Breitung connected the nasal sound with an electrical apparatus to give vibrations. Some specialists use an oval lenticular, rather thickly-covered rubber capsule, which is inserted into the nose and connected with an air pump after Delstanche's principle (see below); vibrations are given to the mucous membrane by the alternate dilatation and contraction in quick time of the capsule.

Personally I may say that results are more quickly obtained if vibrations can be given with the tip of the little finger rather than with any other vibrator.

Velpius has constructed an instrument by which stroking (forward and backward) may be applied to the turbinates.

Laker also uses cotton-covered sounds dipped in the above drugs in the treatment of chronic pharyngitis; the sounds for this purpose, when treatment is to be applied to the roof of the pharynx and the post-nasal region, are screwed to a handle similar to the ordinary handle of the laryngoscope, and have a terminal of 1 to 4 cm. long bent at right angles. He also works through the nares upon the naso-pharynx with the straight sound already mentioned. In treating the pharynx, however, one can work more effectively with the tip of the first or second finger by small, rather firm frictions than with a sound or vibrator. For the roof of the pharynx the bent sounds mentioned above are perhaps most suitable; examination must first be made by the mirror of the laryngoscope. In treating various forms of pharyngitis I have personally been accustomed to insert, by means of forceps, quite a large cotton pellet dipped in alum, and with this work energetically upon the mucous membrane for as long as the patient can bear it, and continue these daily treatments, usually for several weeks, until considerable improvement has been obtained. I have not considered vibrations with smooth beautiful curves a la Laker of the slightest importance, but have only kneaded as I thought suitable with considerable strength. In severe cases of pharyngitis one obtains in this way good results comparatively quickly. I remember that I succeeded in one case of a Swedish artillery officer in. astonishing the famous Austrian specialist Dr. Muller in Carlsbad, who was at the same time treating the patient for disease of the ear.

* Laker uses, unfortunately, very much too strong expressions with regard to the therapeutic results in treating rhinitis especially : "Gerade von zauberhafter Wirkung ist das Verschwinden der pathologischen Reflexscheinungen : Kopfschmerz, Migran, Stirndruck, Thranen, Husten, Neuralgien, uble Laune, Gedachtnisschwache," etc.

These and similar expressions led to Professor Chiari's perhaps rather uncharitable criticism, and made me at first unjust to Dr. Laker in underrating the value of his otherwise serviceable contribution to mechano-therapy. From what I can ascertain, neither his own nor any other person's results are quite so brilliant. The fact remains that all the atrophic forms are very obstinate to treatment of any kind. With regard to the hypertrophic forms of rhinitis, massage is often only an adjunct to surgery, and out of twenty-seven cases with adenoid vegetations Laker himself operated in twenty-one cases.

In the massage treatment of diseases of the larynx we give direct local vibrations and neck effleurage in chronic cases, the latter alone in acute cases.

Laker orders vibrations for chronic laryngitis and for "weakness of the vocal cords," which "absolutely disappears, leaving no trace behind where this is at all possible" (not, of course, where the cause is in the central nervous system, or due to pressure of an aneurysm on the recurrent laryngeal nerve, etc.); likewise he recommends vibrations for infiltrations and for ulcers of whatever character.

The technique resembles that described for rhinitis. The sounds employed for this are more delicate and similarly bent, and in shape they resemble the handle of the ordinary larynx brush; the end is bound with cotton as far as 4 cm. up, and Laker. in these cases dips it into a 10 per cent. solution of cocaine. Under control by the laryngoscope the sound is inserted below the true vocal cords, while the glottis is open during inspiration. At the least touch the sphincter of the larynx contracts; the sound is firmly gripped by the larynx, and the vibrations may be begun first towards one area and then the other, but naturally can only be continued quite a short time. (The sinus pyriformis, the valecula, and all the various parts of the larynx only require one form of sound.) Too strong pressure easily produces ecchymosis. The reaction after treatment may be very strong, and often one is able to apply treatment only every third or fourth day.

Many doctors also use vibrations outside the larynx. Stangen-berg in Stockholm makes use of the vibrator here also. Without wishing to express a definite opinion on the subject, he evidently assumes its probable usefulness.

With regard to the therapeutic results of massage by means of vibrations and frictions on the mucous membrane of the nose, pharynx and larynx, so very differently criticised by specialists, I now consider it certain that in comparison with what is obtained by other treatment the results may be said to be very good. With simple catarrh it is easy to obtain good results; with the hypertrophic forms an energetic curative and prophylactic effect is obtained, and the indications for the use of the galvano-cautery treatment are diminished and the results of its use improved. In the atrophic forms, i.e., in ozaena and dry pharyngitis, with their symptoms troublesome both for the patient himself and for those around him, one has a very hard, but at the same time not altogether thankless task. The treatment must often be continued for months and be repeated later.

By the therapeutic effect upon the mucous membrane of the pharynx a beneficial effect is also exercised upon catarrh which has spread to the Eustachian tubes and to the ear; by the same effect on the mucous membrane of the nose a similar influence is exercised upon catarrh which has spread through the lachrymal duct and possibly affected the lachrymal sac and conjunctiva.

Among the acute catarrhs of this region, acute laryngitis especially has been treated by Gerst, and later by others, by neck effleurage. In the case of false croup especially, good results may be expected from the treatment, which has won such high praise from Bela, Weiss, and others. It should in particular be directed energetically against oedema of the glottis due to this or other causes.

From the above experiences and those of other specialists we may say that, compared with the usual treatment, neck effleurage is of some value in assisting the healing of syphilitic, tubercular, croupous, and diphtheritic processes in the larynx.