It is obvious that if small nutrient injections of 60 - 100 c.c. are used, a piston or simple bulb and tube must be used to prevent undue waste. If, on the other hand, large injections are employed, the fountain syringe affords the steadiest flow and is most convenient. It is difficult to use the Davidson syringe without waste and without introducing air and stimulating peristalsis by the irregular force employed. All manipulations should be gentle, extremes of heat and cold should be avoided, the buttocks should be held together to reinforce the retentive action of the sphincter, and moral suasion should be employed to secure the co-operation of the patient.

While it is theoretically advisable to introduce the nutrient injection high in the bowel, repeated observations have convinced the writer that catheters and tubes similar to stomach tubes almost invariably turn, so as to discharge downward near the anus, or assume a spiral course so as to reach no higher than the ordinary rectal tip, and that tubes of large diameter and heavy walls, which can neither buckle nor curve in a spiral, cannot be introduced more than four to six inches. Of course, if X-ray examinations, using a stilette or some similar opaque device, or digital touch actually prove the possibility of high injections, they should be employed, but success is extremely rare, good authority to the contrary notwithstanding.

Ewald advises the use of enemata of a bulk of 250 c.c, two or three times a day, diminishing the bulk and increasing the frequency, if necessary. A teaspoonful of flour is cooked with a 20% glucose solution; two or three entire eggs are stirred in after the mixture has cooled enough to prevent coagulation, and 50 c.c. of claret is added. One gram of salt is added for each egg. Three such injections represent about 1500 calories and about 25 grams of protein. The flour is added rather to render the emulsion of the eggs more complete than for its amount of nutrient. The value of the claret is problematic.

Leuhe advises the use of scraped lean meat with 1/3 part scraped pancreas, to secure digestion. The mixture may be further softened by rubbing in a mortar with a little warm water. Salt should be added. If 750 c.c. arc given in a day, in three or four injections, by a piston syringe with a comparatively large nozzle, this represents about 150 grams of protein and 700 or possibly 800 calories.

Blood, milk, eggs, gruels and meat extracts are commonly used in rectal injections. The writer prefers the following: Milk, 250 c.c, 3 entire eggs, peptonized, 50 grams of glucose, 3 grams of salt, three times a day. This represents about 100 grams of protein and 1400 - 1500 calories. Beef juice, bovinine, etc., may be used in place of part of the milk once a day, or cereal gruels or proprietary milk foods may be employed.

The conditions in which rectal feeding becomes necessary are: Obstruction, organic or even functional, anywhere along the alimentary canal; diphtheritic inflammation of the throat, postdiphtheritic or other form of paralysis, quinsy, post-pharyngeal abscess, foreign bodies, corrosive inflammation or cicatrical narrowing, various malignant, specific or septic lesions, mainly affecting the pharynx and oesophagus; cancerous, ulcerative, pressure or constricting obstruction of the cardia, pylorus, ileo-caecal valve or hitestine generally or, rarely, obstruction by foreign body, impacted gall stone or food remnants, the condition being such as to preclude operation or to afford hope of non-operative relief.

Paralytic, delirious, comatose, insane or hysterical or extremely painful conditions, or prolonged reflex vomiting as from seasickness, in pregnancy, or from gall stones or other more or less remote lesion.

Gastric or duodenal ulcer, acute gastritis, less frequently analogous conditions situated inferiorly, in which physiologic rest is indicated.

Extreme saprophytosis, as in gastric cancer not acting mechanically, and similar conditions of the intestine.

Exhaustion, functional or organic, of the gastric and pancreatic secretions, as in typhoid, shock, Addison's disease, etc. In these cases, some absorption of predigested food may occur from the lower bowel when it would not, if introduced by mouth. There is, here, no objection to simultaneous use of rectal and mouth feeding, as soon as the latter bids fair to be successful.

Intravascular Injections of warm milk were introduced by Hodder in 1850, to combat the collapse of Asiatic cholera, and have been occasionally employed. The transfusion of human blood may be mentioned under this heading, but it has not been permanently efficacious in all cases, and several cases of haemolysis have been reported.

Hypodermatic Nutrition has been mainly limited to the use of oil and of physiologic salt solutions. The former has produced embolism.

While hypodermoclysis has proved of value in shock and collapse, it should be remembered that the delay of sterilization can be avoided by introducing the salt solution by the rectum, that a given quantity of liquid can be much more rapidly introduced in this way, that it can be used at a higher temperature (55 C. or 131 F. is the proper temperature according to Fenton Benedict Turck), and that, in many cases in which the rapid absorption of water is required, local stimulation of the kidneys by the hot solution in the bowel, is also indicated. Hence, con-trary to the rule for medication, recta! injection should be used in emergent cases, and hypodermoclysis in those in which there is no emergency but in which it is not desired to burden the stomach or bowel - namely those in which introduction of food and drink by the mouth is contra-indicated and in which the bowel is taxed by the introduction of organic nutrients.

Alcohol, and if necessary, gelatin solutions, may be introduced hypodcrmatically, but rather medicinally than for dietetic purposes. In all cases the gelatin should be boiled for half an hour or more, to insure the absence of tetanus bacilli.

Soluble albumin, if injected either into a vein or into thesub-cutaneous tissues, acts as foreign matter, at least to a large degree, being eliminated by the kidney. Obviously, too. it can not be sterilized by heat without precipitation nor by chemic means without toxic effects. While serum albumin can be collected aseptically. the danger of haemolysis must be borne in mind. Peptonized protein, if injected, causes toxaemia, with febrile reaction.

Thus, of all the organic nutrients, carbohydrates alone can be . considered available for hypodermatic injection, and, of the carbohydrates obviously, only the sugars, while, of the sugars, the preference should be given to dextrose, as that is the form in which carbohydrates are utilized finally. The writer has, occasionally, for nearly ten years, employed physiologic salt solutions to which 5 - 10% of dextrose has been added. After sterilization by heat, these solutions are injected, 500 - 1000 c.c. at a time, under the breasts or in the abdomen or flanks. 100 - 300 grams of dextrose may thus be given in 24 hours. No untoward results have developed, nor even glycosuria, owing, no doubt, to the slow absorption and the avidity of the system for readily oxidizable food.

Nutrition Through Unbroken Skin

Milk baths have occasionally been used, but their value is doubtful. Cataphoresis might possibly aid the passage of nutrients through the skin, but no definite knowledge is available.

Inunction of various fatty substances has been practiced and there is no question but that 30 - 100 grams of fat or oil may be made to disappear in the skin and when iodized or treated with other test chemicals, the latter have been recovered from the urine, saliva, etc. While it has not been absolutely proved that the fat itself thus introduced, is utilized, this seems altogether probable. As in the case of ingested fats and oils, it is probable that the utilization is directly as the melting point, hence the softer fats or oils, containing relatively more olein and palmitin and less stearin, are to be preferred. On account of the agreeable odor and slight tendency to rancidity, cacao butter is a favorite but cocoa butter, being softer and containing more palmitin, is preferable. Lard, tallow, olive oil, even cod liver oil, may be employed. The last is, obviously, more in use for tuberculosis, especially in young children who cannot protest against the rancid odor. Lanolin and analogous preparations of sheep fat are well absorbed on account of their miscibility with water and it is possible that, by combining with the bacilli, they exert a strictly antibacterial action. Indeed, the freedom of sheep from tuberculosis may be due to their natural fat.

At any rate, it is possible in any case, to administer the full ration of fat through the skin, by inunction, so that the digestive organs may be spared to this extent. Exact metabolism experiments to establish or disprove the dietetic value of fats thus introduced, are lacking.