only one-half has a cutting-edge (Fig. 69). This instrument, pressing itself against the external wall, cannot slip like a plane chisel, and is bound to gouge out the projecting ledge. It is of service in the case of very broad diffuse tumefaction, especially when situated on the convex side of a nearly plane septum. It is, however, apt to cause perforation, which, in the writer's experience, has not proved a serious objection.

122. In the case of crests difficult to saw by reason of their sloping surface a very serviceable instrument is the trephine run by a motor with a dental handpiece. As it is difficult to hold this instrument steady, the writer uses it under the guidance of a sheath into which it fits closely (Fig. 70). This cylindric sheath has one half of its

FIG. 70.-Nasal trephine, with author's guarding sheath (two-thirds size).

periphery removed, so as to hug the ledge upon which the trephine is to act. When the crest consists of such hard bone that the trephine gets caught, a smaller one is first used within the same guard to perforate the crest longitudinally and weaken it thereby, whereupon the larger trephine easily cuts it away. Work with the trephine is much quicker than with the saw. It can be used, too, to good advantage in order to reach up to the rear end of crests extending up to the sphenoid surface. As the entire width of the trephine is only 8 mm., it can merely cut a groove with a radius of about 4 mm. In the case of broad ledges the guard is withdrawn after the first cut and reapplied slightly turned, so as to inclose now the balance of the tumefaction, which a second action of the trephine thereupon re

moves satisfactorily. The only objection to the trephine is that the wound made by it is concave, and its healing is more likely to be delayed by crust-formation than the plane wound made by the saw.

Lateral ledges and spurs limited to the cartilaginous portion can be cut off smoothly with a sharp knife.

When the contour of a crest has so gradual a slope -for instance, on the convexity of a curved septumthat it is difficult to apply the knife properly, the spokeshave which cuts backward can often be substituted advantageously (Fig. 71). The instrument is pushed in until its cutting-edge surrounds the spur from the rear.

FIG. 71. The spokeshave in two sizes. The third knife, in the shape of an incomplete ring, is used when a total stenosis hinders the introduction of the other forms. Universal handle for nasal instruments (one-half size).

On pulling it out with the necessary strength while keeping it pressed against the septum even hard bony crests can be abscised thoroughly in one sweep without danger of accidental injury. The same instrument may be used to smoothen uneven wounds made by any other mode of operation.

123. The wounds made by these various modes of operation heal kindly, as a rule. The hemorrhage may persist for hours, but is not serious. An aseptic healing cannot be guaranteed, but is usually obtained, especially as long as the passage is evenly packed with iodoform gauze. Where the patient had previously not been able to breathe through that side of the nose, this packing is

not complained of. But most patients without previous complete stenosis prefer the slower healing with unobstructed passage to the advantages gained by a gauze tampon. The best but still not absolutely reliable substitute for iodoform gauze the writer has found in glutol, which adheres quite well to the wound. Other powders, like iodoform or any of its substitutes, do not stay in place at all, but are washed away by the watery secretion of the wound. With open treatment surgical wounds of the septum do not usually suppurate, and practically never ulcerate. The healing, especially if the wound is not even, is apt to be delayed, however, by the formation of crusts. As long as no infection has occurred these wounds are painless. When they become inflamed, dull pain is sometimes referred to the teeth, or described as a diffuse headache. Slight fever may be observed in such instances for a few days, but the wound, as a rule, does not show the infection by any altered appearance except slight swelling of its edges. Occasionally infection leads to tonsillitis on the same side, which may later on pass to the other tonsil.

124. As a substitute for bloody operations electrolysis of cartilaginous ledges has been recommended by various writers. Two needles connected with insulated conducting cords are inserted into the septum prominence, and an electric current up to the strength of about 25 milliampères is gradually turned on. This current, requiring a battery of 20 to 30 cells, is continued for five to ten minutes, and then is again gradually turned off. Any sudden increase or diminution in the strength of the current causes a very painful shock. As the negative pole is the active one, the positive pole may be used in the form of a large external sponge instead of a needle in the septum. This procedure has no influence upon bony crests, but it does cause a gradual shrinkage of cartilaginous prominences. If the effect is insufficient, it may be used repeatedly at intervals of about two weeks. It is, however, painful, and the inflammatory reaction fol

lowing it always lasts several weeks, and sometimes leads to localized necrosis of the cartilage with perforation. Moreover, it is not always efficient. Its indication is hence to be restricted to the case of flat, diffuse tumefactions in very narrow noses in which surgical instruments cannot be used satisfactorily. It is certainly not a desirable substitute for any other feasible operation.

The galvanocaustic burner can be recommended as a more satisfactory measure for the reduction of smaller prominences on the cartilaginous septum. It is not a substitute for a clean cutting operation when the latter is mechanically feasible. But narrow crests which encroach sensibly upon the caliber because they happen to be situated on the convex side of a moderately bent septum can be completely removed by a number of multiple punctures or a few linear incisions with a knife-shaped white-hot burner. The wounds heal in two to three weeks without unpleasant reaction, and the cicatrization causes enough shrinkage to clear the passage.

CHAPTER XVII.

EPISTAXIS HYDRORRHOEA NASALIS.

EPISTAXIS-NOSEBLEED.

125. Bleeding from the nose may depend on various intranasal lesions or different systemic disturbances. As a matter of convenient reference it is well to summarize these different conditions under one head. The loss of blood from the nose may vary from a mere trifle to a flow alarming by its persistence. Yet there are probably no immediate fatal results on record, as the hemorrhage usually stops in the end by reason of fainting. The frequent recurrence of bleeding may, however, cause serious anemia and lessen the resisting power to other diseases.

The most common lesion causing nosebleed is ulceration of the septum in the anterior inferior region immediately behind the pyriform aperture, the ulceration being the intermediate stage between anterior dry rhinitis and perforating ulcer (¶ 75). If the health is otherwise good, the bleeding from this lesion is generally not copious. When the bleeding spot can be seen, the hemorrhage can be checked by cauterization with a bead of nitrate of silver or a cotton pledget containing (melted) trichloracetic acid. The galvanocautery presents no advantage over chemical cauterization. Either measure may fail for the time being and packing may prove necessary. A comparatively rare lesion, but one which bleeds freely, is the "bleeding polypus of the septum" (¶ 237). Its site is above the usual location of the septum ulcer. It appears as a small, red polypoid tumor, bleeding freely on touch. If well accessible, it should be snared radically, otherwise its base should be completely cut through with the galvanocaustic burner.