In emergency methods of feeding, it will be found much easier to maintain good nutrition if the following points are remembered: the introduction of sufficient water, often by a different route from that used for the food; the introduction of 5 - 10 grams of salt, as such; the daily or occasional addition of fruit juice; the feasibility of employing 50 - 100 grams of glucose daily. Glucose is most conveniently obtained as a clear, very thick syrup, of 80 - 90% strength, and therefore yielding 3 - 3.5 calories per c.c.

Nourishment by Enemata still involves several moot points. One school advocates the use of small injections, 60 - 100 c.c, at intervals of two or three hours, another of larger amounts, 250 - 500 c.c, or even more, at intervals of 12, 10, 8 or 6 hours. Some consider peptonization necessary, others not, and among the latter are optimists who regard peptonization as unnecessary because they believe the nourishment to be pretty well absorbed without preparation, and pessimists who hold that even with peptonization, not enough is absorbed to be worth while, so that the method is considered as a placebo. Some add laudanum or some other anodyne or local anaesthetic, as a routine to each injection; others oppose such measures on general principles. Some follow the rule of introducing, in any one day, as much nourishment as possible, by all routes, or, practically, by the two routes of the mouth and the rectum; others hold that, unless in extreme and temporary emergency, one method should be used exclusively, to obtain physiologic rest of the other apparatus. The choice of technic also differs widely.

With so much difference of opinion, it is impossible to avoid personal bias. However, the principles stated are well supported by authority, and it would seem that, in each case, the more logical or more established of two contradictory views is chosen.

Rectal nutrition never approaches complete utilization of the food introduced. The proportionate waste varies within wide limits, is almost always as much as 50%, and, if the injections are not held for at least an hour, it is practically total. Even under the most favorable circumstances it is not feasible to secure more than about half of the standard degree of nutrition - in other words, it is almost never possible to introduce more than the standard mouth ration by the bowel, nor to have more than half absorl)ed. While it has been proved that some degree of digestion occurs by means of ferments present in the lower bowel, the process is undoubtedly reinforced by artificial peptonization, or rather by the joint action of the various pancreatic ferments. Considering the inevitable inadequacy of the method in general, every device to secure better utilization of food should be em-ployed. Whether the vegetable ferments, as of pawpaw, are superior to pancreatic extracts, has not been decided. Opium and local anaesthetics are not usually necessary, unless the bowel is exceptionally intolerant or the patient unreasonable. As they certainly check the digestive and absorptive functions, they should not be used unless absolutely necessary, and if tact and gentleness are employed, they may usually be dispensed with, or, at most, need to be used only occasionally. Two or three hours' retention of the enema is necessary to secure any considerable degree of absorption, and double this time is desirable. Hence, allowing an hour for bowel movements after the preparatory cleansing injection, which is almost always necessary, the nutrient injections can not be given more frequently than every three or four hours, and, preferably, every six to eight hours. If this point is granted, it is a simple matter of calculation that the small injections sometimes recommended are utterly inadequate.

It is a matter of experience that rectal feeding cannot be continued for more than a week or two - with rather infrequent favorable exceptions, in which it may be continued even as long as six or eight weeks - without producing intolerance of the bowel. On the other hand, rectal feeding is usually necessary on account of some gastric condition, such as ulcer, cancer, extreme stagnation from benign obstruction, etc., in which physiologic rest of the stomach is required, and almost as much harm will result from the swallowing of small quantities of food as of the adequate minimum ration. Hence, generally, the advantage of using the combined methods of nutrition is only temporary and specious, and only one method should be used at a time. However, if there is merely a failure of digestive power, as in typhoid fever, or if an operation for the relief of an obstruction is necessary and it is only a matter of securing as complete nutrition as possible for a few days, both methods may be used at once.

While the physician should not deceive himself with the notion that rectal alimentation can ever be physiologically satisfactory, and while, in inevitably fatal conditions, the discomfort to the patient may counterbalance the indication to prolong life, the extreme pessimistic view that rectal nutrition is merely a placebo is not warranted, and this method should be practiced with the feeling that it is doing the best possible under unfavorable circumstances.

If the bowels have been moving freely and there is good reason to believe that the rectum is empty or nearly so, the preliminary cleansing injection may be omitted. Otherwise, as a routine, the rectum should be syringed out with a luke-warm physiologic salt solution about an hour before the nutrient injection is given. After the bowels have been thoroughly cleared out and mouth feeding has been suspended for two or three days, the rectum, in favorable circumstances, retains the nutrient injection for four or five hours or more, and then discharges the residue in one movement, without much indication of putrefaction or fermentation. In such cases, the routine use of the cleansing injection is unnecessary. The physiologic salt solution may still be given to supply liquid to the system, either by the bowel or through the skin, or water may be given by the mouth, according to circumstances.