Massage of the nose, gullet, larynx, and ears has much in common in regard to technique and pathology. It is also performed by the same specialist, and may therefore be suitably considered together.

The commonest affections of these parts that are treated by massage are the chronic catarrhs. Chronic pharyngitis is often present alone, but frequently spreads to the tonsils as chronic tonsillitis, and sometimes also to the middle ear through the Eustachian tube; chronic laryngitis is often present alone, but is not seldom part of a catarrh affecting the whole naso-pharynx.

We must admit that the treatment of all these forms of catarrh and of their sequelae, except in the case of polypi which are easily removed, has been on the whole very unsatisfactory. It seemed, therefore, a great therapeutic gain when massage was at last made use of in this department. The so-called massage of mucous membranes is generally performed by fine, quick vibrations. The Swedish gymnast A. Kellgren, of London, was the first to use or at least to introduce this method into general use. He performed the vibrations on the skin partly over the nerves (supratrochlear, nasal, superior and inferior laryngeal), partly over the angles of the hyoid bone or larynx, or over the neck below the angle of the jaw, etc. Even in this indirect and somewhat primitive and coarse form vibrations (preferably given with a vibrator) seem to have been beneficial, whether used alone or preceded and followed by effleurage of the front of the neck, as practised by Ling and revived by Gerst.

Vibration by means of instruments directly upon the affected mucous membrane was introduced by the Austrian Dr. M. Braun, and after him by Dr. C. Laker. I shall here consider this form only, since its technique is more fully developed and its therapeutic effect more certain.*

* The so-called mucous membrane massage has for long been used by gymnasts in Sweden; in Stockholm Captain Tersmeden has been working in this way since 1886. Like many other workers, he uses a sound or the tip of the forefinger in the throat and the tip of the little finger in the nose. Dr. M. Braun, of Trieste, wrote a paper in 1890 entitled "Massage, beziehungsweise Vibrationen der Schleimhaut der Nasc. dm Nasen-Rachen-Raumes und des Rachens," and Dr. Laker, of Graz, in 1892 published "Die Heilerfolge der inneren Schleimhautmassage bei der chronischen Erkrankungen der Nase, des Rachens, der Ohres and des Kehlkopfes." Professor Chiari, who also made use of massage in this for the treatment of chronic rhinitis straight sounds without handles are used,* the end being wrapped round with a thin layer of cotton-wool, generally dipped in some effective local remedy. Kreolin is used, 5 to 10 per cent. solution of cocaine, 2 to 8 per cent. menthol-vaseline, etc. For ozoema Laker recommends iodine (1 per cent.) in iodide of potassium and glycerine.

Laker recommends that the treatment should be preceded by a thorough rhinoscopy, so that one is familiar with the varying normal and pathological local conditions in each special case. He then carries out the treatment without the aid of sight, standing on the right side of the patient, who is sitting; with the four fingers of his left hand he fixes the patient's head, which is leaning back, and with his thumb raises the tip of the nose. With his right hand pronated Laker holds the sound between the thumb and forefinger, and performs by means of the tonic contraction of his arm muscles and the accompanying rapid trembling of the hand small vibrations at the rate of 600 to 2,000 a minute on the corresponding part of the mucous membrane. In this way he works successively on the whole mucous membrane, on the septum and turbinates, etc. The sittings are from a shorter time up to several minutes, and especially in the beginning are painful to the patient and tiring for the doctor. Bleeding is often produced.

Laker values vibratory treatment both for simple, hypertrophic, and atrophic rhinitis. In the hypertrophic forms, according to Laker, the indications for galvanic cauterisation have been completely changed by the introduction of massage, and since then he only cauterises in extreme cases of hypertrophy and for polypi. After their removal massage is an excellent after-treatment, because it makes the affected region more healthy and prevents recurrence. Even in the atrophic forms he considers the treatment very effectual, for the mucous membrane soon becomes moist, the crusts are easily loosened without haemorrhage, and finally cease to be formed because the secretion becomes looser and is gradually got rid of; the odour disappears. He allows that a long region, and found it of moderate value, has criticised (perhaps rather strongly) Braun, Laker, Hoffinger, and others in the Wiener Klin. Wochenschr., 1892, Nos. 36, 40, and 42.

I would further refer to the introductory account of this treatment: - Lahmann's paper in Allg. Medicin Central Zeitung, 1892; Anton's paper in Prager Med. Wochenschr., 1892; Daly's in Med. Mirror (November, 1892); Garnault's ("Le massage vibratoire et elec-trique des muqueuses du nez et du larynx") in Sem. Med., Aout, 1892; Storck's ("om Slemhindemassage i Saerdeleshed vid Behandlingen af ozoena") in Forh. v. 14de. Skand-Naturforskermi.de, i Kobenhavn, 1892; Laker's in Deutsche Med. Wochenschrift (No. 43), 1892; and in Wiener Med. Presse, Nos. 47 and 48, 1892, and Chiari's reply in this journal (No. 50), 1892; and, finally, Anton's paper in Prag. Med. Wochenschr., No. 49, 1892.

* Laker's sounds are of copper or other material, 23 cm. long, of a thickness corresponding to No. 6 or 7 (Charriere's scale). The end of the sound varies in thickness and is rough for 1 cm., ending in a little button, so that the cotton covering, at all times rather thin, can be securely attached. The remaining 11 cm. are smooth, the handle again rough, period of treatment is necessary; during this, loss of the sense of smell is often the most obstinate symptom, and he dare not promise its restoration to normal with the same certainty as the cure of other symptoms, although this often takes place quite suddenly. Purulent rhinitis is often quickly cured. In simple forms the swelling and secretion is diminished and nasal respiration quickly returns. In general five days elapse before any considerable improvement is seen; the usual pathological reflexes, especially due to changes in the anterior parts of the turbinates, vanish in a wonderful manner.*