In normal individuals it usually takes two or three hours for the tube to go through into the duodenum, but in cases where we have to apply this method, we often have to deal with a pyloric spasm, and then it takes much longer. In some cases I have had to wait twenty-four hours, the longest time being forty-eight hours. During the period of the tube passage, patient is fed by the mouth with liquid diet and tests are made from time to time in order to ascertain the location of the tube.

On the other hand, in cases of achylia gastrica, the passage of the tube into the duodenum takes place very quickly. We test it and find it sometimes already after 5 or 10 minutes in the duodenum. The motility is much greater there. Returning again to the method of feeding: The temperature must be just right. The food introduced must be free from thick particles.

All the food should be strained, because in passing through the long fine tube it would easily become blocked if this precaution were not taken. A thin tube is better for the patient. The smaller the tube, the pleasanter for the patient; but, on the other hand, the more difficult the handling of it. Another rule is that after each feeding, after the food has been given, a little fluid should be thrown in and then a little air when the stopcock is closed, in order to keep the tube always empty. If one is not careful to clean out the tube with water and air, the end becomes clogged in a day or two, and the tube has to be taken out and replaced, with a great deal of inconvenience to the patient, as well as to the doctor and nurse, and that tube is often spoiled. Where I have patients under my direct supervision, nothing of that kind happens. It is simply faulty technique when that occurs.

Another point is that while the patient has the tube in, his mouth should frequently be washed out with some good mouth wash. If these patients do not eat anything, there is nothing to cleanse off the surface of the tongue, and it is very essential that that should be kept clean.

The tube is left in permanently during the course of this treatment. Outside of the feeding, the patient is given a pint or more of saline twice daily by the duodenal tube. The saline may be given either with the syringe or by connecting an irrigator to the tube. The main point is to let the fluid run in slowly and at the right temperature. If the patient does not like that, it may be given into the rectum by the Murphy drip method, for the bowels absorb saline very well. The food is the vital thing. By this method we accomplish perfect nutrition and everything is utilized.

In my first patients I watched the weight very carefully, and found that in most of them it was possible to keep them from losing weight. Some of them lost, but it was mainly due to a loss of water. They lost no real flesh, for the nitrogen examination showed that under this regimen they were able to add to their nitrogen balance. It is very important to make the patients gain a little weight, but not so necessary as to keep them from losing weight. If we want them to gain, we add a little butter to the regimen.

This method of feeding keeps the stomach empty and so gives it perfect rest. The principie of rest is a very important factor in curing disease, and this is an ideal method of accomplishing that purpose. A second point is that very often it is essential to accomplish a change in the size of the stomach. If it is greatly dilated, we can keep it empty, and thus give it opportunity to return to its normal size. Still another point along the same line comes up when we have to deal with a dilated esophagus due to cardiospasm. While the usual method of treatment in such cases is the stretching of the cardia, in some instances we find that this alone is not sufficient, and that everything remains in the esophagus. Here we try to keep the esophagus empty. We must have the food on the other side, and the esophagus and stomach are kept empty.

Another point in the same line is that of saving the organ. This method I have recently applied to the treatment of diseases of the liver, with enlargement of that organ, and cirrhosis of the liver. The object is to lessen the inflow of blood to the portal vein. Everything that is taken into the stomach must pass through the veins of the stomach and then through the portal vein before it reaches the general circulation.

The capillaries in the stomach fill up and the veins carry the blood to the liver. The same occurs with the blood from the duodenum, the esophagus, etc. The fluids have to go into the portal vein and then into the liver before they reach the general circulation. If the liver is diseased, it is difficult for it to take up the amount of blood and exert its functions fully. If you reduce part of the inflow, much saving to the liver is accomplished.

In the large number of patients whom I have watched under this method of treatment, the results have been very satisfactory. One of the important advantages of this method is that by it we are independent of the will of the patient. We often have to deal with conditions in which nutrition becomes extremely difficult, extreme anorexia, or aversion to food, etc. In the case of patients suffering from tuberculosis, kidney trouble, and other conditions, it is most important to keep up the nutrition, and by this method the patient can be fed independent of his will. He does not have to eat anything, and he does not reject his food. Some time ago I met a physician, who was quite well advanced in years, who was suffering from chronic nephritis and who could hardly partake of any food on account of absolute anorexia. I did not feel like suggesting this mode of alimentation to him, but I gave him one of my reprints on the subject. He read it, but did not apply it, and died about two weeks later. If this method of nutrition could have been applied in that instance, his life could doubtless have been prolonged.

This method of treatment is applicable: First, in ulcerations of the stomach and duodenum. Even in perforated gastric ulcer, duodenal alimentation is still at times feasible. Dr. N. de Rosas1 has applied this mode of treatment in a patient with subphrenic abscess and perforated gastric ulcer. In this patient a laparotomy had been performed and it was noticed that when the patient drank milk it came out through the laparotomy wound. When fed through the duodenum no milk escaped. In two cases of duodenal perforation (fistula) of Dr. Willy Meyer and myself, 2,3 duodenal alimentation likewise effected a cure. Second, in a great many cases of dilatation of the stomach without organic obstruction; extreme atony, no matter whether there is a pyloric spasm present or not. (In many instances I have found an actual reduction in the size of the stomach under this treatment.) Third, in cases where nutrition is difficult, nervous vomiting, vomiting of pregnancy, etc. One might at first think it would be impossible to apply this in such cases, for the tube would be vomited, but this is not so.

1 N. de Rosas: Ulcera del estomago perforada y abceso subfrenico Revista Medica Cubana. December 1916, p. 489.

2 Max Einhorn: A case of duodenal perforation successfully treated by duodenal jejunal) alimentation, Med. Record, Nov. 30, 1918.

* Max Einhorn: Duodenal perforation (fistula) treated by duodenal (jejunal) alimentation, another case, Journal American Med. Assoc., March, 20, 1920.

We at first applied some remedies to make it possible for the tube to remain in the stomach, but as soon as it got into the duodenum or further down, the vomiting ceased, or the patients only vomited something from the stomach; as a rule, they do not reject the tube. In many instances where there was very severe vomiting, this method of alimentation has been the only feasible one. Duodenal alimentation can also be employed in disease of the liver, and in inoperable cancerous conditions of the stomach or cardia, where the stomach is not closed up and the duodenum can be reached.

In such conditions this method can be applied and bring comfort to the patient.

In one instance I could not make the diagnosis, but the patient had pains all the time and could not retain any food. As soon as this method of alimentation was instituted, the pain ceased, and for weeks he was free from pain and was happy. When the tube was removed, he was examined and found to have a malignant disease of the cardia, and later he was operated upon and died shortly after, but during all his illness he was never so comfortable as during the time that he had duodenal alimentation.