forward and downward; the fluid will thus reach this cavity. Or, as described in nasal douching, the liquid may be snuffed through the nostrils and thus reach the nasopharynx, but the canal is not as well cleaned as with the former method. The gargling should be continued until about half a glass of the solution has been used; one mouthful is not sufficient for cleansing purposes.

In acute conditions, where gargling must be frequent, as in tonsillitis or diphtheria, the vibrating process may so tire the throat muscles and palate that gargling (or gurgling) need not be repeatedly done. The patient may swash the liquid around the pharynx, tipping the head first to one side and then to the other, so as to reach all parts of the tonsils and around the tonsils. This is a very efficient means of cleansing the tonsils, and is not tiresome.

There are on the market various cleansing, soothing, alkaline compound preparations used for gargling, most of which require dilution. The most important ingredients are always boric acid or borax, sodium bicarbonate, sodium chloride, and some aromatic oils or other flavoring as menthol or wintergreen. Some contain thymol, and some eucalyptol, but they are all about the same. Various powders are offered, to be dissolved in warm water, and these powders contain about the same ingredients as the solutions.

There is no necessity for, and no real advantage in these multiple mixtures. One may improvise a good cleansing gargle with 1/4 of a teaspoonful of salt and 14 of a teaspoonful of bicarbonate of sodium in half a glass of warm water, with just as good results. Or the same amount of sodium borate may be used in place of the sodium bicarbonate.

The advantage of boric acid solutions as gargles cannot be over-estimated. A considerable amount of boric acid may be placed in the bottom of a bottle, and the bottle kept filled with water; then two tablespoonfuls of this saturated solution may be placed in a glass with double that amount of warm water and a suitable gargling solution is obtained. Individual prescriptions may be written for each patient, depending upon the character of the gargle desired. One is as follows:

S. Dilute a tablespoonful with an equal part of warm water and use as a gargle every three hours.

S. Dissolve 4 of a teaspoonful in 1⁄2 a glass of warm water and use as a gargle as directed.

Potassium chlorate is very soothing to the mucous membranes of the throat and mouth, especially of the latter.

Any of the suggested gargles may also be used as mouth washes. Wintergreen water may be substituted for the peppermint water, if preferred. If an astringent gargle is desired, tannic acid or glycerite of tannin may be added to warm water; or a gargle may be prepared as follows:

R Tannic acid..

M.

Glycerin.

Water, q.s..

S. Use as a gargle undiluted.

Gm. or mil

3. 15. ..ad 200.

Very soothing gargles are: hot milk and water, equal parts; physiologic saline solution; or various mucilaginous decoctions, as slippery elm or flaxseed tea, or starch water.

While boric acid gargles are mildly antiseptic, as well as those that contain thymol, the best antiseptic for the mouth is the official Liquor Hydrogenii Dioxidi. This solution should be diluted with three parts of warm water for a mouth or throat wash. It may be used in full strength swabbed onto the tonsils or as an application to some part of the mouth, provided that it is not used on a suppurating spot that has no free opening, as a sinus. Hydrogen dioxide solutions should not be used unless there is free outlet for the secretions with which it comes in contact, as it forms bubbles which may dissect the tissues. As

soon as hydrogen dioxide solutions are used, the subsequent froth and irritant acid formed should be washed off with some alkaline solution.

While tincture of iron may be applied, in suitable cases, directly to a tonsil or other inflamed area, gargles with iron are inadvisable. The same is true of silver solutions; they may be applied, but should not be used as a mouth wash or gargle. Nothing will more rapidly heal canker sores in the mouth than one or two applications, at least one or two days apart, of the solid nitrate of silver, or of a swab wet with a twenty-five per cent. solution of nitrate of silver.

Phenol solutions as antiseptic gargles are not now much in vogue, on account of the danger from swallowing the phenol into the stomach, although the solutions when used are very weak. The preparation termed "Dobell's solution" is as follows:

It is quite a habit for patients, when there is irritation in the throat, to dissolve potassium chlorate tablets in the mouth and swallow the saliva containing this irritant. This is not to be recommended, in fact, should be prohibited, as it is possible that such irritation might cause ulcer of the stomach. Potassium chlorate is harmless if dissolved in water and used as a mouth wash, or gargle, even in a saturated solution, which is a little more than five per cent.

