With the Compliments of TH03. F. RUMBOLD. iOSl, THBOAT ill Ml; Instruments and Remarks. A Description of New Instruments FOR MAKING EXAMINATIONS AND APPLICATIONS TO THE CAVITIES OF TOE HOSE, THROAT AND 1, AND Some Remarks about the Local and General Treatment of the Affections in which they are Applicable. ILLUSTRATED BY THIRTEEN ENGRAVINGS. THIRD EDITION—REVISE THOMAS F. RUMBOLD, M. EL ST. LOUIS A. M. LESLIE & CO., Manufacturers of Surgical and Dental Instruments, 819 North Fifth Street. “In the early stage of any department of knowledge, it is almost a matter of necessity that it should be in the hands of a few. But it is the highest privilege of those who devote themselves to the reclaiming of new spots of territory, to be able after awhile to hand them over to the Com- monwealth, to prove that they are now cultivated and well worthy of annexation.”—Jonathan Hutchinson. This monograph comprises papers which originally appeared in various Medical Journals at different times, and some which appeared in a separate pamphlet form, and a few which now are published for the first time. The first of these, in connection with the last, are again pre- sented in this form to the profession after a careful revision, with the hope that they may have the effect of exciting a greater interest in the import- ance of a rational local treatment of chronic catarrhal inflammation of the mucous membranes of the air passages. From many who have seen and read these papers heretofore pub- lished, I have had encouraging expressions and evidences of approba- tion, which have aided me much in the preparation of this monograph. To such I tender my sincere thanks, and trust that what is here presented will meet their approval. T. F. R. 1205 Washington Avenue, 1875 Instruments for Making Examinations, The Kramer Bi-valve Ear Speculum is a well-known and conven- ient instrument, for dilating small nasal openings, and a modification of this, by Mr. James Hinton, of London, having wider and flattened blades, is well adapted for larger ones. Although some appliance ot this sort is requisite for inspection of the nasal cavities through their anterior openings, it can never be more than a partial examination, be- cause of the peculiar formation of the turbinated processes hiding from view their under-surfaces. The instruments for completing, or making more thorough this examination, are glass mirrors, of various sizes: One, the Pharyngeal Mirror (Fig. .2), placed under and back of the velum palati, and the others, the Anterior Nasal Mirrors, (Fig. 3) passed into the nasal cavities anteriorly, during the dilation of the opening< They are employed to illuminate the surfaces, and reflect their image, so as to ascertain their condition; the former reflector for examining the posterior and inferior portions of the several turbinated processes, the latter their borders and under surfaces. TONGUE DEPRESSOR. A Tongue Depressor is required for both the examination and the treatment of all the diseases of the posterior nares, the pharyngo nasal, the pharyngeal, and the laryngeal cavities, as it provides free access of light, and prevents interruptions by the tongue during the use of other instruments. Almost any pressure on the tongue, made by the physician, produces a retching, a contraction of the pharynx, and an elevation of the soft palate, and renders the examination and treatment impracticable; but if the patient has the Tongue Depressor entirely under his own con- trol, these disagreeable effects are almost entirely avoided. For while the mind is at rest, all apprehension being removed, the muscles of the fauces and velum remain quiet and passive. The patient is directed to place the instrument well on the tongue, to open the mouth wide, and to breathe freely and naturally. In this way, the chief object will 4 be attained, namely: the relaxed condition of all the muscles of the fauces. This method of using the Tongue Depressor is not only more con- venient for the operator, but much more pleasant for the patient; it is. in fact, his instrument during the examination and treatment. For many years I have found that a Tongue Depressor with a handle and shaft twelve inches long (Fig. i) was best adapted to the purposes in view, because it allows the hand that holds the instrument to be kept out of the operator’s way. Into the head of the shaft is fastened, by a milled head screw, either a long or a short tongue piece, adapted to the length of the patient’s jaw. This tongue piece may be bent to any angle with the shaft, which permits the base of the tongue to be depressed as much as is desired, in any case. With this instrument the soft palate, the tonsils, the uvula, the lateral and posterior walls of the pharynx—as high as the first cervical vertebra, and as low as the upper border of the third—may be exposed to view, and frequently the upper border of the epiglottis also may be seen. Fig. 1.—Long-Handled Tongue Depressor (reduced one-fourth.) REFLECTORS. An experience of the inconvenience of the stationary Pharyngeal Mir- ror, in the examination of the posterior nares and the pharyngo-nasal cavity, led me to devise one in which I could alter the angle of reflection at will. Fig. 2.