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pathological Cialis Online Usa process, its nature and stage, ^so that the selection of Cialis Online Usa the correct treatment must* be left to the sound judgment of the experienced physi- cian. Strict indications, or a Cialis Online Usa routine Cialis Online Usa procedure, for lavage of the stomach can therefore not be es- tablished. Perhaps it is for this very reason that nowadays there is too much washing out — or too little. Much less is it possible, therefore, to deter- mine the indications for irrigation of the duo- denum — at least not yet. Time may teach us. .\s I Cialis Online Usa examined the duodenal contents in a num- ber of cases by means of the duodenal tube, there were frequent opportunities, from reasons to be ex- plained later, to apply to the duodenum fluids of various chemical composition. While conducting these investigations, Cialis Online Usa I was preeminently impressed with the possibility of free lavage of the duodenum ; they also taught me in part the functional mechan- ism of the duodenum and furnished certain hints as to intelligent therapeutic procedure. Method. — The patient swallows the duodenal tube weighted at the end by a carefully protected small silver ball to the mark of 45 cm. (ultracardial) ; the patient having now assumed a recumbent posi- tion on his right side, the small ball tends to, and does, gravitate toward the pylorus, drawing the tube with it, which it is allowed to do to the mark of 60 cm. (pylorus). Next the tube is carefully pushed on. practically yielding to the gentle traction of the ball, until the mark, 75 or 80 cm., has been reached. After from twenty to thirty minutes the first aspira- Cialis Online Usa tion is made w'hich will often yield gastric contents mixed with duodenal contents of acid reaction (Congo), but sometimes, even at this distance, pure characteristic alkaline duodenal contents. The tube being safely lodged in the duodenum, the desired lavage can be effected with the patient Cialis Online Usa in a fitting or recumbent posture by simply pour- ing the fluid Cas is done in gastric lavage) into a glass funnel attached to the outer end of the tube which is wide enough for this purpose ; or by direct filling of the glass ball, the "receptacle." The lat- ter method is indicated if the fluid does not flow off rapidly enough, in which case light blowing through the "mouth niece" will ensure the desired result. Great deviations from the conditions observed with indirect irrigation ria the stomach were in a large measure only found in the course of the in- vestigations which followed. The liquid ma\- be allowed to flow out, as in gastric lavage, by simply lowering the funnel or the "glass receptacle" : this is especially done when there is interruption of the outflow which may be remedied by light aspiration. Another way is to allow the injected liquid to re- main in the duodenum, leaving the functional mechanism of the latter to carry it to the jejunum. The liquid introduced into the duodenum does not, as might be supposed, flow at once into the jejunum, but. on the contrary, remains for about two or five minutes, according to the quantity used, Cialis Online Usa stationary in the duodenum, in order, apparently, to be conveyed to the jejunum in jerks (duodenal peristalsis). Furthermore, the injected liquid ef- fects a Cialis Online Usa direct stimulation of the duodenal mucosa, exciting secretion. This can be easily demonstrated by aspiration which, after the liquid has been al- 172 WAUGH: WHEN SEDATIVES ARE TOXIC. [New Ymu Medic\l Joorsa lowed to escape, brings up fresh quantities of pure duodenal juice. The following interesting experiment was made : Fifteen grammes of a o.i normal hydrochloric acid solution were introduced into the duodenum, aspi- rated after one Cialis Online Usa minute, and found to have under- gone partial neutralization ; after two minutes there was alkaline reaction (litmus). In this way it would be possible to measure the alkalinity of the duodenal secretion. So far as appearances go, the alkaline strength of the intestinal juice — the power of neutralizing acids — seems to be enormous. But what indications, if any, will be established in time for lavage of the duodenum, Cialis Online Usa cannot yet be determined at this juncture. Up to the present we have resorted to occasional lavage in ulcus ventri- culi with bismuth solutions in chronic duodenal catarrh with Karlsbad waters, also in diabetes (pan- creas?); furthenuore, in cholelithiasis and pro- nounced persistent icterus, the object being to Cialis Online Usa lib- Cialis Online Usa erate both duodenum and common duct from in- flammatory infectious products. Finally, I wish to add a few data on the func- tional mechanism of the duodenum, in so far as the investigations made warrant conclusions. The fact that in the first part of the duodenum (pars horizontalis superior), and perhaps even a little lower down, the duodenal contents arc nearly always mixed with gastric contents, together with the further fact that the liquids introduced into the duodenum remain there stationary for a time and are then conveyed to the jejunum seem to justify the conclusion that the duodenum is by no means a mere instrument of passage, but that at this part of the digestive canal, notably in its upper portion, there occurs Cialis Online Usa a kind of sifting and mixing of the acid gastric with the alkaline duodenal contents, the pylorus being closed ; a kind of shaking apparatus, in which the neutralized contents are being con- veyed in regular jerks to the jejunum, followed possibly by an extra alkaline wave excited bv the direct Cialis Online Usa stimulation of the contents. The time occu- pied to effect this complete process of mixing will probably depend upon the degree of acidity and the quantity of the gastric contents. The duodenum seems to be a transition organ of great importance in the economy of digestion. I am inclined to compare the work of the duodenum