SW%';'^',<:^;'<';s<:. Class Jff/^'^^ Book 3^^ Goip^ht! \'=]o^^' COPYRIGHT DEPOSIT. ^®.k%^^' i-^r-^^^c «]'>*' r"^ ,4'^ DISEASES NOSE, THROAT AND EAR MEDICAL AND SUEGICAI BY WILLIAM LINCOLN BALLENGEE, M.D. PROFESSOR OF OTOLOGY, RHINOLOGY AND LARYNGOLOGY, COLLEGE OF PHYSICIANS AND SURGEONS, DEPARTMENT OF MEDICINE, UNIVERSITY OF ILLINOIS; FELLOW OF THE AMERICAN LARYNGOLOGICAL ASSOCIATION; FELLOW OF THE AMERICAN LARYNGOLOGICAL, RHINOLOGICAL AND OTOLOGICAL ASSOCIATION; FELLOW OF AMERICAN ACADEMY OF OPHTHALMOLOGY AND OTOLARYNGOLOGY, ETC. ILLUSTRATED WITH 471 ENGRAVINGS AND 16 PLATES LEA & FEBIGER PHILADELPHIA AND NEW YORK 10 OS Two Copies rtecBtvju APR 2B 1908 OttpyriKfi envy ouAW '^ jo^C' «'^ 5OHY s,^ ^ Entered according to Act of Congress, in the year 1908, by LEA & FEBIGER, the Office of the Librarian of Congress at Washington. All rights reserved. PREFACE A NEW work, superadding itself to the already rich literature on the nose, throat, and ear, should justify its creation by some special features which may claim the attention of students and practitioners. Accord- ingly it may be said of the present volume, in the first place, that it includes the whole range of these three subjects, instead of dealing fully with the nose and throat, and only with the associated affections of the ear. It is no longer necessary to explain the advantages of considering these closely interrelated subjects together, since, obviously, they cannot be considered separately without missing most important connections. The relation of the eye to diseases of the sinuses is also introduced, though the significance of its relationship is not yet fully understood. Moreover, our knowledge of the inflammatory diseases of the nose and accessory sinuses, and of the throat and ear, has been increasing with such strides that the time seems to have arrived for presenting the subject on a new and higher plane. The causes of infection and inflam- mation of the cavities lined with mucous membranes are better under- stood, and it has accordingly become possible to give them in their true relation to the diseases. Instead of their mere enumeration, each has been discussed here with the purpose of showing its exact relation to the disease under consideration. The exciting causes are pathogenic bac- teria, while the predisposing causes are those extranasal and intranasal conditions which lower the resistance of the tissues. The numerous extranasal causes of infection and inflammation of the cavities of the nose and accessory sinuses have long been recognized. The intranasal causes of chronic inflammation of these cavities have not, however, been as well understood. The attempt has been made to show the effects of anatomical and pathological obstructions in the various portions of the nasal chambers upon chronic catarrhal inflammations of the nose, and upon chronic catarrhal and suppurative inflammations of the accessory sinuses. The advantage of this viewpoint is that it aft'ordsa more satis- factory explanation of the etiology and rationale of the treatment of infections and inflammatory diseases of all three regions. iv PREFACE The author has long beheved that surgical technique could be most clearly elucidated by describing each step of the various operations in numbered paragraphs, and by complementing them with suitable draw- ings. Nearly every operation is therefore illustrated, some with more than twenty drawings. About five hundred original drawings and plates have been thus used in the preparation of this work. The original sketches were made by the author, and were redrawn by Mr. James Kelly Parker, to whose intelligent cooperation much credit is due, and is gratefully acknowledged. An endeavor has been made to combine the advantages of a text-book and atlas, and, it is hoped, with a measurable degree of success. Tracheobronchoscopy and esophagoscopy have been brought to such a high degree of perfection, and the occasions for their employment are so numerous, that a fully illustrated chapter is devoted to their consideration. Before beginning this work, the author wrote to many of the leading specialists in the United States, England, France, Germany, Austria, Spain, Italy, Holland, Switzerland, Canada, and Russia, asking for reprints of their published articles. The response was most generous, and resulted in the accumulation of nearly three thousand monographs, which have been freely used in the preparation of this volume. With every wish to name each one who so liberally responded, it is obviously impracticable in a work of this character. The author has, however, endeavored to give due credit in the text for writings consulted. A debt of gratitude is also due to colleagues who have so graciously contril)uted to whatever of success this volume may attain. Grateful appreciation is also due to Dr. George F. Suker, Dr. Joseph C. Beck, and Dr. Mortimer Frank for their assistance in translations, and in the compilation of the material used in portions of the text, and also to Dr. Henrietta Gould and Miss INIary Regan for efficient attention to many minor but important details. Finally, to tlie publishers, with whom he has maintained most cordial r(>lations, the author expresses his thanks, not only for the physical appearance they have given to liis work, but also for many valuable aids and suggestions, which have both lightened and added confidence to his labors. W. L. B. 103 State Strekt, Chicago. CONTENTS. PART I. THE NOSE AND ACCESSORY SINUSES. CHAPTER I. THE CLINICAL ANATOMY AND PHYSIOLOGY OF THE NOSE AND ACCESSORY SINUSES 17 CHAPTER II. THE NOSE, THROAT, AND EAR IN RELATION TO GENERAL MEDICINE 29 CHAPTER III. THE OFFICE EQUIPMENT 40 CHAPTER IV. THE ETIOLOGY OF DEFORMITIES AND DEVIATIONS OF THE SEPTUM NASI 60 CHAPTER V. THE CHOICE OF SEPTUM OPERATIONS. THE SURGICAL COR- RECTION OF OBSTRUCTR^E LESIONS OF THE SEPTUM . 71 CHAPTER VI. THE ETIOLOGY OF INFLAMMATORY DISEASES OF THE NOSE AND ACCESSORY SINUSES 105 CHAPTER VII. THE PRINCIPLES OF TREATMENT OF INFL.AMMATIONS. THE MODALITIES FOR PROMOTING THE REACTIONS OF IN- FLAMMATION 117 CHAPTER VIII. THE INFL.VMMATORY DISEASES OF THE NOSE 130 CHAPTER IX. THE I.NDlNIDrAL SINUSES 163 CHAPTER X. GENERAL CONSIDKKA IIOXS IN REFERENCE TO THE SINUSES. 179 CHAPIKI! XT. THE SURGERY OV THE ACCESSOIJY SLNTSES 201 vi CONTENTS CHAPTER XII. NASAL NEUROSES. NASAL HYDRORRHEA. CEREBROSPINAL RHIXORRHEA 240 CHAPTER XIII. NEOPLASMS OF THE NOSE 254 CHAPTER XIV. EPISTAXIS (NASAL HEMORRHAGE). RHINOSCLEROMA. FURUN- CULOSIS. SCREW-WORMS 269 CHAPTER XV. THE SURGICAL CORRECTION OF EXTERNAL NASAL DEFORMITY 277 CHAPTER XVI. CHRONIC GRAXULOMATA OF THE NOSE, THROAT, AND EAR . 285 PART 11. THE PHARYNX AND FAUCES. CHAPTER XVII. DISEASES OF THE EPIPHARYNX AND BASE OF THE TONGUE . 313 CHAPTER XVIII. INFLAMMATORY DISEASES OF THE MESOPHARYNX AND FAUCES 334 CHAPTER XIX. THE FUNCTIONAL NEUROSES OF THE PHARYNX 346 CHAPTER XX. NEOPLASMS OF THE PHARYNX 350 CHAPTER XXI, DISEASES OF THE FAUCES AND. TONSILS 360 CHAPTER XXII. THE INFLAMMATORY DISEASES OF THE TONSIL 376 CHAPTER XXIII. THE SURGERY OF THE TONSILS 393 CHAPTER XXIV. NEOPLASMS OF THE TONSIL 415 CONTENTS vii PART III. DISEASES OF THE LARYNX CHAPTER XXV. INFLAMMATORY DISEASES OF THE LARYNX AND EPIGLOTTIS . 421 CHAPTER XXVI. PACHYDERMIA LARYNGIS. MALFORMATIONS AND DEFORMITIES. PROLAPSE OF THE VENTRICLES. STENOSIS. SUBGLOTTIC STENOSIS 475 CHAPTER XXVII. NEUROSES OF THE LARYNX 482 CHAPTER XXVIII. THE SINGING VOICE 499 CHAPTER XXIX. DEFECTS OF SPEECH 510 CHAPTER XXX. NEOPLASMS OF THF LARYNX 518 CHAPTER XXXI. FOREIGN BODIES IN THE LARYNX, TRACHEA, BRONCHI, AND ESOPHAGUS 548 PART IV. THE EAR. CHAPTER XXXIL THE CLINICAL ANATOMY AND PHYSIOLOGY OF THE EAR . . 567 CHAPTER XXXIII. THE FUNCTIONAL TESTS OF HEARING 583 CHAPTER XXXrV\ THE GENERAL ETIOLOGY OF DEFECTIVE HEARING .... 594 CHAPTER XXXV. FOREIGN BODIES IN THE EAR. CERUMIXOUS PLUGS IN THE MEATUS 600 viii COXTEXTS CHAPTER XXXVI. MALFORMATIONS AND NEOPLASMS OF THE AURICLE . . . .611 CHAPTER XXX\TI. DISEASES OF THE AURICLE AND EXTERNAL MEATUS ... 621 CHAPTER XXXVIII. MALFORMATIONS AND DISEASES OF THE MEMBRANA TYMPANI 637 CHAPTER XXXIX. THE DISEASES OF THE EUSTACHIAN TUBES 651 CHAPTER XL. THE PRINCIPLES AND METHODS OF TYMPANIC INFLATION . 659 CHAPTER XLI. INFLAMMATORY DISEASES OF THE TYMPANUM 670 CHAPTER XLII. HYPEROSTOSIS OF THE BONY CAPSULE OF THE LABYRINTH . 703 CHAPTER XLIII. ACUTE AND CHRONIC SUPPURATIVE OTITIS MEDIA. CHOLES- TEATOMA 708 CHAPTER XLIV. THE SEQUEL.E OF SUPPURATIVE OTITIS MEDIA, MASTOIDITIS, AND CHOLESTEATOMA. SUPPURATION OF THE LABY- RINTH 731 CHAPTER XLX. PRINCIPLES OF TREATMENT AND GENERAL CONSIDERATIONS IN SUPPURATIVE OTITIS MEDIA 740 CHAPTER XLVI. THE GENERAL PATHOLOGY OF OTITIS MEDIA AND MASTOIDITIS 754 CHAPTER XL^'II. INTRACRANIAL AND JUGULAR PYOGENIC DISEASES OF OTITIC ORIGIN 759 CHAPTER XLVIII. THE SURGERY OF THE TEMPORAL BONE 774 CHAPTER XLIX. FACIAL PARALYSIS 841 CHAPTER L. DISEASES OF THE PERCEPTION APPARATUS. AUDITORY NER^'E APPARATUS 848 CHAPTER LI. I)EAF-MUTISM 874 DISEASES OF NOSE, THROAT, AND EAR, PART I. THE NOSE AND ACCESSORY SINUSES. CHAPTER I. THE CLINICAL ANATOMY AND PHYSIOLOGY OF THE NOSE AND ACCESSORY SINUSES. THE NOSE. The Nasal Chambers.— The nose is divided, by the nasal septum, into two chambers, the right and the left. The nasal chambers are for respiratory, olfactory, phonatory, and gustatory purposes. The inspira- tory current passes upward from the vestibules to the middle and superior meatuses, and is thence deflected downward and backward by the middle turbinals and the roof of the nose to the choanse, and on into the epipharynx. The expiratory current is deflected from the vault of the epipharynx into the choanse, and thence forward through the middle and inferior meatuses to the vestibules of the nose. The practical clinical application of the foregoing facts lies in the different effects of stenosis in the inferior and in the superior portions of the nasal chambers. An obstructive deformity of the lower portion of the septum may interfere somewhat with the expiratory current, as it blocks the inferior meatus while the middle and superior meatuses are free, and the expiratory current, therefore, passes through the nasal chamber upon the obstructed side with but little or no impediment. The obstruction in the lower portion of the nasal chamber does not materially interfere with the inspiratory current, as its course is normally higher in the nasal passage. There are exceptions, however, to this rule. If, for example, the deformity of the septum extends well for- ward into the vestibule of the nose it will materially interfere with the respiratory current, as it blocks the entrance to the nose. The indications for the correction of an obstructive lesion of the inferior portion of the septum depend very largely upon whether or not 2 IS THE NOSE AND ACCESSORY SINUSES it blocks the vestibule of the nose. If it does, its correction is positively indicated; if it does not, the indications for its correction are not so clear. If, however, it impinges upon the inferior turbinal, it may produce a sense of "stuffiness," or of a foreign body in the nose, and cause the patient to "sniff and blow" in the effort to relieve the disagreeable sensation. It may, in addition to the foregoing, cause mechanical irritation of the mucous membrane of the inferior turbinal, and cause it to become engorged with blood, thereby increasing the obstruction of the inferior portion of the nasal chamber upon the affected side. When the obstructive lesion blocks the vestibule of the nose the entrance of the inspiratory current of air is materially interfered with. The descent of the diaphragm increases the air space in the lungs, and, according to a law of physics, the air from without tends to "rush in" to fill the vacuum thus created. The presence of the obstruction in the vestibule prevents its speedy entrance, and there is, therefore, a state of negative pressure in the nasal chamber — indeed, in both chambers, as their combined space is not sufficient to accommodate the required volume of air. The negative pressure or partial vacuum thus created results in a hyperemia of the mucous membrane of the nose and accessory sinuses. That is, the blood is attracted to the parts wherein there is a state of negative pressure. In addition to the hyperemia there is a greater or less transudation of serum into the loose submucous tissue. This condition is known as chronic rhinitis with turgescence. If the turgescence is perpetuated sufficiently long, true hypertrophy of the mucous membrane occurs. This is known as hypertrophic rhinitis. It appears, therefore, that obstructions located in the inferior and anterior portions of the nasal chambers are of considerable clinical importance, though not of as great importance as obstructive lesions located higher in the nose, as we shall attempt to show in the follow- ing paragraphs. When the upper portion of the nasal chamber is obstructed the path of the inspiratory current of air is blocked to a notable degree, and there is a sense of pressure through the upper portion of the nose. In addition to this the olfactory fissure is closed and the drainage of the secretions from the superior meatus and the accessory sinuses draining into it (the posterior ethmoidal and sphenoidal) is interfered with. The secretions are retained, undergo decomposition, and irritate the nuicous membrane in this region. Chronic inflammation results. The epithe- lium is lowered in vitality, and is, therefore, less able to perform its functions of elaborating the mucus of the normal secretion and of pro- pelling it to the choance by means of its cilipe. The irritation thus set up produces tissue proliferation or hyperplasia of the mucous membrane of the middle turbinal. This condition is known as hyperplastic rhinitis. The foregoing conditions are favorable for pathogenic infection; hence, suppurative inflammation of the mucous membrane of the nose and accessory sinuses may develop. This condition is known as sinuitis. It appears, therefore, that when the upper portions of the nasal chambers THE NOSE 19 are obstructed, there is not only a disagreeable sense of pressure across the bridge of the nose, but inflammatory diseases of the accessory sinuses may arise. One who has seen many of these cases knows how difficult it often is to thoroughly eradicate the sinus disease when it is thoroughly established in several of the sinuses, hence the importance of recognizing the clinical importance of obstructive lesions in the region of the middle turbinated body. This region is elsewhere described as the "vicious circle" of the nose. The sinus labyrinth is so extensive, and much of it so inaccessible to actual inspection, that a complete effacement of morbid processes in them is often quite difficult except after the most complete exenteration of the sinuses, and especially of the ethmoidal sinuses. The Septum. — This subject is fully discussed in connection with the deformities and malformations of the septum. The Turbinated Bodies. — The turbinated bodies, three in number, are located upon the outer wall of the nasal chambers, and are known as the inferior, middle, and superior turbinated bodies. Only the inferior and middle are of clinical importance. These are characterized by the presence of venous plexuses in the submucous tissue of the membrane known as "swell bodies," or as the erectile tissue of the nose. The erectile tissue is chiefly distributed along the inferior border of the inferior turbinal, and on the posterior ends of the inferior and middle turbinals. Its function is supposed to be that of warming the inspired air and of regulating the amount of serous secretion. Either process is of vital importance to the lower respiratory tract. The lower respira- tory tract does not secrete enough moisture for physiological purposes (protective), nor is it capable of warming the inspired air sufficiently to bring it to the body temperature without injury to its mucous mem- brane. It is important that the heating and humidifying apparatus of the nose should be in good physiological condition. When, therefore, the vasomotor nerves regulating the erectile tissue are disturbed in their function, the preparation of the inspired air for the lower air tract is imperfectly performed. The lower air tract is exposed to the irritating influence of the inspired air, and irritation of the lining mucosa and of the endothelial cells lining the air vessels of the lungs may result in a bronchitis, while the transfusion of the gases, oxygen and carbon dioxide, may be disturbed in the air vesicles. The processes of tissue metabolism or the chemistry of nutrition are perverted. In addition to the foregoing conditions resulting from the disturbed functions of the "swell bodies," the patient may experience either a sense of "stuffiness" of the nose or of a foreign body, or the reverse, an unduly open nose. If, for instance, there is an anterior or vestibular ()l)struction fi-om any cause, the negative pressure thus brought about causes an engorgement of the "swell bodies," with the resuhant dis- agreeable symptoms already described. This condition is known as rhinitis with turgescence. If, on the contrary, the patient is anemic, the swell bodies may become collapsed and the nasal chambers unduly patulous. This condition is known as I'ln'nilis with (■()II;ij)se of theerectile 20 THE NOSE AND ACCESSORY SINUSES tissue. The turbinated bodies are of clinical interest, for the further reason that they divide the nasal chambers into three partial chambers or meatuses. The inferior meatus is the space between the floor of the nose and the inferior turbinal. The middle meatus is the space between the inferior and middle turbinals. The superior meatus is the space above the middle turbinal. The meatuses are of great clinical interest on account of the accessory nasal sinuses opening into them. The Meatuses. — ^^Phe inferior meatus is of clinical importance, as the nasal orifice of the tear duct opens in its anterior portion (Fig. 165), and because it is a part of the expiratory air tract. The Middle Meatus. — The middle meatus is of great clinical impor- tance because the frontal, anterior ethmoidal, and the maxillary sinuses open into it. The frontal and the anterior ethmoidal cells drain into the infundibulum in 50 per cent, of the cases. The bulla ethmoidalis and the cells in the middle turbinal (Fig. 140) do not drain into the infundib- ulum, but open directly into the middle meatus. The bulla is often quite large and bulges so much toward the septum that it encroaches upon the infundibulum, entirely obstructing it. It thereby interferes with the drainage of the frontal maxillary and the anterior ethmoidal cells. The cells opening into the middle meatus are referred to for convenience as Series I. When pus is present in the middle meatus it is significant of empyema of one or more of the cells comprising Series I, namely, the frontal sinus, the anterior ethmoidal, and the maxillary sinuses (antrum of Highmore). The Superior Meatus. — The superior meatus is of clinical interest because the posterior ethmoidal and the sphenoidal cells (Series II) open into it. This meatus cannot be directly inspected on account of its hidden position above the middle turbinal. It can, however, be examined with a probe. When pus flows into it from the posterior ethmoidal and sphenoidal sinuses, and the olfactory fissure is not com- pletely closed, it may be seen lying between the septum and the middle turbinal (the olfactory fissure). Pus in this region is, therefore, of great clinical value in making a differential diagnosis as to which series of sinuses is involved in the suppurative process. The superior meatus is of still further clinical interest because the terminal filaments of the olfactory nerve are distributed there. Formerly it was held that the olfactory nerve was distributed over the superior turbinal and the upper and median surfaces of the middle turbinal and the corresponding portion of the septum. Recent anatomists have found its area of distribution restricted to the superior turbinal and a corre- sjjondingly small area of the septum (Fig. 5). In some of the lower animals its distribution is over a much larger area, and in those with a very acute sense of smell, into the accessory nasal sinuses. The Sinuses' Residual Organs. — The nasal accessory sinuses in man are the residual remains of the olfactory organ, hence they have a low recuperative power after operations. I have repeatedly observed the slow and sometimes incomplete repair after operations even after the THE NOSE 21 most thorough exenteration, especially of the ethmoidal cells. I attribute this to the fact that the structures in man have ceased to perform the function they were originally designed to do. Through long ages of retrogression the tissues have lost some of their vitality and do not regenerate with the same vigor that is manifested by structures still performing their functions. The Nerve Supply of the Nose.— The Sensory Nerves.— The sensory nerves of the nasal septum, the N. ethmoidalis anterioris and the N. nasopalatinus, send their filaments to the anterior and posterior por- tions of the septum, respectively. The N. ethmoidalis anterioris passes through the anterior portion of the cribriform plate (Fig. 1), thence for- ward and downward to the vestibule. The N. nasopalatinus extends forward and downward on the septum to the canalis incisivus, anas- tomoses with that of the other side and with the vessels of the mucous membrane of the hard palate. Nerve supply of the septum nasi, a, N. ethmoidalis anterioris; b, N. olfactorii; c, N. nasopalatinus; d, canalis incisivus. (After Spalteholz.) The sensory nerve supply of the outer walls of the nose is derived from the N. ethmoidalis anterioris and from branches of the ganglion spheno- palatinum. The N. ethmoidalis anterioris supplies the anterior portion of the lateral walls in front of the turbinated bodies, and the turbinated bodies are supplied by branches of the sphenopalatine ganglion (Fig. 2). The hard and soft palates are also supplied from this ganglion. These anatomical facts may be utilized in injecting cocaine for anesthetic purposes (Killian) and in injecting alcohol in the treatment of hy})cr- esthetic rhinitis (O. J. Stein). Vasomotor branches are also supplied to the vessels of the jnucous membrane and erectile tissue of the turbinated bodies from the ganglion sphenopalatinum, and is under the control of the vasomotor centres of the medulla, when there is probably a connection with the nuclei of the vagus through association fibers (Watson Williams). 22 THE XOSE AXD ACCESSORY SIXUSES The distribution of the accessory nerves over the septum and the outer walls of the nose, and especially the branches from the sphenopalatine ganglion over the turbinals, at once suggests the reason for the sensitive- ness of these areas when the mucous membrane is inflamed, or is so swollen that it impinges against the septum. It also suggests the reflex phenomena, as asthma, often observed when there is inflammation or other disease in these regions. The association fibers, referred to above, connecting the sphenopalatine ganglion with the vagus establish a physiological relationship between the upper and the lower respiratory tracts, hence the asthma of nasal origin. I have repeatedly seen cases in which the asthma promptly disappeared after the removal of nasal polypi, or after an exenteration of the ethmoidal labyrinth for sinuitis. The irritation of the terminal filaments of the turbinal branches from Nen'es of the lateral wall of the nose, a, ganglion sphenopalatiniun; b, rami nasales pos- teriores superiores laterales; c, rami nasales posteriores inferiores laterales; d, Nn. palatini; e, Nn. olfaetorii; /, rami nasales interni, N. ethmoidalis anteriores. (After Spalteliolz.) the sphenopalatine ganglion was thus removed, and the reflex stimulus through the ganglion to the vagus and thence to the bronchial muscles ceased to be given off; hence the bronchial spasm (asthma) was cured. The vascular engorgement present in chronic rhinitis with turgescence is due to a paresis of the vasomotor constrictor muscles supplied by the branches of the sphenopalatine ganglion. The paresis may be due to negative air pressure in the nasal chambers, whereby the vessels are overcharged with blood which "rushes in to fill the partial vacuum," or it may be due to the presence of toxic material in the blood, or to local morbid cliaiigcs in the swell bodies. The Olfactory Nerve. — The olfactory nerve descends through the lamina cribrosa (cribriform })late) from the under surface of the olfactory bulb and is distributed in the mucous membrane covering the upper portion THE NOSE 23 of the superior turbinal and a corresponding portion of the septum (Figs. 1, 2 and 5). Formerly it was thought that the distribution of the olfactory nerve in man was over a much more extensive area, the upper and median surfaces of the middle turbinal and a corresponding- area of the septum being included in the area of distribution. In many of the lower animals the nerve has a wider distribution; the sinuses communicating more freely with the nasal chambers are utilized for the spread of the terminal olfactory nerve filaments. In man they are the residual remains of the organ of smell, and only communicate with the nasal cavities through small ostei or cell openings, as they are no longer needed for olfaction. Inasmuch as the sinuses are the residual remains of the olfactory organs, D. Braden Kyle believes that they should not be needlessly opened by operative procedures and thus exposed to the irritating action of the inspired air, to which they are unaccustomed. He cites the uncomfortable sensations produced by the greater column of air sweeping through them after an exenteration of their walls, as an evidence of the possible harmful effects following an operation which opens the sinuses, so that there is free communication between them and the chambers of the nose. His point is well taken. The sinuses should not be need- lessly attacked, as local treatment and probing will in many cases afford relief to the symptoms, if not cure the disease. On the other hand, I have seen many cases in which the disagreeable sensations, caused by admitting a larger volume of air into the opened sinuses, disappear after a few weeks, the sinus disease being entirely eradicated. In some cases a choice must be made between the possible evil consequences of the disease and the evil consequences attending the cure of the disease. To return to the olfactory nerve. It is obvious that, if the middle turbinal and the septum are in apposition, the inspired air does not reach the olfactory region, hence there is anosmia or loss of smell. It follows that if the obstruction to the olfactory fissure is overcome, either by the removal of the middle turbinal or by the correction of the deviation of the septum, air is admitted to the olfactory region and the sense of smell is restored, provided the nerve has not undergone degeneration. Inasmuch as the distribution of the olfactory nerve is limited to the superior turbinal and the corresponding portion of the septum, the middle turbinal and the ethmoidal cells may be removed in their entirety without interfering with its distribution. In such operations the superior turbinal should l)e left intact in so far as it is compatible with a complete exenteration of the ethmoifhxl cells. The Blood Supply of the Nose. — The middle meningeal artery gives olf the spli('iioj)alatiiie branch, which, when it reaches the posterior portion of the lateral walls of the nose, subdivides into the lateral pos- terior nasal arteries. Tliese are distributed over the middle and inferior turbinals and in the middle and inferior meatuses. The superior tur- binal and the anterior portion of the outer walls of the nasal chambers 24 THE XOSE AXD ACCESSORY SIXUSES are supplied by the posterior etlimoidal and the anterior ethmoidal arteries, respectively (Fig. 3). As the posterior lateral nasal arteries are of considerable size, it is to The arterial supply of the lateral wall of the nose, a, A. meningea anterior; b, A. ethmoidalis anterior; c, A. etlimoidalis posterior; d, Aa. nasales posteriores laterales; e, A. sphenopalatina; f, Aa. palatinsD major et minores. The aiterial supply of the septum nasi, a, A. ethmoidalis anterior; b, A. ethmoidalis posterior; c, A. nasales posteriores septi; d, anastomosis with the A. palatina major. (After Spalteholz.) THE PHYSIOLOGY OF THE NOSE 25 be expected that the removal of either the middle or inferior turbinated bodies may be attended by considerable hemorrhage. As a matter of fact, the removal of the middle turbinal is usually followed by more or less bleeding for twenty-four hours. There is a free anastomosis be- tween the lateral nasal arteries and the anterior ethmoidal artery, hence, after the removal of a turbinated body the bleeding may come from both sources though but one artery is injured. The septum is supplied by the A. nasales posteriores septi, a branch of the A. sphenopalatina, through the foramen sphenopalatinum. It has three main branches : one supplying the posterior, another the inferior, and the other the middle and posterior portions of the septum. The A. ethmoidalis anterior and the A. ethmoidalis posterior are distributed to the anterior and the superior portions of the septum (Fig. 4). Severe hemorrhage occasionally attends or follows operations upon the septum, especially when the operative field includes the middle branch of the A. nasales posteriores septi. A nasal douche of iced normal salt solution will often check the bleeding, though in some cases it becomes necessary to introduce a nasal tampon. I know of one case in which the bleeding continued at intervals for several weeks, with an ultimate fatal issue. Such instances are rare, however, and should not materially affect the question of operations upon the septum. The question of tamponing the nasal chambers after operations should be briefly considered in this connection. As the nose is a part of the breathway and is constantly invaded by pathogenic bacteria, it is of the greatest importance that free drainage and ventilation be constantly maintained, as otherwise the growth of the pathogenic bacteria may be encouraged. I believe that many of the secondary hemorrhages occur- ing after operations are due to local sepsis affecting the blood clot in the severed arteries. The septic clot breaks down, the blood pressure dislodges it, and hemorrhage occurs. A nasal tampon should only be used after operations when the indications are positive, and never as a routine practice. THE PHYSIOLOGY OF THE NOSE. The functions of the nose are olfactory, phonatory, respiratory, and gustatory. The gustatory function in man is probably of least impor- tance, the olfactory of secondary importance, the phonatory of tertiary importance, while the respiratory function is of the greatest importance. The Sense of Smell. — The olfactory function, or the sense of smell, is presided over by the upper portion of the nasal chambers, the olfactory nerve (Fig. 5) being distrilmted over the attic of the nose as far down- ward as the upper margin of the middle turbinated body and on the septum over a corresponding area. A knowledge of the area of dis- tribution of this nerve is of practical importance in the diagnosis, prognosis, and treatment of certain diseases of the nose. If there is anosmia, or loss of the sense of smell, the question arises as to whether the impairment is due to a degenerative change in the nerve itself, or 26 THE XOSE AXD ACCESSORY SIXUSES to an obstruction to the entrance of the odoriferous particles or emana- tions to the terminal cells of the olfactory nerve. If, upon examination, the middle turbinated body is resting ajrainst the septum, the removal of a portion of the middle turbinated body, or the correction of a devia- tion of the u])per portion of the septum, may restore the sense of smell. As the normal inspiratory breathway throutjh the nose includes the space above the middle turi)inated body, it is apparent that an obstruction of the type just mentioned would prevent the odoriferous particles or emanations from coming in contact with the olfactory area of the nose during the act of insj)iration. If, on the other hand, the examination shows the results of a long-continued suppurative process in the posterior ethmoidal cells, or an atrophic condition of the mucous membrane in the attic, with no obstructive lesion to prevent the inspired air enter- ing, the anosmia may be due to degenerative changes in the termi- nal epithelial cells of the olfactory nerve. The lesions may, however, be intracranial, in which case there may be no evidence of either an obstructive lesion or of degener- ative changes in the attic of the nose. The loss of the sense of smell, while not comparable to the loss of the nasal respiratory function, is, nevertheless, attended by con- siderable inconvenience. The pleasure experienced by the re- cognition of certain odors is longed for by those affected by anosmia. More than this, they have lost one of the senses where- by they are protected from harm by certain substances, as ammo- nia, etc. By its aid wc are warned of the near approach to decaying matter, or other foul-smelling and unsanitary substances. In the lower animals the sense of smell is of much greater utility in seeking food and in detecting the apj)n)ach of hunters and animals intent upon their destruction. Phonation. — 'I'lic ])art j)layed by the nose in the production of the speaking and singing voice is so great that Jeane de Keske has said that the more he studies the voice the more he is convinced that it is a question of the nose. I have often noted that popular public speakers have well-developed nasal resonance, while speakers otherwise gifted had difficulty in holding the attention of their audiences. While the initial tone is produced by the vibrations of the vocal cords, the voice Sliowing the area of distribution of the olfac- tory terminal nerve cells in the human nose. The triangular flap is the septum turned upward; tlie area of distribution is limited to the region of the superior turbinal, and a corresponding area of the septum of the middle turbinal re- ceiving few or no olfactory cells. THE PHYSIOLOGY OF THE NOSE 27 is decidedly unpleasant and unmusical if it is not rich in overtones from the resonance chambers of the nose, throat, and chest. (See The Singing J^oice.) The nasal chambers and accessory cavities are of prime im- portance in voice production, and any obstruction from swelling of the mucous membrane, deflection, or other lesions of the septum so mate- rially alters the quality of the voice as to make it disagreeable and inartistic. A knowledge, therefore, of the phonatory functions of the nose is of practical importance, as the removal of the lesions which impair this function will convert an inartistic into an artistic, an un- pleasant into a pleasant, a comparatively useless into a useless voice. Nasal Respiration. — As before stated, the respiratory functions of the nose are its most important ones. The nasal chambers are more than mere tubes through which air is drawn into the lungs; they pro- duce certain changes in the air which prepare the air vesicles of the lungs so that they will permit of the normal transfusion of oxygen and carbon dioxide. The respiratory functions of the nose are threefold, namely: (a) to temper, (6) to humidify, and (c) to filter the inspired air. Experiments have demonstrated that no matter what the temperature of the air may be before it is inhaled, it is raised or lowered, as the case may be, to near the body temperature. The delicate structures of the deeper respiratory tract are thereby protected against the great varia- tions and extremes of temperature. It has also been shown that the air in passing through the nasal chambers receives moisture from the nasal mucous membrane. The mucosa of the lower respiratory tract and the epithelial walls of the air vesicles of the lungs are thus protected from the varying humidity of the atmosphere in which we live. In passing through the nose the air is raised (usually) in temperature, thus expanding it and increasing its capacity to absorb moisture. The swell bodies or erectile tissue of the nose, and the serum secreting glands of the nasal mucosa, give off moist- ure, which is rapidly taken up by the expanded air and carried to the lower respiratory tract, where the serum secreting organs are much less developed. It has been estimated that approximately one pint of serum is thus transferred from the nasal cavities to the lower respiratory tract in twenty-four hours. The part of the nasal structures chiefly concerned in the secretion of the serum is generally credited to the swell bodies or erectile tissue, located chiefly along the free border of the inferior turbinated bodies, and on the posterior ends of the middle and inferior turbinated bodies. It is these latter portions that sometimes become enlarged and form the so-called mulberry hypertrophies. It is probable that the mucous glands also secrete some of the serum. The swell bodies are imder the control of the vasomotor nervous system, which, under normal conditions, regulates the supply of moisture to meet the demands. If the air is dry the swell bodies enlarge and become just active enough to fully saturate the expanded air in the nose; whereas, if the atmosphere is humid they are less active. When there are obstructive lesions, or catarrhal inflammation is present, the swell bodies and glands do not 28 THE NOSE AXD ACCESSORY SIXUSES respond normally to the atmospheric conditions, hence the air is not properly humidified in its passage tlirough the nose. The treatment of these conditions should, therefore, be so directed as to restore the swell bodies and glands to their normal activity. In order to do this it may be necessary to give stability to the vasomotor nervous system by judicious bathing, outdoor exercise, etc. In addition, local massage of the mucous membrane and other treatment may be necessary. Surgical interference should always respect the location of the swell bodies, care l^eing exer- cised to avoid their destruction, except in those cases in which they have already lost their function beyond hope of restoration. The surgery of the middle turbinated body may be practised with much greater freedom, because it does not have much to do with the respiratory func- tions of the nose. The inferior turbinated body, however, should be attacked surgically only when its secreting function is largely destroyed, or wdien it is so enlarged by hypertrophic or hyperplastic changes that it obstructs nasal respiration. That the nose is a filter is made evident upon inspection of the secre- tions, and the vibrissee of the vestibule, as they are loaded with dirt. The vibrissse guarding the atrium of the nostrils act as a coarse filter, the larger particles lodging on them, the smaller ones entering the nasal cavities, where they are caught upon the irregular surface of the moist mucous membrane. Tlie lower air tract is thus protected from the irritation which would otherwise result. The Gustatory Function of the Nose. — The real gustatory or taste sense (sweet, soiu-, acid, bitter, and salt) is supplied by the dis- tribution of the glossopharyngeal and the fifth nerves to the fauces and the base of the tongue, whereas, the delicate flavors which give so much pleasure to the consumption of foods and drinks are appreciated through the olfactory nerve. If the nostrils are closed and the eyes covered, it is almost impossible to distinguish between coffee and water of the same temperature, as the aromatic flavor cannot be appreciated by the nose when closed. Summary: The functions of the nose are fourfold, namely: 1. Olfactory, residing in the attic of the nose. 2. Phonatory, enriching the voice by overtones. 3. Respiratory. (a) The air is warmed or tempered to or near the body temperature in passing through the nose, thereby preventing shock and irritation to the mucosa and air vesicles of the lower respiratory tract. (/>) The air is expanded by the warmth of the nasal chambers, and its capacity to absorb the moisture thrown off by the swell bodies and mucous glands is increased. The mucosa and air vesicles are thus moistened, or, at least, their moisture is not absorbed (the air being already saturated in its passage through the nose), and irritation is prevented. The nose keeps the inspired air in a state of saturation. (c) The air is filtered in its passage through the nose by the vibrissae and the moist mucous membrane. The irritation to the mucosa and air vesicles which would otherwise occur is thus prevented. 4. The gustatory (olfactory) sense complements the sense of taste. CHAPTER 11. THE NOSE, THROAT, AND EAR IN RELATION TO GENERAL MEDICINE. The writings of William Meyer, of Copenhagen, William Daly, of Pittsburg, and E. P. Friedreich, of Leipsic, have given a breadth to rhinology, laryngology, and otology they did not have in the days when the practice along these lines was regarded as a "specialty." With this broader view they are now regarded as the pursuit of the practice of general medicine and surgery, with special reference to the diagnosis and treatment of diseases in general, and those of the nose, throat, and ear in particular. A proper comprehension of the relation of the nose, throat, and ear to general medicine and surgery will be facilitated by a brief analysis of the interdependence and coordination of the various organs and parts of the body. ELEMENTARY FACTS. (a) The Breathway. — The upper respiratory tract is the channel in which the air is prepared for the interchange of gases which takes place in the air vesicles of the lungs. The nose is specially concerned in the process of humidifying, warming, and filtering the inspired air, and it is obvious that any disease or obstruction that interferes with these physio- logical processes will affect the transfusion of gases through the capillary walls of the air vesicles. The absorption of oxygen by and the elimina- tion of carbon dioxide from the blood will not occur in normal ratio. The blood will be deficient in oxygen and surcharged with carbon dioxide. As oxygen is essential to the processes of assimilation and nutrition, its lessened quantity in the blood gives rise to certain disturbed conditions of the digestive, the assimilative, and the nutritive functions. The presence of an excess of carbon dioxide also adds to these disturbances. It is well known that the excessive accumulation of carbon dioxide in the blood acts as a poison to the leukocytes, thus interfering with their functional activity. A normal amount of carbon dioxide in the blood favors the assimilative and the nutritive process, and it is only after a greatly increased amount of it is present that there are marked dis- turbances. It not only interferes with the activity of the leukocytes, but also with other cellular structures of the body as well. The combined effect, therefore, of an increased amount of carbon dioxide, and a dimin- ished quantity of oxygen in the blood is to produce general anenn'a, in(h- gestion, malassimilation, and malnutrition. 30 THE XOSE AXD ACCESSORY SINUSES The xantliin group of toxins, indiKlinij; indican, are thrown into the circulation and give rise to certain nervous phenomena, as restlessness, peevishness, headache, mental depression, aj)rosexia, and a general feel- ing of malaise. The digestive disturhances are still further increased by the infected secretions from the epi])harvnx and the tonsils. Putrefactive as well as pathogenic bacteria are swallowed with the secretions from the nose and throat, and give rise to Avhat is connnonly known as chronic dys- pepsia or indigestion. It is probable that the putrefactive germs are more potent in this connection than the streptococci and the staphy- lococci. The contlitions of the nose and throat which most commonly give rise to this kind of discharge are nasal stenosis, atrophic rhinitis, chronic rhinitis, sinuitis, epipharyngeal catarrh, and chronic follicular tonsillitis. There are certain conditions of the stomach and of the intestinal tract which affect the mucous membrane of the upper respiratory tract. If, for example, there is chronic indigestion, there is also malassimilation and faulty metabolism. The imperfect products of indigestion are im- perfectly oxidized and are thrown into the circulation, where they irritate the mucous membrane of the nose, as well as the vasomotor nerves, thus causing local congestion and overnutrition. The secretions of the glands of the mucous membrane of the upper respiratory tract are also thereby modified, thus predisposing to, or at least intensifying, the catarrhal disease present. In the same way hyperacidity and sub- acidity of the stomach may irritate the mucosa of the nose and throat. One of the most potent influences exerted by the products of indigestion is through the reflex nervous system, pharyngitis, hypersensitiveness, sneezing, etc., being the direct expressions of this condition. In atony of the stomach there is a putrefactive formation of gases, which act reflexly and through the circulatory system on the mucous membrane of the upper respiratory tract and cause phenomena quite similar to those just mentioned. Another condition which is quite similar in many respects to the foregoing is that which occurs in gout or lithemia. In connection with this (hsease the larynx and the pharynx are particularly afl'ected. In the pharynx there may be an itching behind the pillars of the fauces, associated with a similar irritation in the external meatus of the ear. Some observers regard these signs as characteristic of gout. When such symptoms apj)car, the administration of calomel and the bicarbonate of soda, followed in twelve hours by a saline i)urge, will give marked relief. After this it is well to administer teaspoouful doses of the phosphate of soda two or three times daily for a few weeks. Vomiting and eructation of gases from the stomach exert an irritating effect upon tlie nuicous membrane of the pharynx, the nasopharynx, and the nose, 'ilie irritation is due to biochemical as well as mechanical causes. Catarrhal iuflannnation in the epipharynx is thus perpetuated and may finally extend to the Eustachian tube and the middle ear, thus giving rise to tinnitus and deafness. ELEMENTARY FACTS 31 (6) Intimate Relation between Organs. — All the organs of the body are more or less intimately connected by the vascular, the lymphatic, and the nervous systems, hence disturbances in one more or less affect the others. The bloodvessels and the lymph channels carry toxic and infective material to all the organs of the body, including the nose, throat, and ear, and thus influence the functions and the pathological processes present in these organs. While the data considered under this subject somewhat overlap those considered under (a), it is well, nevertheless, to emphasize certain features more prominently in this connection. Anemia is a condition of the blood due to various causes, and often gives rise to collapse of the erectile tissue of the nose. This is usually spoken of as "rhinitis with collapse of the turbinated bodies." While rhinitis with collapse is not of great importance, its presence is, never- theless, a source of information to the examining physician. When, for example, upon examination of the interior of the nose the inferior turbinated membrane is found tightly collapsed over the bony framework which supports it, the mucous membrane being comparatively dry and with no crusts distributed over it, it should lead at once to a suspicion that general anemia is present. It is bad practice to limit the treatment to the local nasal condition, as this will disappear under appropriate treatment for the anemia. On the other hand, another condition of the nasal mucous membrane which may cause anemia instead of being a result of it, as related in the preceding paragraph, is atrophic rhinitis. It is characterized by anemia, which is probably due to the absorption of toxic material from the nose, and to the loss of the respiratory functions of the nose. If the lymphatic vessels are charged with infective material, which is finally transferred to the bloodvessels and the tissues of the entire body, a state of general toxemia is induced, the nose, throat, and ear being brought more or less under the influence of the disturbed conditions in the lymphatic circulation. On the other hand, one of the commonest clinical pictures is that wherein the lymphatic glands are enlarged by suppurative diseases of the ear, nose, and throat. This subject is discussed more fully in the chapter on the Clinical Anatomy of the Tonsils. I wish, however, to emphasize the influence of suppurative diseases of the ear upon the lymphatic glands of the neck. As the ear is more intimately connected with the lymphatic glands of the posterior triangle of the neck, it is to the glands in this region that we should look for enlargement in inflammatory disease of this organ. The close approximation of the mucous membrane of the ear to the contents of the cranial cavity may also give rise to serious consequences by the conveyance of infective material thereto. Brain abscess, menin- gitis, septic throm})ophlebitis, etc., may thus be caused, although the usual channel of invasion is through the necrotic area in the tegmen tympani or the tegmen antri. The nervous system, when disturbed in its function, necessarily influences the upper respiratory tract, as well as other parts of the body. 32 THE NOSE AND ACCESSORY SINUSES "We may thus liavc vasomotor rhinitis and asthma, as well as certain functional disturbances of the ear and the larynx. Hysteria probably comes under this heading, and while it is not demon- strable histologically, it has, nevertheless, a histological basis. Hysteria of the nose, throat, and ear, as in other parts of the body, is characterized l)y the disturbance of those functions which are more particularly under the control of the mind, the involuntary functions not being affected. In the larynx, for instance, the normal respiratory movements are not dis- turbed, as they are involuntary; whereas the movements of the larynx which are concerned in the production of speech, being under the con- trol of the mind, are voluntary, and are affected. Hay fever, laryngeal cough, sneezing, bronchial asthma, anesthesia and hyperesthesia of the mucous membrane of the ear, nose, and throat are reflex phenomena, which may result from the irritation of the nervous system by the toxic material in the circulation. Another very important disease generally regarded as due to infection of the blood is rheumatic fever, or acute articular rheumatism. The gateway of infection is often through the tonsils, or, at least, through the Waldeyer's ring. The throat symptoms of this disease are a red- dened pharynx, with a defined or circumscribed inflammation of the larynx, redness and swelling in the arytenoid region, and sometimes fixation of the arytenoid cartilages. Pain and difficulty in phonation and deglutition are also present in rheumatic fever. The physician should not only look upon the tonsils as the portals of infection, but he should look into the pharjmx and the larynx for the symptoms of the disease itself. Acute rheumatic fever also gives rise to certain symp- toms which are not commonly recognized. For instance, it may cause nose-bleed in children, and in some cases is undoubtedly the cause of chorea. Malaria is another disease affecting the blood which gives rise to certain diseases or symptoms in the ear, nose, and throat. IMastoid pain, and, indeed, mastoid suppuration, has been observed in which the malarial element was prominent. In view of some recent observations, it may be questioned, however, whether these cases were distinctly mala- rial in their origin. We know now that there are certain septic conditions which give rise to symptoms so nearly like those due to the plasmodium of malaria that it may be questioned whether these cases were truly malarial, or whether they were septic. It is known, however, that the n)alarial poison may cause nasal hydrorrhea and vasomotor rhinitis. The bloodvessels and lymph vessels are channels of communication between the throat and the appendix. In certain cases of appendicitis it has been shown that streptococcus infection was present both in the throat and in the appendix. Another possible source of communication in these cases is through the alimentary tract. {(') The Digestive Tract.