vomiting, to wash out the bile regurgitated into the stomach, that is causing the nausea and vomiting to persist. A few drops of dilute hydrochloric acid in water, however, will sometimes cause the stomach to resume normal peristalsis and the pylorus to close, and prevent further regurgitation of bile in these postoperative cases. However, lavage will prevent fluids remaining in a paralyzed stomach, and therefore may prevent the serious condition of acute dilatation of the stomach, a not infrequent cause of post-operative shock.

As stated, stomach washing is done too much, and some patients acquire a habit for this daily questionable pleasure, much as they acquire a habit for large daily rectal enemas, and when there is no actual need for this treatment it should be discouraged, and prohibited. Washing out the stomach for simple hyperacidity is not good treatment. If a patient needs an emetic, let him receive it. With a dilated stomach it is sometimes difficult to wash out through a tube all the thickened debris at the bottom of the stomach. Such patients may lie, stomach down, on a bed, with the head hanging over the edge, and they will vomit out, with the aid of gravity, the whole contents of the stomach. Then by taking several glasses of warm water, and repeating the process, the stomach will be thoroughly emptied and cleaned.

Contraindications to the use of gastric lavage are serious heart lesions; aortic aneurism; cirrhosis of the liver that might cause enlarged veins at the lower end of the esophagus; ulcer of the stomach; bleeding from the stomach; and poisoning that was caused by corrosive irritants.

ENEMATA

Injections of water into the rectum to aid the movements of the bowels are taken too frequently by many individuals. As a temporary treatment, or while a patient is in bed and the activity of the bowels is not normal injections of warm water, or of soap and water, or of water containing some more active ingredient, are often advisable, but to continually dilate the rectum and the sigmoid flexure with large amounts of fluid is a serious mistake, as more or less permanent dilatation of the

lower intestine may be caused. When hardened feces occur, however, injections of oil, or of glycerin and water, or of warm soapsuds and water, are necessary and valuable.

Enemas are best given with the fountain syringe, provided the pressure is not too great, i.e., that the reservoir is not too high. If it is desired to increase intestinal peristalsis on account of gas and tympanites, some irritant may be added, such as oil of turpentine. Sometimes solutions of saline cathartics, as Epsom salt, will aid in causing evacuation of the bowels. One of the most efficient and the simplest in the way of a small enema is half an ounce of glycerin and half an ounce of water injected into the rectum by a glass or hard rubber syringe. The movement of the bowels will usually occur in from ten to fifteen minutes, and the large intestine will generally be well evacuated. This is a very simple method of causing evacuation of the large intestine when the patient is long in bed, and it is more effective than a glycerin suppository.

ENTEROCLYSIS

Colon injection is a very useful procedure, and is especially valuable when the patient has lost a large amount of fluid, particularly if he cannot retain fluids by the stomach, and if the more troublesome operations of hypodermoclysis or of saline transfusions are not needed. Colon injections are also useful to cause absorption of water and perhaps some salts or nutriments in conditions in which it is inadvisable to give these substances by the stomach, or the stomach does not retain them, or there is coma, or the kidneys require more liquid to properly excrete.

Colon irrigation is of value in all forms of inflammation of the large intestine. As a surgical procedure in intussusception of the bowel it is sometimes very successful in curing the condition, but the pressure should not be great, as rupture of the bowel may occur, especially if the intussusception has continued long enough to cause softening or destruction of the walls of the intestine. In impacted feces in the colon, repeated and continued injections of warm oil and water are curative. In dysenteric conditions the local treatment of the intestinal wall is of primary therapeutic importance.

Sometimes a double catheter is used for the fluid to enter the bowel and immediately return; but if it is intended that considerable fluid should be retained, or, if possible, passed around to the descending colon by changing the position of the patient, the liquid should be passed through a tube that may be clamped for a few minutes, and then the liquid is allowed to be passed out by the same tube.

The rectal tube should be soft rubber, but rather rigid, about eighteen or twenty inches long, best with fenestræ on the sides of the tube rather than at the end. The fluid is siphoned from the regular reservoir bag placed at an elevation of three or four feet. It is often of advantage to have a glass reservoir graduated to show the amount of fluid actually used. The patient should lie on his back, with the hips elevated, either on a douche pan, or, better, on a Kelly pad. While it is frequently stated that the tube should be passed well into the sigmoid flexure, as a matter of fact, it is exceedingly difficult to do this, and probably the ordinary rectal tube rarely passes any farther than the first part of the sigmoid flexure. Great force should not be exercised as the tube simply doubles on itself; the only way to aid its upward passage is to start the flow of the liquid, and then the tube may be inserted a greater distance. The temperature of the fluid should be 102° to 103° F. in the reservoir, as it will lose heat while passing through the tube and the fluid entering the intestines should ordinarily be from 100° to IOI° F.