—Hinge Pharyngeal Mirror (reduced one-half.) There is a pivot on the back of the frame of the Mirror, (Fig. 2), on which the frame-holder is slipped : This pivot allows rotation of the reflec- tor, so that the longer diameter may be placed in any direction desired. The frame holder is connected with a double stem, by hinge joints, to which any desired inclination of its plane may be given by one of the stems being moved by a lever on the handle. The instrument is complete with one handle and three or more reflectors of various sizes. The advantages of this instrument are; 1st, after the mirror has been introduced within the fauces, the whole surface maybe seen, repeatedly, by reflection, without the elevation and depression of its outer extremity, which is necessary with the stationary mirror, thus avoiding one cause of agitation or disagreeable impression upon the mind of the patient, which, in many cases, especially with first examinations, is sufficient to excite muscular contraction of the fauces; 2nd, that the survey may be more rapidly made, which is a desideratum, as the period for a pendent, soft palate is often very brief; and 3d, that the mirror which is slipped on the frame-holder may be revolved to suit a wide or narrow fauces. Fig. 3.—Anterior-Nasal Mirror. The Anterior Nasal Mirrors (Fig. 3), varying in size from two to five lines in width, and from five to eight lines in length, are each enclosed by a wire placed along the edges, the extremities of which by being firmly twisted together, serve as a handle, as well as the means of framing the mirror. A coating of shellac protects the amalgam of the mirrors from abrasion. Any desired angle may be given to the reflectors by simply bending the wire. The length of instrument is about six inches. Inspection of large nasal cavities may be more thoroughly and rapidly made by the introduction of the hinge mirror. RETRACTORS. It is sometimes necessary to raise the uvula and draw the soft palate slightly forward, in order to obtain a more extended view of the cavity above. During first examinations, the excitability of the velum palati is often so great that the usual hook-shaped retractor, even handled with the utmost care, is very disagreeable to the patient, inducing elevation, and frequently, instead of facilitating the examination, prevents, by its contact, any inspection of the posterior nares or pharyngo-nasal cavity, whatever. 6 Fig- 4-—Uvula Retractor (reduced one-half.) To avoid this I have employed an Uvula Retractor (Fig. 4) of the following description : A tube six inches long and one-eighth of an inch in diameter, having at one end an enlargement three-sixteenths of an inch transversely, and cup-shaped, for the purpose of receiving the uvula. The other extremity is trumpet-shaped, and one inch in diameter, and covered by sheet India rubber. In its use the smaller extremity of the instrument is applied gently to the uvula, whilst the air is expelled irom the tube by slight pressure on the rubber extremity. This done, the uvula is drawn into the tube about one-quarter of an inch. Only slight traction is necessary to lift the uvula and draw the soft palate forward, thus the antero-posterior diameter of the passage may be increased from one-quarter to one-half inch. If carefully handled, patients generally do not feel the application of the instrument. In Surgical cases it is necessary that the whole of the soft palate should be drawn forward to as great an extent as possible. For this, a hook-shaped Retractor is the only kind that is reliable. As the pa- tient is obliged to learn to tolerate the application of such an instrument, any form or shape that will dilate the parts, and not injure them, is all that is required. In the early part of the year 1867, I removed a large polypus from the superior wall of the pharyngo-nasal cavity. The greatest source of trouble, during the operation, was the difficulty encountered in retaining the soft palate sufficiently forward. As a narrow hook could not enlarge the passage to the extent desired, a wider one was employed; but, fre- quently, as soon as this was placed behind the relaxed velum, involun- tary contraction of the pharyngeal muscles ensued, and severe pressure on its edges caused marked suffering of the patient. These circum- stances led me to devise the Spreading Soft-palate Retractor (Fig. 5), which almost entirely obviates the difficulties. Fiff- 5— Spreading Soft Palate Retractor (reduced one-half.) The instrument resembles an ordinary palate-hook, split longitudi- nally; the surface of each hook that comes in contact with the soft palate, is made convex, by binding the plates; the arms are separated by a lever (A) on the handle, and are maintained in this expanded condition by a retainer or wedge—connected with another lever (C) having a spring under it—which insinuates itself between them. The uvula is prevented from dropping into the operator's way by a small piece of thin rubber 7 tubing (B) slipped on the arms over the hooks, which also answers to close the hooks on raising the wedge (C). The elasticity of the arms is such as to yield sufficiently to muscular contractions, when they do occur, to pre- vent injury to the soft palate. The application is easy, the operator passes the closed hooks gently behind the relaxed or pendent soft palate, elevating them sufficiently to engage the velum, then separates the limbs of the instrument by pressure on the lever first-named (A), which stretches the soft palate laterally, then traction on the handle increases the antero-posterior diameter of the passage. By use of this instrument equal retraction of the velum palati—with both relaxation and tension at will—can be effected by the left hand, while the right is engaged in operating, and more room is secured during surgi- cal treatment than by any other kind of retractor. 