be removed. When a large piece of nasal mucous membrane has been destroyed, the injured area for months after may continue to be covered with dry mucous crusts, which give rise to considerable local inconvenience. If extensive injury has been done, the pharynx and larynx are also apt to become dry and crusty, or a condition resembling atrophic rhinitis may be produced.

Local Anaesthesia. A large number of minor intranasal operations can be performed under local anaesthesia. The best drug for this purpose is the hydrochlorate of cocaine, of which a 5, 10, or even 20 per cent. solution may be used. It is best to prepare the solution freshly each time it is required, by dissolving the crystals in sterilised distilled water. The drug in weak solution is apt to undergo decomposition, but a strong solution, to which is added some preservative (such as salicylic acid or resorcin1 of either one grain to the ounce), may be kept a considerable time. With careful use the exact strength of the solution really matters little, for just enough cocaine should be applied to the site of operation to produce complete anaesthesia of the parts. Therefore the stronger the solution, the less of it required. The usual plan of spraying cocaine solution into the nose I have for some time abandoned. The instruments are continually getting out of order; they are dirty, and with the slightest variation in their lumen they give such a different spray that it is difficult to know how much of the drug is being used. If the amount injected with a single compression of the ball of the spray is measured it will often be found surprisingly large. This renders the method unsafe, especially in inexperienced hands. The best plan is to apply the cocaine on small pledgets of wool. In this way the action of the drug is limited to the part required, very little cocaine is used, and there is proportionately less danger of toxic effects. The part to be operated upon is first gently brushed over, and then pledgets of wool soaked in the solution are placed in contact with it for 5-10 minutes. Great care should be taken to prevent any cocaine running down into the throat and being swallowed; therefore, immediately after placing the wool in position, the patient's head should be bent well forward. Anaesthesia is usually complete in ten minutes, and will last five to ten minutes longer. Besides its anaesthetic effect, cocaine produces shrinking of the nasal mucous membrane by emptying the venous sinuses, and thus greatly facilitates intranasal operations by diminishing haemorrhage, and increasing the roominess of the nasal fossae. In children, cocaine must be employed with great care in a 4 or 5 per cent. solution. Since I have adopted the above method exclusively, I have never seen any serious ill effects from cocaine, either in private or hospital practice. It is said that some patients exhibit a remarkable idiosyncrasy with regard to this drug, a minute dose producing dangerous symptoms. Great caution should therefore be exercised when using it for the first time on a patient, and diffusible stimulants, such as sal volatile or whisky should always be at hand in case of faintness. 1 Hall, Brit. Med. Jour., 1896, i. p. 335.

It is well to give very nervous or weakly people a small quantity of stimulant as a prophylactic. The first effects of cocaine are stimu lating, but after a brief period the patient may become pale, excitable, loquacious, and exhibit some loss of self-control. This is followed in the more severe cases by trembling, nervous depression, and physical collapse or prostration. In neurotic people an attack of hysteria is not uncommon. These symptoms should be met by placing the patient in the recumbent position and administering hot stimulating drinks, such as coffee or alcohol. It is better, however, to prevent them by using cocaine in small doses until the susceptibility of the patient to the drug is known, and by employing it in the careful way above described. The combination of cocaine with suprarenal extract by necessitating the use of less cocaine is also useful in this respect.

Eucaine. Eucaine, a laboratory prepared homologue of cocaine, has been strongly recommended as a substitute for the latter, as it is said to have no toxic effects. Its action in other ways is similar, but it apparently takes a little longer to produce complete anaesthesia, it does not produce such marked shrinking of the mucous membrane, and its anaesthetic effect is a little more lasting. It dissolves in water in a 10 per cent. solution, which may be sterilised by boiling without impairing its action.

