Nasogastric tube

“ The stomach tube consists of a piece of india-rubber tubing about three feet long, with a funnel at one end. The method of passing it is as follows:—The patient’s jaws should be kept apart by a gag such as a piece of stick wrapped in lint placed between the back teeth on either side. The left forefinger should be passed into the patient’s mouth as far as possible and the tongue drawn forward; the rubber tube, oiled or smeared with vaseline or glycerine, should then be passed by the side of the finger and down the throat for about twenty inches, taking care to use no great force. ”

“ If the paralysis be partial, it is better to give nux vomica or Ignatia amara by the mouth, in hopes of getting some beneficial astringent influence on the walls of the oesophagus.
In all instances the feeding of the patient is an important element in treatment. Masses of food arrested in the tube should be forced onward with the sound. In some cases nourishment must be habitually introduced through the stomach-tube and nutritive enemata be resorted to. ”

“ All the stones being extracted, there is in most cases little or no bleeding (see infra, Hæmorrhage) . The tube already described may now be inserted and tied into the bladder. It may be{265} retained for forty-eight or seventy-two hours, according to circumstances. Care must be taken lest it be closed up by coagula during the first hour or two after the operation. In children the tube is not necessary, and from their restlessness might possibly do harm, but in adults (though neglected by some surgeons) experience shows it is a valuable adjunct in the after-treatment. ”

“ The œsophageal tube is of very simple anatomical construction, and performs an equally simple physiological function; nevertheless, in the ox it is liable to a large number of diseased conditions. These conditions may affect only a circumscribed area of the mucous membrane or the entire extent of the tube. Again, both the muscular and mucous tissues may be affected, as in inflammation of the œsophagus accompanied or followed by contraction, and in the formation of œsophageal abscesses and tumours; or the muscular tissue alone may be affected, as in cases of dilatation. ”

“ Possibly some of the cures have been due to the dilatation of organic lesions, or to the crowding back of an enlarged malposed, or otherwise abnormal left lobe of the liver, which Mosher has shown to be an etiologic factor.
Certain cases prove very obstinate of cure, and require esophageal lavage for the esophagitis, and feedings through the stomach tube to increase nutrition and to dilate the contracted stomach. Gastrostomy for feeding rarely becomes necessary, for a stomach tube can always be placed with the esophagoscope if it will not pass otherwise. ”

“ Behind the pharynx comes the main portion of the alimentary canal concerned with the digestion and absorption of the food. This forms a tube varying greatly in length, more elongated and coiled in the higher Teleostomes, shorter and straighter in the Selachians, Dipnoans and lower Teleostomes. The oesophagus or gullet, usually forming a short, wide tube, leads into the glandular, more or less dilated stomach. This is frequently in the form of a letter J, the longer limb being continuous with the gullet, the shorter with the intestine. ”

“ The value of making a fistula in the stomach—gastrostomy—in order to feed the patient, is a question about which widely different opinions are held both by patients and by surgeons. Many patients allege that they would prefer to die rather than prolong a precarious existence by being fed through a tube ”

“ If one dispassionately regards this question, and if any of our methods for the study of gastric secretion are reliable, one must be convinced step by step in the laboratory of the uselessness of mechanical stimulation. In the case of dogs with an ordinary gastric fistula, and failing some special reason, not a drop of gastric juice ever escapes from the stomach other than during the digestive period. How could this be the case if the mechanical stimulus were effective, since the inner rim of the fistula-tube is continuously in contact with the gastric mucous membrane? ”

“ In twisting of the bowel, in internal strangulation by band or loop or ring, and in some cases of invagination, the constriction is kept up by the enormous gaseous distension. The obstruction is continued as much by causes within as without the intestine. When tapped and the gas drawn off, the bowel collapses, and may escape from its constriction and return to its natural condition. Tapping is not always certain or safe. The trocar or aspirating tube may pass between the convolutions and no escape of gas take place, or it may be followed by fecal extravasation into the peritoneal cavity. ”

“ No endoscopist has enough practice on the living subject, because the cases are too infrequent and furthermore the tube is inserted for too short a space of time. Practice on the rubber tube trains the eye to recognize objects and to gauge distance; it develops the tactile sense so that a knowledge of the character of the object grasped or the nature of the tissues palpated may be acquired. Before attempting the removal of a particular foreign body from a living patient, the anticipated problem should be simulated with a duplicate of the foreign body in a rubber tube. ”

“ When a pultaceous magma of carbonate of lime accumulates in the bladder it must be washed out by injecting water through a catheter by means of a force pump or a funnel, shaking it up with the hand introduced through the rectum and allowing the muddy liquid to flow out through the tube. This is to be repeated until the bladder is empty and the water come away, clear. A catheter with a double tube is sometimes used, the injection passing in through the one tube and escaping through the other. ”

“ A hard-wood board held between you and the tube is no protection. The streams pass through it unchecked. Sheets of metal even do not wholly stop them. The wonder of it all is that for nearly twenty years experimenters with the Crookes tube have been pierced through and through by these subtle streams and have never known it. Do they produce any effect as they pass through the body? Can they cause or cure disease?
It has been proved that they pass quite freely through the lungs, but if tubercules are present they stop the rays. ”

“ Enemata are usually administered by means of a syringe, bladder, or elastic bag, furnished with a rectum tube; but many ingenious and elegant pieces of mechanism, adapted for self-administration, are made by the instrument makers. Great care should be taken to avoid injuring the coats of the rectum by the use of a rough or improperly shaped pipe, or one that is too long. ”