1 have frequently attached a small stationary Reflector to this Re- tractor, which enabled me to see the parts operated on. ACOU-OTOSCOPE. In the month of February, 1869, I was consulted in regard to an exceedingly troublesome noise in a patient’s ear, occasioned by his own voice passing up the Eustachian tube. I had repeatedly observed the same phenomenon in several other patients during the previous year. Bj7 the aid of the Aural Auscultating Tube, and the peculiarity of the symptoms, I arrived at a conclusion with reference to the cause of this symptom or phenomenon, but still was fearful that I might be mistaken, because the effect of this diagnosis was to disprove the theory held by Otologists, respecting the action of the Eustachian Tube in supplying air to the middle ear. My interest being excited, I determined to more thoroughly investigate the cause of this peculiar symptom, and in doing so, to make a more careful search into the condition of the organ or organs involved, than is usually practiced. In ordinary examinations of the Eustachian Tube and membrana tympani, the canaHs’auscultated at one time, and the drum head inspected at another; therefore, while viewing the latter, during inflation of the middle ear, we only see the effects of the air douche on the membrane, no note can be taken in regard to peculiarity of the sounds that is occasioned bj' the air in its passage through the Eustachian Tube; nor, while listen- ing by means of the auscultating tube, to the sounds in this canal during inflation, can the effects of the air on the membrana tympani be observed; that is to say, during inspection of the ear, no auscultation can be prac- ticed, nor during auscultation can there be any inspection. It was this impossibility of seeing and hearing at the same time, that induced me to attempt a device by which auscultation and inspection could be practiced 8 together. In this I was successful, and have named the instrument—as it combines two kinds of examinations—the Acou-Otoscope. (Fig. 6.) Fig. 6—Acou-Otoscope (reduced one-third). It consists of a truncated conical ear speculum, with its larger end closed by a well fitted piece of plain clear glass; connecting with and opening into its cavity is a metalic tube, about five inches long and one- fourth inch bore, the purpose of which is to conduct the sounds from the patient’s ear to the ears of the Aurist; it also serves for a handle by which the patient may hold the instrument in proper position. The method of using the instrument is thus: The smaller end of the conical portion is fitted into a conical ear speculum, one end of a rub- ber tube, about fourteen inches long, is slipped on the long metal tube, the other end is connected with a Camman’s stethoscope, the trumpet extremity being removed. After placing the Acou-Otoscope in the conical ear speculum, and inserting this into the ear to be examined, the patient is directed to hold the instrument in position most favorable to the Aurist for viewing the membrana tympani, using the hand corres- ponding to the ear inspected. He is cautioned against any movement of his fingers holding the instrument, whereby any sounds may be pro- duced by friction, as the slightest movement thus made will occasion sounds far louder than any that might come from his ear during examina- tion. The Aurist now secures a reflector to his forehead, by which he illuminates the auditory canal, then places the stethoscope in his ears, gives the patient a little water to swallow, and, while inflating the mid- dle ear, he is to look through the glass of the instrument, so that he may observe the effects of the air douche on the membrana tympani. In this way he is enabled to hear the sounds produced by the air in its passage through the Eustachian tube (by their being conducted from the patient’s ear through the ear speculum, the Acou-Otoscope, the rub- ber tube, and the stethoscope, to his own ears,) and note their character- istics, and to observe the movements, or other effects, of the membrana tympani at the same time. In the year 1873 I published a paper on the subject of “The Func- tion of the Eustachian Tube, etc.,” and offered, in support of my views, the symptoms of several patients who were suffering from patency of this canal,—a condition not then recognized. I was aided by the aural auscultating tube, by different simple experiments and by this instru- ment, but only employed it as a means of supplying additional proof of patency of the Eustachian tube. I did not then recognize its great value. Since this time I have had occasion to treat other patients similarly affected, in which I have employed it, and find from its evidence alone, that every case of this class may be correctly diagnosed, and the degree of patency ascertained, and its consequences placed upon a demonstrable basis, leaving no longer room for any reasonable doubt. Indeed, I may say, that in all pathological conditions of the Eusta- chian tube, especially if the membrana tympani is also implicated, the Aurist will find that the evidence afforded him will be most full and sat- isfactory, enabling him to reach a conclusion that justifies but little if any doubt as to the completeness of his diagnosis. The reason for this is very plain and obvious, from the fact that the faculties of seeing and hear- ing are combined in the investigation, which secures a greater accuracy and certainty as to results, than was ever attained when only one faculty at a time could be used, since the recognition of a condition, either path- ological or physiological, by one of the senses, may be confirmed by the operation of the other. 