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tarrh is unfavorable as regards young children and old persons, the attendant disturbances of nutrition not being well borne by either. It has been estimated that intestinal catarrh constitutes one third of the total number of the affections of childhood; the chief cause operating in the production of the disease being a diet other than the maternal mammary secretion or an improper diet at any period prior to dentition. Proper care and intelligence in this ætiological feature would materially lessen the high mortality-rate.

Non-inflammatory catarrh of the small intestine is amenable to treatment, after the alimentary crisis has been relieved by two or three loose stools, followed by an infusion of beef a few hours before resuming the maternal or other diet suitable to the age of the patient. When the chronic form has become established, the prognosis is unfavorable in infancy and old age alike. In middle life, the prognosis is also unfavorable, not from an early fatality, but from the long continuance of impaired nutrition, and from irritation of the general nervous system due to the anatomico-pathological changes incident in part but mainly to the condition of the large intestine.

TREATMENT.-Chronic intestinal catarrh, from the first, involves the nutritive powers in progressively-increasing failure, resulting in marasmus, sooner or later, except when, from extraneous causes, an intercurrent disease produces death. Medicines are nearly or quite impotent to cure, and they serve in a palliative way only, in the attendant constipation, flatulence, diarrhcea, and the like, and in the reaction of these disturbances upon the nervous system. To prevent starvation is the work of greatest moment. In this disease, we should seek to throw the greatest weight of burden upon the stomach by the selection of food from the nitrogenous class; namely, fresh beef and mutton in suitable quantities, boiled, roasted, or converted into soups seasoned with pepper and salt, raw oysters, fresh fish, the white meat of fowls broiled, and milk, when it digests without leaving an unpleasant sense of distention in the hypogastrium one or two hours after being taken into the stomach. A small quantity of stale, light bread, made from

wheat-flour, may be taken if it be thoroughly masticated and insalivated. When the stomach is weakened, digestion may be aided by a solution of pepsin in combination with dilute hydrochloric acid. Suitable quantities of gentian or ipecacuanha may be given to excite the peptic glands to increased action. The peptonized extract of beef, representing the entire substance of the meat, may be used for a short time, when an irritable condition of the stomach exists, repugnance to the taste and the lack of normal distention of the stomach being the chief objections to its use. We are more particularly concerned, however, in intestinal digestion and assimilation, since the small intestine has received the initiatory lesions that have finally culminated in chronic catarrhal inflammation involving a part or the whole of the small and large intestines. The digestive forces are more pronounced in the duodenum, and they grow progressively less until the caput coli is reached. The duodenum receives the pancreatic secretion containing a ferment which transforms starch into glucose, and again, there is another principle in the pancreatic secretion, called trypsine, which changes the proteids, that have passed from the stomach into the duodenum, into peptones. In the duodenum, also, by the action of the pancreatic juice aided by the bile, oil is emulsified and is taken up by the lacteals. With this brief and imperfect sketch of physiological digestion occurring in the duodenum, we can readily appreciate how profound the disturbances to nutrition must become, when this part of the intestinal tract is in a state of catarrhal inflammation, partially or totally closing the pancreatic and the choledoch ducts. The logical conclusion, therefore, would be, that it is not judicious to select food from the class of hydrocarbons, when the duodenum is in a state of acute inflammation. When the small intestine below the duodenum is in a condition of catarrhal disease, the normal functions of the follicles of Lieberkuhn are impaired, and intestinal digestion would be still more weakened as regards the amylaceous group of alimentary substances. In this general morbid condition of the intestine, artificial digestion can be employed with great advantage by the use of pan

creatine, one and a half or two hours after meals, when solid articles of food belonging to the starchy group have been taken.

Gruels made from any farinaceous articles, with or without milk in combination, adding liquor pancreaticus when the gruel is of the temperature of 130° or 140° F., may be eaten when cool. Baked beans, with the hulls removed by a sieve and subsequently made into soup, treated with liquor pancreaticus in the same way as gruel, will be found to be a palatable food. Gruels treated in this way are, also, proper and convenient for purposes of rectal alimentation. Patients may be sustained many days, or until the crisis of acute gastritis or duodenitis has passed, by the use of pancreated liquid food administered by enemata.

Patients suffering from a mild form of chronic intestinal catarrh, with weakened intestinal digestion and feeble peristaltic action, frequently derive great benefit from the use of a teaspoonful of liquor pancreaticus, with one third of a teaspoonful of bicarbonate of soda (fifteen grains) in water, two or three hours after meals; and a pill composed of aloes, rhubarb, or compound extract of colocynth and extract of hyosciamus at bedtime, for the relief of the constipation, will generally secure pleasing results.

In the more severe forms of the disease in question, next to dietetic measures, the irregular and enfeebled peristaltic action of the large intestine presents the greatest obstacle to a successful and satisfactory treatment; and we are, therefore, compelled to resort to drugs, almost daily, to meet this difficulty. The drugs that may be used either separately or in combination, are very many; but only a small number of the established remedies are necessary, colocynth, calomel, aloes, ipecacuanha, rhubarb, castor-oil, and the like, being generally sufficient.

For constipation mainly limited to the rectum, satisfactory relief may be obtained by enemata of tepid water with the addition of olive oil; and, when anal irritation is present, resulting from the passage of hardened fæces, the use of injections of tepid water, after the stool, for the purpose of

removing any remaining fæcal matters, may be employed with advantage.

The bromides, hyosciamus, subnitrate of bismuth, cannabis Indica, atropine, and opium, will be found useful in the management of disturbances of the nervous system. On account of its constipating effects, opium in any form should not be used except when absolutely required.

INTESTINAL OBSTRUCTION.

By AVERY SEGUR, M. D., of Kings County.

Read November 18, 1884.

A PERSON in ordinary health is seized with pain, more or less severe, in some part of the abdomen. The pain continues, nausea supervenes, and, perhaps, vomiting. Soon tenderness is developed, with moderate distention of the bowels. There may have been previously, constipation, or indigestible food may have been taken, or there may have been exposure to cold, fatigue, etc. Ordinary remedies are taken, and pretty certainly a domestic cathartic. This may excite more pain and vomiting, or quite possibly one or two stools may follow. No relief, however, is obtained, and a physician is called to the case.

A diagnosis is felt to be a necessary precedent to good practice. The patient is examined with due care. No hernia is recognized. No local signs of inflammation are discovered. The evidences of any anatomical or mechanical obstruction are wanting. The previous history of the individual is carefully elicited. It may be that the patient has had similar seizures before, which have, after a doubtful progress, happily passed away, but have left no certain clew to the nature of the past or present attack. The physician finds himself unable to make a diagnosis at this stage of the case, and he is forced to treat the symptoms.

Pain requires anodyne, and morphine is injected under the skin. The bowels require both sedation and evacuation, and ten grains of calomel are administered once and again, or even cathartic pills are prescribed. The bowels do not respond to

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