"From the results detailed in the foregoing table, and illustrated in the bottles shown, it will be seen that the albumen is scarcely acted upon at all, and that both ostrich pepsine and ingluvin are destitute of the power of digestion." Much larger quantities of "Ostrich pepsine" and "Ingluvin" might have been taken with probably no difference

in results.

"In the stomach of the river crayfish is found a plentiful supply of a yellowish-brown, feebly acid juice, which possesses an energetic, fermenting power, and rapidly dissolves fibrin, but the addition of a few drops of a dilute hydrochloric acid solution stops the action. Also, a somewhat similar ferment to pepsine, discovered by Fick and Murisier, in the stomachs of frogs, pikes, and trout, differs from it (pepsine) in being more active at a low temperature, as at 20° F., while it loses its digestive power at the temperature of the blood (96° to 98° F.)."

Besides indigestion and weak digestion, there is another class of cases in which pepsine is of the greatest service, in which you must not neglect to employ it. In fever the action of the stomach is more or less disturbed. Indeed, in all fevers the process of digestion seems to be greatly deranged. When the feverish state is induced in one's own organism, one of the first points noticed is loss of appetite. The feverish patient does not feel the ordinary desire for food. When mealtime arrives, he is disinclined to eat. If, therefore, you find a patient who, perhaps, has been suffering from fever for many weeks, especially if emaciation is extreme, and the strength almost exhausted, it will be well to adopt the practice I have long acted upon, and add pepsine to the milk and beef-tea in the proportion of three or four grains to a pint. Milk will be coagulated at first, but soon afterwards it will become partially digested, and the curd may be easily broken up into very small pieces. Both the whey and curd will be in a state favorable for digestion, and for being rapidly absorbed and appropriated by the bioplasm or living matter of the tissues and organs.

If the feverish attack is of a kind which may continue severe for a considerable period of time, the body may lose very much in weight, the patient becoming excessively weak, and his life, perhaps, for some time in jeopardy. Under such circumstances it is of the first import

I 10

ON FEEDING BAD CASES OF FEVER.

ance to support the strength to the utmost. By mixing a little pepsine with the food you will greatly assist the digestive process. It may be during a most critical period of the malady, that the nutriment is given in the form of a peptone, and in a state fit to be immediately taken up by the vessels, and converted into blood constituents, and thus by this expedient life may be actually saved. I have lately (1878) had under my care a poor girl who became excessively emaciated in a prolonged attack of typhoid, the temperature varying from 102° to 105° during a period of six weeks. About the first week distention of the stomach and bowels by gas became considerable, and added much to the distress. I gave six grains of pepsine daily, with a little hydrochloric acid in the beef-tea, and kept this up during the whole period of the illness. The distention diminished after a few days, and I think that this simple plan had much to do with recovery in this instance. In the case of beef-tea you may with advantage add a little hydrochloric acid, and place the mixture before the fire at a temperature of 100°, for an hour or two before the patient takes it. He will not dislike it, and to some the acid beef-tea seems even pleasant. But generally when patients are as ill from fever as I am supposing, the taste is very much impaired, and practically there is no difficulty in getting persons to swallow the easily digestible peptones in the form of beef-tea. Peptonized fluid meat was first made in quantity some years ago by Mr. Darby. This useful preparation may now be obtained ready for use, in small pots or bottles in a form in which it will keep good for some time, of Messrs. Savory and Moore, 143, New Bond Street, London. Do not, therefore, forget this hint as regards the treatment of very bad cases of fever, and of prolonged exhausting disease. Whenever too little nutriment is absorbed for the support of the patient in consequence of the imperfect action of the stomach, the remedy will be useful, and now and then I have no doubt a life may be saved by the practice I have described.

Another plan based on the same principle may be adopted.. Instead of giving strong beef-tea or soup containing pepsine, you may make a sort of meat jam. Underdone or perfectly raw mutton or tender beef may be cut up into small pieces, put into a mortar and well beaten with the pestle until it forms a soft pulpy mass. A small quantity of salt may be added to make it palatable. Pepsine in the proportion of ten grains of the powder to an ounce of meat is then to be beaten up with it, when a drachm or more of dilute hydrochloric acid is to be poured in, and the whole thoroughly mixed together. If you choose you may further add a little sugar instead of salt to the mass. This panada or paste may be spread upon bread and butter, or it may be diffused through beef-tea or soup. Children, and many invalids, will often take a compound of this sort when it is difficult to persuade them to take ordinary meat food at all.

In some cases of illness we are unable to feed the patient by the mouth, and in fevers it sometimes happens that everything that touches the mucous membrane of the stomach immediately excites the most. violent vomiting, and occasionally this state lasts for so long a time that there is danger of the patient perishing from inanition. In these, as well as in those bad cases where there is a physical impediment to the entrance of food into the stomach, or to its escape from the organ into the duodenum, we may keep the patient alive for many months by injecting nutrient substances in small quantities (an ounce to three or four ounces) at a time into the lower part of the bowel. The nutritious matter dissolved, or suspended in some mucilaginous substance like boiled starch, is introduced into a small elastic syringe made for the purpose, and slowly injected into the rectum, the operation being repeated every three or four hours. To the beef-tea employed for this purpose it is well to add two grains of pepsine to the ounce. The rate of its absorption is increased, and it is more easily assimilated and taken up by the vessels of the mucous membrane.

You will find in the memoirs of Dr. W. Roberts, published in the "Transactions" and "Proceedings of the Royal Society," and in his Lectures at the Royal College of Physicians, many new points in connection with the question of the action of the gastric juice, pancreatic, and other secretions concerned in stomach and intestinal digestion, as well as instructions for applying the principles deduced from scientific investigation to the treatment of disease.

