Part 31

In polypus, the passage of air is obstructed, the patient feels as if labouring under a common cold—his head is stuffed: in cold and dry weather air passes through the cavity, though with difficulty; in a damp day the obstruction is complete. The tumour evidently increases, comes lower down, and even projects upon the lip. There is watering of the eyes, the lachrymal secretions being prevented from flowing into the nostrils; and, in cases of old standing, the patient is deaf, from the pressure of the tumours on the extremities of the Eustachian tubes. This latter symptom is not constant, but depends on the position of the tumours. I recollect an old gentleman, an elder of the kirk, afflicted with nasal polypus, who for thirty years had not heard his clergyman, though for twenty of these years he had attended service regularly, and from a sense of duty. On removal of the tumours hearing was perfectly restored.

The nose changes its form, is expanded and flattened. If the disease is extensive, and particularly if the tumour is malignant, the bones are separated, the eyes are protruded, and pushed outwards; indeed, the face is so distorted as to have been compared to that of a frog. Even in the benign form, when of long duration, great deformity of the features is produced, and the patient rendered very uncomfortable. Besides the symptoms already detailed, he suffers from acute pain in the forehead—he breathes loudly and with difficulty, particularly when asleep—he has lost the sense of smell, and does not relish food or drink—and there is often profuse discharge of a dirty mucous fluid, both externally and into the pharynx.

Soft mucous polypus may exist for many years, without depressing the palate, or projecting into the fauces. The anterior nasal cavity is its most frequent seat, and it widens and fills up the fissure between the anterior and posterior cavities: frequently it projects backwards, but is not visible, though it may be felt with the finger behind the soft palate. Its growth is slow. It may become malignant, as well as other adventitious structures equally simple; but such an occurrence is extremely rare. It may exist for many years; and, when at length removed, will be found of simple structure; and, if the operation be well conducted, no reproduction will take place. The tumours are supposed to be easily regenerated; but the truth is, that they are seldom eradicated completely. In general some are left, and these, emerging from the narrow space or cells in which they were confined, soon become fully developed—they expand, and speedily take the place of those which were removed. They can never be got rid of at one sitting: the operation requires repetition once and again; and of this the patient should at the first be made aware.

Malignant Polypi are met with in different degrees of advancement. Many are firm and fibrous, with an irregular surface and wide attachment—do not grow with great rapidity—furnish a sanious and bloody discharge, and give rise to painful feelings. If interfered with, their increase is accelerated. If removed completely, reproduction may not take place.

Tumours with broad bases, and of soft medullary consistence, attended with extensive change in the structure of the membrane, and softening of the bones and cartilages, grow very rapidly, fill the cavities and expand them, giving rise to great deformity, as seen opposite. They show themselves on the face, through the nostrils—protrude through the floor of the orbit—get into the mouth behind the palate, through the tuberous processes of the superior maxillary bone—or project through the alveolar processes. The discharge from them is profuse and fetid, and in some cases blood flows in no small quantity. Such growths usually commence in one or other of the sinuses connected with the cavity of the nose—sometimes, though rarely, in the frontal sinus. When seated in the antrum maxillare, pain is experienced in the cheek for a short time before swelling occurs. Soon the part enlarges, its coverings are thickened, the bony cavity expands, and the patient’s sufferings are excruciating. The teeth loosen, and sanious matter is discharged from their roots. The tumour extends into the nostril, and soon runs the course already mentioned. Malignant disease sometimes, though rarely, commences in the anterior cavity of the nostril.

No satisfactory cause can be assigned for the appearance of either the benign or malignant form of polypus.

