There are some cases of atonic dilatation more difficult to treat. These especially follow severe illness, neurasthenia, prolonged mental exhaustion, worry, and anxiety. The treatment of these cases must be somewhat different. They should be confined to bed, and given a diet which contains very little carbohydrates. The patient should be fed every two hours with a small meal. The food should consist of one to one and a half pints of milk enriched with plasmon or sanatogen in four doses four hours apart. At the intermediate meal he should have raw eggs, scraped beef, beef-juice, pounded chicken or fish, with a small thin strip of dry toast or a bit of pulled bread. The total quantity of food must be small, and not more than a bare sufficiency for a person at rest. After ten or fourteen days of such feeding the patient may be allowed to sit in a chair for an hour or two at a time, and the food may be improved, but each meal should be followed by rest in bed. The diet may now consist of something like the following:-

Breakfast

Two eggs or five or six ounces of light fish and two ounces of dry toast or pulled bread; a cupful of tea or cocoa made with milk at the end of the meal.

Lunch (11a.m.)

A glass of milk, with a sandwich of tongue or pounded chicken.

Dinner (2 P.m.)

Oysters (four or six) or fish, followed by two or three ounces of scraped meat, pounded chicken, tongue, or tripe; a tablespoonful of mashed potato, and a slice of dry toast; followed by a tablespoonful or two of junket, custard, milk jelly, or ordinary jelly and cream; a glass of milk to drink or a glass of red wine.

Tea

A cupful of China tea and a plain biscuit or dry toast.

Supper (7 P.m.)

Similar to dinner.

Bedtime

Milk and sanatogen or plasmon.

In obstructive dilatation other factors come into the problem. In primary atonic dilatation the motor power is absolutely defective, and the idea is to give foods of such a character that they can be quickly passed on to the intestine, where their digestion will almost entirely be performed. In secondary or obstructive dilatation the motor power is at first only relatively defective, there is an obstruction to the passage of foods into the bowels, and the main idea is to give foods which will be digested in the stomach and absorbed through its mucous membrane. It is absolutely useless in such a case to fill the stomach with bread and potatoes, oatmeal, milk puddings, rusks, biscuits, or vegetable purees; they cannot be digested in the stomach and their passage into the bowels is hindered. Moreover, their presence encourages fermentation, with its attendant heartburn, acidity, belching, regurgitation or vomiting. All foods of this class must be entirely removed from the dietary. Milk is still one of the best foods; but it must not be given alone, because of the tendency to form hard curds. It should be combined with citrate of soda, extract of malt, or it may be peptonized. Thus the formation of large curds will be prevented. Moreover, the addition of a tablespoon-ful of extract of malt or half an ounce of milk-sugar to cow's milk increases the proportion of soluble nutriment which may be absorbed. Extract of malt contains maltose which is less liable to fermentation than lactose. In addition to milk we can give raw eggs, scrambled eggs, egg custard, scraped or minced meat, potted tongue, pounded chicken, soft or light fish, oysters, meat-powders, meat-extracts, plasmon, sanatogen, protene, eucasein, and somatose. The total daily amount should include three pints of milk, two eggs, ten and a half ounces of meat, fish, chicken, etc., and one or two ounces of extract of malt. The proper plan is to reduce all food to a pulp by a fine mincer, to remove stringy or fibrous portions, and pass all through a sieve.

If the obstruction increases, it is possible that no food but peptonized milk and similar articles will be retained. We must then confine our attempts at feeding to the administration of peptonized and pancreatized milk, Mosquera's beef meal, meatox (beef powder), beef-plasmon, Carnrick's pep-tonoids, Brand's beef peptone, panapeptone, Kemmerich's peptone, Armour's soluble beef, hipi (mutton essence), Darby's fluid meat, etc. The predigestion of carbohydrates is unnecessary if the right kinds are used - namely, extract of malt, milk-sugar, and golden syrup, which will be propelled easily through the pylorus if anything can go. But all dietaries may be useless in bad cases, and nutrient enemata have to be resorted to until the operation of gastroenterostomy is performed to make a new opening between the stomach and bowels.

Other points in treatment of all cases are important. The patient should rest after every meal, and lie on the right side to facilitate the passage of food into the bowels. The patient should wear a flannel belt with a pad over the umbilicus. Massage is valuable, especially skilled massage of the abdomen at a proper interval after meals. General massage of the body and all tonic and recuperative measures are useful. Gastric lavage or washing the stomach out will restore tone to the stomach, remove fermented materials and micro-organisms, and cleanse the mucous surface. It should be done once a day with an alkaline water (bicarbonate of soda or magnesia), a solution of tannin, or proper Spa waters. After each lavage a dose of olive oil would tend to remove pain and irritation. Exercise in the open air, on foot or horseback, golf or tennis, is beneficial to those able to take it. Indolence and a sedentary occupation should be avoided. Change of air to a bracing climate is very good for all cases. Encourage the patient, avoid depressing tales and circumstances.