membrane which completely fills the inferior meatus, and especially when the nasal fossa is narrow, nothing remains but to remove a slice of the entire length of the turbinate. The operation by means of the spokeshave is easy and rapid, but has the objection that the amount removed cannot be accurately regulated.

It is best to give a general anaesthetic (nitrous oxide and oxygen usually suffices), and to operate with the patient sitting up, or, if recumbent, turned well over on to his side. The surgeon stands on the patient's left side, passes the spoke-shave through the inferior meatus into the postnasal space, and hooks it on to the posterior end of the turbinate with the finger. By dragging the instrument sharply forwards, a large piece of the turbinate is easily sliced off. Haemorrhage is rapid at first, although it usually soon subsides. For this reason the anaesthetic should not be deep enough to abolish the cough or the swallowing reflexes, and means should be at hand for plugging the nose. Dundas Grant met with severe haemorrhage five times and "moderate" haemorrhage seven times in eighteen The easiest method of packing the nose is to retain the finger in the post-nasal space, whilst long strips of gauze are rapidly pushed through the anterior nares until the whole nose, up to the finger in the post-nasal space, is tightly packed.

cases.

An alternative method of operating in these cases is to clip away the free border of the turbinate with nasal shears or scissors such as Panza's. This has the advantage over the operation with the spoke-shave in that there is more control over the amount of tissue removed. The operation, however, is rarely required; the cases in which it would be most useful are just those which can be successfully dealt with by the snare. It is insufficient for the most severe cases in which alone, as above mentioned, the spokeshave should be used.

After-Treatment. Very little after-treatment is required; as a rule the less that is done the better. If the nose has been packed to arrest bleeding, the packing should be removed at the end of 24 hours, and not replaced. After the first two or three days the nose may be washed out with simple cleansing lotions. If the anterior end of the turbinate has been operated on, oily preparations are useful: 'the Pigment. Hydrarg. Nit. may be applied either with the spray or brush. For the first few days, food should be given cold; hot drinks should be especially avoided as they may cause haemorrhage. For the same reason the patient should be cautioned against too vigorous attempts to blow the nose.

Results. The after results of these operations are on the whole good. Patency of the nostrils by one or other method can always be established, but when extensive operations are performed the patient may suffer from dryness of the mucous membrane, not only of the nose, but of the postnasal space, the pharynx and the larynx.1 This is especially liable to occur when the nasal secretion has been deficient before operation. In See Discussion, Proc. Laryngol. Soc. of London, March, 1896-97, iv. pp. 88-97.

my experience it never occurs when profuse watery discharge has previously been present. The dryness usually yields in time and must be treated on the lines laid down for rhinitis sicca (see below).

Occasionally a condition not unlike atrophic rhinitis has followed complete turbinectomy. This is especially liable to occur if purulent or muco-purulent rhinitis be present. In such cases, therefore, the operation should be performed only under very exceptional circumstances and after other methods have failed.

Complete Turbinectomy.

Bibliography.

ABERCROMBIE. Journ. of Laryngol., 1896, xi. p. 181.

Discussion at annual meeting Brit. Med. Assoc., Sept., 1897, reported Journ. of Laryngol., 1897, xii. p. 606, etc.

Discussion at Laryngological Society of London, May, 1897, reported Journ. of Laryng., 1897, xii. p. 368, etc.

Anterior Turbinectomy.

LAKE. Journ. of Laryngol., 1897, xii. p. 233

Submucous Incisions.

DELAVAN. New York Med. Journ., 1897, xvi. p. 798.

Pathology of Turbinal Hypertrophy.

CITELLI. Archiv für Laryngol., 1902, xiii. p. 89.

RHINITIS SICCA.

This affection is characterised by dryness of the nasal mucous membrane. On examining the nose crusts are seen on the anterior parts of the septum and of the middle turbinate, and, more rarely, on the inferior turbinate The crusts are small, adherent, and, in London, usually black, unless the patient is exposed to the inhalation of any particular dust, such as flour.

Causation. Rhinitis sicca occurs under three distinct conditions.

(1) The dryness may be due to anaemia of the nose and collapse of the vascular tissue of the turbinates. This form is met with typically in anaemic individuals, especially in women, often in connection with dyspeptic troubles and constipation. The mucous membrane of the nose, and particularly that lining the inferior meatus, will be found pale and shrunken. The nasal fossae appear wide, and small black mucous crusts are seen on the anterior part of the septum, on the middle turbinate, and more rarely over the whole nasal mucosa.

(2) The affection may be met with under almost directly opposite conditions. This form is most frequent in men of thirty to forty years

1 Stewart, Proc. Laryngol.. Soc. of London, 1897-98, v. p. 57.

of age and upwards, of the plethoric type, who are often gouty, and almost always addicted to alcohol. The mucous membrane of the nose is congested, dark red, and covered everywhere with small black crusts. The throat is congested and irritable, the fauces and uvula are thickened, the mucous surface has a dry, glazed appearance. The tongue is furred,

the breath has a vinous odour.

(3) The affection may be due to unfavourable local conditions, such as excessive exposure to dust, flour, etc., or confinement to ill-ventilated overcrowded rooms (see also page 131). Of course these conditions may be, and often are, associated with either of the preceding.