The nostrils can be readily cleared of benign polypi, but seldom completely, as already stated, by one operation: in several cases, wherein only one or two tumours obstructed the cavities, I have had no occasion to repeat my interference. If the attachments are broad and extensive, a small curved blunt-pointed bistoury, or probe-scissors, may be employed for their separation. Sometimes the tumours can be pushed off by the finger, or by a probe with a blunt and forked extremity: then they either are blown out by the patient, or fall into the posterior cavity, thence into the pharynx, and are coughed up or swallowed. In cases such as are usually met with, forceps and a small vulsellum are the best instruments. The forceps should be about half the size of those generally used or sold by cutlers as polypus forceps. The patient is seated facing a good light and the body of the prominent tumour is laid hold of by the vulsellum; the forceps are then introduced, with the blades expanded, and carried backwards so as to reach its neck, which is then to be firmly grasped by the instrument, and gently twisted, so as to separate its connexions with the membrane. No force, no jerking or pulling, is allowable. It may happen, even with the gentlest and most careful management, that a small fragment of bone comes away along with the tumour; but this generally can or should be avoided: the cure is not rendered more certain by such an occurrence, as has been supposed. One tumour being thus detached, the same process is repeated with the others, till the cavity is cleared so far as hemorrhage or the patient’s fortitude will admit. Both nostrils, if, as is usually the case, both are stuffed, may be emptied at the first sitting, so as to enable the patient to blow through them. When the tumours filling the passage to the throat have been removed, so as to allow the ready egress and ingress of air, and when the forceps can be passed along the floor of the cavity, and are expanded and shut without meeting any obstruction, examination is to be made with the finger. In those who have long laboured under the disease, the fissure between the cavities is so much expanded as to admit the little finger easily, and by it the situation of the remaining tumours is ascertained, and instruments guided to them.

After the operation the nostrils are stuffed gently with lint, to prevent the access of cold air; and, if the hemorrhage be profuse, long pieces of lint pushed well back will generally be sufficient to arrest it: if not, the posterior cavity must be plugged from behind. It is prudent to prepare for the stuffing posteriorly in bad cases in which violent hemorrhage may be expected. Instruments with springs, &c., have been contrived for the purpose, but are useless, and cannot always be had. A loop of thin flexible wire, or of thick catgut, is passed along the floor of the nostril, and on reaching the throat is caught by the finger, or by a hook or forceps, and brought into the mouth. A piece of strong thread is then attached to the wire or catgut, and the latter is withdrawn; one extremity of the thread hanging from the nostril, the other from the mouth. To the middle of the thread a piece of lint rolled up to the size of the point of the thumb is affixed, and this is pulled back into the mouth, and directed into the posterior nares with the fingers; by the pressure of these, and by pulling at the thread, the dossil is firmly wedged into the aperture. Lint is preferable to sponge, as being more easily removed; sponge swells, and is apt to produce inconvenience. The plug must be well proportioned to the opening: if too large, it cannot be lodged in its situation; if too small, it does not fill it, and may be pulled through altogether. It should be smaller, of course, for young subjects and females than in adult males. It may be necessary to close both nostrils in this manner, when both are bleeding profusely, or when they communicate through an aperture in the septum. The anterior cavity is then closed with lint, and the hemorrhage, however violent, is completely commanded. The posterior plug is removed on the second or third day by pulling the oral extremity of the thread, and, if need be, by pressing through the nostril with a strong probe. Plugging may be required in epistaxis from other causes, when other means, as cold applied to the surface of the body, and astringent injections to the part, have failed. The latter remedy is not much to be depended upon.

The operation for polypus may be repeated when the parts have recovered, and the pain and discharge ceased. Ere then the patient again finds himself unable to propel air easily through the nostril, and, on examination, greyish, shining tumours are again visible. The same process of extraction is repeated until all are eradicated. Escharotics may be then applied with some advantage, but must be used with caution, and not of too active a nature: nitrate of silver and the red oxide of mercury are those commonly employed. But it is questionable whether these applications have any effect in preventing the future growth of the tumours.

The malignant form of the disease, even in a very early stage, is unmanageable: the tumours, if removed, are speedily reproduced, and the fatal termination may be accelerated by the interference. I have removed tumours from the antrum maxillare, and from the frontal sinus; but the parts became soon occupied by morbid growths of a more formidable character than the preceding: the membrane and bone appear to assume a disposition to generate such, and the fungous protrusions cannot be kept down with escharotics, nor with the actual cautery: nor, after free removal with cutting instruments, have escharotics, however freely applied, any effect in counteracting the inherent disposition to the disease, and preventing its recurrence.

The antrum, when filled with such tumours, is easily laid open. The cheek is divided perpendicularly from over the inferior orbitary foramen to the mouth, and the soft parts are dissected from off the bone. The cavity may then be exposed by means of a small trephine: but this instrument is scarcely ever required, the parietes being so softened as to yield easily to the knife: pliers or cutting forceps may be useful in enlarging the cavity. By the guidance of the finger, the attachments of the morbid growth are separated with a blunt-pointed bistoury; and a scoop is used to turn out the diseased mass. The root of the tumour is then touched with a red-hot iron, and by this implement, or by dossils of lint, the hemorrhage is easily arrested. But such operations, considering the result of those which have been practised, are scarcely justifiable.

