procedure, and is practised as follows: The patient is placed in
position as for laryngoscopy, and the light directed upon his face so
that the centre of the circle of reflection from the head mirror falls
upon the tip of the nose. The examiner then elevates the tip of the
nose with his left hand, resting the fingers on the forehead of the
patient, and lifts the ala away from the septum with a slightly bent
probe, when he will be enabled to see a considerable distance into the
nasal cavity. It is, however, better to employ a speculum instead of
the bent probe, because the parts then are seen in their usual relation
to each other, and are not distorted by the forcible traction necessary
when the probe or a dilator is employed. The nasal speculum (Fig. 12)
is best made of hard rubber and shaped like the ordinary ear speculum,
except that the narrow end is oval instead of round. This instrument is
to be introduced by a sort of rotatory motion until the end has passed
the edge of the vestibule, when it will remain in position, displaying
the interior of the nose. Great care should be exercised, when
introducing the speculum, not to scratch the mucous membrane of the
septum, for this will give rise to pain and start hemorrhage, both of
which are to be avoided as much as possible. When applications are to
be made to the mucous membrane of the septum or turbinated bones, or
when operations are to be performed within the cavity, it is best to
employ an instrument called a nasal dilator, of which there are a large
number of different forms, the most satisfactory of which is shown in
Fig. 13. The dilator is introduced by compressing the blades between
the thumb and fore finger, and pushing them into the nostril until
their ends have passed the edge of the vestibule. The pressure is then
removed, and the spring separating the blades holds the nostril open;
the handle or stem of the instrument, hanging down, need not be held or
supported, as the blades press sufficiently upon the tissues to retain
the instrument in position. If the pressure is too great, however, it
will soon produce pain, and the patient will object to the use of the
instrument.
[Illustration: FIG. 12. Nasal Speculum.]
[Illustration: FIG. 13. Bosworth's Nasal Dilator.]
The view obtained both by the speculum and the dilator is rather
limited, and usually comprises only the anterior portions of the lower
and middle turbinated bones, together with the cartilaginous portion of
the septum. In order to get a good view of the lower and middle meatus
and of the floor of the nose the patient's head should be inclined
forward or backward as occasion requires. The student should, however,
not be satisfied by simply inspecting the parts, but should aid the eye
by the sense of touch, for pathological changes are of common
occurrence, and their nature, whether soft and fleshy or hard and bony,
erosions of the mucous membrane, or deep ulcerations, can often only be
determined by the aid of the probe. In the same manner can the
permeability of the meatuses be determined better than by inspection
{37} only. In cases where it becomes necessary to determine whether the
anterior portion of the septum is of normal thickness, or whether a
projection seen through the speculum is due to localized deflection, an
instrument called the septometer is of great assistance (Fig. 14). This
instrument is similar to the one used by mechanics to determine the
diameter of a piece of wood or iron being turned on the lathe. In using
it the long straight shanks are introduced one in each nostril, and,
being closed upon the septum, the rounded points are gently moved up
and down and backward and forward over the bulging portion of the
septum. The motion of the index attached to the curved shanks of the
instrument accurately indicates the relative thickness of tissue
grasped between the points in the nose. By means of this instrument we
can thus ascertain whether we have to deal with a deviation or a
localized thickening of the septum; for if it is a deviation the index
will move but slightly, while it will travel a considerable distance
when the points pass over a thickened portion.
[Illustration: FIG. 14. Septometer for Measuring Thickness of Nasal
Septum.]
Although simple in its details, anterior rhinoscopy is often made
difficult or altogether prevented by obstacles which are mostly due to
malformation of the parts, such as deviation of the cartilaginous
portion of the septum, exostoses from the superior maxillary bones
reaching into the nasal cavity, adhesion between the anterior portion
of the lower turbinated bone and the septum, nasal polypi, anterior
hypertrophies of the mucous membrane, and so forth; or they may be due
to faulty instruments, as too much pressure in the spring of the
dilator; or, finally, they may be caused by want of care in the
handling of the instruments, as when the septum is scratched by the
edge of the speculum and hemorrhage ensues.
