In this entire group the ordinary way of nutrition, while at times somewhat impaired, is, however, always possible. The extrabuccal alimentation is here employed as a means of curing or ameliorating diseased states.

This group may be suitably divided into two parts: (a) diseased states of the digestive tract proper (exclusive of stenoses); (b) diseased states of other organs situated without the digestive canal.

(A) Diseased States Of The Digestive Tract Proper (Exclusive Of Stenoses)

Severe inflammatory processes, injuries, and ulcerations of the digestive apparatus often demand perfect rest of the affected part in order to achieve complete recovery. This, however, is possible only then when the food contact is entirely removed from the diseased area.

If the lesions just named involve the mouth, pharynx, or esophagus, gastral alimentation by means of a stomach-tube or a thin tube à demeure will be resorted to.

In case the seat of the lesion is located in the stomach or duodenum, duodenal alimentation will be employed. It is self-understood that in affections of the duodenum the capsule end of the tube will have to lodge about 5 to 10 cm. or still more below the diseased part. In fresh hemorrhages of the esophagus, stomach, or duodenum rectal alimentation is best administered during the first two or three days, and then duodenal alimentation instituted. Ulcers of the stomach and duodenum have been particularly benefitted by this mode of treatment. Besides in the affections just mentioned duodenal alimentation can be employed to great advantage in the following conditions: dilatation of the stomach (due to weakened musculature) and severe neuroses accompanied by persistent vomiting.

In case the above lesions (described at the beginning of this group) are situated in the small intestine, rectal alimentation is employed, if needed - and if located in the colon - subcutaneous alimentation. It is self-understood, however that in the last-named instances artificial nutrition will be resorted to merely as an extreme measure, for neither rectal nor subcutaneous alimentation, nor the two combined, are able to supply adequate nutrition to the organism.

(B) Diseased States Of Other Organs Situated Without The Digestive Canal

At first sight it appears rather strange that artificial nutrition should be indicated in diseases of organs not participating directly in the act of digestion. If we consider, however, what intimate relations exist between the digestive apparatus and the organs of circulation as well as of elimination - with each ingestion of food there is an overflood-ing of the circulation with new material and as a consequence an augmented activity in the circulatory and eliminative systems - it is plausible that leniency toward the digestive tract will exert a beneficial influence on other remote organs.

In fact it has been long known that a scanty insufficient nutrition, as, for instance,"Karell's diet," applied for a short period, is of distinct benefit in disturbed compensation of the heart.

Occasionally the ingestion of the smallest amount of food into the stomach produces an irritative state of the neighboring organ, the heart, especially if the latter is badly diseased. In such instances artificial nutrition (rectal or duodenal alimentation) may be indicated.

In two cases of severe myocarditis causing stenocardia in a high degree - and in which the minutest quantity of food given by mouth brought on attacks of severest dyspnea greatly endangering life - I have seen duodenal alimentation applied without the slightest inconvenience to the patient. This mode of nutrition greatly alleviated the condition of the two patients and prolonged their life.

There is, therefore, an indication for artificial nutrition in severe affections of the heart in which the ordinary mode of alimentation is accompanied by severe dangerous symptoms. Rectal or, still better, duodenal feeding will then be used.

Diseases of the fiver occasionally require a course of artificial nutrition (rectal or, still better, duodenal alimentation), in order to relieve somewhat the functions of this important organ. In several cases of cirrhosis of the liver1 I have observed the greatly beneficial influence of duodenal alimentation on this disease.

1 Max Einhorn: On the Beneficial Effect of Duodenal Alimentation in Cirrhosis of the Liver, Medical Record, July 26, 1913.