case absolute inability to breathe occurs, there is probably an occlusion of the tube by membrane, and then if relief does not come by coughing withdrawal of the tube may be necessary. There is no need of force in introduction, though sometimes a slight pressure is necessary to push the tube home. In the spasmodic case referred to the first introduction of the tube appeared to be successful and the string was withdrawn, but the child kept gagging and choking. Inspection about five minutes later showed the head of the tube riding up behind the soft palate in the vault of the pharynx while the lower end was in the larynx and the patient was breathing through the tube. On removal and re-insertion it was found that the tube, instead of being too small, as was at first supposed, had not been pushed home.

The extraction of the tube is often a difficult matter. In my first case the fourth attempt was successful. In the second case of recovery, four unsuccessful attempts were made when a bitten finger decided the requisition of the services of Dr. Northrup, who extracted it on first attempt. In the next case of extraction the first trial was successful, thanks to Dr. Northrup's method, which is to feel for the interarytenoid space and the pointed end of the tube-then, following that forward with the extractor the opening of the tube is easily reached. There is a possible accident which should be guarded against in extraction, which, as far as I know, has not yet occurred, and that is the result of too much pressure in opening the jaws of the extractor, causing breakage of one of the jaws and consequent dropping of the piece through the tube into the trachea. It is well to have the tubes ready threaded for use, for time may be lost in threading, owing to the occlusion of the holes of new tubes by the polishing powder.

In the cases referred to there was no trouble experienced in feeding -that is no serious trouble-all were able to take the necessary amount of nourishment, though some strangled more or less. Condensed milk, ice cream, and semi-solids were generally allowed and most were able to take fluids and in one case solid food was given.

It is not necessary to review the argument in favor of intubation, as compared with tracheotomy, they are familiar to all who are interested in the subject, yet the writer is constrained to offer this experience, such as it is, as an argument in favor of intubation in a selected class of cases.

LOCAL TREATMENT IN NASO-PHARYNGEAL CATARRH.

BY GEORGE G. SHELTON, M. D.,

NEW YORK CITY.

Can a case of genuine chronic naso-pharyngeal catarrh be cured by local treatment only? I answer, no. Again, can a similar case be cured by the exclusive use of homoeopathic medication? To this proposition I answer, rarely, if ever. And this decided negation arises from the results of both methods in the experience of close observers in both hospital and private practice.

I have thus bluntly and concisely stated my belief in regard to the treatment of this troublesome class of cases, and believing that an unwise prejudice exists on the part of a large number of our school against the use of topical applications and local treatment, and the belief that the successful treatment of this common disease demands a wise and careful application of both methods, has prompted a brief paper on this trite subject.

While fully recognizing and believing in the grand results of a close adherence to the tenets of therapeutic law, I still believe that many diseases demand additional measures in overcoming the peculiar pathological condition by which they are surrounded, and that the subject under consideration is one of them.

Without entering into the minute division into which chronic naso. pharyngeal catarrh has been divided in its pathological relation, it is enough for our purpose to describe the two broad divisions of atrophic and hypertrophic catarrh, the latter observed with the greatest frequency, but by far the most amenable to treatment. We have seen a condition where the mucus membrane, through repeated inflammatory action, has been piled upon itself in successive layers, diminishing the nasal breathing space to a point of at times total occlusion, leaving in the sinuses, above and behind, oftentimes pockets and irregular surfaces where the masses of inspissated discharges can remain and accumulate, attaching themselves firmly to the sub-mucous structure, and upon their forcible removal denude the sensitive membrane of its

natural epithelium, and leave a fresh raw surface, again and again to be re-exposed to this same denuding and destructive action, or to become the seat of ulcerations and unhealthy abrasions from the chemical decomposition that these masses of accumulated filth must undergo.

The other form, known as the atrophic, as in pharyngitis sicca, where the glandular structures have become either entirely lost or are so diminished in secreting power that but little moisture flows over the dry, glistening membrane, and most of that which is secreted remains in a dry scale tightly glued to the mucous membrane beneath, to undergo the same process of forcible detachment and to leave a worse condition behind it after each repetition of this removal.

In that form of disease known as ozæna, where the mucous and submucous structures are the seat of ulcerated disease, and the sinuses surcharged with these accumulations decomposing and producing the foulest odors only to involve adjacent healthy structure in the same destructive process. These are the conditions we have to meet. The question at issue is: Can they be successfully met by a reliance upon the carefully selected homoeopathic remedy alone, or will this same remedy exert a much more powerful influence, if these masses are softened by irrigation, the foul odors and the destructive chemical action of these decomposing masses be removed by some artificial yet simple means ?