POSTERIOR RHINOSCOPY.--Posterior rhinoscopy is much more difficult than
laryngoscopy or anterior rhinoscopy, and requires more patience and
dexterity on the part of the examiner than either of the former,
because but very few persons have control over the movements of the
velum palati, and in most of these the upper portion of the pharyngeal
wall is so sensitive that the slightest touch with an instrument gives
rise to reflex cough and to gagging. In many cases, however, with
patience and skill the naso-pharyngeal cavity and the posterior portion
of the nasal cavities can be illuminated and inspected. To do this the
patient is placed in the same position as for laryngoscopy, except that
the head is not inclined backward, and after the mouth is opened as
wide as possible the light from the reflector is thrown into the oral
cavity. The tongue is then depressed with a tongue depressor. This
instrument in its simplest form in which it is daily used by the
practitioner for examining the fauces is the handle of a spoon. For
laryngoscopic or rhinoscopic purposes, however, the spoon is not to be
recommended, because the hand holding it must be on a level with the
mouth, thus obstructing the view and light. An instrument has therefore
been constructed which obviates this difficulty. It consists of a
leaf-shaped blade of silver or German silver bent at right angles and
inserted into a flat wooden handle. The lower surface of the blade is
slightly concave, and ribbed so as to take a better hold of the
slippery back of the tongue, and from the bend is about 3 inches in
length. It is introduced into the mouth as far back as possible, and
pressed upon the back of the tongue while the hand of the examiner is
below the chin of the patient. For the sake of convenience in carrying
the instrument the blade has been so hinged to the handle that it will
fold up against the latter and will {38} open at a right angle with it
(Fig. 15). A more elegant and lighter instrument of the same
description has lately been introduced in which the handle is also made
of metal, and, like the blade, is heavily nickel-plated, and which when
folded can be carried in a pocket-case. Soon, however, the metal tongue
depressor becomes tarnished by the secretions of the mouth or by the
substances used for applications to the throat, and then presents an
appearance disgusting to many patients, who will not on that account
submit to its use. For the sake of greater cleanliness, J. Solis Cohen
devised a tongue depressor made of hard rubber, which is known as
Cohen's tongue depressor (Fig. 16). It consists of a piece of ebonite
bent upon itself, either end being a little over 3 inches long. The
bend being more than at right angles, the hand holding the instrument
rests underneath the chin of the patient; but if a different curve be
desired for any particular case it can easily be obtained by placing
the instrument for a little while in hot water. When soft it can be
bent into any shape, which it will retain when cooled by immersion in
cold water. Great care should be exercised not to carry the blade of
the instrument too far back, as then gagging will at once set in. In
cases where the tongue resists the pressure of the tongue depressor, it
is better to exert but a gentle pressure upon the back of the organ,
under which it will slowly recede, than to try to subdue it by force,
for in the latter case it will unavoidably slip from under the blade of
the instrument, and the desired space in the fauces is not obtained.
With children the writer has found the fore finger of the left hand to
be the best means of depressing the tongue, for the little patients as
a rule have a horror of the formidable-looking instrument.
[Illustration: FIG. 15. Folding Tongue Depressor.]
[Illustration: FIG. 16. Cohen's Tongue Depressor.]
After the tongue has subsided into the floor of the mouth a small
laryngoscopic mirror is introduced into the pharyngeal space behind the
velum palati, with the reflecting surface upward, and is held there
without touching the wall of the pharynx. The handle of the mirror, as
in laryngoscopy, is brought into the angle of the mouth, so as to be
out of the line of vision. As is usually the case, the velum palati at
the approach of the mirror will rise and apply itself to the posterior
wall of the pharynx, when of course the naso-pharyngeal space, being
shut off, cannot be illuminated. Under these circumstances the velum
must be made to hang down as in the act of nasal respiration, which is
most easily accomplished by telling the patient to breathe through his
nose. It is of course impossible to do so when the mouth is open, but
the patient, not being cognizant of the fact, will make the attempt,
and the palate will come down, permitting illumination and inspection
of the naso-pharyngeal space and the posterior nares. In those cases in
which this {39} expedient fails it becomes necessary to forcibly pull
down the velum by means of a blunt hook made by bending a silver
laryngeal probe, or to tie it down by passing small elastic bands
through the anterior nares and bringing the ends through the mouth and
tying them over the upper lip. The smallest black rubber tubing is
admirably suited for this purpose, as it can be introduced without an
instrument. When the palate is pulled down with the palate hook, or
when operations in the naso-pharyngeal space are to be performed, the
patient must hold the tongue depressor himself, so as to leave the
other hand of the operator free. Few persons can do this, however,
satisfactorily, and it will be found more convenient to use Jarvis's
tongue depressor and rhinoscope, as modified by the writer (Fig. 17).
