in which the charge of inefficiency is made, first, based upon the impenetrability of the middle and upper parts by reason of the thickening of the mucous membrane. We are greatly indebted to him for the note of alarm sounded as to its dangers, and, as the subjoined case shows, have unhappily verified one of the accidents (rupture of the drum) to which he alludes. But while he has proved by the citation of clear cases most incontrovertibly the dangerous results that may follow, he has failed to sustain the other point made. Lest the latter should derive undue weight, and receive, perhaps, the tacit approval of the profession-from mere association in the same paper with admitted dangers the statement of its inefficiency deserves re-examination.

He says, after particularizing the proximity of the turbinated bones and septum, "but in naso-pharyngeal catarrh the mucous membrane covering the septum and turbinated bones is thickened, and in consequence the opposite surfaces are pressed together. If, by means of our instrument, a gentle stream is passed into the nostril, the open space at the floor of the passage will be traversed; but that above, exterior to and between the turbinated bones, will be untouched by the fluid. If we increase the pressure by elevating the reservoir, the mechanical irritation will cause a determination of blood to the part that will temporarily increase the thickening of the mucous membrane, and render the above-named spaces only the less pervious to the passage of the fluid. In either case the object of the thoroughly cleansing or of introducing remedial agents into the passages will be partially defeated. It is true that a little of the fluid may insinuate itself between the turbinated bones, or into the upper nasal space, but so little as to be of practically no use; and if much pressure is used it is more than likely to cause a severe headache. It is but the floor of the nasal passages that the operation can thoroughly reach."

If it be true that "the opposite surfaces are pressed together," the conclusion is irresistible that nasal irrigation is impossible to the extent claimed. But is this true of chronic naso-pharyn

geal catarrh? We think not. When the secretions are removed, simple inspection shows that the turbinated bones (you cannot see distinctly beyond the middle one) are not in direct apposition with the septum. Does not the clearness of the nostrils after removal of liquid or concrete obstructions show the perviousness of the several channels of the nostril? Is not the sense of entire clearness of the nostrils experienced most comfortably by the patient good evidence of an open state of the whole cavity? Does not the sense of smell still usefully retained indicate access of air to parts above (where the olfactory nerves are chiefly distributed)? May not fluid gently forced traverse all parts entered by the respired air?

We are satisfied that the occlusion (its degree and cause) here specified does not exist in a large majority, if indeed any, of these cases of catarrh. In the chronic stage the passages may be claimed to be pervious to air and fluid when free from the presence of obstructing secretions. And it is only in intensely acute catarrhs produced by iodic, syphilitic or other causes that perfect occlusion occurs from simple swelling of the parts: the distress of the subject under these circumstances of embarrassed nasal respiration is in striking contrast with that of the chronic state. In the latter, it will require a stronger obstacle than muco-pus, however concrete or viscid, to prevent the occupation of every part by the fluid gently insinuated by this continuous

current.

Moreover, if it can be shown that "other means of cleansing and of introducing remedial agents into the nasal passages are equally efficacious," we are prepared to entertain most seriously the question of the abandonment of the nasal douche. A sense of duty would compel us to adopt the safest; because, where two methods of treatment, or kinds of appliances, equally efficacious, are at command, duty, and not mere preference, must determine which shall be used. Unhappily, in this instance, we have no such choice; for few will agree with him that a "posterior nares syringe will accomplish all that can be expected from the nasal douche," to say nothing of the greater inconve

nience and difficulty involved in its employment. All syringes are partial, and as insufficient now as the vexatious experience of the profession has always shown them to be.