— Tlie digestive tract, which prepares the food for tissue building, is affected by the putrefactive and the patho- genic microorganisms from the nose, throat, and ear. The primary treatment should be addressed to the relief of the diseased conditions of ELEMENTARY FACTS 33 the upper respiratory tract, rather than to the stomach and the intestines. The presence of dyspepsia, or other functional disturbances of the stomach and the intestines, should lead to the examination of the nose and throat, with special reference to the discharges from them, which may be swallowed by the patient. On the other hand, if there is an irri- table state of the nasal, pharyngeal, and laryngeal mucous membranes, which is not explained by any local source of irritation, careful attention should be given to the condition of the stomach and the intestines, or to the organs of digestion and assimilation in general, with a view to deter- mining whether they are properly performing their functions. If they are not, the nutritive properties of the food are thrown into the circu- lation imperfectly or insufficiently prepared for their purposes. The irritation thus carried to the nasal mucous membrane and to the nerves supplying it may be the chief cause of the local disturbances. It is obvious that under these circumstances the treatment should be addressed to the correction of the disorders of the digestive tract, rather than to the nose, throat, and ear. (d) Excretory Organs. — The function of the excretory organs is to throw off the refuse material formed during the processes of nutrition. The refuse consists not only of the material not needed for the nutrition of the body, but also of the toxic material and the half-way products of oxygenation already referred to. Hence, any impairment of the functions of these organs results in an excess of toxic material in the blood and the lymphatic vessels, thereby causing congestion, irritation, hypertrophy, hyperplasia, or altered secretions in the upper respiratory tract. This feature of the subject is intimately associated with those in the preceding paragraphs. Nevertheless, it has its place in this con- nection, and should be considered apart from them. The skin and the kidneys being the chief excretory organs of the body, our attention will be given largely to their consideration. We will dismiss the skin with a brief reference to the fact that eczema, lupus, etc., affecting other portions of the body, may also involve the external nose and the external ear. Or, the pathogenic processes may begin with the skin of the nose or the external ear, and extend to other parts of the body. We will also mention incidentally that erysipelas of the nose may involve the nasal mucous membrane, and that erysipelas of the skin over the mastoid process may extend to the middle ear and the mastoid cells, or even to the cranial cavity through the lymphatics and the bloodvessels of this region. The kidneys, however, are the excretory organs which chiefly interest us in this connection. Bright's disease may manifest its earliest symp- toms in the mucous membrane of the throat. The throat symptom complained of is dryness. This same symptom may also be present in diabetes. Diabetes is mentioned here not because it is a disease of the kidneys, but because its chief symptom is to be found in the examina- tion of the excretions from the kidneys. When a patient complains of persistent dryness of the pharynx his urine should be examined for albumin, casts, and sugar. In some cases 3 34 THE NOSE AND ACCESSORY SINUSES albumin will not be found at first, but after a few years its presence may be detected. In other words, the dryness of the pharynx is by some regarded as one of the earliest symptoms of this disease. Edema of the glottis, causing laryngeal stenosis, is often due to uremia developing as a result of Bright's disease. In the milder forms of uremia, bronchial asthma and hemorrhage of the upper air passages are some- times found to be the chief expressions of the disease. In the more pronounced uremic conditions there may be aphasia from edema of the brain. (e) Proximity of Organs.— The close proximity of the organs of the head favors a correlated pathological activity. The eye is near the nose and has immediate communication with it through the tear duct, as well as through the lymphatics, the bloodvessels, and the nervous system; hence, disease in one often gives rise to certain symptoms in the other. Experiments with certain colored solutions dropped into the eye have sho\Aai the coloring matter within a very short time in the nasal mucous membrane. The instillation of bacteria yields the same results. Clinically it is not uncommon to observe an inflammatory condition in the eye simultaneously with or following a similar process in the nose. I have often had cases referred to me by ophthalmologists wdio w^ere unable to prescribe satisfactory glasses until after I had corrected the nasal condition, usually involving the middle turbinated body or the ethmoid cells. The proximity of the nose to the ear, as well as the physiological communication between them via the Eustachian tube, gives rise to a very intimate relation between these organs. It is well known that inflammation of the epiphar\Tix sometimes extends through the Eustachian tube, by continuity of tissue, to the middle ear. This condition may develop until there is suppurative otitis media, mastoiditis, and even intracranial complications. Adenoids are also a fruitful source of mischief to the ear and the mastoid process. They may mechanically obstruct the Eustachian tube, or the epipharyngitis which almost invariably accompanies them may cause the ear disease. The removal of adenoids in children is often followed by immediate I'elief of deafness or even of suppurative inflammation of the middle ear. While the stomach is not so closely related to the ear as the epipharynx, nevertheless it has a close pathological and anatomical connection through the esophagus. In vomiting, foreign matter may be forced into the Eustachian tube and the middle ear, and may cause otitis media, with all its attending complications. From this same organ eructations of gas may also cause irritation in the epipharynx and the Eustachian tube. The nasal discharges, especially when there is empyema of the acces- sory sinuses of the nose, usually pass backward into the epipharynx and cause irritation and inflammation in this region. They also pass to the larynx and cause more or less trouble there. Stenosis of the nose interferes with the functions of that organ, and thus allows the air to pass into the epijiharvnx, the larynx, and the bronchial tubes insufficiently warmed, insufficiently moistened, and imperfectly filtered. Irritation ELEMENTARY FACTS 35 of the mucosa of the respiratory tract below it is thus caused and gives rise to catarrhal inflammation. The ear is separated from the cranial cavity by a partition of bone which in places is not more than one-sixteenth to one-eighth of an inch in thickness. Chronic suppuration within the middle ear and the mastoid cavity often results in necrosis of this thin plate of bone, thus opening a channel of communication between the middle ear and the cranial cavity. The sequels or complications of mastoiditis, such as meningitis, brain abscess, septic thrombophlebitis, etc., may thus result from ear disease. The nose is but slightly separated from the cranial cavity, and through the ophthalmic veins may cause thrombophlebitis of the cavernous sinuses, which is attended by such fatal consequences. (/) Infections. — Systemic infections from the upper respiratory tract have already been more or less considered in this chapter as well as in the one on the Tonsils as Portals of Infection; hence, the subject will not be elaborated here. (g) The Central Nervous System. — It is obvious, inasmuch as the central nervous system supplies the innervation of the nose, throat, and ear, that in disease of the central nervous system the parts which it supplies with innervation must be affected. In other words, in certain diseases of the central nervous system some of its characteristic symp- toms may be found in the upper respiratory tract. In tabes dorsalis there may be certain motor laryngeal disturbances, which may be either bilateral or unilateral. There may be ataxic movements of the vocal cords. Laryngeal crises, as spasmodic cough, may be present. Ear symptoms in tabes are rare. The cochlear and vestibular nerve endings may, however, be congested. In this event there will be diminished or entire absence of bone conduction and hearing for the higher tones. Meniere's symptom-complex may also be present in excep- tional cases. In multiple sclerosis the laryngeal symptoms are a tremulous voice, which is easily fatigued, and is deep and hoarse in character. Muscular palsy of the laryngeal muscles is rare. The ear symptoms in this disease are tinnitus, and loss of hearing by bone conduction through the sclerotic degeneration of the nuclei. The symptoms found in paralysis agitans are about the same as those found in multiple sclerosis. (h) The Lymphatic System. — There are certain constitutional symp- toms due to infections tlirougli the lymphatic system which should be especially singled out, although they have already been referred to in Section (a) of this chapter. We now recognize that a fever, characteristic of childhood, which has heretofore been regarded as one of the ill-defined malarial infections, is due to an infection through the adenoid growths in the nasopharynx. The fever usually runs an irregular course of aliout ten days, and is characterized by an afternoon temperature of 100° to 104° with rest- 36 THE NOSE AND ACCESSORY SINUSES lessness, peevishness, sharp pains through the ears at night, anemia, general debiHty, loss of appetite, coated tongue with indentations from the teeth, constipation, and cervical adenitis. jNIouth breathing is not essential as a factor in causing the infection. A small amount of lym])hatic tissue in the epipharynx is a sufficient portal for the entrance of the bacteria. The presence of this type of fever is almost always an indication for the removal of the adenoids. If the child is known to be tuberculous, some consideration may be given to the matter before removing them, for, if the removal is imperfectly done, it may give rise to a recrudescence of the tuberculous infection, which may extend to the lungs and lead to a fatal issue. Another ])lood disease which may express itself through certain patho- logical changes in the ear, nose, and throat is syphilis. The nose may be the primary seat of the lesion, the infection taking place in the removal of crusts from the septum with the finger. The tonsils are occasionally the seat of the primary lesion or chancre through the use of infected instruments in the throat. The author has seen cases in which both tonsils were the seat of chancre as a result of the instruments used in lancing the tonsils during an attack of peritonsillar abscess. In one case there was the characteristic initial lesion in the left tonsil, with the cervical bubo on the same side, which was followed a few days later by the characteristic skin eruption. The source of the infection in this case was the dirty instruments used in lancing a peritonsillar abscess. I first saw the case six weeks after the tonsils were lanced. The patient had been complaining of sore throat for two or three weeks. The tonsils and the bubo were still very much in evidence and the eruption on the skin had just begun to show. In the course of another week the corona veneris developed. The copper-colored eruption on the face showed much plainer at a distance of twelve or fifteen feet than it did when viewed near by. Secondary syphilis may manifest itself by mucous patches in the buccal cavity, by hyperemia of the larynx, hoarseness, and syphilitic coryza with scanty, thick secretion from the nose. Syphilitic coryza is not always recognized by the family physician, being regarded as a simple ol)stinate cold in the head. The scanty, thick discharge, with stenosis of the nose, should, however, excite suspicion of the true nature of the disease. I once saw a case in which there was a marked arrest of development of the bones of the face because, when in childhood the syphilitic coryza developed, the family ])hysician regarded it as an ordinary cold. He treated him for the same without success, and was finally surprised to find the nasal bones and the septum giving way. The soft palate and the ])harynx later became involved and rapidly melted away under the blighting influence of the sy])hintic poison. The patient is now thirty- four years old, and has the most pronounced "frog" face I ever have seen. Adhesive bands ])ind the soft palate to the pharvngeal wall, making it difficult for him to s{)eak distinctly, though he is now successfully engaged in business. ELEMENTARY FACTS 37 The tertiary manifestations of syphilis are syphihtic pharyngitis and laryngitis, with a raucous voice. Syphilitic lesions of the tonsils, presenting a dirty grayish necrotic surface resembling diphtheria, are occasionally observed. Syphilitic gummata are not excessively destruc- tive in character. Syphilitic papillomata of the tonsils and the soft palate are elsewhere described. Recent investigations have discredited the oft -repeated statement that the skin and the mucous membranes of the animal organism are insur- mountable barriers to microorganisms so long as the epithelial coat is intact. Bono and Frisco report that the researches undertaken at the Institute of Hygiene at Palermo have established the fact that "germs deposited on the intact skin or mucosa are found soon afterward in the lymphatic ganglia of the respective regions. If the germs are so numerous or so virulent as to overcome the resistance offered by the lymphatic ganglia, general infection may result. If not, there is merely a local reaction on the part of the ganglia, which become tumefied and undergo various modifications in their structure proportional to the number of germs which reach them." To establish the relationship between the nasal mucous membrane and the eye, microorganisms were placed on the nasal mucous mem- brane, both with and without obliteration of the nasolacrymal canal. The result of the experiments showed the penetration of the germs into the vitreous and the aqueous humors of the eye on the same side. "None of the animals exhibited any signs of general infection. One or two colonies, at most, could be derived from the blood in the heart, the liver, the spleen, and the lymphatic ganglia of the neck, and occasion- ally from the anterior auricular, the submaxillary, the deep jugular, and the carotid lymphatic ganglia. This fact, considered in connection with the presence of large numbers of germs in the aqueous and the vitreous humor, and the absence of general infection, warrants the con- clusion that the bacteria penetrated directly into the eye from the nasal and the conjunctival mucous membrane, and that they also arrived secondarily in the eye through the blood, but reduced in numbers and virulence. Part of the germs were retained by the ganglia connected with the anterior lymphatic vessels of the eyeball and its appendages. In further experiments with instillations of India ink it was possible to trace the exact route followed by the particles from the conjunctival lymphatics along Schlemm's canal into the anterior chamber and thence into the vitreous. From the lymphatics of the nasal mucosa the particles passed into the ethmoid cells and the lamina papyracea, thence into Tenon's capsule, and on into the eyeball. The practical results of these researches are particularly important in the pathology of the eye." Eye Diseases Due to Nasal Lesions (especially Optic Nerve Lesions). — F. Mendel, after observing many cases, comes to tlic conclusion that the nasal infection and inflannnation is transferred to the eye by the direct connection or continuance of the epithelium of the nasal mucous mem- brane to the conjunctiva, as well as by the intimate vascular association. The ophthalmic artery gives off the anterior ethmoidal, which supplies 38 THE NOSE AND ACCESSORY SINUSES the nose and the lacrymal canal. The venous supply of the nasal mucous membrane, by means of the lacrymal plexus, is in direct com- munication with the ophthalmic vein. Heber Nelson Hoople, in a paper read before the American Laryn- gological, Rhinological, and Otological Association, 1901, advances the theory that faulty pressure within the nose can cause asthenopia of both the ciliary and external ocular muscles. That is, mechanical pressure in a limited area of the nose, called by Mackenzie the reflex area, can cause muscular asthenopia. By muscular asthenopia he means the impairment of the efiiciency of the ocular muscles in the performance of their ordinary functions. The pressure to which Hoople refers is confined chiefly to the middle turbinal, especially to great enlargement of the middle turbinated body, A concomitant symptom usually occurring in conjunction with the asthenopia is a browache or headache referred to the frontal region or to the occiput in rarer instances. He cites a number of cases in his own practice and in that of others in which the asthenopia disappeared as soon as the nasal trouble was cured. The asthenopic cases referred to belong to the so-called normal type rather than to the excessive type. He concludes that a moderate amount of pressure or mechanical irri- tation of the middle turbinated body against the adjacent septum will temporarily impair the function of the ciliary muscle; to a lesser or more variable degree, it will also impair that of the external ocular muscles. If mechanical irritation (from congestion or swelling of the soft tissues) can impair the function of these muscles, how much more would a con- tinuous pressure from a septal spur or other deviation of the septum digging into the middle turbinal keep up this impairment ? The reason for the association of headache with asthenopia is that they have a common cause — pressure upon the sensori-motor branches of the trigeminus. So far as the sensory part is affected, a radiated or a reflex headache is produced; so far as the sympathetic fibers are affected a vasomotor reflex is produced. This is equally true where there are inflammatory conditions, as ethmoiditis. It matters little whether the pressure is from within the ethmoid cells and turbinal or from with- out these structures. The important point is that the same branches of these nerves are pressed upon, and, therefore, the same kind of dis- turbances should be expected to follow. The asthenopic disturbance is probably due to irritation of the sym- pathetic fibers in this particular class of cases. That it is such in all cases is also probable. It could be inferred from other facts, e. g., when treatment addressed to the uterus, the bladder, or the stomach has given relief of the asthenopic symptoms. In the light of the foregoing views expressed by Hoople, asthenopia or disturbed function of the ciliary and external ocular muscles is usually due to intranasal pressure and irritation in the middle turbinal and ethmoidal regions, rather than to toxemia from infection of the sinuses. The speedy relief of the asthenopia following the divulsion or the removal ELEMENTARY FACTS 39 of the offending middle turbinal seems to prove this view rather than the view referring the disturbance to toxemia. In the cases referred to by Hoople the headaches were of the ocular rather than the sinus type, as they were induced, or aggravated, by the use of the eyes, and were relieved upon retiring for the night. Sinus headache is not always aggravated by using the eyes, and is often most pronounced upon awakening in the morning or in the night. CHAPTER III. THE OFFICE EQUIPMENT. The chief thought in the equipment of an office should have reference to facihty in handhng and treating patients. The treatment and consul- tation rooms should be equipped for work rather than for entertainment. Ever}^hing for facility and thoroughness; nothing for show. "Bluff" is a confession of unfitness. Thorough knowledge and frankness of statement will inspire confidence and give an impression of mastery as no amount of bluffing will do. The essential furnishings of the consultation-room and treatment- room should consist of the following outfit : (a) Treatment and operating chair. (6) A revolving stool for the surgeon, (c) A treatment table or cabinet, {d) A fountain cuspidor, (e) A linen cupboard. (/) A writing desk, {g) A sterilizer, {h) A revolving desk chair, {i) Tw^o small chairs, {j) An adjustable bracket for the examination lamp, {k) A selection of instruments and apparatus for examinations, treatments, and operations. The Treatment and Operating Chair.— The treatment and operating chair should have a revolving bottom, as suggested by Dr. Robert Levy, as it is desirable to turn the patient from side to side in treating his ears, and for other reasons as well. The bottom should be on a central screw pin, so that it can be adjusted to different heights for children and adults. The back should be so constructed that it can be lowered on a level with the bottom in case of faintness and in case it is desirable to operate in a prone position. An adjustable head-rest should be attached to the back of the chair. Chairs responding to the foregoing requirement are shown in Figs. 6 and 7. An ordinary chair may, of course be used, but, in the case of faintness, etc., the work is greatly facilitated and the comfort of the patient assured if the chair is of the adjustable type described. The Treatment Table or Cabinet. — If an assistant is employed it is preferable to have the instruments in a separate cabinet adjoining the sterilizing room or corner. The treatment cabinet may then consist of a metal enamelled frame with a plate-glass top, or it may be a double- decked table, with top and shelves about one foot apart. These tops afford ample room for the distribution of bottles containing remedies for topical applications and for the instruments of examination and operation. The treatment table or cabinet (Fig. 8) is an important item of furniture. Its selection should depend largely upon whether the surgeon has an assistant or nurse to wait upon him. If he has such an assistant the cabinet need not be constructed to contain all his instruments, as the THE OFFICE EQUIPMENT 41 assistant will bring the necessary instruments for each case. If he does not have an assistant, it is convenient to have the instruments in the cabinet within his reach. The Hot-water Basin. — A most excellent addition to the table is a basin set in the centre of the upper glass top, with running hot water for rinsing instruments during the course of treatments. If preferred, the hot- water basin may be attached to a special wall bracket (Fig. 9), as it is only intended to provide a convenient arrangement for rinsing instruments during treatments and operations. It is also convenient for c^*^ Operating chairs. cleansing and warming the laryngeal mirror during throat examinations. No matter how sterile the tongue depressor is when brought in, its introduction into the mouth the second or third time without cleansing is, to say the least, disgusting to the patient. A basin of running hot water is, therefore, an invaluable, and I might add an indispensable, adjunct to the office equipment. It is not indis- pensable in so far as the safety of the patient is concerned, as only his own secretions contaminate the instrument used. If the fundamental principles of common cleanliness are to be recognized it is a valuable 42 THE NOSE AXD ACCESSORY SINUSES and necessary office fixture. It is not a question of whetlier it pays, but rather one of common decency, and that always pays. Clark's hot-water basin. Clark's fountain cuspidor. A bowl of antiseptic solution is not a substitute for running hot water unless the bowl is refilled for each rinsing. The solution w^ould soon become thick with secretions and detritus, and the introduction of an THE OFFICE EQUIPMENT 43 Fig. 11 „ 4s instrument into it for rinsing purposes would be even more digusting than no rinsing at all. The Examination Lamp. — ^The examination lamp may be a kerosene, gas, or an electric lamp, preferably the latter, as it gives off less heat and requires less attention. The lamp may or may not have a hood with a focusing lense, according to the preference of the surgeon. Personally, I prefer an electric lamp of 50 candle-power (Fig. 11), with a ground-glass surface except a circular area on one side, where the glass is clear. This affords plenty of illumination, is simple, throws out little heat, and is inex- pensive. / A wall bracket to support the lamp is an I important item, inasmuch as it is constantly I used, and should, therefore, be well constructed \ and accommodate itself to the varying con- ditions under which it is used. That is, it should be so constructed that the lamp can be raised and lowered and turned from side to side with the least trouble to the operator. It should be so well made that it will never get out of order, a state or condition into which many wall-lamp brackets are prone to lapse. That shown in Fig. 12 has proved quite satis- . ^^ ,, , , . o r 111 A 50 candle-power electric factory m nearly every respect, though the lamp. t'all-lamp bracket. electric bulb attached should be turned upward. A Kierstein head lamp (Fig. 13) is preferred l)y some operators. Compressed-air Apparatus. — The compressed-air apparatus may be one of three types: (a) A hand bulb; (6) a tank pumped by hand or some automatic device, as a water pump; or (c) a system of com- pressed air supplied throughout the building by means of pipes from a central compressed-air tank. The latter is preferable when it can 44 THE NOSE AXD ACCESSORY SINUSES he obtained, as it requires no attention whatever. A compressed-air tank in the office automatically supplied by means of an hydraulic pump is the next most preferable arrangement. A hand pump is incon- venient and entails considerable labor. The hand bulb is suitable when eight pounds or less of pressure is required. An Accessory Regulating Air Tank. — An accessory regulating air tank is a very convenient and valuable addition to the compressed-air system, as it enables the surgeon to use the amount of pressure required for various purposes. The nasal mucous membrane, for example, will not tolerate a higher pressure than ten pounds with the De Vilbiss spray tube, whereas the pharynx will tolerate from twenty to forty pounds' pressure. A nebulizer requires a higher pressure than the spray tube, and in inflation of the Eustachian tube and middle ear the pressure required varies from eight to twenty pounds, according to the degree of obstruction present. Hence a regulating air tank is a convenient Kierstein lamp and head bracket . if not a necessary apparatus. The tank should be connected with the main reservoir and the compressed air turned on until the gauge indicates the required pressure, say twenty pounds. If at another time in the treatment but ten pounds' pressure is needed the escape valve may be opened until the gauge indicates ten pounds. There are many other ways in which such a regulating air tank may be used to advantage. The gauge regulators on the market are not nearly so satisfactory as the regulating tank, and are not recommended. Massage Apparatus. — Ear Drum. — Pneumomassage or the massage of the ear (liuiii by the alternate rarefaction and condensation of the air in the external auditory meatus is accomplished by means of a hand pump, as first devised by Delstanche, of Brussels (Fig. 14), or it may be operated by an electric motor, as first devised by Chevalier Jackson, of Pittsburg, and later, in 1893, improved by Pynchon (Fig. 15). The pneumomassage of the ear drum is recommended in deafness and ear THE OFFICE EQUIPMENT 45 noises of catarrhal origin, though its vahie has been greatly exaggerated. Delstanche was of such high repute, that he was awarded the Lavele prize Delstanche's rarefactor and artificial leech. Fig. 15 The Victor electrocautery and for having designed the best instrument for relief of deafness, hence the procedure was adopted by aurists all over the world. Subsequent 40 THE NOSE AND ACCESSORY SINUSES experience with it and its modifications has not met the high expectations with which it was received. Pneumomassage has a place in aural practice, however, as by it the mucous membrane is brought into a more active and resistant state, and the labyrinth is also stimulated to greater functional activity by it. The ossicles of the ear are rendered more mobile and transmit sound better after its application in a limited number of cases. Tinnitus is also occasionally improved by it. Such cases require rare skill and knowledge to determine what is best to do for them. Routine of inflation and of pneumomassage lead to bitter disappointment except in a few cases. Accurate diagnosis is of first importance; then the treatment should be very carefully and intelligently prescribed. Not every case of deafness and tinnitus is improved by pneumomassage or any other method of treatment. Then, too, the massage apparatus, hand or mechanically driven device, should be regulated to suit each case. The length of the piston stroke, the frequency of the vibrations, and the length of time the massage should be used are questions to be settled according to the peculiarities of each case and the experience and judgment of the surgeon. Massage per se is of no value as a therapeutic agent. It is only when it is mixed with "brains" that it becomes of value. Surgeons who are uninformed and inexperienced are often tempted to furnish their offices with formid- able looking mechanical devices, with the belief that they are thus pre- paring themselves to adequately cope with disease. If they are intelli- gent observers, they soon learn that the "man behind the gun" is the first requisite for the attainment of success. I must confess that I have rarely observed marked improvement in deafness and tinnitus that was clearly due to pneumomassage. I have, however, found the hand apparatus of Delstanche of the great- est value as a diagnostic agent. With it the ear drum may be observed under compression and rarefaction, points of adhesions and of atrophy being clearly demonstrated. When the air is rarefied in the meatus the ear drum is pulled outward, the points of adhesion being fixed while the balance of the membrane bulges outward, leaving no room for doubt as to the condition of the middle ear. If there is an atrophic area in the ear drum it bulges like a blister beyond the balance of the membrane. If the otoscopic portion of the apparatus is provided with a magnifying lens the texture of the ear drum is clearly demonstrated. Aside from the diagnostic value of the Delstanche apparatus its greatest usefulness is in the treatment of the exudative forms of middle-ear catarrh. It is in the protracted course of these cases that the adhesive processes form. The viscid exudate agglutinates the ear drum to the inner tympanic wall, becomes organized, and thus permanently fixes it to the inner wall of the middle-ear cavity. The timely and intelligent use of the Delstanche rarefactor, or other pneumomassage apparatus, may prevent ])ermanent adhesions. The apparatus should in the beginning be used daily with a slow, long stroke of the piston. After the inflam- matory })rocess has abated and the exudate is less viscid antl less profuse the treatment may be gradually reduced in frequency and finally aban- THE OFFICE EQUIPMENT 47 doned. The length of the stroke (force of the suction) should be grad- ually diminished, as a too long-continued stretching of the membrana tympani will render it abnormally lax from pressure (suction) atrophy. Aiiother device for the massage of the ear drum consists of a glass tube partially filled with metallic mercury (Fig. 16). The open end of the tube is shaped to fit the external meatus, and when not in use is closed with a rubber cork. Its application is simple, the uncorked end being placed firmly in the external meatus, and the patient instructed to move the head from side to side, allowing the mercury to drop against the ear drum. This procedure is repeated several times at each daily seance. According to Dr. Joseph C. Beck-, its originator, the rationale of its use consists in the impact of the mercury against the malleus and ear drum, the force being transmitted to the entire ossicular chain and to the labyrinth. This stimulates the functional activity of these structures and improves the condition present. Dr. Beck has found its chief useful- ness in the relief of the tinnitus rather than the deafness, a fact which to my mind is significant. That is, the mechanical shocks thus applied to the membrana tympani and transmitted to the labyrinth affect the circulation of the labyrinth, improve the nutrition and increase the local leukocytosis. These changes affect the labyrinth in such a way as to relieve the tinnitus. Beck's mercury massage. Dr. Beck has also noted that the improvement was usually transient, lasting only a few days or weeks after discontinuing the treatment. The Electrocautery. — So much has been said within the past six years about the use, or rather the uselessness, of the electrocautery (Fig. 15) that I feel impelled to rise in its defence. It is still a very use- ful apparatus, and an office is incomplete without it. It is true that it has been too frequently, indiscriminately, and unintelligently used, but it still fills a place of great usefulness in the armamentarium of the specialist. Its usefulness in turgescent rhinitis has been greatly abridged by the improved methods of operating upon the nasal septum (notably the sub- mucous resection), but even in this condition it still aft'ords a means of temporarily overcoming the excessive swelling of the inferior turbinated bodies. It also affords a valuable means of treating chronic granular pharyngitis witli lymphoid enlargements along the lateral and posterior walls of the pharynx. Still other uses could be described, but as they are mentioned in connection with the respective diseases, the two citations are sufficient to show that the electrocautery apparatus is not an obsolete instrument. Spray Tubes. — Tlie spray tubes and the medicated fluids used in them have also come under tlie ban as therapeutic agents. There was a time when the rhinologist and laryngologist was called the "spray 48 THE NOSE AXD ACCESSORY SIXUSES specialist," more derisively the "squirt-gun doctor." Whatever grounds there may have been for these charactei-izations it is certain that they do not apply to the specialist of the present time. Nearly all special sur- geons now recognize the futility of attempting to cure diseases of the nose and throat by means of medicated water and oil. The etiology of the catarrhal and suppurative inflammations of the nose and throat is better understood, and the ideas concerning their treatment have under- gone corresponding changes. It is being more and more recognized that mucous-lined cavities are subject to catarrhal and infective inflammation somewhat in proportion to the degree of obstruction to their drainage and ventilation. This one factor is probably the most significant etiolog- ical factor emphasized in recent years. Goodale and Jonathan Wright emphasize it in reference to the crypts of the tonsil. Heath has recently emphasized the same truth in reference to the mastoid antrum and the De \'ilbiss' atomizer and nebulizer. middle ear. (See Heath's Masinid Operation; also the Clinical Anatomy of the Nose, and the Inflammatory Diseases of the Nose and Accessory Sinuses.) In view of this more modern conception of the etiology of the inflam- matory diseases of the ear, nose, and throat, surgical procedures have largely replaced the topical, medical, and caustic applications once in popular favor. The spray tube or atomizer occupies a less conspicuous place than it did a few years ago (Fig. 17). An array of fifty or a hundred spray bottles, each with a different medicated or perfumed solution, is no longer a necessary part of an office outfit; indeed, such an array of spray formula is in some ways a confession of an antique, if not altogether obsolete, conception of medical practice. Spray tubes are, nevertheless, necessary adjuncts to the office outfit, as they should be used to cleanse the nasal and throat cavities before operating and to treat acute and chronic inflammations. THE OFFICE EQUIPMENT 49 The Mechanical Vibrator. — Some years ago the mechanical vibrator was mentioned as acting favorably upon tinnitis and deafness, but its more general use by English and American otologists has demon- strated its comparative uselessness for these purposes. At that time it was stated that when applied over the spinal column it seemed to act favorably upon the ear. I have tried it faithfully for this purpose, with no appreciable effect. Its chief field of usefulness is in reducing the swelling and sensitiveness of the glands of the neck and the headache accompanying the various sinus affections. But even these conditions are better and more pleasantly ameliorated by the leukodescent lamp. The vibratory or mechanical massage increases the lymphatic flow, improves the nutrition, and increases local leukocytosis. Hence, it Pynchon's modification of Dabney's vacuum aspirator leukodescent therapeutic lamj). relieves pain and tenderness, and reduces the activity of an inflammatory process, provided it can be applied to the parts. In this respect it acts upon the principle of Bier's constriction and negative pressure treatment, and the leukodescent-light treatment; that is, they each increase the local leukocytosis, improve the local nutrition, and thus diminish the inflam- matory y)rocess. Negative Pressure Apparatus.— This apparatus consists of a device whereby the air pressure is reduced in the upper air passages, notably the nose and accessory sinuses (Fig. 18). The negative air pressure within the nose and accessory sinuses facilitates the* discharge of the secretions and purulent accumulations, increases the local nutrition and leukocytosis, and acts favorably upon the inflammatory process. Its chief 4 50 THE NOSE AND ACCESSORY SINUSES field of usefulness seems to be in the treatment of the subacute inflamma- tions of the sinuses, though it exerts a favorable influence upon chronic sinuitis. The Leukodescent Lamp. — The leukodescent lamp is a single incan- descent globe of 500 candle-power (Fig. 19), around which is placed a reflector eighteen inches in diameter. The reflector focuses the rays of light, thus increasing their penetrating power. The therapeutic properties of the leukodescent light is in the heat and chemical rays. The leuko- descent light is rich in blue-violet rays, in addition to the light and heat rays. The blue-violet are very active chemical rays and increase the tissue metabolism and the leukoc^-tosis, thus providing for the destruction of the pathogenic bacteria. Clinically, I have found the leukodescent light of value in inflammatory and infectious processes. For instance, I have seen cases of chronic maxillary empyema with granulations cease discharging under its influence. The pain, tenderness, and swelling likewise disappeared. In no case, however, have I seen a cure by this mode of treatment. In acute sinuitis I have seen marked and rapid improvement follow its use. Infective inflammation of the mastoid W'Ound rapidly improves under its use three times daily. Cervical adenitis usually responds readily to the rays. Pain of almost any origin is relieved and in many cases stopped by it. The pain of sarcoma is almost invariably checked. It seems to exert a slight control over an oozing postoperative hemorrhage. Its power to increase tissue metabolism and local leukocytosis reduces the bacterial activity. The latter is probably due more to the increased leukocytosis than to the bactericidal property of the rays. While they are bactericidal when applied continuously for ten minutes at a distance of thirteen inches in the laboratory, they are probably not batericidal at eighteen inches for a few moments at short intervals in their clinical application. The rays are too hot to be tolerated constantly at close range, hence the effects produced in laboratory experiments cannot be duplicated in actual practice. Lamps of less candle power are correspondingly poor in the blue- violet rays, the 50 candle-pow^er lamp having scarcely a trace of them. It has also been shown that ten 50 candle-power lamps in group have indentically the same quality of rays as a single 50 candle-power lamp, and that the rays are in no way similar to those given off by a 500 candle- power lamp. I therefore recommend that a single 500 candle-power lamp be chosen, as a lamp of less capacity is not sufficiently rich in chemical rays to ])roduco the best results. A Sterilizer for Instruments and Gauze.— An office outfit is not complete without a sterilizer of some kind. All instruments should be boiled for at least twenty minutes before they are used, for either examina- tions, treatments, or surgical operations. The instruments may be boiled in a porcelain-lined bucket or pan, or in a specially designed sterilizer, as shown in Fig. 20. The apparatus shown in the illustration is provided with a drying chamber in addition to the boiling tray, and is recommended on this account. Instruments are often damaged or THE OFFICE EQUIPMENT 51 altogether ruined because they are not dried after being steriHzed. With this sterihzer they may be boiled and dried after an operation. Topical Applications. — ^Topical remedies which should be upon the treatment table are numerous, though individual preference may greatly modify their number and character. I shall only refer to those which have proved satisfactory in my practice. Nitrate of Silver. — ^The following solutions of nitrate of silver should be kept on the treatment table in blue-glass bottles, or in a cabinet within convenient reach of the surgeon or his personal assistant. 'Bj,. — Argenti nitratis Aquae des. Sf^M. This is approximately a 2 per cent, solution of the silver salt, and is useful where a mild but positive astringent action is required, as in simple subacute catarrhal inflammations of the upper respiratory tract. It may be applied with a spray tube, the essential parts of which are made of hard rubber and aluminum, or of glass. Other metals are acted Pynchon's sterilizer and instrument dryer. upon by the silver salt, and are not suitable for the silver solutions on this account. The silver solution may also be applied with a cotton- wound applicator. A camel's-hair brush is not recommended, on ac- count of the difficulty of keeping it sterile. I^. — Argenti nitratis gr. xx Aquae des 5J — M. This solution is approximately 4 per cent, in strength, and may be used as No. 1 when a more positive astringent and antiseptic action is required. I^. — Argenti nitratis gr. xl Aquae des 5J — M. This solution is approximately 8 per cent, in strength, and is useful in the more chronic catarrhal inflammations of the upper respiratory tract. Solutions of greater strengtli than this are rarely indicated in chronic inflammations of the mucous membrane except when a caustic action is required. Higher strengths are apt to cause irritation and an aggravation of the local chronic inflammation. Oj THE NOSE AXD ACCESSORY SIXUSES In the very acute inflammations a much higher percentage of silver may be used. I^. — Argenti nitratis oss Aquse des q. s. ad 5J — ^^^ This is a 12?, per cent, solution and is a valuable local remedy in acute lacunar inflammation of the tonsils. The more acute the attack and the more edematous the tissue the stronger the silv-er solution should be. I^. — Argenti nitratis oij Aquae des q. s. ad 5J — ^I- This is a M) per cent, solution and is useful as a local application in acute infectious inflammations of the fauces and the nasopharynx. It is especially useful in acute lacunar tonsillitis, one application in the primary stage often being sufficient to abort the inflammatory process. I^. — Argenti nitratis gr. ccccxxxij Aquae des q. s. ad 5J This is a 90 per cent, solution and is useful in acute lacunar tonsillitis in the most \'irulent and acute stage. It should only be applied when the inflammation is very recent and aggravated in type. The tissues should be succulent and highly inflamed. In such a case of acute lacimar tonsillitis it is a specific remedy. I have never seen a case corresponding to the above description in which a second application of the remedy was necessary. Its use in this strength is not painful, but, on the contrary, relief immediately follows its use. If this strength of solution were applied to a subacute inflammation the chemical trauma would probably aggravate the existing inflammatory process rather than relieve it. Solutions of silver salt in the higher strengths coagulate the mucous secretions and blanch the surface of the inflamed mucous membrane. It is also a powerful germicide. The inflammatory infiltration of the tissue is checked and the vitality of the infective bacteria is lowered or destroyed. A caution as to the use of silver nitrate. The silver salt in any strength has a marked irritating effect on the intrinsic muscles of the larN-nx. To avoid this accident the cotton-wound applicator shoukl be freed of the excess of the solution by squeezing it with a liberal wad of cotton. When this is done the inflamed area should be lightly brushed with it. Silver Maxims. — (a) The milder the inflammation the milder the solution, (h) The more intense the inflammation the stronger the solu- tion. Guaiacol Solutions. — Solutions of guaiacol in olive oil are useful local remedies in acute inflanmiation of the fauces and the pharynx. The strengths recommended are 10, 25, and 50 per cent, of guaiacol in ])ure olive oil. The more severe the inflammation the stronger the solution required. While guaiacol is not as efficient a remedy in acute tonsillitis as the stronger solutions of silver, it is nevertheless very positive in its action, many cases recjuiring but a few applications to check the inflammatory THE OFFICE EQUIPMENT 53 process. It produces a pungent, hot sensation which lasts for about thirty seconds. Compound Tincture of Benzoin. — The compound tincture of benzoin is a valuable local remedy in the throat where a mild but positive astrin- gent and antiseptic remedy is indicated. It may be used in chronic granular pharyngitis during the mild exacerbations of the disease with good effect. Its chief value is as an adjunct in dressing the nasal accessory cavities. The gauze should be moistened in the solution, the excess removed by squeezing, and packed in the nasal cavity. It prevents decomposition and stimulates healthy granulations. A plain gauze dressing in the nasal chambers, if allowed to remain more than twenty-four hours, often takes on a very offensive odor. If the gauze is moistened with the compound tincture of benzoin, it may remain in the nose seventy- two hours without acquiring an offensive odor. A foul-smelling chronic otorrhea may be rendered sweet by mopping the cavity dry and applying a dressing of gauze moistened with the compound tincture of benzoin. SECTIDN SHDWING POWDER SCOOP Powder insufflator. Sub nitrate of Bismuth Powder. — This powder may be used with gauze dressings as a substitute for the compound tincture of benzoin. It also prevents decomposition, though not over so extended a period. It may also be insufflated (Fig. 21) into the nose after an intranasal operation, where it forms a coating which acts as a mechanical and a chemical protection to the underlying tissue. Ichthyol Solutions. — Ichthyol in aqueous and glycerin solutions may be used as a topical application in the nasal chambers where there is a foul or ozenic secretion. The nose should be packed with cotton or gauze saturated with the solution. Personally I prefer to use a cork- screw applicator wound with cotton and dipped in the ichthyol solution. This is then introduced into the nasal cavity and the applicator removed with a reverse screw motion, leaving the ichthyol pad in the nose. This should be left in place for from ten to thirty minutes, according to the degree of infection and tumefaction of the tissue. If the secretions are profuse and dried in the nasal cavities, the aqueous solution should be used; if there is a state of sepsis and local tumefaction of the tissues, the glycerin sohitioii should be used on account of its hygroscopic action. Iodine Solutions. — Iodine in a glycerin menstruum is a vahia])]e remedy in chronic granular phar>mgitis, and in tliosc cases of middle- ear catarrh associated with granular pharyngitis. 54 THE NOSE AXD ACCESSORY SINUSES The following f orraul?e may be used in such cases : I^.— Tr. iodini Itlxlviij Glycerini q. s. ad 5J — M. I^. — lodoformi gr. j Potas. iodidi gr. x— xx Morphia sulphat is gr. j Glycerini 5j — M. I^. — Iodini gr. v-xx Potas. iodidi gr. x— xxx 01. gaultheriae Ttlv Glycerini 5j — M. IJ.— Tr. iodidi, Tr. ferri chl., Glycerini . aa q. s. 5j — M. The fourth formula is very astringent and is used to promote even healing by granulation after tonsillectomy in adults. It is also of great value in the subacute type of granular pharyngitis. Carbolic Acid. — Carbolic acid may be used in any strength from 10 to 93 per cent, aqueous or glycerin solution. IJ. — Carbolic acid gr. xx Glycerin 5j — M. This is approximately a 4 per cent, solution and may be used in sub- acute dry dermatitis of the external auditory meatus and in subacute otitis media. I^. — Carbolic acid 3 Glycerin q. s. ad §j — M. This is a 12 per cent, solution and may be used in acute otitis media. It should be dropped into the meatus two or three times daily and a cotton plug introduced to prevent its escape. It is claimed that if dropped into the meatus in the initial stage of acvite suppurative otitis media it aborts the further progress of the inflammation in nearly every instance (A. H. Andrews). On the other hand it is claimed that its frequent use causes a fibrosis and thickening of the ear drum, and thus causes permanent diminution of hearing. It may be said, however, that its frequent use is not often required to abort an attack of acute otitis media. I^. — Carbolic acid gr. ccclvj Aquae des gr. xxiv — M. This is a 95 per cent, solution of carbolic acid and may be used when a superficial caustic effect is desired, as in infective granulomata of the middle ear and mastoid, either before or after operation. I have occasionally used it in old foul-smelling otorrheas to diminish the odor and to stimulate healthy granulation. It should be carefully dropped into the middle ear without allowing it to come in contact with the ineatal skin, and at the end of one minute alcohol should be instilled to check its action. THE OFFICE EQUIPMENT 55 Alcohol. — Alcohol is also a valuable remedy for topical applications. I know of no better ingredient for a gargle than alcohol. It is astrin- gent and antiseptic, and, when properly diluted, is grateful to an inflamed surface. I^.— Alcohol, Cinnamon water aa Bij Formaldehyde tTlij Glycerin 3v Aquae des q. s. ad §viij — M. The above formula is a good gargle in acute tonsillar and pharyngeal inflammations and in the soreness following the removal of the tonsils. In very young children it may be used in a more diluted form. In chronic otorrhea alcohol may be used in the following dilutions and mixtures. I^. — Alcohol 1 part Aquae des. 2 parts — M. I^. — Alcohol 1 part Aquae des 1 part — M. I^. — Alcohol 2 parts Aquae des 1 part — M. I^. — Alcohol 3 parts Aquae des 1 part — M. IJi — ^Alcohol 95 per cent. The alcoholic dilutions given above are used principally in the treat- ment of chronic suppurative otitis media. They constitute the so-called "alcohol treatment" of this disease: The meatus is first filled with the weakest solution, then mopped out, and each solution applied in series until the patient tolerates the 95 per cent, solution. If the strongest solution is applied at once it causes considerable pain and irritation, whereas if the strength is gradually increased unpleasant results are avoided. Alcohol is a positive astringent and antiseptic remedy of considerable value. I^. — Alcohol (95 per cent.) 5j Boric acid gr. xx — M. I^. — Alcohol (95 per cent.) 5j Iodoform gr. v — M. The addition of boric acid and iodoform is supposed to give the local antiseptic effects of these drugs. If an excess of either drug is added, and the solution is agitated just before the instillation of the solution, a precipitate of the partially suspended drug is deposited on the diseased mucous membrane. These solutions should be used after having applied the weaker alcoholic solutions. Ointments. — Various drugs may be prepared with an oily menstruum, preferably lanolin, as it has greater aflfinity for the mucous membrane 56 THE yOSE AXD ACCESSORY SIXUSES tlian vaseline. Pure olive oil may also be used as a menstruum. The following mixtures are recommended : I^. — Zinc oxide gr. xlviij Lanolin 5J — M. I^. — Zinc oxide gr. xlvij Morph. sulpli gr. g Atropine gr. yjij — M. The first formula is soothing to an inflamed surface, and may be applied in those cases in which there is an irritating mucous or sero- mucous discharge in catarrhal sinuitis. It is also of use in the massage of the nasal mucous membrane in rhinitis with collapse, and in turges- cence of the swell bodies. For this purpose a delicate silver applicator should be wound with a small wisp of cotton and dipped into the oint- ment. The nasal mucous membrane should then be gently massaged with the ointment, the probe being lightly held between the thumb and forefinger. The wrist movement, or the combined wrist and forefinger movement, should be used in performing the massage. The applicator should be held so lightly that if the cotton-wound applicator should strike a turbmated body or other obstruction the probe will slip through the fingers and do no damage. The sensitiveness of the mucous membrane may be quickly removed by the above procedure. The second mixture is of value when the nasal mucous membrane is sensitive and when there is an acute exacerbation of the inflammation. The morphine and atropine relieve the sensitiveness and reduce the con- gestion. I^. — Ichthyol gr. xlviii Lanolin §j — M. The ichthyol ointment may be used in those cases where the secretions are dried in the nasal cavities to stimulate the glandular functions. It may hv apj)]ie(l by massage, as described above. Chemical Caustics. — Chemical caustics are largely replaced by the electrocauteiy, though there are instances in which the chemical caustics are preferable. The following are recommended : Carbolic Acid (95 per cent.). — Where a superficial and diffused cauter- ization is desired, as in an unhealthy granulating surface, carbolic acid is an ideal caustic agent. It does not penetrate deeply, nor does it produce pain. It is also of value in old suppurative ear cases in which there is a foul odor and exuberant granulations. The ear should first be thoroughly freed from secretions with a cotton-wound probe, and the carbolic acid applied afterward. After one minute has elapsed alcohol should ])e dropped into the meatus to check the action of the carbolic acid and to prevent its action upon the skin of the meatus and auricle during its removal. The carbolic acid should be dropped into the middle ear with a medicine dropper, care being exercised to avoid getting it in contact with the cutaneous surface. THE OFFICE EQUIPMENT 57 Carbolic acid may also be used in the pharynx where a diffused superficial caustic action is desired, as in a mild case of granular pharyngitis, though in these cases it is usually preferable to puncture the follicles or nodules scattered over the pharyngeal wall with the galvano- cautery. Chromic Acid. — Chromic acid has long been a favorite chemical caustic in the nose, throat, and ear, though it has been largely replaced by the galvanocautery. A few crystals are engaged upon the end of a probe and held over an alcohol or gas blaze to drive off the water of crystallization, but not long enough to reduce them to an ash or cinder. The bead of acid thus formed is drawn across the area to be cauterized, where it rapidly abstracts the water from the tissue and thus destroys or cauterizes its superficial layers. It may be used in turgescent rhinitis, follicular pharyngitis (granular pharyngitis), and in any other condition requiring cauterization. It is not as deep in its pentration as is usually desired in either of these condi- tions, hence it is not as reliable as the galvanocautery. In order to increase its efiiciency, Norval H. Pierce and Max A. Gold- stein have devised instruments for its subcutaneous use. The submucous method has not, however, appealed strongly to the profession, as the galvanocautery is easily and efficiently applied with equally good or even better results. It should be remembered that chromic acid is quite irritating to the kidneys, and may cause albuminuria. Its extensive use is, therefore, contraindicated in cases already thus affected. Technique. — (a) Local cocaine anesthesia. (&) Puncture the mucous membrane at the anterior end of the free border of the inferior turbinated body, (c) Introduce a probe or other elevator through the puncture and tunnel the substance of the mucous membrane, keeping near the periosteum, (d) Introduce the Goldstein concealed probe containing the bead of chromic acid into the depth of the tunnel, (e) Uncover the bead of chromic acid and withdraw it through the tunnel. This cauterizes the wall of the tunnel within the mucous membrane. If sloughing does not occur the result is very good. Trichloracetic Acid. — This is a valuable chemical caustic agent and is generally used in a 20 per cent, solution. It has been employed chiefly in tuberculosis of the lar^mx, in conjunction with curettage, and in hypertrophied and diseased tonsils after splitting the crypt walls. In larjmgeal tuberculosis after the intralaryngeal removal of all the tuberculous tissue available by this route the operated area is swabbed with a 20 per cent, solution of trichloracetic acid, to destroy any remaining tuberculous tissue and to seal up the lymphatic openings to prevent the spread of the tuberculous process. Kaufmann has recommended the free and deep incision of tlie crypt walls of the tonsil, especially of those crypts opening into the supra- tonsillar fossa, and applying a 20 per cent, solution of trichloracetic acid to the incised surfaces. INIore than one sitting is usually required for this purpose. The object of this procedure is to destroy the diseased 58 THE NOSE AXD ACCESSORY SIXUSES epithelial lining of the crypts and to cause cicatricial contraction of the substance of the tonsil. In this way the tonsil is reduced in size and its non-resistant cryptic epithelium is destroyed. The acid applications are very painful for a prolonged period of time. This, together with the fact that repeated applications are often necessary, renders the procedure an undersirable one. The complete removal of the tonsil by dissection is a more certain and desirable procedure, as both tonsils may be removed at one sitting. The Nitrate of Mercury. — A 10 per cent, solution of the nitrate of mercury may be used to cauterize deep sloughing syphilitic ulcers of the nose and throat, as it excites healthy granulation, and thereby checks the sloughing antl sypliilitic ozcmki. Antiseptic and Detergent Solutions. — Cleansing the nose and throat with detergent sprays and washes is not as popular a procedure now as formerly. Experience has sho^Ti that such applications exert little curative action on catarrhal and other diseases. They do, however, promote temporary increase in the hyperemia and leukoc}iosis. Such solutions also stimulate the constrictor muscle fibers of the swell bodies of the turbinals, and thus temporarily reduce the turgescence. The antiseptic action is probably but slight and of little value. The three useful effects of the antiseptic and alkaline nasal washes are therefore as follows: (a) Detergent or cleansing effects. (6) Muscular contrac- tion of the interlacing fibers of the swell bodies, (c) Slight promotion of the reaction of inflammation. The detergent and stimulating solutions recommended are as follows : (1) Seller's solution. (2) Dobel-Pjmchon solution. (2) IJ.