The instrument consists of a stout wire, which, after having been
forked or divided at some distance from its insertion into the handle,
forms the loop for the tongue depressor. The two branches then cross
each other, and are bent to form another loop at an angle to the larger
one. The ends of the wire are somewhat flattened and press against each
other, thus closing the smaller loop and forming a sort of pincette,
which can be opened by pressing the sides of the larger loop toward
each other. The ends of the pincette are perforated by a small hole,
which receives a pin attached at right angles to the short shaft of a
small mirror, thus forming a hinge, so that the mirror can be placed at
any desired angle with the handle or stem. The spring of the pincette
cannot be made strong enough to prevent a change of the angle of the
mirror by coming in contact with the pharyngeal wall, and therefore a
ratchet was placed at the shaft of the mirror where it hinged to the
end of the pincette, and a small steel spring, coming from one of the
branches of the wire where they cross each other to form the small
loop, by engaging in the teeth of the ratchet holds the mirror at the
angle given to it before introducing. The large loop acts as a tongue
depressor, so that with this admirable instrument the examination of
the post-nasal cavity can be made with one hand, leaving the other free
for the manipulation of other instruments. In order to be able to exert
more pressure upon the tongue and to bring the hand out of the line of
vision, the handle may be attached to the stem at an angle like the one
in the folding tongue depressor. Except in cases of cleft palate the
naso-pharyngeal cavity cannot be illuminated in its whole extent, and
must be studied in parts, which when placed together in the mind of the
examiner form the rhinoscopic image, a slightly diagrammatic drawing of
which is seen in Fig. 18.
[Illustration: FIG. 17. Jarvis's Rhinoscopic Mirror and Tongue
Depressor.]
[Illustration: FIG. 18. RHINOSCOPIC IMAGE. 1. Vomer or nasal septum. 2.
Floor of nose. 3. Superior meatus. 4. Middle meatus. 5. Superior
turbinated bone. 6. Middle turbinated bone. 7. Inferior turbinated
bone. 8. Pharyngeal orifice of Eustachian tube. 9. Upper portion of
Rosenmüller's groove. 11. Glandular tissue at the anterior portion of
vault of pharynx. 12. Posterior surface of velum.]
THE RHINOSCOPIC IMAGE.--In the middle of the drawing we see a
triangular plate with its apex downward; this is the posterior margin
of the vomer or nasal septum. On either side we notice curtain-like
folds projecting against the septum; these are the posterior aspects of
the turbinated bones. On either side of these and on the margin of the
drawing we notice pointed elevations projecting toward the interior of
the cavity, with a crater-like {40} depression on their apices; these
are the lateral pharyngeal walls with the orifices of the Eustachian
tubes. Above we see the vault of the pharynx, and below the posterior
surface of the velum palati with the uvula.
Another method of examining the laryngeal and naso-pharyngeal cavities,
which is especially valuable in cases where neoplasms or impacted
foreign bodies hide the parts forming the laryngoscopic and rhinoscopic
images, is by means of digital palpation. Even where no obstruction is
present the beginner will do well to resort to this method in all
cases, for he will thus become better acquainted with the topography of
the parts than by inspection only. The procedure is not as difficult
nor as disagreeable to the patient as might be imagined, and needs but
little description.
When the laryngeal cavity is to be examined by palpation, the head of
the patient is thrown back, and steadied in that position by the left
hand of the examiner while he introduces the index finger of the right
hand into the mouth and slides it along the back of the tongue until
the tip comes in contact with the upper margin of the epiglottis.