It has been proposed for this disease to remove the tumour, along with its investment—to separate and dissect out the superior maxillary bone. It is a very severe operation, and one which puts the patient’s life in imminent jeopardy, from profuse hemorrhage or constitutional disturbance. In one case, the surgeon began the operation after having tied the common carotid of the affected side; but, having made the incisions of the cheek and palate, was obliged to desist, on account of the violent bleeding: eight days after, the common trunk of the temporal and internal maxillary was tied on the opposite side, and the incisions repeated, but the result was the same; the growth increased, and the patient perished. The disease is very insidious in its progress, and has gained much ground before the patient becomes alarmed and applies for surgical aid. The parietes of the antrum are expanded and softened; the tumour has projected behind through the tuberous process, upwards through the plate of the orbit, or inwards to the nostril; and has contaminated by its presence and contact all the neighbouring parts. Then removal of the maxillary bone, or of all the bones in that side of the face, can be of no service. The disease is seldom if ever seen by the surgeon early enough to admit of any operation being practised with the least chance of ultimate success. At a sufficiently early period, the removal of the bone—of the parietes of the cavity containing, and from which the tumour has grown, must without doubt afford a better chance, and is, in every point of view, to be preferred to the old operation described above of what was called trephining the antrum. In one case of soft and brain-like tumour filling the antrum, and evidently commencing there, I succeeded in removing the entire disease. The patient remained sound. I have more than once seen the operation performed for this soft and malignant growth of only some months standing; portions of the bone and tumour crumbled under the fingers of the operator—the operation was harsh, painful, and appalling—the cases hopeless. Execution of the manual part is not attended with serious difficulty, and it can seldom be necessary to tie arteries previously. To expose the bone, the cheek is divided from the angle of the mouth, to the origin of the masseter, and a second incision made from the inner canthus to the edge of the upper lip near the mesial line, detaching the alæ of the nose from the maxillary bone.

The flap of the cheek thus formed is dissected up, and the nasal process of the maxillary bone and the body of the os malæ are divided with a saw, or with strong cutting pliers. An incision having been made through the covering of the hard palate, near the mesial line, a small convex-edged saw is applied to the bone; and the alveolar process is cut through by the pliers, after extraction of the middle and lateral incisors. The bone is then pulled downwards and forwards, and its remaining adhesions separated by means of the knife or pliers. This last part must be accomplished rapidly, so as to reach the vessels, and arrest the hemorrhage. During the progress of the operation, cut branches of the facial and temporal are commanded by ligature or pressure, and the violence of the hemorrhage is moderated by compression of the carotids. After removal of the bone, the deep vessels, branches of the internal maxillary, are secured either by ligature, or by firm pressure with charpie or dossils of lint. The facial flap is replaced, brought together over the charpie by which the cavity is filled, and united by interrupted or convoluted suture. Cures by such proceedings, in such cases, are reported; the patients do not always die immediately after the operation; but there is reason to complain of want of candour as regards the ultimate result.

The disease, it is said, has been arrested by ligature of the common carotid; the allegation is not borne out by facts, nor is it easy to discover on what principle the practice was adopted. Such a result is not to be expected à priori, nor to be believed without farther trial; and these trials are not likely to be made.

