EPISTAX1S bleeding of independent origin is rather rare in young infants, but in older children on tbe other hand it is frequently habitual, and may be classed with the numerous school maladies, being favored by a stooping position, tight collars, etc. Slight traumatisms and picking the nose are the most frequent contributing causes in older children. Local diseases such as rhinitis, foreign bodies, ulcerations, and adenoids, often cause nasal htemorrhage. Severe infectious dis eases, typhoid fever, sepsis, scarlet fever, and diphtheria (in the latter disease without the nose being always affected) may be accompanied by haunorrhage. In severe cases of whooping-cough, the paroxysms are often accompanied by violent hmnorrhages from the nose. Of re mote diseases, cardiac lesions, severe anannia, general hannophilic dia thesis, are occasionally brought into play. In older girls, nose bleeding may occnr vicariously it the place of the menses. During early infancy, nasal htemorrhage is rare; in the nen-born it usually points to syphilis or to a general sepsis.
Symptoms.—The bleeding usually takes place from one nostril only, and usually subsides spontaneously. The loss of blood is usually less than the attendants believe. Profuse, debilitating htemorrhages occur usually only in the course of severe infections and in ha-morrhagic diathesis.
The diagnosis demands a knowledge of the cause, and, if possible, the site of the bleeding. For this purpose examination by means of the speculum is frequently required. In the vast majority of cases of habitual bleeding in older children, as in adults, the seat of bleeding is in the cartilaginous septum in front and below, therefore, at a point. where it may be readily surveyed. The mucous membrane at this point is very thin, well supplied with dilated veins and capillaries which easily rup ture. Frequently, a chronic catarrh in this situation (ritinitis anterior sicca) leads to brownish red, later n-mre grayish discoloration of this part, with firmly adherent crustaceous secretion. The dry, itching,
sensation causes the children to pick the nose whereby the thin dry sub jacent epithelium is often torn away and the blood vessels ruptured. After the cessation of the bleeding a small crust of blood is frequently seen at this place. Rarely does the bleeding take place from the floor of the nasal cavity or from the mucous membrane of the inferior turbi nate(' bone. it is then often impossible to find the bleeding point. If the nose bleeding occurs during sleep or in the recumbent posture, the blood often flows backwards through the nitres into the pharynx. Ex pelled by vomiting or coughing it sometimes is a source of alarm to the parents as "blood vomiting" or "blood coughing." Prognosis.—In severe infectious diseases and in hfemophilia, Inemor rhage may persist until a stage of exhaustion dangerous to life is reached.
Prophylactic measures consist ultimately in overcoming the aniemia, and in forbidding in school children stooped positions and the wearing of tight neck-ware. An ointment of lanolin with boric acid (byrolin), or with 1-3 per cent. of yellow oxide of mercury or white precipitate ointment, acts very favorably where there is a tendency' to bleeding from the anterior portion of the septum.
Treatrnentin mild cases, that do not frequently recur, is unnecessary. The usual popular remedies (cold compresses to the back of the neck, elevation of the hands) are of no avail, but have the advantage of caus ing parents and children to await with more patience the cessation of the bleeding which usually soon occurs. The snuffing up of cold water, or the introduction into the nose of small pieces of ice is often useful. Blowing the nose should be avoided. Haunorrhage, occurring as the result of severe overheating or cephalic congestion, often causes great relief. The child should sit before a basin with the head bent forward so that the blood drops into the vessel, and should he instructed to take deep nspirations by which the bleeding is usually caused to cease promptly.