THE NASAL DOUCHE. 
WHAT IT ACCOMPLISHES AND WHAT IT 
DOES NOT. 
BEVERLEY ROBINSON, M. D. THE NASAL DOUCHE: WHAT IT ACCOMPLISHES AND WHAT 
IT DOES NOT. 
By BEVERLEY ROBINSON, M. D., 
SUBGEON TO THE MANHATTAN EYE AND EAB HOSPITAL (DEPAETMENT OF THE THEOAT); 
PHYSICIAN TO THE DEMILT D1SP1NSAEY, ETC. 
Read before the New York Medical Library and Journal Association. 
Since Roosa, Moos, Knapp, Parclee and other well-known specialists 
have made known to the profession the evil effects upon the organ of 
hearing which may and do result from the use of Weber’s douche, in ap- 
plying medicated solutions to the mucous lining of the nasal passages, 
its employment has become more restricted. 
A few practitioners, it is true, have persistently denied that unfortu- 
nate sequelae are ever directly caused by this convenient appliance. 
Others, more numerous, admit that inflammation of the middle ear, fol- 
lowed by purulent discharge, may infrequently be occasioned by the 
douche; but they add that, when properly used, viz., when the patient 
does not swallow during the period which the operation consumes; when 
due attention is paid to the temperature and degree of concentration of 
the solution employed, to the force of the jet of liquid and the duration 
and frequency of the application, objection to its use are rarely, if ever, 
valid. 
Others, again, in their writings, bid their colleagues to beware of em- 
ploying the nasal douche, no matter how imperative the indication of its 
use may appear to be, and consider its adoption, as a method of treat- 
ment, to be ever attended with danger to the ears of the patient. 
Amongst these latter Professor Roosa stands forth prominently; and as 
he is of the opinion (Treatise on Disease of the Ear, p. 291) “that its 
use should be discountenanced by the profession,” no doubt, when his 
work appeared, many of those physicians who still remained faithful to 
the douche, abandoped it, though loath to do so, “ as it is thought to be 
so thorough in its work of cleansing the nostrils and pharynx.” (Loc. 
cit.) 
Against this received opinion, which we deem to be a great though 
generally accepted error, we here desire to enter our protest. 
The nasal douche does not, in our estimation, do wThat it purports to do, 
viz., cleanse thoroughly the nasal passage and naso-pharyngeal cavity, 
but in reality leaves a considerable space untouched by its action. If 
such be the case, those members of the profession who gave up its use 
with reluctance need at present have no regrets. 
We will now endeavor to demonstrate the truth of the above asser- 
tion. The diameter in all directions of the jet of liquid which flow's 
from the nozzle of the ordinary Weber’s douche is certainly not more than | to | of an inch. The anterior openings of the cartilaginous por- 
tion of the nose (nostrils) in the adult, and during normal respiration, 
are of oval form, and speaking generally, from f to i of an inch in the 
lateral, and from f to £ in the antero-posterior diameter. The posterior 
openings are likewise somewhat oval in configuration and about half an 
inch in the short, or transversal, and 1 inch in the long, or vertical 
diameter. The depth of the nasal passages at their median portion is 
nearly double this latter measurement; whereas the lateral diameter in 
this region measures, upon the floor of the fossa, or interiorly, only six 
lines, and becomes rapidly narrower as we approach nearer to the roof, 
or superior part of the nose, where it has only about 1 line. 
This lateral diameter does not vary much anteroposteriorly, but re- 
mains nearly the same on a given horizontal plane. These data being 
accepted as true, let us see how the douche acts. When the nozzle is 
introduced into one of the anterior openings of the nose, and the stream 
begins to flow, but a few seconds usually elapse before a jet of water of 
like calibre with the entering one makes its exit from the opposite nos- 
tril. Now, the physiological fact upon which the use of Weber’s douche 
is based is, that one side of the nasal and the entire naso-pharyngeal 
cavity being'filled with liquid by hydrostatic pressure, the soft palate is 
raised up by the contraction of the levatores palati muscles, and perfect 
coaptation between its posterior border and the walls of the pharynx is 
effected, and thus the passage-way for the escape of any quantity of 
liquid dowmvards into the pharynx is completely intercepted. The in- 
jected liquid must, therefore, of necessity, make its exit by the other 
side of the nasal passages, and in doing so comes in contact with all the 
parts contained in or limiting the side of these cavities through which 
the stream enters. 
To this we reply that if, during the operation, one-half the nasal pas- 
sage, and the entire naso-pharyngeal space were flooded with liquid, we 
doubt not that the whole of the interior of these cavities would be 
cleansed and rinsed very completely. But, practically, is this often or 
ever the case ? 
Wo put aside temporarily, without considerin'" them, those cases in 
which the passages are so much obstructed by the swollen and infiltrated 
condition of the mucous membyane, or from some other cause, that the 
stream either cannot pass, or flows slowly and imperfectly; and we 
would draw attention to the following propositions 
1. Inasmuch as in the majority of cases the column of water escapes 
in equal volume, and with as great force and rapidity as the entering 
jet, how can the passages be flooded ? 