— Powd. sod. bibor. (Squibb). Powd. sod. bicarb. (Merck). Thymolin Oss Glycerin (C. P.) Diss First mix and triturate the two salts and place same in one-gallon bottle, adding one-half the quantity of glycerin; then let it stand twenty- four hours uncorked, with frequent agitations. Next add the remainder of the glycerin and continue the agitations for another twenty-four hours, with the bottle uncorked as before. Lastly, add the thymolin and let stand twenty-four hours. One ounce of this mxture should be added to one pint of water, when it is ready for use. The solutions may be used with an atomizer, a nasal douche, or a syringe. They may also be used as gargles, although the distinctly alkaline taste is usually disagreeable to the patient. Oily Solutions for Use with a Nebulizer. — Aromatic and antiseptic drugs may be added to an oily menstruum and thrown into the respiratory tract with a nebulizing device. The action of such mixtures is as an emollient or protective agent, and as a stimulant to the mucous glands. They also cause contraction of the circular muscle fibers of the arterioles, and thereby reduce the congestion. The effects are transient and afford relief without exerting a marked curative effect. THE OFFICE EQUIPMENT 59 The following formulse are recommended: 1. Chloretone inhalant. I^. — Chloretone gr. xv Camphor gr. xxx Menthol gr. xxx Oil cinnamon ad TTlv Oil petrolatum gij — M. 2. Acetozone inhalant. I^. — Chloretone . . . vij Acetozone xv Oil petrolatum q. s. ad §ij — M, The spray bottles and nebulizing bottles devised by De Vilbiss (Fig. 17) have proved more satisfactory than any others, as their construction is simple and they rarely need repairing or other attention. The nasal douche is also a useful device for washing the nasal cavities, and is often preferable to the spray tube, as it does not injure the epithelium of the nasal mucous membrane. The air pressure allowable for spraying the various mucous surfaces with De Vilbiss' spray apparatus is as follows : (a) The nasal mucous membrane, 4 to 10 pounds. (6) The epipharynx (nasopharynx), 8 to 20 pounds, (c) The mesopharynx (oropharynx), 10 to 30 pounds. {d) The hypopharynx and lar}Tix, 10 to 30 pounds. The air pressure needed for the De Vilbiss nebulizing bottles, 10 to 40 pounds. The regulating tank elsewhere mentioned is of great value in conjunc- tion with the spray and nebulizing tubes. Solutions Producing Ischemia. — Solutions producing local blanchmg of the mucous membrane are chiefly derived from the suprarenal glands of sheep. They produce a powerful contraction of the circular muscle fibers of the arteries, which lasts for several minutes. They are on this account of diagnostic and therapeutic value. They also reduce the amount of primary hemorrhage in operations. The following formulae are recommended : I^.— Adrenalin chloride 1 to 1000 I^. — Adrenalin chloride 1 to 2000 IJ. — Adrenalin chloride 1 to 4000 It is rarely necessary to use the first formula except when there is a great deal of secretion and blood to dilute the solution. If applied to a clean mucous membrane the second and third formulae are of sufficient strength to contract the vessels. Local ischemia is produced for diag- nostic purposes in the various forms of rhinitis and in reducing the engorgement of the tissues so as to admit of a view of the nasal cham])ers. Adrenalin is also used to check local oozing of blood after operations. CHAPTER IV. THE ETIOLOGY OF DEF0R:\I1TIES AND DELATIONS OF THE SEPTUM NASI. "The chief cause of deviations, and probably of many other deformities of the septum, is the lack of development of the hard 'palate. Trendel- enburg WHS, perhaps, the first to associate the high-arched palate with deformity of the septum, but did not, so far as I can learn, consider it due to a lack of deyelopment of the maxillary bones. Loewy expresses somewhat the same idea, but regards the Gothic, or high-arched palate, as of rachitic origin. Ziickerkandl rather scouts this idea and says he has been unable to associate rickets with deviated septa, and that it is chiefly the lower jaw, not the upper, which exliibits the rachitic influence. On the other hand, it is in the every-day experience of us all to find the high-arched palate associated with a deviated or otherwise deformed septum" (Freeman). Thus in 302 cases of high-arched palate there were only twelve where there was no marked deformity of the septum. We have 96 per cent, of deformed septa, which shows that there is undoubt- edly a very close relationship between the high arch and septal deformities. One must not, however, in drawing conclusions as to the relationship between the Gothic-arched palate and deformities of the septum, con- sider that every high arch is an abnormal one. In studying the skulls in the ]Mutter collection. Freeman found that a perfectly straight septum was not uncommonly associated with a high arch. This, however, was chiefly in dolichocephalic heads, in which, with the high, narrow skull, there was associated a high, hard palate, and, in spite of the latter's position, the choanre were also very high and narrow. The skulls w^re those of non -Europeans, in w4iom, as Ziickerkandl has pointed out, one finds deformities of the septum much more infrequent than with us. The infant hard palate is of the Gothic type, and anything which interferes with the skull and perfect development of the child prevents also the development of the hard palate and consequently its descent. Indeed, as years go by, the Gothic arch becomes more and more peaked by the further development of the alveolar processes and the eruption of the teeth. On account of the high position of the palate the septum must bend or twist, acconnnodating itself to the boundaries imposed by the unyielding framework of the bones with which it articulates. Another point in favor of this view is that mentioned by Welcker, that in some cases there is a descent of one of the maxillary bones, the other remaining high arched, in which case the convexity of the deviation of the septum is toward the lower (Freeman). DEFORMITIES AND DEVIATIONS OF THE SEPTUM NASI 61 Eugene S. Talbot has written more extensively and carried on a wider range of observations regarding deformities of the facial bones, including those of the nose, than perhaps any other investigator. His views are briefly presented in the following quotation: "Morgagni believed they were due to excessive development of the vomer. Trendelenburg held that they were due to a crowding up of a high-arched palate, as he had observed the two conditions frequently connected. Jarvis has reported 4 cases, all in the same family, and suggests they are due to direct hereditary defect, while neurotic or de- generate conditions which underlie the building up of the system may produce the deflection; direct heredity here, as elsewhere, is rare. Schaus' and Welcker's investigations show there is a family development of the facial skeleton. Bosworth and others believe that septal defor- mities are due to traumatism. "According to Bosworth, the clinical history of many of these cases affords direct evidence of this, and even in those cases in which the direct injury is not testified to, I think it safe to say that an injury has occurred which may have been of so slight a character as not to have excited special attention at the time of the occurrence. An injury to the nose need not necessarily give rise to the immediate development of a notable deformity, as in fractures, but it may set up a low grade of morbid action, which, going on through a number of years, finally develops a condition by which the normal function of the nose is seriously hampered. The point on which he lays special emphasis is that the deformity is primarily the result of traumatism, and secondarily of a slow inflammatory process which results therefrom. "Deviation of the nasal septum to one side or the other is the result of an unequal development of adjacent bony parts, more especially and directly of that of the turbinated bones. It depends largely, if not exclusively, upon the development and position of the latter. They, in turn, are dependent in great measure upon the development of the facial bones, which are modified as the facial angle increases and prognathism is lost, the turbinated bones being, as it were, exostosed, not moulded in many directions by adjacent parts, encroaching more irregularly upon the nasal cavity, as their origins are disturbed or dislocated. Freedom of the nasal passages for the transit of respired air is essential. In normal respiration the tendency is for both nostrils to share equally. The natural consequence is that the vomer, the ossification of which is incomplete until puberty, is deflected and occupies, as a rule, nearly a midway position between the bony prominences on either side. De- flection of the septum therefore is a compensatory arrangement in the evolutionary variations of facial development. It is therefore most frequent in the higher races, while in the lower its occurrence is markedly less. "Instability of tissue building is to be expected in neurotics and degenerates. It is easy to see how, with such an unstable ])one tissue to build upon, the mucous membrane of the nose may undergo atrophy, hypertrophy, or adenoid growths resulting in mouth breathing. 62 THE NOSE AND ACCESSORY SINUSES "Total collapse of the outer walls of the nose is frequently observed among neurotics and degenerates. This is associated with arrest of development of the bones of the face and jaws, deformities of the dental arch, contracted chest, round shoulders, husky voice, etc. In most cases of this description the nose is very long and thin. The nasal bones are excessively developed, and there is marked deflection of the septum. Frequently nasal catarrh is present. During inspiration turgescence of the swell bodies is produced and nasal breathing is impossible." An analysis of the foregoing quotations from Freeman and Talbot gives an epitome of some of the theories that have been advanced as to the etiology of deformities of the nasal septum. These theories may be tabulated as follows: 1. INIorgagni thought they were due to excessive development of the vomer; the vomer crowding upward against the descending perpen- dicular plate of the ethmoid caused septal deflection to one side, in order to allow of continued development. 2. Trendelenburg and Freeman think the chief cause of the deflection is in the persistent high or Gothic arch of the hard palate. The vomer and the perpendicular plate of the ethmoid are thereby crowded and deflected in order to find room for further complete development. 3. Jarvis believes the chief cause is heredity and quotes observations in support of this theory. 4. Schaus and Welcker advance the hypothesis of a faulty develop- ment of the facial bones, including those of the nose. 5. Bosworth argues that traumatism is the chief cause of deflections. 6. Talbot takes the theory of Schaus and Welcker and carries it still farther, and says that malformations of the septum are due to neuroses or stigmata of degeneracy, which result in irregular development of the facial bones. He believes that the pigeon chest, adenoids, and deformed nasal septa are all due to the same neurotic influences, which arrest development in some parts while in others there is an increase in the development. It is difficult to arrive at a final conclusion concerning these theories, as data of almost any kind can be found by one who diligently searches for it. It is easy to say there is excessive development of the vomer, and to report so many thousands of observations on skulls in which this theory is substantiated. Trendelenburg and Freeman have satisfied themselves that the Gothic arch is the cause. They say the high arch of childhood does not descend as it should, and that the space for the vomer and the ethmoid plate is thereby encroached upon and deflection results. Talbot and others have studied the so-called high arch and find that it rarely exists, also that in some instances there is lack of lateral development of the superior maxillae, which gives rise to the Gothic arch, or what appears to be an abnormally high arch. Actual measurements show them to be no higher than normal. Then, too, Talbot claims that many hard ])alates which are lower than the average are attended by sep- tal deformities. He does not deny that traumatism does in some instances account for septal deformities, but he does deny that it is the chief cause A CLASSIFICATION OF DEVIATIONS OF THE SEPTUM NASI 63 of deviations. He believes that consanguineous marriages predispose to the neuroses and that facial deformities result therefrom. He holds that the facial bones are transitory and more subject to developmental influences than most parts of the skeleton, hence are either arrested or overdeveloped in those tainted with the stigmata of degeneracy. Dr. Talbot's views present the most rational explanation of this much mooted question that has yet been ofi^ered. He does not name the overdevelopment of a particular bone nor does he claim the failure of the palatine arch (roof of the mouth) to descend as being the cause of deviations of the septum. If these conditions are present he claims they are incidental signs of a neurosis or degeneracy. The factor back of an excessive develo'pment of the vomer or of a Gothic or narrow (not high) arched palate is also back of the deformed septum. In conclusion I will epitomize the etiology of deformities of the nasal septum as follows, in the order of their importance: (a) Neuroses or stigmata of degeneracy which cause either an arrest or an excessive development of the bones of the face, including the nose; one of the expressions of the neurosis being deformed septa (Talbot). The theories of Trendelenburg, Freeman, Morgagni, Jarvis, Schaus and Welcker are swallowed up in that of Talbot. The individual theories they advance imperfectly convey the true explanation, while Talbot's comprehends them all and strikes at the root of the matter. (b) Bosworth's traumatic hypothesis is true as to a certain number of cases. That it explains a majority or even a large percentage of them is doubtful. The phraseology used by Talbot may be objectionable, inasmuch as it assumes that there are "stigmata of degeneracy" present in all cases not due to traumatism. It would be better perhaps, to say that deflections of the septum are usually due to an incoordination in the development of the bones of the face, including those of the nose. A CLINICAL CLASSIFICATION OF DEVIATIONS OF THE SEPTUM NASI. Malformation and deviations of the nasal septum may be either developmental or traumatic in origin. When developmental, any or all portions of the septum may be involved, whereas if it is of trau- matic origin the anterior or cartilaginous portion only is affected, except in exceptional cases. The point of chief clinical interest, however, is in the type and location of the deformity rather than in its origin. Even the type and location of the deviation have to a considerable degree lost their clinical significance in so far as treatment is concerned, since the perfection of the submucous resection of the septum has been accomplished, and so many types of septal malformations are found to be amenable to it. Cartilaginous Deviations. — When the deformity is limited to the cartilaginous portion of the septum it is one of three types, viz.: 64 THE NOSE AXD ACCESSORY SLXUSES (a) A deflection of the anterior portion generally known as the columnar cartilage (Fig. 22). The antero-inferior border of the cartilage is turned outward into the vestibule of the nose and obstructs the respiratory passage. This type of deviation is not as serious in its consequences as those that obstruct the nasal chamber in the region of the middle tur- binated bodv, as it only interferes with the areation of the nasal chamber and accessory sinuses, the dramage being unimpaired, except in so far as it depends upon the mechanical aid of the Fig. 22 air Current in propelling the secretions to the epipharjTix. (b) An angular deviation in an antero- posterior direction is serious in proportion to its proximity to the middle turbinal. If it is limited to the region of the vesti- bule or of the inferior turbinal it is of less clinical importance, though its removal is still indicated. If it obstructs both the middle and the inferior meatuses its re- moval is of the greatest importance, as it interferes with both the drainage and ventilation of the nasal chamber and the accessor}^ sinuses of the nose. Deviation of the anterior portion (c) A perpendicular deviation of the carti- of the septal eartilage, which may be i ^ • i. e 'i.! i.1 iM a" 'xU removed through Hajek'. incision by ^^gC Only UlterferCS With the VentllatlOU, Wlth- sharp dissection. out blocking the drainage of the secretions, except anteriorly, which is inconsiderable. Osseous Deviations. — For clinical purposes osseous deviations of the septum may be divided into three types: (a) A bony ridge or crest along the upper border of the crista nasalis and the vomer. The direction of this deformity is backward and upward, usually beginning anteriorly about one-half inch from the border of the inferior portion of the nasal opening, near the floor of the nose. A ridge in this location does not necessarily obstruct the normal inspiratory tract (middle and superior meatuses), nor does it greatly interfere with the drainage of the secretions. It does, however, encroach upon the inferior turbinated body, and thus causes irritation of this important physiological organ and produces a sense of stuffiness of the nose. It interferes also to some extent with the posterior drain- age of the secretions. It also projects to some extent into the respiratory pathway and forms a favoraV)le place for the desiccation of the secretions. Crusts are, therefore, generally found upon the anterior extremity of the ridge, and in blowing the nose become detached, tear the epitlielium, and give rise to epistaxis. \Miile the ridge may not cause nasal obstruc- tion, it shoukl be removed on account of the mechanical irritation of the inferior turbinal and the resulting turgescent and hypertrophic rhinitis. (b) Tlie perpendicular plate of the ethmoid bone is often convex or cup-shaped and impinges upon the middle turbinal upon the side of A CLASSIFICATION OF DEVIATIONS OF THE SEPTUM NASI 65 convexity. This is, perhaps, one of the most serious obstructive lesions of the septum, as it obstructs both the drainage and the ventilation of the superior meatus, and of the frontal, ethmoidal, and sphenoidal cells. Sufficient importance has not been given this type of deviation, hence I wish to lay special emphasis upon it. It is this type of deviation, more than any other, that gives rise to conditions which eventuate in catarrhal and suppurative inflammations of the accessory sinuses. In the first place the secretions are retained, undergo decomposition, and impair the vitality of the mucous membrane. Infection and inflammatory reaction naturally follow. The ostei of the sinuses become closed from swelling of the mucosa, and this still further interferes with the drainage. Furthermore, the ventilation of the superior meatus and of the obstructed sinuses is partially or completely lost, and the de- composition of the secretions is thereby encouraged. The oxygen of the air within the obstructed sinuses is absorbed and rarefaction results. The blood of the lining mucous membrane is attracted to the parts by the negative pressure thus created, and catarrhal inflammation is favored. If, in the course of events, active pus-producing microbes, as Fig. 23 the streptococci, staphylococci, dip- lococcus pneumoniae, etc., find lodgement there a suppurative in- flammation of the sinuses results. It is obvious that this type of deviation is of the greatest impor- tance and that the indications for its removal are urgent. (c) The combined deviation, in- cluding the ridge along the crest of the vomer and the convexity of the perpendicular plate of the ethmoid bone (Fig. 23), is a very common type of septal deformity, and often calls for correction at the hands of the surgeon. The indications for operative interfer- ence are given under (a) and (6) of Osseous Deviations, and need not be further discussed here. The indications are obviously more urgent than in either the simple ridge or the convex perpendicular plate of the ethmoid, as the ill eft'ects of both deviations are to be reckoned with. It should be noted that the convexity of the perpendicular plate of the ethmoid is usually on the opposite side from the ridge along the crest of the vomer, though it may be on the same side. It should also be noted that the cartilaginous portion of the septum is deviated with the perpendicular plate of the ethmo'd, and should, of course, be in- cluded in the operative field. 5 A compound deviation of the septum. The upper deviation is of the greater clinical im- portance, as it blocks the ventilation and drain- age of the sinuses. 66 THE XOSE AND ACCESSORY SIXUSES (d) There are still other deformities of the osseous septum, as the so- called spurs on the anterior portion, which in reality are composed of the crista nasalis and cartilage in combination, though they may be true osteomata. THE COMPLICATIONS AND SEQUELS OF OBSTRUCTIVE LESIONS OF THE SEPTUM. A review of the preceding paragraphs naturally leads to the conclusion that many of the catarrhal and suppurative inflammations of the nasal and accessory sinuses are often due either directly or indirectly to obstruc- tive malformations of the septum. The whole truth is not expressed in the above statement; nevertheless, the deduction is fundamental and should form the working basis in a large majority of cases. The etiology of the inflammatory diseases of the nose and accessory sinuses is given in Chapter VI. The following morbid conditions within the nose and accessory sinuses are either directly or indirectly caused, or their course is often largely influenced, by a preexisting deviation of the septum: 1. Acute rhinitis or coryza. 2. Chronic turgescent rhinitis. 3. Chronic h}'pertrophic rhinitis. 4. Chronic h\'perplastic rhinitis. 5. Acute sinuitis, catarrhal and suppurative. 6. Chronic sinuitis, catarrhal and suppurative. 7. Polypoid degeneration of the mucosa of the nose and sinuses. 8. Atrophic rhinitis. It is apparent, therefore, that deviations of the nasal septum should be a primary rather than a secondary subject in a systematic text-book on diseases of the nose. They are, therefore, herein discussed before taking up the consideration of the inflammatory^ diseases which are so largely dependent upon them. The indications for the correction, or the removal, of obstructive deviations of the septum are based upon the following considerations: 1. If the deviation of the septum does not interfere wdth (a) the func- tional activity of the swell bodies of the inferior turbinals, (6) the venti- lation of the middle and superior meatuses and the accessory sinuses, and (c) the drainage of the same areas it should not be subjected to surgical treatment. In other words, deviations of the septum should never be corrected simply because they are departures from the median line of the nose, but only when they obstruct ventilation and drainage, or interfere with the function of the swell bodies. 2. The positive indications for the correction of deviated septa are present when the septum (a) interferes with the normal functional activity of the swell bodies, or (6) j^revents the normal ventilation and (c) drain- age of the nasal chambers and accessor}^ sinuses. If, for instance, a ridge along the crest of the vomer is so prominent THE SYMPTOMS OF DEVIATIONS OF THE SEPTUM 67 as to touch the inferior turbinal, or if it extends forward into the vestibule far enough to partially obstruct the inspiratory current of air, and thereby produces rarefaction of the air posterior to the obstruction, it should be removed. The same is true in reference to anterior angular deflections of the cartilaginous septum. If the deviation is higher up, in the region of the middle turbinal, and interferes with the ventilation of the superior meatus and the accessory sinuses draining into it, it should be corrected. If a septum is tested by the foregoing standards, with a negative result, it should not be subjected to surgical correction, no matter how great the deviation or deviations may be. If, on the contrary, a septum is tested by the foregoing standards, with a positive i;esult, it should be corrected by some surgical procedure. THE SYMPTOMS OF DEVIATIONS OF THE SEPTUM. The Subjective Symptoms of Obstructive Deviations.— The subjec- tive symptoms of nasal obstruction are (a) a sense of fulness, either in the lower or upper portion of the nasal chambers, according to the location of the deviation. If, for instance, the deviation impinges upon the swell body of the inferior turbinal there is a sense of stuffiness or fulness in the lower portion of the nose; whereas, if it is in the region of the middle turbinal there is a sense of stuffiness or pressure through the bridge of the nose between the eyes. (6) If the obstruction in the region of the middle turbinal is great enough, or has given rise to a catarrhal inflammation in the anterior ethmoidal cells, there may be pain at the inner angle of the orbit over the lacrymal bone, either with or without pressure. When pain is elicited upon pressure in this region, it is very significant of anterior ethmoidal inflammation and possibly of the frontal sinus as well. (c) Frontal headache is frequently present in high deviations, and is most severe in the morning upon awakening. If of ocular origin it dis- appears at night and recurs during the day while using the eyes. (d) Dizziness or vertigo is sometimes a direct expression of pressure or irritation in the ethmoidal and the frontal sinuses. The dizziness is often exaggerated, or is produced by stooping forward or suddenly rising from the stooping posture, and is present when the eyes are closed. Dizziness or vertigo of ocular origin is often relieved when the eyes are closed, as the irritation from the light is thereby eliminated. Dizziness of nasal origin is aggravated by jarring the body. (e) Asthma of reflex nasal origin is sometimes due to intranasal pressure and irritation in the middle turbinal and ethmoidal regions. This is particularly true when polypi are present. (/) The nasal secretions are changed in character and quantity. If a chronic catarrhal inflammation of the lower portion of the nasal nuicous membrane has developed the secretions are heavier than normal, and expulsion is only accomplished by blowing the nose. If the obstruction 68 THE NOSE AND ACCESSORY SINUSES MMM A. Types of non-obstructive septa. a, deviated from the median line; b, normal, straight septum in the median line; c, deviation of the lower portion of the septum with a concavity in the left nasal chamber, but with compensatory liypertrophy of the left inferior turbinated body. B. Types of obstructive septa, a, ridge pressing against the inferior turbinal; b, ridge pressing against the left inferior turbinal and a convexity higher up on the right side obstructing the olfactory fissure on that side; c, a split .septum causing double obstructive convexity of the septum. C. a, an S-shaped septum causing obstruction in the inferior portion of the nasal chamber on the right side and the superior portion of the chamber on the left side; b, a liigh, angular devia- tion of the septum causing obstruction of the olfactory fissure of the left side. D. a, marked deviation of the septum along the crest, the vomer wedged firmly against the left infeiior turbinal; 6, abscess or hematoma of the septum obstructing both nasal chambers. THE SYMPTOMS OF DEVIATIONS OF THE SEPTUM 69 is in the middle turbinal and ethmoidal regions and a simple inflammation is present in the ethmoidal cells the secretion is sometimes watery in consistency, though it may be mucoid and quite acrid in character. Associated signs of this type of secretion are the reddened and irritated appearance of the mucosa and a fissure or eczematous eruption of the margins of the nostrils and the upper lip. (g) Postnasal or epipharyngeal "dropping" is usually complained of. The olfactory fissure may be obstructed, and, as the closure prevents drainage through the fissure, the secretions flow backward over the middle turbinal into the epipharynx. (h) Intermittent stenosis is usually present in those cases in which there is an anterior deviation which does not completely block the nasal passage. The obstruction interferes with the intake of air, and the de- scent of the diaphragm acts as the piston valve of a syringe and produces A traumatic deformity of the external nose and of the septum. The straight dotted line indicates the median line of the nose while the curved one indicates the deviation of the septum. rarefaction of the air in the nasal chamber posterior to the obstruction. This in turn developes turgescence of the erectile tissue and a temporary stenosis. (i) Alternating stenosis is another sign of an obstructive lesion in the lower portion of the nasal chambers and is due to the same causes given in the preceding paragraph. The associated disease is usually turges- cent rhinitis. The Objective Symptoms of Obstructive Deviations. — (a) The appearance of the septum and its relation to the various aspects of the outer walls of the nose constitute the most important objective symptoms. For example, if the septum is characterized by a ridge on the left side opposite the inferior turbinal and by a convexity in the region of the middle turbinal on the right side an examination shows the deviations and the impingement of the same against the inferior tur])inal on the left side and the middle turbinal on the right side (Fig. 24 B, h). Each 70 THE XOSE AXD ACCESSORY SIXUSES case should be carefully examined widi reference to the equal distribu- tion of space in the respiratory tract of the nose and with reference to its aderjuacy for physiological purposes. The various types of deviations, of course, present different pictures upon examination, each having its peculiar clinical significance in proportion to the degree of obstruction caused by it, and in particular to its proximity to the middle turbinated body. (6) The presence of pus and dried secretions in the olfactor}' fissure between the deviation of the septum and the middle turbinal is sugges- tive of the causative relationship of the deviation to the diseased posterior ethmoidal sinuses, from which the secretions in all probability flow. (c) Hemorrhage or epistaxis is often a sign of a deviated septum, more particularly in its lower and anterior portions. A prominent crest pro- jecting into the breath way is subjected to an undue exposure to the air current and the secretions become dried and adherent to it. Wlien the crust is detached, either by blowing or picking the nose, the epithelium is torn from the mucous membrane and hemorrhage results. (d) External deformity of the nose is often indicative of a corresponding deviation of the septum (Fig. 25). CHAPTER V. THE CHOICE OF SEPTUM OPERATIONS. THE SURGICAL CORREC- TION OF OBSTRUCTIVE LESIONS OF THE SEPTUM. There is no one method of correcting obstructive deviations or mal- formations of the septum nasi. The submucous resection of the septum is the most nearly universally applicable, though there are some devia- tions in which it can be used with great difficulty, whereas another method of surgical procedure can be easily and successfully used. Under such conditions poor judgment would be shown in selecting the sub- mucous operation. In choosing a surgical procedure a method should be adopted that will remove the obstructive lesion of the septum with the simplest technique and the least risk to the integrity of the nasal septum. The object of the operation should be to establish free drainage and ventilation of the nasal chambers and of the accessory nasal sinuses (see Etiology of the Inflammatory Diseases of the Nose and Accessory Sinuses), rather than to exploit one method of operating over another. It will be my endeavor, therefore, to give some general rules to guide the surgeon in the proper selection of an operation for the correction or removal of obstructive lesions of the nasal septum. Cartilaginous Deviations.— When the deviation is limited to the septal cartilage other operations than the submucous resection may often be chosen to correct it; indeed, they may often be chosen in preference to the submucous resection. This is not of universal application, however. An extreme angular deviation of the septal cartilage (Fig. 35) is rather difficult to correct by the submucous method, and is easily corrected by the Sluder operation (Figs. 34, 35 and 36). The Sluder operation is practically limited to extreme angular deviations, as stated by its author. A cup-shaped deviation may be corrected by the Asch, the Gleason, the Watson, the Price-Brown, or the submucous resection operation. The simpler of these procedures are the Watson, the Gleason, and the Price- Brown operations, and of these the Watson is, perhaps, the more simple. The choice of operation will largely depend upon the location of the cup- shaped deviation and the thickness of the cartilage surrounding it. If, for example, the cartilage anterior to the deviation is extremely thin, or has become fibrous from an antecedent chondritis, the triangular flap of the Watson operation will not engage against the opposing incised cartilage. If, on the other hand, the cartilage anterior to the cup is of the usual thickness and texture the Watson operation may be used with excellent effect. The cup deviation may also be corrected by the Gleason operation if the cartilage below the cup is firm and of the usual thickness. The H-incision of Price-Brown is also well adapted to this type 72 THE NOSE AND ACCESSORY SINUSES of deviation. The perpendicular incisions should be made, one anterior and the other posterior to the cup, and the intersecting horizontal inci- sion through die centre of the cup. The two rectangular flaps thus made are forced to the side of the convexity, thereby removing the obstruc- tion. The flaps should be held in position with a splint tube or gauze dressing for two or more weeks. If for any reason neither of these operations is applicable or desirable the removal of the cup-shaped cartilage may be accomplished bv submucous resection (Figs. 32, 33, 37, 38, 39, 44 and 50). Compound or S-shaped deviations or compound angular deviations of the septal cartilage are peculiarly well adapted to the Kyle operation (Figs. 47 and 48). The redundancy of cartilage may be removed with the V-shaped file saws at the crest of each convex surface, thus permitting the septum to be forced to an upright position in the median line. This type of deviation is also easily corrected by the submucous operation by the author's method with the swivel knife, and is perhaps more fully and surely thus corrected. In this type of deviation there is usually little difficulty in elevating the mucoperichondrium, after wdiich the cartilage is readily encircled with the swivel knife and removed en masse with dressing forceps. Simple angular (anteroposterior) deviations and L-shaped angular deviations of the septal cartilage are usually very successfully corrected by the Watson operation (Figs. 32 and 33), though they are equally well adapted to the submucous resection operation with the swivel knife. The deviated portion of the cartilaginous septum may be readily removed by submucous resection in practically all types of deviations except the extreme angular type, and even this may be thus removed. It is often preferable, however, to use one of the other methods of operating, as they are simpler and almost, if not quite, as satisfactory in their results. When, however, the obstructive deviation also involves the bony portion of the septum it is often expedient to adopt a method of operatmg that will be equally applicable to both the cartilaginous and bony deviations. Obstructive deviations usually involve both the cartil- aginous and osseous framework of the septum, hence the indications given above are not unqualifiedly applicable, except in deviations limited to the cartilaginous portion of the septum. One of the chief objections to the operations other than the submucous resection is the necessity of wearing a dressing or splint in the nose for two or more weeks. This alone should often influence the surgeon to elect the submucous operation. Osseous Deviations. — As osseous deviations of the septum are nearly always associated with one or the other of the types of cartilaginous devia- tions already referred to a method of operating should be adopted that will successfully remove both the cartilaginous and the bony deviations. The operation most universally applicable is the submucous resection. There are, however, important exceptions to this rule, notably a simple spur or ridge, unattended by other deviation of the septum. Another important exception is a deviation limited to the perpendicular plate of the ethmoid, which may be successfully reduced with Roe's forceps. THE CHOICE OF SEPTUM OPERATIONS 73 1. A simple spur or ridge may be successfully removed with a saw or spokeshave, with less risk to the integrity of the septum than it can by submucous resection. If, however, the spur or ridge is accom- panied by a deviation of the cartilage or the perpendicular plate of the ethmoid it will become necessary to adopt some other method of pro- cedure, preferably the submucous resection. 2. Spurs or Ridges Associated with a Cartilaginous Deviation.- — These types of compound deviation may be effectively corrected by first removing the ridge with a saw or spokeshave, and subsequently correcting the cartilaginous deflection by one of the methods described under carti- laginous deviations; or both may be removed at one time by the sub- mucous resection operation. 3. Spurs and Ridges Associated with an Obstructive Deviation of the Perpendicular Plate of the Ethmoid. — These types of compound osseous deviations may also be corrected by two operations, or by a single opera- tion. The ridge or spur may be removed with a saw or spokeshave at one time and the deviation of the perpendicular plate of the ethmoid at a subsequent time, with Roe's crushing forceps. The submucous resection operation is usually preferable, as the operation is completed at one sitting, and the results obtained are usually much better than by the two operations. 4. A Simple Deviation Limited to the Perpendicidar Plate of the Ethmoid. — ^Two operative procedures are applicable to this type of deviation, one the Roe operation and the other the submucous resection operation. Of the two operations my own experience is limited to the submucous resection, though I can readily conceive the successful applica- tion of Roe's method with his crushing forceps. As generally practised, the submucous resection operation sacrifices more or less of the cartilage, whether it is deviated or not. This is done to expose the bony parts to operative interference. I have, in a few cases, in which the deviation was limited to the perpendicular plate of the ethmoid, made the incision just anterior to the union of the cartilage and perpendicular plate of the ethmoid, elevating the mucoperiosteum over the ethmoid plate on the side of the incision, then extending the incision through the cartilage and elevating the mucoperiosteum on the opposite side of the plate, as is done when the Killian incision is made. After the elevation was thus completed the deviated portion of the perpendicular plate of the ethmoid was removed with the Foster- Ballenger forceps (Figs. 65 and 70). While this procedure is rather difficult, on account of the inability to see the parts while the forceps are in the nasal chamber, it can be done by exercising the proper care in instrumentation. The chief difficulty encountered is to avoid the inclu- sion of the mucoperiosteum, upon the side of the incision, within tlie bite of the forceps. A probe, or flat applicator, introduced into the mucoperiosteal pouch, to lift the mucoperiosteal membrane away from the bone, will effectually guard the membrane from the forceps. Finally, it should be said that the submucous resection operation is of the most universal application for the correction of obstructive 74 THE NOSE AXD ACCESSORY SINUSES deviations of the septum, antl that by it the most perfect correction may be made. On the other hand, there are many cases in which the deviation may be satisfactorily corrected with greater ease, with less danger of affecting the integrity of the septum and with less shock to the patient. Furthermore, there is always a possibility of producing a sunken nose by the removal of a portion of the cartilaginous septum by the submucous operation. While the accident has rarely been recorded, it has doubtless occurred oftener than is generally known. This accident is particularly liable to occur in deviations of traumatic origin, as in these cases perichondritis and chondritis sometimes followed the injury and destroyed the cartilage, especially along the ridge of the nose. If the parts are still further weakened by the removal of cartilage the ridge of the nose may fall in. In all cases sufficient cartilage should be left along the ridge of the nose to ensure ample support. THE SURGICAL CORRECTION OF OBSTRUCTIVE LESIONS OF THE NASAL SEPTUM. Having first determined that the deviation is an obstructive one (see indications) the surgeon should next elect the procedure that will afford the greatest amount of correction with the least shock and inconvenience to the patient. The type of deviation will have much to do with the election of the operative procedure. No hard-and-fast rules can be laid down as to the choice of operation, each case being somewhat different from all others. The following operative methods will, however, with slight variations in technique meet nearly all the indications for the surgical correction of the various types of septal deviations. 1. Soft Hypertrophies of the Septum.— Soft hypertrophies of the mucous membrane of the septum occur at two points, namely: (a) at the anterior portion just opposite to or below the inferior margin of the middle turbinated body, and (6) at the posterior end of the vomer. In the first instance the enlargement closes the anterior end of the olfac- tory fissure and interferes with the proper ventilation of the superior meatus and the sinuses draining into it. Its reduction is best accom- plished as follows: First, induce local anesthesia with a 5 to 10 per cent, solution of cocaine applied to the parts with a thin pledget of cotton. Second, make one or two linear incisions through the hypertrophied tissue with the actual cautery at a bright cherry-red heat (Fig. 26). This procedure may be repeated two weeks later if the first application was insufficient to reduce the mass. In posterior hypertrophy of the septum the same procedure may be followed, having first reduced the engorgement of the turbinated bodies with a spray of 1 to 2000 solution of adrenalin. 2. The Removal of Spurs and Ridges with a Saw. — Wlien the septum is normally placed, with the exception of a spur or ridge, the obstructive OBSTRUCTIVE LESIONS OF THE NASAL SEPTUM 75 lesion may be removed with a nasal saw (Fig. 27). If the deviation is a pronounced one, it may be preferable to resort to the submucous resection operation, as all other deflections can be removed by it at one time. The reduction of an anterior hypertrophy of the mucous membrane of the septum. (Pynchon.) Region of anterior end of the middle turbinal. It is sometimes called the tubercle of the septum, o, linear cauterization; 6, cautery electrode making a second linear incision. Apply at cherry-red heat. Fig. 27 Bosworth's saw. Fig. 28 Fig. 28. — a, ridge or deformity of the septum; b, the inferior turbinal encroached upon by the deviation; c, line of incision to be followed in removing the ridge with a saw. Fig. 29. — Showing the method of applying the saw to remove ridges from the septum. The technique of the saw operation is as follows : (a) Induce local anesthesia over the spur or ridge by the application of'pledgets of cotton saturated with a 5 per cent, solution of cocaine. After ten minutes remove the cotton, as anesthesia is usually complete in this time. (b) Introduce the nasal saw beneath'the ridge or spur with its cutting edge turned inward and upward, as though it were the intention to saw obliquely through the septum (Figs, 28 and 29), 76 THE NOSE AXD ACCESSORY SIXUSES (c) After the saw is engaged in the bony tissue direct it upward (Fig. 29), parallel with the surface of the septum, until the ridge or spur is completely severed from it. It is not necessary to make a preliminary incision along the crest of the spur or ridge for the purpose of elevating the mucoperiosteum, as experience has sIioami that healing takes place quite as quickly and satis- factorily when the mucoperiosteum is removed with the bone. Healing takes place by granulation and the periosteum is extended by the same process of repair over the sawed surface. In a number of cases thus operated, and subsequently operated upon by the submucous method, I have had little difficulty in elevating the mucoperiosteum over the old field of operation. Piscliel's collodion dressing, a, a thin pledget of cotton placed over the wound after the re- moval of a septal ridge with a saw; b, the collodion being appUed to the cotton with a medicine dropper. The postoperative dressings should be omitted altogether unless the method described by Dr. Pischel is adopted. He first secures absolute dryness of the wound, and then applies a thin pledget of cotton over the surface and saturates it with an ethereal solution of collodion by means of a medicine dropper and allows it to dry in place (Fig. 30). He thus hermetically seals the wound with the collodion film and protects it from the nasal secretions. The collodion dressing should be left in position until it is voluntarily thrown ofl^, which usually occurs in three or four days. Subsequent dressings are not required. 3. The Removal of Spurs and Ridges with the Spokeshave. — The spokeshave may be used instead of the saw, tliough it is attended by more risk to the integrity of the septum and shock to the patient. OBSTRUCTIVE LESIONS OF THE NASAL SEPTUM 77 The technique is as follows: (a) Local anesthesia. (6) Make an elliptical incision around the base of the spur or ridge so as to prevent tearing of the mucous membrane with the spokeshave. (c) Introduce the spokeshave (Fig. 31) into the nostril until its blade engages the posterior end of the ridge, and then pull it forward with considerable force, again and again if necessary, until it splinters the ridge from the septum. The elliptical incision previously made saves the mucous membrane from mutilation. (d) The dressing may be omitted or the collodion dressing may be used. Caution. — So much force is usually required to engage the spokeshave that there is danger of fracturing the cribriform plate and causing meningitis. Another accident which should be taken into consideration is perfora- tion of the septum. It is not possible to exercise full control over the course of the spokeshave, as it does not cut through the tissue (bony) but acts as a wedge. I have sometimes resorted to a little procedure which in a measure controls the direction of the splintering, as follows : After making the elliptical incision, grooves are made with a saw at the base of the ridge on its upper and lower aspects. The grooves guide the spokeshave as it comes forward through the bone and thus prevent cutting too deeply into the tissue. The grooves weaken the attachment of the ridge and render its removal possible with less force. Chaleway's spokeshave. The Watson Operation. — The Watson operation consists in making one or more incisions through the septum and then pushing the projecting or deviated portion toward the concave side, the bevelled edges formed by the incision retaining the septal flap in its new position. Indications. — This operation is suitable for angular deviations of the cartilaginous portion of the septum, but is not applicable to bony devia- tions or thickenings. When the deviation is simple, that is, when there is a single angular deviation extending anteroposteriorly, the incision is made from the convex side, beginning at the posterior extremity of the deviation and beneath it, extending to its anterior extremity, and thence curving forward and upward beyond it, as shown in Fig. 32. In compound deviations two incisions are made — one beneatli tlie horizontal crest and the other at right angles to the first, and behind the perpendicular deviation, as shown in Fig. 33. Technique. — (a) Local anesthesia. (b) Make the incision or incisions with a short-bladed bistoury. (c) Introchice the index finger or a broad, blunt instrument into the nose on the side of the septal convexity and force the deviated portion to the opposite side. If the single incision is mnde (Fig. 32), force the angu- 78 THE NOSE AND ACCESSORY SINUSES lar flap to the opposite side along the entire hne of incision. If the double incision (Fig. 33) is made, first force the anterior triangular flap (a) to the concave side and then force the posterior triangular flap (b) to the concave side. The bevelled edges formed in making the incision help to hold the flaps in the new position. (d) Additional support should be given to the flaps by a tampon on the side of the convexity or by a septum tube splint (Fig. 45) for a period of from seven to ten days. Sluder's Operation. — Dr. Greenfield Sluder has used a modification of the Watson operation, with excellent results, and he especially recom- mends it in children with extreme angular cartilaginous deflections. Fig. 32. — The Watson operation for correcting a simple angular deviation of the cartilaginous septum. The angular flap is forced to the opposite or concave side, and held in position with a gauze dressing or with a nasal tube. Fig. 33. — The Watson operation for a combined horizontal and perpendicular bowing of the nasal septum. An incision through the mucous membrane and framework of the septum beneath the horizontal convexity, and a secondary perpendicular convexity. The secondary inci.sion should unite with the primary one. The anterior triangular flap a thus formed should be pushed with the finger to the concave side, and then the posterior flap b should likewise be forced to the concave side and held in position with nasal splints for a week or ten days while union takes place. Technique. — (a) Cocaine anesthesia. (6) Make three parallel incisions through the entire thickness of the septum parallel with the crest (Figs. 34 and 35). The middle incision should extend the whole length of the crest. The other incisions are made at the apices of the less acute angles a and b. Two strips of cartilage are thus formed, their only attachments being at the anterior and posterior extremities. (c) Either the upper or lower strip is then forced to the concave side with the index finger or a blunt instrument. (d) The other strip is likewise displaced to the concave side, thus causing the strips to overlap, as shown in Fig. 36. (e) An Asch nasal tube is then introduced on the side of convexity to hold the strips in position while union takes place, that is for from two to three weeks. The tubes are removed and cleansed every two to seven days, according to the amount of irritation produced by them. OBSTRUCTIVE LESIONS OF THE NASAL SEPTUM 79 If the opposed surfaces are curetted before coaptation, union will take place more rapidly. Dr. Sluder reports 24 cases, 5 in adults and 19 in children, without perforation of the septum, all of his cases being extreme deflections. 