The quantity of water used in the washing should be measured so that it all may be siphoned out again, as it is undesirable to leave any fluid behind.

When the tube is introduced for the first few times it may excite efforts at vomiting, but it is not necessary to remove it, for the patient can usually regurgitate the long, stringy mucus alongside of it. Salivation is often produced in the first few trials. After one or two attempts patients will learn to swallow the tube themselves with very little assistance and cease to gag upon its introduction.

If there is hyperaesthesia of the pharynx the pharyngeal wall may be touched with a 2- or 4-per-cent cocaine solution just before the introduction of the tube, or several large doses of bromide of potassium may be administered during the previous twenty-four hours. If nausea occurs when the tube first reaches the cardia it is usually overcome by pouring in a little fluid. The success of the operation at the first trial depends largely upon the skill of the physician and the degree to which he has obtained the confidence of his patient, and has been able to overcome any nervous feeling in regard to a process which is at best highly disagreeable. After the sufferer from gastric dilatation has experienced the relief which lavage of the stomach can give, he usually requires no urging to allow the process to be repeated. In withdrawing the tube it should be compressed in order to avoid having any of its contents trickle into the larynx.

The fluid used for washing the stomach may be either cool, warm, or quite hot water. Warm water is best, but it is well to sterilise it by previous boiling. If much mucus is present or much acidity, sodium bicarbonate may be added in the proportion of two or three per cent (15 grains to the pint), or a similar quantity of sodium borate or boric acid, a one-half-per-cent solution of salicylic acid, or a i-per-cent solution of sodium salicylate. Vichy is occasionally used.

The best time for conducting lavage is shortly before the midday meal, the patient having had a very light breakfast, and it should only be performed when the stomach is believed to be comparatively empty. If the tube is introduced before breakfast, having had nothing to eat for a number of hours, patients are more apt to be disagreeably affected, especially if the washing be long continued, and I have occasionally seen them become faint under these circumstances. It is better, therefore, that a light breakfast of bread and milk, pancreatinised milk, or of a scraped-beef sandwich and a cup of black coffee should be taken; three hours later the stomach is to be washed. There are exceptional cases in which the patient is so distressed by the effort to pass the tube or by the operation of rinsing the stomach itself that it has to be abandoned. Lavage must be avoided in cases complicated by much prostration, feeble heart action, aneurism, haematemesis, or haemoptysis.

Accessory measures which are to be used in connection with lavage and careful regulation of diet are massage and medicinal treatment which consists largely of the administration of tonics, especially strychnine, with the object of increasing the muscular action of the stomach. This remedy may be given hypodermically if necessary.

Massage

Gastric massage should be performed about two and a half or three hours after each meal for ten minutes. The patient must lie upon his back, with knees drawn up and muscles relaxed. The movements, stroking and kneading, must be always made over the stomach in the direction of the pylorus, the object being to facilitate emptying the stomach through that opening, and to stimulate peristalsis. If not too weak, the patient may be taught to perform these movements himself. This treatment is often of considerable aid in mixing the food and gastric juice and in propelling the food into the intestine. It increases peristalsis.

Electricity

Faradisation of the stomach is believed by many to increase its muscular tone, and various forms of electrodes have been devised for this purpose. It is probable that very little, if any, electric stimulation reaches the stomach when currents of ordinary strength are applied over the epigastrium, although Ewald and Sievers claim that it does in some cases. This is especially true of faradism. Canstatt first proposed to apply the current directly within the stomach wall, and methods have been devised by Bardet, Einhorn, and others to serve this purpose.

The ingenious electrode invented by Einhorn, of New York, is easily passed into the stomach. It consists of a hard-rubber capsule about the size of a small French olive. The hollow capsule has numerous perforations and within it is a small metallic electrode. The capsule is fastened to a fine flexible conducting wire, which is attached to the battery, and the wire is protected by a minute soft-rubber tube one inch in diameter. This electrode is readily swallowed by placing it upon the dorsum of the tongue and then drinking water. About forty centimetres of the wire should be swallowed. In withdrawing the electrode after use it sometimes catches at the cardiac end of the stomach, but if the patient swallows a little water it slips past. When this electrode is in the stomach, which has been previously partially filled with a pint or more of warm water or saline solution, the second electrode, broad and flat, is placed over the epigastrium or over the back to the left of the seventh dorsal vertebra, and the electric current is carefully turned on.

This treatment is designed especially to increase the muscular tone of the stomach in atonic dilatation and stimulate peristalsis, but it also serves to promote secretion, and hence it doubly aids digestion. The electric current may be applied daily, immediately after lavage, for ten or fifteen minutes, and it should be strong enough to induce good peristalsis. Even patients who are not accustomed to lavage seldom object to swallowing the electrode.

A variety of medicinal remedies are also used with the object of preventing fermentation of food in the stomach and intestine and for artificially aiding digestion by these organs. Among the former are to be mentioned creosote and other substances allied to carbolic acid, naphthaline, salicylic acid, etc. -The use of hvdrochloric acid 37 and pepsin have been described in connection with chronic gastric catarrh (p. 540).