Not infrequently the physician and nurse are confronted with a condition where the feeding by way of the mouth is impossible for a period of a few days, or even in rare cases perhaps weeks. If such a condition happen as a sort of sudden emergency, and the patient is in a well-nourished condition, a fast of seventy-two hours or even more could be well borne. However, as a rule, the condition is found as a culmination of changes that have been going on for many weeks or months, and is usually associated with a considerable disturbance of nutrition and loss of weight. A protracted fast would seriously complicate the case. Nutriment must be given; there must be no interruption in the income of materials for repair and for fuel. This necessitates rectal feeding. When this method of introducing nourishment into the body is followed with the proper technic, it may suffice for maintenance of the body for many days. A few general directions must be observed:

I. The rectum should be prepared for the feeding by a more or less copious injection, whose purpose is to empty and rinse out the descending colon and rectum. At the end of this rectal lavage two or three ounces of normal saline solution (0.6 per cent common salt dissolved in water) may be injected high up in the rectum and left there to be absorbed.

II. For rectal feeding use high injection only, which can be accomplished best through the use of a large catheter or a stomach tube. Normal saline solution and nutrient enemata should always be carried eight or ten inches into the rectum in order to facilitate its retention and its readier absorption.

III. The patient should lie upon his side with the hips elevated when that is possible. When the patient cannot lie upon his side the foot of the bed may be elevated.

IV. The catheter should be oiled with vaselin and should be introduced with great care in order not to irritate the mucous membrane by catching the point of the catheter in its folds. If the catheter is advanced slowly and twisted as it is advanced this can usually be accomplished without irritation.

V. The quantity of the enema should never exceed three ounces for an adult, and would better, as a rule, be one and a half or two ounces. In children it should be proportionately smaller.

VI. As to interval of time, nutrient enemata should not be given more frequently than once in four or five hours. Between the nutrient enemata thirst-slaking enemata may be given in the form of normal saline solution (0.6 per cent sodium chlorid).

VII. As to foods adapted for use in rectal enemata: Among the proteins, white of egg and expressed beef juice are the best adapted of the native proteins. When thus given they should always be salted, as the presence of salt seems to facilitate absorption. The white of egg is, of course, diluted with several volumes of water; the beef juice may be diluted with an equal volume of water. While these proteins will be in part absorbed through the wall of the rectum, absorption of proteins is much facilitated if they are peptonized.

In peptonizing proteins for rectal feeding the pancreatic ferment trypsin should be used, because peptonization with trypsin takes place in alkaline medium, while peptonization with pepsin takes place in acid medium only. A mixture of peptone and proteoses in solution may be given. However, the peptonizing process may take place within the rectum if hashed pancreas or pancreatic extract is mixed with the food. Preparations of "pancreatin" represent the pancreatic ferment and are easily obtainable, and may be mixed with the food in its preparation. The peptonizing process, beginning in the warm food material outside of the body, will continue as absorption progresses until the whole mass is peptonized.

Milk is much used in rectal enemata, but should always be peptonized through the use of pancreatin before injection, as the casein is not readily absorbed. Even hashed beef may be mixed with pancreatin and reduced to a pasty mass diluted with several volumes of normal saline solution and serve as one source of protein food.

Unchanged fats, as olive oil, cream, and butter, seem not to be absorbed from the rectal mucous membrane. It is, therefore, useless to introduce fats in any form as they not only fail to be absorbed, but may interfere with the absorption of other foods. Even the yolk of egg contains too much oil to make it a favorable rectal food. Applying the general principle of predigestion of rectal food, we would expect fat to be largely absorbed if introduced in the form of a very dilute soap solution. Inasmuch, however, as the carbonaceous foods are amply provided for in the absorption of sugars and starches, there would seem to be no special advantage in the use of fats.

Sugar is readily absorbed from the rectum, but its solution should be quite dilute, never exceeding three or four per cent in strength. When peptonized milk is used, the milk sugar represents just about that strength, and no more sugar need be added. When beef juice or white of egg is used sugar may be added up to the proportion suggested. If sugar or salt is present in the rectum to a greater degree of concentration, it is likely to act as an irritant to the rather sensitive mucous membrane and lead to an expulsion of the contents. While thoroughly boiled and diluted starch is in part absorbed from the rectum, the proportion absorbed will be very greatly increased if a diastasic ferment is added, as this will digest the starch, reducing it to maltose.

Some of the nutrient enemata that have been devised contain wine, but inasmuch as wine interferes somewhat with the absorption of foods present, its admixture with an enema is not advisable.

If the physician wishes to administer alcohol, that would best be done in a separate enema when the rectum is free from food; it should be diluted with normal saline solution and should not exceed four or five per cent in strength. Not over three ounces should be given at one enema. About the proper strength would be attained by adding one teaspoonful of grain alcohol to three ounces of normal saline solution.

It sometimes happens that the patient has a good deal of difficulty in retaining the contents of the rectum. Observe the following precautions: Introduce the enema very slowly, having it at body temperature; introduce it through a narrow catheter put high in the rectum, the patient lying upon his side. Firm pressure should be exerted over the anus with a towel for some minutes after the introduction of the enema. If, after observing all of these precautions, the patient is unable to hold the contents in the rectum, then it may be made less irritable by adding five to ten drops of laudanum to the enema. As the use of an opiate for this purpose interferes slightly with the absorption of the food and exerts its regular systemic effect, it is better never to use it unless absolutely necessary.