The same kind of catheter and funnel, but with a shorter rubber tubing. is employed for the introduction of fluid nourishment into the stomach. The funnel, tubing, and catheter are filled with the food: the tubing is then pinched while the catheter is being introduced. When the tendency to choking, after the introduction, has ceased, the fluid is allowed to flow as slowly as possibly, to approximate the normal in take of food, interrupting the flow whenever coughing or choking occurs. When sufficient nourishment has been introduced, the tubing is again pinched and the is withdrawn as quickly as possible. In many cases where food is refused owing to weakness, it is possible, at least small children, hy carrying out this method of feeding three to five times daily, to gain time for seVeral days, until nourishment is taken naturally. Sometimes, however, the procedure is attended hy failure, the contents which were introduced being expelled immediately, or Ivithin a short time. It is particularly in such cases, where the stomach is unable to retain anything, that rectal /ruling should be considered. Here it is a question of introducing substances which will be readily absorbed: i.e.. salt, sugar, and alcohol in aqueous solution. beside fat, but, above all, water itself. As a rule, it is possible to give a nutrient, enema only four to five times in the 21 hours. for a few days. It is hardly to be expected that a suflicient quantity of nourishment intro duced into the body in this way for any great period. The quantity ranges from ten to thirty Gm. (,:3--S drams) in infants, up to one hundred Gm. (28 drains) in older children, and only rarely is larger than this. A rectal irrigation must be given once daily for cleansing the bowel, after which the bowel should be allowed to rest at least an hour before introducing the nutrient enema.
For small enemata—about ten Gm. small rubber bulb is used, or, better still, a small piston syringe with a tip sufficiently long. For larger children use an irrigator with a longer semi-soft tip, the tip being well lubricated. Avoiding the entrance of air, the lukewarm fluid is allowed to flow slowly into the rectum. It is best to take milk, to which a little salt and sugar have been added and into which an egg may be stirred (one egg to four ounces of milk). As the fluid is generally the essential ingredient, the white of egg can be omitted. should it cause irritation of the rectum through putrefaction. In its stead alcohol (cognac, etc.) can readily be used if the occasion demands. Particu larly in young children, irritation of the mucous membrane, with dis charge of mucus and tenesmus, soon occurs, or the nutrient enema may be soon expelled, in which case tincture of opium may be carefully added. The indications for rectal feeding, therefore, should be held within nar row limits: i.e., in the uncontrollable vomiting of small children, or the temporary closure of the upper portion of the gastrointestinal tract, better results usually being obtained by other methods.
The mechanical emptying of the rectum is the most frequent pro cedure employed in the nursery, either with rubber bulb syringes (less frequently with piston syringes), or else with the fountain syringe. The fluid is permitted to enter while the child is in the ordinary position on the side, or upon the back with raised buttocks, or even, with older children, in the knee elbow position. This softens the mass in the bowel,
and, assisted by the reflex irritation of the abdominal and intestinal muscles, should produce an evacuation. An indifferent fluid is usually all that is necessary (chamomile tea, or six-tenths per cent. salt solution). Soap water, which is so popular, is more harmful, and is therefore to be avoided in small children; while castor oil (with egg or a little starch), or, if need be, a decoction of senna leaves (one dessertspoonful to one quart of water) acts upon the bowels powerfully and with little irritation. The quantity of the enema ranges between 30 and 50 Gm. for infants and 100 and 250 Gm. for larger children. Smaller quanti ties (30 to 100 Gm.) are required with oil enemata, which should be re tained until the hardened fecal masses have become softened, when after a few hours they will he evacuated spontaneously, for which reason the bed should be well protected. Glycerin enemata occupy a special place, because of the small quantity required (one teaspoonful to one dessert spoonful in equal or double the quantity of water to prevent irritation of the bowel); they are introduced by means of the small rubber bulb or piston syringe, not by means of an irrigator.
Aside from the injuries which may result from the use of hard tips in giving enemata, particularly where the child strains, the ampulla be comes dilated through their constant use, and, even where this does not occur, they lose their effect. If the bowel must be emptied artificially there should at least be a change of method from time to time. But certainly, in most cases, where there is no congenital dilatation of the colon, it should be possible to overcome constipation by dietetic or mechanical methods; i.e., by change in the character of the food, by more exercise, or by abdominal massage. There are a certain number of eases of chronic constipation which fail to respond to ordinary methods and which are psychical in origin; they should therefore be treated by suggestion.
That in the temporary constipation which occurs during acute febrile diseases, an enema is the simplest and quickest procedure, there can be no question; but here also a fixed rule is to be avoided. In con trast with those injections that are employed simply to remove feces, larger injections should be used in acute catarrhal colitis and less often in chronic disturbances of the colon, for the removal of poisonous and irritating matter, thus attacking the seat of the cause of the disease. For local effect a medicament may he put into the first or subsequent injections (tannin, one per cent.; liquor alumini aeetatis (P. G.), one per cent.; liquor phimbi subacetatis, one per cent.,—the latter to be used only once or twice). These injections should not be retained. like those given for moving the bowels, but should be given in a constant stream which is at once allowed to escape; if at the end, however, some of the solution is retained and absorbed, it is of benefit in most instances. In intestinal invagination, high and copious injections are of use only if the invagina tion enters the lowest portion of the colon.