouillon, even if it nauseates him; if the nausea is persistent his stomach is washed. On the second day, finely chopped, cooked squab, chicken or veal is added; on the third day, beef, potato purée, and cakes; on the fourth, chopped ham (raw), soft zwieback, and soft-boiled eggs; on the fifth day, white bread and spinach. After the seventh day the meat is not chopped and then the patient returns gradually to normal diet. The bowels are regulated with oil enemas. The shock of the operation does not usually last beyond the third day.

After operations on the rectum the patient is kept on a fluid

1 Münchener medicinische Wochenschrift, 1904, ii., 613, No. 14.

diet for from four to five days; after this a soft diet is given, and finally, in six or seven days, solid food may be prescribed.

Feeding Through Gastric or Intestinal Fistulas.— After gastric or intestinal fistulas have been made, the patient may, if necessary, be fed through these openings as early as a few hours after the operation. It is best at first to give only very small quantities of liquids at frequent intervals. Kehr advises alternately, every two hours, one-half cup of tea with cognac, milk, and egg, and, on the second day, wine with peptone. He adds bouillon with an egg on the third day, and begins with "mushy" food, such as potato soup, flour soups with egg, beef-tea with minced breast of chicken on the eighth day. After three weeks the patient may be allowed to masticate his food, and then, by means of a rubber tube, pass it into the stomach through the fistula.

Diet in Pancreatic Fistula.-Heineke has pointed out that in persistent fistula following operation on the pancreas, where there is maceration of the skin due to the action of the pancreatic secretion, Wohlgemuth's method of dieting gives satisfactory results. Wohlgemuth found that the amount of fluid discharged from the pancreas depended on the composition of the food taken by the patient. With fatty diet the secretion was very scanty, and with an albuminous diet it increased on the addition of carbohydrates and became very abundant. Secretion is increased by acids and diminished by alkalis. Bicarbonate of soda in small, frequently repeated doses is perhaps the best method of administering alkalis in these cases.