9 Instruments for Making Applications. SPRAY PRODUCERS. In local treatment of the Nose, Throat and Ear, affected by what is understood as chronic inflammation of their mucous membranes, the main defect of all plans has been the -want of mildness combined -with thorough- ness. Especially is this true of the nasal and pharyngo nasal cavities, as they are difficult to cleanse and treat without doing injury, equal to any benefit intended. Whatever method for cleansing and medicating the inflamed surfaces may be chosen, it should be such a one as will cause but slight irritation, not lasting beyond a very few minutes. Experience has taught me that Spray Producers of various forms, that throw streams in the directions required to make direct applications, and of such capacity and power, that the quantity and force may be regulated to suit the severity of the case, are the best means that can be employed.* When used to cleanse covered surfaces, they blow and wash the muco- purulent secretions away from their lodging places, in a manner that is mildly yet thoroughly accomplished ; and when used for treatment, they force the medicated solution, into every irregularity, into places that have never been reached by the brush or spray, or even viewed during life. As the instrument can throw a stream in one direction only, acting upon a surface of about three-fourths of an inch in diameter, and as the avenue for application to the extensive surfaces of the nasal and the pharyngo- nasal cavities, are the narrow space behind the sensitive soft palate and the anterior nares, and to the larynx over a reclining and sensitive epi- *The agent employed to produce the spray is air forced from India rubber bulbs, rep- resented in the illustration of the Catheter Nasal Douche (Fig. n). I prefer that the bulbs should be attached close to each other, rather than separated by six inches of tub- ing. This proximity will prevent the reservoir bulb from becoming an encumbrance, and allow it to be more readily reached, as the hand used to compress them can be slipped from one to the other, when desirous of making a continuous spray, or one short, light, or heavy stream. glottis, therefore a number of nebulizers whose points are so con- structed, as to throw streams in the various directions that are re- quisite to cleanse and medicate every portion of the diseased surfaces, are indispensable. My experience has taught me, that five varieties of Spray Producers are necessary to treat the superior cavities, Fig. 7—Spray-producers for the pharynx, the pharyngo-nasal and nasal cavities (reduced one-half.) No. x throws a spray directly for- ward into the mouth. No. 2 into the anterior nares. No. 3, upon the posterior wall of the pharyngo-nasal cavity. No. 4, the superior wall of same. No. 5, into the posterior nares. (Fig. 7—Nos. 1 to 5, inclusive), and three the larynx (Fig. 8—Nos. 6 to 8, inclusive)—viz: one, (No. 1) throwing a horizontal stream, acting upon the surface of that portion of the pharynx which is in view when the mouth is open and the tongue depressed, washing the anterior portion of the soft palate, the tonsils, and by elevation of the outer extremity, the posterior wall of the pharynx from the third cervical vertebra upward to the middle of the second; one, (No. 3.) throwing a stream at an eleva- tion of forty-five degrees, directing the spray against that portion of the posterior wall covering the first and second vertebrae; one, (No. 4,) throw- ing its stream vertically, reaching the superior surface or arch boundary of the pharyngo-nasal cavity; one, (No. 5) reach ing through the posterior nasal openings, throwing a stream upward and forward, at an angle of forty-five degrees, washing the under surfaces, borders and sides of the superior middle, and inferior turbinated processes ;* and still one other, (No. 2) intermediated in direction between the first and second named, is introduced into the anterior nares, and by elevation and depression of its outer extremity, made to wash and medicate the remaining portions of the nasal passages. Fig. 8.—Spray Producers for the Pharynx and Larynx; (reduced one-half ) *The point of No. 4 and 5 should be placed a little behind the lower border,of the soft palate, alternately upon the right and left side of the uvula. 11 For the Larynx, one, 6, Fig. 8,) that throws a stream on that por- tion of the posterior wall of the pharnyx which is in front of the third and fourth cervical vertebrae; one, (No.7) that directs its stream into the lar- ynx, and, accompanying slight inhalation, the trachea; and one, (No. 8) washing the base of the tongue and posterior surface of the epiglottis. Slight rotationof the instruments will be required to treat the lateral walls. The history of this variety of Spray-producers is as follows: In the month of June, 1866, I bought from A. M. Leslie & Co., of this city, three of Maunder’s glass Spray-producers—the illustration of which was then placed by Otto & Rynders, of New York, in their advertisement—one of which threw a stream horizontally, one downward, and one vertically. To each instrument was attached a small bottle to contain the medicated fluid. After using them a few times, one was accidentally broken. As I could not wait for a supply from New York, and as my patients had become very much attached to this method of making applications, I resolved to try to make my own instruments. After a few failures, I at length suc- ceeded in making a Spray-producer fully equal to the expensive one in- jured, and in a few weeks afterwards, blew upon the end of the tube that had been inserted into the container, a cup or reservoir in which the med- icated liquid was placed. This I found to be a great improvement on the bottle, as I had by this time learned that the fluid should be warmed before being used. Fig. 9.