Digestive Enzymes

FUNCTIONAL AND INFLAMMATORY DISEASES OF THE STOMACH.

BY SAMUEL G. ARMOR, M.D., LL.D.

Functional Dyspepsia (Atonic Dyspepsia, Indigestion).

As a rule, the food should be such as will require the least possible exertion on the part of the stomach. Raw vegetables should be forbidden; pastries, fried dishes, and all rich and greasy compounds should be eschewed; and whatever food be taken should be eaten slowly and well masticated. Many patients digest animal better than vegetable food. Tender brown meats, plainly but well cooked, such as beef, mutton, and game, are to be preferred. Lightly-cooked mutton is more digestible than beef, pork, or lamb, and roast beef is more digestible than boiled. Pork and veal and salted and preserved meats are comparatively indigestible. Bread should never be eaten hot or fresh—better be slightly stale—and bread made from the whole meal is better than that made from the mere starchy part of the grain. Milk and eggs and well-boiled rice are of special value.

But to all these general dietetic rules there may be exceptions growing out of the peculiarities of individual cases. These should be carefully studied. The aged, for obvious reasons, require less food than the young; the middle-aged, inclined to obesity and troubled with feeble digestion, should avoid potatoes, sweets, and fatty substances and spirituous liquors; persons suffering from functional derangements of the liver should be put, for a time, on the most restricted regimen; while, on the contrary, the illy fed and badly-nourished require the most nutritious food that can be digested with comfort to the patient.

To these general predisposing causes may be added indigestion occurring in febrile states of the system. The cause here is obvious. In all general febrile conditions the secretions are markedly disturbed; the tongue is dry and furred; the urine is scanty; the excretions lessened; the bowels constipated; and the appetite gone. The nervous system also participates in the general disturbance. In this condition the gastric juice is changed both quantitatively and qualitatively, and digestion, as a consequence, becomes weak and imperfect—a fact that should be taken into account in regulating the diet of febrile patients. From mere theoretical considerations there can be no doubt that fever patients are often overfed. To counteract the relatively increased tissue-metamorphosis known to exist, and the consequent excessive waste, forced nutrition is frequently resorted to. Then the traditional saying of the justly-celebrated Graves, that he fed fevers, has also rendered popular the practice. Within certain bounds alimentation is undoubtedly an important part of the treatment of all the essential forms of fever. But if more food is crowded upon the stomach than can be digested and assimilated, it merely imposes a burden instead of supplying a want. The excess of food beyond the digestive capacity decomposes, giving rise to fetid gases, and often to troublesome intestinal complications. The true mode of restoring strength in such cases is to administer only such quantities of food as the patient is capable of digesting and assimilating. To this end resort has been had to food in a partially predigested state, such as peptonized milk, milk gruel, soups, jellies, and beef-tea; and clinical experience has thus far shown encouraging results from such nutrition in the management of general fevers. In these febrile conditions, and in all cases of general debility, the weak digestion does not necessarily involve positive disease of the stomach, for by regulating the diet according to the digestive capacity healthy digestion may be obtained for an indefinite time.

