try or spaces, the so called agoraphobia, from fear of shut in spaces, as elevators, locked rooms, trains. For eight years past he had lived a hermit's life unable to go farther than two blocks from his home during these years. For the last six months he was in a state of nearly constant panic or distress afraid to look at a newspaper because of a suicide note he might see there, afraid to sit by an open window because of the fear of jumping out, and all the time uncertain of his own stability of mind. The whole symptom complex corresponded closely to a severe type of psychasthenia. Analysis of this case revealed a strongly inhibited sexuality resulting in a psychic impotency, a symptom whose psychogenesis was clearly proven. The fear of open country or of getting about was a beautiful example of the principle of displacement or switching of emotional states from one idea or set of ideas to another, of replacing the original set of ideas which caused the emotion by symbol which may or may not be recognized by the individual as having relations to the ideas it represents.

The terror and fear he felt at the thought of going out was the same terror and fear he felt following an experience at the age of nine. At this time he was the witness of the suicide of a woman, who drove a knife into her throat with a hammer. This suicide happened in an open field or country. Mental associations formed at this time of a personal nature made this memory extremely painful, and he apparently forgot them. At the age 24 certain events happened which stimulated this group of painful associations, the terror and fear came to the surface without the memory of the original event and its associations, and were switched or displaced to the idea of open country where the suicide took place. Although he had forgotten about the suicide, the patient here feared the open country because the open country represented or symbolized in his subconscious mind, the dead woman and the painful thoughts which had caused so much terror in earlier years. A full analysis and explanation of these hidden and previously unconscious memories relieved the fear. This patient for eight years had resisted all treatment by ordinary methods of reeducation, suggestion, Dubois method, but by careful analysis in the light of Freuds discoveries is now entering again upon a valuable active life that has been interrupted for ten years.

The Vacuum Treatment of the Ear, Nose and Tonsils. *By H. B. LEMERE, M. D., Omaha, Neb.

A cursory glance at a specimen of the skull will show how impossible it is to reach the ethmoidal cells and the frontal, maxillary or sphenoidal sinuses by means of a spray applied from the anterior nares, yet this is the means ordinarily used in general practice for relieving affections of the nose involving these cavites. The tympanic caviety is even more remote and the crypts of the tonsils are not affected beyond their mouths by the sprays and gargles usually used.

Ordinary colds affect any or all of these cavities and are a congestion generally accompanied by infection of the mucus membrane, lining and contiguous to them. The commoner infections of these structures are the staphylococcus, pneumococcus, influenza bacillus and the streptococcus. The more virulent the infection the more extensive it is likely to be and the greater are the chances of resulting necrosis. Severe and repeated infections which do not go on to complete resolution leave more or less active infection of these cavities which take the form of acute suppurative ethmoiditis, sinusitis or otitis media or the so-called catarrhal condition of these cavities.

The more I observe catarrhs of the nose and ear the more I am convinced they are a chronic or unresolved form of acute infection and that they should be so treated. Chronic tonsillar disease often accompanies these latent infections and should be regarded as a glandular lymphatic infection secondary to primary infection of the nose.

In chronic follicular tonsilitis, even though the infected tonsils are removed in capsule, leaving no vestige of tonsilar tissue, the primary seat of their infection, whether it be in the teeth and gums or in the nose, should be sought and if it still exists should be cleaned or the surgeon has not done his full duty and the patient may not be relieved.

Early in my practice I recognized the difficulty of effectually reaching these structures and I have used with considerable success nasal washes of sufficient volume and under conditions which enabled them to reach many of the cells and even the sinuses. In using douches under these conditions I have been alive to the need of special care that the infected material should not be carried into the middle ear. The bad results of nasal douches in which the ear has been infected are only equalled by the good

Read before the Nebraska State Medical Association, Omaha, May 2, 3 and 4, 1911.

results when the douche is properly used. Though the instructions I give the patent for the proper use of the wash have undoubtedly often been transgressed in spite of my emphasis on their importance, still I can conscientiously say that only one case of middle suppuration following their use has come to my knowledge and was the result of failure to follow my instructions. In this case the inflammation was not violent and the ear returned to normal in a few days.

Surgically for the past eight years my object always has been to provide proper drainage of the nose rather than aiming primarily for a patulous nose, and I never sacrifice the inferior turbinates in order merely to make an air passage. I prefer to trust to these structures to reduce themselves sufficiently after they are relieved of the constant irritation of pus and secretion from the structures above.

The radical operative treatment of the sinuses which aims to make the sinuses and nasal cavities into one large caviety calls for such an extensive sacrifice of nasal structures as to render the nose almost completely useless for the purpose of moistening and heating the inspired air. The cure by radical operations is at the cost of the upper respiratory function.