—Warm Spray Producer (reduced one-third.) Since that time I have made all the Spray Producers that I have used ; lately, my son—a lad thirteen years old—has made them for me. For some time I thought that I was the first to put a cup or reservoir on the glass Spray Producer, but it will be seen from the following that Dr. J. Solis Cohen, of Philadelphia, preceded me a little over one year. He says, on page 32, in his work on “Inhalations” : “In May, 1865, I exhibited to the Surgical Section of the American Medical Association a portable instrument in which I had turned the Bergson tubes, as modified by Winterich, upside down, and screwed a little reservoir on the large extremity of the perpendicular tube- Where glass tubes are employed the extremity of the perpendicular tube is blown out into a reservoir.” The tubing I obtain from the glass blowers is much heavier than is ordinarily seen in drug stores, and flattened on one side—a section of which is represented by the small figures at the left of the cup, No. 6, Fig. 8. They are less bulky in this shape, than two round tubes would be when attached together. One tube is straight and seven inches in length; the other, five inches long, with a bulb or cup blown on it. I form the points on each kind of tubing, and bend them and the tubes to their proper shape, over a small gas light or alcohol lamp, and attach them by again heating and placing a small piece of piepared gutta percha between them, such as is used by Dentists. A short experience will enable any one having a little “knack” to form and adapt the points, for either a fine or a coarse spray. They are fragile, it is true, but the loss by fracture—ordinary care being taken—is quite small compared with the numerous advantages they present. I would recommend that any one making frequent use of such sprays, should begin early to acquire the ability to make and repair them. Cases of chronic thickening of the nasal mucous membrane in adults, and of sub-acute forms of thickening in children, affecting also the Eus- tachian tubes, in which the secretions are almost entirely wanting, are often met with, and especially require the effects of heat along with medi- cinal preparations used. To fulfill these indications, I have, after vari- ous efforts, constructed a Warm Spray Producer (Fig. 9) which in fact is but an addition [to the Siegel-Bergson steam apparatus. It is a thick glass tube (D) four inches long, three-fourths of an inch in diameter. This is pointed at one extremity, so as to present a half inch opening; the other is closed with a rubber cork having two perforations, one for hold- ing the stem of a small nebulizer, that is placed within the larger tube (D) or container, and the other for the reception of the steam pipe from the boiler (A). The nebulizer and the boiler are connected with the India rubber air bulbs by a double tube (B and C) of the same material. On the arm which is connected with the boiler is a faucet (C). A small lamp is placed under the boiler to generate heat. The outer end of the container (D) is slightly elevated for the more convenient insertion into either nostril. The mode of application is as follows : A little water is placed in the boiler (A)—a small quantity of iodine, ammonia, carbolic acid, or other volatile agent, may be added—which is heated to about 1200 F. The medicated fluid to be converted into spray, is placed in the container (D) ; over the end of the container is slipped a common rubber nipple shield, a quarter of an inch of the closed extremity cut off, to prevent the spray from escaping, except by return from the other nostril, and to pro- tect the patient from the heat of the glass. After the introduction of the instrument into one of the nostrils, air is forced by the air-bulbs both into the nebulizer and the boiler, the effect of which is to produce a warm spray of the temperature desired ; the intensity of the heat being gov- erned bv the amount of air allowed to pass into the boiler through the faucet (C). Many of my little patients prefer this instrument, both for the treatment of the nostrils, and inflation of the middle ear. They need only to close the nostril not treated, when the warm spray will inflate both middle ears, sometimes without the act of deglutition; more frequently an involuntary act of swallowing will take place, and then the spray is forced into the Eustachian tubes in greater quantities. Experience, in reference to the temperature of air forced into the mid- dle ear, is much in favor of the warm air over that of the cold. This instrument has also proved very beneficial in myringitis, result- ing from acute catarrh of the middle ear, and in furnuncle. The heat and the anaesthetic property of the carbolic acid, have a very soothing effect. The force applied to the air bulbs for the treatment of these afflictions, should not be as great as that required for the treatment of the nasal cav- ities. » CATHETER NASAL DOUCHE. When the mucopurulent secretions have been hardened, adhering closely to the mucous membrane of the superior portions of the nasal and pharyngo-nasal cavities, and the spray-producers have not sufficient force to remove them, this may be accomplished to some extent by the posterior nares syringe; but, however carefully handled, it may cause, by its appli- cation behind the soft palate, occasional injuries, and the force of the injection such unpleasant sensations, that the patients refuse to submit to it. The apparatus most resorted to in such cases, is the Weber nasal douche (improperly called Thudichum’s). That this mode of cleansing is beneficial, either when the disease is wholly situated low enough for the medicated stream to wash it—which is very seldom—or when the secre- tions are so abundant as to flow or extend to the inferior portion of the cavity, is not doubted; but it is needless to say it is of no benefit if it will not cause the medicated fluid to be applied to the diseased surfaces. When the head is inclined forward (as recommended in this method), the