Exhaustion of the nerves of organic life strongly predisposes to the atonic forms of dyspepsia. We have already seen how markedly the digestive process is influenced by certain mental states, and it is a well-recognized fact that the sympathetic system of nerves is intimately associated with all the vegetative functions of the body. Without a certain amount of nervous energy derived from this portion of the nervous system, there is failure of the two most important conditions of digestion—viz. muscular movements of the stomach and healthy secretion of gastric juice. This form of indigestion is peculiar to [p. 441]the ill-fed and badly-nourished. It follows in the wake of privation and want, and is often seen in the peculiarly careworn and sallow classes who throng our public dispensaries. In this dyspepsia of exhaustion the solvent power of the stomach is so diminished that if food is forced upon the patient it is apt to be followed by flatulence, headache, uneasy or painful sensations in the stomach, and sometimes by nausea and diarrhoea. It is best treated by improving in every possible way the general system of nutrition, and by adapting the food, both in quantity and quality, to the enfeebled condition of the digestive powers. Hygienic measures are also of great importance in the management of this form of dyspepsia, and especially such as restore the lost energy of the nervous system. If it occur in badly-nourished persons who take little outdoor exercise, the food should be adapted to the feeble digestive power. It should consist for a time largely of milk and eggs, oatmeal, peptonized milk gruels, stale bread; to which should be added digestible nitrogenous meat diet in proportion to increased muscular exercise. Systematic outdoor exercise should be insisted upon as a sine quâ non. Much benefit may be derived from the employment of electric currents, and hydrotherapy has also given excellent results. If the indigestion occur in the badly-fed outdoor day-laborer, his food should be more generous and mixed. It should consist largely, however, of digestible nitrogenous food, and meat, par excellence, should be increased in proportion to the exercise taken. Medicinally, such cases should be treated on general principles. Benefit may be derived from the mineral acids added to simple bitters, or in cases of extreme nervous prostration small doses of nux vomica are a valuable addition to dilute hydrochloric acid. The not unfrequent resort to phosphorus in such cases is of more than doubtful utility. Some interesting contributions have been recently made to this subject of gastric neuroses by Buchard, Sée, and Mathieu. Buchard claims that atonic dilatation of the stomach is a very frequent result of an adynamic state of the general system. He compares it to certain forms of cardiac dilatation—both expressions of myasthenia. It may result from profound anæmia or from psychical causes. Mathieu regards mental depression as only second in frequency. Much stress is laid upon poisons generated by fermenting food in the stomach in such cases. It may cause a true toxæmia, just as renal diseases give rise to uræmia. Of course treatment in such cases must be addressed principally to the general constitution.

But of all predisposing causes of dyspepsia, deficient gastric secretion, with resulting fermentation of food, is perhaps the most prevalent. It is true this deficient secretion may be, and often is, a secondary condition; many causes contribute to its production; but still, the practical fact remains that the immediate cause of the indigestion is disproportion between the quantity of gastric juice secreted and the amount of food taken into the stomach. In all such cases we have what is popularly known as torpidity of digestion, and the condition described is that of atony of the stomach. The two main constituents of gastric juice—namely, acid and pepsin—may be deficient in quantity or disturbed in their relative proportions. A certain amount of acid is absolutely essential to the digestive process, while a small amount of pepsin may be sufficient to digest a large amount of albuminoid food. [p. 442]Pure unmixed gastric juice was first analyzed by Bidder and Schmidt. The mean analyses of ten specimens free from saliva, procured from dogs, gave the following results:

Lack of the normal amount of the gastric secretion must be met by restoring the physiological conditions upon which the secretion depends. In the mean time, hydrochloric and lactic acids may be tried for the purpose of strengthening the solvent powers of the gastric secretion.

EXCITING CAUSES.—The immediate causes of dyspepsia are such as act more directly on the stomach. They embrace all causes which produce conditions of gastric catarrh, such as excess in eating and drinking, imperfect mastication and insalivation, the use of indigestible or unwholesome food and of alcohol, the imperfect arrangement of meals, over-drugging, etc.

