Lavage

In cases of either dilatation or catarrh of the stomach which fail to improve on restricted diet and other methods of treatment lavage or stomach washing becomes necessary. This is an entirely safe procedure, and one to which patients become readily accustomed, provided sufficient tact and care is employed when the method is first applied. It was first practised by Kussmaul in 1867. The operation met with so much success that it has since that time been generally adopted, and it is perfectly easy to perform with a little experience and care. It should be attempted in all serious cases in which other methods to relieve the patient have been already tried and have failed. It is almost indispensable in those cases in which the atony of a greatly distended stomach wall prevents the food from being expelled into the intestine, causing constant accumulation and fermentation, or in cases in which decomposing food passes into the duodenum, exciting intestinal dyspepsia, meteorism, and diarrhoea.

As many as sixteen varieties of bacteria have been obtained from the washings of a dilated stomach in which food had been stagnating.

The advantages of lavage are twofold; it not only removes irritating and fermenting material from the stomach, and the ropy, tenacious mucus which it contains, and allays vomiting, but the water itself applied to the mucous membrane cleanses it and stimulates the gastric glands to normal secretion and the stomach wall to contraction. It also promotes more regular action of the bowels.

The relief from the sensations of weight, oppression, discomfort, and nausea which is promptly experienced after lavage is usually immediate and lasts for several hours. It is so great that patients not infrequently learn to pass the oesophageal catheter themselves, and, holding a pitcher of warm water in one hand and a funnel in the other, they wash and siphon out their own stomachs with ease. Usually it is sufficient to wash the stomach once a day. In extreme cases it may be necessary to perform the operation twice a day, but when improvement is once established, washing may be limited to every other day or may be employed occasionally, according to need, but it should be continued for several weeks after the subsidence of all symptoms. As a result of this treatment, the stomach may diminish in size, and the food is always better digested and more completely absorbed, while nutrition and assimilation are correspondingly improved.

The best time for digestion of the principal meal of the day is within an hour after each lavage, when the stomach is empty and thoroughly cleansed, and the meal can often be assimilated completely. If decided repugnance to food exists, the tube may be used for forced feeding, and peptones and predigested milk may be poured in before it is withdrawn from the stomach, although, as a rule, it is best that too much fluid food should not be given.

In performing the operation of lavage a medium-sized oesophageal tube should be selected, about one third of an inch in diameter, having two or three large smooth eyes or "velvet" fenestra and made of good, smooth red rubber which is sufficiently flexible without being so easily bent as to allow the tube to double upon itself in its passage. This tube should be fully eighteen inches long, and it is attached to a length of three feet of common rubber tubing by means of a small glass tube; the other extremity of the rubber tubing is fastened to a funnel through which warm water is poured into the stomach. A glass funnel is preferred, which makes it easier to examine the washings as they return. The patient is cautioned to keep the head straight forward and thrown back and not to bite the operator's finger, and the tube is gently pushed over the dorsum of the tongue down over the posterior pharyngeal wall into the oesophagus. The insertion of the tube will be facilitated by oiling it slightly with a little olive oil, butter, white vaseline, or glycerin, but white of egg or milk are less likely to nauseate.

If there is any difficulty in introducing the tube, its downward passage may be aided by passing the forefinger to the back of the pharynx. If the patient, who either sits or stands, is instructed to make an effort at swallowing while the tube is being inserted it will descend much easier, and pains should be taken to explain the process and reassure him, for nervousness and struggling may excite spasms of the laryngeal muscles and make it difficult or impossible to pass the tube. On reaching the cardiac end of the stomach, the tube is occasionally stopped for a moment, but the patient should be instructed to try and swallow, and with gentle pressure the orifice soon relaxes and the tube enters the stomach. Or a little water poured into the tube may cause the cardia to relax. The funnel is raised above the patient's head, but before pouring in much fluid it should be ascertained that he is able to breathe comfortably and quietly when the tube is momentarily compressed. He should be reassured that he will not choke. Accidents have occasionally happened from passing small tubes down into the larynx, and I have known of one fatal case in which a nasal tube was thus passed and milk was poured into the lungs.

A case has been reported in which beef tea was poured into the lungs in this manner, but the patient recovered and the beef tea was coughed up or absorbed. There is very little danger of introducing an oesophageal tube of the ordinary size in the wrong direction, for any attempt to push it into the pharynx will be met by obstruction and spasmodic coughing. If the stomach is full when the tube is first passed, some of the contents may be immediately siphoned out by lowering the funnel below the stomach level and holding it over a foot tub or pail. If necessary, water can be poured in gently to the extent of a quart, or until the patient complains of uncomfortable fulness in the stomach. Care should be exercised not to admit air bubbles. The tube and funnel are then inverted over a foot tub or wash basin and the contents of the stomach are quickly siphoned out. This operation may be repeated a number of times until all the food and mucus have been removed and the washings return quite clear and neutral in reaction.