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may be neglected, in cases where the use of the latter is not considered advisable.

Fig. 93.


Vertical Sectign Of The Face Anil Neck (Leidy).—1, Oval cartilaee of left nostril; 2, triangular cartilage; 3, line of separation; 4, prolongation of oval cartilage along the nasal eohinmi; 5, superior nasal meatus; C, middle meatus: 7, inferior meatus; 8, sphenoidal sinus; 9, side of posterior naris; 10, mouth of Eustachian tube; 11, naso-pharynx; 12, soft palate and uvula; post-labial region; 14, roof of mouth and hard palate; 15, communication between the hueeo-dental space and mouth; 16, tongue; 17, fibrous septum of tongue; 18, genio-glossal muscle; 19, genio-hyoid muscle ; 20, mylo-hyoid muscle; 21, anterior half arch of the palate; 22, posterior half arch of the palate; 23, tonsil; 24, 25, floor of the fauces; 26, 27, pharynx; 2%, cavity of the larynx; 29, ventricle of the larynx and vocal cords; 30, epiglottis; 31, hyoid bone; 32, 33, thyroid cartilage; 34, thyro-hyoid membrane; 35, 36, cricoid cartilage; 37, sternothyroid muscle.

Gruber has given directions for injecting the nose anteriorly, for the purpose of cleansing the naso-pharyngeal space and medical

ing the Eustachian tubes. A two-ounce syringe with a rounded nozzle is filled with the fluid desired, pressed into one nostril, and* quickly injected. If it is required merely to cleanse the nasopharynx, the other nostril is left open, and the fluid escapes thereby; if to force the fluid into the tubes, it is partially or wholly closed for an instant. No directions are given the patient about breathing, reliance being placed on the instinctive action of the base of the tongue and soft palate to shut off the upper pharynx from the throat. I think the patient should be instructed to keep his mouth well open, and to breathe through it, as I have tried the method of the distinguished professor several times, and instinct failed so ignominiously, that the whole injection went into the stomach.

There is considerable difference of opinion among authors in regard to the advisability of using the nasal douche. From observation and experience, I am inclined to the belief, that the instrument is not injurious to the ear when used in a proper manner. I have known many cases of naso-pharyngeal catarrh treated by the douche, without injury to the ears, even when diseased, and I use it frequently in my practice with the best results.

There are several kinds of douche, in the market, but I shall allude to only two, the siphon, and the modified Thudicum douches.

The siphon douche consists of a piece of simple rubber tubing, fitted with a good sized nipple or olive-shaped, hollow nose-piece at one end, and a perforated, hemispherical, nickel-plated weight at the other. The base of the latter has an elevated scolloped rim around the circumference, so that when it rests base downwards, the fluid can flow freely to the central hole, which communicates with the tube upon the upper side. Any vessel, preferably a pint tincup, completes the apparatus.

The vessel should be filled with the desired solution; then put the instrument into it until the tube is filled, close the nose-piece tightly with the finger, and remove all of the tube except enough to leave the weight upon the bottom of the receptacle, and it is ready for use.

The modified Thudicum douche, as recommended by Dr. Seiler, consists of a nose-piece and length of rubber tubing, connected 'with a pint tincup by a tube soldered into a hole near the bottom. When fluid is placed in the cup, and the tube is held below, the flow from the nose-piece immediately begins.

A tincup is preferable to a crockery or glass bowl, because it will not break, and is inexpensive. I prefer the siphon apparatus and a glass bowl, however, for medicated solutions, as the tin becomes oxidized and the iron rusty from the chemical action of certain remedies.

The physician before applying the nasal douche should note if the patient can breathe freely through both sides of the nose, and

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examine both nasal fossae anterior and posterior, to be certain there is no obstruction sufficient to prevent the flow of fluid both ways.

If obstruction is found, the douche should not be tried. If no obstacle exists, he should then instruct the patient to breathe through his mouth, keep this wide open, and incline his head a very little forwards above a receptacle. The clothes should be covered with a towel or rubber apron, and the patient encouraged to keep quiet and obey orders.