“ The perforation in the stopper, which is easily made by a glass blower, thus allows the overflow, when the stopper is inserted into the full tube, to pass into the side tube. The stopper is then turned so as to cut off the urine in the latter from that in the large tube, and the latter is thus made tight. After allowing it to remain at rest long enough to permit subsidence of all that will settle, the stopper is gently turned and a drop taken off the lower end upon a slide, to be examined at leisure with the microscope. ”

“ It is well to have a stomach-tube at hand in order to withdraw the gas in case unpleasant symptoms develop. Sometimes the stomach fails to become distended by this procedure. This is due in some cases to the escape of the gas through the pyloric orifice into the intestine—a condition designated by Ebstein as incontinence of the pylorus. It may be that sometimes the gas produces such firm [p. 597] contraction of the gastric walls that the stomach does not expand by the pressure of the gas. ”

“ When the trouble is in the lower bowel considerable relief may follow the insertion of the rectal tube. Irrigation of the colon, when permissible, may stimulate peristalsis in the higher segments of the bowel. A routine intended to militate against intestinal paresis in celiotomies, and worth a fair trial, is to administer with the morphine sulphate a small dose of eserine sulphate hypodermatically. For the ordinary adult the dose should be about one-fourth of a grain of morphine sulphate and one fiftieth of a grain of eserine sulphate given subcutaneously one-half hour before narcosis. ”

“ An aperture on both sides prevents drawing in the mucosa. It can be used for insufflation of ether if desired. An aspirating tube of the same design, but having a squarely cut off end, is sometimes useful for removing secretions lying close to a foreign body; for removing papillomata; and even for withdrawing foreign bodies of a soft surface consistency. It is not often that the foreign bodies can be thus withdrawn through the glottis, but closely fitting foreign bodies can at least be withdrawn to a higher level at which ample forceps spaces will permit application of forceps. ”

“ Changing the outer tube rarely presents any difficulty because the tissues of the neck soon become matted together, a funnel being thus produced along which the canula is introduced with ease. A new tube should be prepared before removal of the old, and dilators should be at hand for use if the child is frightened, struggles, or coughs: the canula should be introduced quickly and without hesitation, sufficient force being employed to overcome any obstruction. ”

“ In the case of gastric dilatation from pyloric obstruction great relief may be afforded by washing out the viscus by means of a long rubber tube, a funnel, and a jug of hot water, as originally suggested by Adolf Küssmaul. ”

“ Such an investigation is all the more desirable because clinical study of the same subject (notwithstanding the zeal devoted to it during the last ten years and the results derived therefrom) has to contend with serious difficulties. We must not forget that the sound or stomach-tube, the chief clinical instrument, is more uncomfortable than the ordinary form of gastric fistula which was previously practised on animals, and yet the physiology of the stomach, even with the aid of the latter, made no material progress for many long years. ”

“ It is rarely the foreign body itself which is producing these symptoms, and the removal of the object will not cause their immediate subsidence; while the passage of the tube through the lacerated, infected, and inflamed esophagus might further harm the patient. Moreover, the foreign body will be difficult to find and to remove from the edematous and bleeding folds, and the risk of following a false passage into the mediastinum or overriding the foreign body is great. Water starvation should be relieved by means of proctoclysis and hypodermoclysis before endoscopy is done. ”

“ The pulse at the beginning is not remarkably full nor frequent, from which fatal mistakes and irremediable{278} procrastination, have often ensued in medical practice: the urine is in small quantity, or suppressed. It is much more frequent in the narrow than the wide part of the intestinal tube. In the rectum, constant tenesmus, excretion of mucus; and in the male sex strangury are natural consequences and symptoms. Inflammation or nephritick paroxisms in the kidneys and ureters, with which it has been confounded, are hereafter discriminated. ”

“ This objection was finally set aside by Pasteur, who showed that it was not necessary to seal the end of the tube before boiling, but it could be closed by a plug of cotton wool, which mechanically removed the organisms from the air which entered the tube, or if the tube were bent in the shape of a U and the end left open, organisms from the air could not pass into the tube against gravity when air movement within the tube was prevented by bending. The possibility of spontaneous generation cannot be denied, but that it takes place is against all human experience. ”

“ The inlet gas tube is fitted at its inner end with a sliding flanged collar (F) , which is kept pressed against the rubber diaphragm by a spiral spring. Just behind the collar the inlet tube is perforated by a small hole, so that the gas supply is never wholly cut off, even though the rubber diaphragm completely occludes the inner aperture of the pipe.
The mode of working of the regulator is as follows: when the water tank of the incubator is filled with distilled or rain water at the temperature required, it presses upon the india-rubber diaphragm with a certain degree of pressure. ”

“ When the drainage-tube has completely contracted, the stilette is withdrawn. The drainage-tube is then transfixed with a safety-pin inserted close to the skin, and the superfluous tubing cut off. Pus flows freely from the tube, which now firmly plugs the wound in the abdominal wall and liver, and bridges the peritoneal cavity. When the abscess has nearly emptied itself the usual antiseptic dressing is applied. In operating through the thoracic wall, if deemed desirable, part of a rib may be excised before the trocar is introduced. ”

“ The choice of a proper tube, one suited to meet the special indications in a given case and specially adapted to the age of the patient and the calibre and position of his trachea, is no unimportant matter, and may do much not only to facilitate the immediate success of the operation, but likewise prevent the occurrence of those possible unfortunate results, ulceration, fatal hemorrhage, abscess, pneumonia, and pyæmia, no lack of which are recorded in our literature. ”