and it is practically certain to leave a visible scar. The number of hairs which may be taken on one occasion naturally varies with the coarseness and distribution of the hairs; one may, however, take forty as an average number.

'After the operation is finished the patient may be given some lead or calamine lotion to cool the part, but nothing will hasten the healing of the damaged areas. The natural sequence of the after-effects is as follows: Immediately on the completion of the operation the part is somewhat red and shiny to the eye and hard to the touch, while there are numerous little yellowish dots indicating the mouths of the follicles. The œdema passes off in one or two hours, and the yellow dots dry up into scabs within the first twenty-four hours, forming dark brown crusts which show rather more than the original marks. These crusts fall off in about three days and the process is practically complete, with the exception of possibly a little redness. Patients differ a good deal in the rapidity with which their skins recover the normal appearance, and for those who have a tendency to pustular acne it is a safe plan to prescribe frequent dabbing with a 1 in 4000 perchloride of mercury lotion to prevent infection of the destroyed follicles. It is wiser not to exceed this strength, as sublimate lotions have a tendency to stimulate the growth of hair.

'From this it will be seen that the same area may usually be gone over twice in one week, but on no account oftener.

'If the electrode is not grasped until after the needle is well engaged in the follicle and is dropped before the needle is withdrawn, the pain is not great, and is usually described as irritating rather than severe. The chin is usually far less painful than the upper lip, and the centre of the latter is much more sensitive than the outer parts.

'It should be remembered that the patient would prefer to have a hair return, and let it be destroyed on another occasion, to being marked with a permanent scar. It is therefore wise to err on the side of too weak rather than unnecessarily strong currents. With care and experience, however, relapses should not be more than one per cent., even with the use of very moderate currents.

'It is, however, advisable in the case of young women, in whom the growth of hair is obviously progressive, to be careful in explaining that the treatment does not prevent the growth of hair in other parts of the skin, and that, until either all the hair is destroyed or the progressive growth stops, the treatment will have to be renewed from time to time.

'For the destruction of small hairy moles the method of procedure is almost identical. Owing to the fact that the hair is almost invariably stronger and that a scar must necessarily result from the destruction of the mole it is usual to work with a stronger current (five milliampères). All the hairs in the mole should be first carefully removed, and after a few days, if the mole has not been entirely effaced in the process of destroying the hairs, the needle may be run through it in various directions, and the

current passed until the whole growth looks white and distended with the gas. The result is a perfectly even, white scar, somewhat smaller than the original growth.

'When the patient demands an anæsthetic for these small operations, the following method of introducing cocaine through the unbroken skin by cataphoresis may prove useful.

'A ten per cent. solution of cocaine (the alkaloid itself, not the hydrochlorate) in pure guaiacol is used. A piece of clean blotting-paper is soaked in the solution and placed on the area to be anæsthetised, and a suitably shaped incorrodible electrode is placed on the top of it. This electrode is connected with the positive pole, and a current of about four or five milliampères passed for five minutes or so. Fifteen cells will probably be required at first, but the resistance soon diminishes, and then some may be switched off. A pricking sensation is felt at first, but this soon passes off, and is followed by complete anæsthesia to pain. The anæsthesia passes off in about a quarter of an hour. The only objection to this method is the penetrating odour of the solution. In rare cases anæsthesia is not produced at the end of five minutes, and it has been found to be advantageous in such cases to reverse the current after this time.'

MALIGNANT TUMOURS.

These form the most important group of tumours on the face, and may be either sarcomatous or carcinomatous in nature. The former present no special points of interest, and do not differ in any way from sarcomata elsewhere.

CARCINOMATA.-The face is one of the common seats of the slow-growing flat epithelial carcinoma so frequently met with in elderly people. This generally commences in some small pigmented seborrhoea. patch or in a pigmented mole, but it may occur without any antecedent disease of the skin. The treatment is very satisfactory; if it is removed freely, a perfect recovery may ensue with an insignificant scar. Glandular infection occurs very late in the disease.

Another form is the tuberous epithelial carcinoma, which usually starts at the junction of the mucous membrane with the skin, most frequently in connection with the lower lip. This form is referred to more in detail in connection with affections of the lips (see Chap. XXXIX.).

A third form of epithelial carcinoma frequently met with on the face is the so-called rodent ulcer. The characters of this growth have already been referred to (see Vol. I. p. 241). Its growth is usually extremely slow, but it may ultimately lead to widespread destruction of the bones, and cause the death of the patient by affecting the dura mater and so setting up septic meningitis, or by leading to hæmorrhage or to attacks of erysipelas. The treatment of this affection is dealt with in Vol. II. p. 23.

CHAPTER XXXVIII.

FRACTURES OF THE NASAL BONES.