Of exciting causes, errors of diet are amongst the most constantly operative, and of these errors excess of food is doubtless the most common. The influence of this as an etiological factor in derangement of digestion can scarcely be exaggerated. In very many instances more food is taken into the stomach than is actually required to restore tissue-waste, and the effects of such excess upon the organism are as numerous as they are hurtful. Indeed, few elements of disease are more constantly operative in a great variety of ailments. In the first place, if food be introduced into the stomach beyond tissue-requirements, symptoms of indigestion at once manifest themselves. The natural balance betwixt [p. 443]supply and demand is disturbed; the general nutrition of the body is interfered with; local disturbances of nutrition follow; and mal-products of digestion find their way into the blood. Especially is this the case when the excessive amount of food contains a disproportionate amount of nitrogenous matter. All proteid principles require a considerable amount of chemical alteration before they are fitted for the metabolic changes of the organism; the processes of assimilative conversion are more complex than those undergone by fats and amyloids; and it follows that there is proportional danger of disturbance of these processes from overwork. Moreover, if nitrogenous food is in excess of tissue-requirement, it undergoes certain oxidation changes in the blood without becoming previously woven into tissue, with resulting compounds which become positive poisons in the economy. The kidneys and skin are largely concerned in the elimination of these compounds, and the frequency with which these organs become diseased is largely due, no doubt, to the excessive use of unassimilated nitrogenous food. Then, again, if food be introduced in excess of the digestive capacity, the undigested portion acts directly upon the stomach as a foreign body, and in undergoing decomposition and putrefying changes frets and irritates the mucous membrane. It can scarcely be a matter of doubt that large groups of diseases have for their principal causes excess of alimentation beyond the actual requirements of the system. All such patients suffer from symptoms of catarrhal indigestion, such as gastric uneasiness, headache, vertigo, a general feeling of lassitude, constipation, and high-colored urine with abundant urates, together with varied skin eruptions. Such cases are greatly relieved by reducing the amount of food taken, especially nitrogenous food, and by a systematic and somewhat prolonged course of purgative mineral waters. Europe is especially rich in these springs. The waters of Carlsbad, Ems, Seltzer, Friedrichshall, and Marienbad, and many of the alkaline purgative waters of our own country, not unfrequently prove valuable to those who can afford to try them, and their value shows how often deranged primary assimilation is at the foundation of many human ailments. The absurd height to which so-called restorative medicine has attained within the last twenty years or more has contributed largely to the production of inflammatory forms of indigestion, with all the evil consequences growing out of general deranged nutrition.

The use of indigestible and unwholesome food entails somewhat the same consequences. This may consist in the use of food essentially unhealthy or indigestible, or made so by imperfect preparation (cooking, etc.). Certain substances taken as food cannot be dissolved by the gastric or intestinal secretions: the seeds, the skins, and rinds of fruit, the husks of corn and bran, and gristle and elastic tissue, as well as hairs in animal food, are thrown off as they are swallowed, and if taken in excess they mechanically irritate the gastro-intestinal mucous membrane and excite symptoms of acute dyspepsia, and not unfrequently give rise to pain of a griping character accompanied by diarrhoea. Symptoms of acute dyspepsia also frequently follow the ingestion of special kinds of food, such as mushrooms, shellfish, or indeed fish of any kind; and food not adapted to the individual organism is apt to excite dyspeptic symptoms. Appetite and digestion are also very much influenced by the life and [p. 444]habits of the individual. The diet, for instance, of bodily labor should consist largely of digestible nitrogenous food, and meat, par excellence, should be increased in proportion as muscular exercise is increased. For all sorts of muscular laborers a mixed diet is best in which animal food enters as a prominent ingredient. Thus, it has been found, according to the researches of Chambers, that in forced military marches meat extract has greater sustaining properties than any other kind of food. But with those who do not take much outdoor exercise the error is apt to be, as already pointed out, in the direction of over-feeding. It cannot be doubted at the present time that over-eating (gluttony) is one of our popular vices. Hufeland says: "In general we find that men who live sparingly attain to the greatest age." While preventive medicine in the way of improved hygiene—better drainage, better ventilation, etc.—is contributing largely to the longevity of the race, we unfortunately encounter in more recent times an antagonizing influence in the elegant art of cookery. Every conceivable ingenuity is resorted to to tempt men to eat more than their stomachs can properly or easily digest or tissue-changes require. The injurious consequences of such over-feeding may finally correct itself by destroying the capacity of the stomach to digest the food.

