usually to be seen in these stools. If these are only from the vegetables and fruit eaten, they are not significant, but if remnants of meat are found, a serious disturbance of digestion is always present, usually involving the stomach as well as the intestine.

Fourth, mucus is found in small shreds, seen only on very careful examination.

Boas suggests a test lavage of the intestines, for the purpose of diagnosis. It is really a high enema of plain water, given after the movement of the bowels. Mucus in all forms, including the membraneous, is thus washed out in comparatively clean water, permitting of easy examination.

I have found this a most useful procedure in several obscure cases.

It must not be forgotten that mucus and undigested food particles may be passed in what may be called a nervous diarrhea, no especial catarrh being present; but careful consideration of all the symptoms and conditions of the patient, will usually make the diagnosis clear, except, perhaps, in the atrophic form.

May I suggest once more, that careful examination of the stools, will help in the diagnosis of many obscure cases, and well repay the trouble and annoyance.

The general condition of the patient suffers markedly when the intestinal catarrh is at all extensive. Usually there is considerable loss in weight, more or less suffering, or at least discomfort, and a general depression, both mental and physical, of which the patient complains greatly. I strongly believe that many so-called neurasthenics are really sufferers from the discomforts, poor nutrition and auto-intoxication of a chronic enteritis, especially where this involves the small bowel.

For children this is also a very important disease, the malnutrition resulting from it, interfering with growth, and increasing the possibility of other diseased conditions. Intermittent fever is a frequent symptom with

children, the cause of such a fever being unexplained, until examination of the stools shows the catarrhal conditions. Restlessness, especially at night, irregular and morbid appetite, more or less distension of the abdomen, alternately a constipation or diarrhea, are the constant results of this chronic catarrh. And so important is all this in the life of the child, that I have come to consider it a really serious condition, especially in view of the difficulty, if not the impossibility of a complete cure.

As already stated, the diagnosis is limited to distinction between catarrh of the small and large bowel, and I mention a few of the distinguishing points.

In catarrh of the small bowel, there is almost certainly a pressure sensitiveness in the immediate region of the umbilicus. The stools are, with few exceptions, fluid or semi-fluid, containing shreds, bile pigment and undigested food particles, especially meat fibres. Normally bile pigments are found in the contents of the small but not of the large intestine. When, therefore, the stools show undecomposed bile pigment, there is to be inferred an increased peristalsis of the small intestine, and almost certainly a catarrh. Yellow pigmented bits of mucus in the stools are characteristic of catarrh of the small bowel.

In the occasional cases, where with the small bowel involved, constipation exists, an examination of the stools will still show the bile pigment just mentioned, and in addition, a test lavage, (as already described), of the large bowel, should be made. If the water washes out quantities of membraneous or viscid mucus, there is certainly catarrh of the large bowel, whatever the state of the smaller one. If the lavage brings no mucus, and the stools are constipated, the diagnosis is extremely dif ficult. A well-marked catarrh of the large bowel is very evident.

There is tenderness on pressure, usually in localized areas, especially in the descending colon, and sigmoid

flexure, occasionally in the caecum. The stools, if the rectum and sigmoid are involved, show pure mucus, perhaps in quite large masses, easily seen by the naked eye, or if constipation exists, the solid masses are covered with mucus. If diarrhea is present, the mucus and fecal matter are mixed but not so thoroughly as when the small bowel is involved, and there may be occasional passages simply of mucus.

In the early stages, cancer of the rectum causes increased secretion, and often involuntary, of a thin mucus. Atrophy of the muscular layer, as well as of the mucous membrane, with disturbed enervation, are the cause of the alternate constipation and diarrhea, so characteristic of this condition.

In certain cases, where a catarrhal diarrhea has existed perhaps for years, a change may take place, and a constipated condition follow.

Inasmuch as the pathological change in the bowel which caused the catarrh, still exists, the change can only be explained as coming through the nervous system. Just how, is not well understood. Also the so-called membraneous enteritis, the passages of mucus being in the form of membraneous pieces, sometimes of quite large size, is recognized by most German and English writers, as a peculiar secretory neurosis, although it is admitted by the majority, I think, that it cannot be classed with hysteria. The exact cause is not as yet determined.

In considering the treatment of chronic enteritis, several points should be kept clearly in mind.

First, the pathology, with its inflammations, its degenerations or its atrophies, all permanent conditions, and if extensive, interfering seriously with the functions of secretion, motion and absorption.

Second, the importance of the disease in its effect on the general health.

Third, the relation of the nervous system to the action

of the intestines, in some cases increasing the diarrhea, and in some, the constipation.

Fourth, the marked tendency to relapses.

Fifth, that these organs cannot be put entirely at rest, but must instead, be constantly irritated by the presence of food products.

Sixth, that the condition is shown by both diarrhea and constipation, (opposite states), the first due to increased fluidity of the intestinal contents; the latter due to atrophies of the mucosa and muscular layers, wih disturbance of enervation.

Seventh, consider the general condition of the patient. He is losing flesh and strength. He is suffering more or less pain and discomfort, is almost invariably depressed mentally as well as physically, and suffers from autointoxication. If a child, he has colics and is perpetually fretful, and has irregular fever-a very important symptom-and usually sleeps poorly.

Eighth, these patients are all markedly susceptible to attacks of grippe and colds. being easily chilled. They are all anemic. If the duodenum is involved, they have catarrhal jaundice, if no worse condition, and are perpetually bilious.

If this pathological and clinical picture is correct, the treatment is evidently not a simple matter. No pill before meals, with some change or other of diet, will cure the case. The whole system must be considered, and even hygienic and therapeutic means will be needed.

To a certain extent, prevention is possible. Every acute enteritis in adult or child, must be really cured, because many of them lead to the chronic condition. Chill, from whatever cause, must be avoided by warm clothes and dry feet. Dietetic errors, and overstrain of the nervous system must be carefully considered.

In attempting to write a definite treatment, one real

izes that every case is individual, and must be treated by itself, and that only general principles can be stated.

A few things are clear to me. Even in the mild cases the patient must be impressed with the importance of the conditions, and the fact that his own sense and good judgment must be used, if he is to improve.

In severe cases, I am sure of another thing, viz., that the patient must go to bed, if necessary, for several weeks. This rest in bed prevents exposure to wet and cold, dietetic errors, mental and physical exertion, and gives the physician a great advantage in the carrying out of his treatment. Further loss of flesh and strength are probably prevented.

Also massage, electricity and certain hydro-therapeutic measures can be used to the greatest advantage. Massage is important in stimulating the circulation and general nutrition of the patient. Electricity has its place also, for I still believe that general faradization improves nutrition and circulation.

Hydropathic measures can be used in many cases, and may be very helpful. For example, the use of a cold pack over the abdomen at night, and for a few hours during the day, for the bed patients, seems to lessen discomfort and to help somehow, in regulating peristalsis. I once thought this could only be done for the constipated cases, but find that even the diarrhea is often improved. Baths are less easily applied, but the ice-bag placed over tender places here and there, is for some a great relief.

Enemas, hot or cold, large or small, are most applicable to catarrh of the large bowel, but they seem to do more than simply cleanse the bowel, and are quite as useful in the diarrheal as the constipated cases.

The drinking of water, especially some of the spring waters, may be made useful for some cases, especially perhaps those tending to constipation, though I cannot say that permanent improvement is likely to result, es