Rectal Alimentation

Before taking leave of this very interesting class of diseases and of their modes of treatment, it seems proper to introduce a few remarks upon the subject of rectal alimentation, as it is now a well-recognized and much-practised means of sustaining those whose stomachs are unequal to the work which in health is so easily and unconsciously performed. In the use of the lower bowel as an absorbent surface of alimentary substances many failures have been reported, a fair proportion of which, it is safe to infer, are due to the methods employed, to the nutritive matters employed, and to the condition of the rectum at the time. Firstly, as to the state of the rectum, it must be empty. Wait a reasonable time, say an hour, after stool, so that the gut may be more passive; have the patient in the recumbent posture; direct him to resist tenesmus and to exert both the will and the muscular power to retain the aliment. The syringe must be of hard rubber, must be rectal-ended, and of the capacity of two fluidounces, and perfect in action.

The preparation to be introduced, after being warmed to a temperature of 98° or 99° F., should be very slowly injected with the syringe, which should be also warmed and oiled. The enema must never exceed in amount two fluidounces. If this be rejected, wait a reasonable time and try again, using a less amount. If tenesmus proves an insurmountable barrier to ordinary means, an opium suppository is to be introduced three hours prior to another attempt. It has been suggested, inasmuch as tenesmus is often relieved by the application of cold to the rectum, to introduce the aliment in that state; but this method is open to the objection that rectal digestion would be much less likely to take place under this condition, as the bowel would then have thrown upon it the additional work of warming up the substance prior to absorbing it.

The usual errors made in applying this means of sustaining the patient are, that the injections are too large, are too rapidly introduced, and are not of the proper temperature. Allowing an interval of eight hours between the enemata would afford three in the twenty-four hours, which method has been found to offer the best results. This must be persevered in at regular daily intervals for the patient to derive its full benefit, and there is reason to suppose that the nervous system gets expectant of these daily hours of support, as it does in the case of our ordinary meal-times. An examination of the well-formed daily stools of patients thus sustained will prove how close the analogy is between this and digestion proper.

Next, as to the substances to be employed. The best of these are milk, eggs, concentrated beef-extracts or beef or chicken peptones, and brandy or whiskey of good quality. These substances may be combined in various proportions to suit the individual requirements of the case. A very good mixture for this purpose is two tablespoonfuls of milk, one tablespoonful of whiskey, and an egg, using both the yelk and the albumen. To this add a little salt. This should be well beaten up and properly warmed.

It is well to persevere in the use of these enemata even though at first most of them appear to be rejected, as after a time, the rectum becoming accustomed to their presence, absorption or so-called rectal digestion may take place. This form of alimentation should be kept in reserve in a case of chronic illness until all other methods of sustaining the patient prove insufficient to support life. It is not contraindicated even in some cases of chronic diarrhoea with persistent vomiting and loss of peptic function, advantage being taken of the intervals between the evacuations to introduce a small and very concentrated nutrient enema. In ordinary cases not complicated by diarrhoea the most convenient times will be found to be about seven o'clock in the morning, three in the afternoon, and eleven at night. Wetherill suggests the possibility of forming with solid extract of beef, pepsin, and pure suet a nutrient suppository which might be retained and absorbed in some cases in which it has been found impossible to retain the enemata. A very small addition of white wax, he thinks, would keep these solid during warm weather; if not, the suet might be replaced by ol. theobroma (as in ordinary suppositories), which is probably as likely to be absorbed as the suet.