Food may also be introduced into the stomach in an undigestible form [p. 445]from defects of cookery. The process of cooking food produces certain well-known chemical changes in alimentary substances which render them more digestible than in the uncooked state. By the use of fire in cooking his food new sources of strength have been opened up to man which have doubtless contributed immeasurably to his physical development, and has led to his classification as the cooking animal. With regard to most articles the practice of cooking his food beforehand is wellnigh universal; and especially is this the case with all farinaceous articles of food. The gluten of wheat is almost indigestible in the uncooked state. By the process of cooking the starchy matter of the grain is not only liberated from its protecting envelopes, but it is converted into a gelatinous condition which readily yields to the diastasic ferments. Roberts, in his lectures on the Digestive Ferments, points out the fact that when men under the stress of circumstances have been compelled to subsist on uncooked grains of the cereals, they soon fell into a state of inanition and disease.

Animal diet is also more easily digested in the cooked than in the raw state. The advantage consists chiefly in the effects of heat on the connective tissue and in the separation of the muscular fibre. In this respect cooking aids the digestive process. The gastric juice cannot get at the albumen-containing fibrillæ until the connective tissue is broken up, removed, or dissolved. Hot water softens and removes this connective tissue. Hence raw meat is less easily digestible. Carnivorous animals, that get their food at long intervals, digest it slowly. By cutting, bruising, and scraping meat we to a certain extent imitate the process of cooking. In many cases, indeed, ill-nourished children and dyspeptics digest raw beef thus comminuted better than cooked, and it is a matter of observation that steamed and underdone roast meats are more digestible than when submitted to greater heat.

Some interesting observations have been made by Roberts on the effects of the digestive ferments on cooked and uncooked albuminoids. He employed in his experiments a solution of egg albumen made by mixing white of egg with nine times its volume of water. "This solution," says Roberts, "when boiled in the water-bath does not coagulate nor sensibly change its appearance, but its behavior with the digestive ferments is completely altered. In the raw state this solution is attacked very slowly by pepsin and acid, and pancreatic extract has no effect on it; but after being cooked in the water-bath the albumen is rapidly and entirely digested by artificial gastric juice, and a moiety of it is rapidly digested by pancreatic extract."

It is a mistake, however, to suppose that cooking is equally necessary for all kinds of albuminoids. The oyster, at least, is quite exceptional, for it contains a digestive ferment—the hepatic diastase—which is wholly destroyed by cooking. Milk may be indifferently used either in the cooked or uncooked state, and fruits, which owe their value chiefly to sugar, are not altered by cooking.

The object in introducing here these remarks on cooking food is to show that it forms an important integral part of the work of digestion, and has a direct bearing on the management of all forms of dyspepsia.

CONSTIPATION.

BY W. W. JOHNSTON, M.D.

SYNONYMS.—Costiveness, Fecal retention, Fecal accumulation, Alvine obstruction, Obstipation. Ger. Koprostase, Stuhlverstopfung, Hartleibigkeit, Kothstanung. Fr. Constipation, Paresse du ventre, Échauffement. It. Constipazione. Older synonyms: Constipatio vel obstipatio alvi; Alvus tarda, dura, adstricta; Tarda alvi dejectio; Obstipatio alvarina; Stypsis; Coprostasis (Good).

NATURE AND DEFINITION.—The act of defecation is almost wholly due to the working of an involuntary mechanism which may be set in play by the will, and is in part dominated by it, but which is frequently independent and uncontrolled by volition. Deep inspiration, closure of the glottis, downward pressure of the diaphragm, and contraction of the abdominal muscles are accessory, but not essential, to the expulsion of feces from the rectum. In certain persons, and occasionally in all persons, especially in diseases where the fecal mass is in a semi-fluid or fluid form, the strongest effort of the will cannot resist the expulsive contractions of the rectal muscle. The sphincter is kept in a state of tonic contraction by a nervous centre situated in the lumbar portion of the spinal cord. The fecal mass, supported by the bladder and the rectum, does not at first touch the sphincter; the rectum is usually empty; but when the column has been well driven into the rectum peristaltic action is excited in the rectal walls and the sphincter is firmly pressed upon. The lumbar sphincter centre is now inhibited, and the ring of muscle opens, the accessory and voluntary muscles contract, and the expulsive act is completed. In the well-ordered and healthy individual the rectal walls and the sphincter do not receive the maximum of irritation from pressure of the advancing column but once in twenty-four hours. The habit of having one movement in each day is, it may be believed, in accordance with the natural and physiological demand, although both the number and the hours of evacuating are fixed to a great extent by education. The habit once established, the mechanism of expulsion recurs at the same hour and entirely without the direction of the will. If the desire be resisted, it will be most apt not to return until the same hour on the next day.