4. The Gleason Operation. — The election of this operation may be made when the septum is bowed or cup-shaped, and without a heavy Fig. 34 Fig. 35 Fig. 34. — Sluder's septum operation. 1, 2 and 3, the lines of incision. Fig. 35. — Sectional view of the nose before the Sluder operation. 1, 2, 3, tlie lines of incision shown in Fig. 34. 4, the median line of the nose. ridge along the crest of the vomer. It consists essentially of a U-shaped incision extending either entirely through the sep- tum and both its mucous coverings, or only through the mucous membrane of one side and the bone and cartilage, the opposite membrane being left intact. The incision may be made with a saw, though the portion through the cartilage may be made with a knife. The Technique. — (a) Local anesthesia is induced with a 5 to 10 per cent, solu- tion of cocaine applied to the mucous membrane on both sides of the septum. (6) The nasal saw is applied on the convex side of the septum at its inferior portion, and the incision is carried through the septum in an upward di- rection, the ends of the saw remaining upon the side of convexity while its middle portion passes through to tlie concave or opposite side. A U-shaped incision is thus made with a tongue-flap suspended between the limbs of the U (Figs. 37 and 38). Sectional view of the nose iifter the Sluder oi>eration. 1, 2, 3, (he lines of incision as shown in Fig. 34. The bands of cartilage overlap and should be held in position with a nasal tube. 80 THE XOSE AXD ACCESSORY SIXUSES On account of the low position of the nasal orifice the anterior limb of the incision is usually too short. This is obviated by removing the saw and re-inserting it through the anterior limb and continuing the incision upward, or it may be extended with a knife, as the framework of the septum is cartilaginous in this region. Tlie Gleasoii ojieration. A tongue flap of the deviated portion of the septum. Gleason's tongue flap. If it is not desirable to extend the incision through the mucous mem- brane on the concave side the saw should be directed upward parallel with the septal surface on the concave side just beneath the mucous membrane. This is not at all difficult, as the mucoperichondrium and periosteum usually separate very readily from the cartilage and bone. Or the membrane may be first elevated on the concave side by the injection of normal salt solution beneath the muco- perichondrium and periosteum, thus lifting it away from the cartilage and bone. (c) Having made the U-shaped incision, the tongue-flap should be forced from the convex side through to the con- cave side with the finger inserted into the nostril. The bevelled edges of the flap and those of the fixed portion of the septum engage so as to hold it in its new position on the concave side (Fig. 39). The tongue-flap has a tendency to spring back into its former position, owing to the elasticity of the cartilaginous and bony tissue contained in it, hence it is necessary to overcome its resiliency by forcing it as far to the concave side as possible, the flap being thus fractured at its upper extremity. By the foregoing procedure the convex portion of the septum is dis- placed toward the side of the greatest nasal space, and the obstructed side is opened for freer drainage and ventilation. Objections. — One objection to this operation is that it is sometimes followed by perforation of the septum. The same is true, however, of nearly all other operations which may be substituted for it. n, sectional view of the septum after the Gleason operation. OBSTRUCTIVE LESIONS OF THE NASAL SEPTUM 81 Another and more serious objection to it is, that better results can often be obtained by the submucous resection of the septum. It is obvious that the obstructive portion of the septum can be but partially displaced by this operation, whereas, it can be completely removed by the submucous resection. Dressings. ^ — It may be necessary to insert a nasal tube (Fig. 45) on the side of convexity for a day or two to ensure the fixation of the tongue- flap in its new position. Otherwise, dressings are not needed. 5. The Roe Operation. — ^The Roe operation may be used in the same type of deviation described under the Watson, Sluder, and Gleason operations, and it may also be used to correct the bowing of the septum in the region of the middle turbinal, where there is also a ridge on the lower portion of the septum, though it is not applicable for the correction of an obstruction due to a heavy ridge. Roe has devised special forceps, with a male and a female blade (Fig. 40), for this operation. The Roe operation, a, schema showing correct method of applying ^the blades of Roe's com- minuting forceps; b, schema showing the deviated septiun forced to the concave side; c, schema showing the forceps applied to the septum, the male blade over the convexity and the female blade over the concavity. Technique. — (a) Local anesthesia upon both sides of the septum, indeed of the whole nasal mucous membrane, is necessary; or the operation may be done under general anesthesia. (b) The Roe forceps should be introduced, the male blade into the side of convexity and the female blade into the opposite side. By closing the forceps blades the convex portion of the septum is forced toward the opposite side through the opening of the female blade. The entire area of obstruction may be thus fractured and forced toward the concave side. (c) The fractured portion of the septum should be held in its new position with nasal splints, or with strips of bismuth gauze, for two or more weeks, or until it becomes fixed in its new position. 6. The Asch-Meyer Operation. — This operation consists of a crucial incision tlirough the cartilaginous portion of the septum, the four tri- 6 82 THE XnSE, AXD ACCESSORY SIXUSES angular Haps thus croattMl beino; pushed toward the side of coucavity and held in their new position with a Meyer nasal tube (Fig. 45). The opera- tion may be used in curved or cup-shaped deviations of the cartilaginous septum. In other words, the (ileason, Watson, Sluder, Roe, and Asch- Meyer operations are suitable for much the same type of deviated septa. I have often included the deviated portion of the perpendicular plate of the ethmoid in the field of operation with good residts, and see no objection to it, though the operation as originally devised })y Dr. Asch was limited to the cartilaginous portion of the septum. Technique. — {a) The operation may be performed under local anes- thesia, though it is generally preferable to do it under general anesthesia, as the shock and pain are otherwise considerable. Asch's curved scissors Fig. 42 Asch's straight scissors. Fig. 43 Asc'li's septum force) (/;) After cleansing the nasal chambers and the face, the straight Asch scissors (button-hole) (Figs. 41, 42 antl 43) should be introduced into the nostrils, the narrower blade into the side of convexity and the wider into the opposite from three-eighths to one-half of an inch above the floor of the nose, and the septum cut through. The Asch angular scissors are then introduced and the jxM-pendicular incision made, bisecting the middle of the horizontal one. Four triangular flaps are thus made (Fig. 44). (c) The sej)tuui should next be seized with forceps and fractured by rotating it from side to side. It has been my practice to include the OBSTRUCTIVE LESIONS OF THE NASAL SEPTUM 83 perpendicular plate of the ethmoidal bone in the grasp of the septum forceps, as it is nearly always deviated with the cartilaginous portion. I have also included the remnants of the ridge left after the sawing opera- tion, thus fracturing it (the vomer) from its attachment to the maxilla. Fig. 44 ^ (d) The index finger is then in- serted into the nostril on the side of septal convexity and the four trian- gular flaps pushed as far as possible to the opposite side (Fig. 44), care being exercised to fracture the flaps at their uncut bases. If this is not done the resiliency of the cartilage gradually brings them back to their original position. (e) Severe hemorrhage usually oc- curs, but it may be quickly checked by the introduction of the Meyer nasal tubes. The tubes are prim- arily used, however, for the purpose of holding the incised and fractured septum toward the concave side (Fig. 45). The tube selected for the convex side should be large enough to force the septum beyond the point it is desired to fix it, as it will swing back a little toward its old position in spite of all precautions. A smaller tube should be introduced into the opposite nostril to exert counterpressure against the septum to check the hemorrhage. After-treatment. — Both tubes should be left in position for two or three days and then removed. A tube one size smaller should then be introduced into the side of convexity but none into the opposite side. The tubes should be worn for about six weeks, being removed and Schema of the Asch operation. The crucial incision is made through the de'viated portion of the quadrilateral cartilage of the septum, thus forming four triangular flaps. The flaps are then pushed forcibly to the convex side of the septrmi and fractured at their bases, as shown by the dotted lines. This is done to overcome the resiliency of the cartilage. cleansed every alternate day during this jjeriod. Experience has shown that the septum graihially swings back to its former position if the tube is not worn for about this length of time. Objections. — (a) Perforation of the septum sometimes follows the operation, (b) The shock attending the operation is often pronounced. (c) The inflammatory reaction is sometimes severe, (r/) The presence 84 THE XOSE AXD ACCESSORY SINUSES of the tube in the nose for six weeks is a source of considerable annoyance. (e) The hemorrhage is occasionally severe and difficult to control. In spite of these objections, the operation has served, and will doubtless continue to serve, a useful purpose, though the submucous resection of the sc}>tum bids fair to take its place in most cases. 7. The Kyle Operation. — The Kyle operation may be used in simple and compound curvatures of the thhi portion of the septum. It consists in making V-shaped grooves in the septum along the lines of greatest convexity, the object being to remove tissue where it is redundant, so that the septum may be made straight without overlapping along the lines of incision. ^iiipp^ Fetterolf's file saw. Fig. 48 Fig. 47. — Side view of septum after groove is made. Fig. 48. — a, sectional view of the septum after the V-shaped iucisioii; b, Kyle's malleable tube holding the septum in position. (Kyle's operation.) Kyle's malleable tubes. Technique. — (a) Local anesthesia of both sides of the septum should be induced. (6) A linear incision with a small bistoury should be made along the lines of convexity. (c) The Fetterolf V-shaped file saw (Fig. 4G) should be used along the lines of incision until the thickness of the cartilage and bone are penetrated (Fig. 47). OBSTRUCTIVE LESIONS OF THE NASAL SEPTUM 85 (d) The incised septum should then be forced into the median Hne by the introduction of Kyle's malleable tubes into either nasal chamber (Figs. 48 and 49). (e) The after-treatment consists in removing and re-introducing the tubes until all tendency of the tissues to return to their former position is overcome. The Price-Brown Operation. — This method of operating consists of making two perpendicular incisions and uniting them by an intersecting horizontal incision as shown in Fig. 50. The two rectangular flaps thus formed are pushed through to the side of concavity and held in position The Price-Brown operation. Two parallel incisions are made, one on either side of the long axis of the deviation. An intersecting incision is then made across the long axis of the devia- tion. All incisions are made with bevelled edges, so that when the two quadrilateral flaps are pushed to the concave side they will engage in the opening as in the Watson and the Gleason operations. If this operation is applied to a horizontal deviation (dotted Hues), the two parallel incisions would be parallel with the ridge. If bony tissue is involved, the incisions should be made with a chisel. for a few days or weeks with a nasal splint or dressing upon the side of the convexity. The operation is extremely simple, and is especially applicable to cup-shaped deviations of the cartilaginous portion of the septum. This operation is also applicable to simple perpendicular or horizontal angular deviations of the cartilaginous septum, the intersecting incision being made across the crest of the angular deviation, as shown in Fig. 50. Moure's Operation. — Moure's method of straightening the septum is especially applicable to those cases in which there is a concavity on one side of the septum and a marked thickening or ridge of bone upon the 86 THE XOSE AXD ACCESSORY SIXUSES opposite side (Fig. 52). This type of deviation is also well suited for the submucous operation. Technique. — (a) Cocaine anesthesia. {b) Remove the ridge with a spokeshave or saw as indicated by 2 in Fig. 02. The removal of this ridge of bone materially relieves the pressure upon the middle (5) and inferior turbinated bodies (4). The septum may still crowd too much to the convex side, hence Moure ad- vises the following procedure to force the remaining portion of the septum (3) to the opposite side : (c) Having removed the ridge, two incisions are made as shown in Fig. 53. One is made below the ridge, and the other above and in front of it, parallel with the ridge of the nose (Fig. 54). The incisions are made with specially devised scissors resem- bling those of Asch. (d) A malleable metal splint is then inserted on the side of convexity and spread with forceps until the septum is sufficiently forced to the opposite side, as shown in Fig. 55. The two incisions permit the septum to be forced to the opposite side, where it should l3e held with the malleable splint until it becomes fixed in its new position. After-treatment. — The splint should be removed in three or four days, cleansed, and re-inserted and moulded to the parts. This pro- cedure should be repeated every two or three days for from two to five weeks, or until firm union has taken place. Should exuberant granula- tions form they should be reduced with fused chromic acid crystals. The open skeleton tube used by INIoure permits of free respiration and of luisal irrigation while it is in place. The removal of tlie bony ridge of the septum, the preUminary step in Moure's oper- ation for the correction of deviations of the septum. THE SUBMUCOUS RESECTION OF THE SEPTUM. 1. Apply a 1 to 2()()() solution of adrenalin to the entire surface of both sides of the septum on thin pledgets of cotton, which should be left in position for from eight to ten minutes. 2. Local anesthesia: A small cotton-wound probe, slightly moistened in water, is dipped into pulverized cocaine and applied about one-half minute, by massage, to each side of the septum (Freer). Applications should be made every seven minutes. From three to five applications induce complete local anesthesia. Occasionally a 20 per cent, solution of cocaine applied over the septum widi thin pledgets of cotton acts better than the above method. 3. Blanchiu"; and local anesdiesia beiny; induced, the incision of the Fig. 52. — Cross-section of the nose, illustrating certain details of Moure's septum operation. 1, the ridge severed with the spokeshave; 2, the incision with the spokeshave; 3, the septinn; 4, the inferior turbinate crowded upon by the ridge of the septum; 5, the middle turbinate also crowded upon by the de^dated septum. Fig. 53. — The incisions of the septum in Moure's operation. 1, the incision along the floor of the nose below the septal ridge; 2, the thickened septal ridge; 3, the upper incision through the septum being made with Moure's scissors. Fig. 54 Fig. Fig. 54. — Making the incisions through the septum with Moure's scissors. 1, Moure'.s scissors; 2, the septum. Fig. 55. — Moure's malleable splint in operation. 1, the septum displaced to the right side of the nose; 2, the incision made with Moure's .septum scissors; 3, the outer wall of the nasal splint resting against the inferior turbinated body; 3', the inner wall of Moure's nasal splint crowding the seiitiim to the right side of the nose. 88 THE NOSE AND ACCESSORY SINUSES mucoperichondrium upon one side only, by Hajek's or Killian's method, is performed (Fig. 5G), though in exceptional cases, Freer's incision is preferable (Fig. 57). 4. The mucoperichondrium (and periosteum) is next elevated upon the side of the incision (Figs. 58 and 59). 5. The incision is next carried through the cartilage, but not through the opposite mucoperichondrium (Fig. 60). To carry the incision through both membranes results in a permanent perforation, unless one side is closed by suture. Fig. 56 Fig. 56. — Incisions for the submucous resection of the septum, a, the Hajek incision; b, the Killian incision. Fig. 57. — Freer's L-shaped incision; a a, anteroposterior incision along the crest of the ridge; a b, perpendicular incision at the anterior end of the horizontal incision. The mucoperiosteima should be elevated over the triangular area (a a b) and the curved de\-iation (c c) of the cartilage and perpendicular plate of the ethmoid removed, after which the ridge (a a) is removed. This incision should be used when the operator is reasonably certain that he cannot avoid mutilating the mucous membrane in operating through the Hajek or Killian incision. 6. Elevate the mucoperichondrium on the opposite side by intro- ducing the elevators through the incision in the cartilage (Fig. 61). 7. Remove such portion of the cartilaginous septum as may be neces- sary with the author's swivel knife (Figs. 62 and 63). 8. Remove the deflected portion of the perpendicular plate of the ethmoid bone with the Foster-Ballenger bitmg forceps (Figs. 64 and 65). For the removal of the deformed vomer, or ridge, the author uses a septum forceps for fracturing it from its attachment to the superior maxillae (Fig. 66), though the gouge or Hurd forceps may be used (Fig. 67). THE SUBMUCOUS RESECTION OF THE SEPTUM 89 Thus far Hajek's elevators seem to be best suited for the separation of the mucoperichondrium from the cartilage, though smaller and sharper elevators are occasionally necessary. Additional reasons for adopting a simple armamentarium, requiring few introductions for instruments, are the lessened shock and the shorter time required for the performance of the operation. These are all- important matters from the patient's point of view. The patient has a right to expect the best results, with the least shock, in the least period of time, and with the greatest safety to his septum. The author believes the method herewith illustrated possesses these qualities. The elevation of the mucoperichondrium upon the side of the primary incision in the mucous membrane. The elevation is begun with a sharp or semisharp elevator and is completed with the blunt elevator. The successful elevation of the mucoperichondrium depends upon several factors, namely: (a) The location of the incision, (b) the degree of adhesion of the perichondrium to the cartilage, (c) the care with which the incision is made, (d) the instruments used in the elevation, (e) the personal equation. The location of the incision, whether in the vestibular skin or poste- riorly in the mucous membrane (Fig. 56) largely determines the ease witli which the membrane is elevated. If made in the skin of the vestibular portion of the septum, as practised by Hajek, the elevation is difficult on account of the close adherence of the membrane to the underlying hbro- cartilage, unless a certain technique is followed. When the incision is thus made, injections of Schleich's solution should be made beneath the 90 THE XnSK AM) ACCESSORY SIXUSES mucojjorichondriuni before makiiif^; the incision. This separates or par- tially separates the jjerichondriuin from the fibrocartilage and renders the remaining steps of the elevation comparatively easy. Indeed, if this technique is followetl the membrane is more quickly elevated than by any other method in any location. If Killian's incision is made in the mucous membrane just posterior to the vestibular skin, considerable difficulty is sometimes encountered in starting the elevation, many min- utes often being consimied in this step. The difficulty is not so much on account of the close adhesion of the perichondrium to the cartilage, as the faulty technique employed. The mucous membrane is rather loosely adherent to the perichon- drium and the operator failing to engage the elevator beneath the perichondrium proceeds to separate ^1 v( the mucous membrane from the mJ (i\ perichondrium. The elevation pro- li/ O )m ceeds slowly and the operator wrongly infers that the mucoperi- chondrium is bound down by an inflammatory exudate. The so- called adhesions are exceptional rather than the rule. When the elevation proceeds with difficulty the membrane should be pushed away, the wound dried with a cotton-wound applicator, and the denuded sur- face examined. If it presents a velvety pink surface, the perichondrium is still attached to the cartilage. If it presents a smooth, white, glisten- ing surface, the elevator is beneath the perichondrium and the elevation may be safely continued. An experience in about 300 submucous resec- tions has taught me that the perichondrium is less tightly adherent in certain areas than others. This knowledge has led me to seek the path of least resistance, namely, along the ridge of the nose. In other words, the elevation should be begim at the upper end of the incision and con- tinued beneath the I'idge of the nose for the distance of an inch or more before attempting to elevate the lower portion. Having thus success- fully begun the elevation do not make the mistake of using the tip of the elevator to complete it. The tip of the elevator is only of use in starting the elevation. After this is accomplished the long edge of the instru- ment should be used to coinplete it. It is ol)vious that the tip is more liable to perforate the mucoperichondrium than is the long, dull edge of the elevator. The perichondrium and periosteum may be readily stripped from the underlying framework of the septum, while they are dissected from it with difficulty and hazard. This is a fact that should l^ understood, for if it is not understood, operators will tear the mem- brane in endeavoring to elevate it with the tip of the instrument. Elevation of the mucoperichondnum by Beck's method. THE SUBMUCOUS RESECTION OF THE SEPTUM 91 Fig. 60 The mucoperichondrium being elevated, the cartilage is incised, care being exercised to avoid perforating the mucoperichondrium upon the opposite side of the septum. The finger is intro- duced into the opposite nasal chamber to detect the point of the knife the moment it penetrates the substance of the septal cartilage. The incision should be slowly and delicately performed. Should the mucous membrane upon the opposite side of the septum be incised, it will be neces- sary to suture it to prevent permanent perforation of the septum. Fig. 61 The cartilage being incised, the mucoitericl elevated. Tlie elevation is begun with a sh blunt elevator. 92 THE NOSE AXD ACCESSORY SINUSES Fig. 62 I The mucoperichondria being elevated on both sides of the septum over the area of the obstruc- tive deviation, the cartilage is removed with the swivel knife. The tines or prongs of the knife aie placed astride the cartilage and between the mucoperichondria (a Foster septmn speculum (Fig. 78) being used to separate tlie mucoperichondria if desired). The swivel knife may be engaged at either the inferior or the superior aspect of the cartilage, according to the preference of the operator. The anterior portion of the cartilage is sometimes fibrous, and the incision should then be started with a knife or scissors. If the swivel knife is engaged in the inferior por- tion of the cartilage, as shown in this illustration, it should be pushed along the crests of the spina nasalis and vomer to the junction of the perpendicular plate of the ethmoid and the vomer. The knife should then be drawn forward and upward along the antero-inferior border of the perpendicular plate of the ethmoid, and thence downward and forward to the superior end of the incision in the cartilage. The cartilage of the septum is thus completely encircled and ready to be removed. The advantages of this method of removing the cartilage are the simplicity of the procedure, the short time consumed, and the preservation of the specimen for inspection. Fig. 63 The cartilage having been excised submucously with the swivel knife, niucoperichondrial pouch with dressing forceps. removed from the THE SUBMUCOUS RESECTION OF THE SEPTUM 93 Another point in the technique of the elevation of the mucoperichon- drium is how to elevate beyond a perpendicular angular deviation. Showing the mucoperichondrial pouch after the removal of the cartilage. The bony crest of the vomer is shown in the bottom of the pouch, while deep in the pouch is shown the perpen- dicular plate of the etlimoid extending upward from the crest of the vomer. This should be removed with the Ballenger-Foster forceps, as shown in Fig. 65. The removal of the perpendicular i)!ate of the etlunoid hone with the Fostei-BallcMjier for- ceps, a, the area of cartilage previously removed with the swivel knife; b, the area of bone removed with a single bite of the forceps. Two or three bites remove nearly all of the perpen- dicular plate without removing the forceps from between the mucoperiostia. This is a matter of some importance, as each iiitnidtii'tidti of an instruinont oiuhmgors flio iiilogiity of the mucous membrane. Curved elevators have been devised for this purpose, and tliey may be used if the operator desires. My practice has been to spring the devi- 94 THE XOSE AXD ACCESSORY SIXUSES atcd cartilage to the concave side, thus rendering it straight, and then to proceed witli a blunt, heavy elevator. I have also taken advantage of the resilience of the tip of the nose, bending it to one side until the elevator was parallel with the surface of the cartilage posterior to the crest of the deviation. By taking advantage of the flexibility of the cartilage and even of the same quality in the perpendicular plate of the ethmoid I have been able to elevate the mucoperichondrium with ease when it appeared to be a difficult procedure. Schleich's solution may be injected prior to making the Killian incision, thus facilitating the elevation. I The author's method of remov-ing the ridge of bone in the submucous resection of the sept uiu. a, the septum forceps grasping the ridge, the blades being external to the mucous membranes. The forceps is rotated on its longitudinal axis as in the Asch operation, thus fracturing the vomer from its lower attachment. During the fracturing process the mucoperiosteum below the ridge becomes detached from the bone, b, the area of cartilage and perpendicular plate of the ethmoid previously removed. The mucous membrane is shown removed, though this is not actually done in the operation. Having fractured the ridge (vomer) from its attachment at the floor of the nose dressing forceps are introduced into the mucoperichondrial pouch, i. e., between the elevated membranes, the bony ridge seized and removed through the anterior Killian or Hajek incision. A Httle gentle manipulation may be necessary to completely detach the bone. This method is only adapted to adults in whom ossification is complete. As the cartilage and bone between the vomer and cranial plate is removed the fracture of the vomer does not transmit shock to the brain. Only when these facts are fully comprehended and observed will the submucous operation be performed with ease and success. The author's swivel knife is made in two parts — the handle and the prongs, and the swivel blade. It is only used to remove the cartilaginous portion of the septum, which it does in one piece. The illustrations show the two widths of the swivel knife (Fig. 69). The wider one is for extreme deviations of the septal cartilage, and for the removal of part or all of the inferior turbinated body. The swivel knife is swung on pivots between the prong tips, between which it freely swings in a complete circle. The direction of the cutting edge (concave edge) is controlled by the resistance of the cartilage through which it pas.ses. i THE SUBMUCOUS RESECTION OF THE SEPTUM 95 In the submucous operation the cartilage is removed en masse, one minute rarely being required for this purpose. The operation is thus shortened, the number of instrumentations considerably diminished, and the speci- The removal of the thickened crest of the vomer with the author's V-shaped gouge. The gouge should be tapped with a m^allet, and when well engaged, prying movements will splinter the bone. The whole of the thickened or deviated crest may be thus removed in one or more pieces. If the mucoperiosteum is adherent to the vomer beneath the deviated crest, it will sepa- rate as the bone sphnters from its attachment to the intermaxillary bone. Should some por- tions of the deviated bone remain after the use of the gouge, they may be removed with bone forceps (Fig. 75). Fig. 68 This shows the principle underlying the use of the semisharp and dull elevators in the subcu- taneous resection of the septum. The first figure shows the semisharp elevator with its edge against tlie mucoperichondrium (a b). It is obvious that a false move would cut through the peri- chondrium and cause a perforation. The chief use of the sharp and semisharp elevator should be limited to starting the elevation at the original point of incision and at points where there i;! inflanimatory adhe.'^ion. The second figure shows the dull elevator lifting the mucoperichon- diium alioad of its tip or dull edge. As the mucoperichondnum and mucoperiosteum of the seiituin onlinarily strip readily, they may be elevated rapidly and safely with the blunt elevator. Fig. 6 iiiiiiiiiiiiinifflimffliiiiffliiii||pipipiimimr"wm|,. The author'.s swi\el cartilage knife. 96 rjIE NOSE AXD ACCESSORY SIXUSES men is preserved for inspection. The swivel knife renders the sub- mucous resection of the nasal septum, especially the cartilaginous portion, simple and attractive. The use of the instrument is so easily mastered that a novice should feel at home with it after the first trial. It is under the absolute control of the operator. Foster-Ballcnger perpendicular plate bone forceps. Fig. 71 '=3Efci Hajek-lialleiiger umcupeiicliuuaiia elevators. Fig. 72 |-| ... !ii!i!ii The author's mucosa knife. Fig. 73 Hajek's septiun gouge. — , ,^_'ii'"" iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiniiiiiiinm^ F.A.HfiPDr8 co.cHicneo The author's septuni gouge. Some writers have stated that the swivel knife is objectionable because it Is liable to tear the mucous membrane. Such a statement can mean but one of two things, namely, (a) that the operator is extremely awkward, or (/;) that he failed to sufficiently elevate the membrane. THE SUBMUCOUS RESECTION OF THE SEPTUM 97 Any operator with but a moderate experience with the subcutaneous resection of the septum knows that it is next to impossible to tear the mucous membrane with the swivel knife if the mucoperichondrium is previously elevated over the entire operative field. One writer makes the claim that the swivel knife is not an exact instru- ment — is not under the exact control of the operator. This is a mistaken idea and is not based upon personal experience, but is a theo- retical deduction. As a matter of fact it is one of the most exact and Fig. 76 Kurd's bone septum forceps. Fig. 77 Allen's nasal speculum. Fig. 78 F.A.HARDYXCO, CHICAGO, Beck's operative nasal speculum. Ballenger-Foster septum specuh easily controlled instruments used in this operation. It cuts cartilage with l)ut slight resistance, and may be directed with the greatest pre- cision so as to encircle the amount of cartilage it is necessary to remove. It is stated in the fourth edition of Kyle's Text-hook on the Diseases of the Nose and Throat that the swivel knife was first suggested by Dr. N. H. Pierce and introduced by Dr. W. L. Ballenger. This is erro- neous (without intention to misstate), as neither Dr. Pierce nor anyone else suggested the idea of the swivel knife to me. The idea occurred to 7 98 THE XOSE AXD ACCESSORY SIXUSES me when I first saw Killian's septum knife or spokeshave, which has a fixed bhide between the prongs of the instrument. The thought occurred to me then that if the blade were pivoted at its edge to allow it to swing between the tines or prongs of the instrument, it could be made to encircle the cartilage and remove it en masse. I immediately had the instrument made bv Mr. Kratz- miiller, of F. A. Hardy & Co., and it has since then been kindly received by rhinol- ogists in every country where rhinology is practised. Author's differ as to the re-formation of the cartilage of the septum after its re- moval. According to J. C. Beck (Figs. 80 and 81), no cartilage cells were found in the tissues after a lapse of two and one-half years. The removed cartilage was replaced by dense fibrous tissue. Freer, on the other hand, claims that the cartilage re-forms, especially in the younger sub- jects. json's nasal sponge splint Fig. 80 ^^^?cr?^^^^^^^^^^ .j^ ^^^^^^^te^is^^ij^i^.^^ -'^ I^^^^SIIlIM ' ^^^^^^Pl Section of septum two and one-half years after a submucous resection of bone and cartilage shows no regeneration of either bone or cartilage, but is replaced by a dense fibrous tissue. Age forty-seven years. (Specimen kindly loaned by Dr. J. C. Beck.) After-treatment.— x\fter all of the obstructive cartilaginous an(l bony frame of the se])tuin has been removed, a Simpson sponge tent (Fig. 79) should be introduced into each nasal chamber to force the mucous mem- branes together. A few drops of sterile water should be instilled into the ends of the tents to cause them to swell and compress the septum, (iauze impregnated with subnitrate of bismuth powder may be used instead of the tents, or a thin rubber finger-stall may be placed in each THE SUBMUCOUS RESECTION OF THE SEPTUM 99 nasal chamber and packed with gauze (Casselberry) . The Simpson sponge-tents should be removed in from twenty-four to forty-eight hours after the operation. They may be removed layer by layer and a thin lamina left over the line of incision for a day longer. If the mucous membrane along the line of incision is not torn, healing should take place by first intention. If the mucoperichondrium is torn or otherwise destroyed at any point, healing will occur by granulation and will require from five to fourteen days, according to the area of mucous membrane destroyed. Th's constitutes the chief objection to the extensive Freer incision. The flap is large and retracts and leaves a large surface to heal by granulation. Fig. 81 Fig. 80, only higher power. General Remarks.— The Asch, Watson, and Gleason spokeshave, the sawing operation of Bosworth, and the submucous resection of the septum may be followed by perforation of the septum. The Asch and Gleason spokeshave, the Moure and the submucous resection operations are more liable to this accident than the sawing operation, the Sluder, Roe, and Watson operations. The submucous resection of the septum, if carefully carried out, is no more liable to perforate than either of the other opera- tions. I am partial to this operation, because by it any type of devia- tion of any portion of the septum may be removed, whereas, the other methods of operating are only applicable to certain types of deviations. In view of the difficulties encountered in the performance of the sub- mucous resection of the septum, the average operator should carefully consider the simpler methods of correcting the obstructive deviation before resorting to the submucous resection operation. The submucous resection of the septum is a major operation, and should be reserved for LOfC 100 THE NOSE AXD ACCESSORY SINUSES those cases which cannot be corrected by the simpler operations. Unfortunately, a majority of the cases requiring the removal of septal deviations cannot be adequately corrected by any operation other than the submucous resection. It is often better to correct the deviation in the region of the middle turbinated body, even at the risk of leaving a per- manent perforation of the septum, than it is to do a simpler operation which but partially overcomes the obstructive lesion. If further expe- rience demonstrates the wisdom of removing the middle turbinal and the ethmoidal cells rather than the high deviations of the septum, the indica- tions for the submucous resection of the septum will be greatly modified. In view of the difficult technique and of the possible complications attending the submucous resection of the upper portion of the septum, I am still endeavoring to find a method of procedure attended by less technical difficulties and fewer complications and sequels. Notwith- standing this fact, I am of the opinion that, as we now understand nasal and sinus diseases, the submucous resection of the septum should be the operation of choice in a majority of the cases of obstructive deviations of the septum. PERFORATION OF THE SEPTUM. Etiology. — The causes of perforation of the septum may be divided into (a) congenital, (b) chronic granuloma, (c) traumatic, (d) acute infection, and (e) atrophic or perforating ulcer. (a) Congenital perforation is extremely rare, Zuckerkandl having reported a few cases. (h) Chronic granulomata, as syphilis, tubercle, and lupus, are respon- sible for a considerable percentage of the cases, some authors attributing as high as 50 to 60 per cent, to syphilis alone. In my experience the percentage due to syphilis is much less than this; syphilis is not, however, as common in this as in some other countries. Syphilitic perforations almost always include the bony portion of the septum, whereas, tubercle and lupus are limited to the cartilaginous portion. The tuberculous and lupous origin of the perforating ulcer may be determined by finding the tubercle bacilli, or tuberculous histological changes in the tissues. A slow but a reliable method of demonstrating the tuberculous process is to inject a guinea pig with some of the tissue from the ulcer. Six weeks later hold a postmortem on the pig and note the presence or absence of a tuberculous process. (c) Traumatic perforations may include any portion of the septum, as they are usually due to surgical procedures, though they may be due to accidental violence and to picking the nose with the finger nail. (d) Acute infectious diseases, as diphtheria, scarlet fever, typhoid fever, phlegmonous abscess, etc., may result in perforations. (e) Atrophic or perforating ulcer of the septum is probably the most common type of perforation. Several conditions contribute to the etiology of this type of perforating ulcer. An anterior spur or deviation PERFORATION OF THE SEPTUM 101 of the cartilaginous portion of the septum is usually present, and on account of its projection into the field of the inspiratory current of air, it is subjected to constant mechanical irritation and to the desiccation of the secretions which constantly accumulate upon it. The ciliated columnar epithelium undergoes retrograde changes to a less specialized type of epithelium (pavement epithelium). The dust and other foreign substances in the aifalso irritate the epithelium and mucous membrane. The cartilage (c) being removed with the author's single-tined swivel knife in Goldstein's plastic septum operation. The crusts' thus formed in this area become adherent, and are forcibly blown or picked off with the finger nail, the epithelium coming away with them. Hemorrhagic deposits in the mucous membrane occur, and epistaxis is of frequent occurrence. The retrograde process continues until the entire thickness of the septum is destroyed. Infection plays a part in the foregoing process. Symptoms. — ^The symptoms of perforation of the septum vary with the size, cause, and location of the perforation. A small anterior per- foration sometimes gives rise to a musical whistling sound, whereas a The author's mucosa swivel knife. large one does not. If the perforation is associated with a prominent bony spur, there may be a sense of stuffiness in the nose. Crusts, if of large size, may cause the feeling of a foreign body in the nose, and, if forcibly blown or picked off, may give rise to nasal hemorrhage. Re- peated epistaxis should arouse suspicion of a perforating ulcer. Syphil- itic ulceration is usually accompanied by an offensive necrotic odor. Many cases will progress to complete perforation without the patient's knowledge of the fact. 102 THE NOSE AND ACCESSORY SIX USES Treatment. — If seen in the ulcerative stage, before perforation, the progress of the local retrograde changes may be checked by appropriate Fig. 84. — Sliowng the method of outlining the flap with the author's swivel mucosa knife for the closure of a perforation of the septum. Fig. 85. — f, the plastic flap sutured in the perforation; c, the pedicle of the plastic flap; b, the denuded area from which the plastic flap is removed heals by granulation; d, the edge of the plastic flap between the mucoperichondria of the .septum. Fig. 86 Schema of Hazletine's plastic operation for the closure of i)erforations of the septum, ab, incision in front of the perforation; ee, the incision posterior to the perforation on the oppo.site side of the septum; cc, the freshened edges of the perforation. PERFORATION OF THE SEPTUM 103 local cleansing and antiseptic washes and ointments, or, if due to syphilis, by the administration of the proper remedies for this disease. When the perforation is complete, little can be done except in a surgical way. Large perforations are not, however, amenable to surgical closure. Small ones may often be closed by proper plastic surgical procedures. Goldstein's Plastic Flap Operation. — Dr. M. A. Goldstein has suggested and successfully used a plastic flap of mucous membrane turned into the opening and inserted and sutured between the elevated membranes of the two sides of the septum. Detaifof Fig. 86, showing the opposite side of the septum. Detail of Fig. 86. a, the denuded cartilage after the plastic flap is sutured (/ /). Technique. — (a) Cocaine anesthesia. (6) The rim or edge of the perforation is freshened by paring off the epithelium and mucous membrane. (c) The mucoperichondrium is then elevated for a distance of one- half inch around the edge of the perforation. (d) A ring of cartilage is then resected for one-eighth to one-fourth inch from the edge of the perforation, the author's single-tined swivel knife being used for the purpose (Fig. 82) . (e) A mucous membrane flap, the area of whicli is considerably larger than the perforation, is then dissected from tlie most convenient surface 104 THE NOSE AND ACCESSORY SINUSES of the septum and turned into the perforation and tucked between the elevated membranes around the perforation. I have devised a traihng swivel knife (Fig. S'3) for outlining this flap. The method of using it is is showai in Fig. 84. (/) "NMien the pedicled flap is in position (Fig. 85) three or four stitches hold it in position. One surface is covered by epithelium, while the other is left to heal by granulation from the edges of the closed perfora- tion. Hazletine's Plastic Operation. — This operation is also only suited to small perforations. It is simpler than the pedicled flap operation, and appears to be a more satisfactory procedure. Technique. — (a) Cocaine anesthesia. (b) Freshen the edges of the perforation and elevate the mucoperi- chondrium, as in the submucous resection operation. (c) Make a long curved incision (Fig. 86 b h) through the mucoperi- chondrium one-fourth to one-half inch anterior to the perforation, as shown in Fig. 86. (d) ^Nlake a long curved incision {e e) through the mucoperichondrium of the opposite side of the septum, one-fourth to one-half inch posterior to the perforation. (e) Suture the anterior flap to the freshened posterior edge of the mu- cous membrane of the perforation (Fig. 88), and the posterior flap on the opposite side of the septum to the freshened anterior edge of the membrane of the perforation, as showTi in Fig. 87. The areas a and a heal by granulation. (/) Remove the sutures in twenty-four to thirty-six hours. By this procedure the perforation is covered by two mucous membranes, and, the lines of suture not being apposite, closure of the perforation follows. CHAPTJEK VI. THE ETIOLOGY OF INFLAMMATORY DISEASES OF THE NOSE AND ACCESSORY SINUSES. INFLAMMATION. Before discussing the causes of inflammation, it will be well to define inflammation. Acute InJBammation. — Acute inflammation is a threefold reaction excited by the presence of certain noxa, or irritant material, in the tissues. The noxa or irritant is usually a pathogenic microorganism and its toxin, or it may be of chemical or traumatic origin. When of chemical or traumatic origin the irritant primarily consists of the dead or broken- down cells of the tissues. Dead or broken-down cells, when present in the tissues in excess, be- come foreign bodies, and, as such, a reaction of the living cells is excited for the purpose of eliminating them from the body. Furthermore, the dead cells in the process of disintegration give off a ferment or chemical substance which also excites a reaction, the purpose of which is to free the tissues of its presence. The reaction thus far excited is directly traceable to the presence of dead and disintegrating tissue cells. Or- dinarily, after a short time, a secondary irritant gains entrance to the injured tissues and becomes the more important factor in the reactionary process. That is, pathogenic bacteria infect the impaired tissues so that in nearly every acute inflammatory process, whether it is due to primary infection or to chemical or mechanical trauma, pathogenic microorganisms must be regarded as the paramount exciting or noxious agent causing the reaction of inflammation. The reaction of inflammation is, therefore, an increased physiological activity of the living tissues of the body for the purpose of disposing of a noxious or irritant substance or organism that has invaded them in excess of the normal quantities. The reaction of acute inflammation is a threefold process, namely: 1. Increased hyperemia. 2. Increased nutrition (increased resistance). 3. Increased leukocytosis. 1. Increased hyperemia is a constant and important reaction, as through it the cells are provided with the extra nutrition they need under conditions of stress. The increased blood supply also stimulates and facilitates the increased migration of leukocytes, and it flushes the poisoned area and dilutes the noxious substance, and tlius reduces the intensity of the irritation. The hyperemia is nearly always passive in 106 THE NOSE AXB ACCESSORY SINUSES type. It has been demonstrated that passive hyperemia is more potent in overcoming bacterial irritation than active hyperemia, though active hyperemia, when well established, is also very efficient. 2. Increased nutrition of the tissues is promoted by the hyperemia for obvious reasons. They are under stress because of the presence of noxious substances, and need extra nutritional facilities. Their vital force, or resistance, is not equal to the emergency placed upon them, and upon their resistance depends the issue of the warfare. Their means of defence may be characterized as twofold, namely: (a) Their ability to envelop and digest microorganisms, and (6) their ability to produce and emit a biochemical substance or ferment, the purpose of which is to weaken or destroy their foe. This all requires increased nutrition (blood), which begets increased powers of resistance. If the nutrition is not adequate for these purposes, the microorganisms and their toxin, or l)iochemical irritant, may cause destructive and what we are accustomed to call pathological changes in the tissues. 3. Increased leukocytosis is also an important reaction of inflamma- tion. Wliile the function and modes of activity of the leukocytes is not fully understood, it has been fairly well demonstrated that the poly- morphonuclear leukocytes envelop and destroy bacteria, while the lymphocytes envelop and destroy broken-down cells. Other cells, as the fibroblasts, also participate in these functions under certain conditions. I have not time to enter into a discussion of all the processes included in the reaction of inflammation, and only desire briefly to suggest the more important and well-known processes in order to prepare our minds for a clearer understanding of the etiology of the inflammatory diseases of the nose and accessory sinuses. Quality of Reaction. — Parenthetically, I wish to add one additional statement concerning the adequacy of the reaction of inflammation. According to Adami the reaction of inflammation may be of three types : 1. Adequate reaction. 2. Inadequate reaction. 3. Excessive reaction. The reaction is usually inadequate. That is, the increased hyperemia, cell nutrition, and migration of leukocytes is insufficient to dispose of the pathogenic microorganisms before they have caused considerable damage to the tissues. It follows, therefore, that in the treatment of inflammatory diseases the reaction of inflammation should be promoted rather than diminished. By so aiding the defensive and offensive activities of the tissues, the bacteria, their toxins, and the }>roken-down tissue cells may be speedily removed and a cure effected. Inflammation Affecting Mucous Surfaces. — Adami says: "The main distinguishing feature of the mucous surface is the presence there of a layer of mucous cells of a glandular type, capable, when stimulated, of forming and discharging relatively large amounts of mucin. The hyperemia, the exudation of serum, the migration of leukocytes, all these occur in the submucous layer just as in the subserous layers. The changes in the reaction are due solely to the interposition of this layer of mucous INFLAMMATION 107 cells. There is, in the first place, a more definite basement substance interposing a certain amount of resistance to surface exudation. The layer of mucous cells is more complicated, and although the fully devel- oped cells may be discharged, they are apt to remain relatively undif- ferentiated 'mother cells' at the base; or otherwise the same intensity of irritation does not lead to as extensive a denudation. And, thirdly, by the combined action, it may be, of the irritant and of the hyperemia, the fully formed mucous cells are stimulated to produce increased amounts of mucin, so that an inflammation of moderate grade is characterized by an abundant amount of mucinous discharge rather than of fibrinous deposit. "We speak of such a moderate case, with exudation of serum con- taining abundant mucin, cast-off mucous cells, and relatively few leuko- cytes, as a 'catarrhal inflammation;' if there be sufiicient leukocytes ex- truded the character is altered to that of a ' mucopurulent inflammation;' if more severe, with complete destruction of the mucous membrane proper, then, as in serous surfaces, there is the same tendency for the leukocytic exudation to favor a deposit of fibrin upon the surface, and then we obtain a 'membranous inflammation.' "Despite the fact familiar to all that diphtheria is a disease set up by a specific bacillus, and the equally well-known fact that a like membranous inflammation may be induced by several forms of microbes, we still commonly speak of such a membrane as being diphtheritic. It would be better to confine this term purely to cases in which we know that the Bacillus diphtheria is the causative factor; failing this, we may accept the term diphtheritic as covering all such membranous inflammation, and employ the term diphtherial for such cases as are of pure diphtherial origin. "Further, if there be yet more severe destruction of the surface cells, this may go on to ulceration. Where we have pyogenic organisms present, there is a dissolution and breaking down of any fibrin that is formed and consequent absence of a membrane. In such cases there is a distinct tendency for the process to extend in the submucosa beneath the still intact mucous membrane, the part becoming infiltrated with pus. This form is spoken of as 'phlegmonous inflammation.'" Chronic Inflammation. — ^The reaction of chronic inflammation con- sists of the following phenomena: (a) Slightly increased hyperemia. (6) Slightly increased cell nutrition. (c) Slightly increased migration of leukocytes. It is needless to add that the reaction is inadequate to remove the noxa or irritant, which, according to pathologists, is usually bacteria of low virulence. A product of chronic inflammation that is always present is the pro- liferation of fixed cells, usually of the least differentiated type, namely, connective-tissue cells. Having thus briefly defined inflammation, we are prepared to discuss its causes. 