be first applied to the nose, but the applications are not very painful as a rule, and are followed by very little reaction. Their action is, however, a little more uncertain than that of the galvano-cautery, and it is more difficult to limit. For this reason the galvano-cautery should usually be given the preference. If caustics are used, nitric acid is probably the best. After it has been applied its action may be arrested by mopping the nose with pledgets of wool soaked in a weak solution of bicarbonate of soda. The after-treatment is the same as when the galvano-cautery has been used.

Electrolysis is very rarely used in the nose, but has been employed for the removal of tumours and septal growths. Quite recently it has been recommended in the treatment of atrophic rhinitis. If used in the latter affection one needle should be inserted into the inferior turbinate and the other into the septum. A current of 30 to 40 milliamperes may be allowed to pass for 5 to 10 minutes: if pain be produced a weaker current should be used. When applied to tumours considerable reduction in size will take place, provided the tissues are soft. When a tumour contains cartilage or bone, as in spurs or crests of the nasal septum, a much longer time and more applications are required. The method is already falling into disuse.

Arrest of Haemorrhage. The bleeding after cutting operations on the nose is often profuse, but it is generally sufficient to let the patient lie down quietly and to apply cold to the face by sponging with cold or iced water. No attempt should be made to blow the nose; sneezing, coughing, or straining should be forbidden. All food must be given cold, and in the intervals the patient may be encouraged to suck ice. In more serious cases folds of lint wrung out of iced water may be applied to the face and frequently renewed: a small piece of ice may be occasionally introduced into the nose.

If these means fail, and the bleeding is profuse, it will be necessary to pack the nose. If the blood come from the anterior part of the septum it is sufficient to introduce a plug of gauze or wool into the affected nostril and to compress the nostrils with the finger and thumb. When the haemorrhage is not too profuse, it may be arrested temporarily by applying cocaine and suprarenal extract, and then the bleeding vessels may be sealed with the electric cautery. If bleeding comes from some other known area it is well to pack the spot with a strip of gauze. If the bleeding area is unknown or extensive, as after a somewhat large operation upon the nose, it is better to pack the whole nostril. The easiest and most effective method is to pass a finger through the mouth into the postnasal space, to introduce a long strip of gauze through the anterior nares, and to pack the nose tightly from behind forwards, the finger in the postnasal space preventing the gauze passing through the posterior nares. The disadvantage of packing is that the removal of the gauze is liable to be followed by renewed bleeding. It should be removed gently and slowly, whilst the nose is frequently douched so as to wash rather than to pull it

used (Fig. 38).

away. Instead of gauze packing, a Cooper-Rose's or Howard's bag may be This is a soft rubber bag which can be introduced into the nose and inflated in situ: it will be found a most effectual means of arresting haemorrhage. Plugging the post-nasal space with the aid of Bellocq's sound is happily obsolete. Whether gauze-packing or an inflatable bag be employed it should be removed within 24 hours, and the nose

cleansed, otherwise sepsis and constitutional disturbances are apt to occur. The following articles may be consulted:

WYATT WINGRAVE. (Nasal Douches.) Lancet, 1902, i. p. 1373.

BRADEN KYLE. (The Use of the Suprarenal Gland.) Therapeutic Gazette, 1902, 3rd series, xviii. p. 438.

GOLDSTEIN. (Post-operative Treatment.) Laryngoscope, 1902, xii. p. 729. Discussion on Post-operative Treatment. KREBS and others. Journ. of Laryngol., 1904, xix. p. 15.

Discussion on Post-operative Treatment. SEMON and others. Proceedings Laryngological Society of London, 1903, xi. pp. 1-41; Journal of Laryngol., 1904, xix. p. 22.

RETHI. (Post-operative Mishaps.) Archiv für Laryngol., 1896, iv. p. 403.

CHAPTER IV.

NASAL OBSTRUCTION, ITS SYMPTOMS AND EFFECTS.

OBSTRUCTION to the free passage of air through the nose is one of the most frequent and important consequences of nasal disease. The obstruction may be partial or complete, periodical or constant. In complete obstruction the patient breathes entirely through the mouth, and the condition is obvious. Partial obstruction may be easily overlooked unless the patient be closely observed or questioned, when it may be found that he breathes through the mouth once in every 3 or 4 respirations; or he may state that there is obstruction in one nostril only, that sometimes one side, sometimes the other is obstructed, but never both at the same time; or there is obstruction only at night or under certain conditions such as during exercise, excitement, etc.