Defecation depends for its normal character upon the healthy functioning of the organism, but especially upon the normal processes of digestion. The character of the rectal contents as to composition and consistence, and the time of the arrival of the mass at the sphincter, are [p. 639]regulated by the taking of food at stated hours and by its normal digestion and absorption. Unaltered or partly-changed remains of the ingesta pass down the bowel, mingling with the secretion from the intestinal glands and with mucus and epithelium. As this mass passes into and through the colon, being propelled by regular peristaltic waves, it acquires odor from the development of a substance which is a final product of the putrefaction of albumen.1 Gradually the more fluid elements are absorbed, and in the descending colon a less fluid or semi-solid consistence of the feces is reached. A healthy digestion and assimilation, with active and regular contractile movements of the muscular walls of the small and large intestines, are essential to normal defecation.

14. Food which has but little waste to be got rid of—as milk or beef—leaves a small residuum to be propelled along the intestine, and therefore in one sense is constipating. Insufficient food acts in the same way. An indigestible diet in excess, especially vegetable food, a large part of which is insoluble, constipates by filling the bowel with matter which cannot be got rid of, and chronic catarrh results. The stones and seeds of fruits, as cherry- and plum-stones, raspberry- and currant-seeds, husks of corn and oats, produce acute or chronic constipation with serious symptoms. Intestinal worms (generally lumbricoids) when in large numbers cause obstruction of the bowel;8 and various foreign substances taken by caprice or to take the place of food have produced the same result: among these stick cinnamon,9 sawdust,10 and clay (among the clay-eaters of the South) have been mentioned. Magnesia, insoluble pills, and other medicines sometimes form concretions in the bowel. Enteroliths and accidental concretions form in the intestinal canal and are sources of obstruction. Any foreign body is a nucleus around which concentric layers of phosphate of lime are deposited, and thus a hard calculus is formed. Gall-stones may pass into the canal and there accumulate in such numbers as to interfere with the passage of the fecal matter.

The sigmoid flexure is usually the seat of the greatest dilatation; its expansion may be a cause or a consequence of constipation.12 It may reach a maximum of distension when it fills the entire abdominal cavity, compressing all the abdominal organs and pushing the stomach, liver, [p. 644]and intestines into the thorax. In a case of this kind the circumference of the dilated part was twenty-seven inches.13 The descending colon may be distended with the sigmoid flexure, or the whole colon may be dilated from the upper part of the rectum to the cæcum;14 the same thing happens rarely in the small intestine. In one case, in which there was an accumulation of feces in the sigmoid flexure, the large intestine presented itself as two immense cylinders lying side by side, extending from the epigastrium to the pelvis.15 Each was about five and a half inches in diameter, and together they filled the abdominal cavity. The circumference of the stretched colon varies from ten to thirty inches. Pouches forming little rounded tumors are seen on the outer surface of the colon; they are sometimes hernial protrusions of the mucous membrane through the muscular coat (Wilks and Moxon), or if large they are dilatations of the pouches of the colon.16