108 THE NOSE AND ACCESSORY SINUSES The causes of inflammatory diseases of the nose and accessory sinuses are divided into two groups, namely: 1. Excitmg causes. 2. Predisposing causes. 1. Exciting Causes. — The exciting causes are bacteria and chemical and traumatic destruction of tissue cells. This phase of the subject has already been discussed imder Inflammation, and will not be dwelt upon in this connection further than to say that pathogenic bacteria cannot irritate the tissues of the body so long as the resistance of the cells is normal ; that is, so long as they are healthy. There may be an exception to this rule when the germs are exceptionally virulent, though this is rare. Virulent pathogenic bacteria are constantly present in the upper respiratory tract, though they are harmless until the resistance of the cells is lowered by some intracorporeal or extraneous influence. 2. Predisposing Causes. — There are many predisposing causes of inflammatory diseases of the nose, some of which are best explained by grouping them around a well-recognized physiopathological law, namely, When the drainage and ventilation of a mucous membrane-lined cavity is impaired or blocked, the conditions are favorable for the growth of patho- genic bacteria. If this is true, each case of inflammatory disease of the nose and acces- sory sinuses should be examined to ascertain if the drainage and ventila- tion of these spaces are impaired or blocked. If they are, the obvious therapeutic duty is to remove the obstruction by such remedial measures as wall best accomplish the purpose. These measures may be either medicmal, hygienic, or surgical. If, on the contrary, no obstructive lesion is found, other causes for the lowered resistance of the tissue should be sought for. If the inflamma- tion is a primary acute one, and the lowered resistance is due to shock from exposure, it may be useless to attempt to remove the cause, as it was transient. The immediate duty in such a case is to promote the reaction of inflammation and thus check the inflammatory process. As Adami so aptly says, the way to cure inflammation is to increase it. In order to logically approach the consideration of the causes of the lowered resistance of the mucous membrane of the nose and accessory sinuses they should be divided into two groups, namely: (a) Extranasal. (b) Intranasal. Extranasal Predisposing Causes. — Age seems to exert some influ- ence upon the resistance of the nasal mucous membrane. Young children and young adults are more frequently subject to inflammatory diseases of the nose and accessory sinuses than those of more advanced years. This is, no doubt, due in part to indiscretion, as the improper care and protection of the body from the inclemencies of the weather. Persons of more mature years have more mature minds and better judgment, and they do not expose themselves needlessly, as in youth and childhood. Then, too, the tissues acquire a resistance, or immunity to the noxious irritations. INFLAMMATION 109 Sex, perhaps, exerts some influence on the occurrence of inflammatory processes. Males are more exposed and more reckless than females, hence they are more often affected by inflammatory diseases. They are more pugilistic and more often have broken noses and consequent nasal obstruction than females. Climate undoubtedly influences the occurrence of inflammatory processes. In regions where there is much cold, wet weather with sudden changes of temperature and of hygroscopic conditions of the atmosphere, it is more difficult to protect the body, particularly the feet, from the shock incident to such exposures. The shock thus sustained by the vasomotor nervous system leads to a lowered resistance of the mucous membranes, especially of the nose and accessory sinuses, hence the growth of bacteria in these regions is favored. Exposure, especially unusual or unequal exposure of the body to damp, cold, or other atmospheric and metallurgic conditions, weakens the resistance of the tissues. The exposure of the feet to damp and cold is a most fruitful source of rhinitis and inflammations elsewhere in the body. Draughts striking a single portion of the body are detrimental to the resistance of the tissues much more than when the whole body is thus exposed. Within certain limitations the exposure of the whole body often has a tonic effect, as all the animal mechanisms of the body are equally and simultaneously stimulated. When partial exposure is experienced, only a portion of the mechanism is stimulated, and an unbalance of the functional activities results; that is, there is confusion and havoc in the cellular activities, the nasal expression of which is often some form of inflammation. The clothing is an important factor in maintaining or lowering the resistance of the mucous membrane of the upper respiratory tract. Too much is as productive of evil as too little clothing. If too much is worn, the skin is rendered sensitive to slight exposures, and if too little is worn, the body is subjected to continual stress, and exhaustion of the vital forces results. Either condition prepares the soil for the growth of pathogenic bacteria in the respiratory passages. Perhaps the most vulnerable part of the body is the feet, through the soles of which course large bloodvessels. Anyway, cold, wet feet is a common cause of acute rhinitis and sinuitis. The proper selection of underwear is a much mooted question. Wool is advocated by some, while linen or linen mesh is strenuously rec- ommended by others. In the meantime, most persons buy cotton for summer and cotton and wool mixtures for winter wear; not because they believe they are the best, but because they are cheaper. My ideas on the subject are as follows : Linen absorbs moisture better than either cotton or wool, and is, therefore, better for sinnmer wear. Wool is warmer than either cotton or cotton and wool, and is better for winter wear. Some persons perspire easily in winter, and for them linen should be worn next to the skin. If this does not retain enough body heat, light wool should be worn over the linen underwear. Cotton or cotton and wool mixtures are perhaps 110 THE XOSE AXD ACCESSORY SINUSES never preferable to wool and linen, and wool combinations for the winter months. The outer garments should be medium weight for the winter months, the overgarments being depended upon for extra protection for outdoor wear. If the indoor clothing is too heavy, the skin becomes tender and subjects the wearer to shock upon undue exposure when out of doors. The underclothing and outer garments should, therefore, be selected for their absorptive and heat retaining properties. Hard-and-fast rules cannot be laid down in reference to the clothing, each subject being a law unto himself. The aim should be to so regulate the clothing as to avoid either extreme, as to do otherwise subjects the system to shock, and thus lowers the cellular resistance and prepares the soil for the growth of microorganisms and inflammation. The digestive tract is by some writers justly held responsible for in- flammatory processes of the upper respiratory tract. If the processes of digestion and nutrition are imperfectly performed, noxious material enters the vascular lymphatic circulation and thus places extra stress upon all the fixed and migrating cells of the body. Lowered resistance, therefore, naturally follows. Certain constitutioual diseases likewise produce a lowered resistance of the tissues, including the mucous membrane of the nose and accessory sinuses. Diabetes, syphilis, and all diseases due to faulty metabolism especially affect the tissues of the respiratory tract, and predispose them to infection and inflammation. Heredity probably has no direct influence in the predisposition to infectious and inflammatory diseases of the nose. Indirectly it may have such an influence. That is, certain anatomical conformations of the nasal chambers may be transmitted from parents to the child and thus lead to a predisposition to infection and inflammation. Adenoids may interfere with the drainage and ventilation of the nose and accessory sinuses, or inflammation focalized in them may lower the resistance of the mucous membrane of the nasal and accessory sinuses, and thus predispose to infection and inflammation. These and other extranasal influences may prepare the soil for the growth of pathogenic bacteria in the nose and accessory sinuses and may eventuate in em- pyema of the sinuses without obstructive lesions in the nose. Wliatever the cause of the lowered resistance of the mucous membrane the result is the same. I do not wish to be understood as saying that infection and inflamma- tion always follow a lowered resistance of the nasal mucous membrane. I only claim that a lowered resistance predisposes to such a process. The virulence of the microorganisms and other conditions enter in the equation. Intranasal Predisposing Causes. — In this coimection I wish to repeat the physiopathological law which largely explains the occurrence of infection and inflammation of the nose and accessory sinuses, namely: Cavities lined with 7nucous membrane are predisposed to inflammation when their drainage and veniilation are obstructed. From experience, we know that when such obstructions are present { I NFL AM MA TION 1 1 1 and are removed, either by local applications or by surgical interference, relief often promptly follows. Let us direct our attention, therefore, to some of the obstructive lesions of the nose which predispose the mucous membrane to infection and inflammation. Obstruction of the Lower Portion of the Nose. — I desire to first call attention to a fact that has long impressed me as very important, namely, that obstructions in the lower portion of the nasal cavity have a different clinical significance than obstructions located higher in the nasal passages. I also wish to call attention to the clinical significance of anterior obstruc- tions as contrasted with obstructions otherwise located. Obstruction of the Inferior Portion of the Nose. — Obstruction of the inferior portion of the nasal passages causes an approximation or an impingement of the inferior turbinal against the septum, at least at certain points. The pressure may be either intermittent or constant. The question of greatest importance is. How does such an obstruction affect the drainage and ventilation of the nose and sinuses? As most of the mucous membrane of the nose and sinuses is located above the inferior turbinal, it is obvious that ventilation is but little affected by such an obstruction. The pathway of the inspiratory current is largely limited to the middle and superior meatuses of the nose, and, inasmuch as an obstruction located inferiorly does not materially occlude the inspiratory tract, there is comparatively little disturbance of function. Furthermore, the drainage of the secretions is not materially blocked. The usual obstructive lesion in this region is a spur or ridge on the septum. The ridge is rarely equally prominent along its entire length. On the contrary, it presents one or two prominent spines or knuckles which approximate or impinge against the inferior turbinated body, thus leaving wide gaps through which the secretions may drain to the floor of the nose without marked impediment. The practical deduction to be drawn from these facts is, that an ob- struction in the lower portion of the nose does not markedly reduce the resistance of the mucous membrane, especially in the upper portion of the nasal chambers and in the accessory sinuses. It does, however, have some influence in this direction, and in a degree predisposes to infection and inflammation. The crests of the spines or knuckles may accumulate secretions, which become desiccated in the form of moist or dry crusts. The tissue cells beneath the crusts are injured and their resistance lowered, and to this extent there is a predisposition to infection and inflammation. Furthermore, the impingement of the spur or spine against the outer wall of the nose causes traumatic injury and results in some degree of lowered resistance, which may lead to bacterial infection and inflammation. The irritation is not usually pronounced and only causes an increased hyperemia and nutrition of the tissues. Obstructive lesions in the lower portion of the nose, therefore, may cause a turgescence of the mucous membrane, which is richly supplied with erectile tissue (the swell bodies), which after a more or less pro- 112 THE NOSE AND ACCESSORY SINUSES longed period may result in hypertrophy. In the early or tiirgescent stage the condition is called turgescent rhinitis; in the later stage it is called hypertrophic rhinitis. If, however, repeated infection occurs, the irritation is of a different type and causes hyperplastic changes. Unfortunately, however, a deviation of the lower portion of the septum is usually accompanied by a deviation of the upper portion of the nose in the region of the middle turbinal. ^^Qlen this is the case the type of inflam- mation is radically different from that present in an uncomplicated lower deviation. That is, a deviation in the region of the middle turbinal often obstructs the drainage and ventilation of the superior meatus and of all, or nearly all, of the nasal accessory sinuses. The secretions are retained, undergo decomposition, liberate a ferment, and irritate the mucous membrane. In brief, the inflammation is attended by the pro- liferation of the least differentiated of the fixed cells, or connective tissue cells. In other words hyperplasia of the mucous membrane occurs. This is kno^Ti as hyperplastic rhinitis. The irritation from the middle turbinal region may extend by continuity of tissue to the inferior turbinal and cause hyperplasia of this structure as well. Hence, hyperplastic rhinitis often involves both turbmated bodies. In simple deviations, however, limited to the lower portion of the nasal chambers the inflamma- tion is usually of the hypertrophic type. Obstruction of the Anterior Portion of the Nose. — Deviation of the anterior portion of the septum from traumatism is the common cause of obstruction of the anterior portion of the nasal chamber. The relation- ship it bears to inflammatory processes of the nose and accessory sinuses is interesting and instructive. An anterior deviation does not interfere with the drainage of the secretions except in so far as it may affect the mechanical force of the respiratory currents of air. The mechanical force of the inspired air is especially manifested in the region of the infun- dibulum and posterior ethmoidal cells where the inspiratory current sweeps over the hiatus semilunaris and the ostei of the posterior ethmoidal cells and causes slight rarefaction of the air within the sinuses drained by these openings. The mechanical impact facilitates the flow of secretions from the ostei and hiatus semilunaris, and thus prevents desiccation and blockage of these openings. To this extent obstructive anterior deviations of the septum interfere with drainage. The ventilation upon the obstructed side is, however, very materially affected. The slight interference with the flow of the secretions caused by the absence of the mechanical impact of air results in a moderate reten- tion of secretions. Decomposition of the secretions may therefore take place and cause a lowered resistance of the mucous membrane, and thus establish a predisposition to infection and inflammation. When the ridge or spur in the lower portion of the nose extends well forward into the vestibule, it also interferes with the ventilation and drainage, as described in the preceding paragraph. When either type of anterior obstructive deviation is present, another and more important etiological factor must be taken into consideration, namely, the rarefaction of air posterior to the obstruction. Air being INFLAMMATION 113 unable to enter the nostrils rapidly enough during the descent of the diaphragm is rarefied, or a state of negative air pressure is established. This, according to Bier's theory, should prevent serious inflammatory processes, as the negative air pressure thus produced promotes the reac- tion of inflammation and should prevent serious inflammatory disease. Doubtless the negative pressure thus automatically produced does exert a favorable influence upon the inflammatory process excited by the lack of ventilation and the slight retention of the secretions. Thus, strange as it may seem, the anterior obstructive lesion predisposes to infection and inflammation, and at the same time tends to cure it. Clinically, I have often noted the comparatively slight inflammatory disease of the nasal mucous membrane present in simple anterior devia- tions. The chief departure from the normal is a turgescent or a hypertrophic rhinitis of the inferior turbinals. Little pathological change is present in the middle turbinal region unless there is an associated obstruction in that location. The negative air pressure easily accounts for the turges- cence of the erectile tissue of the inferior turbinals. After a prolonged duration of the turgescence, whether intermittent, alternating, or con- stant, hypertrophy occurs as a result of the increased nutrition. Obstruction in the Middle Turbinal Region. — Obstruction in this por- tion of the nasal chambers is productive of more serious inflammatory disease of the nose and accessory sinuses than obstruction in any other portion of the nose. The reason is obvious when we recall the fact that the ostei and sphenoidal sinuses drain into the superior meatus above the middle turbmal, while the frontal, anterior ethmoidal, and antral sinuses drain mto the middle meatus beneath the middle turbinal. If the septum is deviated so as to press against or approximate near to the middle turbinal, the olfactory fissure is blocked and the drainage of the posterior ethmoidal, and possibly of the sphenoidal cells, is inter- fered with. Clinically I have noted the presence of two types of deviations of the septum that close, or nearly close, the olfactory fissure. One is a bowing of the perpendicular plate of the ethmoid bone and triangular cartilage, and the other is a thickening of the septum in the region of the middle turbinated body. The bowed septum is thin and easily corrected by the submucous resection of the septum, whereas the thickened septum often involves only the mucous membrane and is more difficult to correct. In some subjects there are large pneumatic spaces in the middle turbinal which may either close a part or all of the olfactory fissure, or they may encroach upon the hiatus semilunaris beneath it. In the first instance the drainage and ventilation of the superior meatus of the nose, and in the second instance the drainage and ventilation of the frontal, anterior ethmoidal, and maxillary sinuses are impaired. A large bulla ethmoidal is projecting median ward and downward may obstruct the hiatus semilunaris, and thus obstruct the drainage and ventilation of the cells draining into the infundibulum, namely, the frontal, anterior ethmoidal, and maxillary sinuses. 114 THE NOSE AND ACCESSORY SINUSES Likewise, the occasional pressure of cells in the inner wall of the infundibulum, or uncinate process of the ethmoidal bone, may block the infundibulum and cause serious inflammatory disease of the frontal and anterior ethmoidal cells and the maxillary antrum ("vicious circle"). In about 50 per cent, of the cases the frontonasal canal does not com- municate with the mfundibuhun, but opens directly into the middle meatus more anteriorly. In these subjects an enlarged projecting bulla eth- moidalis and cells in the uncinate process would not block the drainage and ventilation of the cells draining through the frontonasal canal, namely, the frontal and anterior ethmoidal cells. The ostium of the antrum, however, may be obstructed as it always opens into the infundibulum. The Results of High Obstructions in the Nose. — When the olfac- tory fissure is obstructed by either septal or turbinal deformity, the drainage of the secretions and the ventilation of the posterior ethmoidal and sphenoidal sinuses are impaired. The secretions are retained and undergo retrograde changes. The mucous membrane bathed in the secretions is injured and its functional activity and resistance are lowered. The biochemical substances liberated in the process of decomposition constantly irritate the mucous membrane, especially of the middle turbinated body. Acute infection occasionally occurs. During the intervals between the acute inflammatory processes a mild staphylococcal or other mfectious inflammation persists. Under these conditions there is a proliferation of fixed cells in the tissues, usually the least dift'erentiated of the fixed cells, viz., connective-tissue cells. The result is knowTi as hyperplastic rhinitis, which chiefly involves the middle turbinated body, though it often extends to the inferior tur- binal as well. Obstriiction of the Olfactory Fissure. — The partial or complete closure of the olfactory fissure and the consequent retention of the secretions of the superior meatus, and the ethmoidal and sphenoidal sinuses drain- ing into it, cause hyperplastic changes in the mucous membrane, not alone of the middle turbinal, but of the superior meatus and of the ethmoidal and sphenoidal sinuses opening into it. The conditions thus produced are favorable for infection and inflammation. The inflammatory process may be either catarrhal, purulent, fibrinous, or phlegmonous in type, and in each instance it is in part due to pathogenic microorganisms. The sinuitis thus excited may contmue for years without engaging the attention of either the patient or physician. Headache and slight dizziness, aggravated upon stooping, may be the only symptoms com- plained of, except, possibly, recurrent attacks of acute coryza. Or the sinuitis may be distinctly and frankly purulent, with copious discharge into the epiphar^Tix, and possibly to some extent through the olfactory fissure into the middle meatus. Atrophic rhinitis with ozena is, in my opinion, in adults often a sup- purative sinuitis with atrophy of the mucous membrane. Space does not permit of a full discussion of this phase of the subject. Personally I have repeatedly overcome the ozenic secretion by treating the case as though it were a suppurative sinuitis. I have made skiagraphs of INFLAMMATION 115 several cases of atrophic rhinitis with ozena, and without exception they have shown the existence of sinus disease. This does not, of course, determine which was primary, the atrophic rhinitis or the sinuitis. My opinion is largely based upon the results following the treatment for the sinuitis. Obstruction Due to the Bulla Ethmoidalis in the Middle Turbinal and Uncinate Cells. — As previously stated, a large bulla ethmoidalis may occlude the infundibulum and thus block the drainage and ventilation of the maxillary sinus, the frontal and anterior ethmoidal cells. This, as heretofore explained, causes the retention of the secretions and lowered resistance of the tissue, thus establishing a predisposition to infection and inflammation. (See "Vicious Circle" of the Nose.) Cells in the middle turbinated body and uncinate process hkewise may block the infundibulum and cause similar results. The exception has been referred to wherein the frontonasal canal opens directly into the middle meatus anterior to the infundibulum. It appears, therefore, that there are several factors entering into the causation of inflammatory diseases of the nose and accessory sinuses. The excitmg cause is nearly always pathogenic microorganisms, while the predisposing causes are numerous extranasal influences which are often combmed with obstructive lesions in the nose. The latter should always be studied with reference to whether they interfere with the drainage and ventilation of the nose and accessory sinuses. If only extra- nasal causes of lowered resistance are found, the treatment should be addressed to their removal; and if in addition to the extranasal influences obstructive lesions are found, they should be corrected by probing or by surgical interference. Conclusions.- — 1. Acute inflammation is usually a threefold reaction excited by pathogenic bacteria and their toxins, namely : (a) Increased passive hyperemia. (6) Increased nutrition of the tissues. (c) Increased migration of leukocytes. The reaction of acute inflammation is the response of Nature's forces for the purpose of destroying the bacteria and their toxins. 2. The reaction of inflammation is usually inadequate to quickly remove the infective bacteria and their toxins, hence the inflammation contmues for several days, or it may be indefinitely prolonged. 3. Chronic inflammation consists of the same reactions in much less degree, and is still further characterized by the proliferation of fixed cells into the tissues, notably connective-tissue cells. 4. The exciting cause of inflammation is generally some pathogenic microorganism. 5. Pathogenic bacteria do not, per se, cause inflammation. There must be a lowered resistance of the tissues before they will rapidly mul- tiply and produce inflammation. 6. Anything that lowers the vitality or resistance of the mucous mem- brane of the nose and accessory sinuses predisposes it to infection and inflammation. 116 THE XOSE AXD ACCESSORY SIXUSES 7. The extranasal influences that lower the vitahty of the mucous membrane are sex, climate, exposure, improper clothing, digestive disorders, constitutional diseases and dyscrasias, hereditary anatomical peculiarities of the framework of the nose, adenoids, etc. S. The intranasal predisposing causes of inflammation of the mucous membrane of the nose and accessory sinuses are, perhaps, best explained by the well-recognized law: Obstruction of the drainage and ventilation of mucous-lined cavities predisposes them to infection and inflammation. The character of the inflammation and the end result are partially determined by the location of the obstruction in reference to the various tissues of the nose and to the accessory sinuses. 9. Anterior and inferior obstructions more often cause turgescent and h^-pertrophic rhinitis, as they do not materially interfere with the tlrainage of the secretions, and therefore cause very little or no irritation. 10. Obstruction higher in the nose, in the region of the middle turbinal and the infundibulum, causes the retention of the secretions and interferes with the ventilation of the superior meatus and the accessory sinuses, thus lowering the resistance of the tissues and establishing a marked predis- position to infection and inflammation of the nasal and accessory sinuses. The inflammation may be catarrhal or suppurative, and acute or chronic in type. 11. The long-continued mild irritation excited by obstructive lesions in the middle turbinal region often results in hyperplastic rhinitis, which may be limited to the middle turbinal, though it may extend to the inferior turbinal. 12. Inflammation also extends to adjacent parts by the continuity of tissue, hence it may extend from one part of the nasal mucous mem- brane to another, or it may extend from the nasal mucous membrane to the sinuses, the Eustachian tube and cavum tympani. I CHAPTEE VII. THE PRINCIPLES OF TREATMENT OF INFLAMMATIONS. THE MODALITIES FOR PROMOTING THE REACTIONS OF INFLAMMATION. Acute Inflammation. — As Adami so aptly says," Inflammation is a danger signal, but by no means necessarily a danger." Inflammation is a beneficent reaction, Nature's attempt to ward off or destroy an invading irritant. The inflammatory process thus started should be encouraged rather than discouraged, at least for a short time. The increased hyperemia and leukocytosis should be added to rather than detracted from. Cold applications are generally contraindicated, as they diminish the hyperemia and leukocytosis and lower the cell resistance. Heat is indicated, as it increases the cellular resistance and leuko- cytosis, at least up to a certain pomt. Passive hyperemia by Bier's method of treatment is along the right line. The hot-air treatment and the leuko- descent light also increase the hyperemia and leukocytosis, hence the irritant causing the inflammation is disposed of, the inflammation sub- sides, and normal conditions are restored. Wliatever the mode of treatment, its object should be to augment the hyperemia and leukocytosis. As Adami says, the inflammation is not the real danger, but is the signal of danger, and as such its warning should he heeded. Physiological and physical rest for the inflamed part should be pre- scribed. If the middle ear is infected, quiet should be enjoined. If the eye, a darkened room. In addition to physiological rest, local hyperemia and leukocytosis should be augmented by the use of the leukodescent light. Bier's treatment, etc., to hasten the destruction of the infecting bacteria. If cold applications are used, the local hyperemia and leukocytosis are reduced, the cell resistance is lowered, and Nature's effort to throw off the irritant is thwarted. Remember that inflammation is not a destructive process, but is a benign process for the purpose of destroying the microorganisms and their toxins. Promotion of the Reaction of Inflammation. — The grand purpose of treatment should be to promote the inflammatory reaction. Failing in this, or if, for various reasons to be discussed later, it is not deemed wise to wait the full establishment of the reaction of inflammation, opera- tive interference may be called for. Adami classifies reactions of inflam- mation as follows : (a) Adequate. (6) Inadequate to neutralize the irritant and bring about repair. (c) Excessive for these purposes. 118 THE NOSE AND ACCESSORY SINUSES (a) Adequate reaction is present in aseptic incised wounds, the natural liealing of fractures, etc. Such conditions need no local treatment, as the reaction of the tissue cells is adequate to dispose of the irritant noxa; that is, the passive hyperemia and leukocytosis is sufficient to destroy the bacteria, toxins, and broken-down cells. At the end of about twenty- four hours the reaction has reached its maximum. The cell resistance and the nature of the lesion are favorable for the establishment of adequate reaction; hence, interference, other than to maintain these conditions, is contraindicated. Healthy blood and a normal nervous system are prime requisites for establishing adequate reaction. Physiological rest of the injured parts and the regulation of the excretory organs are the only indications for treatment in such cases. If the infection is virulent, or the condition of the blood and the excre- tory organs are below normal, the beneficent reactions of inflammation will be inadequate to speedily remove the infectious irritant, at least before impairment of the tissues has occurred. Thus in mild but pro- longed middle-ear inflammation the repair is usually so slow that, unaided by the aurist, the integrity of the conduction apparatus may be impaired and permanent deafness follow. In such a case there is inadequate reaction, hence the reaction of inflammation should be pro- moted. ib) Inadequate reaction is usually present in most cases of acute inflammation. Formerly most surgeons regarded the reaction as excessive and attempted to reduce it. Such a course is inimical to the wefl-being of the patient. The reaction needs promotion rather than abatement. It should be remembered that the increased temperature, pulse, and respiration are not essential parts of the reaction; they are incidental concomitant phenomena. The reaction, that is, the aroused forces of Nature to combat the invading microorganisms, the passive hyperemia and the leukocytosis being inadequate to dispose of the noxa or irritant, should be promoted, not abated. Many methods of increasing the hyperemia and leukocytic migra- tion are in vogue. Among them are poultices, counterirritation, scarification, constriction by ligature, negative air pressure, massage, leukodescent light, heat, incisions, and irrigations with bland irritants, as normal salt solutions. Some of the modes of treatment have been in use for many centuries, perhaps all of them in some modified form, at least in isolated instances. 1 )r. Brawley called my attention to the fact that certain American Indians cured acute coryza by constricting the neck of the patient with the hands, thus practising what Bier has reduced to scientific principles. Rhinol- ogists have long resorted to irrigation of the accessory sinuses of the nose in the treatment of sinuitis. They have also used more irritating solutions. Irrigations with normal salt solution have been used with the idea of removing the products of inflammation, rather than increasing the hyperemia and the leukocytic migration. Perhaps an increased familiarity widi the principles underlying the treatment of inflammation will materially modify the technique employed in the treatment of in- THE PRINCIPLES OF TREATMENT OF INFLAMMATIONS HO flammatory diseases of the upper respiratory tract. Each case should be studied individually and the modality applied that best meets the peculiar conditions present. In acute inflammation of the maxillary sinus the surgeon should decide whether he will resort to counterirritation, irrigation, the leuco- descent light, negative air pressure, or some surgical procedure. The chief question is, What method of treatment will best promote hyperemia and the migration of leukocytes ? The aim should not be to check the inflammatory process in the sinus, as that is established to rid the parts of the irritant noxa (pathogenic microorganisms) and to prevent its extension to contiguous structures. A counterirritant is not desirable, as it may temporarily, and possibly permanently, disfigure the face. Irrigation is usually impossible, except through an artificial puncture. The leukodescent light is easily applied, relieves pain, and increases the migration of leukocytes to the infected area. The expense of the apparatus practically limits its use to office and hospital practice. Its use is also limited to districts supplied with electric power. Where it is practicable to use it, it is a valuable mode of treatment. Bier's constriction treat- ment necessitates the application of an elastic band around the neck, and is more or less uncomfortable. It is, nevertheless, easily applied, and may be used by any physician understanding its application. Nega- tive air pressure may be used in the nasal chambers by bulb suction, hence its application is not limited by expense or complex apparatus. Each treatment should extend over a period of several minutes, hence the bulb apparatus necessitates prolonged personal attention and mus- cular effort on the part of the patient or an attendant. Other and better negative air-pressure apparatuses require water, compressed air, or electric motor power, and are, therefore, practically limited to ofiice and hospital practice. The mode of treatment is of considerable thera- peutic value in acute sinus inflammation, and should be utilized much more than it is. Puncture through the inferior meatus increases the hyperemia and leukocytic migration, but it soon closes and necessitates a repetition of the procedure. It is a disagreeable procedure, and is some- times complicated by a deeper infection of the tissues, marked soreness being present. It appears from the foregoing cursory review of some of the methods of procedure that the leukodescent light and the negative air pressure offer the most rational and effective modes of promoting adequate reaction in acute sinuitis. None are of universal application, for the reasons already given, hence, the surgeon may be compelled to resort to puncture, or puncture and irrigation combined, or to some other method of procedure. This discussion is given not because it is intended as a guide in the treatment of sinus inflammation, but to show that various factors have to be considered in each case. In acute otitis media the various modalities must be considered in connection with the peculiar anatomical and physiological conditions present. The location of the middle ear in a deep bony recess is an obstacle to the application of the leukodescent light. Heat is easily applied 120 THE NOSE AND ACCESSORY SINUSES by means of a hot-air apparatus or by hot irrigations through the external meatus. Counterirritation over the mastoid is but feebly effective. Cold is ordinarily contraindicated, as it diminishes the congestion and leukocytic migration. An exception in its favor is in inflammation of an encapsulated organ. The organ of hearing, being encased in bony tissue, is essentially an encapsulated organ, its capacity for expansion under congestion being limited. Only its outer wall, the membrana tym])ani, allows of expansion. Cold should be considered as a therapeutic measure imder certain conditions. The congestive reaction following the ischemia produced by the cold may be beneficial. Another factor of great importance is die })resence of the delicate chain of bones concerned in the transmission of sound waves to the labyrinth. If the inflamma- tion, widi its attending inflammatory products, continues for any con- siderable length of time, the inflammatory exudates become organized and the hearing is impaired. It is important, therefore, to institute some therapeutic measure that will quickly check the infectious process. Two alternatives suggest themselves, namely, incision of the drumhead and the local application of an irritant drug to the ear drum. A 12 per cent, solution of carbolic acid in glycerin has proved of decided value for this purpose (A. H. Andrews). In acute laryngitis the following considerations are presented. Counter- irritation is inadequate to sufRciendy promote the inflammatory reaction. Scarification and incision are impracticable. The leukodescent light is probably not active enough, unless it is applied three or four times a day. The patient should l3e confined to the house, hence the light is practically out of the question unless a lamp is installed. The inhala- tion of hot medicated vapors promotes hyperemia and leukocytosis, but not sufficiently to be of great value except as an adjunct to other modes of treatment. The marked muscular activity of the soft parts of the lar}Tix is a great impediment to the successful treatment of larjTigitis. The prime object of treatment should, therefore, be to abolish the func- tional activity of the intrinsic muscles of the larjaix. This can be done by ])roliibiting the use of the voice, requiring all conversation to be carried on with pencil and paper. Twenty-four hours of such functional rest often results in the triumph of the reactive inflammatory process over the invading bacteria and their toxins. Vibratory massage applied externally over the lar}aix increases the congestion, unloads the lymphatic vessels, and promotes leukocytic migration. The foregoing illustrative cases suggest the method of thought to be applied in the selection of the modalities for the promotion of the reactions of inflammation in the treatment of acute inflammation, where inade- quate reaction is the rule. (c) Excessive reaction is rarely present. ^Nhen present it is usually due to an excessively virulent microorganism, or to marasmus or other cause of lowered vitality. In such conditions a moderately virulent microorganism may cause excessive reaction. The tissues are intensely swollen, and a linear incision quickly promotes normal reaction by converting the passive into active congestion and unloading die engorged THE PRINCIPLES OF TREATMENT OF INFLAMMATIONS 121 lymphatics. With these changes normal or adequate reaction is es- tablished. It is in these cases that the application of cold is indicated. Cold reduces the hyperemia, checks leukocytic migration, and diminishes the excessive cell proliferation. General Systemic Treatment. — The objects of all systemic treatment for the promotion of normal reactive processes are (a) to increase the resistance of the cell structures, and (6) to eliminate the infecting micro- organisms. To accomplish these ends the food should be highly nutri- tious but bland in character, while the elimination of the toxic products should be encouraged by the administration of saline cathartics. The skin, liver, and kidneys should also be rendered more active. Excessive febrile reaction should be overcome by hydrotherapy or the administration of quinine, salicylates, etc. Pain may be relieved by the administration of opiates or belladona, though the leukodescent light is a better remedy. Treatment of Chronic Inflammation. — Adami says: "It is through no desire to be epigrammatic that one makes the statement that there is no treatment for chronic inflammation. The process consists, as we have seen, of hyperemia, slight exudation, slightly increased leukocytosis, and great tissue proliferation. "The last-named process is probably not to be checked by any direct means we can employ; and any mechanical or chemical means we use is likely, per se, to increase rather than diminish it. But our mechanical means, directed toward an increase of the rapidity of income and output of the tissues, do more good in this way than harm in the other way. It may thus be said that our treatment of a case of chronic inflammation is not applied so much to the condition as in spite of it. If fibrosis has taken place, we cannot wholly undo it; but by increasing the vitality of the tissues we may check the continuance of the process and may render the absorption of the debris more rapid. "Newly formed fibrous tissue may, however, in some cases undergo absorption. The remarkable diminution in size of syphilitic gumma ta under potassium iodide can mean nothing else; as, also, fibroid tubercles scattered over the peritoneum seen at one laparotomy have been found wholly absent at a subsequent laparotomy some months later. This fact affords the suggestion that a mild grade of acute inflammation superimposed upon a chronic favors absorption and explains the good effects of induced hyperemia in leading to the removal of adhesions and the restoration of movements in joints. "If a low degree of microbic inflammation be still present there is an accompanying hyperemia, with slowing of the blood stream; the nutri- tion of the part, while appearing to be excessive, is often under par, and by the use of various agents we strive to increase its nutrition. Such modes of treatment are as follows: The use of cold for sliort times at intervals, bringing about an alternation of contraction and dilatation of the bloodvessels; the use of heat more or less continually; the use of electricity; rubbing, handling, and massage of the tissues, to the end that 122 THE NOSE AND ACCESSORY SINUSES the venous exodus from the part may be more rapid and more thorough; active and passive movement of the part, to accompKsh the same result by pressure of contracting muscles; the use of counterirritation, rube- facients, vesicants, etc., which have this in common, that they probably increase the total amount of blood brought to the part. The use of the seton, now discontinued, had in view the same end. "The result of all these modes of treatment is that the overturn of blood is rendered much greater, the venous return assisted, and the arterial blood permitted to enter more freely. The normal diapedesis of leukocytes tends to the removal of cellular debris, and the circulation in the part is approximated to the normal." In the early stages of adhesive processes of the middle ear the appli- cation of the foregoing principles of treatment may accomplish much toward their removal. The internal administration of theosinonin has proved beneficial in such cases. Its use in old fibrosis of the middle ear is without appreciable effect. It is probable that any beneficial effects of pneumomassage is due more to the increased lymphatic flow, the increased nutrition, and to the absorption of the inflammatory pro- ducts than to the increased mobility given to the ossicles. In hyperplastic rhinitis the object of treatment should be to remove the cause of the irritation, usually a chronic sinus inflammation with its discharge. Operative interference is usually necessary. In addition to the removal of the primary source of irritation, a reactive acute in- flammation is superimposed upon the chronic inflammation. This favors the absorption of the products of chronic inflammation. MODALITIES FOR PROMOTING THE REACTION OF INFLAMMATION. In the first part of this chapter I have shown that acute inflammation is a series of reactions excited by the presence of bacteria, their toxins, and the cellular debris. The object of the reactions is to rid the tissues of the bacteria, toxins, and cellular debris. Experience has shown that in acute inflammation the reaction is not sufficient to do this as quickly as should be to prevent damage to the tissues. That is, necrosis, cellular deposits, and adhesive processes are liable to occur before the reaction frees the cellular structures of the irritants. It is rational therapy, therefore, to promote the inflammatory reaction rather than to repress it. As a concrete example, I will cite acute coryza, or "cold in the head." This is a reaction due to certain bacteria and their toxins. It is under- stood, of course, that certain predisposing causes have prepared the soil for the growth of the bacteria. Ordinarily, the reaction (increased hyperemia and leukocytosis) is inadequate to quickly throw off the bacteria and the toxin. The question naturally arises, how to promote or increase the reaction ? Do not make the common mistake of assuming that the inflammatory reaction is already excessive. It may be, but it is usually inadequate. Those who assume the reaction to be excessive MODALITIES FOR THE REACTION OF INFLAMMATION 123 often apply adrenalin locally to reduce the reaction. This reduces the hyperemia, cell nutrition, and leukocytosis, whereas, they should be increased. It does establish better drainage. The same law applies to nearly all acute inflammations of the upper respiratory tract, including the ear. It is the purpose of this section to discuss the various procedures whereby the reaction of inflammation is promoted or increased, and to outline the indications and the methods for their therapeutic application. Counterirritation. — Counterirritation has long been used to counter- act inflammatory processes, the prevalent idea being that it diverted the blood to the surface and away from the seat of inflammation. We know now that while its use was rational, the explanation of its good effects was irrational. Counterirritation applied over the inflamed area not only increases the superficial hyperemia, but it increases it in the deeper tissues as well. It also increases the leukocytosis and cell nutrition. Thus, instead of counteracting the inflammation, it promotes the inflammatory reaction. Counterirritation has but little place in otolaryngological practice, for two reasons: (1) Because the blistering and scarring which occasionally result from it are objectionable for cosmetic reasons, and should surgical interference become necessary the skin is in bad condition; (2) because there are other modalities that are more efficacious. Poulticing. — This is also an old method of treating inflammation. The moist pabulum of bread and milk, or other ingredients, is usually applied hot, the whole being covered with cloths or oiled silk to retain the heat and moisture. While poulticing promotes inflammatory reaction, it has fallen into disuse, because better modalities have taken its place. It obviously has little place about the head. Scarification and Wet Cupping; Artificial Leeching.