Preparations containing hexamethylenamine under various names have been recommended and used in the form of tablets to dissolve in the mouth, and to be dissolved in water for mouth washes and gargles as preventives of colds. While there seems to be much clincial evidence that various germ conditions in the mouth, nose, throat, and ears have been helped by these hexamethylenamine preparations, laboratorily it seems proved that there can be no germicidal activity from formaldehyde

1

preparations except in acid media. When absorbed it acts as an antiseptic in the kidney and bladder, where it meets acid, but it has not been experimentally proved that it can act on any other part of the body as a germicide.

GAVAGE

This is a term applied to forced feeding, recourse to which is had when for any reason a patient refuses to take nourishment. It is generally done by passing a stomach tube, if that is practical; if that cannot be done, by passing a long catheter through a nostril down into the esophagus. The food introduced, especially by the latter method, must be very thin and contain some concentrated nutriment, warmed to the temperature of 101° in the reservoir or receptacle; from a pint to a quart may be given at one time. Milk, malted milk, thin gruels, and meat juices, sugary and salty solutions, may be thus administered, so that the individual may receive the needed nutriments.

GASTRIC LAVAGE

Stomach washing in certain conditions is of great benefit; it, however, has been done both too frequently and for too long a period in the same individual. The simplest method of washing out the stomach is to pass the so-called stomach tube, which should be not far from five feet in length. In an ordinary sized adult individual the distance from the lips to the bottom of the stomach is about eighteen inches, and there should be marks on the tube to indicate the number of inches passed. A good form of this tube is one that terminates in a rubber funnel; or if a tube without a funnel is used, a glass funnel may be attached to it. The rubber material should be firm and very smooth, and should be large enough in size to allow particles of undigested food to pass through. Some operators prefer a tube with a large opening at the stomach end; others prefer to have fenestræ on the sides.

The tube is passed quickly over the tongue to the back part of the pharynx and gently forced into the esophagus, the patient being directed to swallow. Some operators prefer to have the

tube perfectly dry, believing that the esophageal walls grasp it better and pass it more readily on to the stomach. Others prefer to wet the tube with hot water so that it will pass a little more readily, but the tube should not be oiled. The first sensation as the tube is passed is that of nausea, and retching soon occurs, but if the operation is repeated in the same individual, after two or three times nausea does not occur, and the patient learns how to manipulate the tube and aid in its passage.

If the stomach is filled or partially filled, regurgitation occurs almost immediately through the tube, and sometimes to prevent this kind of regurgitation which is very likely to plug the tube, the funnel end of the tube is immediately raised and warm water, either plain, or as physiologic saline, or containing a little sodium bicarbonate, is poured in and allowed to flow into the stomach, until the patient feels a sense of distention, and indicates it. The funnel end of the tube is then quickly dropped toward the basin on the floor before the fluid has entirely passed out of the upper end of the tube-in fact the tube should be pinched to stop the flow while this lowering operation is done so that the fluid from the stomach will flow out into the basin by siphonage. This process of filling the stomach and then allowing the fluid to run out should be repeated until the fluid comes away clear. This will often require several quarts of the fluid, which should be at a temperature of 100° or 101° F. If unpleasant symptoms occur, or the patient shows unexpected distress or signs of heart weakness, the lavage should be abruptly ended. If during the outflow the tube becomes plugged, filling the tube again with water from above will wash the plug back into the stomach, and the siphonage may be again resumed.

Gastric lavage is done in dilated stomachs, in ptosed stomachs, and whenever there is serious obstruction at the pylorus, especially if the patient does not vomit and thus evacuate the stomach. The improvement in appetite, in nutrition, and in good feeling is sometimes very great. Stomach washing is also done in cases of poisoning where there has been no erosion from a corrosive drug, and is especially valuable in opium and morphine poisoning. It is also done in serious post-operative