To those, who, through high-living and overfeeding, have given the liver work beyond its capability, the experience of the fast is often trying. Bile is cast out in large amounts and floods the intestines to such extent that, often before it can be carried downward, some of it finds its way into the stomach, with nausea and vomiting as sequelae. There is no absolute certainty of the appearance of this sign, but it is usually present in the subjects referred to. In extreme form nausea with vomiting suggests either the presence of an obstruction in the small intestines situated below the opening of the gall duct, or that of organic disease of the liver. If the latter exists, the vomited fluid is ordinarily blackish in color; if the former be the case, the bile vomited is usually yellow or greenish-yellow in tint. In any event the symptom is distressing and it may be more or less serious as to cause, but a number of instances with it intermittently in evidence are noted that progressed to favorable outcome.

The above remarks may be amplified by stating that, for the reason that excessive vomiting of bile during a fast is a symptom that indicates the probability of organic disease of the liver or an obstruction of the intestinal tract, in these cases caution is urged in the employment of the protracted fast. The symptom is not to be regarded as alarming when the fluid raised is yellow or greenish-yellow in hue, nor when nausea occurs at infrequent intervals. But if its color be a vivid green or, as in instances of extreme organic derangement, blackish in tint, the case may be considered as serious in character and of doubtful prognosis. In any event, when nausea is present during a fast, it is far better to rid the stomach of its contents through the mouth than to permit them to remain with the certainty of absorption and toxication. For this purpose drinking of warm water, a quart or so at a time, will ease the act of retching, and at the same time will cleanse the stomach. If difficulty is found in vomiting, titillation of the palate with the end of the index finger will usually suffice to cause the muscular contraction necessary. And this sort of stomach lavage is much more simple in operation and just as efficacious as that by means of a pump. In fact, whenever during a fast there is reason to suppose that the stomach because of inaction has gathered secretion upon its walls, cleansing of the organ in the manner described is in order, and it is always beneficial.

There are patients with livers organically diseased who undergo a fast with no appearance of bilious vomit. Observation in post mortem examination leads to the conclusion that these subjects usually are affected with some form of cirrhosis, and the instances referred to were in body of thin and wiry type. On the other hand, those in whom excessive vomiting occurs during fasting usually are inclined to obesity, and, if organic disease exists and death follows, post mortem examination will in all probability show a liver deteriorated or degenerated in structure.

Bile forced into the stomach may produce through irritation spasmodic contractions of the diaphragm, or hiccoughs. These may also occur because of other stimulation of the diaphragmatic nerve, a frequent happening in cases of functional disturbance of the liver or of the small intestines. When the reason for this annoying symptom is purely functional in character, it may ordinarily be quickly relieved by drinking water or by inducing vomiting; but, if it persists, the case at once assumes gravity in prognosis, for in all probability extreme organic defect has been uncovered. This observation is entitled to additional credence because of several instances in whom persistent hiccoughing occurred shortly before death, and in whom the autopsies revealed organic disease of the upper portion of the small intestine.

In the earlier stages of a fast there will probably be fermentation with consequent formation of gas in the bowels, and this may continue for a few days, depending upon the amount of waste retained, and upon what may be termed the virulence of the bilious excretion deposited in the intestinal tract. The gas formed is often the cause of colicky pains, and is always a source of uncomfortable moments until it is discharged. To this end manipulation of the abdomen and hot water applications upon its surface are of much assistance. By these measures peristalsis is stimulated, and the inflated bowel is reduced by forcing the gas to the rectum, thence to discharge. However, the enema is to be regarded as the greatest ally of the body for the assistance of bowel evacuation, and it should be resorted to in the circumstances related and in all other similar situations.

In all cases in the fast the evacuations from the bowels are much alike. At first old feces more or less abundant in quantity are discovered floating in a brownish fluid that often shades to black. Solid waste is usually present for a number of days, although its amount depends in great measure upon the time devoted to preparation for the total abstinence period. These formed feces offer definite evidence of the truth of the statement that an overloaded colon does not fully evacuate its contents even though daily passages are the rule.

At some point or other in the purifying process there appear in the evacuations stringy masses of white or yellowish mucus. In catarrhal cases these are discovered at the beginning of treatment and they usually continue in evidence until purification of the system is completed. In other subjects mucus commonly does not appear until the fast is well under way, but it is certain to be found in the discharges before the end of abstinence.

More extended discussion of this phenomenon will later be given, for upon it is based a most interesting question in pathology. It suffices here to say that, when the intestinal walls are about freed of old feces, and are in the relaxed condition that results from the processes in operation during the fast, bowel excretion takes the form of an exudation of pathogen from the blood, and this waste is deposited in the form of mucus upon the walls of the intestines. The mucus membrane of the latter in its relaxed state will usually freely slough this coating, especially if peristalsis is stimulated by manipulation of the abdomen and the enema is properly employed. The deposit is discharged, often in formed bodies. An instance recurs in which there came away a mass tubular in shape, eight feet in length, a replica of a portion of the intestinal tract. And often shorter formed sections are discovered. This mucus is viscous, glue-like, in consistency, and, when it disappears, systemic cleansing is near its end.