rubber tube inserted into the nasal opening of the affected side, and the fluid allowed to flow into the cavity, it can only rise a little higher than the lower border of the posterior nasal opening of this side (indicated by the horizontal line e, Fig. 10) ; then it flows around the posterior border of the septum nasi, over that portion of the soft palate That joins the hard palate, on its way out through the other nasal passage, and this is equal Fig 10—Antero-posterior section of the face and head; a, inferior turbi nated process; b, middle turbinated process; c, superior turbinated process; dd, location of inciustations to be removed; e, line showing the height of the water in the nostril irrigated by the Weber douche. “Dotted line” indicates the position of the posterior border of the septum nasi, the turning point of the liquid in leaving the other nostril. in heighth to only one-half of the nasal fossa; the half that is very rarely incrusted, or requiring treatment, as its affection is only secondary, being caused by the secretions flowing down upon it from the original seat of the disease; leaving the pharyngo-nasal cavity untouched. In the other nasal passage the floor only is washed by the escaping liquid. The ele- vation of the soft palate against the posterior wall of the pharynx, will not alter the turning place of the liquid, nor cause it to rise much higher in the cavity. Closure of the communication downward, is not a provis- ion, as asserted by the advocates of this method, that will allow either a more rapid current into the cavity, or its filling, by closure of the other nostril, as either will occasion forcible, involuntary deglutition, lowering of the palate, followed by a choking sensation. Of course a continuance of this manner of application would be of short duration, certainly not long enough to be efficient. At this moment the water may be forced into the Eustachian tube, which may induce inflammation of the middle ear. That my statements are in conformity to facts may be demonstrated by an experiment that will designate the relative positions of the surface incrusted, and the portion of the cavity that has been washed by the Weber apparatus, viz: An aqueous solution of starch (5j ad O j) is first passed through the nasal passage by the Weber douche, immediately following this, a weak solution of iodine and iodide of potassium is thrown by spray upon all the mucous surfaces within that cavity. The result, (which may be seen on inspection with pharyngeal mirror placed under and behind the velum palati), will be a discolation of the surface reached by the douche, the characteristic blue of the iodine of starch. In my opinion this test is conclusive evidence of its inefficiency. When masses of fetid matter are loosened during the use of the Weber douche, it merely shows that the secretions were so abundant, as to flow within reach of the irrigating fluid; or, it may tje, that the irri- tation by the medicated liquid excited a greater flow of mucus, which would detach a portion of the crust, and have an effect similar to that of an irritating powder when snuffled into the nostrils. Upon careful examination of a badly affected case, after the use of this douche there will be observed in the superior portion of the passage a quantity of the inspissated secretions still remaining, ■which cannot be removed by it-. After years of observation of the inadequacy of this plan, I devised an apparatus which I have called the Catheter Nasal Douche (Fig. n). It will throw a shower or coarse spray from the flow of the nostril upward, reaching every portion of the irregular surface of the passage, making per- Fig. ii—Catheter Nasal Douche (reduced one-third); a, reservoir; b, metal tube for the passage of the fluid, having a small aperture in its side for the entrance of air; c, rubber tube; d, foramina for escape of coarse spray; e, catheter; f, India rubber air bulbs, used to force air in the bottle. 16 fectly efficient and direct local application. When warm salt water is used, the only sensation it occasions is that of tickling, which is never objected to by the patient. The apparatus consists of the following parts : A flask-shaped bottle (a) of a pint or a pint and a half capacity; into its rubber stopper are inserted two metallic tubes, whose outer extremities are bent at right angles, and turned in opposite directions; one of these tubes is short, passingjust through the cork, and has attached to it the India rubber air bulbs (f) ; the other (b) almost reaches the bottom of the vessel, and has attached to its outer extremity a hose fc), about twelve inches long, a part of which consists of rubber and part of glass tubing, the latter being about three inches long, inserted in about the middle of the hose. This glass tube is placed here that the operator may inspect the relative quan- tities of air and water passing through it. To the hose is fastened a No. 5 or No. 6 flexible catheter (<1), at the further end of which are made five small openings on a line with its axis, three-eights of an inch apart. The free extremity of the catheter is closed. The metal tube, whose lower extremity dips into the medicated fluid, has a small aperture (b) in its side, just under the rubber stopper; this is to allow air to enter during the passage of the liquid, the effect of which is to cause it to con- tain beads of air and fluid of equal size, the right proportion being about one-half inch of air,* and one-half inch of liquid, so that when escaping from the openings in the catheter, (d) it will resemble a coarse spray. In its application, the catheter is introduced horizontally into the affect- ed cavity, with slight rotation on its axis; the