Passing downward along its lateral margin on either side, the
ary-epiglottic folds and the tips of the arytenoid cartilages can be
felt, and likewise the upper surfaces of the ventricular bands. The
vocal cords are, as a rule, too low down to be reached by the tip of
the finger. An examination of this kind should of course be made
quickly while the patient is holding his breath, so as not to obstruct
respiration too long, which in cases of narrowed glottis by neoplasms
might give rise to serious results. When the naso-pharyngeal space is
to be explored by the finger, the patient's head is bent forward, and
the index finger is gently pushed upward between the velum and the
pharyngeal wall. When this is accomplished, the velum is drawn forward
and the finger pushed along its posterior aspect until the different
portions forming the rhinoscopic image are reached and explored by the
sense of touch.
{41}
DISEASES OF THE NASAL PASSAGES.
BY HARRISON ALLEN, M.D.
Coryza.
Coryza is an acute inflammation of the mucous membrane of the nasal
chambers. The disease is ordinarily idiopathic, but may be produced by
irritative vapors, pollen, or dust. In the idiopathic form the symptoms
of coryza are often preceded by malaise, with chilly sensations, and in
severe attacks with headache. The attack itself is divided into two
stages: that of determination or congestion, and that of exudation. In
the first stage the excessive quantity of blood flowing into the
arterio-venous network and the capillaries of the nasal mucous membrane
distend them and obstruct the nasal chambers.
The symptoms are referable either to such obstruction of nasal
respiration--in which group are included oral respiration, sensations
of distension, and throbbing in the nose--or to reflexes, such as
frontal headache, attacks of sneezing, and dull aching pain in the
teeth.
The first stage lasts for a period varying from a few hours to several
days, and is followed by the stage of exudation. This is characterized
by a free watery or mucoid discharge from the nasal chambers, and by
the cessation of the symptoms due directly or indirectly to pressure of
the layers of swollen mucous membrane against each other. The discharge
at first is watery, and is doubtless composed of transuded liquor
sanguinis. It is followed by a mucoid fluid, which in severe or
neglected cases may assume a purulent character. In many instances,
even in mild cases, the discharge becomes muco-purulent toward
recovery. The second stage is associated in children and adults of
delicate constitution with excoriations of the nostrils.
Suppuration may take place in nurslings and in old people. It would
appear that in coryza, as it exists in the northern countries of
Europe, the beginning of the second stage is apt to be marked by free
suppuration.
Acute coryza may involve the sinuses of the face, particularly the
maxillary sinus. The involvement of the frontal and sphenoidal sinuses,
while possible, is infrequent. Pharyngitis, laryngitis, and
occasionally acute aural catarrh, often coexist with the disease.
The symptoms of coryza are so distinctive that the diagnosis is easily
made. But since any obstructive or catarrhal state of the nose is
described by patients as a cold in the head, it is necessary for the
medical attendant to distinguish the various diseases so denominated.
Acute coryza may be confounded with angiose hypertrophy; with the
obstruction to nasal respiration due to deflection of the nasal septum
or to an inflamed soft polypus; with catarrhal irritation affecting
surfaces which are already enlarged by hyperplasia or which are
undergoing atrophy; or with the effects of operative interference in
the nose.
In angiose hypertrophy the swollen membranes will contract under a mild
{42} current of electricity or by change in the position of the body.
Both chambers are rarely involved at the same time. Reflexes are of
infrequent occurrence. Obstruction to nasal respiration due to a
deflected septum arises from causes which are insignificant and do not
affect the constitution. The genuine influenzal or catarrhal element is
absent. In an inflamed soft nasal polypus an attempt at inspiration
will, as a rule, detect the presence of the growth. In diffuse multiple
polypi the case is different. Many persons who are reputed to take cold
readily, or who may be said never to be free from cold, are really
sufferers from neglected polypi. Persons suffering from atrophic
catarrh always speak of an exacerbation of their symptoms as a fresh
cold, and describe the disease itself as a cold. The sense of fulness,
the throbbing, the heat, and the characteristic discharge of coryza are
absent. A fresh cold in atrophic catarrh is an attack of inflammation
(often catarrhal in character, it is true) which affects the involved
surfaces, but is attended with an increase of plastic exudation and
accompanying fetor.
It is a common occurrence for patients who have had a cautery
application made or a polypus removed to return after a few days'
absence with the report that they have contracted a cold. While the
condition may be an attack of acute coryza, the chances are in favor of
the symptoms being excited by the manipulation or the reaction from the
operation. The symptoms are mild in character.
