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in addition endeavoring to secure for the organ in question physical and physiological rest.

In meeting these indications necessity will be found for all the fertility of resource which the improved facilities of the present day should evoke.

The most serious obstacle to overcome in diseases of the gastrointestinal tract, including inflammatory deformity, and neoplastic, has been the necessity for adequate nourishment with inability on the part of the organs to secure it. Manifestly with our present resources, we can cope with the situation many times, if we can secure a receptacle for our digested food, which shall at the same time be a source from which absorption can occur.

This want we can supply by utilizing the rectum and lower bowel.

We find here a most convenient substitute for a stomach as receptacle, and as an active organ it presents the following necessary conditions. Warmth, an absorbing surface, and a certain undetermined digesting power, of which however, we know too little to speak positively.

Its supply of absorbents, though good, is less lavish than that of the upper bowel, and this coupled with the less amount of surface exposed, lend certain practical restrictions in the practice of rectal feeding.

With means of predigesting food, with methods of introducing the products of such digestion into the body, in condition to be absorbed, I maintain that our resources in the combat with disease are immensely reinforced.

In illustrating practical preparation of foods we would perhaps better take as an example the treatment of milk, as being most universally useful, and at the same time presenting most prominently certain cardinal points in these methods.

Preliminary to the digestion of milk, its casein, and incidently its fat, must be precipitated; in other words curdled. Human peptic fluids possess this special curdling ferment. Many artificial pepsins have it in a very insufficient degree. A combination of calf and pig pepsin furnishes this in an adequate amount.

A portion of milk subjected to good pepsin, acidified to the extent of 2 per cent. will be curdled and the curd digested. But the following difficulties will be encountered. 1. The curd will be bulky, and the process slow in proportion to the bulk. 2. The process will

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flag as the peptones accumulate, except they be removed by dialysis. 3. The fluid product will be disagreeable to the taste, and irritating to the rectum. The nutrient possibilities are limited to the nitrogenous elements. Hence I regard its practicability in this immediate field, as comparatively slight.

Papain added to milk curdles it and at once attacks the casein. The curd is rendered more delicate and less rapid of formation by rendering the milk slightly alkaline. Kept at a temperature of not more than 105°, nor less than 100°, its activity proceeds rapidly until at the end of two hours the process is complete, the amount of papain necessary being about 10 grains to the pint of milk.

This method, which is very satisfactory in some respects, has the disadvantage of being limited to the digestion of proteids, and also of necessitating an agent as yet rare in pure condition.

There remains to be considered the product of appropriately treated pancreas or as it has been called, extractum pancreatis. In this product we have I believe the most useful product of all before us, and for the following reasons: 1. It is active in slightly, acid, neutral, or alkaline media hence digestion started outside can be completed in the stomach. 2. At no period of the digestion is the taste extremely bad and in early stages the taste of the milk is scarcely altered. 3. Its curdling ferment and proteolytic ferment act so simultaneously, that the curd is reduced to mere flocculence, and the fluid is at no time lumpy. because of its triple powers,it admits of admixture of all classes of food in one nutrient preparation, with assurance of accomplishing the digestion of each as is desired. The ferments have in common this feature. Heat above about 160°F destroys their activity. Cold, below 400 holds it in check, with power unabated. 1100F is a mean temperáture, at which these processes go on most rapidly.

In considering the preparation of milk with pancreatic extract, the following considerations must receive attention.

Degree of dilution. 2. Temperature. 3. Time.

3. Time. 4. Extraneous substances. 5. Necessary amount of digesting agents.

To describe a typical case of the preparation of milk with the extractum pancreatis of some approved quality, I should proceed as follows: Take a gill of cold water, 5 grains extract pancreatis, and 15 grains of bicarbonate of soda, mix and add one pint of milk and put in a bottle, setting the bottle in hot water, or, put in a vessel


and gently heat to a degree not hotter than can be sipped, which will range from 1100 to 120°F.

The length of time will depend upon what the further purpose is. If it be desired to terminate finally all digestion, after 25 minutes boil: you will have a more manageable food, in which no further spontaneous digestion can occur, the taste of which is not disagreeable. If it is desired to hold digestion in abeyance, place on ice at 25 minutes, and the process is checked, with an agreeable tasting food, which is ready to proceed at once when the temperature is raised to that of the body. If it be desired to completely predigest, allow the temperature of 110 to continue from 1/2 to 2 hours, and the product will be a complete solution of peptones, whose taste will be somewhat bitter.