coarse spray or spattering current of liquid and air, which passes directly upward, will wash and blow the secretions from their lodging places, in a milder and more effi- cient manner than a steady flow from any apparatus in use. The cleans- ing process may be greatly assisted by the patient closing the nostril of Fig. 12—Nose Spout (reduced one-third *The relative size of the beads of air and water may be ascertained by suddenly arresting the cuirent in its passage through the ho=e, by compressing it near the cathe- ter, and inspecting at the glass part. If the air beads are relatively larger, the opening (b) in the long metalic tube is too large; if smaller, then the opening is too small. In either case, the aperture must be so made as to give about equal size of beads. the other side, then giving a quick and forcible blow out of the one being washed, expelling the liquid and everything loose, with great force. A perforated, triangular plate of rubber, with one inch border, is slipped on the catheter (e) about three and one-half inches from the closed extrem- ity, which will serve as a guide both in regard to the direction of the stream and the distance of insertion ; at the same time, it will prevent the liquid from flowing on the operator's hand. A Nose Spout, (Fig. 12) to be used by the patient, resembling an ear spout, will be useful in preventing the liquid and muco-purulent secre- tions from falling on the lips, and from soiling the clothing while blow- ing the nose. THE AURAL DOUCHE. The same apparatus that is used for cleansing the nose (the Catheter Nasal Douche) may, with a slight alteration and two additions, be con- verted into an Aural Douche. The changes to be made consist, first, in the removal of the catheter (e Fig. ii,) from the hose (c), and in its place is inserted one of Lucae’s soft metal ear nozzels, which is so made that the liquid escaping from the ear is prevented from running down on the patient; and, second, in slip- ping one inch of soft rubber tubing on the longer metal tube, so as to close the aperture (b) in its side, thus preventing the entrance of air, which was desirable in the Catheter Nasal Douche, but not in this. This apparatus is superior to the common aural syringe, both in re- spect to its efficacy and convenience for either the removal of inspissated cerumen, or the treatment of otorrhcea, because it throws a continuous stream. In the treatment of simple otorrhcea, as that of nasal catarrh, success depends mainly in the cleansing being thoroughly yet mildly performed. We must keep in mind that it is not alone the auditory canal that is to be washed clean, but principally the tympanic cavity; also, that the up- per half of this cavity is above the superior wall of the auditory canal, therefore filling this passage with an irrigating fluid, only half fills the tympanum, (provided the head remains in the erect position) its upper half being occupied by air; nor can this air be displaced by forced injec- tions of liquid, if limited by the patient’s endurance. As we know that the surface of that portion occupied by the air, is not being washed, therefore we must place the tympanic cavity in a position similar to that which we would a bottle of the same shape, and a like position, that is, cause its mouth or outlet to be placed over the air bub- ble, then its escape readily takes place. To attain this result with my patient, I cause his he td to describe a circle in the following manner: Commencing with head in the erect position, the stream is allowed to run a few seconds, that he may be- come accustomed to the sensation it produces, he is then directed to incline his head forward until the forehead assumes the horizontal posi- tion; the motion is slowlycontinued to the leftside—provided the right ear is the one treated—until the stream falls perpendicularly into the ear*. The rolling motion is continued backward until the head is thrown back far enough, for the forehead to again assume the horizontal position; then it is brought forward to the position first named. This rotating motion is continued until the cleansing is completed. It is some times quite beneficial to inflate the middle ear during this process, also to per- form the act of deglutition with the nostrils closed; this, because it rari- ties the air in the pharyngo-nasal cavity, causes the irrigating liquid to enter and wash the Eustachian tube. It is advisable that inflation of the middle ear—the head being inclined to the affected side—should fol- low the irrigation, to drive out all the remaining fluid. In this way, every portion of the tympanic cavity is cleansed com- pletely and speedily. The speed will undoubtedly be modified by the size of the aperture through the membrana tympani, the smaller the openng, the longer the time required to properly cleanse the tympanum. THE TUBULAR LARYNGEAL FORCEPS. The obstacles encountered in the extraction of laryngeal tumors, are numerous, and to a certain extent prevent their removal. One of the difficulties in the way is, that the greatest length of the vertical portion of the laryngeal forceps which can pass into the pharynx without touching any of its parts, is not long enough to reach the vocal cords, in a large majority of cases, without at the same time depressing the base of the tongue from one-fourth to three-fourths of an inch. The patient may learn to tolerate this pressure on the tongue, and to overcome the natural tendency of the fauces to close spasmodically when touched, but it requires from one to three weeks’ practice to do so. Even after this culture, the force exerted by the tongue in its upward action—a result of pressure upon it—is not always the same, because of the