fields of medicine, wherever permissible, to make painstaking experiment and draw conscientious conclusions in the recognition and treatment of disease. We should not rest contented with the uncertain methods of our forefathers, but, with Lessing, we must proclaim “Not the bare truth, which everybody possesses, or thinks he possesses, but the earnest endeavor which was made to understand the whole truth, and to get at the foundation of it makes the true worth of a man." Ours is a profession which can ill afford to be satisfied with mere possession, but its power is best shown by its earnest search for truth. Ours is a task of blasting in the quarries of the unknown, where are hidden innumerable precious truths awaiting development. Thus may our noble art "gain the reach and certitude of sway over disease, which we all yearn for it to possess."

Sir Michael Foster has recently said: "The phenomena of disease, being phenomena of living beings, present themselves as mixed problems of physics, chemistry, and biology, to be grappled with by the general practitioner as they are grappled with by the physicist, chemist, and biologist."

"Diagnosis," says Dr. Eisener, "is the true password in the medical science of to-day, and this should be realized by many who continue satisfied with the uncertain methods of the past."

When Leube, in 1871, first recommended the stomach-tube for diagnostic purposes he cleared the way for the ready diagnosis of stomach diseases. Bacteriologic diagnosis of certain diseases has become a matter of routine importance with the scientific, up-to-date physician, and to him we shall look for the solution of many important problems in the prevention and recognition of disease. The number of lives annually saved by the application of bacteriologic methods in diagnosis of disease can not be estimated. It has been unjustly stated that the time occupied in making blood examinations with the microscope is out of proportion to the knowledge acquired. This is an unjust charge. To gain exact information of disease should be our aim, regardless of time and expense, but fortunately with our newer methods and modern technique a thorough blood examination can be made in less than forty minutes. These are important matters, and should not be forgotten by the general practitioner.

That most valuable instrument, the ophthalmoscope, should constitute one of the important adjuncts to the equipment of the general practitioner, by which he is enabled to recognize the grosser pathologic

changes in the eye, leading to a diagnosis of brain, kidney, and nerve lesions, that are so often overlooked and maltreated.

It is no secret that the charge has been made that too many patients in this country are often ignorantly and incompetently treated, and our medical schools and system of medical education are held responsible for this state of affairs. We must admit that we too often fail to stimulate the "scientific sense"; men are not educated to work systematically, and hence we fall short in many important essentials that go toward rounding up a thorough knowledge of the work in hand.

Many causes might be cited that contribute to this unfortunate state of affairs. A spirit of commercialism seems to have gotten hold of many of our American medical institutions, and as a natural sequence its influence is felt in the ranks of the profession. That unconquerable thirst for "filthy lucre" has been the indirect cause of more failures in, and has brought more discredit upon, the medical profession of the United States than all other causes combined. In this particular sense the profession has, I am sorry to say, retrograded from the old landmarks. This is, in part, due to the overcrowded condition of the profession and the multiplicity of medical colleges. According to reliable statistics our colleges are sending out six thousand graduates each year, or distributing annually to each State in the Union an average of one hundred and thirty-three doctors. If this continues ten years longer we will be able to boast of having one doctor to every three hundred of the population.

With this overcrowding of the profession it is but natural to conclude that competition will grow keener each year, and commercialism, specialism, and professional antagonism will keep pace with each other in the ratio of demand and supply. Are these crude, cold facts not worthy the careful and calm consideration of every unbiased, honestthinking physician of the United States?

ROANOKE, VA.

OBSTRUCTIONS OF THE NASAL PASSAGES.*

BY M. F. COOMES, A. M., M. D.

Professor of Physiology, Ophthalmology, Otology, and Laryngology in the Kentucky School of Medicine; a Member of the American Medical Association, the Kentucky State Medical Society, and the Louisville Clinical Society; Ophthalmic Surgeon to Louisville City Hospital and the Kentucky School of Medicine Hospital; Consulting Ophthalmic Surgeon to

Sts. Mary and Elizabeth Hospital, etc.

Barring the presence of foreign bodies and occlusions as a result of acute traumatism, there are three things which obstruct the nasal passages. First, morbid growths, in the shape of tumors of one kind or another; secondly, malformations of the septum, either in the shape of exostoses or deflections, and thirdly, relaxed or hypertrophic conditions of the membrane covering the turbinated bones.

I will not attempt in this paper to give any statistics as to the frequency with which these different forms of obstructions occur, but will confine myself to the diagnosis and treatment.

It

Ocular inspection will enable us to determine in all instances whether the obstruction in the nasal passages is due to the presence of a morbid growth; that is, if a polyp or other tumor exists. sometimes happens that there is a great deal of relaxation of the nasal mucous membrane. This relaxation is readily overcome by means of adrenalin, and once having the mucous membrane thoroughly contracted it will become a matter of little difficulty to determine the exact condition of the nasal passages, as to whether or not there exists a tumor. The shape of the supposed tumor and its color will frequently enable us to determine its nature.