Nor can we concede that the atomizer is more than a useful auxiliary, particularly for the application of certain remedial agents (as nitrate silver or other articles to be used in small quantities). If the "opposite surfaces are pressed together the nebulized fluid can no more enter the upper nasal space than the continuous current of the douche, and if simply: occupied by secretions there would be lack of force in the spray to overcome any material obstruction. A certain degree of. force or pressure is necessary to the thorough renovation of the nasal cavities, which is only secured by the nasal douche in the uninterrupted flow through both nostrils-the return current or reflux being equal to the direct one, thereby cleansing both at the same time. Nothing can exceed the simplicity of this. invention or offer greater facilities for the performance of the act of cleansing or purification of the part. That it is disagreeable is merely admitting what is true of all appliances contemplating the application of fluid substances within the nostrils; that danger of injury to the ear attaches to its use is equally true, but does not warrant the abandonment or condemnation of the instrument until something safer and more efficacious (because safer) is presented. Huffishly to cast aside all mechanical appliances that involve even serious risks in their use will greatly restrict our resources-rather let us, until certain improvements are within reach, throw around them every safeguard, taking all reasonable precaution to prevent injury or accident. Exceptions to the safe employment of the nasal douche are rare. Let us, therefore, hesitate to discard it.

In the following case, the publication of which is the moving consideration in the preparation of this article, we attribute the accident to the carelessness of the subject, believing it the result of the accidental inclination of the head to the right side, and the unnecessary pressure of the column of fluid determined

by the elevation of the basin. To insure safety, we think three things should be insisted upon-to wit:

First. Oral respiration, with the mouth wide open.

Second. The lowest pressure practicable, to be secured by placing the reservoir at the lowest level necessary to secure the

current.

Third. The position of the subject, which should be leaning forward in the sitting posture with the head perpendicular to the plane of the surface or vessel intended to receive the escaping fluid. Inclination to the right or left would favor the passage of the fluid into the eustachian tube.

Mrs. K, aged twenty-five, of delicate constitution, the subject of naso-pharyngeal catarrh for twelve months or longer, under our direction began to use the "nasal douche" on the 17th of October, being directed to wash out the nostrils twice daily. It was subsequently reduced to once daily, and used regularly and satisfactorily until October 30th, when her husband called at the office to report that during its use that morning water had escaped from the right ear, preceded and accompanied by decided pain and a sense of fullness about the ear; pain gradually abated, lasting until the evening. Hearing confused and indistinct, but deafness not marked.

He was instructed not to use it again until I saw the patient. At 9 A. M., 31st October, visited Mrs. K—, eliciting the following facts: She makes no complaint of the ear or of deafness-simply feels "funny" (as she expresses it) when attention is directed to the organ. States that she used the douche carelessly by stooping forward over the chimney-place with the head inclined to the right side (which, she thinks, was the immediate cause of the accident), the nozzle of the instrument occupying the left nostril, and the reservoir being placed upon a high mantel-piece. Her awkward position caused her to strangle by some of the water escaping into the pharynx, at or about which time she felt the escape of water from her ear.

She was ordered to discontinue it for the present. November 4th visited patient. Says she has experienced no inconvenience

from the accident further than the conscious, audible escape of air from the ear on one occasion when blowing the nose. No pain nor disordered sensations. Hearing good, and states moreover that two days since she resumed the use of the douche, employing it daily not only without the recurrence of the accident, but with ease and comfort.

She was, however, directed to desist for a week longer from its use, in order that all injury sustained might certainly be repaired.

ECLECTIC DEPARTMENT.

"Carpere et colligere."

ART. I.-ON SUCCESS IN VACCINATION. BY FRANK P. FOSTER, M. D., House Physician to the New York Dispensary.

The success or failure of a given attempt at vaccination often has much to do with the repute of the practitioner, and what is of far greater importance, not infrequently determines whether or not one or more children are to undergo the terrible infliction of small-pox; and thus it may become an affair of life or death. Viewing the matter in this light, it is the duty of every practitioner to make himself familiar with the elements necessary to success in the operation. I am not aware that any of our medical schools afford to the student anything approximating to adequate instruction in this branch of practice; but, on the other hand, I am very well convinced that the great majority of physicians commence practice without the most distant idea as to the conditions which most conduce to successful vaccination, and that, unfortunately, many of them complete their career without materially adding to their stock of knowledge in regard to this subject. Failure in a given instance is for them proof, either (1.) of the child's insusceptibility, or (2.) of the worthlessness of the vaccine.