The Suprarenal Gland Extract. This drug produces marked constriction of the vessels of the nasal mucous membrane, and renders it white and anaemic. Used in conjunction with cocaine, it produces more complete and longer anaesthesia, and prevents haemorrhage during small operations, making it possible to see accurately what is being done. The combination with cocaine is especially valuable in patients who are intolerant of the latter drug, as complete anaesthesia can be obtained with very little cocaine, which, moreover, is less liable to be absorbed, owing to the constriction of the vessels. Suprarenal extract alone is useless as an anaesthetic. The advantages of this drug are so obvious that for local anaesthesia in the nose I invariably use a mixture of cocaine and suprarenal extract, which I prepare in the way originally suggested by E. A. Peters.1 A test-tube is filled for about one inch with commercial desiccated suprarenal glands, treble the quantity of distilled water is added, and the tube, closed with a wool plug, is placed in boiling water for ten minutes. The solution is filtered and an equal quantity of a 20 per cent. solution of cocaine is added to it. In this way a powerful anaesthetic and astringent solution is obtained. The exact strength of this preparation may vary somewhat, but this is a matter of little importance, as no more should be applied than is necessary to produce the full effect of the drugs. Lederman advises the extraction of the dried suprarenal glands with glycerine. He adds one part of dried gland to six parts of a 25 per cent. glycerine solution for 48 hours. Peters' method of preparation has been employed by me for more than four years, and gives as good a result as any of 1 Peters, Brit. Med. Jour., 1899, ii. p. 851. 2 Laryngoscope, 1899, vi. p. 217.

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the drugs which have hitherto been placed on the market. I have experimented with most of these, and can recommend both Hemisine and Adrenalin. The former is very convenient, being sold in small soloids. Adrenalin is sold in solution, and may be mixed with cocaine solution, or applied separately after the parts have been anaesthetized.

The objection to the use of suprarenal extracts is that the constriction of the vessels is followed in 3-5 hours by extreme dilatation. Thus when the drug has been used as an aid to diagnosis, the patient may subsequently experience marked nasal obstruction, accompanied by profuse rhinorrhoea and sneezing. After operations, there is an increased tendency to haemorrhage, and consequently it is advisable to keep the patient within reach of the surgeon for at least 24 hours, or, if this be impracticable, to pack the nose immediately the operation is finished.

The objection

General Anaesthesia. If general anaesthesia be preferred, the choice of agent must generally be left to the anaesthetist. For short operations, nitrous oxide, alone or combined with oxygen, is probably the safest and best. When a longer anaesthesia is necessary, chloroform, ether, or some mixture of these, such as the A.C.E. mixture, can be used. that ether increases the bleeding, is probably more theoretical than real; and even if there be a little more haemorrhage, the patient's breathing is more vigorous, and the reflexes are more easily maintained. Whatever agent be chosen, the safety of the patient lies in not pushing the anaesthesia too deeply. The air passages are often unavoidably filled with blood, and it is necessary that the cough and swallowing reflexes should not be abolished. If this precaution be adopted, any anaesthetic may be given with safety. When nasal obstruction is present, before inducing anaesthesia it is necessary to insert a gag, or to place a small prop between the teeth to maintain a free passage through the mouth. When there is free bleeding, it is better to turn the patient over on to his side or face; this is preferable to the position with the head hanging over the end of the table. Sponges mounted on long handles must be at hand to remove blood from the pharynx. If, in spite of this, blood enters the larynx or trachea and causes obstruction, the patient should be at once inverted and the finger passed into the larynx to try and dislodge the clot. Of course tracheotomy instruments must always be kept ready.

Nasal Antisepsis. As already stated, the nasal mucous membrane proper is usually free from micro-organisms, and therefore it is worse than useless to apply irritating antiseptics before operating upon the healthy nose. Of course all the usual surgical precautions must be taken to avoid introducing infection from without. The instruments, the operator's hands, and any material used, must be sterilised as carefully as in operations upon other regions. The hygiene of the patient's surroundings must also be attended to. This is of especial importance, as it is generally impossible to apply dressings, and consequently the inspired air and all it contains passes directly over the wound. For this reason it is a great advantage to

operate in a good surgical home, unless the patient's home conditions are exceptionally favourable.