Again, the use of adrenalin will enable us to determine the exact condition of the septum. It is a well-known fact to all of us that the septum is rarely a straight partition wall; the rule is that it deviates in nearly all persons. This deviation sometimes amounts to complete obstruction of one side of the nose; again, it may mean temporary obstruction, as in the case where the septum is close enough to the turbinated bone to produce closure when the erectile tissue covering that bone is distended. These deviations, when they have once been determined, can readily be understood by the surgeon, and the means of dealing with them also determined. Again, the determination of whether we are dealing with a relaxed nasal membrane or a tumor is set at rest by the liberal use of adrenalin. It shrinks the tissues

* Read at the meeting of the Ohio Valley Medical Association, May 1, 1902.

covering the turbinated bones and the septum, and will also blanch the surface of the tumor if such exists, and in this way we are enabled to make a perfect and complete inspection of the entire surface of the nasal mucous membrane, including that which covers the turbinated bones and the septum; in short, the anterior and posterior rhinoscopic examinations will enable us to determine the exact condition of the nasal passages. The diagnosis having once been made, the next thing under consideration will be the treatment. In general, it is good surgery to remove all tumors from the nasal passages, and in this connection it is very difficult to keep from referring to the pharyngeal box as well; however, there are some cases in which many of us would hesitate to undertake the removal of a growth from the nose, simply because of the fact that the patient would live longer by letting it remain than by attempting to remove it. These are cases of sarcomatous growths found in this locality. Fortunately, I have not yet met with. a case where I deemed it advisable to let the growth remain. With our modern means of gaining entrance into the nasal passages all operations about this locality can be performed without very much danger to life. I will not attempt to detail here the various methods of getting into the nasal cavities, as such directions may be found in most of the works on general surgery, and all the works devoted especially to surgery of the nose. In many cases it is not a matter of choice with the surgeon-it is simply the choice that presents itself; so in nearly all cases where operative procedure is to take place the surgeon will make his own selection and modify the various operations devised for this purpose to suit the individual case. There is one operation, however, that I think there is very little good in, and it is certainly not to be recommended in private practice, and that is the Annandale operation, in which the hard palate is sawed in two and the halves separated so as to give a greater field to operate through. I do not believe that the end justifies the means, for the reason that the amount of advantage gained by this procedure is so little that in the final result I believe the surgeon would do a better operation, or do it more rapidly, if this bone were not separated.

Again, what instrument or instruments should be used in any particular case can not be here stated, for the reason that each individual case demands a certain form of instrument, some being more thoroughly dealt with by means of the snare, others by turning the nose to one side, or turning it down or up, as the case may be, and entering

the passages and detaching and removing the growth. Again, others may be removed by means of the cautery wire. I do not believe that there is much benefit gained by injecting tumors in the nose. If they can be reached with an injection they can also be reached by instruments which will remove them en masse-this method being much more preferable than that of having them slough out, with the chances of an incomplete removal.

The removal of bony growths from the septum and the removal of turbinated bones that are of abnormal size may be done with a chisel, with a knife, or with a scissors, or any of the various instruments which have been devised for that purpose-the location of the bone to be removed, that is, whether it is a spur from the septum, or whether it is an excessively long turbinated bone, determining the kind of instrument to be used.

Again, here I would like to note the fact of the very great value of the adrenalin solution in shrinking up the tissues in the nasal cavities, thus increasing the area of the operative field and making many of these operations bloodless.

Further, I have noted with great care the effect of the adrenalin in this kind of operative work, and I do not believe there is any more danger of hemorrhage when this drug is used than without it. I feel sure that the hemorrhages that have been laid to the door of this drug have been due to faulty packing of the nasal cavities by the surgeon after the operation has been performed. It is sure that you will have bleeding whether you use adrenalin or not, and there is no reason for believing that the adrenalin will make blood-vessels more liable to remain in a relaxed condition after it is used than before.

Lastly, and most important, is the dealing with the relaxed erectile tissues covering the inferior turbinated bones. When I say that ninety per cent of the disturbances, that is, obstructed breathing through the nostrils, is due to this condition, I am sure that I do not exaggerate, and this being the case it can readily be understood how important it is to manage this condition properly. All of us who have dealt in this kind of surgery know the results of excessive burning. The idea of Sajous, who first brought the operation of cauterizing the nasal mucous membrane into vogue, was to pass the hot needle through the nasal mucous membrane and burn the membrane and attach it to the bone-as it were, tuck it up. This mode was soon discontinued because of the excessive sloughing produced and the permanent injury done to many