THESE injuries are practically always caused by some form of direct violence; sometimes, however, they may be due to extension from a fracture of the anterior fossa of the base of the skull. Fractures occur more often in adults than in children, in whom the nose is more yielding; they are usually compound through the mucous membrane and not uncommonly comminuted. One bone alone may be broken, but usually both are fractured and may be separated from each other. The fracture may involve the nasal processes of the superior maxillæ and in badly comminuted cases usually also runs through the perpendicular plate of the ethmoid or the lachrymal bones. Lastly, the cartilages may be detached from the nasal bones, and it is not uncommon for bending or even dislocation of the cartilaginous septum to occur.

The deformity is greatest in cases of comminuted fracture, in which the bridge of the nose may be so depressed that it is difficult to replace the bones and to keep them in position. In many cases the nose is displaced laterally, while in others there is comparatively little displacement of any kind. The swelling is often so great as to mask both the displacement and the crepitus.

As a rule, these fractures are unaccompanied by complications, but when there is severe damage the following conditions may be met with :

1. Epistaxis.-Bleeding from the nose is constant, but is usually only slight. If, however, one of the larger vessels is ruptured, there may be considerable and persistent hæmorrhage, which sometimes necessitates plugging of the nostrils.

2. Emphysema.-Escape of air into the tissues about the orbit or the forehead and bridge of the nose is not uncommon, and is due either to injury of the nasal duct or to a free opening from the interior of the nostril to the cellular tissue outside. The emphysema is usually developed when the patient attempts to blow his nose. It generally subsides spontaneously and seldom gives rise to any trouble.

3. Epiphora.-Epiphora, or overflowing of the tears, usually occurs in connection with fractures of the lachrymal bone accompanied by injury to the lachrymal sac; it may also arise from fracture and blocking of the nasal duct.

4. Cellulitis and suppuration about the nose: this only rarely follows fracture of the nasal bones.

TREATMENT.-Apart from the question of the complications, fracture of the nasal bones calls for careful and immediate treatment, because, if left to itself, considerable deformity may result either from flattening of the bridge of the nose, or from lateral displacement of the organ nasal obstruction may also be produced. These deformities are difficult to remedy at a later stage, the worst being the displacement of the cartilaginous septum.

Of the Fracture.-In cases unaccompanied by displacement, little treatment is required; the application of an ice-bag externally, or even syringing the nose with ice-cold water to check the bleeding and effusion, will suffice. The patient must be cautioned against touching his nose or attempting to blow it; he often finds it difficult to resist doing this, because of the irritation set up by the fracture and the accumulation of blood.

If there is depression of the bridge or lateral displacement of the nose, it is essential to replace the bones as soon as possible, and for this purpose it is well to administer an anesthetic. It is not advisable to wait for the subsidence of the swelling or even for the hæmorrhage to cease, because repair takes place with extreme rapidity, and the deformity may be very difficult to correct unless it is treated at once.

Lateral displacement of the nose is readily remedied by pushing the nose back into position. A little manipulation over the bridge will usually get the nasal bones into their proper relative positions, after which the nose must be examined to see that the septum is in place; if not, it must be put right. When the bones have been replaced, there is no great tendency to subsequent displacement, and no appliance for keeping the bones in position is required as a rule. The patient should lie on the side opposite to that towards which the displacement has occurred, and a small ice-bag should be placed on this side of the nose; this will check the effusion of blood, and its weight will tend to keep the bones in position. The patient should be seen daily at first, and if the displacement should recur, it must be remedied at once. In five or six days the bones will be fairly firm, but the patient should still be forbidden to handle or blow the nose.

When the septum has been displaced, every effort must be made to remedy the displacement, but this is sometimes very difficult; as a rule, it does not occur in connection with lateral dislocation of the bone. some cases the septum can be pushed into position by introducing a narrow, thin spatula into the nose. In others, it is necessary to use

In

special forceps (see Fig. 201), by which the cartilage can be seized and forcibly twisted into position. In these cases the deformity is apt to recur, and means must be taken to prevent this. In some cases Lake's flat rubber splint (see Fig. 202) may suffice. In others, however, it is necessary to introduce rolls of gauze into the upper part of the nostril, and to keep

ALLEN & HANBURYS

FIG. 201.-FORCEPS FOR STRAIGHTENING THE SEPTUM. One blade is inserted
into each nostril.

them in place by hollow vulcanite plugs through which the patient can breathe (see Fig. 203). At the anterior ends of the plugs are holes for threads, which are fastened on the cheek with strapping. The packing must be renewed daily for the first four days, when it may be discontinued. The plugs should be taken out twice a day for cleansing, the nose washed

8

ALLEN & HANBURYS

FIG. 202.-LAKE'S NASAL SPLINT. The splint is made of rubber and is flat and of various sizes.

FIG. 203.-HOLLOW VULCANITE NASAL

PLUG.

out with saline solution, and the plugs covered with boric ointment and replaced. Should this method fail, it may be necessary to perform. submucous resection of the septum at a later date, in order to remedy the deviation.

In comminuted fractures with depression, the restoration of the bones is much more difficult, and their retention in position requires a great