The superior maxilla is liable to become the seat of other tumours beside the preceding. It may be occupied by fibrous tumour, commencing in the bone, or in the alveoli. The tumour feels hard, and very often not encroaching upon the antrum, is evidently circumscribed, and presents a smooth and botryoidal surface. It has not that disposition to involve neighbouring parts, hard as well as soft, but may remain long without extending farther than the superior maxillary bone, and occupying only a part of it. In such a case, excision of the maxillary bone is warrantable, and ought certainly to be performed; for there is no risk of the parts being extensively contaminated. I met with one instance of it in the latter situation a good many years ago. The patient was a female, about twenty-five years of age. The tumour was of four years’ duration, and its origin was attributed to a severe bruise of the cheek upon the corner of a table. The teeth had loosened soon after the injury, and the disease commenced in the gums. When she applied, there was a hard prominent swelling in the forepart of the maxillary bone, and a firm tumour involved the gums on the same side, and a part of the hard palate: the disease had made much progress during the previous six months, but had evidently none of the malignancy of the soft tumours which originate in, or early involve, the cavity of the antrum: at first it had possibly been of the nature of epulis. I removed the bone in the same way as already described, and had the satisfaction to find the disease completely taken away. The hemorrhage was restrained by compression behind the angle of the jaw during the incisions, and not more than ℥iii. of blood were lost. The tumour, when cut into, presented a homogeneous and fibrous appearance; at one or two points, softening had begun, and a small quantity of pus had been deposited. The external wound healed by the first intention, and the internal cavity granulated kindly. The patient remains perfectly free of disease, and bears little mark of so serious a disease or of so severe an operation. Within the last four or five years I have repeated the operation for this disease very often, and with uniform success. The cases are recorded in the Medico-Chirurgical Transactions, vol. xx., in the Lancet, and Practical Surgery, to which the reader is referred for further information on the subject. One of the tumours had attained an enormous size, and weighed nearly four pounds.

Of Inflammation, Abscess and Ulceration of the Nose, and Cavities connected with it.—Inflammation may be excited in the nose by external injury, as a bruise, or fracture, or displacement of the bones. The acute symptoms are swelling and discoloration of the integuments, turgescence of the Schneiderian membrane, which covers the septum narium and the turbinated bones, and consequent obstruction to the passage of air. Unless active measures are pursued, abscess follows, with great swelling and obstruction; and extensive loss of substance, with deformity, may ensue. Unless the acute symptoms, the short duration of them, and the rapid supervention of tumour be considered, the swelling may be mistaken for polypus.

The septum suffers more than other parts of the nose, from the concussion produced by a blow, and is in general more seriously affected by the morbid action which is induced. Matter is effused beneath the membrane, in one or both sides, usually in both, and tumours are thereby formed, which project into the cavities of the nostrils; when attentively examined, fluctuation is felt, and, if the affection has existed for a considerable time, the abscesses are found to communicate with each other, the septum having been absorbed or necrosed at one or more points. An individual received a severe blow over the extremity of the ossa nasi, and a slight wound was produced. The breathing soon became obstructed, by swelling in the nostrils, and great pain in the part was complained of. A large tumour formed on the septum, and completely filled the cavities; it was opened, and a great quantity of matter evacuated. The septum was destroyed by ulceration to a considerable extent, and a slight falling down of the middle of the nose followed. Such cases are of common occurrence.

Independently of any vice in the constitution, ulceration of the nostrils may be induced by injury, and proceed until great ravages are effected, if the treatment be not properly conducted. A young gentleman, playing at ball, was struck accidentally on the nose with the flat part of his companion’s hand. Inflammation took place, externally and internally, and the passage of air was obstructed, abscess formed, and the matter was evacuated spontaneously; extensive ulceration ensued; the cartilage and bone became affected, portions of them separated, and a bloody fetid sanies flowed from the nostrils. All the cartilaginous and part of the bony septum were destroyed; the morbid action ceased after having continued for a long time; but the organ was curtailed, sunk on the face, and altogether much deformed. In this case I first proposed, and some time afterwards performed for the first time, the operation for the formation of a new columna nasi from the lip.

The alæ, as well as the septum, may suffer from external injury, indeed the whole cartilaginous part of the nose may be destroyed.

Incited action must be subdued by abstraction of blood from the external parts, or from the Schneiderian membrane, leeches being applied in sufficient numbers, and repeated. Should suppuration not be prevented, the abscess, particularly when internal, must be early opened; the surgeon is, perhaps, somewhat to blame, if the patient, having been under his care from the first, sustains any deformity. If abscess has formed on both sides of the septum, each must be opened freely; afterwards hot fomentations are to be used, and the cavity should be frequently cleansed by the injection of a bland and tepid fluid.

Intractable ulceration of the nostrils is often induced by trifling irritations or injuries in constitution, either originally unsound, or rendered so by imprudent conduct; slight blows on the prominent part of the organ produce swelling with discoloration, and that is followed by abscess and ulceration. Internal ulceration is frequently caused by the continued use of snuff, or the presence of other irritating matters,—by irritation communicated from diseased gums or alveoli, or from decayed or crowded teeth, particularly the incisors of the upper jaw—by stumps in any part of the mouth, or the pivoting of artificial teeth on them—or by introducing the dentist’s perforator, with a view of destroying the nerve of a tooth. I have seen ulceration, and loss of substance in the skin, membranes, and bones of the face, arising from each and all of these causes.

