The changes of dressings are made in a special room. After the removal of the old dressing and cleansing of the surrounding parts with benzine the head of the patient is wrapped in a sterile towel which has a central opening through which the ear and the wound appear. The sterile dressings are only handled with sterile instruments.

Small operations like the removal of adenoid vegetations should not be performed in the dispensary rooms. It is well known that infections frequently follow this operation. Usually 48 hours after the operation, sometimes later, rarely earlier, the temperature rapidly rises and after 6 to 12 hours deposits are found on the faucial tonsils or on the salpingopharyngeal folds, a complication which is usually without danger but very unpleasant and may be followed by a severe otitis media, or infect a relative of the patient or the physician himself. As the period of time between the operation and the onset of the angina is always the same, it is evident that the infection is caused or favored by the removal of the pharyngeal tonsil. The non-operative anginas also begin in the pharyngeal tonsil. If we examine these patients early with the post-rhinoscopic method, we will nearly always find deposits on the pharyngeal tonsil even before they appear on the faucial tonsils. The pharyngeal tonsil may therefore be regarded as the site of infection. We know that the relapsing so-called habitual anginas frequently disappear entirely on the removal of the pharyngeal tonsil, while if the palatal tonsils alone are removed, they recur as before and deposits form on the stump of the previous tonsil.

The anginas after removal of the pharyngeal tonsil have become very much rarer with us since we performed the operation in a special room. I should like to add that an angina of this character may follow the digital examination of the naso-pharynx; we consequently now always examine with a protected finger.

For the sake of completeness in this discussion on surgical anginas, I should like to state that they may occur after operations on the nose. The site of infection in these cases is the lymphatic tissue in the nasal mucous membrane. The removal of the pharyngeal tonsil in a special room is

also desirable to prevent the possibility of infection with scarlet fever which not rarely follows from a wound in this region.

It is well known that a surgical scarlet fever exists which sets in after operations in the most varying parts of the body and usually runs its course without producing the customary angina. This is explained by the fact that the entrance for the scarlet fever poison in the ordinary non-surgical scarlet fever is found in the lymphatic ring which presents distinct pathological changes. If any operative wound furnishes the site of entrance for the scarlet fever germ, the scarlet fever angina is absent. Hence scarlet fever after the removal of adenoids is a particular form of surgical scarlet fever, as the site of entrance is in the same location as in ordinary scarlet fever. Consequently in these cases the angina is also present but it differs from the former disease inasmuch as the period of incubation is shorter and more uniform (2 days).

Many minor operations have to be performed in the dispensary rooms. How can we best avoid infection of the wound in these cases? It is well known that infectious germs are not transmitted by the air but usually by the instruments, bandages, or hands. We must therefore only employ instruments which have been boiled, dressings which have been sterilized, and touch the wound as little as possible with our fingers.

It is just as well to keep the air in the dispensary as pure as possible. Our dispensary is arranged like an operatingroom. The walls are painted, the floors are of mosaic. They are washed every day. There are numerous wash basins with cold and hot water. Patients with severe infections, especially with erysipelas, are excluded from this room. We endeavor to keep the clinic as free from the pus as possible of all acute and profuse chronic otorrhoeas. The canal is drained with a strip of gauze and an ear dressing is applied. On changing the dressing the gauze and cotton is immedi ately placed in a porcelain pail. The well-known black ear patch is not allowed.

The aural suppurations in the hospital are treated in the

same manner so that the pillows, floors, and tables are not infected with the purulent dressing.

It is especially important to keep the hair away from the wound. This is especially true in the treatment of furuncle of the auditory canal in which these hairs often furnish a constant source for relapses. All instruments should be boiled, even the olive tips of the auscultation tubes and pharyngeal mirrors. A mirror which does not stand boiling should be returned to the maker. All instruments after use are placed in a porcelain dish, the nurse collects these dishes, and the instruments are boiled and returned to their places. Our syringes are fitted with metal pistons. As an irrigating fluid we use a mixture of hot and cold water without the addition of any disinfectant. Gauze and cotton are always at hand in a sterilized condition. The cotton is wound around the ends of thin pieces of wood which are thrown away after use. They are collected in small test-tubes in which they are sterilized. The gauze strips have a selvedge and are in rolls.

To grasp the tongue in examining the larynx we use gauze handkerchiefs. We endeavor to instruct our patients in the exercise of cleanliness; gauze and cotton must not be removed from the ear by the patients.

The most common pathogenic microbe is the staphylococcus albus. This organism is of special importance to us as it causes a secondary infection by which acute suppurations become chronic. If our precautions are efficient, the acute middle-ear diseases usually heal promptly. The bacillus pyocyaneus is also an excellent control of our precautions as it is ubiquitous and can be cultivated in any axilla under moist dressings. The pyocyaneus is not the ordinary saprophyte but is sometimes pathogenic in ear diseases. It can produce an acute otitis media and seems to cause the dreaded perichondritis after the plastic step in the radical operation. This is according to the observations of Brieger and Leutert and in the four cases of perichondritis which I have observed in the last twelve years this organism has been present.

The acute pyocyaneus otitis is characterized by a bloody

serous exudate in the tympanum and the simultaneous presence of vesicles in the canal. If the operative wound be infected by the pyocyaneus, the margins become red, the temperature rises, and erysipelas is suspected. On the following day the character of the infection becomes manifest by the greenish discoloration of the gauze. The redness and fever disappear in a few days but the pus retains its green color. I have found packing and dressings impregnated with a 2 to 5 % silver nitrate solution to be most effi cacious against this infection.

Finally a few words on the protection of the physician against infection.

The patients suffering with laryngeal phthisis are the most dangerous as during examinations and treatment they exhale and cough up a spray of fluid containing bacilli.

We pro

tect ourselves by carrying a square handkerchief over the nose and mouth held at the upper corners by means of tapes, weighted with lead bullets which are suspended over the ears.

AFTER-TREATMENT OF RADICAL OPERATIONS

I

WITHOUT PACKING.

BY DR. A. VON ZUR MUEHLEN, RIGA.

N recent years I have modified the after-treatment of the radical operations; in certain cases I leave out the packing after the first or second dressing. The advantage of this should not be underestimated. The procedure of packing is often painful and difficult, especially in children, and the after-treatment without packing in a certain number of cases seems to have shortened the length of treatment. The depressions and cavities formed at the operation fill in with newly formed tissue; they appear smaller and less deep, and, consequently, are easier to oversee and to keep clean. The anatomical relations of the entire organ may resemble under favorable conditions closely the normal. My procedure after operation, in brief, is as follows:

At operation I endeavor to proceed as conservatively as possible. I remove from the healthy bone only so much as is absolutely necessary to expose the diseased bone, and especially all of the recesses and cells. The new cavity, therefore, is as small as possible, and consequently will be covered with epidermis more quickly. The wisdom of this conservative principle is surely now granted by everybody. At the same time, too great caution may induce certain unpleasant complications, to which I wish to return later on.

I do not wish to enter into a discussion of the various methods of the plastic step of the operation. Pathological conditions found at operations determine which plastic procedure will give the best results. Thus, in some cases I have had very good results by only splitting the posterior