When chronic nasal obstruction occurs at an early age it exercises deleterious effects on the neighbouring parts, on the general well-being, and on the development and growth of the whole body. The full consequences of nasal obstruction are most frequently seen in children suffering from adenoids. It is of great importance that these effects should be thoroughly recognised, for there is still much misconception with regard to them. The evils of nasal obstruction have been grossly exaggerated in some directions, and too much importance has been ascribed to quite trivial degrees of obstruction. Operations to relieve slight defects of which the patient was totally unconscious have been so frequently performed that the whole subject has been brought into disrepute. This is very unfortunate as the full significance of some results of nasal obstruction is perhaps even yet generally unappreciated. In discussing this subject I shall attempt to be as impartial as possible.

The symptoms resulting from nasal obstruction may be divided into the following groups:

(a) Snoring.

(b) Alteration of voice.

(c) Anosmia.

(1) Direct effects.

(d) Difficulty in breathing through, and in blowing the nose, and its

consequences.

(a) Loss of the nasal functions and its effects on the nose and neighbouring organs (see 2).

(B) The open mouth and its mechanical consequences (see 3). (e) Obstructed respiration during sleep, and its consequences. (a) Deficient oxygenation of the blood (see 4). (B) Deformity of the chest walls (see 5).

(2) Effects on the nose and on the neighbouring organs from loss of nasal functions, from mouth breathing, etc.

Liability to repeated colds: chronic nasal catarrh hypertrophic rhinitis. Post-nasal catarrh : adenoids.

Catarrh of the Eustachian tube and middle ear, acute and chronic. Dryness of the mouth, gums and tongue.

Early decay of the teeth.

Septic tonsillitis and pharyngitis.

Pharyngitis sicca and pharyngeal catarrh.

Laryngitis sicca and laryngeal catarrh.

Tendency to bronchitis and pulmonary affections.

Enlargement of the cervical glands.

General debility and ill health.

(3) Symptoms due to the constantly open mouth.

The typical facies.

Ill development of the upper jaw: high narrow palate: V-shaped alveolar arch crowded teeth.

Deformity of the nasal septum.

Collapse of the alae nasi.

Ill development of the lower jaw.

(4) Symptoms due to deficient aeration of the blood during sleep.

Restless and unrefreshing sleep disturbed by terrifying dreams.

Cyanosis profuse sweating.

Headache and languor in the mornings. Capricious appetite.

Impaired health and general malnutrition: anaemia and stunted. growth.

General stupidity and inaptitude for mental exertion.

General moroseness: nervous depression: "peevishness": or listless

ness.

(5) Mechanical results of the difficulty in breathing during sleep. Inspiratory retraction and, ultimately, deformity of the chest walls.

(6) Symptoms of reflex or obscure origin.

Nocturnal enuresis.

Hay fever and asthma.

Laryngeal spasm.

Laryngismus stridulus.

Congenital laryngeal stridor.

Persistent cough.

Stammering, stuttering, and other defects of speech.
Epilepsy. Epileptiform convulsions.

Chorea.

This last group and a few other affections are often described as results of nasal obstruction. In some of them nasal obstruction may be a more or less important factor in the causation, in others when present it is simply a coincidence.

It will be necessary to consider some of these symptoms in detail especially with regard to their probable mode of causation and their

treatment.

(1) Direct Effects. (a) Snoring is a very common symptom in children : it may occur during waking hours, and if the obstruction be marked is a constant feature during sleep. In adults marked nasal obstruction may exist and compel mouth breathing without any snoring whatever. Snoring in children is due to the passage of the air through the narrowed nostrils, for it has been found that when a child is asleep and snoring vigorously with open mouth, the greater part or whole of the respiratory air is passing in and out of the nose. This observation can easily be verified by holding a few strands of cotton wool in front of the child's nose and mouth while it is asleep.

(b) Speech is curiously altered in the way so familiar as the result of an ordinary cold. The nasal resonance is partly or entirely cut off, consequently M, N, and the sound expressed by ING, are difficult or impossible to pronounce accurately. They are usually replaced by в and D. In addition to this there is a flat tone about all vocal sounds due to the diminished resonance space. The voice is usually said to have a nasal quality; this of course is just what it lacks. Other defects of speech are common in children suffering from nasal obstruction, but are not actually due to the shutting off of the nose (see later).

(c) Anosmia. The power of smell and in a less degree that of taste for flavours is lost or diminished. In some cases this may be due to the obstruction preventing the olfactory particles reaching the sensitive area, and in other cases to the associated nasal catarrh.

(2) Effects on the Nose and on the Neighbouring Organs. Children, and in a less degree adults, with nasal obstruction have a great tendency to repeated or chronic colds in the head. This is probably due to insufficient nasal drainage, the obstruction preventing