— Scarifiers were once in every family physician's outfit, whereas they are now rarely seen. Scarification was usually combined with cupping, and was designated "wet cupping." With a comb-like knife or with a series of concealed blades liberated by pressing a spring, the super- ficial layers of the skin were many times incised, and a cup in which a few drops of alcohol or a piece of paper was burned was quickly applied over the incised surface, and the negative air pressure created by the heat in the cup caused free oozing of blood. The idea prevailed that this diminished the excessive inflammatory reaction, whereas, as a matter of fact, it increased it. That is, it increased the hyperemia and leukocytosis, established adequate reaction, and hastened the elim- ination of the bacteria, toxins, and cellular detritus. Wet cupping was formerly much practised in acute mastoiditis, and doubtless with beneficial results. I have often used it for this purpose, and recommend it as a valuable mode of treatment in the early stages. Leeching. — This is a venerable tlierapeutic measure of great value in promoting inflammatory reaction. I have seen children with broncho- pneumonia quickly pass from a state of stupefaction, with a pulse of 200 per minute, to one of complete consciousness, with quiet respirations 124 THE XOSE AND ACCESSORY SIXUSES and a pulse of 100 per minute after the application of a few leeches to the chest. Likewise, I have seen the pain and tenderness in acute mastoiditis subside under leeching. With the improved technique of mastoid surgery-, and with the accmnulated observations of aural sur- geons to the effect that, Avhile many of the cases of acute mastoiditis subsided, but few were cured, leeching and kindred measures have been gradually abandoned. The kepiote to the present-day mastoid therapy is the total eradication of the diseased process at the earliest possible moment by surgical intervention. Doubtless the pendulum has swung too far to the surgical side. An increased knowledge of the pathology of inflammation and of the processes of repair will enable the surgeon to difl'erentiate more closely between the operative and non- operative cases. From three to six leeches may be applied over the mastoid process and in front of the tragus in the veiy early stages of acute mastoiditis with decidedly beneficial effect. This is good treatment while watching the development of a case, and in some cases promotes the inflammatory reaction (increased hyperemia and leukocytosis) to such a degree as to lead to a speedy recovery. It is doubtful if leeching is efficacious after the disease has continued several days. Even then, however, it will affect the inflammatory process favorably, though not enough to effect a cure. The case must then be treated surgically (removal of adenoids in children, and possibly the exenteration of the ethmoidal sinuses in adults, or a mastoid operation) or allowed to assume a latent or chronic form. Irrigation or Lavage. — This mode of treatment has long been applied to inflamed mucous-lined cavities of the nose and accessory sinuses of the nose. The prevalent idea as to its mode of action is that the solu- tion used mechanically removes the inflammatory secretions, and thus lessens the noxa or local irritant, all of which is doubtless true. It also increases the local hyperemia and migration of leukocytes, i. e., promotes the inflammatory reaction. Its action, however, is usually slight and transient, and inadequate for the purpose. The inflammatory process passes into the chronic type with tissue deposit, thus causing permanent changes detrimental to the physiological integrity of the structures. There are circumstances, however, under which lavage must be used in the treatment of sinuitis. If, for any reason, operation is refused or is not advisable, lavage may be practised through the ostia or through artificial openings into the sinuses. In acute cases the reaction thus established quickly overcomes the noxa, and healing speedily results. In chronic cases the reaction thus promoted is inadequate, and, indeed, in the nature of things, is not calculated to arrest the noxious process. Chronic inflammation consists of hyperemia, slight exudation, slight migration of leukocytes, and great tissue proliferation. The last-named process is probably not to be checked by any direct means we can employ. From the foregoing it is plainly good treatment to employ such solu- tions by irrigation as will increase the hyperemia, the migration of leuko- cytes, and tlic nutrition of tlie chronicallv inflamed mucous membrane. MODALITIES FOR THE REACTION OF INFLAMMATION 125 To these ends normal salt, boric acid, mild iodine, and other solutions may be employed. Even normal salt solution promotes the reaction of inflammation. It is to be expected, therefore, that while lavage will not remove the tissue proliferation, it will promote the inflamma- tory reaction, increase the nutrition, and remove the infective noxa still remaining. It also removes the irritating toxic secretions and thus relieves the tissues of another source of vicious irritation. Massage. — Under this term are mcluded three modalities of treat- ment, namely: (a) Manual massage, (6) mechanical massage, and (c) alternate rarefaction and condensation of air in a cavity, the so-called pneumomassage as devised by Delstanche and as modified in the various mechanically driven machines so commonly used in America. The effect of massage upon inflamed tissue is to increase the hyperemia and nutrition, and the diapedesis of leukocytes. The inflammatory reaction is thereby promoted and the tissues measurably relieved of the irritant noxa. (a) Massage of the larynx in acute laryngitis and for the relief of singers' nodules has been used with decided benefit. It may be applied by hand manipulations or by a vibratory massage machine. The motion and physical force thus applied to the exterior of the larynx increases the hyperemia and leukocytosis of the parts, and thus aids in the removal of bacterial infection and improves the nutrition of the cells, thereby fostering resistance to mechanical irritation from faulty use of the vocal apparatus. (6) Mechanical or vibratory massage is of special value in acute adenitis of the cervical glands, its application quickly reducing the swelling and tenderness. It is not good treatment, however, to limit the attention to this mode of procedure, for to do so is to ignore the primary source of the glandular disease, namely, the tonsils, adenoids, and pharyngeal glands. The massage is only an adjunct to the treatment. (c) Pneumomassage by means of hand or mechanically driven devices has been used extensively and almost empirically for the relief of deaf- ness and tinnitus, with but little result. The same procedure applied in cases of acute otitis media would be of vastly more use to patients. That it has been used for this purpose I am unprepared to say. It stands to reason, however, that the movements thus imparted to the membrana tympani and the ossicular chain would increase the hyperemia, the cell nutrition, and the migration of the leukocytes in the inflamed mucous membrane, and thus hasten the reparative process. Leukodescent Light. — During the past few years radiant energy in the form of h'ght from a 500 candle-power incandescent globe has been used in the treatment of inflammatory processes. The beneficial effects are, perhaps, best explained by saying that it promotes inflammatory reaction (by hyperemia, cell nutrition, and diapedesis of leukocytes) and thus hastens the removal of the bacteria and other noxious material causing the irritation. I have been using the light for about three years, and have found it one of the most useful, if not the most useful, mechani- cal agency for promoting reaction in inflammatory diseases of the upper 126 THE NOSE AND ACCESSORY SINUSES respiratory tract. Acute coryza sometimes succumbs under its influence. I have repeatedly seen chronic suppurative sinuitis become painless and cease to discharge purulent secretions into the nose. I have never cured such a case with it, the purulent discharge returning in a few days or weeks after ceasing its use. ^Vllether its prolonged use would have effected a cure I am not prepared to state. The light relieves pain, tenderness, and swelling in a surprisingly short time, and superficial infections sometimes disappear rapidly. This is not surprising in view of our knowledge of radiant energy from the Finsen light, the Rontgen ray, and the high-frequency electrical currents. The 500 candle-power lamp is known to possess high chemical and penetrating properties. In addition to this the heat rays are, of themselves, of great usefulness in promoting inflammatory reactions. The combination of the chemical and the heat rays is ideal for the treatment of inflammatory diseases, as the reaction excited is more profound than with either the heat or the chemical rays alone. The range of application of the 500 candle-power lamp is as wide as inflammation itself. It wiU not cure all cases, but if the reaction is inadequate it will benefit in so far as it promotes ade- quate reaction. If there is excessive reaction its use is contraindicated, cold being indicated. If adequate reaction is present, as in incised wounds healing by first intention, its use is contraindicated. It should be remembered that the inflammatory reaction usually reaches its maximum of efficiency at the end of about twenty-four hours, and that to get the maximum results by any of the modalities referred to in this section they should be applied within the first twenty-four hours, before tissue proliferation begins. Tissue proliferation of a permanent type begins at about the fifth day of acute inflammation, and becomes more and more established as time goes on. This is practically illus- trated in acute mastoiditis, where the simple operation is almost always successful if performed within the first five days of the disease, whereas after that period its permanent success is more and more doubtful. The explanation is obvious in view of the well-known fact that tissue proliferation is a manifestation of chronic inflammation, and that chronic inflammation is not readily checked by any direct mechanical means at our command, except by a most thorough exenteration of all the diseased tissue and the establishment of free drainage. Bier's Treatment. — Bier's treatment has attracted a great deal of attention within the last few years. It is based upon the promotion of hyperemia in the treatment of acute suppurative, tuberculous, and other conditions. He promotes both active and passive hyperemia; active by the use of hot air, and passive by constriction of the parts and by negative air pressure in cavities. He finds active hyperemia of more value in chronic cases, where proliferated tissue is to be absorbed. He also finds it useful in acute cases, but not so useful as passive hyperemia induced by compression so applied as to temporarily obstruct the effer- ent veins of a part, without arresting the entry of blood through the afferent arteries. [He also employs suction by cupping over small inflamed areas, and by large glass chambers into which the affected MODALITIES FOR THE REACTION OF INFLAMMATION 127 part, as the hand or foot, may be introduced and the surrounding air rarefied. Sondermann has devised an apparatus especially adapted for pro- ducing negative air pressure in the air cavities of the head. Brawley, Dabney, and Pynchon have also devised apparatuses for this purpose. Bier's treatment is applicable to those cases of acute inflammation in which the inflammatory reaction is inadequate to cope with the irritant noxa causing the inflammation. The treatment should not be applied so as to produce excessive reaction (white edema) of the tissues. It should never cause pain. It must not produce paresthesia or false sensation. In the nasal chambers it should not be kept up for more than one-half to one hour at a time. The mode of treatment requires great caution in its use, as much harm can be done with it. If white edema is induced, the bacteria spread through the tissues and the process becomes more generalized. Heat is then indicated. Inflammation is not yet fully understood, and until it is cases cannot be individualized for treatment. Wright's demonstration of antitro- phins, precipitins, lysins, and opsonins in the blood, and that the opsonins are of greater importance than the leukocytes, as the latter are depend- ent upon the former for their efficiency, has disturbed existing ideas to such an extent that there is a "shuffling of dry bones" in the scientific world. It appears that the leukocytes cannot digest or neutralize the bacteria until they have been acted upon, weakened, or rendered vul- nerable by the opsonins. It would seem that these researches show that Bier's method of inducing hyperemia does not simply flush out the inflamed area, but that the supply of leukocytes and antitropins causes a rapid removal of the dead bacteria from the field of action through the energized leukocytes (Adami). It appears therefore that the opsonic index is of even greater importance than the leukocytic index. Should the leukocytosis be marked and the opsonins scanty, the bactericidal and scavengerial properties of the leukocytes would be greatly impaired, and the reaction, while apparently adequate according to the older standard, would be inadequate according to the newer standard of the opsonins. (See the Opsonic Index and Vaccine Treatment of Infectious Diseases.) However this may be, further observations are necessary before the older standard is abandoned for clmical purposes. Technique. — In acute inflammatory diseases of the nose and accessory sinuses negative air pressure produced by the Sondermann, the Brawley, or the Dabney-Pynchon devices may be obtained as follows : (a) Introduce the nasal tip or tips into the anterior naris, turn on the exhaust power (hand bulb, water, or compressed air, according to the apparatus used), and instruct the patient to swallow. This brings the soft palate in contact with the posterior wall of the pharynx and closes the communication between the epipharynx and the mesopharynx. The air in the nose and accessory sinuses and the Eustachian tubes is rarefied, and liyperemia of the mucous membrane results. After a little practice the patient is able to maintain the state of negative pressure for several minutes at a time. 128 THE XOSE AND ACCESSORY SIXUSES (b) The negative pressure should be alternated every three to five minutes with periods of rest, the whole period of treatment extending over fifteen to forty-five minutes. (c) If the treatment is attended by pain, bleeding, or white edematous swelling the negative pressure is too great and should be reduced. Heat in the form of hot air is indicated to counteract the white edematous swelling should it occur. (d) The nose-piece should be patterned after the Seigel otoscope, so that the mucous membrane may be inspected during the course of applica- tion of the negative air pressure, and if the membrane becomes pale and edematous, or bleeds, the treatment should be abandoned for twenty- four hours; that is, paralysis instead of dilatation of the vessels has occurred, and the nutrition of the cell structures and the local leuko- cytosis have been still further diminished. The method of treatment, therefore, requires the greatest care and intelligent application to be beneficial. Its careless and indiscriminate use can only produce harm- ful effects. The greatest objection to the mode of treatment is the ease of a])])lication and ease with which great harm can be done with it. Indicaiions. — (a) In the first five days of acute rhinitis. (6) In the first five days of acute sinuitis. (c) In the first five days of acute in- flammation of the phar\Tigeal tonsil, (d) In acute tubal catarrh, (e) Chronic purulent inflammation of the sinuses. In chronic cases the negative air pressure should be very moderate, as otherwise it might produce edema and white swelling and add fuel to the flames. Its greatest efficiency will be found in acute inflammation. In chronic in- flammation, either catarrhal or suppurative, heat in the form of hot air is a more rational mode of treatment, as it produces an active hyperemia and increases the cell nutrition. The negative pressure produces a passive hyperemia and leukocytic migration, processes much needed to promote speedy resolution of the inflammatory process. (e) When purulent secretions are present they are drawn into the bottle reservoir of the apparatus. In these cases the negative air pressure not only promotes the inflammatory reaction, but it removes the instating secretions as well. (/) The treatment should be repeated every day or every other day. THE OPSONIC INDEX AND VACCINE TREATMENT OF INFECTIOUS DISEASES. The opsonic index and vaccine treatment is essentially a painstaking laboratory process, and cannot be used as a routine mode of treatment. It should only be attempted, therefore, when such facilities are at the service of the physician. The method appears so promising, however, that it should be tried whenever suitable cases and expert laboratory control are available. The value of the opsonic index control has been best demonstrated in local tuberculous lesions, but it has also been demonstrated in a lesser number of cases in which streptococcal, staphylococcal, colon, and other bacterial infections are present. THE OPSONIC INDEX AND VACCINE TREATMENT 129 The opsonic index is based upon the average value of a number of healthy non-tuberculous subjects, and is indicated as 1.0. The principle underlying the vaccine treatment under the guidance of the opsonic index is as follows: Certain white blood cells and endothelia are enabled to take up and destroy bacteria. This process is called phagocytosis. Wright and others have shown that these corpuscles can only do this after the bacteria have been acted upon by the opsonins of the blood. If the amount of opsonins is normal, or 1.0, phagocytosis is normally and rapidly per- formed; if the opsonins are below normal, phagocytosis is imperfectly performed. The opsonic bodies probably attach themselves to the bacteria, and weaken or otherwise prepare them, so that they are readily enveloped and destroyed by the white blood corpuscles. If, therefore, the opsonins are deficient, the bacteria are not sufficiently prepared for destruction by the white corpuscles. The opsonins appear to be an index of what has formerly been called the "resistance" of the cells of the body. Opsono is a Latin verb, which means, "I prepare for food." When a subject is infected by tubercle bacilli, or other pathogenic microorganisms, he has less than the normal amount of opsonins in the blood and is said to have a lowered opsonic index, or lowered resistance. This fact has been utilized in diagnosticating obscure hidden local tuberculous processes. Wright and others have shown that when a subject affected by local tuberculosis is injected with Koch's new tuberculin, the opsonic index first falls a little, then rises to, or above, normal. The opsonic index is taken daily, and after a few days it begins to fall. Wlien it has again receded considerably below normal another injection of Koch's tuber- culin is given. In this way the patient's opsonic index is maintained near normal, and the maximum of bacterial destruction is maintained. The general condition of the patient is better when the opsonic index is high or near normal, and it is worse when it is low. Too small or too large a dose of Koch's new tuberculin is ineffective. Indeed, too large a dose is marked by a rapid, steep fall in the opsonic index and the impoverishment of the patient. This shows the impor- tance of using the opsonic index in regulating the dosage of Koch's new tuberculin, and explains the various and conflicting results reported from its improper use. The serum treatment of sinuitis and mastoiditis under opsonic con- trol, according to J. C. Beck, affords apparently good results, though it is too early to foretell its ultimate place in the therapy of the infectious diseases of the accessory cavities of the head. The leukodescent light also seems to give good results, though their permanency has not been demonstrated. A more rational therapeutic measure is to establish ventilation and drainage, thereby removing the chief predisposing cause of infection and inflammation, and then administer the appropriate serum prepared from the bacteria peculiar to each case, the opsonic index being determined at intervals of two or three weeks. This is in accordance with Wright's own statement. 9 CHAPTER VIII. THE INFLAMMATORY DISEASES OF THE NOSE. ACUTE RHINITIS DUE TO MICROORGANISMS OF SPECIFIC FEVERS AND TO CONSTITUTIONAL DYSCRASIAS. It is a well-recognized clinical fact that the initial stage of the various exanthematous or specific fevers is characterized by an attack of acute rhinitis. Certain constitutional dyscrasias also give rise to acute rhinitis. The infectious or exanthematous fevers commonly characterized by an attack of acute rhinitis are smallpox, typhoid fever, acute articular rheumatism, epidemic influenza (la grippe), erysipelas, and diphtheria. The symptoms of all the foregoing types of specific acute rhinitis are about the same, except in diphtheria, where a pseudomembrane may be present. There are the usual manifestations found in coryza with con- junctivitis and photophobia. An examination of the mucous membrane of the nose and fauces sometimes shows an eruption quite similar to that found on the skin. The treatment should consist in the use of mild alkaline solutions with an atomizer or a nasal douche. The objection to the douche is the possibility of carrying the infection to the middle ear should the patient happen to swallow while the fluid is in the nose. The nose should be irrigated three or four times daily. The constitutional dyscrasias which cause acute rhinitis are acute articular rheumatism, diabetes mellitus, and scorbutus. In diabetic rhinitis the symptoms when present rise and fall with the percentage of sugar in the urine. Scorbutic rhinitis is associated with infantile scurvy, and is characterized by an excoriation about the nasal orifice. The treatment should be addressed to the relief of the local nasal symptoms and to the improvement of the constitutional dyscrasias. ACUTE RHINITIS. Symptoms. — Acute coryza; cold in the head. Definition. — Acute rhinitis is an acute inflammation of the nasal mucous membrane, characterized by chilly sensations, lassitude, nasal discliargc, and a swelling of the mucous membrane of the nose. The patient also complains of a stuffiness of the nose and sneezing. Etiology. — The chief predisposing cause of acute rhinitis in adults is an ol)structive lesion of the nasal septum, which predisposes to the local growth of the padiogenic bacteria and the development of their toxins, ACUTE RHINITIS 131 hence the inflammatory reaction in the form of an acute rhinitis. The ridge or other deviation of the septum impinges upon, or is closely approxi- mated to, the inferior nasal concha (inferior turbinated body), thus interfering with drainage and ventilation of the nose and accessory sinuses. When the anterior portion of the septum is thus deformed it obstructs the breathway, and each descent of the diaphragm acts like the piston valve of a syringe and rarefies the air in the nasal chamber posterior to the obstruction. The negative pressure thus created causes the blood to fill the vascular tissue of the swell bodies on the inferior and middle turbinals, hence the stuffiness of the nostrils. Furthermore, the me- chanical irritation caused by the pressure of the ridge or other deviation against the turbinals still further aggravates the irritation and swelling of the mucous membrane. The secretions are thereby increased in quantity and changed in character. Inquiry usually elicits the statement that the patient (if an adult) has been inclined to chronic rhinitis; indeed, a complete examination often shows the patient to have been subject to acute exacerbations of a chronic rhinitis, and that a septal deformity is present. Septal deformity is not, however, always present, hence each case should be studied for the peculiar etiological factors back of it, so that the treatment for the ultimate cure and prevention of the acute exacerbations may be intelligently directed. Another very common cause of acute rhinitis is an imbalance in the vasomotor nervous system. There is a paralysis of the vasocon- strictor muscle fibers of the capillaries or an irritant in the blood which affects the dilator fibers. The paresis and irritation may be due to the presence of uric acid and its kindred products or to other acquired dyscrasia. The imbalance of the vasomotor nervous system may. also be due to the inadequate ventilation of the living and sleeping rooms, offices, etc., or to the wearing of improper clothing. The removal from the country to the city is often followed by frequent attacks of acute rhinitis on account of the changed conditions of living. In the country the houses are less tightly con- structed and but partially heated, whereas in the city the houses are more tightly constructed and either overheated or, as is often the case, is underheated in all its rooms. In either event the conditions are worse in the city dwelling, as fresh oxygen is a negligible quantity on account of the poor ventilation. Then, too, while resident in the country much of the day is spent in the open air, whereas in the city it is spent in crowded and illy ventilated offices and shops. It is obvious, therefore, that rliinitis due to poor ventilation should be treated by changing the mode of living to one which keeps the patient in the open air or in a well- ventilated residence and business buildings. The causative relationship of clothing to acute rhinitis is unf[uestioned, though it is difficult to describe the exact mode of clodiing that predis- poses to rhinitis. It may be said, however, that clodiing which favors perspiration is vicious. There is normally some evaporation of moisture from the bodv, hence the underwear should be of such material as to 132 THE NOSE AND ACCESSORY SINUSES readily absorb it. The function of underwear is twofold, namely, (a) to retain the body heat between it and the skin; (6) to absorb the excess of perspiration. If, therefore, the clothing is of such density that it causes undue perspiration, and of such material that it does not absorb it, the conditions are favorable for the development of acute rhinitis, even though the septum is normal. Wool retains the body heat, but is a poor absorbent. Cotton is neither a good heat retainer nor an absorbent. Linen is a fair heat retainer and a good absorbent. In some cases wool retains too much heat and induces profuse perspiration. A garment of wool and cotton, or wool and linen, or of thin linen under a hglit woollen garment, seems to be suitable to the proper protection of the body. Linen mesh in some cases is insufficient protection during the winter months for some people, whereas it is worn with the greatest comfort and satisfaction by others throughout the year. It should be determined in each case whether the rhmitis is due, in part, at least, to excessive protection and perspiration, or to deficient absorption of the perspiration. Then, too, the question extends to the external garments worn both in and out of doors. For the sake of convenience the outer garments should be lessened or added to as the exposure to the tempera- ture and weather demands, while the undergarments should be of moderate weight and capable of absorbing the visible and invisible perspiration. A preexisting chronic rhinitis is a common factor in the causation of acute rhinitis, especially in adults, whereas infants and young children are more susceptible, and often have colds in tlie head without a pre- existing chronic rhinitis. As stated in Chapter VI, mflammation is almost always of bacterial origin, the conditions necessary for the growth of the bacteria being a lowered vitality of the cells of the tissues. I also stated that mucous membrane-lined cavities with blocked drainage and ventilation were especially subject to infection and inflammation. Trauma, chemical injury, and shock also lower the cell vitality and prepare the soil for infection and inflammation. Exposure to cold and draughts are com- mon sources of shock that result in acute coryza or inflammation of the nasal mucous membrane, hence obstructive lesions of the nasal septum are not always present in patients subject to acute coryza. Certain constitutional diseases, as diabetes, rheumatism, etc., reduce the vitality of the mucous membrane of the nose and accessory sinuses, and are, therefore, predisposing causes of this disease. All conditions, local and general, which lower the vital resistance of the mucous membrane of the nose act as predisposing causes to infection and inflammation of the nasal mucous membrane. I W'ish to emphasize again the fact that in many instances the chief predisposing cause of acute coryza (acute infectious inflammation of the nasal mucous membrane) is an obstruc- tive lesion of the septum. The influence of exposure to cold, draughts, foul air, poor ventilation of houses, offices, etc., have heretofore been given undue prominence, to the neglect of nasal stenosis (partial and complete), which so often bears an important relation to this disease. It ACUTE RHINITIS 133 follows that chronic rhinitis is often present in persons subject to recurrent attacks of coryza, a condition which still further lowers the vitality of the nasal mucosa and predisposes to the growth of bacteria and the development of their toxins, which excite the inflammatory reaction known as acute coryza, acute rhinitis, and a "cold in the head." In emphasizing these facts I do not wish to obscure or belittle the other factors that reduce the vitality of the tissues and which predispose to the acute inflammatory disease. I only wish to give a true perspective to the underlying causes of acute coryza, so that in the treatment a more rational basis of procedure may be adopted. Acute rhinitis undoubtedly has an infectious origin, the foregoing etiological factors predisposing to the mfection. Nasal polypi and other morbid processes within the nasal chambers also predispose to rhinitis. Pathology.- — The vasomotor constrictor muscle fibers of the capillaries are paralyzed and the dilator fibers irritated, and, as a consequence, there is a passive hyperemia of the venous capillaries and lymph vessels, and the nose becomes "stuffed." There is also an increased migration of leukocytes and a transudation of lymph and serum. The production of mucus is temporarily checked, but later is increased. The epithe- lium is exfoliated and admixed with the other inflammatory products and secretions. During the first stage the secretions are greatly reduced in quality or are entirely absent. In the second stage the secretions are at first serous, and later become thick and viscid from the excessive degeneration of the goblet and glandular epithelial cells. In the third stage the secretions are mucopurulent or purulent in character. The duration and course of the inflammatory process varies. The natural history of the average case is completed in from eight to ten days, though under appropriate treatment it may be greatly shortened. Symptoms. — ^The symptoms are, for clinical purposes, divided into three groups, as follows: First Stage, or Onset. — ^The patient experiences a sense of dryness or prickling in the nose, with itching at the inner canthi of the eyes. Chilly sensations and a feeling of malaise are complained of. Examination shows the mucosa to be red and hyperemic, but not fully turgescent. The mucous membrane is abnormally dry and free from secretions. Headache is usually present, and there is a sense of fulness between the eyes. This stage lasts but a few hours. The temperature ranges from 100° to 103°. Second Stage. ^ — This stage is characterized by a profuse serous dis- charge and turgescence of the mucous membrane. In some cases the headache and the sense of fulness between tlie eyes are diminished, whereas in others it is increased, depending upon the patency or closure of the ostei of the accessory sinuses. In those cases in which there is a marked deviation of the nasal septum in the region of the middle turbinal the obstruction of the ostei on one side may be great and the pain and sense of fulness correspondingly increased on tliat side. 134 THE XOSE AXD ACCESSORY SIXUSES Third Stage. — This stage is characterized by a mucopurulent or puru- lent (lischai'ge and by a marked decrease in the temperature. The headache and the sense of fulness between the eyes may be diminished so as to amount to a dull heavy feeling across the forehead and between the eyes. If the nasal accessory sinuses are also markedly involved in the inflammatory process the frontal headache and the sense of pressure are correspondingly pronounced. If the sinuses are not involved these symptoms may be entirely absent. Dizziness and vertigo also may be present if the sinuses are involved. The use of the eyes m reading, sewing, or at the theatre often produces headache and other evidence of ocular irritation when the sinuses are involved in acute rhmitis. Prognosis. — The natural duration of acute rhinitis is from eight to ten days. When the sinuses are also involved the duration is extended to two weeks, or even longer, unless the attack is aborted by appropriate treatment. Some writers claim there is no curative treatment of acute rhinitis. I believe this to be an erroneous view, and hold that nearly all cases may be cured if taken sufficiently early and rational treatment is used. Treatment. — The treatment of acute rhinitis should be undertaken with a knowledge of the nature of inflammation and the chief predis- posing and active etiological factors in mind. These are (a) obstructive lesions; (&) lowered tonicity of the cellular structures of the nasal mucous membrane, and (c) the mfectious microorganisms. (a) If there is an obstructive lesion in the nose it should be located by rhinoscopic exammation. Wlien found, and demonstrated to be spongy or erectile tissue, local applications of cocaine, adrenalin, and antipyrine should be made to this region to reduce the swelling and to establish the patency of the nasal chambers. By so doing drainage and ventilation are reestablished, points of immense value in promoting the reaction against the bacteria and toxins causing the disease. It is not advisable to attempt to remove by surgical means the obstructive lesion during the acute symptoms, though such a procedure may well be under- taken after they have subsided. The retention of the secretions and the lack of ventilation, together with the mechanical irritation from pressure, aggravate the existing irritation and tend to perpetuate the reaction of inflammation and prolong the disease. The reaction is often inadequate to throw off the bacteria and their toxins, hence measures should be used that will promote the reaction of inflammation, which is Nature's effort to cure the disease. The question naturally arising in this connection is. How may the reaction of inflammation be promoted? That'is, what measures may be adopted that will aid in combating the bacteria and their toxins? As stated in the section on Inflammation, acute inflammation consists in three reactions, namely: (a) Increased hyperemia; (b) increased cell nutrition, and (c) increased migration of leukocytes. The purpose of these reactions is (1) to increase the vitality of the attacked tissues (2) to remove the bacteria and toxins, and (3) to remove the dead and broken-do\Mi cells. ACUTE RHINITIS 135 The increased hyperemia furnishes extra food for the attacked and weakened cells, while the increased migration of leukocytes provides for the destruction and removal of the invading bacteria and the dead and broken-down cells. Adami has shown that in acute inflammation the inflammatory reaction is usually inadequate for these purposes, although it has generally been held that it is excessive. He advises, therefore, that acute inflammations be treated by such modalities as will promote the reaction of inflammation, rather than check it. Ac- cording to former formulae of thought, remedies which acted favorably upon acute inflammations were said to lessen the inflammatory reaction, whereas a more correct and scientific statement is, that the remedies promoted the inflammatory reaction (Nature's effort to rid the tissues of bacteria and their toxins) and thereby hastened the cure of the disease. It is with this understanding that I advise the use of such remedial measures as will promote the reaction of inflammation. The exact effect of the many drugs upon these reactions is so little understood that it is a difficult task to undertake to give their use a scientific basis. The empirical use of drugs has long been practised, and must doubtless continue to be practised, empirically at least, until their action is better understood. We know enough about a few of them to criticise their use in acute coryza. Adrenalin has been much used in this disease because it was thought that the progress of the disease would be affected favorably by reducing the inflammatory reaction. I believe that its use for this purpose is contra-indicated, because the inflammatory reaction is an effort to remove certain noxa or irritants from the tissues, and should not, therefore, be checked by the local use of adrenalin or any other substance. The physician should recognize the activities known as inflammation as forces directed against a noxious foe, and should aid or promote them rather than thwart or check them. The chief difficulty in arriving at a correct understanding of inflammation is that the results of inflammation are confused with the process itself. When I advise the promotion of inflammatory reaction, I do not mean that it should be made worse, that cell proliferation should be increased, that the pain and soreness should be increased, that adhesive processes should be encour- aged, etc. These are the results of inflammation, and are not essential features of the reaction. \¥liat I mean by promoting the reaction of inflammation is to use such modalities of treatment as will increase the hyperemia, the cell nutrition, and the migration of leukocytes. By so doing the irritant noxa is removed, and the cell proliferation, pain, and adhesive processes are quickly relieved or altogether prevented. Unfortunately, the treatment of acute coryza has not been systemati- cally treated upon the basis herein outlined, hence there is little accumu- lated evidence upon which to base a scientific and well-established mode of treatment. Science is not science until proved; hence there is no scientific method of treating acute rhinitis. While the metliods of treatment to be given are somewhat hypothetical and in some instances purely empirical, they have been rather extensively tried and have proved to be of more or less value in promoting tlie 136 THE NOSE AND ACCESSORY SINUSES inflammatory reaction of acute coryza; that is, they have hastened the destruction of the bacteria and noxa causing the disease. (6) The tonicity of the vasomotor nervous system should be mam- tained by the administration of strychnine and arsenous acid in the usual tonic doses. Furthermore, the patient should have plenty of fresh air in his room, if it can be arranged without exposing him to a draught. The admmistration of aconite or belladonna may be resorted to for the immediate effect upon the turgescence and the secretions, especially in the second stage. An alcohol rub over the entire body also acts as a tonic to the vasomotor nervous system and increases the hyperemia of the arterials and capillaries, and thereby increases the nutrition of the mucous membrane. (c) ^N\n\e it has not been shown that the disease is due to a specific microorganism, it is evident that bacteria are the exciting cause of the disease. An endeavor should be made, therefore, to establish conditions favorable for their destruction and elimination. This is best done by establishing and maintainmg drainage and ventilation and promoting the reaction of inflammation. The use of antiseptics has no effect in destroy- ing the bacteria, though they do promote reaction of inflammation. Surgi- cal experience has shown that free drainage is of prime importance in the treatment of infected cavities, as, for instance, in septic peritonitis com- plicating a ruptured appendix. Irrigation of the abdominal cavity has been abandoned and simple drainage substituted, with the most brilliant results. The operative procedure promotes the reaction of inflamma- tion, and thus hastens the destruction of the infecting bacteria. The same principle applied to acute infectious inflammations of the nasal and accessory sinuses brings equally brilliant results. Hence, the mode of treatment described in paragraph (a) wall, in most instances, meet the indications. If it does not, the obstructive lesions of the septum (or other lesion) should be removed by surgical means at the earliest possible time, so as to prevent such a complication during subsequent attacks of acute rhinitis. In addition to the foregoing measures the use of the leukodescent lamp over the nose and eyes is recommended, to promote the reaction of inflammation. The light from this lamp is rich in blue violet rays, in addition to the heat rays, and they exert a powerful and immediate salutary effect upon the inflammatory process; that is, they greatly in- crease the hyperemia and the leukocytosis, and thus dispose of the bac- teria, their toxin, and the dead cells of the tissues. Having done this, the reaction often rapidly subsides and a cure is effected. A treatment with the lamp should cover a period of from twenty to thirty minutes, at a distance of about eighteen to twenty inches from the face. The light is more effective if applied over the closed eyes, as the tissues are soft and easily penetrated by the rays, and because the veins of the accessory sinuses empty into the ophthalmic vein. Hence, any increased flow tln-ough the ophthalmic vein favors the flow from the veins of the sinuses and tlie nose. As acute rhinitis is essentially an acute simiitis, the reaction afl'ecting the sinuses effects a speedy relief or a cure. CHRONIC RHINITIS WITH TURGESCENCE 137 The above mode of treatment is based upon rational principles, which, for the sake of emphasis, are recapitulated here: (a) The establishment of ventilation and free drainage of the nasal accessory chambers. (&) The establishment of the tonicity of the vasomotor nervous system. (c) The promotion of the elimination of the bacteria by the drainage and ventilation of the nasal and accessory sinuses. (d) The promotion of the reaction of inflammation by the leuko- descent light. Other Methods of Treatment. — 1. The administration of full doses of quinine and a hot lemonade at bedtime will, in some instances, during the first stage, abort acute rhinitis by increasing the hyperemia and leukocytosis. If given during the second or third stages they are ineffective. This method is not so efiicacious as the one given above, but is worth trying. 2. Ten grains of Dover's powder and a hot mustard foot bath at bed- time promote the reaction of inflammation to a considerable degree, and during the first stage may abort the disease. During the second and third stages it is more difficult to promote the reaction of inflammation, hence this mode of treatment is not powerful enough to be of much value. 3. The administration of rhinitis or coryza tablets, containing quinine, belladonna, and morphine, during the first stage will in a number of cases abort acute rhinitis. One tablet should be given every twenty minutes until dryness of the nose is produced. 4. Aconite administered hourly in the first stage in 1 minim doses until dryness of the throat or tingling of the fingers is produced will sometimes abort the disease. During the second and third stages the remedy is of little use. \i.. [ CHRONIC RHINITIS WITH TURGESCENCE. Synonyms. — Alternating stenosis; simple chronic rhmitis. |3| Definition. — Chronic rhinitis with turgescence is characterized by fugitive swelling or turgescence of the swell bodies of the inferior tur- binated bodies, the patient complaining of attacks of nasal obstruction and a thick mucous discharge. Etiology. — ^The causes of rhinitis are given under the etiology of acute rhinitis, and will not be repeated in detail here. It should be stated, however, that in most cases there is a deviation of the septum in its lower and middle portion. The deviation may also be an anterior one near the vestibule of the nose in the cartilaginous portion of the septum, thereby producing anterior nasal stenosis. With each descent of the diaphragm the air is rarefied posterior to the obstruction, and a negative pressure in the nasal chambers results. The blood in the mucous membrane lining the nasal chambers is thus determined to the venous plexuses (swell bodies) of the turbinals, and turgescence or engorgement results. In the section on the Deviations of the Septum I have shown that 138 THE XOSE AXD ACCESSORY SIXUSES obstructive lesions in the region of the inferior turbinal act in such a way as to produce engorgement of the tissues without much irritation. Hence, the effect at first is simply one of turgescence, which in the course of years of increased nutrition results in hypertrophy or hypertrophic rhinitis. If, in addition to the local turgescence, there is an associated obstruction in the region of the middle turbinal, the retention and de- composition of the secretions in the superior meatus and the posterior ethmoidal cells cause a prolonged low-grade irritation which may result in a hyperplasia of the mucous membrane, not only of the middle turbinal, but of the inferior as well. As an obstructive lesion of the septum in the middle turbinal region often co-exists with the obstructive ridge or spur in the inferior tin-binal region, hyperplasia or hyperplastic rhinitis affecting the inferior and middle turbmals is often present, ^^^len, however, the upper obstruction is absent, the rhinitis is usually of the turgescent or hypertrophic type. Pathology. — In the early stage there is a distention of the venous or cavernous tissue of the conchse (turbinals). If the inflammatory^ process continues a true hypertrophy or hyperplasia of the tissues takes place on account of the increased nutrition from the large blood supply. Symptoms. — The symptoms are chiefly referable to transient stenosis of the breathway of the nose. In addition, the secretions are heavier; that is, the mucoid element is increased, while the serous element may be decreased in quantity. The patient believes there is an actual increase, whereas, as a matter of fact, there is probably a decrease in the amount of secretion. The apparent increase is due to the increased consistency of the secretion, which renders it less absorbable by the ingoing current of air. In a normal nose the secretions are compara- tively thin or serous and are largely absorbed for physiological purposes in the lower respiratory tract. The transient stenosis is either intermittent or alternating; that is, both sides may be stenosed for a period and then open, or the stenosis is on one side and changes to the other. These symptoms are quite characteristic of turgescent rhinitis. The objective signs of turgescent rhinitis are chiefly found in the evi- dences of the engorged swell bodies of the inferior turbinals. Upon inspection by anterior rhinoscopy the outline of the inferior turbinal is smooth and bag-like, whereas, in true hypertrophy, hypertrophic rhinitis it is firm and unyielding. The application of cocaine or adrenalin shrinks the mucous membrane covering the inferior turbinal, whereas, in hypertrophic rhinitis there is little or no shrinkage. The secretions are mucoid in character, and when the swell bodies are contracted strings of mucous extend from the septum to the inferior turbinal. A spur or ridge is usually present upon the lower portion of the septum, causing ()])struction in some degree in the region of the inferior turbinal. The cartilaginous portion of the septum may also be deflected, thereby causing anterior nasal stenosis and a consequent rarefaction of the air within the nasal chambers with each inspiratory current. CHRONIC RHINITIS WITH TURGESCENCE 139 Epistaxis is also occasionally complained of. The ridge or crest of the septum projects into the inspiratory tract, and is thereby subjected to excessive evaporation of the secretions accumulated upon it. The dried crusts are blown or picked off, tearing the underlying epithelium and the capillary vessels, hence the epistaxis. Cough may or may not be present, and is due to an associated bron- chitis or to a nasal reflex. A posterior examination of the nasal choanse may reveal an enlarge- ment of the swell bodies upon the posterior ends of the middle and inferior turbinated bodies. The enlargement has often been likened to a mulberry. It is nodular in outline and of a grayish-blue color. Prognosis. — If allowed to run its course, true hypertrophy of the tissues in the region of the swell bodies occurs. Under appropriate treatment the disease is curable. Method of moistening a thin pledget of cotton with cocaine or adrenahn solution, a, the solution in an inverted bottle; b, the pledget of cotton. Treatment. — The treatment should be twofold in character: (a) The removal of the predisposing causes, and (6) the control of the immediate symptoms. (a) The removal of the predisposing causes is usually accomplished by the correction of the deviated septum. (See Treatment of Deviations of the Septum.) When this is done the negative air pressure in the nasal chambers disappears and the blood ceases to be determined to the mucous membrane, and the tendency to intermittent and alternating stenosis is greatly reduced. The operation of election should be deter- mined according to the type and location of the deviation of the septum. (b) The palliative treatment should be addressed to the immediate control of the distressing symptoms, namely, the stenosis and the heavy secretions. The transient stenosis may be controlled by the use of the electric or chemical cantorv or bv incisino- the turo-escent swell bodies. 140 THE NOSE AND ACCESSORY SINUSES Electrocauterization. — The teclmique of electrocauterization is as fol- lows: (a) Induce cocaine anesthesia by the application of a 4 per cent, solu- tion of cocaine on a thin pledget of cotton to the swollen free border of the inferior turbinal for a period of ten minutes (Figs. 89 and 90). (6) Turn on the electric current until the point of the cautery electrode is of a bright cherry-red color. (c) Introduce the electrode into the nasal chamber cold and place it on the free border of the interior turbinal (Figs. 91 and 92). Then move it backward and forward, while still cold, until sure of its correct position. Maintain the to-and-fro motion and press the contact spring of the cautery handle for one or two seconds, when the contact should be broken. The to-and-fro motion should be continued until the elec- trode is cold, that is for two or three seconds after the spring contact is broken, and then it should be removed from the nose. Method of applying the pledget of cotton to the inferior turbinated body, a, the pledget of cotton after being moistened with the cocaine or adrenalin solution is engaged upon tlie tip of a delicate silver probe; b, the pledget of cotton being "pasted" or spread upon the inferior tur- binated body. If these instructions are followed the procedure is painless and does not tear the eschar from the turbinal. If the to-and-fro motion is not maintained before, during, and after the electrode is heated, the eschar will be torn off and the cautery effect lost. The eschar must be left in place. If bleeding follows the removal of the electrode, the eschar is lost and the cauterization rendered useless. The cauterization should be linear, and should be about one inch in length. The whole length of die inferior turbinal may be cauterized in three sittings (Fig. 93), never in one, as too great a reaction and sloughing may follow. The sittings should be from five to seven days apart. A week after the first cauterization the opposite side may be treated in like manner. At the end of another week the middle portion of the inferior turbinal CHRONIC RHINITIS WITH TURGESCENCE 141 first cauterized may be thus treated. And so continue to cauterize the turbinals ahernately, at weekly intervals, until the whole length of both turbinals has been cauterized. The after-treatment of a cauterized turbinal should consist in an immediate spray of an alkaline solution — Dobel's or Seller's solution. Cauterization of the inferior turbinated body. Lateral view, showing the cautery electrode in position for cauterizing the inferior turbinated body. An oily aromatic nebula should follow this. Prescribe Seller's solution for daily use by the patient. The wash should be used with a glass nasal douche rather than an atomizer, as the force of the spray might injure the eschar covering the cauter- ized surface. Should infection occur, gently pack the nose with small cotton pledgets saturated with a 10 per cent, aqueous solution of Merck's ichthyol. Remove the pledget in about fifteen minutes and insufflate bismuth powder into the nose. The clothing should receive thoughtful attention and be regulated according to the indications. Heavy-soled shoes should be prescribed. Submucous Cauterization. — N. H. Pierce first introduced the submucous cauterization of the inferior turbinated body for the reduction of turges- cent and liyjicrtrophic rliinitis. The mucous membrane was punctured near the anterior end of the free border of the turbinate and a tunnel made with a blunt probe beneath the turgcscent membrane. A fused bead of chromic acid was then introduced into the artificial tunnel or Showing the lines for linear cauterization in tur- gescent rhinitis. A, B and C, representing respec- tively the first, second, and third cauterizations, which should be made one week apart. 142 THE XOSE AXD ACCESSORY SIXUSES channel. M. A. Goldstein improved the instrument for this procedure, as shown in Fig. 94. By Goldstein's method the bead of chromic acid is concealed in the cannula while being introduced, the fused bead of acid then being thrust from the end of the cannula and withdrawn through the channel in the submucous tissue. Goldstein's cliiomic acid applicator for submucous cauterization. Sloughing sometimes follows this method of cauterization. Chromic acid is verv irritating to the kidneys and may cause nephritis. It should never be used in a patient already subject to nephritis, for obvious reasons. HYPERTROPHIC RHINITIS. Synonyms. — ^True hypertrophic rhinitis; obstructive rhmitis; hyper- trophic nasal catarrh; hypertrophic ozena; hypertrophy of the turbinated bodies; hyperplastic rhinitis. Definition. — Chronic hypertrophic rhinitis is characterized by a more or less constant stenosis of the nasal passages. The mucous memlirane along the free border of the inferior turbinals is usually hypertro- phied, and the stenosis is chiefly referable to the lower portion of the middle turbinal by the bowing of the septum. Such cases are, there- fore, sometimes complicated by catarrhal or suppurative sinuitis and hyperplasia. The uncomplicated cases of hypertrophic rhinitis usually present free and unobstructed olfactory fissures on both sides of the sep- tum, the obstructive lesion l)eing limited to the anterior portion of the cartilaginous septum, or to the ridge along the crest of the vomer. Etiology.— The causes of hypertrophic rhinitis are essentially those given under turgescent rhinitis. AMien there is an anterior devia- tion of the septum there is a negative air pressure within the nasal chambers with each inspiratory effort. The hyperemia resulting there- from leads to an overnutrition of the mucous membrane and especiallv in the region of the swell l)odies. The contact of the deviated sep- tum with the mucosa of the inferior turbinal irritates it and thus still further excites the hypertrophic process. The altered secretions add HYPERTROPHIC RHINITIS 143 to the irritation and still further increase the hypertrophy of the mucous membrane. In those cases complicated by a high deviation of the septum, and in which there is a complicating sinuitis (catarrhal or suppurative), the tissue changes are somewhat modified. Instead of an hypertrophy, the irritating discharge from the sinuses often causes an hyperplasia of the mucous membrane. There may be present, therefore, both an hyper- trophy and an hyperplasia of the tissue. Either the hypertrophy or the hyperplasia may predominate. The so-called hypertrophic rhinitis may, therefore, be divided into two groups: (a) The hypertrophic variety, and (6) the combined hypertrophic and hyperplastic variety. This subdivision is still further justified by the clinical fact that the symptomatology and treatment of the two conditions are often quite different. The hypertrophic variety presents symptoms chiefly referable to the anterior and the inferior obstruction of the nose, whereas the combined variety presents symptoms referable to obstruction in the middle turbinal region as well as to the obstruction in the anterior and inferior portions of the nasal chambers. The causes of uncomplicated hypertrophic rhinitis are, therefore, those conditions which give rise to a chronic hyperemia of the mucosa and to a passive engorgement of the swell bodies. These conditions are the anterior and inferior obstructive deviations of the nasal septum and the climatic and hygienic conditions which affect the vasomotor nervous system. In addition to these factors, the mild infection remain- ing after attacks of acute rhinitis may cause the disease or contribute toward it. Pathology. — The morbid anatomy of hypertrophic rhinitis consists in an increased blood supply and an increase of tissue from nutritional causes, rather than from irritative and inflammatory causes. The part most frequently hypertrophied is the mucous membrane containing the swell bodies, as there is naturally a greater determination of blood to these vascular bodies. Symptoms. — The symptoms are chiefly those of more or less nasal stenosis. The secretion is usually heavier than normal, and pasty in consistency, although it may be comparatively thin and watery, especially during an acute exacerbation. The nasal stenosis may be limited to one side, the side of greater septal convexity. The inferior turbinal on the side of the concavity is often greatly hypertrophied, a so-called compensatory hypertrophy, although, as a matter of fact, it may be due to a negative air pressure within the nasal chamber on that side. The anterior opening of the nose on that side, while normal in size, is, on account of the diminished size of the opposite chamber, inadequate to admit air rapidly enough for phy- siological purposes; hence, engorgement and subsequent hypertrophy result. It follows that l)oth nasal passages are often more or less con- stantly blocked in the region of the inferior turbinal. The patient com- plains of stuffiness, or sense of a foreign body in the nose, and makes frequent but ineffectual attempts to remove it by blowing the nose. V '^- ^:-^^4"iJ 144 THE NOSE AND ACCESSORY SINUSES Upon anterior rhinoscopic examination the inferior turbinal is ob- served to be enlarged and to have an irregular nodular surface. Probe pressure does not cause pitting, as in turgescent rhmitis, but elicits a sense of resistance and of thick, fleshy tissue. The application of cocaine or adrenalin is not followed by marked contraction of the tissue. Epistaxis from the dislodgement of an adherent crust upon the crest of the deflection occasionally occurs. Prognosis. — If allowed to run its natural course, hypertrophic rhini- tis tends to become worse rather than better. Indeed, in the course of time the secretions may become so heavy and so adhesive in quality as to be removed with great difficulty. In such subjects irritation results and a hyperplasia of the tissue follows. If this is allowed to progress the vascular and glandular tissues become enmeshed in the contractile hyperplastic tissue, and atrophy of the mucous membrane begins. If, on the contrary, appropriate treatment is instituted sufficiently early in the disease the prognosis is fairly good. Treatment.