of the septum and lateral wall. We use a very sharp flat knife and continue well up beneath the skin, dissecting the skin and subcutaneous tissue well above and to both sides of the area selected for our insert. Thanks to our hypodermic we have neither pain nor any great amount of bleeding. We then shape from one of the bones or cartilage fragments taken from the septum our insert, paring it with knife or scissors to required size and shape and inserting it with slender forceps. If necessary

we can superimpose one or more inserts till we entirely correct our deformity. Then one stitch and our operation is complete. In dealing with the hooked or exaggerated Roman nose, our After our problem is a different and more difficult one. sterilization, and anaesthesia, an incision is made along the border of the nasal process of the superior-maxillary bones in both nostrils. With sharp dissector we then elevate the entire tissue, including the periosteum, from the nasal bones clear up to the root of the nose and over the nasal processes of the superiormaxillary down to the cheeks; this to avoid wrinkles and redundant tissue after removal of the hump.

Where the cartilage is also included in the deformity another incision must be made along the edge of the septum parallel with the bridge of the nose. We then dissect away the membranes, and with scissors or curette remove strip of cartilage.

After our elevation is complete, by means of chisel, saw, rasp, or reversed chisel, an instrument I have found most useful, we remove the hump, carefully place our rubber tissue drains, and mould our soft parts into shape.

The long tipped nose can be remedied by removal of a triangular piece of cartilage and suturing up the membrane with two or three stitches on either side. Great care, however, must be used not to take off too much; error on the too little side can be readily handled by simply removing another small strip; applying the simple rule of "try and fit."

One very interesting case came to me about two years ago, in which there was congenital lack of any triangular cartilage.

The nose was broad and flat with no tip, but rather a rounded bulbous ending (a). We first did a submucous resection to relieve his nasal stenosis. Then we split the entire septal membrane, working from our incision forward clear to the columella. Then we attempted to insert a quadrilateral piece of the vomer,

с

but could not push out the nose to accommodate it, as we did not have sufficient material for a new columella. This we secured from the upper lip, as shown in the sketch (b); then elevated it into position and inserted the quadrilateral piece of vomer, giving him a nose of contour (c). It was still rather broad at the tip with nares very broad and quadrilateral in shape. A later plastic operation on both sides remedied to a large