Collections of fecal matter may be found in any portion of the colon, but more frequently in the rectum, sigmoid flexure, descending or [p. 645]transverse colon, or cæcum. They lie within the intestinal tube, partly or wholly occluding it, or within lateral pouches, forming tumors which are sometimes quite large. In this last form there is no obstacle to the free passage of feces along the canal. Fecal accumulations occur as small round, oval, or irregularly-shaped lumps (scybalæ), and are often covered with layers of transparent semi-fluid mucus, puriform mucus, or mucus in filaments. The small concretions vary in density; they may be so hard as to resist the knife, and may be mistaken for gall-stones; larger masses, semi-solid or solid, are most commonly seen in the rectum and sigmoid flexure. Here the collection may reach an immense size. In one case fifteen quarts of semi-solid, greenish-colored fecal matter were removed at the autopsy.19 In two other cases the weight of the feces found in the bowel was thirteen and a half20 and twenty-six pounds21 respectively. The whole colon from the anus to the cæcum may be filled with such a mass, as in a case mentioned by Bristowe, where the colon "was completely full of semi-solid olive-green colored feces. The small intestines were also considerably distended, ... and were filled throughout with semi-fluid olive-green contents."22

The color of these collections is black, reddish, deep green, or yellow. In composition the scybalæ, concretions, and larger masses consist of fecal matter, with unaltered vegetable fibre; they may be composed partly of skins of grapes, cherry-stones, biliary calculi, hair, woody fibre, magnesia, or other foreign substances. Where fecal concretions long remain in the intestine they acquire a hardness like stone, and can with the microscope only be distinguished from mineral matter.23 Hemorrhoidal tumors, anal fissures, perirectal abscesses, fistulæ communicating externally or with the gut, are found in connection with constipation. Abscess of the iliac fossa has been observed in the same relationship.24

SYMPTOMS.—In persons who have a daily movement an occasional interruption of two to four days may take place without local or general signs of inconvenience. It is often asserted by patients that one day's omission induces suffering, and recourse is immediately had to laxatives. This may be justified sometimes, but in the majority of cases no actual suffering follows a very rare and short constipation.25 If, however, symptoms do occur after a constipation of one to three days, there is a sense of fulness and heat about the rectum which is greater after stool; when the bowels are moved, it is with effort (provided that no enema or purgative has been taken), and the bulk of the expelled mass is much greater [p. 646]than usual, being moulded and hardened from its longer retention in the rectum. The margins of the anus are tender, and the unsatisfied feeling after stool is due to distension of the hemorrhoidal veins and oedema of the tissues around them—a condition which ends in painful or bleeding hemorrhoids. There are signs of impaired digestion, loss of appetite, a coated tongue, oppression after eating and flatulence, and distension of the abdomen. Headache is apt to be present, with flushing of the face and general discomfort or irritability of temper. These phenomena may all disappear within two or three days by a spontaneous stool or by the use of a purgative.

The skin is often parched, sallow, and is sometimes covered with eruptions, as acne, psoriasis, eczema, erythema, or prurigo. Injuries, wounds, and cracks of the skin heal slowly.

TREATMENT.—The physician can render great service by giving to parents advice which will prevent constipation in children. He should insist upon the importance of habits of regularity in defecation. At the period of puberty in young girls this is of even greater moment, and no opportunity should be lost for pointing out the danger of neglect. As a prophylactic measure in adults counsel should be given suited to the occupation. To persons leading sedentary lives the necessity of exercise ought to be made clear. In the trades little can be done, but in the case of literary men and those who read or write for many hours prevention is easier than cure. Daily exercise, walking or riding, frequent bathing with active sponging and friction of the surface, especially over the abdomen, will be of much service. Avoiding constrained positions where pressure is brought to bear upon the abdomen, as in bending forward to write, is quite an important item. Among ignorant people advice of this kind is rarely attended to, but even here the doctrine of regularity should never cease to be preached. Active business-men, especially young men, need emphatic teaching. They cannot plead ignorance for the habitual and persistent neglect of the simplest rules of health of which they are in this country so often guilty. The symptoms of indigestion which are precursors of constipation should receive due attention, and a mode of life and dietary suited to a complete digestion of the food will favor the timely and proper expulsion of waste matter.

When it is desirable to empty the bowel in acute constipation a warm-water enema for adults and children is the best means. When a laxative is necessary in case of a failure of the enema, one mild in its operation [p. 652]should be chosen—a compound rhubarb pill, one to five grains of calomel, a teaspoonful of Rochelle salts, or half a bottle to a bottle of the solution of the citrate of magnesia or the tartro-citrate of sodium. For children calomel, in doses of one-third of a grain to one grain, is one of the most certain and least objectionable. One grain of powdered rhubarb can be added to this for a more active effect.