The solution having been prepared and put in the cup, the nosepiece is pushed into the nostril and held so as to close it, the patient cautioned to watch his breathing, and the cup steadily raised till its bottom is upon a level with the eyebrows. As the fluid flows through the meatus, around the naso-pharynx and septum, and out of the other nostril, and the patient gets accustomed to the new sensations, the cup may be elevated one or two inches higher; but under no circumstances should it be raised above the head, as the increased pressure will force the fluid into the Eustachian tubes, frontal sinuses, and even farther, and produce serious consequences.

The first application should be short, and half a pint of fluid is sufficient for it. The quantity may be increased, as the patient becomes accustomed to the treatment, until a pint or more is passed through the circuit. The patient may be instructed how to use the douche by one or two office applications, and then cleansing and topical medicinal treatment may be carried on by him at home; the physician, however, should not remit his attentions on this account, but use the instrument upon the patient several times a week, in conjunction with the posterior nasal syringe, in order to insure thorough work.

All fluids introduced into the nose ought to be raised to a temperature agreeable to the patient. This will be a little below blood heat, and may be approximately determined by dipping the back of the hand in the solution, or putting a few drops in the palm. The first filling of the syringe or douche should be wasted, especially in cold weather, as its heat is abstracted by the cold instrument.

Another important matter is the specific gravity of the fluid. Simple warm water as advised by many persons is positively injurious to the nasal mucous membrane. The douche must be of the same density as the serum of the blood, or osmotic effects will be produced.

When warm water, or a fluid of less density than the blood serum, is brought in contact with the nasal lining, endosmosis will take place, the numerous capillaries will become engorged, and pain induced.

When a fluid of greater density than the blood serum is employed, exosmosis will occur, the blood corpuscles, deprived of part of the liquor sanguinis in which they float, will accumulate and stagnate in the capillaries, and cause irritation and burning pain.

A solution of 56 grains of common table salt in a pint of water will neither swell nor crenate the red blood corpuscles, and is, therefore, of the same density as the blood serum. This property, and the well-known antiseptic nature of chloride of sodium, render this liquid excellent for cleaning purposes, and it may Ik used as a vehicle for medicinal substances with which it is not chemically incompatible. In such instances, the quantity of salt must be diminished in proportion, as other substances are added, in order to preserve a specific gravity of 1030.

The solution may be made near enough for practical purposes by adding an even teaspoonful of table salt to a pint of warm water. Sea salt, sold by druggists for bathing purposes, is agreeable for nasal applications, and may be substituted for the common article.

After warm douches and warm spraying, a patient ought not to go out of doors for some time, especially, in the cold season; and in all seasons he should be careful of exposure to drafts and damp places. I have seen sweat stand in great beads upon the forehead after a moderately warm nasal douche, and one of my patients took a severe cold from making a call soon after an application, having been obliged to stand some minutes waiting at the door for a lazy servant to let him in.

The post-nasal syringe and the nasal douche are to be used with the salt solution to cleanse the nose and pharynx whenever required. It may be necessary at first to do this twice a day, but once daily is generally sufficient. The patient must co-operate in the treatment by blowing the nose hard, and by taking forced nasal inhalations, in order to remove all morbid secretions. A good deal of trouble is necessary occasionally, particularly when the patient is first seen, to dislodge the foul crusts and scabs, which cling to the narrow passages of the nose; but by repeated snuffing, blowing, syringing, and douching success is gained, and if proper measures are adopted, they will not accumulate in quantity again.

Inflation with the air-bag aids in clearing the passages, and will often remove the dreadful frontal headache that comes from stuffed sinuses.

After the nasal passages are clear and clean, it is desirable at least once a day to apply antiseptic and medicinal solutions to the mucous membrane. This may be done with the syringe, douche or atomizer. One of the best lotions after cleansing is a warm solution of Muriate of ammonium (Ammonii muriasSy, Aqtia Oj),

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