The amount of fluid injected at one time may be a pint, a quart, or more, depending on the discomfort which it causes. If it is desired to wash the whole colon, if possible, the quantity injected should be as large as the patient will comfortably retain. Then the patient should lie on the right side, to aid the fluid in flowing through the transverse colon to the ascending colon. He then should reverse his position to allow all the fluid to flow out. At times it is well to use several quarts of solution in repeated injections and outflows at the same sitting. At other times it is best for the patient to retain the injection until he can go to a toilet, or commode, and evacuate the liquid by ordinary peristaltic action. Or, he may attempt to retain

the fluid for a short time and then evacuate it. If abdominal pain is caused by these injections, the amount of fluid that has been used is too large, or the medicament used was too irritant.

Tannic acid solutions are sometimes injected; also quinine and ipecac solutions, in dysenteric conditions. For cleansing purposes physiologic saline solution, from 0.5 to 0.9 per cent., or a bicarbonate of sodium solution, or a salt and soda solution may be used. If borate of sodium or boric acid solutions are used they may be of from 2 to 4 per cent. strength. They wash off the mucus and are mildly antiseptic, but large amounts of such fluids should not be allowed to remain in the intestine. Weak potassium permanganate solutions are sometimes used. Silver solutions in small amount are often used, but they are generally inadvisable unless the treatment is to be applied only a short distance up the intestine. Retained silver nitrate solutions are dangerous, as, even if they are neutralized by injected sodium chloride solutions, it is uncertain how much silver will be absorbed. It is not known how much silver of the various organic preparations can be absorbed and cause poisoning. This is not to state that applications made through the proctoscope or even some short distance up the intestine are not valuable and are not perfectly safe, but the safety of higher injections of silver is questionable.

Injections of oil to soothe irritated membranes and to soften fecal matter and to coat the intestines are often useful, olive oil being the oil most frequently employed. However, mineral oil administered by the stomach will soon reach the colon.

URETHRAL INJECTIONS

Almost the only object of anterior urethral injections is to promote the cure of gonorrhea, or to prevent venereal disease in the male. High injections and urethral washings with a high siphon tube, and therefore with force, the so-called Valentine apparatus, was a mistake, and such injections should not be given. By these injections many times the urethra was torn by pressure, infection was driven into the tissues, the tissues were made soggy, strictures were caused, and the disease was pro

longed. For cleansing purposes and to curtail and shorten the disease, if possible, urethral injections must be given frequently, sometimes four or five times a day.

The patient must be instructed how to give himself these injections. He should first urinate; then he should clean the parts very carefully before the injection is given. The syringe, generally a glass one with a soft rubber, cone-shaped nozzle, capable of holding about 20 mils of liquid, should be warmed by previously filling it with hot water, and then the solution to be used is drawn into it. The penis is then held in the left hand, the glans between the forefinger and thumb, which support it from underneath; the syringe in the right hand is then introduced into the meatus and the liquid is slowly injected. The syringe is then removed and the meatus is pinched with the fingers so as to retain the fluid for as long a time as the patient has been instructed, from one to five minutes. The fluid is then allowed to run out.

The liquids employed for the prevention of infection are silver solutions (either the nitrate or the organic salts), or a weak corrosive sublimate solution. Local curative treatment of gonorrhea consists of silver solutions of proper strength, or, at times, simple alkaline washes. Later, milk of bismuth solutions may be used, or more in vogue, zinc sulphate solutions.

Deep urethral injections can only be well done by the physician, and posterior urethral injections require a special syringe for the application of the medicating fluid directly to the part diseased. Or the urethroscope may be passed, the mucous membrane studied, and the diseased areas swabbed with the medicament.

Prevention of Venereal Infection. The U. S. Public Health Service publishes the following rules of procedure:

To prevent gonorrhea in the male.-"1. Wash the genitals with soap and water, followed by a 1-2000 bichloride solution. Dry the parts thoroughly.

"2. Empty the bladder.

"3. Inject into the urethra a 2 per cent. protargol, or a 10 per cent. argyrol solution freshly made. Hold in the urethra five minutes. Urinate at the end of this time."