TREATMENT.--The treatment of coryza is both local and constitutional.
The local treatment consists in applications of agents which tend to
constrict the vessels of the nasal mucous membrane. In the first rank
of such agents may be named cocaine, which in a 2 per cent. or a 4 per
cent. solution will often give notable relief by overcoming the sense
of obstruction. Individuals will be found in whom the effect is of
short duration, and in some persons I found the medicine to have no
effect whatever. In more favorable subjects the relief will be
acknowledged for a period varying from four to six hours. Next in rank
may be named a current of constant electricity (say from six to ten
cells) passed through the cheeks. Should neither of the above-named
agents be available, inhalations of iodine vapor, a few drops of
chloroform rubbed upon the palms and inhaled, or the inhalation of the
spirits of ammonia may be recommended. Toward the later stages of the
disease detergents and mild astringents are well borne. The
constitutional treatment includes the administration of diaphoretics
and minute doses of opium, especially in the early stages of the
disease. Coryza is commonly self-limited, and by far the larger number
of cases do not come under the care of the physician.
Chronic Nasal Catarrh.
Chronic nasal catarrh embraces those more or less persistent affections
of the nasal chambers whose symptoms resemble those of acute coryza.
The term catarrh is inexact. It is used to include several diseases
associated by a single characteristic--namely, the existence of an
increased amount of mucous secretion upon the affected membranes.
In order to understand the varieties of nasal catarrh, it is necessary
to have clear conceptions of the uses of the nasal chambers. The normal
performance of the function of respiration demands that when the mouth
is closed the currents of air should pass through the nose. These
currents, however, do not sweep over the entire nasal surfaces, but are
confined to those portions which answer to the inferior meatus and the
space bounded within by the septum, without by the median surface of
the inferior turbinated bone, and above by the under surface of the
middle turbinated bone. In the lower mammals this space is separated
posteriorly by a transverse bony lamina which {43} effectively excludes
the upper portion of the nasal chambers from the tract just named.
Anteriorly, at the termination of the inferior meatus and the middle
turbinated bone, the tract is in freer communication with the upper
spaces. The passage thus briefly defined may be called the respiratory
tract, and when it remains patulous no serious interference with nasal
respiration can occur.
The transverse diameters of the tract are subject to frequent changes,
owing to the erectile character of the mucous membrane in its walls.
But as long as the surfaces do not touch one another obstruction cannot
exist. The passage, even when narrowed to a chink or line intervening
between the median and lateral walls of the tract or between the floor
and the roof of the inferior meatus, is sufficient evidence that there
is room for the transit of the currents of air. The membranes
themselves are subject to changes in form which are dependent upon the
degree of development of their erectile tissue.
There is doubtless a disposition on the part of the erectile tissue to
grow in the direction of the least resistance, and thus to occupy, by a
process of compensative hypertrophy, the spaces left as the result of
variations or defects in development in the bones composing the
framework of the nasal chambers. The greater development of the
erectile tissue may in this way be found on the side answering to the
larger respiratory tract, which may therefore be more apt to suffer
from changes in the conditions of nasal breathing than the chamber
having the smaller tract. The erectile tissue acts as a monitor to the
throat and lungs by presenting warm surfaces over which the air passes,
thereby having the temperature raised before it enters the throat and
lungs. It also acts by occluding the chamber, and thus aids in shutting
out irritant vapors and dust. The lower animals possess a higher degree
of development of the tissue at the point where the adducted ala
presses against the septum. This point answers to the position of the
organ of Jacobson. With man, the locality of the adduction corresponds
to the junction of the premaxillary with the maxillary portion of the
nasal chambers, and is often the seat of a delicate band of mucus
extending across from the inferior turbinated bone to the septum.
That portion of the nasal chamber above the respiratory tract may be
called the olfactory tract. It does not appear to be involved in the
diseases under consideration, or, if it is, no clinical signs or
symptoms are presented with which the author is acquainted. It will
therefore receive no attention in this article.
For convenience the varieties of chronic catarrh may be classified as
follows:
FIRST VARIETY--that dependent on defective nasal respiration.
This variety is caused by--