The causes of epistaxis are both local and general. Among the local causes may be included traumatism, either from blows or other injuries, attempts on the part of the patient to relieve irritation by picking the nose, or from the {51} use of cutting or other instruments in the hands of the surgeon. Septal ulcerations in this way are often accompanied by moderate bleeding. In a case reported by R. G. Curtin the nasal branch of the ophthalmic artery was thought to have been ruptured. Among the general causes the most frequent is undoubtedly the depressed state of the system preceding or accompanying typhoid and other anæmic states. Thus, among the prodromes of typhoid fever epistaxis holds a conspicuous position. It is also seen in chlorotic females, especially in those suffering from that phase of anæmia known as Grave's disease. It also occurs in vicarious menstruation and in local facial or encranial congestions. In those disorders of nutrition accompanied by a tendency to capillary extravasation, such as purpura and scurvy, the nasal mucous surface participates in the general disorder. In a case of the former disorder coming under the notice of the writer the blood had forced its way out in large quantities by every capillary avenue. TREATMENT.--Epistaxis when a symptom of a dyscrasia is of course to be treated as a local expression of a general condition. In typhoid fever, scurvy, and purpura or anæmia the bleeding is a sign of the general distress, and requires no special local method of treatment. Epistaxis when of local character should be treated, first, by removing the cause; second, by diminishing the flow of blood to the part; third, by cold and astringent washes to the affected surface; and, fourth, by compression.