if possible. In such subjects even the galvanocaustic burner may lead to embarrassing secondary hemorrhage. Several personal experiences, however, with bleeders terminated well ultimately.

30. At the present time every surgeon recognizes that it is his duty to have every instrument sterilized before it is brought into contact with a wound or an absorbing sur

face. The only method that gives absolute assurance of complete disinfection is three minutes' boiling in 1 per cent. sodium carbonate solution. In the absence of spores, even one minute suffices to kill germs. On account of the solvent action of hot soda solution upon dirt this renders unnecessary the painstaking scrubbing which must precede immersion in cold antiseptic solutions (5 per

cent. carbolic acid or o.1 per cent. corrosive sublimate). It is advisable to have a sterilizing kettle (Fig. 31) in permanent use next to the instrument table, and to get into the habit of throwing all instruments into it after use. For instruments used inerely for examination and not coming into contact with wounds,-for instance, the rhinoscopic mirror and the nasal speculum,-scrubbing with a brush under running water suffices, whereas the mere dipping into a disinfecting solution is useless, because inefficient. When there is any suspicion, however, of contagious disease, syphilis, tuberculosis, diphtheria, or even acute angina, it is our duty to boil the instruments after use, even if the rhinoscopic mirror does deteriorate gradually. The nozzles of rubber throatatomizers withstand boiling without damage. Cotton swabs wound on tooth-picks for mopping and for applications can be kept aseptic by handling the cotton with a sterile cloth instead of with the naked fingers.

It has been claimed by St. Clair Thompson and Hewlett that the normal nasal lining is generally free from bacteria, and that they are largely deposited in the vestibule or expelled from the mucous surface by the movements of the epithelial cilia. As all other mucous membranes are likely to have germs upon their surfaces, this statement ought not to be accepted fully until it is extensively corroborated. The impossibility of practically sterilizing other even more accessible mucous membranes, like those of the conjunctiva or vagina, excludes all hope of successfully sterilizing the surfaces of nose or pharynx by present methods. Since the nasal mucous membrane cannot be made sterile, we cannot guarantee an aseptic course after operations. Attempts to keep the surfaces protected against germs by means of painting with methyl-violet and other antiseptic substances have not proved successful and do not seem rational to the bacteriologist. The only real protection is afforded by iodoform gauze packed closely against a wound, since iodoform in powder form is soon swept away by secretion.

Clinical experience has led me to trust, to some extent, to glutol in coarse powder blown upon the thoroughly clean and dry wound. This substance, by reason of its absorbing power, helps to stop bleeding and forms a welladhering crust under which wounds in the nose and throat have healed in a very clean and rapid manner. Fortunately, however, wounds in the nose and throat do not often follow an untoward course. Superficial infection is almost inevitable except under iodoform gauze or under a glutol scab, but suppuration of wounds is not common in the nose, although more so in the pharynx. Traumatic erysipelas is very rare. Pyogenic infection

of nasal wounds sometimes leads to acute tonsillitis-on the same side and perhaps later on the other side—or to suppurative inflammation of the middle ear or of the maxillary sinus. Streptococcus infection may manifest itself by the prolonged formation of false membranes with delayed healing, but usually without serious danger.

History and Literature.--The former scanty knowledge concerning surgical diseases of the nose and pharynx (polypi, malignant tumors, empyema of frontal and maxillary sinus, and tonsillar enlargement) can be found in the text-books on surgery of the various times. From a medical point of view, these parts received no attention worth mentioning prior to the introduction of the laryngoscope by Türck and Czermak (1858), except in the case of acute infections of the pharynx. In 1859 Czermak applied the inverted laryngoscopic mirror to the postnasal space. Anterior nasal inspection through a speculum was employed by Markusovszki, of Pesth, in 1859, but popularized by Thudichum (Duplay, and especially B. Fränkel) only after 1868. Thudichum also introduced into therapeutics the nasal douche (1864) previously used for physiologic purposes by Weber. The danger While the

of the douche to the ear was later shown by Roosa. knowledge of the various affections of the nose was gradually augmented by laryngologists of all countries, the most important discovery regarding postnasal pathology was the description of the enlarged pharyngeal tonsil (adenoid vegetations) by W. Meyer, whose first report in Danish literature in 1868 was supplemented by his more accessible German publication in 1873. Medical interest in the nose as a source of wide-spread nervous

"reflexes" (asthma, headache, etc.) was aroused by Hack's announcements in 1881, continued for several years. The important rôle played by the accessory cavities in suppuration hitherto considered of intranasal origin was emphasized by Ziem in 1881, and has received extensive attention within the last twelve years.

Rhinologic study should begin with the fundamental treatise by Zuckerkandl on the anatomy of the nose (magnificently illustrated), Normale und pathologische Anatomie der Nasenhöhle, Bd. i., 1882, and 2. Ed., 1893, Bd. ii., 1892. Nasal pathology is illustrated by Seifert and Kahn's Atlas der Histopathologie der Nase, Mundrachenhöhle, und des Kehlkopf's, 1895. Among general treatises on nose and pharynx B. Fränkel's volume in Ziemssen's Handbuch d. spec. Pathologie (1876) was the earliest in date, while among the most comprehensive recent text-books may be mentioned Burnett's System of Diseases of the Ear, Nose, and Throat, 1893, and especially the Handbuch der Laryngologie und Rhinologie, begun in 1896 under the editorship of P. Heyman. Among the landmarks on this subject may be mentioned the Diseases of the Throat and Nasal Passage by J. Solis Cohen, 2 Ed., 1879, and The Diseases of Nose and Throat, by Morell Mackenzie, vol. i., 1880, and vol. ii., 1884. Much historic information can be found in this work and in J. N. Mackenzie's articles on "Nasal Affections" in Wood's Reference Handbook of the Medical Sciences, vol. viii.

CHAPTER IV.

DISEASES OF THE VESTIBULE OF THE NOSE.

CORYZA.

DISEASES OF THE VESTIBULE.

31. The entrance into the nose is not often the primary seat of disease, but suffers frequently in the course of various intranasal affections, especially purulent rhinitis.

Eczema occurs sometimes in the acute, more often in the chronic, form. The characteristic vesicles are soon transformed into moist scabs covering an excoriated, bleeding surface. The patch extends usually downward over the upper lip, but is sometimes limited to the floor and sides of the vestibule. Eczema is most commonly seen in scrofulous children. Sometimes it is also a persistent annoyance in adults with morbid nasal secretion. When of long duration, it is likely to cause thickening of the upper lip, typically seen in scrofulous children. The eczematous abrasion may permit the entrance of the tubercle bacillus into the lymphatic system, as indicated by permanent enlargement of the anterior cervical lymphglands. It may likewise prove the starting-point of facial erysipelas. The eczematous crusts should be removed, and the surface protected by a zinc oxid lanolin salve (50 per cent.). Rebellious cases are cured in the quickest manner by cauterization with silver nitrate, repeated if necessary. Oil of cade salve (1:4) and balsam of Peru act more slowly, but are especially useful in preventing relapses.

An annoying and easily overlooked lesion is a shallow fissure at the junction of the septum and the lateral wall of the external nose. It is more or less painful, always tedious in its course, and likely to recur if partially healed. Sometimes it maintains an embarrassing red