Pathological Results. As already stated, the crusts tend to collect chiefly on the anterior part of the septum, that is on the spot where the inspiratory air current first impinges on the nasal mucous membrane. The crusts cause a certain amount of irritation, and the patient is apt to detach them by picking or by violent efforts at blowing the nose. This forcible detachment leads to excoriation of the mucous membrane and to permanent damage of the ciliated surface epithelium. The latter, repeatedly removed and regenerated, ultimately reverts to a simple type, loses its cilia and becomes squamous. The crusts now adhere more firmly than ever, and as the process continues definite ulceration is produced which may go on until the whole thickness of the mucous membrane is destroyed and the perichondrium exposed. Ultimately the cartilage necroses and a perforation of the septum is formed. The crusts adhere to the edges of this perforation, and it slowly increases in size, but never extends to the osseous septum. The separation of the crusts from the excoriated and ulcerated surface as above described gives rise to repeated attacks of epistaxis. Numerous dilated venules may be seen crossing the affected area, and often small blood clots are found, on detaching which epistaxis is at once produced. In this affection the bleeding may occur frequently, once or more daily, but is usually only slight in amount (see also pp. 83 and 125).

Symptoms. The patient may complain of nasal obstruction associated with irritation, stiffness of the nose, or pricking pains, but he most commonly seeks advice on account of the epistaxis or of the associated throat troubles. The latter consist of a feeling of constriction or of a lump in the throat, hoarseness, tickling cough, pricking or burning sensations. The nasal obstruction in this affection is often purely subjective. The objective features have already been sufficiently described and the diagnosis presents no difficulties.

tion.

Treatment. The patient's general condition requires careful atten

In the plethoric cases alcohol must be strictly limited in amount or entirely interdicted. Smoking should be indulged in moderately, (cigarettes are especially harmful), and the diet must be regulated. Medicinal treatment may be commenced with the administration of an

aperient such as sulphate of magnesia or one of the natural aperient waters. In the well-to-do a cure" at a watering place such as Carlsbad or Contrexéville may be strongly recommended. Subsequently treatment on general lines must be adopted.

In the anaemic cases tonic treatment must be ordered, such as a liberal diet, change of air, and outdoor exercise according to circumstances; digestive and other troubles must be inquired into and remedied. Medicinal tonics may also be prescribed.

Local Treatment. Although general treatment alone may suffice to effect a cure local measures are of great assistance. They consist in cleansing the nose with a non-stimulating alkaline lotion two or three times a day followed up by the application of oily solutions with a brush or atomizer. The thorough application of oil or ointment to the anterior part of the septum is most essential. It protects the mucous membrane, prevents the adhesion of crusts, arrests ulceration, and consequently prevents perforation and cures the epistaxis. When simple alkaline lotions are ineffective ammonium chloride or carbolic acid may be added (see formulae 1 and 3). Sometimes steam inhalations containing cubebs or menthol are useful, especially when the rhinitis is associated with marked laryngeal and pharyngeal symptoms.

When there is much tendency for mucus to accumulate in the postnasal space, leading to constant hawking, and even to nausea and vomiting in the morning, the post-nasal region must be thoroughly cleansed by means of a special syringe or spray. In addition it is well to brush over the post-nasal space and the posterior wall of the pharynx with Mandl's solution or other astringent (see formula 25).

These measures will often be successful, provided that the patient's general habits can be corrected or that he can be removed from his unfavourable surroundings; but in many cases long continued treatment is necessary, and various modifications on the lines above indicated will suggest themselves. In obstinate cases it is sometimes well to rest the mucous membrane by plugging the nostrils with wool or gauze moistened with oil, and to encourage mouth-breathing. So long as air is excluded from the nose the nasal mucous membrane remains moist. This treatment may be persisted in for months, gradually diminishing the number of hours in which the nose is plugged. In spite of all that can be done, many patients-especially those in whom extensive degeneration of the epithelium has taken place, and in whom the anterior part of the septum has become covered with squamous epithelium-will require to use a nasal wash regularly. For such cases a solution of common salt (a teaspoonful to the pint of warm water) is the simplest and the best.

When One Nostril is Obstructed. In this condition the opposite side of the nose-if at all wide-does double work and is very liable to become dry. Under these circumstances it is generally advisable to clear the obstructed nostril. This usually means an operation on the septum,

and one should be chosen which entails the sacrifice of as little mucous membrane as possible. There is a tendency to dryness after all intranasal operations, and in these cases it will be well to plug the nose until healing is complete. The condition may even be made worse for the time being, but the ultimate result should be beneficial.

Of Epistaxis. The prophylactic treatment consists in the prevention of the formation of crusts on the septum by the application of oily preparations, and the patient should be cautioned against picking or rubbing the nose. As already seen, the bleeding area is always on the anterior part of the septum. Active bleeding may therefore be arrested by inserting a strip of gauze or wool covered with ointment into the affected nostril and firmly closing the anterior nares, thus bringing direct pressure to bear upon the affected part. When the means are at hand the bleeding may be temporarily arrested by applying cocaine and supra-renal extract, and then the bleeding points may be at once sealed with the electric cautery. In repeated epistaxis where this treatment has failed, the veins traversing the excoriated area of the septum may be obliterated by a few touches of the cautery. In the worst cases it may even be necessary to excise a piece of the mucous membrane.

Of Perforating Ulcer of the Septum. As already shown, the ulceration and perforation are really traumatic, and are due to the adhesion and forcible detachment of the crusts. Later the crusts tend to adhere to the edges of the perforation, and thus to produce its extension. The patient must be carefully instructed to apply oil or ointment to the ulcerated areas with a brush, and this must be continued until the edges of the perforation have soundly healed. In severe cases it is well to exclude the air from the nose by means of a plug of wool or gauze dipped in oil. The following works may be consulted:

VICTOR LANGE. Heymann's Handbuch der Laryngologie u. Rhinologie, Bd. iii., Wien, 1899.

RIBARY. Archiv für Laryngol., 1896, iv. p. 301.