Under such circumstances as a blocking up of the bowel with a mass of partially digested or undigested food, fruit-stones, skins, or other foreign bodies, where the symptoms are violent pain, tympanites, and vomiting, the best method is to give large enemata of warm water through a long rectal tube passed as high up as possible, and to administer calomel in doses of one to three grains, repeated every two to three hours until the bowels are moved. Cold can be applied to the abdomen to diminish tympanites and prevent inflammation. Should the constipation not yield and the pain, vomiting, and tympanites augment, the case will then be considered one of intestinal obstruction, and be treated as such.

When called upon to treat chronic constipation, the physician should remember that it is not the symptom, but its causes, to which he should direct attention. Constipation is so often a symptom, a complication, of other diseased states that its management is a matter of secondary importance. Moreover, its causes are so peculiar to the individual and depend upon so many variable habits of life that each case asks for special study. The cure is only to be found by learning the particular cause—the habit of neglect, hurried eating, the use of aperients, uterine displacement, or any of the many causes enumerated.

The digestion and all that concerns it is of primary importance, and to it attention should be at once directed. The stomach and intestinal digestion should be examined separately, and the relative power to digest different articles of food determined. A diet, then, should be selected, not with a view to correcting the constipation, but as to its suitability to the digestive capacity of the patient. No system of diet can be fixed upon as suited to every case: the aim is to secure normal digestion and absorption and normal peristalsis. Many trials may have to be made before a proper dietary can be chosen. When there is indigestion of fats and malnutrition, with pale offensive stools containing much mucus, an exclusive nitrogenous and easily digestible diet—such as is advised in the article on INTESTINAL INDIGESTION—should be prescribed. In constipation connected with membranous enteritis a similar system of diet is proper. The drugs given should be those which aid intestinal digestion, and reference must be made again to this subject, already treated of. Many cases of constipation can only be cured by this treatment; the routine treatment by purgatives and a diet of vegetables and fruits would aggravate and not relieve. A course of exclusive milk or skim-milk diet, if persevered in for some weeks, will cure cases of constipation of this kind without the use of laxatives. Of course a purgative must sometimes be given if enemata fail, but the least irritating one should be selected.

The best diet for cases of atony of the colon and rectum is one which is easily digested and has a moderate amount of waste, as a full colon will stimulate muscular action. Various articles are suggested with a view to excite peristalsis by irritation of the mucous surface, but as such substances are in themselves insoluble and innutritious, it is unwise to resort to them. The following list includes the foods suitable to such cases: Fresh vegetables, as spinach, raw or stewed tomatoes, lettuce, kale, salsify, peas, asparagus, kohlrabi, and other summer vegetables; in winter canned vegetables, if well prepared, take their place. Among fruits, fresh fruit in general, especially grapes, peaches, and oranges; dried fruit, as figs, raisins in small quantity, stewed prunes, and baked or stewed apples, can be tried.

Too much vegetable matter is harmful, as the bowel is filled with an excess of waste, much of which is undigested food; the quantity must be regulated by the appearance of the stools and by the success of the regimen. If the blockade continues obstinately, the vegetable diet should be reduced. The microscope in many cases can alone decide the amount of undigested vegetable matter. Meats are all advisable in moderation. The least digestible, as ham and veal, are to be avoided. Graham-flour bread, brown bread, or bran bread are better than bread made of the best bolted flour. The first is more digestible, and bran bread46 is thought to increase peristalsis, but this is a doubtful effect. Oatmeal well boiled, fine hominy, corn meal, or cracked wheat with milk are pleasant and digestible. A cup of café au lait at breakfast or before breakfast is the best morning drink;47 it has a laxative influence. Tea is thought to have the opposite effect. Milk at breakfast answers well for those who take it with relish. An orange on rising in the morning is a pleasant remedy.