mental apprehension so natural ar.d even unavoidable with patients about to undergo such an operation; therefore, the power required to overcome the resistance, varies to such an extent, as to occasion frequent failures. ♦While the head is in this position, less force should be given to the current, to avoid symptoms of vertigo. The length of the vertical portion of the forceps is necessarily limited by the boundary of the space through which it must pass to enter the larynx; that is, during its passage, no part of it should touch the base of the tongue, the epiglottis or the posterior wall of the pharynx, since mere contact of the instrument, in a throat not educated to such usage, would produce instant depression of the epiglottis, if not closure of the fauces, and consequently that attempt to reach the vocal cords would not be successful. To overcome this obstacle, I have devised an instrument (The Tubu- lar Laryngeal Forceps, Fig. 13), which can be passed readily into the larynx, and then lengthened to the extent required to reach the vocal cords in the longest neck. Fig. 13—Tubular Laryngeal Forceps (leduced one-half.) It consists of a tube (3, c,) seven inches long, bent at a right angle, forming a horizontal and a vertical portion, the latter (c) being two and a half inches long. To the horizontal portion of the tube (3) is attached a handle (A) six inches long, at an angle of 45 ° . On the handle is a lever (l) two and a half inches long; this is connected with a rod (/') which passes through the entire length of the tubular portion (3, c.) and is attached, at its lower extremity, to a smaller tube (t) within the larger one, by which the vertical portion (c) is lengthened, and the forceps closed at will. Underneath this rod, is another rod (/'), whose upper extremity is serrated, which also passes through the tubular portion, and terminates in a socket; into this socket is screwed the forceps (_/). There is a slide on the handle, which is moved by a hook-shaped projection (V). This is so connected to two levers which act as retainers (r,) that pressure on the hook-shaped projection (r') causes the retainer to grasp the serrated rod (f) and retain it in the position desired, and thus prevent the further descent of the forceps. The outer side of each limb of the forceps, is serrated, the purpose of which is to cause the descending tube, that closes them, to retain its hold, or position, even when the pressure on the lever is withdrawn. Forceps (1, 2, 3, 4 and f) of various shapes and sizes may be used. The method of using the instrument is as follows: After the vertical portion (c) has been introduced into the larynx, it is lengthened by the lever (7) pushing both rods f and f) into the horizontal portion (b, c), which causes both the smaller tube (t) and the forceps (f) to descend (see dotted lines). As soon as the length desired has been attained, then the serrated rod (f) is arrested by pressure being made on the hook- shaped projection (r') with the thumb, causing the retainers to grasp it firmly, retaining it and the forceps in the position required. The forceps are then closed by continuing the pressure on the lever (/) causing the rod which is attached to it (f) to push the smaller tube (t) over the base of the forceps From the result of observations made, during eleven years expe- rience in the treatment ot chronic catarrhal inflammation of the Nose, Throat and Ears, on the phenomena presented by the disease itself, and on the hidications of what is proper to be done for its removal or ameli- oration, I have come to the following conclusions : (i.) That this affection cannot be cured in a short time, nor by harsh means. (2.) That all patients who ultimately regain a healthy condition of these parts, do so by the membrane growing to the normal state, under conditions which favor and assist the natural processes of repair. (3.) That a large number of cases, mostly the young, will recover without other treatment than that of maintaining the surfaces free from the extraneous products of inflammation. (4.) That the surfaces covered by unhealthy secretions must be cleansed before a proper treatment can be effective, unless the coating is so slight that the application itself will both cleanse and medicate at the same time. But if it be necessary to continue the application ©f the solulion to the parts coated with secretions longer than is proper to treat the parts not thus covered, then it will be found that those surfaces that did not require this lengthy application, will be injured by the excess of treatment necessary for the other parts, and thus produce an increase of the inflammatory action in the whole cavity. (5.) That there are three indications for the cessation of all applica- tions: 1st—Pain—This should not under any circumstances be pro- duced to such a degree of severity as to continue beyond a few seconds, even should it occur during the attempt to remove accumulated secretions by the mildest measures. 2d— When the parts are cleansed—As soon as the secretions are removed, the washing process should be at once discontinued. The statement of the patient that its effects are pleasant, T^aBEE, Ages. % 1866 and 1867 1868. 1869. 1870 1871. | 00 w | 1 i873- 1874. No. Patients who came to be treated lor diseases of the Nose, but were also affected in the Ears and Throat. No. Patients who came to be treated for diseases of the Ears, but were also affected in the Nose and Throat. No. Patients who came to be treated for diseases of the Throat, but were also affect- ed in the Nose and Ears.' Total. Tobacco used by Males. C/> d S | Females. | Males. | Females. tn JL> ~d | Females. JS d Females. Males. Females. j Males. | Females. C/7