— The treatment consists mainly in overcoming the sten- osis and the removal of a part or all of the hypertrophic tissue. Sprays and douches of alkaline, antiseptic Fig. 95 solutious do little more than tem- porarily increase the reaction of in- flammation and relieve the symptoms by the removal of the altered secre- tions. The removal of the nasal ste- nosis is accomplished by the surgical correction of the septal deformity and Ily pel trophy of the mucous membrane the rcmOVal of the CXCCSsively liypcr- of the inferior turbinated body, a, an- , i • j j. i • i j." /-r\' n^\ /a terior attachment; p, posterior aUachment. trophicd turbmal tlSSUC (Fig. 9o). (See Removed by the author with his turbino- Obstructivc Deviations of the Septum tome (Fig. 100). (Dr. Henrietta Gould's ^nd the Mcthods of Correcting Devia- tions of the Septum.) Be assured that in most instances hypertrophic rhinitis is a surgical rather than a medical disease. Be assured, also, that hypertrophic rhinitis cannot be cured by sprays and other local medicinal applications, although they may temporarily relieve some of the symptoms. The actual cautery has been recommended for the reduction of the hypertrophied mucous membrane. I can only condemn it as it is in- adequate for this purpose. If it is used freely enough to really accom- plish anything, it produces excessive scar tissue, a result to be carefully avoided. Surgical Treatment. — If the hypertroj^hy is great enough to obstruct the nasal passages, it should be removed surgically with scissors, saw, spokeshave, the swivel knife, or the submucous resection of the inferior turl)inated bone. The Scissors. — The scissors are usually used for the removal of the hypertrophied portion of the free border of the inferior turbinated body. The technique is as follows: HYPERTROPHIC RHINITIS 145 (a) Induce local anesthesia by the application of a 5 per cent, solution of cocaine by means of a thin pledget of cotton pasted over the hyper- trophied area for ten minutes. (6) With nasal scissors (Fig. 96) cut off the necessary portion of the hypertrophied membrane. s serrated scissors. (c) Use no dressing except an antiseptic dusting powder. An ex- ception may be made, however, in favor of Pischel's collodion dressing if perfect dryness of the parts can be secured. (d) If severe hemorrhage occurs, it becomes necessary to pack the nose to check it. This may be done by introducing a postnasal tampon with Boloc's cannula (Fig. 97), or with a rubber urethral catheter and then pack a long strip of gauze through the anterior nares against it Wlien such a tampon is used it should be moistened with the com- pound tincture of benzoin or dusted with bismuth powder to prevent decomposition of the secretions. When either of these precautions is taken the tampon may be left in place for three or four days without putrefaction. Boloc's postnasal tampon cannula. I'he Saw. — ^The saw may be used instead of the scissors when it is necessary to remove a portion of the inferior turbinated bone with the hypertrophied membrane (Holmes, Vail). Technique. — (a) Induce local anesthesia with cocaine. (6) Introduce a slender nasal saw beneath the inferior turbinated body and saw in an inward and upward direction through it. If it is impossible to in.sert the saw beneath the turbinated body it may be introduced above it and the incision carried downward and outward through the tissue. 10 14G THE XOSE AXD ACCESSORY SIXUSES (c) Either use no dressing or use the Pischel collodion dressing when conditions are favorable, that is, when all hemorrhage ceases. llie Spokeshave. — The spokeshave may be used if it can be engaged posteriorly in such a position as to enable the operator to control its direction in cutting forward. This operation is rarely justifiable, as too much of the turbinate is removed by it. The Technique. — (a) Induce local cocaine anesthesia. (6) Make a linear incision along the mediosuperior surface of the inferior turbinal Showing the incision preliminarj' to the removal of the inferior turbinated body with the spokeshave or swivel knife. The author's >\vi\ el turbinotome. just at the upper margin of the hypertrophied tissue (Fig. 98). The incision is for the purpose of preventing laceration of the mucous mem- brane as the spokeshave is drawn through it. Healing is promoted by a clean cut. (c) Introduce the spokeshave (Fig. 99) at the posterior extremity of the turbinal if there is a mulberry hypertrophy there, or along the free border of it if only that portion is involved. Engage the tur- binated body and pull forward in such a direction as to only include the HYPERTROPHIC RHINITIS 147 hypertrophic tissue. The spokeshave should not be used unless it is desired to remove some bone as well as soft tissue. The removal of the anterior two-thirds of the inferior turbinal with the author's wide swivel knife (Fig. 100). Showing the removal of the inferior turbinal with the author's large swiAel knife. Fig. 103 The elevation of the mucoperiosteum of the inferior turbiiuUcd bod.y iireparalory to the submucous resection of tlic bone. 148 THE NOSE AND ACCESSORY SINUSES (d) Follow the same method of after-treatment given in the previous operations. The submucous resection of the border of the inferior turbinated bone with the author's swivel knife. Removal of the severed border of the inferi-.r turbinated bone after its submucous resection with the author's swivel kmfe. Fig. 106 Removal of the hyperplastic free border of the inferior turbinal after the submucous resection of the bone shown in Figs. 103 to 105. The fleshy border is not thus removed, except when very pendulous, as it shrinks greatly upon being sutured. (Beck's method.) HYPERTROPHIC RHINITIS 149 The Swivel Knife. — The author's large swivel knife (Fig. 100) may be used with even greater advantage than the spokeshave, as it can be made to engage or leave the tissue at any desired point along the free border of the turbinal. The knife used for this purpose is especially designed with a view to its width and strength. Otherwise it is similar to the one used in the submucous resection of the nasal septum. The Technique. — (a) Induce local cocaine anesthesia. (6) Insert the swivel knife as though it were a spokeshave and force the blade into the turbinate posterior to the hypertrophied tissue (Figs. 101 and 102). ^Tien it has sufficiently engaged in the tissue pull it forward, as in the spokeshave operation, and disengage it by directing it downward toward the floor of the nose when the anterior limit of the hypertrophy has been reached. The preliminary incision of the membrane is Un- Sohema showing the technique of making a continuous suture of the mucous membrane jBaps after the submucous resection of the inferior turbinated bone. a, the shpknot at the posterior end of the turbinated body — the suture thread should be eighteen inches long, so that the slip- knot may be arranged outside of the nasal chamber and then pulled into position; h b, the curved needle on a fixed handle; c, the hook for pulling the thread e through the needle wounds in the flaps, and from the eye of the needle. When the thread is thus liberated the needle is reversed and removed from the nose. It is again threaded with e and another stitch taken. Four or five stitches are sufficient to coapt the edges of the flaps. When all the stitches are made introduce the hook / and exert tension upon each stitch, beginning with the posterior one. At the same time keep up tension on the proximal end of the thread e. In this way the whole length of the wound may be closed. Fix the anterior end of the suture by a knot. Remove the suture on the third day. necessary, as the cutting edge of the blade is concave and prevents laceration of the mucosa. Bone, as well as soft tissue, may be removed with it. (c) The after-treatment should be the same as in the other operations. The Submucous Resection of the Inferior Turbinated Bone. — Dr. J. C. Beck has developed the following technique for the reduction of enlarged and obstructing inferior turbinals: (a) Cocaine anesthesia. (h) Make an incision through the mucous membrane at the anterior end of the inferior turbinated body (Fig. 103). (c) Introduce a small blunt probe or elevator through the incision and elevate the mucous membrane from the turbinated bone on its median and external surface (Fig. 103). 150 THE XOSE AXD ACCESSORY SINUSES (d) Introduce the swivel knife through the anterior incision into the mucous pouch and engage the turbinated bone, and sever it as shown in Fig. 104. (e) Remove the bone with small dressing forceps (Fig. 105). (/) If this does not sufficiently reduce the size of the turbinated body, a portion of the hypertrophied membrane may also be removed with scissors (Fig. 106). In some cases the submucous removal of the bone alone will be sufficient to overcome the stenosis. When the hypertrophied mucous membrane is also removed it is good practice to close the wound with sutures, as they prevent hemorrhage and the absorption of septic matter. Dr. Beck's method of suturing within the nasal cavity is simple and quickly accomplished, and is as follows : (g) A short curved needle set at right angles to the shank of the in- strument is introduced into the nasal chambers as far as the posterior end of the incision. The needle is then passed through both edges of the cut membrane, the thread caught with a small hook, and the needle withdrawn. For further description of the suture see Fig. 107 and the accompanying legend. HYPERPLASTIC RHINITIS. Synonyms. — The same as given under hypertrophic rhinitis, as the two conditions are often confused. Definition. — Hyperplastic rhinitis is characterized by an increase in the thickness of the mucous membrane and its contents as a result of prolonged mild irritation by the secretions from the sinuses. It differs from hypertrophic rhinitis in its causation and in its morbid anatomy. In hypertrophy there is an increase in the size of the cells from over- nutrition, whereas in hyperplasia there is an increase in the number of cells, and especially of the connective-tissue cells, from the slight but prolonged irritation. Etiology. — The chief causes are pressure, or the close approxima- tion of the septum to the middle turbinal, the resultant retention of the secretions, and the inflammation of the obstructed sinuses. The septum does not, in all cases, impinge upon the middle turbinal, and is not, therefore, a constant etiological factor in producing the hyperplasia. The sinuses may be diseased independently of the septal deviation, and may thus be the primary cause of the hyperplasia. In either event the irritation resulting from the secretions constantly flowing over the nnicous membrane of the middle and inferior turbinals causes the morbid changes in these structures. The secretion is not necessarily purulent, but, on the contrary, is often serous or mucous in character; that is, the inflammation in the sinuses may not be suppurative, but may be catarrhal in c-haracter. Symptoms. — The symptoms of hyperplastic rhinitis are often com- plex, as the disease is often associated with a catarrhal or a suppurative HYPERPLASTIC RHINITIS 151 inflammation of the ethmoidal, sphenoidal, and possibly the frontal sinuses. The symptoms arising from the hyperplasia are those of nasal obstruction, especially in the region of the middle turbinal; that is, there is more or less nasal obstruction and a sense of stufiiness or of pressure in this portion of the nose. The handkerchief is frequently used in an effort to dislodge the secretions and to overcome the sense of stuffiness. Wliile the secretions may be thus removed, the stuffy feel- ing remains, as it is due to the contact of the turbinate with the septum. The secretions may be either serous or mucopurulent, depending largely upon the complicating disease of the sinuses. Anterior rhinoscopy shows the inferior turbinal to be enlarged, paler than normal, although it may be red and boggy, and somewhat nodular in outline. If the septum is deviated, and it usually is, a ridge corre- sponding to the crista nasalis and the crest of the vomer may be present on one side, while there is a bowing of the septum toward the opposite side in the region of the middle turbinal. The septum is also often thickened in its upper portion on both sides, thereby obstructing both olfactory fissures. If an empyema of the ethmoidal cells (cellulse ethmoidales) is present, pus may be seen in the olfactory fissure as well as in the lower portion of the nose. If there is catarrhal ethmoiditis the anterior end of the middle turbinal may be red and boggy in texture. Patients with this type of ethmoidal inflammation sometimes complain of soreness or of fissures in the skin at the margin of the vestibule. The subjective symptoms are due to obstructive lesions and to the disease in the accessory sinuses of the nose. The obstruction in the upper part of the nose gives rise to a sense of stuffiness and of pressure across the bridge of the nose. These symp- toms are rather constant, as the tissue enlargement is permanent. The obstructive lesion in the upper portion of the nose gives rise to the additional symptoms of headache and vertigo peculiar to sinus inflammation; that is, there is headache in the frontal region limited to, or more pronounced on, one side, and to a feeling of soreness or tenderness of the eyeball upon ocular movements. The stooping posture increases the headache, and temporary vertigo is often thereby produced. The headache is also sometimes referred to the temporal, vertexial, and occipital regions. The symptoms given in the above paragraph are due to the sinuitis, and are not always present in hyperplastic rhinitis. They are, however, often present, as a careful examination of the patients will show. Prognosis. — ^The prognosis of hyperplastic rhinitis is not as favor- able as that of hypertrophic rhinitis. The etiology is more complex and the disease more serious, and it entails more extensive surgical procedures for its eradication. If the diseased processes are allowed to run their natural course, they may eventuate in an atrophy of the mucous mem]:)rane, especially of the middle and inferior turbinated bodies, tliough there is but slight tendency (o atrophy in hypertrophic rhinitis. 152 THE XOSE AXD ACCESSORY SIXUSES If the treatment is instituted sufficiently early, the atrophic process may be checked and the stenosis and sinus disease eradicated. Treatment. — The treatment of hyperplastic rhmitis should have two grand objects, namely: (a) The removal of the obstructive lesion. Casselberry's plain scissors. whether it be a deviation of the septum or the hypertrophic tissue of the middle or inferior nasal conchse (middle or inferior turbinals); and (b) the cure of the catarrhal sinuitis, if present, whether it be in the ethmoidal and sphenoidal, or the frontal and maxillary sinuses. The removal of the anterior end of the middle turbinated body with Casselberry's scissors. Hyperplasia of the inferior nasal concha (inferior turbinal) may be removed by any one of the operative procedures described under hyper- trophic rhinitis. Hyperplasia of the middle nasal concha (middle turbinal) may be removed with the scissors and snare, the author's turbinal knife (Figs. ]()(), 17.'^ and 174), or with the swivel knife. HYPERPLASTIC RHINITIS Fig. 110 153 Griinwald's right-angle forceps ■ may be used to complete the removal of the turbinate instead of a snare. Holmes' middle turbinal scissors. 154 THE NOSE AND ACCESSORY SINUSES The Scissors and Snare. — The technique is as follows: (a) Induce local anesthesia with a 10 per cent, solution of cocaine. A weaker solution is often inadequate in hyperplastic tissue. (b) Grasp the anterior attachment of the middle nasal concha (middle turbinal) with the scissors (Fig. 108) and make an incision about one inch in length thus severing the attachment of the anterior one-diird or one-half of the middle turbinated body (Fig. 109). The removal of the anterior half of the middle turbinated body with Holmes' scissors. (c) Introduce a cold wire loop over the detached portion of the turbinal and cut it off at the posterior limit of the incision, or sever the detached portion of the turbinal with Griinwald's forceps (Fig. 110). Still more tissue may be removed if necessary. Tlie anterior half of the middle turbinal removed with Holmes' scissors, exposing tlie bulla ethmoidalis. Holmes' Scissors. — With Holmes' scissors (Fig. 112) the snare is not necessary, as the blades are so curved that the cut made with them extends backward and downward until it emerges from the tissue (Figs. 113 and 114). HYPERPLASTIC RHINITIS 155 The Swivel Knife. — The technique of the removal of the middle tur- binal with the swivel kiiife differs from that employed with the same instrument in the removal of the inferior turbinal. The author's narrow swivel kmie placed at the anterior attachment of the middle turbinal preparatory to removing it as shown in Fig. 116. The technique is as follows: (a) Induce local anesthesia with a 10 per cent, solution of cocaine applied on a thin pledget of cotton over the whole of the middle turbinal. It may be necessary to apply a 20 to 30 per cent, solution with a delicate cotton-wound applicator to the less accessible areas. Tlie removal of the middle turbinal with the author's narrow swivel kr (b) Introduce the swivel knife and engage the anterior attachment of .the middle turbinal (Figs. 115 and 116), so that one prong tip is above and the other below the attachment. (c) Carry the swivel blade backward with short strokes until the whole or a part of the middle turbinal is severed from its attachment. The severed middle turbinal does not pass between the prongs of the instru- 156 THE NOSE AND ACCESSORY SINUSES ment, but is pushed downward beneath them. If only a portion of the middle turbinal is to be removed, the swivel blade is directed downward through the turbinal at the desired point, or, failing in this, the swivel knife is removed and the loop of a snare is engaged over the detached fragment and the removal completed. Remarks. — The swivel knife is not of universal use for turbinec- tomy or turbinotomy, although in many cases it is an ideal instrument for these purposes. In each case the instruments and mode of operation should be selected with reference to the conditions present rather than to blindly follow any described method of operating. (d) The postoperative treatment should consist of the insufflation of an antiseptic powder, and, in the case of severe persistent hemorrhage, the nose should be packed with iodoform, or compound tincture of benzoin gauze. Hemorrhage. — The middle turbinal is supplied with blood by the anterior and posterior ethmoidal arteries (A. ethmoidalis anterior et posterior) (Fig. 3), and hemorrhage of considerable severity may occur either at the time of operation or at a later period. As a matter of fact an oozing of blood continues in many cases for twenty-four hours. The danger of septicemia and of meningitis is increased by nasal tampons, hence it is not advisable to pack the nose except in extreme necessity. The packing should be done firmly but with caution, and the gauze should be moistened with the compound tincture of benzoin and squeezed until the excess of fluid is removed. CHRONIC RHINITIS WITH COLLAPSE OF THE ERECTILE TISSUE. Definition. — This is not a true inflammatory disease, but is usually classed as such. It is a local manifestation of a general anemia, and is characterized by the collapse of the erectile tissue of the nose and simulates atrophy in this region. Etiology. — Its chief cause is general anemia. Atrophic rhinitis is also characterized by anemia that is secondary to the conditions causing the atrophy. In simple collapse of the swell bodies the anemia is pri- mary and the collapse secondary. It is most often found in women, as they are more subject to anemia. It is occasionally found in gouty individuals. Symptoms. — The chief symptoms are drpiess of the upper respira- tory tract and patency of the nose. Upon anterior rhmoscopic examina- tion the inferior turbinals appear quite small, on account of the collapse of the swell bodies. Upon probe pressure the mucous membrane is found to be thin and tightly drawai over the underlying bone. The great space in the nasal chambers and the small size of the inferior turbinals at once suggest an atrophic condition, though true atrophy is absent; crusts and ozena are, however, absent, nor is there a history of their pre- vious presence. An examination of the blood shows anemia to be present. The sense of smell is imimpaired and ulceration of the mucosa and caries ATROPHIC RHINITIS I57 of the bone are absent. The condition is always bilateral, as it is due to constitutional rather than local causes. Treatment. — ^The treatment should be directed to the anemia. It is necessary, therefore, to ascertain the type of the anemia by blood examinations and to carry out the treatment accordingly. I wish to suggest in this connection that an examination of the rectum will some- times reveal ulcerations or other pathological processes that may be the cause of the anemia and the resultant collapse of the erectile tissue. ATROPHIC RHINITIS. Synonyms. — Chronic dry rhinitis; simple mucous rhinitis; mucopuru- lent rhinitis; ozena. Definition. — Atrophic rhinitis is characterized by a sclerotic change in the mucous membrane and occasionally of the underlying bone, and by the presence of crusts and an offensive nasal breath. The conditions giving rise to these phenomena are varied and often complex. Etiology.— The three causes generally held to produce this condition are as follows: (a) A simple atrophic process which is not dependent upon other local disease of the mucous membrane. Meissner holds that atrophic ozena (see below) is due to a primitive or broad, shallow nose, and to a congenital development of pavement epithelium instead of the columnar or mucus-producing variety. (6) Pressure necrosis due to excessive distention of the bloodvessels. This is a cyanotic congestion due to a heart lesion, the general venous circulatory system participating in the sluggish venous flow. The mucosa covering the vessels is kept upon a constant stretch, and pressure atrophy results, as in red atrophy of the liver. (c) Sclerotic atrophy due to a pre-existing sinus inflammation, during which there is an excessive proliferation of connective-tissue cells. These after a time become fibrous tissue and gradually cut off the blood supply and choke out the glandular and vascular structures of the membrane. The nutrition of the mucous membrane is diminished, and functional activity is diminished or destroyed. These and various other theories are held as to the cause, or causes, of atrophic rhinitis. None of them is definitely proved, although the one advocated recently by Griinwald, and by Vieussens, Reininger, and Guns at the end of the seventeenth century, has rapidly gained ground in popular opinion. Those who hold to this theory believe that all or nearly all cases of atrophic rhinitis are due to suppuration of the accessory sinuses of the nose, more especially the ethmoidal and sphenoidal. My own experience is in accord with this view. I have seen many cases cured or greatly relieved by attention to the accessory sinuses. The ozena is invariably influenced favorably. In conjunction with Dr. Joseph Beck I have had skiagraplis of the sinuses made in cases of atrophic rhinitis, and without exception the sinuses appear cloudy, as 158 THE NOSE AND ACCESSORY SINUSES they do in sinuitis, i. e., their outhne is illy defined and the area of the cavities is opaque. This shows that in atrophic rhinitis the sinuses are often diseased, though it does not prove the sinus disease to be primary. (a) Simple Atrophic Rhinitis. — Simple atrophy may take place in the nasal mucous membrane as well as in mucous membranes elsewhere in die body. Etiology. — The etiology is not clear, and yet it is probable that it is due to the presence of some irritant in the blood, as in syphilis, tuber- culosis, scrofula, etc. At any rate, the trophic nervous system is in- volved and nutrition modified. Treatment. — The treatment should be addressed to the constitutional dyscrasias, upon the disappearance of which the atrophic and ozenic processes improve or disappear. (6) Atrophic Rhinitis Due to Pressure (Cyanotic Engorgement). — Etiology. — (a) There is some lesion of the heart, kidneys, liver, or lungs which causes a damming back of the venous blood upon the nasal mucous membrane, as well as elsewhere in the body. (6) The organs thus affected do not eliminate the waste products as rapidly as they should, and they are retained in the blood, where they act as irritants, exciting inflammatory reaction of a low grade. These two factors account for the phenomena knpwii as pressure atrophy as it occurs in the nasal mucosa. Symptoms. — Although there is true atrophy, the membrane is con- gested to such a degree that there is nasal stenosis. The mucosa of the nose is boggy, purplish red in color, and inflamed. The ozenic odor may be slight. There is an exudation from the engorged vessels, but it is not a true mucous secretion. The skin of the nose may be red. There is a sense of fulness across the bridge of the nose, and frontal headache is commonly present. The conjunctiva may be infected and attended by an overflow of tears. D. Braden Kyle refers to a case due to organic mitral lesion. I have seen a case of this character in which the whole mucosa of the upper respiratory tract was cyanotic; the tonsils were enlarged and markedly blue from cyanotic congestion. Prog nosis. ^Th'is depends upon the curability of the lesion giving rise to the cyanotic congestion. The patient had a valvular heart lesion. It is obvious that the treatment in such cases must be palliative only. (c) Atrophic Rhinitis Due to Suppurative Sinuitis. — Etiology. — All the causes given under the various types of catarrhal rhinitis may act as causes of this type of disease. The inflammation attending them is followed by a deposit of connective-tissue cells, which after they become organized cut off the blood supply and choke down the glandular tissue. The functional activity is gradually lost and the true mucous elements of the membrane finally disappear. The secretions become thick and in- spissated. Tliey dry upon the surface of the membrane, where, through biochemical changes, they develop the ozenic odor. Various theories have been advanced in explanation of the odor, but none of them is proved. ATROPHIC RHINITIS 159 The following are suggestive but not conclusive: (a) Simple decomposition of the mucopus. (6) Degenerative changes in which certain fatty acids are liberated, giving rise to the odor. (c) The presence of certain bacteria, as the bacillus fetidus. Ozena a Symptom. — Ozena is not a disease, but a sign of certain dis- eased conditions. It is a "stench," and it is in this sense that it is used. The fetid odor is associated with an inspissated secretion, which is seen in the form of greenish crusts covering the whole of the nasal mucous membrane. There may be other peculiar conditions associated with it, especially in those cases in which there is marked atrophy of the mucosa. For example, the nose may be broad and flat, the tip somewhat elevated, and the blood anemic. The anemia is secondary and not primary as in chronic rhinitis with collapse of the erectile tissue. The absorption of septic material and the loss of the respiratory functions of the nose are probably the chief causes of the anemia. It is a well-recognized fact that in mouth breathing due to the presence of postnasal adenoids there is anemia, which quickly disappears after their removal. The mucous membrane becomes atrophied in the later stages, and after a longer period the secretion and foul odor spontaneously disap- pear and leave a comparatively clean but sclerotic membrane. The ozenic odor disappears spontaneously after a number of years, hence it is a self-limited symptom. The mucous membrane, however, is left very much damaged. Its histological character and physiological func- tion are changed or entirely lost. The sclerosis and ozena in this type of atrophic rhinitis is in all prob- ability due to a chronic sinuitis, or to other focalized suppurative processes, as has been shown by Griinwald in his work on Nasal Suppuration. In other words, the atrophy is not primary, but is secondary to a suppu- rative sinus inflammation. Indeed, nearly all cases of atrophic rhinitis probably fall under this category. This subdivision of atrophic rhinitis is, therefore, from a clinical standpoint of the greatest importance. The rationale of the atrophic process is generally as follows: The secretion from the sinuses, more particularly the frontal, eth- moidal, and sphenoidal, flows downward over the nasal membrane, where it becomes dried into crusts. It undergoes decomposition and irritates the underlying mucosa. There is, in addition, a mechanical irritation from the shrinkage and contact of the crusts with the mucous membrane. The chemical and mechanical irritation thus produced cause a proliferation of connective-tissue cells, which, when fully organ- ized, contract and choke out the true elements of the mucous membrane. Shrinkage and atrophy progress until the mucous membrane is replaced by a sclerotic one, devoid of mucous glands and columnar ciliated epithelium, pavement epithelium replacing the columnar type. During the progress of the atrophic process the ozena is a symptom, but after the true mucous membrane is destroyed the mucous secretion and ozena cease. Crust formation and ozena are self-limited phenomena, many years being required, however, to rid the patient of them. 160 THE NOSE AND ACCESSORY SINUSES Symptoms. — The symptoms vary with the state of advancement and activity of the process. The chnical picture presents the features showTi in the comparative table given below. This is adapted from MacDonald's work on Diseases of the Nose. Comparative Table of the Symptoms of Atrophic Rhinitis and Rhinitis with Collapse. Chronic Rhinitis with Collapse of the Erectile Tissue. 1. Chiefly in anemic women. The anemia is primary. 2. No peculiarity of physiognomy. 3. Mucous membrane anemic. 4. Collapse of erectile tissue; no tendency to atrophy. 5. No ulceration. 6. Always bilateral. 7. Spontaneous cure if the anemia is relieved. 8. Olfaction not affected. 9. No characteristic odor. 10. Little or no incrustation; if present, is lim- ited to the anterior third of the middle turbinals. Atrophic Rhinitis with Sclerosis and Mxtcous Secretion. Ozena. 1. Chiefly in women and children; all subjects become anemic. 2. Small, sunken wide nose with wide nasal fossEe. 3. Mucous membrane anemic. 4. Collapse of the erectile tissue with tendency to atrophy. 5. Sometimes there is ulceration, and necrotic bone if the disease is of sinus origin. 6. Usually bilateral; may be unilateral. 7. After some years there is a tendency to im- provement of the sj-mptoms. The ozenic sj-mptoms disappear as the atrophy be- comes more complete. 8. Olfaction is often lost. 9. Breath tj-pically ozenic. 10. Crusts are distributed over the entire mucous membrane. Treatment. — When seen in the early stage the treatment should aim at (o) the removal of the causes of the inflammation that produces the sclerotic process, and (b) intranasal cleanliness. (a) The Removal of the Causes. — The causes of the inflammation are numerous. Some have already been considered under acute catarrhal hyperplastic rhinitis, chronic suppurative sinuitis, and the congenital primitive nose with its pavement epithelium. Other causes are trauma- tism, deflections, and other obstructive lesions of the septum. By the removal of these exciting causes of the inflammation the sclerotic process may be modified or stopped altogether. From the foregoing statements concerning focal suppuration within the sinuses and elsewhere in the nasal chambers, it is evident that in many cases the treatment should be addressed toward the cure of the suppuration of the sinuses, rather than to the atrophy resulting from it. (/;) Intranasal Cleanliness. — Intranasal cleanliness is obtained by the use of antiseptic douches containing a liberal amount of mild alkalies to soften and dissolve the crusts and tenacious mucopus. A solution of 8 grains of sodium bicarbonate to the ounce of water as hot as can be borne should be forcibly injected into the nostrils at frequent intervals during the day. A fountain syringe is well adapted for this purpose. The patient should be instructed to clear the nose by blowing after each injection. The injections may be administered by the physician at first, as the patient will not or cannot thoroughly cleanse his nose. To free the nostrils from crusts and tenacious mucus, a warm antiseptic aqueous solution of borax, sodium bicarbonate, oil of eucalyptus, carbolic ATROPHIC RHINITIS 161 acid, glycerin, and alcohol should be injected into the nostrils. A two- ounce hard-rubber or an Alpha and Omega bulb syringe is well adapted for this purpose, as considerable force is necessary to dislodge the crusts. Personally, I prefer to pack the nose with cotton-wool saturated with a 10 per cent, aqueous or glycerin solution of ichthyol, which should be removed in from twenty to thirty minutes, the crusts being softened and easily detached by blowing the nose or by the use of a cotton-wound probe. This course of treatment, if faithfully carried out, will afford great relief. Mild astringent stimulating solutions, or powders, are of value in reducing the local infection. Powder with 5 to 20 per cent, of silver nitrate or a 1 to 2000 trichloracetic acid solution may be used for this purpose. The associated sinus diseases should be treated as described under the Accessory Sinuses. Indeed, this is often the only method of treatment attended with success. Even this fails if the atrophy is far advanced. Paraffin Injections in Atrophic Rhinitis. — ^Paraffin injections beneath the mucous membrane of the inferior turbinated body and of the septum have been used by several rhinologists with great improvement of the symptoms. The crusts are either diminished or disappear altogether. Most writers recommend using paraffin in melted form, although the danger of thrombosis is ever present. More recently paraffin has been used in semisolid form to obviate this danger. A special syringe (Fig. 196), adapted to the use of semisolid paraffin, has been devised by Dr. J. C. Beck for this purpose. With this device the danger of thrombosis is reduced to the minimum. The injections should be made under local cocaine anesthesia. The amount injected at each sittmg varies with the friability of the mucous membrane. In some cases only one or two minims or grains should be injected, as to exceed this amount would tear the mucous membrane. In other cases as much as one to two drams may be injected. The injec- tions should be made at intervals of from five to ten days, enough time being allowed between the sittings for the subsidence of the reaction. Either the inferior turbinal (nasal concha) or the septum may be chosen for the site of the injections. The needle should be introduced a half-inch or more beneath the mucoperiosteum, and a small amount of paraffin injected. It should then be withdrawn, a quarter of an inch and more of paraffin injected, and so on until the needle is withdrawn. The effects produced are a lessening or the disappearance of the crusts, a thinning of the secretions, a sense of air passing through the nasal cliambers, and occasionally edema of the eyelids. The good effects have remained for a period of two years and promise to last much longer. The lumen of the nasal chambers is diminished, thus accounting in a measure for the lessened desiccation of the secretions. It is also quite probable that the irritation of the paraffin, a foreign body in the tissues, produces an increased hyperemia and leukocytosis. Whatever the ex- planation may be, it appears that paraffin injections beneath the muco- perichondrium of the nasal septum and beneath the mucoperiosteum of the inferior turbinal materially improves the symptoms in the so-called atrophic rhinitis with incrustations. In those cases wherein the sinus 11 162 THE XOSE AXD ACCESSORY SINUSES origin of the suppuration and crusts is in doubt, and wherein the patient refuses operative interference on tlie sinuses when they are kno\ni to be the focal centre of the disease, paraffin injections may be used with the reasonable assurance of an improvement of the symptoms. SUPPURATIVE RHINITIS; NASAL SUPPURATION. (A symptom, not a primary disease.) Suppurative rhinitis has been described by various authors, notably by Bosworth in his work on the Diseases of the Nose and Throat. He described suppurative rhinitis in children as a primary disease, which, when neglected, eventuates in atrophic rhinitis in adults. The trend of opinion is gradually breaking away from the view that primary suppuration of the nasal mucous membrane is often found. On the contrary, it is believed that it rarely exists except secondarily to sinuitis. Personally, I hold the latter view. Pus in the nasal chambers is present in the later stages of acute coryza, which is an infectious disease and is usually complicated by a purulent infection of the sinuses. Purulent secretions may also accompany syphilitic, tuberculous, and gonorrheal processes in the nose. The specific or exanthematous fevers are characterized by a purulent inflam- mation of the nasal and accessory sinus membranes. The various accessory sinuses, when affected by a purulent inflammatory process, discharge their purulent secretions into the nasal passages. Generally speaking, if after the nasal chambers are cleared of pus by mopping with a cotton-woimd applicator the pus reappears within a few minutes in the middle meatus, it comes from the sinuses discharging into this meatus, namely, the frontal, anterior ethmoidal (including the bulla ethmoidalis), and the sinus maxillaris (antrum of Highmore). Occasionally one of the anterior ethmoidal cells discharges through the inner or median wall of the middle turbinal into the olfactory fissure or superior meatus. When the pus appears in the superior meatus, it is probably from the sinuses opening into the meatus, namely, the posterior ethmoidal and the sphenoidal sinuses. An occasional exception to this is when the sinus maxillaris (antrum of Highmore), whose posterior and superior median wall is in relation to the superior meatus, discharges through a perfora- tion into the superior meatus. Such a condition is rare, hence pus in this meatus as seen in the olfactory fissure is generally indicative of suppura- tion of the posterior ethmoidal and the sphenoidal sinuses. It is barely possible that there may be a focalized ulceration of the nasal mucous membrane in the superior meatus, and that the pus is from the meatus rather than the sinuses. It appears, therefore, that nasal suppuration is rarely, if ever, a primary disease, but that it is always, or nearly always, secondary to some other disease of die mucous membrane and bony walls of the nasal chambers or the accessory sinuses of the nose. Suppuration of the nose as a primary disease will not, therefore, be described, but the other diseases to which it is secondary are described, and the reader is referred to diem for further iiiforniation. PLATE I Anterior Reconstruction. On account of the multiplicity of lines, the individual ethnnoidal cells are not sho\A^n; however, the two groups are represented, the anterior being lined hori- zontally and the posterior perpendicularly. The left sphenoidal sinus lies far above the right; its inner wall extends almost as far to the right as the outer wall of the right sphenoidal sinus. (H. W. Loeb.) PLATE II Left Lateral Reconstruction. In this and Plate I the frontal sinus is colored yellow, the maxillary purple, the sphenoid green, and the ethmoid red, the anterior group being lined hori- zontally and the posterior group perpendicularly. The ethmoidal cells are to be noted in two groups, the anterior two in number, and the posterior three. The first anterior cell is shown dis- placing the anterior wall of the frontal. The frontal is seen opening into the frontonasal canal. The antero-inferior wall of the second ethmoid constitutes the bulla ethmoidalis. (H. W. Loeb.) CHAPTER IX. THE INDIVIDUAL SINUSES. The sinuses are divided for clinical purposes into two groups, namely, the anterior and the posterior sinuses. The anterior group is composed of the frontal, the anterior ethmoidal and the maxillary sinuses. Hajek calls this group Series I. The posterior group is composed of the posterior ethmoidal and the sphenoidal sinuses, and is called Series II (Fig. 117). Our knowledge of the etiology, symptomatology, pathology, and sur- gical treatment of the sinuses has increased so greatly during the last ten years that it seems to be proper to depart from the traditional manner of presenting this subject, wherein each sinus is separately described and treated. As a matter of fact, a single sinus is rarely diseased, two or more being commonly affected at the same time. Indeed, it is not uncommon to find all the sinuses on one side of the head affected. The maxillary sinus is perhaps more often affected singly than either of the other sinuses. This is accounted for by the fact that in about one-half of the cases it is infected from the teeth rather than from the nose, whereas the other sinuses are nearly always infected from the nose. Having a common source of infection, they are, therefore, more often simultane- ously diseased. For this reason a general discussion of sinus inflammations is to be preferred to a discussion of each sinus individually. Nevertheless, it will be advantageous to present the peculiar symptoms and other con- siderations of each sinus separately. The following considerations are therefore to be read in conjunction with the general description which follows. SERIES I. The Frontal Sinus.— The frontal sinus is an extension upward of the etlimoidal cells between the plates of the frontal bone. The extension occurs at about the age of puberty, hence in infants and young children tlie frontal sinuses are absent. The size and shape of the frontal sinuses vary greatly in different individuals, and indeed the two sinuses often vary greatly in the same individual. Reference to Plates I, II, III, IV and V show some of the variations in the frontal sinuses, the drawings being taken from skiagraphs of some of the author's cases. These varia- tions are of surgical interest, as the difference in size will often determine the method of operating. If there is a large and deep frontal sinus, great external deformity may f()llf)\v tlic complete removal of the anterior wall. 164 THE NOSE AXD ACCESSORY SINUSES In such a siil)ject the operation may be so executed as to avoid, or to greatly rc(hicc, the probaliiHty of marked disfigurement. H. W. Lceb's projections of the sinuses (Plate I and II) show more clearly than any other work the relations of the sinuses to one another The anterior portion of the right side of the skull has been rendered transparent. A catheter is passed into the Eustachian tube. 1, catheter; 2, Rosenmiiller's fossa (recessus pharyngeus); 3, tubal fold (torus tubarius) and plica salpingopharyngea; 4, pharyngeal opening of Eustachian tube; 5, plica salpingopalatina; 6, levator palati muscle; 7, hard palate; 8, soft palate and uvula; 9, external nose and naris; 10, inferior turbinate; 11, middle turbinate; 12, superior turbinate; 13, frontal sinus; 14, ethmoidal cells in middle nasal meatus — two ethmoidal cells appear, one above the other, extending to the middle turbinate; 15, ethmoid cells in superior nasal meatus; 16, sphenoidal sinus; 17, antrum of Highmore, seen through the interior of the nose in the middle meatus; 18, same in the inferior meatus; 19, mouth and lacrymonasal duct; 20, superior meatus; 21, alveolar process with three teeth— the roots are faintly seen within the alveolar process; 22, roof of orbit seen in anterior fossa of skull; 23, juga cerebralia and impressiones digitata;; 24, lesser wings of the sphenoid with anterior cHnoid jjrocesses and optic foramen; 25, sella turcica; 26, middle fossa of skull; 27, lamina cribosa; 28, crista galli; 29, frontal bone. (After Bruhl- Politzer.) and to the structures of the nose. The anteroposterior and lateral pro- jections are shown. Plates III, IV, V and VI also give a good idea of the distribution of the sinuses. PLATE III Fig. 1 Fig. Large right frontal and a small left frontal sinus (From author's skiagraph.) Absence of the frontal sinuses in a patient aged twenty-nine years. Small anterior eth- moidal cells are shown. This patient had exten- sive necrosis of the ethmoidal and sphenoidal bones, and secondary mastoiditis complicated by a brain abscess in the motor area for the arm and leg. The arm and leg on the opposite side were partly paralyzed. The ethmoidal and sphenoidal sinuses, mastoid and brain abscess were successively operated upon without result. (Author's case.) Very large frontal sinuses. (From author's skiagraph.) Very large irregular riglit front: frontal sinus. (From aull... rid a small left skiagrai.h.) The Distribution of tlie Frontal Sinuses as Shown by Skiagraphy. PLATE IV Large frontal sinuses and an anterior ethmoidal cell extending well over the right orbit. (From author's skiagraph.) Narrow longitudinal frontal sinuses, the right havTng an ethmoidal cell encroaching upon its floor. (From author's skiagraph.) Very large left frontal sinus, almost divided by a septum. The left sinus e.xtends about one-half inch beyond the median line. (From author's skiagraph.) Large right frontal sinus with an anterior eth- moidal cell (bulla frontalis) encroaching upon its floor. (From author's skiagraph.) The Distribution of the Frontal Sinuses Skiagraphy. as Shown by PLATE V Side view of frontal sinus with great depth and upward extension. A small anterior ethmoidal cell, the bulla frontalis (see Fig. 117), encroaches upon its floor. (From author's skiagraph.) Another large frontal sinus with marked back- ward extension over the orbit. (From author's skiagraph.) Side view of the frontal sinus with limited up- ward extension and moderate backward extension. (From author's skiagraph.) unusual downward extension of the frontal sinus. (From author's skiagraph.) The Anteroposterior Extension of the Frontal Sinuses as Shown by Skiagraphy. PLATE VI Frontal sinus with extreme extension backward, and with a large anterior ethmoidal cell encroach- ing upon the posterior portion of its floor. (From author's skiagraph.) Side view showing absence of the frontal sinuses in a patient aged twenty-nine years. Anterior view shown in Plate III, Fig. 2. (From author's skiagraph.) Side view showing a frontal sinus of moderate depth. (From author's skiagraph.) An extremely large and deep frontal sinus, (From author's skiagraph.) The Anteroposterior Extension of the Frontal Sinuses as Shown by Skiagraphy. THE INDIVIDUAL SINUSES 165 Skiagraphy. — The skiagraphic plate affords good information con- cerning the presence or absence of disease in all of the sinuses except the sphenoidal if the exposure is properly made. It is not yet known what causes the cloudy appearance when the sinus is diseased. Coakley says it is not known whether it is due to the thickness of the inflamed membrane, to the presence of pus, or to the changed condition of the bone. I have a skiagraph of a patient affected with a severe chronic catarrhal sinuitis upon whom I performed a double ICillian opera- tion, in which the right frontal sinus as shown by the plate was cloudy, but less so than the left. Upon operating the right sinus was found to be free of pus, and its periosteum and mucous membrane were entirely gone. The bone was chalkv white and slightly roughened. The left sinus was free of pus, but was filled with granulation tissue and viscid mucous secretion. The patient had complained for several months of an acrid Fig. lis secretion which irritated the nasal mucosa. This case is related in this connection, as it is unique, and demonstrates that a frontal sinus devoid of membrane, periosteum, and purulent secretion gave a cloudy effect in the skiagraph, though not so pronounced as that given by the sinus in which the mem- brane and granulations were present. Pus was not present in either sinus. Tenderness upon Pressure. — Tenderness over the frontal bone is rarely present in frontal sinuitis except in very acute cases with obstructed drainage. Tenderness is often present, however, when pressure is made against the floor of the affected sinus near the inner angle of the orbital cavity (Fig. 118). The finger tip should be placed well under the roof of the orbit and the pressure directed upward. Pain is thus often elicited even in chronic catarrhal cases. Tenderness in this region does not, however, always indicate frontal sinus disease, as the anterior eth- moidal cells sometimes project beneath the floor of the sinus (Fig. 143). When such an anatomical deviation is present the surgeon may be led to a wrong conclusion. This difficulty may be obviated by having a skiagraph made, as it will aid in determining the position and condition of the frontal and anterior ethmoidal cells. The tenderness present in frontal sinuitis is so nearly in the same posi- tion as that in ethmoidal sinuitis that a careful distinction sliould be made. In ethmoidal sinuitis the tenderness is usually located a litde above the median palpebral commissure (inner can thus) of the eye and a little deeper in the orbital cavity than the canthus. The pressure should be made inward toward the median line, rather than upward, as in testing the frontal sinus. The correct method of making pressure under the floor of the frontal sinus. Pressure is often made under the supra-orbital ridge, whereas it should be made much deeper. 166 THE NOSE AND ACCESSORY SINUSES Redness and Swelling. — Redness and swelling over the frontal region are only present in severe acute inflammation of the frontal sinus where the bone is affected by an infective osteomyelitis and the skin has yielded to the inflammatory process. There are perhaps a hundred cases of frontal sinuitis in which the redness and swelling are absent to one in which they are present. The day is past when a surgeon should wait for such symptoms before deciding to operate upon the frontal sinus. There are other positive indications of sinus disease to guide him to a diagnosis and to a choice of the mode of treatment. Mucous Discharge. — AVliile catarrhal inflammation of the sinuses is generally referred to in the text-books, no clear idea of the symptomatology and diagnosis is given. The presence of pus in the nose has been an essential requirement for making a diagnosis. I have found it almost as easy to diagnosticate sinuitis without pus as with it. The symptoms are much the same as those in purulent sinuitis, except that pus is absent. The secretion is mucous or seromucous in character, and might easily escape observation. The patient may or may not complain of burning sensation in the anterior portion of the nasal passages, or of fissures or excoriations at the margin of the nostrils as a result of the acrid catarrhal discharge. Headache. — Frontal headache limited to, or originating on, the side affected is generally complained of. The headache is often worse during the night, especially upon awaking while in bed, or in the morning. It is often confounded with eyestrain. Headache due to eye-strain is generally relieved upon closing the eyes, especially upon retiring for the night. The headache caused by frontal sinuitis (catar- rhal or suppurative) is not aggravated by attendance upon the theatre; whereas if due to eye-strain, it is thereby aggravated. Dizziness; Vertigo. — Dizziness or vertigo of slight degree is present in most cases, severe in others. It is often present in simple catarrhal inflammation, as well as in suppurative inflammation of the frontal and ethmoidal sinuses. It is especially aggravated by stooping, or, if in a stooping posture, upon assuming the erect posture. Careful inquiry is often necessary to elicit this symptom, as the patient does not consider it of any significance. Ocular Symptoms. — According to Fish, Zeim, Wood, Stucky, Coffin, and others (Eye in Relation to the Sinuses), inflammation of the frontal or any other sinus may give rise to morbid processes in any of the structures of the eye. This is accounted for by the free anastomosis of the veins of the sinuses with the ophthalmic vein. Congestion in the sinuses causes a like condition in the eye. Infection is thereby favored; papillitis, choroiditis, optic neuritis, iritis, keratitis, etc., thus becoming established. Intracranial Complications. — Extradural and brain abscess, meningitis, and sinus thrombosis may arise from sinuitis. Inasmuch as the posterior wall of the frontal sinus is thinner than the external or anterior wall, it is curious that intracranial complications are so rare. The superior longitudinal and the cavernous sinus occasionally become tlirombosed in frontal sinuitis. Meningitis of sinus origin is more THE INDIVIDUAL SINUSES 167 frequently reported now than formerly, a fact significant of a better understanding of the subject. The Anterior Ethmoidal Sinuses.