The ulceration occasionally commences, even in young subjects, in a wart or fissure on the integuments of the nose or upper lip; it thence extends to the alæ and floor of the nostrils; the cartilages, and even the bones, are destroyed; the discharge is thin, acrid, bloody, and fetid, and the action is with much difficulty controlled. The disease is met with of various degrees of severity and malignancy; it may cease spontaneously, may appear to be arrested by constitutional and local treatment, or, resisting all means employed against it, may go on consuming portions of the face, both hard and soft; destroying the nose, lips, and eyelids, and ultimately the bones in their neighbourhood. Horrid cases are occasionally met with, in which scarcely the vestige of a feature is discernible—the patient is nourished, and life is often protracted for a long period, by food conveyed over the root of the tongue, through funnels or tubes. Noli me tangere, and lupus, are names applied to the advanced stages of the disease.

Ozœna, which denotes the internal ulceration of the nose, or rather the discharge indicating such, is generally of long continuance. The discharge is at one time profuse, at another scanty; sometimes it ceases almost entirely, but the accompanying fetor, of a most disgusting nature, is still perceptible on approaching the patient, or coming within the influence of the air expired over the diseased surface; the stench is particularly offensive when portions of bone are separating. The bones may die either from inflammatory action in them running high, or from being uncovered and deprived of support by ulceration of the investing membrane. In many cases, the disease is not arrested till the cartilaginous and bony septum, the turbinated bones, the hard and soft palate, and frequently the alveoli, are completely destroyed. The patient, if he live, is in a miserable plight;—his countenance is deformed and ghastly; the situation of the nose is occupied by a large dark and foul sore; the discharge is profuse and weakening; the expired air is as a pestilence to himself and those around; speech is almost unintelligible; breathing is difficult; the strength is gradually exhausted; and the spirits sink under the harrowing impression of misery. All these ills result more frequently from the injudicious employment of mercurial preparations than from any other cause. In almost every instance, the predisposition to such frightful ulcerations has been induced by the use of mercury, and can readily be traced to it. Exposure to atmospheric changes, during or after the exhibition of mercury, may render the mucous surface and the coverings of the bones more susceptible of the disease; that medicine may be given with the utmost precaution, but for long after the constitution cannot shake off its influence; and too frequently more of the poison is administered for disease produced by it. Ulceration of the tonsils, and other parts in the fauces, often coexist with disease of the nostrils.

Ulceration of the nostrils is arrested with difficulty. It cannot be expected to cease till dead parts have separated, become loose, and fall out, or are removed by art. Portions of the bones, forming the floor of the nostril, can often be removed, when dead, through ulcerated apertures in the palate; whilst others are brought away through the nostrils, there being generally sufficient space allowed for their discharge—the nasal cavities being laid into one by destruction of the columna, and more or less of the septum. Occasionally the ossa nasi, or parts of them, escape through an opening in the superimposed integuments; sometimes they cannot be discharged otherwise, as in the following case:—Matter had come to the surface over the nasal process of the frontal bone, an incision was made for its evacuation, sequestra were found loose, and some extracted; one was pushed down with the view of pulling it through the nostril, but this was found closed from the effects of small-pox.

Various applications to the ulcerated cavities are employed. Injections of spirituous and aromatic lotions are used to wash away the discharge and correct the fetor, as diluted tincture of myrrh, or of aloes, a lotion containing a proportion of kréosote the sulphate of zinc, solutions of the chlorides of lime or soda, &c. Applications, soothing or stimulant, are made to the exposed sores according to their appearance and disposition. When the ulcer is of an angry and irritable aspect, it is to be touched lightly with the nitrate of silver, in substance or solution, and then covered with a bread and water poultice. Fowler’s solution of arsenic is useful in some cases, when the object is to clean or destroy the surface; this is also effected by a slight application of the potass. A very manageable and efficient escharotic is the chloride of zinc. It is mixed with an equal quantity of dried plaster of Paris or flour, and made into a paste, with a few drops of water for application. Black wash sometimes agrees well, as also a liniment of olive oil and lime-water, with citrine ointment (three parts of the former ingredients to one of the latter), or the sulphate of zinc lotion. When the sore is very indolent, showing no signs of granulation, it may be touched occasionally with spirit of turpentine, either pure or combined with alcohol, and afterwards covered with an ointment composed of ung. ceræ and spir. terebinthinæ; under this application ulcers often heal, after having resisted all others. But nitrate of silver applied gently, and repeated at the interval of two or three days, will, in the majority of cases, be found the most efficient remedy, combined with the simple dressing of tepid water. Constitutional treatment must not be neglected. When the disease cannot be traced to mercurial action, small doses of the bichloride of mercury are allowable when excitement is required. The arsenical solution given internally sometimes produces good effects. In foul internal disease of the nostrils with cachexia, no medicine exerts so beneficial an influence on the general health and local disease, as sarsaparilla, exhibited either in decoction, in extract, or in powder.