Let us analyze this simple process and ask, why add the gill of water? It retards the curdling to the extent of rendering the curd very flocculent and fine. Why add the soda? It does not facilitate digestion but it has two advantages. (1) If it be desired to terminate the process while incomplete, by boiling, it prevents the coagulation of undigested casein, which would occur without it, and further (2) it reduces the acid reaction of the stomach, when the process is to be perfected there. Moreover it is agreeable to the rectum in case enemas are used. It is on the whole, a desirable adjuvant. A mean temp. of 120° F., a mean time of 25 m. and about 5 gr. of the ferment bearing powder to the pint, are the remaining points.

Combinations of starches, proteids and fats follow naturally upon a familiarity with the preparation of milk.

I am firmly of the opinion that often the mixed food, be it for enema or otherwise, is rationally indicated. I venture to depart a little from my subject to put in a plea for the use of more carbohydrates in the treatment of febrile processes; and with this universal digesting agent it is entirely easy to accomplish. It must be borne in mind, that with proteids fine subdivision is necessary, to yield satisfactory results, and with starch, breaking up of the granules, by boiling.

Fats will not admit of permanent emulsion by this method, because possibly, we cannot furnish to the pancreatic fluid, its active, and in this respect necessary adjuvant, the bile.

It will be easy to devise means for preparing nutritious gruels, soups, ground meats, etc., in the sick room where time and labor are not lacking. For use in less severe cases where some lesser degree of aid is called for, some of the peptonized preparations, which are on the market are serviceable. In this however as in all directions, we must turn to business houses of known integrity, whose claims, we can feel confident are not false, before we can with confidence rely upon the materials.

While I believe that familiarity with these materials and methods, will lead us to resort to them, perhaps more frequently than is necessary, I believe also that they furnish a most acceptable aid in many serious situations.

I would not be understood, as holding the opinion that considerable discrimination is unnecessary. In no branch of therapeutics is it desirable to apply a remedy, without at least an effort to ascertain the cause of the condition, for whose relief its aid is invoked, and artificial alimentation offers no exception to this principle.

It would be superfluous therefore to more than suggest the possibilities of management in this direction, leaving the adaptation to be made as the case arises. We can scarcely imagine a disease in which this mode of feeding might not under some circumstances apply; on the other hand, there is not a disease to which in every case it is even desirable to apply it.

Artificial methods of introducing food may be matters of necessity; they may be matters of expediency.

For example, the introduction of a fully peptonized meal into a dilated or strictured stomach, through a stomach tube, which has been primarily introduced for the purpose of washing out the stomach, can hardly be called necessary, yet convenience and experience commend it. On the other hand introduction of food through the stomach tube, in persons refusing to take food, or per rectum, in cases, where from intolerance, or unfit condition of stomach it is desirable, are strictly cases of necessity. Add to these, instances of mechanical obstruction, functional failure of deglutition, delirium in acute sickness where the stomach tube is out of the question; and we have a long array of circumstances, which seem to demand rectal feeding.

Feeding per rectum, does not necessarily involve artificial digestion, but its usefulness will be very dependent upon it. The wer bowel has feeble digestive powers, and possibly is capable of assuming vicarious function, but by predigestion it is possible to secure larger amounts, with less residuum, and by reason of more rapid absorption, to encounter less likelihood of rejection.

It is desirable to attend to the following points in introducing nourishment into the rectum. ist, its quantity, and, its temperature 3d, rapidity of introduction, 4th, frequency of injections, and 5th, condition of bowel.

The rectum and descending color should be empty, should be emptied by warm water injection. At first, generally, injections of food should not be given oftener than once in 8 to 10 hours, slowly introduced by constant pressure preferably, at body temperature, in as great quantities as can be borne. This latter point

the most important, and I do not deem it possible to establish a rule. Varying with the age of the patient and conditions of disease, I can only say that from 2 oz. in the child to 8 oz. in the adult, will furnish the limits within which the process may be instituted. As toleration is established greater quantities will be easily retained, and I regard it as a safe principle to adopt, to reach the maximum nourishment, by increasing the quantities of the injections rather than by decreasing the length of intervals between them, for occupation of the bowel is not irritating to it, but manipulation is.

I am aware that there are substances and methods which I have not touched upon, but the omission is premeditated, that discussion of practical, useful means, might not suffer.

The very important subject of infant feeding, has been advisedly ignored, for the reason that its treatment not only demands such detail in discussion of material and methods, but also consideration of relations so extensive as to render it unsatisfactory to treat briefly, and to entitle it to the dignity of separate consideration.

In conclusion, I may say that from successful artificial alimentation, we may expect to secure, not great results in the cure of disease, not perhaps great results in prophylaxis of disease, but immunity from the complications and embarrassments in treatment, which though not essential to the disease process, are yet the reefs upon which the heavily laden and struggling system may sink.

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