OF CONSTIPATION.

We must now consider a very important and almost universal accompaniment of the most common forms of deranged digestion and indigestion, and of which the majority of persons at some time or other have to complain. Constipation, a condition which varies greatly in degree, would, perhaps, be more correctly described as imperfect or insufficient action of the bowels. Probably nearly every one of us has suffered more or less from this trouble. And those who are accustomed to sedentary pursuits and intellectual work have usually a more extended experience of sluggish action of the bowels than those who take a good deal of exercise, and those who have to live by bodily labor. But I suppose there is hardly one who follows any walk of life whatever, or who follows no walk at all, who has entirely escaped this derangement. The most idle, as well as the most industrious, often have to complain of constipation, and the condition may afflict people of all ages and of all classes and in all climates. It is probably one of the most common of the slight derangements to which civilized man is subject. Whether savages suffer from it I do not know, but unquestionably the majority of persons forming a civilized community experience the discomfort.

The word "constipation" comes from the Latin "constipare, to crowd together." Generally speaking, people attribute constipation to the accumulation of fæces in the large bowel, and infer that it is invariably to be relieved by purgatives. But you will see, as I go on, that in cases of constipation a number of points have to be considered, and that many cases, so far from being relieved by the frequent administration of purgatives, are aggravated by that proceeding.

Most persons empty the lower part of the large intestine, or at any rate partially empty it, once during each period of twenty-four hours. But some persons' bowels have a habit of not being relieved oftener than every other day; some have an evacuation once in two or three or four days, and a few females maintain that once a week is enough to empty their bowels. Nay, I have heard it asserted that an action once in a fortnight was sufficient, and I am bound to admit that there are instances in which habitual constipation is not associated with derangement of the health, although, as a general rule, this sluggish state of the bowels brings about general disturbance of the health, and sometimes leads to very distressing results. Of course, in cases in which fæcal accumulation goes on for many days, the lower part of the large bowel gradually attains enormous dimensions, and considerable increase in its capacity and stretching of its walls-must ensue before it is sufficiently large to hold the excrementitious matter formed, as well as all the refuse material of the food which accumulates during the considerable periods of time just mentioned. I need scarcely say that this is a very unsatisfactory state of things, and if allowed to persist for years, is likely to lead to disastrous consequences as age advances. There is no doubt, that if the large bowel, and indeed the intestinal canal generally, is to retain its healthy state, and to be preserved in good working order for sixty or seventy years, or more, its contents ought to be expelled, as I have before stated, once in every period of twenty-four hours.

Many of the physiological processes of the body, like this one, occur periodically and uniformly at about the same time during each period of twenty-four hours. Regularity as regards time much assists the daily evacuation of the bowels, and it is very desirable that every one should do all he can to acquire the habit. I do not think it matters much whether the bowels act the first thing in the morning, after breakfast, or the last thing at night, so that the habit is acquired and a fixed time kept. Even in the case of animals, at least domestic ones, this operation is usually performed with the greatest regularity at a particular hour. If you have a pet cat or dog, you will find it convenient to teach it to evacuate its bowels at a given time, and it will prove more than inconvenient if the creature should be unteachable in this respect. An unmanageable disposition, or disobedience in this respect, renders an otherwise valuable animal almost worthless.

COMPLETE EMPTYING OF Bowels.

113

You must impress upon all patients the importance of regular habits, which are, in fact, easily acquired, and ought never to be broken through. Many small ailments and troubles of various kinds will almost certainly result from carelessness in this particular, and serious maladies are not unfrequently the consequence of disregarding advice.

Having referred to the desirability of regular action, I must now try to impress upon you the equal importance of complete, or nearly complete, evacuation of the lower part of the large bowel, for what is called regular action may be associated with very imperfect removal of the contents. Although a small quantity of fæcal matter is daily discharged, this bears so small a proportion to the quantity formed, that there is a constantly increasing residue, which goes on accumulating, to the great discomfort of the patient, and the derangement of his health. In not a few cases this is no doubt due to the weak muscular contraction and imperfect action of the parts above, so that too small a quantity is sent down to the rectum to excite that part of the tube to sufficiently vigorous contractile action. As regards efficient action, a good deal usually depends upon the rectal contents. If a person lives upon highly nutritious diet, such as very strong soup or potted meat, he may find that his bowels will soon get obstinately constipated. If now he adds to this highly nutritive diet a quantity of amylaceous and soft fibro-cellular vegetable matter, which in itself possesses very little nutritive value, and of which comparatively little may be absorbed, he will find that the bulk of excrementitious material will be augmented, and the action of the bowels will become more satisfactory. In fact, if we are to be in good health, we have to take a certain quantity of material with the food which is not in any way of use to the nutritive operations. The proportion of nutriment in bread and potatoes is small as compared with that existing in fat meat. To obtain an equal amount of nutritious matter, a comparatively large quantity of bread must be taken, and of potatoes. many pounds daily must be swallowed, if this is the only article of diet. Up to a certain point the admixture with the really nutritive materials of a large amount of innutritious dross is advantageous, and even in the case of vegetable feeders this matter has to be considered. A horse does not do so well upon pure corn as upon corn and hay. Chaff is of far more value than you would be led to suppose from its chemical constituents. Many of us indeed require a certain amount of chaff to keep ourselves in fair health. Brown bread is very dear, because it contains so much valueless material, and is a rougher kind of bread than white bread. If you examine brown bread, you will find that it contains a large percentage of the testa of the wheat, which is quite indigestible. Oatmeal is useful in the same way. All these things help to increase the bulk of the evacuation, and in this respect are of great use and do good. Unless there is a certain bulk to excite the fine nerve network of