Intestinal Obstruction. It should be clearly recognized that the chief and, indeed the only acute danger, is strangulation of the intestinal wall, mere coprostasis being compatible with life for days, weeks or, in a few extreme cases, months. Thus, we should distinguish sharply between mechanically acute cases or those in which distension with contents may produce an acute strangulation, and those in which the obstruction to the lumen of the bowel is practically the sole condition.

In the former class of cases, dietetic management must have in mind potential or actual septic or gangrenous lesion, with im minent perforation, and the obvious preparation for surgical intervention. With rather rare exceptions, therefore, all food should l>e withdrawn, and water should be freely used to assist vomiting or by lavage. Of course, water should not be given for several hours before operation and, often, as in intussusception, there is a period of justifiable delay but in which everything should be in readiness for operation. Hypodermoclysis may be indicated.

The latter class of cases is obviously predisposed to by ulceration, cicatrization and various partial mechanic strictures due to external pressure. A haemorrhoid or any painful rectal or anal lesion may also lead to voluntary constipation which gradually leads to obstipation, atonicity and dilatation of the large intestine and, ultimately, absolute coprostasis. Old age, and less frequently early childhood, are especially predisposed.

The prophylactic diet should be such as to favor soft passages and to prevent lodgement. It is impossible to lay down any fixed rule for any single ingredient of the diet. Even water, though expediting peristalsis, should not be used in excessive amounts as these might induce gastric dilatation, though scarcely intestinal. Fruits containing small seeds may cause diarrhoea in some persons, while in others they regularly tend to accumulate, especially in the recesses of the colon, so that in elderly, constipated persons, they may be gradually discharged weeks after the corresponding berry season. In many instances, the relatively innutritious vegetables are theoretically indicated to furnish a large, soft, indigestible mass upon which the bowel may act efficiently but, if the mass surpasses the smallest calibre of the bowel, it establishes a dam against which finer debris accumulates and, even if this does not occur, excessive fermentation of cellulose may produce dilatation which ultimately results in obstipation. Tea and coffee may at times exert an astringent or even a paralysant action while, again, they may apparently cause diarrhoea.

Generally speaking, the prophylactic diet, should be fairly bulky, containing much fruit and soft vegetables, if there is neither marked stricture nor dilatation. If either of these complications exists, the solid food should consist largely of meat, milk, eggs and fine cereals so as to leave little residue, and due attention should be paid to any digestive defect. On the other hand, peristalsis should be favored by using considerable water, including soft, pulpy fruits. In either case, it is a serious error to seek a laxative action from fruits containing small seeds or from fruit or other foods, including sugar and syrups, which are laxative by virtue of the irritation of fermentative changes to which they predispose. In any case, the use of salines and of animal and vegetable oils, as cathartics, should be kept at a minimum. Purpetrol and, if necessary, cascara and other cathartic drugs should be employed as needed, the former almost as a routine.

When coprostasis has been established, the first question to be considered is the possibility of strangulation of the bowel wall. If this seems probable, no food should be given and, if hydraulic methods do not promptly relieve the obstruction, operation becomes necessary, so that the dietetic indication is negative, as already discussed.

In no case should violent cathartic treatment be instituted and, in the aged and feeble, the exhaustion of enemata may prove fatal. In many instances, digital or instrumental excavation of a faecal lodgment in the rectum may remove a dam and facilitate the action of enemata to such a degree that cathartics may be safe and effective. Oil of peppermint etc., are of value as indicators of the establishment of a passage through the obstructing mass.

In cases of pure coprostasis, without fear of immediate lesion of the wall of the intestine, the slight additional mass derived from easily digestible foods, may be more than compensated by the gain in strength and it is often advisable to spare the patient's strength by prolonging the work of excavation and hydraulic measures over several days. If the lodgement is relatively high in the bowel, there is no objection to nutrient enemata and hypodermatic nutrition may be carried out, as well as inunction which may be united with massage to assist the emptying of the bowel.

Enteroptosis occurs mainly in the form of coloptosis, the extreme movability of the small intestine rendering it difficult to assign a limit between normal and abnormal location. There is a general impression that the various abdominal ptoses are usually or. at least frequently, associated as a general splanchnoptosis, but the author has seen only two or three eases in which the latter diagnosis would be supported, whereas nephroptosis occurs in about one woman in four in digestive practice and gastroptosis is also fairly frequent, though not so frequent as one would infer from the writings of those who confuse it with atonic gastric dilatation.

While pot belly does not alone justify the diagnosis of enteroptosis or of coloptosis, dietetic excesses, including excessive beer drinking, that habitually distend the alimentary canal with gas and that cause a deposit of fat in the abdominal wall, tend, both by increasing internal pressure and diminishing external muscular tonicity, to cause ptosis. However, it should be remembered that the normal support of the alimentary canal is due in part to its gaseous contents rendering it so light that it almost may be said to float in the abdominal cavity. Moreover, if the intestine con-tained no gas, the peristaltic propulsion of liquids and solids would be more difficult, since there would be no vis a tergo unless along a continuous mass of solids and liquids.

Even after enteroptosis has developed, care must be taken not to reduce the intestinal contents, either of solids, liquids or gases, to an undue degree, by exclusion of indigestible residue and fermentable foods. Such a course leads to so much contraction of the alimentary canal that the ptosis is increased and there is even danger of coprostasis.