When pus or other discharges are present in the nose, true asepsis or antisepsis is out of the question. The surgeon must be content to cleanse the nose by syringing with boracic acid or some other non-irritating antiseptic solution. An efficacious means of removing crusts or pus is the application of a 20 per cent. solution of hydrogen peroxide on cotton wool pledgets. This solution rapidly loosens crusts, even the large masses found in ozaena. Septic troubles following operations on the nose are, however, very rare, even in these conditions. probably because of the free drainage which is provided. It is particularly important to allow this free drainage, and the nose should never be packed unless it be urgently required for the arrest of haemorrhage; should packing be inserted, it should be removed at the earliest possible moment, at least within 24 hours, and not replaced.

THE APPLICATION OF CAUSTICS.

The galvano-cautery is chiefly employed for the reduction of enlarged turbinates, for the removal of small growths, and for the arrest of haemorrhage. When applied to a swollen-as distinct from a hypertrophied-inferior turbinate, considerable shrinkage may follow a single application. Other indications for its use will be given later. The objection to the cautery is that it destroys a certain amount of the ciliated epithelium, and tends to produce dryness and crusting of the mucous membrane. Also, if the septum and the outer wall of the nose be by accident simultaneously

MAY

FIG. 37.HOVELL'S CAUTERY HANDLE.

injured and denuded of epithelium, the opposing raw surfaces are apt to come into contact when the reactionary swelling occurs, and adhesions may follow. The advantages of the cautery are, that its application is painless when cocaine is used, and the patient does not dread it, that there is no bleeding, and that the reaction after the operation is slight. It is a most valuable method of treatment when used in suitable cases and with discretion; but like other good methods, it has, undoubtedly, been used excessively, and has thus been brought into undeserved disrepute.

The instruments required are a cautery handle with several platinum points (see Fig. 37). The electric current can be obtained from

an

accumulator or battery, or better still, directly from the main current by means of a transformer. The nose should be anaesthetized with suprarenal extract and cocaine as above described. This solution, by rendering the mucous membrane anaemic and shrunken, widens the inferior meatus, enables the whole of the inferior turbinate to be seen, and lessens the risk of injury to the septum. The cautery may be applied superficially by means of flat points, or a sharp point may be plunged deeply into the tissues of the mucous membrane. The latter method-the so-called sub-mucous cauterization has the great advantage of not destroying much of the superficial epithelium, but it is apt to be followed by greater reactionary swelling and disturbances. Ultimately, however, considerable contraction takes place. The more usual method of superficial cauterization consists in drawing two or three parallel lines the whole length of the swollen turbinate. The exact method in which the cautery produces its effect when applied in this manner is unknown, but it seems certain that if swelling only of the turbinate be present permanent shrinking out of all proportion to the actual destruction of tissue will ensue. Very little should be done on each occasion, as the action of the cautery occasionally spreads far beyond the actual limits to which it is applied, and much disturbance may follow. Small superficial sloughs form over the burnt areas, and separate generally about the 7th to the 10th day, when healing rapidly takes place. Sometimes these sloughs are thick and extensive, and if removed, re-form time after time. Healing may thus be delayed for from four to six weeks. For a few hours after operation a plug of wool may be worn in the nose. The best after-treatment is the introduction of an oily preparation such as the pigment. hydrarg. nit. (see formula 23) or of simple lanolin. The lanolin should be gently warmed until fluid and then applied to the interior of the nose with a small brush or wool mop and sniffed up as far as it will go. In this way it forms a protective coating to the injured surface. If there is much discharge, an alkaline lotion may be used for two or three weeks. There is little danger of bleeding if the cautery be used gently and not at too great heat. Adhesions are often spoken of as a serious-almost an unavoidable risk, but they will never occur if care be taken to avoid simultaneous injury to the septum and inferior turbinate.

Although the cautery is so useful a means of reducing swelling of the inferior turbinate, it should never be applied to the middle. The mucous membrane in this region is intimately blended with the periosteum: periostitis and osteitis are very liable to follow its application, and to aggravate the mischief for which it was applied.

Caustics. When the galvano-cautery is not at hand chemical caustics, such as nitric acid, trichlor-acetic acid, chromic acid, or nitrate of silver may be used. The two last are best applied as beads fused upon the point of a probe. Trichlor-acetic acid or solutions of chromic acid may be applied with small pledgets of wool on a probe; nitric acid must be used with small wooden sticks or glass brushes. A little cocaine may