That catarrhal otitis media is one of the most intractable conditions to treat is attested by the enormous number of mechanical and electrical apparatus, all of which fail to give relief in the general run of cases. Surgical treatment of the nose is very disappointing insofar as the relief of deafness and tinnitus is concerned, even when the nasal obstruction is undoubtedly the primary cause of the catarrh of the ear. The tympanic cavity is so remote that even when the nose is restored to health the infection often remains in the ear. A brilliant exception to these statements is the removal of adenoids in children, where the results in regard to the ears are generally perfect.

Shortly after vacuum cleaning proved so successful in household economics the vacuum treatment of the nasal cavities and of the tonsils was urged. Biers theories and instruments were ably seconded by Brawley's apparatus. In taking up this treatment, however, nose and throat men have been impressed more with the value of the improved drainage obtained than with the theory of the advantage of hyperemia.

In the nose the value of the treatment in acute sinusitis is now very generally recognized and practiced. Many, however, do not use it and but few of the text books mention it. My

work has led me to the conclusion that it has a very much larger field than the relief of acute maxillary and frontal sinusitis only.

Old cases of so-called dry catarrh, with symptoms of odor from the nose, headaches, attacks of grippe with cerebral symptoms and lack of mental concentration, severe supra orbital and occipital neuralgia, have under persistent vacuum treatment drained immense quantities of stagnant secretion lying dormant in the nasal cavities. The relief of the nasal obstruction is then perceived even though previously no obstruction had been recognized by the patient. The mental clearing following this relief is very marked. Simple inspection of the nose frequently does not reveal this condition so that the vacuum becomes an essential and indispensible diagnostic agent

In acute follicular tonsillitis for the treatment of which the Bier cups were specifically recommended I have had no success and no longer use this method. In quinsy partially but insufficiently drained and remaining inflamed indefinitely I have found this method of promoting drainage invaluable.

In distinction to the acute variety, chronic follicular tonsillitis yields admirably. The infected plugs and frequently liquid pus is drawn from the follicles leaving them absolutely clean. All the symptoms of pain and fullness of the throat are relieved, the enlarged cervical glands resulting from the infection subside. The condition is however liable to return and 1 consider enucleation the preferable proceedure. Certain cases however refuse operation and the vacuum can be used to keep the throat in a healthy condition.

With persistent and troublesome pain in the throat the innocent appearing tonsil with no congestion of the pillars or swelling of the gland is sometimes at fault and may by means of the tonsil cup be made to disgorge purulent and caseons matter from its depths. This deep infection may show in rheumatic trouble due to absorbed toxines. It may also cause inflammation of the surrounding structures, the Eutachian tube, the pharynx and the larynx. The diagnostic use of the cup would be more general if its value were better known.

It is only in the past few weeks that my attention has been directed to the direct effect the vacuum treatment of the nose and naso pharynx has on acute and chronic middle ear infections whether catarrhal or suppurative. Pratt in the "Journal A. M. A., March 18, 1911," advocates drawing the secretions by vacuum from the middle ear through the Eutachian tube. I have noticed that a drawing sensation is experienced in the middle

ear and often distinct relief experienced after vacuum is applied to the nose. I have not seen any good result from vacuum applied to the external auditory meatus.

A case illustrating this use of the vacuum came under my care this year. Hearing, for conversation, in the right ear was gone and in the left only loud voice could be understood. The patient's main complaint however was tinnitus, which had existed for over five years. All kinds of disturbing noises were heard which lately had increased to such an extent that they had taken on the form of musical selections heard either as a full orchestra or as the human voice producing "Yankee Doodle", "Rest for the Weary" and other selections. All the ordinary methods of treatment had been used at different times for the past five years without in any way ameliorating the condition. The nose showed no gross anatomical obstruction except somewhat swollen middle turbinates. There was a bitter disagreeable odor from the nose not at all like the odor of ozena but an odor to me characteristic of chronic dry ethmoidal infection. The ear drums were thickened, lacked lustre and were slightly retracted. Rinne was negative in each ear. I commenced treating the ethmoid with vacuum hoping to affect the ear secondarily. I was delighted to find there was an immediate improvement of the symptoms which I judged was due to the direct effect of the vacuum on the tympanic cavity. The noises were very much diminished and were at times absent for the first time in the past five years. The nose which had for years been dry, discharged great quantities of foul smelling pus which gradually decreased in amount till after a months treatment all that could be obtained was colorless mucus with now and then a flake of pus. The musical selections were probably cerebral and ceased with the clearing up of the headaches. It will be born in mind that the frontal and sphenoidal sinuses and the superior ethmoid cells are adjacent to the base of the skull and with the subsidence of the inflammation of these cavities the mental condition improved. That the otitis was directly benefited was shown by a marked reduction of the tinnitus and a considerable improvement in the hearing of both ears so that the voice can now be distinguished in the right ear, and the left ear hears a more modulated tone than formerly.

The second case of otitis media which I wish to mention was also treated inadvertently while attempting to improve the nasal condition. Two years ago I had treated this patient for slight deafness in the right ear and marked deafness in the left ear