2. Water naturally seeks its level, and when it can pass freely around 
the posterior border of the nasal septum, how can it be made evident 
that it goes so far upward as the vault of the pharynx, or penetrates to 
the depth of the nasal cavities ? 
S. We must remember that, in using the douche, the patient is told to 
bend his head over a basin or receptacle for containing the issuing liquid. The floor of the nasal passages thus becomes a plane inclined forwards 
and downwards, and the medicated solution employed has by the mere 
force of gravity, an impelling tendency to go around the septum narium 
and flow out by the lower meatus. 
We may now return to the cases where the passages are greatly ob- 
structed ; and, first, we question whether—and though the calibre of the 
stream be sufficient to fill up one of the anterior openings of the nares, 
and be used under the condition of hydrostatic pressure ordinarily em- 
ployed with the douche—whether we say, in like case the remaining 
portion of the side of the nasal cavities by which the stream of liquid 
flows in would be entirely filled. When we penetrate a short distance 
into these cavities their dimensions are greater in the different diameters 
than those of the anterior nares, and with similar calibre of orifice of 
exit to orifice of entrance, both being placed on the same level, the li- 
quid must take the shortest and most direct road towards the opening 
of escape outwards. 
If, however, the force and rapidity of the current be very great, and if 
owing to excess of obstruction on the opposite side to that of the enter- 
ing fluid, this latter cannot so quickly leave the nasal passages as it flows 
into them, one side, at least, of these cavities may be entirely filled with 
liquid; but even in that case it would only be during a few seconds. 
For. admitting the possibility of the case supposed, is it not apparent 
that the subjective sensations of the patient would become so unpleasant, 
or the pressure in the nasal cavities and naso-pharyngeal space be such 
that the soft palate would give way almost immediately. 
Some liquid would then pass into the stomach by an effort of deglutr 
tion, or else, owing to confused breathing, get into the larynx and pro- 
duce a violent paroxysm of cough. In the last-mentioned event the 
whole of the inflowing liquid would be violently rejected through the 
mouth and nose, whilst the operation itself would of necessity be sud- 
denly interrupted. 
We do not believe, therefore, for our part, that either the vault of the 
pharynx, the superior and middle turbinated bones, or the superior 
meatus, are cleansed at all by the nasal douche. True it is that a great 
deal of inspissated mucus, hard crusts, and soft, fetid secretions, are 
frequently brought away; and we were disposed, for a long while, to 
console ourselves in the belief that the nasal cavities were effectually 
rinsed at the termination of each operation. Experience, however, has 
taught us the fallacy of such a belief; and now that we inspect the nares, 
anteriorly after one of these washings, and, what is still better, make a 
rhinoscopic examination posteriorly, when it is possible, we find at 
times there still remains at the top of the pharynx, or around and con- 
tained in the posterior openings of the nose, strings of viscid mucus 
which have been left untouched. Whenever this proof is wanting wre 
shall have to consider the striking clinical fact of a crust or large muscle 
shaped bit of mucus being expelled from the nose after what we inferred 
wrongly had been a most complete cleansing. The explanation of this phenomenon is readily found. Large pieces 
of mucus have become detached from the roof of the nose, and more 
particularly from the cribriform plate of the ethmoid bone, the posterior 
surface of the nasal bones, and the upper turbinated bones, owing, no 
doubt, to increased temporary secretion, brought on by the use of the 
douche, and have fallen to the floor of the nasal cavities. Here they 
have been the occasion of more or less unpleasant and abnormal sensa- 
tions, and a strong effort of expiration is sufficient to expel or throw 
them off altogether. Whilst much of the irritating and concrete mucus 
is thus got rid of, a certain amount remains behind, and, by the morbid 
alterations which it assumes, is the source of further disease, or, at all 
events, by its constant contact with parts already diseased, protracts or 
renders impossible the return of these latter to their normal state. 
We would not have our readers believe that the foregoing remarks 
originated wholly with ourselves. They have been suggested partly by 
the perusal of an interesting communication from the pen of Thomas F. 
Rumbold, M. D.,which appeared in the number for September, 1873, of 
the St. Louis Medical and Surgical Journal, partly by a short article in 
Archiv. fur Ohrenheilkunde (vi. Bd. 4 Heft, 1873), by Ludwig Schultze, 
of Leipzig, and partly, we feel free to add, by our own individual 
thought and experience. The subject of these brief remarks is assuredly 
one worthy of attention. 
Affections of the nose are not infrequent with us. Nasal catarrh es- 
pecially is met with each day and on all sides. 
It becomes, therefore, the duty of every practitioner of medicine, and 
not merely of the specialist in diseases of the throat and nose, to know 
how this last-mentioned and other analogous affections may be treated 
prudently and efficaciously; and true it is, unfortunately, the treatment 
of them has hitherto been most unsatisfactory. So much is this the 
rule, in point of fact, that already, amongst unprofessional persons, 
“catarrh ” is classed with other “opprobria medicorum.” 
May not the secret of this lack of successful therapeutics be found in 
the statement, we ask, that thus far no instrument has come into general 
use which meets the one evidently essential indication in the treatment 
of every case, viz., to thoroughly cleanse the entire nasal cavities. 
15 West 26th steeet.