Loss of substance, from ulceration or injury, is repaired by surgical operation. A portion of integument is borrowed from some other part, and by the adhesive process is made to cover and supply the deficiency. Such operations were contrived and practised by Sicilian and Italian surgeons some centuries ago, and were revived in our day in Germany. The integument was borrowed from the upper part of the arm; it has sometimes not been applied immediately, but detached gradually, and allowed to thicken, to change its consistence, and to become more vascular, previously to its adaptation to the mutilated organ. When considered sufficiently prepared, it has been shaped so as to fit accurately, though still remaining attached at one point to the arm; the cicatrized edges of the deficient parts should then be made raw, and the new substance affixed by suture; the original attachment is preserved entire, and the patient kept in a constrained position—the arm and head being approximated and bound together by apparatus—for many days, till union occurred. Then the flap is separated entirely, and the new nose moulded into its proper form, by subsequent paring and compression.

The Rhinoplastic operation, introduced from India—where from time immemorial it has been practised by one of the castes—has superseded the preceding, and is variously modified. It is less difficult in execution, not so liable to failure, and more easily undergone by the patient. The same preparation of the flap is not required, though it is said that the Indian operators are in the habit of previously pummelling, with the heel of their slipper, the integument to be used for the new nose, so as to excite the circulation, and produce thickening; from the similarity of texture in the integument of the face, its application to the new situation is not much observed.

The apex and alæ can be readily repaired by a flap of proper shape and dimensions from the forehead. The cicatrized edges where the nose formerly rested, must in the first place be dissected off pretty deeply, so as to be prepared for the attachment of the new appendage. The size of the lost organ, and the dimensions necessary for its replacement, are then to be taken into consideration. It is recommended to make a mould in wax of the part, and after flattening it out, to use it as a guide for the incisions. But a piece of card or soft leather is more convenient; this having been cut of the proper size and form, is laid down on the forehead, the part representing the root of the nose resting between the eyebrows. It is held firmly by an assistant, whilst the surgeon traces its dimensions first with ink, or at once with a knife carried deeply through the integuments. The pattern is then removed, and the flap dissected down, being laid hold with the finger and thumb, or with a hook. It is then twisted round, the lower part being left undisturbed. This attachment at the root of the nose may be narrow and long, so as to admit of its being twisted, but it is not to be cut thin; it must embrace the fibres of the corrugator supercilii, so that its vascular supply may be abundant. The incision on the side opposite to which it is proposed to make the turn may be brought a little lower than the other, so as to facilitate the twisting. After bleeding has ceased, the flap is applied to its new situation, and retained in apposition with the raw edges of the truncated organ by a few points of interrupted or convoluted suture; a little oiled lint is placed in the nostrils to support the flap, but no other dressing should be applied. To cover the part with pledgets of lint smeared with ointment, and adhesive strap, can answer no good purpose, and the subsequent removal of such must endanger the adhesion. The attention must now be directed to the wound of the forehead; the lower part is easily brought together, and retained by a stitch; thereby the whole surface is diminished, and what remains will soon be repaired by granulation. It is at first dressed merely with a pledget saturated with tepid water, afterwards some stimulating lotion may be gradually added. The operation should not be performed in very cold weather, and even in summer the patient should be enjoined not to leave his chamber. The lint may be removed in three or four days, and then, too, some of the stitches may perhaps be dispensed with. The flap will be found adherent, but loose, and raised by every expiration; very soon granulations rise from the inner surface, the part derives support from below, and becoming firm, preserves its form well. It will be necessary during the cure to keep the nostrils of their proper size and shape, by means of dossils of lint, or well-fitted tubes.