It is not my purpose in this paper to discuss any especial form of treatment, but aid in overcoming an unwise prejudice against sprays, detergents, washes, etc., etc., all of which should have a proper recognition in the treatment of catarrh, and without the use of which to overcome the natural obstacles described above, in many cases the treatment must be without avail.

I care not what theory of the etiology of this disorder is accepted, whether the scrofulous diathesis to which so many obstinate cases are due, or the theory of Woakes that it is essentially a neurosis, or that of McKenyon that it is largely due to local and climatic conditions, atmospheric spores and dust; whether attributable to diet, dress, habit or heredity, all of which exert a most profound influence as an ætiological factor, we have the same local manifestations to combat, and these views point as decidedly to the one as the other.

What are the grounds for objection to the use of these various adjuvants aside from our prejudices as a school of medicine? Principally that the post-nasal douche endangers the eustachian tube and that inflammation of the middle ear frequently follows such applications. To this I reply that in over five years of hospital and private practice in this

department of medicine, when the douche or spray, or some other method of local treatment has been in daily use, I have seen but one case of the trouble described, followed such treatment; and careful investigation at the time failed to discover any reason why this was more than coincident and in any way attributable to the douche. I admit the greater liability to the young, and advise against the too frequent use in children of these measures; and also recognize that some little skill is requisite, but with a little care and patience the technique is easily mastered.

From this and foregoing reasons, I claim that if these conditions were more fully recognized and faithfully followed, and the remedy carefully selected-attention in this latter regard being paid much more to the constitutional conditions than to the local manifestations-the obloquy that rests upon this disease and that has produced in the mind of the laity an impression that it is incurable, would cease.

In the general treatment of such a case I advise first, a careful elimination of all venereal taint; a thorough knowledge of the personal and family history and the habits of life; examine carefully the manner of dress, especially the feet, insist upon thick soled shoes and high neck flannels. Surgically remove excessive hypertrophy, deflexion, polypi or other growths, bone, etc., and not allow these hardened masses of mucus to be torn from the membrane, but to be first dissolved and carefully removed by the use of tepid alkaline solutions, applying to the surface such known remedies as the local condition may demand, as for example: if ulcerated, the glycerole of Hydrastis; if fetid and decomposing, some disinfectant; if dry, inflamed, some stimulating preparation, such as the Lugol solution of Iodine, Iod. of Potassium and Glycerine, etc., etc., and then after protecting the local sore from the repeated destruction previously described, the well-selected remedy will leave an opportunity to combat the constitutional taint, and this local manifestation will gradually yield and the annoyance cease, to the credit of the doctor and the relief of the patient.

LOCAL TREATMENT OF DIPHTHERIA.

BY CHARLES E. TEETS, M. D.,

NEW YORK CITY.

So much had been said and written in favor of and against local applications in diphtheria, that, in the beginning of the winter of 1886, I had fully determined, if afforded the opportunity, to try and discover if possible what part (if any) local applications took in the cure of diphtheria. Now, after treating over thirty cases of diphtheria, and watching carefully the effects of local treatment upon this dreaded disease, I have come to the conclusion that it plays a most important part; and that a case of diphtheria cannot be treated successfully without it. I have heard physicians remark that they did not care to be called to a case of diphtheria, but I am of the opinion that if they had used proper topical treatinent they would not have feared the disease and would have met with success, almost in every case. There has been a great diversity of topical applications used with a view to detach, dissolve or destroy false membrane; some advise Borax and Glycerine, others a solution of three drachms of Lactic acid in eight ounces of Lime water; but one of the best, and the one I use, is Turpentine and Alcohol, in the proportion of one of Turpentine to eight of Alcohol. I then put a teaspoonful of this mixture in a third or half a glass of water, and have the patient gargle every two hours and in extreme cases every hour day and night until the case is relieved. If the child is not old enough to gargle, I have the nurse swab the throat every hour; or if preferred, the atomizer may be used. It is urged by some that internal local applications are harmful, that very little advantage is derived from them; that they are often mischievous and ought never to be used; that they do not curtail or greatly modify the natural course of the general disease. They contend that topical applications can hardly ever be used in young children without exciting resistant struggle which agitate and exhaust the patient. The risk of incurring the danger often forbids their employment. But notwithstanding all that has been said against local treatment, I still insist that it is pre-eminently