^ — The anterior ethmoidal cells vary in number from two to eight, and are smaller than the posterior cells. They all drain into the middle meatus. According to Logan Turner, the frontonasal canal opened in the infundibulum in about one-half of the specimens examined, and directly into the middle meatus in the remainder. The anterior cells are separated from the posterior cells by a thin trans- verse bony partition. The attachment of the middle turbinated body to the external wall of the nose also marks the line of division between the anterior and the posterior group of cells. The anterior cells lie in front of and below it, while the posterior cells lie above and behind it. Clinically the two groups of ethmoidal sinuses are, therefore, divided into anterior and posterior cells. The anterior cells belong to Series I, while the posterior cells belong to Series II. Fig. 119. — Empyema of tlie ethmoidal sinuses with perforation through the lacrymal plate at the inner canthus of the right eye and marked bulging at this point. Both upper eyelids are edematous and purple. The right eye is entirely closed, the left almost. One year previously had a similar attack following scarlet fever. (Author's case.) Fig. 120. — Same case six days after operation. External wound gradually filled in by granu- lation and became closed in two months. (Author's case.) Accessory ethmoidal sinuses are sometimes present in the middle turbinal and in the uncinate process, and when present drain into the middle meatus and belong to the anterior group or Series I. The upper wall of the ethmoidal cells is a rather dense but thin plate of bone. The cribriform plate is not covered by the cells, but is freely exposed in the attic of the nose. While the bone is dense and not easily fractured by ordinary force exerted during an operation, its numerous openings render it a possible atrium of conveying infection to the meninges. The outer wall of the ethmoidal sinuses is the os ^planum or lamina papyracea of the ethmoidal and the lacrymal bones. These plates of bone are extremely thin, and form the inner wall of the orbital cavity. Should this plate of bone be perforated, orbital cellulitis, with protrusion of the eyeball, might result. In Fig. 119 is shouoi a ca.se of ethmoidal suppuration in which the lacrymal bone was carious and perforated. When first seen there was a large nipple-like projection of the skin at the inner angle of the orbit. lOS THE XOSE AXD ACCESSORY SIXUSES or lateral wall of the nose, in this region. The right eyelid was swollen and closed, while the left was less swollen and partially closed. The upper and lower lids of both eyes were discolored purple. Protrusion of the eyeballs was absent, as orbital cellulitis was not present. Had the per- foration occurred more posteriorly through the os planum, orbital cellu- litis would in all probability have occurred. The patient had a similar attack one year previous to this one. The swelling subsided, but the nasal discharge continued, and the eye was uncomfortable. Skiagraphs showed marked cloudiness in the ethmoidal region on the right side, while on the left it was less cloudy. The frontal sinuses were absent, or if present were very small. The lower meatus of the nose was quite open. Frontal headache and dizziness were prominent symptoms. The nipple-like projection was incised at once and discharged a half- ounce of thick yellow pus. On the following day, under general anes- thesia, the region was exposed by an external skin incision extending from a point below the nipple-like tumefaction to the middle of the right eyebrow. The lacrymal bone was almost entirely destroyed by necrosis. The frontal process of tlie maxilla was removed with rongeur forceps, thus fully exposing the anterior ethmoidal cells to operative interference. The author's ethmoid curette. The entire ethmoidal labyrinth, including the middle turbinal, was re- moved with a curette (Fig. 121). The curette was also used through the anterior nasal opening, to make sure that no remnants of the cells were left. The cranial plate and the os planum were carefully but thoroughly curetted until they were smooth. The left side was operated through the nose, the middle turbinal and the edunoidal cells being removed in their entirety, in so far as they could he reached with the curette by this route. Fig. 120 shows the patient one week after operation. The edema and discoloration of the eyelids have entirely disappeared, and the wound in the lacrymal region on the right side permits of a clear view of the interior of the nose. The marked change m the facial expression is suggestive of the improved condition of the patient. The purulent secretion may penetrate the orbital plate, as shown in Fig. 122, and cause orbital cellulitis. The Maxillary Sinus (Antrum of Highmore). — ^The maxillary sinus, the third and last sinus belonging to Series I, is the largest, and, according to the prevailing opinion, is more frequently diseased than either of the other sinuses in both series. Personally, I question this statement, as according to my own observations the ethmoidal and frontal sinuses are more frequently involved. Our knowleflge of the THE INDIVIDUAL SINUSES 169 symptomatology of sinus diseases in general has greatly increased during the past five or ten years, with the result that ethmoidal, sphenoi- dal, and frontal sinuitis are diagnosticated twenty times where they were once ten years ago. While the antrum still holds an important rank as a seat of disease, the ethmoidal and the frontal occupy an equally important place. The diagnosis of antral inflammation has been understood for many years, and this has given rise to the impression that it is much more common than inflammation in the other sinuses. It may be infected from the nose or the teeth, the cases probably being about equally divided between these two sources of infection. On account of the dental origin of so many cases of maxillary sinuitis, it is more often affected singly than either of the other sinuses, in which the infection is almost always of nasal origin. When the infection is of nasal origin quite naturally more than one group of sinuses is simultaneously af- fected. The osteum maxillare is situated in the up- per portion of the naso-antral wall as far away from the floor of the sinus as possible. This apparently renders the drainage of the secre- tions quite difficult or impossible, except as they overflow when the antrum is filled. This is not the case, however, as there is but little secretion in the sinus in health — only enough to keep the mucous membrane moist. The epithelium of the antral mucous membrane is of the modified ciliated columnar variety, though it is but slightly developed and in patches. The wave-like motion of the cilise aids in carrymg the scanty secretions to the osteum maxillare at the top of the sinus, where it is discharged through the infundib- ulum into the middle meatus. In the course of severe or long-continued inflammation of the mucous membrane of the antrum the cilise are injured or destroyed altogether, and the secretions are retained in the antrum because they are not carried to the ostium maxillare. The secretions are greatly increased in quantity, a fact that still further tends to promote the accumulation within the sinus. The second bicuspid and the first and second molar teeth are in close relation to the floor of the sinus. Indeed, they sometimes project into tlie bony cavity, l)eing only covered by mucous membrane. A suppurative process around the root of either of these teeth might easily affect the mucous membrane of the sinus through the lymphatics and bloodvessels. Indeed, an affection of tiie crown of the teeth may extend through the lymphatics to the antrum. Showing the thin orbito-etli- moidal wall partially destroyed. During etlimoiditis this wall may be broken or perforated, and give rise to orbital cellulitis. (Au- thor's specimen.) 170 THE NOSE AND ACCESSORY SINUSES The superior wall or roof of the sinus is crossed in its central portion by the infra-orbital nerve, which lies in a groove on the broad mferior side of the plate of bone. It is covered by mucous membrane and may be easily injured during the curettement of the sinus. As it is a nerve of sensation rather than of motion, it regenerates readily after being injured, even if long portions of it are removed. Motor nerves do not thus readily repair. SERIES II. Series II is composed of the posterior ethmoidal and the sphenoidal sinuses, and their ostei open into the superior meatus of the nose. The Posterior Ethmoidal Sinuses. — The posterior ethmoidal are usually fewer in number and larger in size than the anterior ethmoidal cells. Sometimes they occupy nearly all the ethmoidal labyrinth, ex- tending to the anterior portion of the nose, and sometimes the anterior cells extend backward almost to the sphenoid bone. The ostei open into the superior meatus and are in relation to the posterior half of the middle nasal concha (turbinated body), upon which the secretions flow\ As the middle turbinal slopes slightly dowTiward and backward, the secretion flows toward the posterior choana, though it also flows over the median border of the turbinal through the olfactory fissure, or space between the turbinal and the septum, hence a purulent secretion in the olfactory fissure is usually indicative of posterior ethmoidal suppu- ration. It may, however, indicate sphenoidal disease, or a combined empyema of the ethmoidal and sphenoidal sinuses. The secretions may also be forced into this position from the middle meatus by snuffing the nose. The ostei of the posterior cells are not visible by either anterior or posterior rhinoscopy, nor are they accessible to the probe or cannula. The symptoms of posterior ethmoidal suppuration are not so distinct as those in either of the cells comprising Series I. As the posterior cells are deeply situated, external tenderness is not present. Exoph- thalmos may result from the retention of the purulent secretion in the cells, the os planum forced outward behind the eyeball, causing it to protrude forward. This also gives rise to diplopia and strabismus and to a circumscribed visual field, especially for colors. The ocular disturbances are extremely rare in proportion to the number of cases in which the posterior ethmoidal cells are diseased. According to my own clinical observations, the ethmoidal sinuses (anterior and posterior) are more often diseased than the maxillary sinus, which is generally regarded as the most frequently affected. The ethmoidal sinuses are so situated in the upper and narrow portion of the nasal chambers, where a moderate deviation of the septum or an enlargement of the middle tur- binal closes the olfactory fissure and thus blocks ventilation and drainage of the superior meatus and accessory cells. For these reasons the ])osterior ethmoidal cells are often the seat of disease. THE INDIVIDUAL SINUSES 171 The secretion in the posterior portion of the olfactory fissure is sig- nificant of ethmoidal suppuration, though the pus may come from the sphenoid. Indeed, the posterior ethmoidal and sphenoidal cells are so closely associated that when one is diseased both are often affected. A postrhinoscopic examination showing purulent secretion on top of the middle turbinal is almost certain evidence of disease of the posterior ethmoidal and sphenoidal cells. Crusts and secretions in the vault of the epipharynx are likewise indicative of the same affection. The Sphenoidal Sinus. — ^The ostium sphenoidale is situated in the anterior wall of the sphenoidal sinus near the top of the cavity, though it is occasionally a little lower down. It is near the septum of the nose and is hidden from view by the close approximation of the middle turbinal to the septum. If there is marked atrophy of the turbinal, or if the sep- tum deviates to the opposite side, it may be seen by anterior rhinoscopy. The opening varies from ^ to 4 mm. in diameter. The purulent secretion flowing from the ostium either drains directly through the posterior choana into the epipharynx or on to the posterior end of the middle turbinal. Ocular inspection can usually only be made after the removal of the entire middle turbinated body. The pain or headache occurring in sphenoidal inflammation is usually referred to the occipital region on the affected side, though in some cases it is diffused and ill defined. Catarrhal inflammation causes the same headache as suppurative inflammation, though it may not be so severe. The ocular symptoms usually ascribed to suppuration of the sphe- noidal sinus are those dependent upon the compression of the optic and oculomotor nerves. The optic nerve passes over the roof of the sinus, hence in closed empyema in which the thin bony wall of the roof softens, compression if not actual destruction of the optic nerve may take place. If only optic neuritis occurs, this is followed by atrophy and blindness. If the pressure reaches the sphenoidal fissure, the oculo- motor nerves, the third, fourth, and sixth, become involved and strabis- mus in some form follows. Intense neuralgia may result from a neuritis of the ophthalmic division of the fifth nerve. Other ocular lesions arising in the course of inflammatory diseases of this and all the other sinuses have already been referred to in the Eye in Relation to the Sinuses. DIFFERENTIAL DIAGNOSIS. To illustrate the methods of difl^erential diagnosis, a series of hypo- thetical cases will be given, assuming the symptoms characteristic of the simple and combined empyemas of the various sinuses in the open, closed, and latent forms. Simple empyema refers to those cases limited to one group of cells, as the maxillary sinus, frontal, anterior ethmoidal, posterior ethmoidal, or the sphenoidal sinus. Open empyema refers to an ompyema, either simple or coml)ino(l, in which the ostei are open and permit of driiinage and ventilation. 172 THE NOSE AKD ACCESSORY SINUSES Closed empyema refers to those eases in wliieli the ostei are closed by pathological changes and the secretions are retained and cause pressure. Latent evipijema refers to tliose cases in which the ostei are open but the secretion is so slight that it is not demonstrable, except by irrigation of the affected sinus. The ostei of the sinuses are so situated that they drain into either the middle or die superior meatus of the nose. The sinuses situated an- t(M-iorly drain into die middle meatus, while those situated posteriorly drain into the superior meatus. The anterior group, or those draining into the middle meatus, are the antrum, die frontal, and die anterior ethmoidal cells. These have been designated by Hajek as Series I. The posterior group, or those draining into the superior meatus, are die posterior ethmoidal and the sphenoidal sinuses. These are desig- nated as Series II. For the sake of brevity and clearness these terms will be used. Having defined the terms, we are ready to recite a series of hypothetical cases, illustrative of the symptoms and procedures necessary to arrive at a positive differential diagnosis between empyema of the various sinuses or combinations of them. Case I. — (a) Complains of unilateral discharge from the nose. (6) No pain. (c) Subjective fetid odor. (d) There is an ulcer at the root of the second bicuspid tooth on the side of the nasal discharge. (e) x\nterior rhinoscopy shows pus in the middle meatus. The conclusion, based upon the above data, is that one or more of the anterior group of cells, Series I, is involved. Wliile the ulcerous bicuspid suggests the antrum as the sinus most probably affected, it is by no means proved, nor are the frontal and anterior ethmoidal sinuses knowm to be free. To still further differentiate the focal centre of infec- tion the following procedures must be instituted : 1. Remove the secretions from the middle meatus with the douche or a cotton-wound probe, and place the patient in Escat's position, i. e., the head dirown forward with the affected side turned upward to favor die flow of pus from die antrum. After remaining in this position for a few minutes the middle meatus should be reexamined, and if pus is found die antrum is probably involved. This is not absolutely established, however, as it might have come from the frontonasal canal. To still further clear the diagnosis, introduce a cannula and trocar through the naso-antral wall in die inferior meatus (under cocaine anesthesia) (Fig. 123) and irrigate die antrum. If pus is found the antrum is involved. The diagnosis is not yet complete, as it remains to be demonstrated whether the frontal and anterior edimoidal cells are affected. If after diorough irrigation of die antrum pus does not reappear in the middle meatus, die probabilities are strongly in favor of a simple em- pyema of the antrum. This is true in view of the fact that the flow of ])us from die frontal sinus is nearly constant, as its outlet when the patient is in a sitting posture is in the most dependent portion of die DIFFERENTIAL DIAGNOSIS 173 sinus. In this case pus does not reappear in the middle meatus for several hours, unless the patient assumes Escat's position, hence the condition is probably a simple empyema of the antrum. To still further strengthen the diagnosis transillumination of the antrum and frontal sinus should be performed. If the side involved shows opacity over the lower eyelid, a non-luminous pupil, and the absence of the sense of light with the eyes closed, empyema of the antrum is indicated. If, in addition, transillumination of the frontal sinus is negative, the diagnosis of a simple empyema is fairly well established. The anterior ethmoidal cells are still to be considered. Transillu- mmation does not help us here. The bulla ethmoidalis belongs to the anterior ethmoidal cells, and if it is enlarged toward the septum, or downward against the uncinate process, it is probable that the anterior ethmoidal cells are involved. Fig. 123 Introducing a trocar and cannula into the maxillary antrum beneath the inferior turbinal for diagnostic purposes. If pus is removed by irrigation from the anterior ethmoidal cells, the case is one of combined empyema of the antrum and anterior ethmoidal cells. If it is also removed by irrigation from the frontal sinus, the case is one of combined empyema of Series I. Skiagraphy shows the frontal and ethmoidal areas clear. Case II. — (a) Unilateral discharge of pus from the nose. (h) Dull aching pain in the left cheek bone. (c) Pus in the middle meatus. (d) Slight tenderness over the cheek bone on pressure. (e) Case under observation for several days; pus not always found in the middle meatus. ( /') Outer nasal wall on left side bulges toward septum. ((/) Pus occasionally discharged in great quantities, after wliicli the dull ache in the malar region is relieved. After performing the procedures described in Case I the purulent secretion is excluded from the frontal and an'erior ethmoidal cells, and is localized in the antrum. The diagnosis is a simple closed empyema of 174 THE NOSE AXD ACCESSORY SINUSES the antrum. Tlie retention of the purulent secretion gives rise to the pain and tenderness over the left cheek bone and to the bulging of the outer nasal wall toward the septum. At times the pressure of the puru- lent secretion was great enough to force it either through the ostium maxillare or the accessory ostia, which were closed by the swollen mucous membrane. The pain caused by the pressure was relieved after each spontaneous discharge. This was a case of closed empyema of the antrum. Case III. — (o) No nasal discharge. (6) There is a previous history of nasal discharge from the right side. (c) Frequent attacks of frontal headache on the right side. (d) ]\Iental depression. (e) Aprosexia. (/) Transillumination of antrum and frontal sinus is negative. (^) Pus not present in either the middle meatus or the olfactory slit. (h) Irrigation of the sinus through a puncture in the inferior meatus (Fig. 123)^shows a very small amount of pus. (i) Irrigation of the frontal and anterior ethmoidal cells is negative. (j) Irrigation of antrum continued until pus disappears. {k) Supra-orbital pain, mental depression, and aprosexia disappear. Diagnosis. — Latent empyema of the maxillary sinus. Case IV. — (a) Unilateral nasal discharge. (6) Supraorbital pain and tenderness on percussion. (c) Pressure on the roof of the orbit (floor of frontal sinus) elicits pain. (<^) Pus present in the middle meatus. (e) When wiped away it reappears after a few minutes. (/) Escat's position of the head has no influence on the flow of pus. (g) Lying upon the back checks the flow. (h) Frontal headache beginning on the affected side, more marked in the morning. (i) Dizziness upon stooping (;') Transillumination shows the crescentic light over the lower eyelid, the red pupillary reflex, and the sense of light in both eyes with the lids closed. (k) Transillumination of the frontal sinus seems to show diminished luminosity on the affected side, although the difference between" the two might easily be accounted for by anatomical variations. (/) Puncture of maxillary inus through the inferior meatus negative. (m) The cannula is introduced into the frontonasal canal (Fig. 124) and irrigation through it brings pus. Pus reappears in the middle meatus in a few minutes. (n) Skiagraph shows cloudiness of the frontal sinus. Diagnosis. — Simple open empyema of the frontal sinus. Case V. — (a) Complains of constant nasal discharge, right side. (h) Supra-orbital headache on right side. (c) Tenderness and swelling over the right eyebrow. (d) Anterior rhinoscopy. Septum deviated to right, in the region of the middle turbinal. Polypi in middle meatus on right side. DIFFERENTIAL DIAGNOSIS 175 (e) Probe shows polypi attached to uncinate process and the middle turbinal. (/) Series I involved, probably localized in the frontal or the frontal and anterior ethmoidal sinuses. (g) Transillumination, maxillary sinus, faint crescent and pupillary reflex. Frontal opaque. (h) Polypi removed. (i) Maxillary sinus punctured through inferior meatus and odorless pus is washed out. (j) Frontal irrigated through cannula. Pus abundant. (k) Frontal irrigated daily, maxillary sinus occasionally; absent in maxillary after the first irrigation. (I) At end of six weeks frontal sinus still discharges pus. (m) Radical external operation; caries and polypi found in frontal sinus. Diagnosis.— Empyema of frontal sinus with secondary involvement of the maxillary sinus, which acts as a reservoir, but is not a focal centre of disease. Case VI. — (a) Complains of purulent crust formations in right nostril and in the epipharynx in mornings. Hawks up crusts from the epipharynx. Frontal sinus cannula. (6) Dull headache variously located; sometimes it is frontal, then vertexial, and then occipital. (c) Mental depression and aprosexia. (d) Anterior rhinoscopy: Septum deviated to right in region of middle turbinal. Olfactory slit narrow and filled with pus and crusts. Small polypi springing from the border of middle turbinal. (e) Posterior rhinoscopy shows purulent secretions flowing over the posterior end of the right middle turbinal and the posterior epipharyn- geal wall. Crusts not found, as they form at night when the position of the head and the quietness of sleep favor accumulation. (/) Middle meatus free from pus. {g) Provisional diagnosis: Empyema of Series II. (h) A cannula is passed into the sphenoidal sinus through its ostium. Irrigation shows no pus (Fig. 131). (?") A curved silver probe introduced through the olfactory slit shows bare rough bone in the superior meatus. Diagnosis. — Open empyema of the posterior ethmoidal cells. The irrigation of the sphenoidal sinus eliminates it from consideration, and as Series II is only composed of the sphenoidal and posterior ethmoidal sinuses, the empyema is located by exclusion in the posterior 176 THE NOSE AND ACCESSORY SINUSES ethmoidal cells. This is still further substantiated by the presence of rough, bare bone in the superior meatus. Case \ll. — (a) Complains of the formation of crusts in the epipharynx; also of postnasal "dropping." (6) A subjective sense of odor is present, even in the absence of such an odor. (c) Vertexial and occipital headache. (d) Field of vision, especially for colors, diminished. (e) IVIental depression. (/) Anterior rhinoscopy; olfactory slit occasionally filled with pus, though it is usually clear. (tum ])ressing against tiie outer wall of the nose, or to gummatous swelling of the sejitum. These and other jxithological lesions of the adjacent structures may cause sinuitis. All cases should, dierefore, be carefully studied in order to determine the predisposing causes of the inflammation. GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 181 The Exciting Causes. — The exciting causes of sinus inflammation are the various microorganisms causing the exanthematous and other infec- tious fevers. It is weh known that coryza is often one of the early phenomena of this disease, and that it is due to the microorganisms and their toxins. The inflammation usuaUy extends to the sinuses, where it may remain in a latent or chronic form. In some cases it is only after many years that the sinus involvement becomes obvious enough to attract the attention of either the patient or the physician. It is probably true that the sinus inflammation thus started is more apt to become chronic in those cases in which the cell openings are more or less blocked by anatomical deviations of the septum or other obstruc- tive lesions of the nose. If, for example, the septum in its upper portion is deviated to one side, so as to approximate to the middle turbinal, the sinus inflammation arising during an attack of one of the infectious fevers is more liable to continue into the chronic form than it would be if no such obstructive deformity of the septum existed. Pathology.— The pathological changes occurring in the mucous membrane and bony walls of the antrum in the course of suppurative inflammation are what one might expect in a mucous-lined cavity. Much discussion has arisen on this subject between anatomists and clinicians. Anatomists have found less marked changes, probably because they only examined such cases as came to them from the dead- house, while clinicians describe much more extensive changes in living cases, from whom specimens were removed during life, or upon the postmortem table. I prefer to base the pathology upon the clinical rather than upon the anatomical data. Acute inflammation of the sinuses may be divided into the exudative and the diphtheritic, although the latter is rarely present and is not a true diphtheritic membrane. The exudative inflammation may be serous, fibrinous, sero- purulent, or purulent in character, according to the intensity of the inflammatory process. For didactic purposes the changes occurring in the tissues may be studied in the following order, which represents the usual sequence of the pathological events: (a) The submucous tissue is infiltrated with serum, while the surface is dry. Leukocytes also fill the meshes of the submucous tissue. (b) The capillaries are dilated, and the mucous membrane is red in consequence. (c) After a few hours, or a day or two, the serum and leukocytes escape through the epithelial covering of the mucosa, where they become admixed with bacteria, epithelial debris and mucus. In some instances capillary hemorrhage occurs and blood becomes admixed with the secretions. The secretions, at first thin and watery, later become thicker and tenacious, on account of the coagulation of the fibrin of the serum. (d) In many cases resolution by the absorption of the exudate and the cessation of the dischai-ge of the leukocytes takes place in from ten to fourteen days. 1S2 THE XOSE AXD ACCESSORY STXUSES (r) In otlicr casos, liowvvcr, the inflainmation passes from the catarrhal to the purulent type, the leukocytes l)einen made on die antrum, because it is more accessible to inspection GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 183 through the canine fossa. There is no particular reason, however, why- similar changes may not occur in the other sinuses. I will therefore describe in general the pathological changes occurring in the entire sinus labyrinth, pointing out the changes peculiar to each group of cells, in addition to the changes common to them all. In general, it may- be said that the pathological changes in the accessory sinuses of the nose correspond with the descriptions in general pathology. The slighter changes are quite like those in acute suppurative inflam- mation affecting other mucous membranes and bone tissue. The mucous membrane may present a granular surface, villous and fungoid excrescences, granular, cushion-like thickening, etc. In the older cases there is thickening from hyperplastic and pyogenic membrane deposits, or the membrane may be destroyed in spots by ulceration, exposing smooth, bare bone, or the bone may be soft or rough from caries. In some cases necrosis and bone sequestra are present, or there is an entire loss of the bone. A microscopic examination of sections of the mucous membrane sometimes shows a loss of the epithelium and glands, which are replaced by connective tissue. Ulcerations of the membrane are often surrounded by granulatioii tissue, especially if there is bone necrosis. Granulation buds may encroach upon the periosteum, and thus unite the bone and mucous membrane. Wliere this happens the bone is superficially absorbed and somewhat roughened in conse- quence. Osteophytes, or bony scales or plaques, resulting from plastic exudation sometimes form on the surface of the bone. Cysts of the mucous membrane of the maxillary sinus are present in a large number of the cases, according to some observers, while they are rather infrequent according to others. Cysts of the middle turbinate are usually located in the anterior end, and appear to be dilated ethmoidal cells filled with air, mucus, or pus, or an admixture of them. I removed one from this region holding a half-dram of stinking pus. It should be remembered that the middle turbinated body is a portion of the ethmoid bone, and that the pneumatic spaces in it are a part of the ethmoidal labyrinth. Cysts are more rarely found in the walls of the frontal and sphenoidal cells. Polypi have been found in all of the sinuses, although they are more common in the antrum and ethmoidal cells. They are much more common in the ethmoidal cells than is generally supposed. Their hidden location within the small ethmoidal spaces renders their diagnosis rather difficult. In the antrum, however, they are more easily diagnosticated, as it is quite frequently exposed through the canine fossa. As this sinus is quite large, the polypi are easily seen and diagnosticated. They have been found in the frontal and sphenoidal smuses, although not so fre- quently as in the antrum and ethmoidal cells. The polypi in the eth- moidal cells are usually quite small, on accojunt of the limited space within tiie cells, whereas, in the antrum they are much larger. In one case, in which I exposed the antrum through the canine fossa, the cavity was filled with polypi. In empyema of the ethmoidal cells the thin lamina papyrnccjp separating the ('('lis from the orbital cavity may bo pcM-foratcd l,S4 T/ri-: \osi-: axd accessory sixuses or entirely destroyed by tlie siip])iirative proeess. The same is true of the eranial ])hite sei)aratin(; the cells from the anterior hemisphere of the l)rain. In the latter ease the meninges are exposed to infection, and may he the seat of meningitis or epidural abscess. Such an exposure of the meninges may exist in cases of latent ethmoidal empyema, with no other sym])toms than a slight headache and mental irritability. A slight intranasal operation, especially on the middle turbinated body, may light uj) the slumbering fires and rapidly lead to a dangerous, or even a fatal, meningitis. The cases of meningitis occurring after intra- nasal operations are probably to ])e explained in this way, as has been shown by (iriinwald in his work on Nasal Suppuration. Thrombosis of the longitudinal and cavernous sinuses occasionally complicates ethmoidal empyema. Retrobulbar suppuration, or ocular cellulitis, is a comparatively infrequent complication of ethmoidal empy- ema from narcosis and perforation of the lamina papyrace?e. In frontal empyema the floor and posterior wall are most often the seat of destructive changes. The floor near the median line is in apposi- tion with the anterior ethmoidal cells and nasal septum, hence the cells and septum are frequently more or less involved in the carious and necrotic retrograde changes. The -anterior ethmoidal cells are always filled with pus in frontal empyema. Symptomatology. — The Objective Symptoms. — The objective symp- toms may be extranasal or intranasal. The extranasal symptoms are those changes in the appearance of the skin of the face, and of the fundus of the eye as shown by ophthal- moscopical examination. In addition to the objective signs the results of transillumination and of skiagraphy afford important objective informa- tion. The intranasal objective signs of sinus disease are those changes in the appearance of the outer walls of the nasal chambers and the location of the secretion as it drains from the aftected cells. The Extranasal Objective Symptoms. — (a) AMien any of the sinuses contiguous to the skin of the face are involved (frontal, anterior ethmoidal, or antrum) diere may be redness, swelling, and heat of the skin covering the afl'ected area. If, for instance, the frontal sinus is acutely inflamed there maybe swelling, redness, and heat of the skin in the frontal region; likewise in the malar region in antral disease and at the inner angle of die orbit in anterior ethmoidal disease. Tenderness upon pressure (a subjective symptom) is also present when redness and swelling are found. (/;) The fniidns of the eye sometimes affords very useful and important objective evidence of sinu inflammation. Dr. H. M. Fish has shown this comiection more clearly than any other writer, and I am chiefly indebted to his writings and to personal conversations with him for the facts given in reference to the eye symptoms of sinus inflammations. (See Relation of die Eye to Accessory Sinus Disease.) (c) 'J'ransillumination of die face affords objective information as to the condition of the inaxillarv sinus, and sometimes of the frontal sinus. GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 185 but none in reference to the other sinuses. In transilhimination of the antrum (see Methods of Examination) three points should be noted, namely, the red pupillary reflex, the crescent of light corresponding to the position of the lower eyelid, and the sense of light in the eye when closed. If the red pupillary reflex and the crescent of light are absent the antrum is probably affected. Note both sides at once, and thus determine which one, if either, is affected. A comparison of the lower portion of the field of illumination may be very misleading, as the anterior wall of the antrum varies greatly in density, irrespective of the disease present. The orbital or upper wall of the antrum is, however, more nearly uniform in its density in all cases, and affords a fair opportunity for a comparison of the transilluminated light through the two orbital plates; that is, when both orbital plates of the antrum are healthy the amount of light transmitted through them is about equal; whereas when one is thickened it interferes with the transmission of light, hence the crescent of light is dimmed or altogether absent. Likewise when Birkett's transilluminator for the simultaneous illumination of both frontal sinuses. both orbital plates are healthy (antral disease absent) the light transmitted into the interior of the eyeball is shown in the red pupillary reflex in each eye; whereas if one antrum is involved the pupillary reflex is absent upon that side and present in the other. The sense of light (eyes closed) is present on the healthy side and absent upon the diseased side in maxil- lary diseases. Transillumination of the frontal sinuses is an uncertain means of diagnosis, as the anterior wall often varies so much in thickness on the two sides in the same individual. The hooded lamp should be placed under the floor of the frontal sinus at the upper and inner angle of the orbit and the two sides compared. Dr. Birkett has devised a double lamp (Fig. 125), so that both sides can be illuminated at once to facili- tate comparison. If the lamp is not placed well under the supra-orbital ridge the skin transmits the light and may thus lead to a false deduction. Taken as a whole, ti-iinsilliiiniiiatioii of the tVontal sinuses is not a reliable procedure. l.SO THE XOSE AXD ACCESSORY SIXUSES SJciaffraphi/. — Skiagraphy of tlie accessoiy sinuses of the nose should Ik- a routine j)ractice when aeeess is had to a competent radiographer. Prof, (iustav Kilhan first practised it in diseases of the nasal accessory sinuses. Dr. C (t. Coakley has, ])erhaps, used it more extensively than anyone else in this field of work. Dr. J. C. Beck and the author have also made skiagraphs of about 200 cases. The great difficulty has been to find a radiographer who understands the technique well enough to j)roduce clear skiagraphic plates. Dr. Caldwell recently published his techni((ue, the essentials of which are herewith given. Schema showing the proper and improper angles for making a skiagraph of the frontal and ethmriidal sinuses, a, the i)roper angle for passing the 3--rays tlirough the head; b, the improper angle, as the rays must pass tlirough a great deal of dense bone (rf) to reach the sinus; (f ) an 8 x 10 inrli photograiiliic i)late against which the forehead sliould rest; e, the table upon which the patient lies. Tiie forehead should be placed upon a triangular block with an inclination of twent.v-five degrees, as tliis is more comfortable to the patient and renders the line (a) perpen- dicular to the table. To get a j)late with clearly defined oudines of the sinuses, and with a clear definition of die area of Uie sinuses, it is neces.sary to so place the a:-ray tube as to avoid the heavy bone of the floor of the cranium, as it would interfere with the passage of the rays through the head. The .T-ray tube .should be aj)])lied, dierefore, to the back of the head at a point above the occiput and floor of the cranium, as .showni by the line a in Fig. 12(1. If the tube is apj)lied at b, the ravs would have to traverse GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 187 through the dense bone of the occiput and the long axis of the plate of bone forming the floor of the cranium before it reached the frontal and ethmoidal sinuses, thereby interfering with the formation of a clear shadow of the dense bone forming the walls of the sinuses and the pro- duction of a clear definition of the area of the sinus cavities. If, how- ever, the x-TSij tube is applied at a, midway between the occiput and the vertex, the rays have an unimpeded course to the frontal and eth- moidal sinuses, and the outline and area of the sinuses will be clear and well modulated. The delineation of the maxillary sinuses is not so clear, as the rays must pass through more bone tissue to reach it. A clear skiagraph of this sinus is not so essential, however, as this sinus is easily and successfully examined by transillumination with an electric lamp in the mouth. The advantages derived from skiagraphy of the accessory sinuses are : (a) Diagnostic. — If a sinus is healthy its outline on the plate or negative is clear and distinct (light) and its area is clear and dark. If the sinus is diseased its outline is less clear and distinct and its area is cloudy or hazy upon the negative or plate. Prints from the plates are rarely satisfactory for diagnostic purposes. (6) The dimensions of the frontal sinuses is clearly defined, thus affording the surgeon positive information as to the extent of exposure necessary before he begins an external operation. A skiagraph through the lateral dimensions of the head will show the depth of the frontal sinus, thus affording the surgeon additional data as to the probable deformity to be expected should the Killian operation be performed. The wider and deeper the frontal sinus the greater the deformity following the com- plete removal of the anterior bony wall of the sinus. The information gained from the two views of the frontal sinus may determine the operator to either select or reject a given method of operation. If, for example, the skiagraph shows a small, shallow frontal sinus the Killian operation might be chosen in preference to other methods, as it is a thorough and satisfactory method of operating, and would in such a case be fol- lowed by little or no external deformity. If, on the other hand, the plates show a large and deep frontal sinus the surgeon might be influenced to adopt some other method of operating which would not be attended by such marked external deformity. (c) In some instances, when the frontal sinus seems to be involved, the skiagraph will show a total absence of it, information of no small consequence to both the surgeon and the patient. The Intranasal Objective Symptoms. — (a) The contour of the outer nasal wall sometimes affords information as to the condition of the sinuses. In closed empyema of the antrum the inner wall of the antrum may be pushed toward the septum. Likewise in empyema of the bulla ethmoidalis its median wall may be distended so as to close the hiatus semilunaris, or even impinge against the external surface of the middle turbinal. (//) The texture of the mucous membrane of the nose, especially that portion of it covering the middle turbinated borly, is sometimes indicative 1,9,S THE XnSK AXD ACCKSSORY SIXUSES of sinus disease; that is, when the nuieosa of the anterior end of the middle turhinal is l)o^'^;v and velvety in texture it usually sif^nifies the existence of an ethmoidal sinus inHannnation. ((•) Polypi are often associated with sinus disease, and are, I believe, usually secondary to the sinus infiannnation. {d) Pus within the nasal chambers is usually significant of sinus emjn-ema. The nasal nnicosa is rarely the focal centre of suppurative infiannnation, whereas the sinuses are commonly the focal centre of such an inflammation. The presence of pus in the nasal chambers should, therefore, excite suspicion of the existence of a sinus inflammation. To determine which of the sinuses is involved, see Diagnosis. In a general way it may be stated that pus in the middle meatus signi- fies an involvement of the frontal, anterior ethmoidal, or the maxillary sinus, as these cells drain into the middle meatus. If pus is seen in the olfactory' fissure (between the septum and middle turbinal) the posterior ethmoi(lal or the sphenoidal cells are involved, as these cells drain into the su|)erior meatus (above the middle turbinal). The Subjective Symptoms. — The subjective symptoms of sinus inflam- ination liave refiM'euce to the sensations of pain and of pressure, the equi- lii)rium of the mind, and the impairment of the special senses. (a) Pain referable to the region of the sinus involved may or may not be present. In active antral or frontal inflammation pain is often distinctly referred to the region involved. In the case of the deeper sinuses, as the ethmoidal and sphenoidal, the pain is vaguely deep seated in the head or referred to the periphery of the head without reference to the location of the sinus. For example, sphenoidal inflammation may give rise to pain in the occipital or the frontal region. As a matter of fact, inflammation in any or all of the sinuses usually causes pain in the frontal region. These pains are almost universally callefl headaches by the patient. (h) Headache is, therefore, one of the commonest and most significant signs of sinuitis. Headache has multitudinous causes, and is not, there- fore, pathognomonic of inflammatory or other diseased conditions of the sinuses. Headache may signify eyestrain, but in this case it is usually bilateral, whereas in sinus disease it is more often unilateral, or, if not mvilateral, more pronounced on one side, or it begins as a unilateral headache and extends to the other side. The headache of sinus origin is increased upon st()oj)ing forward and upon a sudden jar of the body. It may persist upon closing the eyes upon retiring, or in a darkened room ; wlu-reas, if if is of ocular origin it disappears under such conditions. The liciKJaciic of ocular origin is greatly increased upon prolonged reading and upon attendance at the theatre. The headache caused by attendance at the theatre is so characteristic of ocular disturbance that it maybe termed "theatre pain." The theatre pain is not characteristic of simis disease. 'Phe j)ains and headache (Uw to disease of the frontal sinus may assume the form of sharp, shooting ])ains through the eyes and in the orbital region, or they may be dull antl heavy, and nearly constant; or they GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 189 may consist of a full feeling in the forehead, aggravated by leaning forward, which in females is especially well marked during each menstrual period (H. M. Fish). Pressure under the floor of the sinus at the inner angle of the orbit (Fig. 118) usually elicits pain in these cases. (c) Tenderness upon Pressure. — Tenderness and pain upon finger pressure may be present in disease of those sinuses contiguous to the surface of the face, viz., the frontal, anterior ethmoidal, and the maxil- lary sinuses. For the examination of the frontal sinus, pressure should be made over the anterior wall above the supra-orbital ridge, and under the floor of the sinus near the inner angle of the orbit. In the examination of the anterior ethmoidal cells, pressure should be made at the inner angle of the orbit against the orbital plate of the ethmoid. In the examination of the antrum of Highmore pressure should be made over the canine fossa of the superior maxilla. (d) Disturbances of Equilibrium. — Giddiness and vertigo or a momen- tary sense of blurred or darkened vision and imminent fainting are frequently present in disease of the sinuses. All these symptoms may be aggravated or produced by stooping forward. The patient should be carefully questioned in regard to these symptoms, as otherwise they may be overlooked. When these and the other signs of sinus disease are present the diagnosis is fairly well established. (e) Disturbances of the Special Senses. — ^The olfactory, visual, and auditory senses are frequently disturbed or altogether lost in sinuitis. The olfactory sense may be perverted (parosmia), the patient appar- ently perceiving odors that are not in evidence to normal noses. A more common symptom is the loss of olfaction (anosmia). This is accounted for by the blocking of the olfactory fissure by the swollen tissues in the region of the middle turbinal, and by the presence of polypi and a deviation of the septum in this region. The ventilation of the superior meatus of the nose is thereby prevented, hence the loss of the sense of smell. In some cases the loss of the sense of smell may be due to the degeneration of the terminal filaments of the olfactory nerve, although in most cases coming under my observation the sense of smell is regained after opening the olfactory fissure either by reducing the swollen membrane or resorting to some surgical procedures, as the removal of polypi or a portion of the middle turbinal. The ocular fiuiction may be disturbed or altogether lost in the course of sinus disease. The disturbance may be due to either arterial or venous congestion, and to toxins, or to thrombosis of the veins intercom- municating between the sinuses and the eye. The morbid process in the eye may take the form of a papillitis, neuroretinitis, retrobulbar dis- ease, keratitis, errors of refraction or of accommodation, photophobia, epiphora choroiditis, iridocyclitis, marginal blepharitis, conjunctival in- jection, or restricted field f)r loss of vision. The Relation of the Eye to Sinus Diseases. — The intimate relation between the veins of the nose and accessory sinuses and of the eye lol) THE XOSK AXD ACCESSOEY SINUSES (Fig. 127), as pointed out by Dr. H. M. Fish and others, shows how rea- sonable is the assumption that many of the ocular lesions heretofore attributed to auto-intoxication from the intestines, gonorrhea, syphilis, and rheumatism, may in many instances be due to an extension of the disease from the sinuses to the ocular apparatus via the veins and lymphatics. Dr. Fish says: "The ocular symptoms resulting from an affection of the accessory sinuses of the nose have attracted a great deal of attention during the past few years, and various theories have been announced to explain their pathogenesis. According to Ziem, they are manifestations of a passive orbital hyperemia from a faulty oxygena- tion of the blood, resulting from a hindered nasal respiration, a nasal stenosis from edema, polyj)i, purulent secretions, etc. As this hypothesis fails to account for a circulatory disturbance limited to the ocular region, as well as the instances in which there I'ic. 127 is no hindered nasal respiration, the nostril presenting a practically normal appearance, as it does in some cases, the writer has modified the above theory and considers the stasis in the peri-orbital circulation to be the result of a vasodilatation resulting from an irritation of the sympathetic by the secretion pent up in a closed sinus. This theory is based on Gur- witch's demonstration, that the vaso- supra-orbitalia, frontalia, ethmoid- alia, and ophthalmofacialia carry the greater portion of the venous blood from the nostril and its sinuses into the ophthalmic vein, and the fact, as shown by Ziickerkandl, that the upper walls of the various cavities situated at the base of the brain are pierced by minute openings, through which the lymph and bloodvessels pass, thus affording a direct communi- cation between the circulation in these cavities and to the convolutions of the brain. An intracranial circulatory disturbance results m cerebral symptoms, as vertigo (one of the early and most constant phenomena of sinuitis), epileptoid attacks, or unconsciousness (Lichtwitz, Engle- mann, Mayer, and the writer), or it may produce meningitis or abscess of the brain. A stasis appearing in the orbital circulation may cause an edema of the lids, or an exudate behind the globe with a resultant ])rotrnsion, or it may show itself in any of the eye tissues. If it appears in the cornea, for instance, there may be an elevation of the epithelium, abrasion, infection, and corneal abscess, with perforation, Avhich may necessitate a subsequent emicleation of the eyeball. Should a severe intra-ocular involvement take place, and later the fellow eye show inflam- matory symptoms, resulting from a sinuitis of the corresponding side, Schema showing the venous connections of tlie ethmoidal cells with the eyeball. aaaa, anterior and posterior ethmoidal cells; b, eyeball; c, the superior ophthalmic vein; d, the posterior ethmoidal vein; e, the anterior ethmoidal vein. GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 191 the condition could well be mistaken for one of sympathetic ophthalmia. Such an instance with enucleation, the only one in the literature, has been reported by Ziem." It has been claimed by some writers that partial or complete blindness may arise as the result of pressure on the optic nerve in closed empyema of the sphenoidal sinus. It is quite probable, however, that most cases of blindness occurring in the course of sinuitis are due to venous stasis and thrombosis rather than to direct pressure upon the optic nerve. In the case reported by Dr. Fish, in which the eye symptoms were prominent, the frontal sinus was involved, although eye lesions may arise in the course of an inflammation in any of the sinuses. In addition to the foregoing eye lesions, the patient may complain of pains shooting through the eyes, and other signs of inflammation of the visual apparatus. The auditory functions may be more or less disturbed by sinus disease. The discharge from the sinuses into the epipharynx may cause infection of the mucous membrane of the Eustachian tube and middle ear. Sinuitis may indirectly be the cause of middle-ear catarrh or of sup- purative otitis media and mastoiditis. In addition to the foregoing ear complications, there is another symptom I do not happen to have seen mentioned in the literature, namely, a momentary roaring accompanied by a fulness in the ears and dulness of hearing. These phenomena are especially liable to occur on stooping forward. The Principles of Treatment. — The cure of sinus inflammation depends upon two propositions, namely, (a) the establishment of free drainage and ventilation, and (6) the removal of the morbid material. In those cases in which the interference with drainage and ventilation is due to a simple hyperemia of the mucous membrane the local application of cocaine, antipyrine, or adrenalin may be quite sufficient to establish a cure. In such subjects the morbid material is the secretion, hence drainage removes it. On the other hand, in those cases in which there is marked obstruction due to a deviation of the septum or to hyperplasia of the middle turbinal it is often necessary to resort to surgical measures in order to obtain relief. Furthermore, in those cases in which the sinus is filled with granulation tissue and the bony walls are necrosed the establishment of drainage even by surgical means may not effect a cure; the morbid material (granulations and necrotic bone) must also be re- moved. The Indications. — An appreciation of these fundamental principles enables the surgeon to decide upon the method of treatment in each case. In the following discussion of the treatment the foregoing principles will be constantly referred to with a view of enabling the student and prac- titioner to elect the proper mode of treatment in the cases coming imder his observation. Before entering upon a detailed description of the various modes of treatment a general discussion of the vaiying conditions to be met will be given. Acute catarrhal sinuitis is usually an extension of a similar inflannna- tion of the nasal mucosa to the sinus, in the course of a coryza or cold |(,2 '/•///■; vo.s/-; .t.\7) .i('C7;.s',sYj/i')- sixuses ill the lic;i(l. 'I1ic inufous iiK'inhraiie of the nose and sinuses is liyperemic and swollen. The cell openings may be closed from swelling of the nuKoiis nuiiil)rane around them. TJie obvious indication is to relieve the swelling by the local a])})licati()n of certain drugs, surgical intervention being rarely justifiable. Acute su"j)j)urative sinuitis occurring in the course of coryza is charac- terized by hyj)eremia and swelling of the mucous membrane of the nose and sinuses, and the indications are to reduce the swelling by local medi- cinal aj)])lications, as in the acute catarrhal variety. Chronic c-atarrhal sinuitis due to pressure in the middle turbinal region demands the removal of the tissue causing the pressure. If the nnicous membrane is chronically swollen, temporary relief may come from the aj)j)licati()n of antiphlogistic drugs, as adrenalin. If the secre- tions have dried and blocked the cell openings, probing may afford temporary relief. In most cases the middle turbinal is enlarged from hyperplasia or from cystic formation, and blocks the infundibulum. In some cases, therefore, it is necessary to either straighten the septum or remove a portion of the middle turbinal in order to give permanent relief from the symptoms. The bulla ethmoidalis may also block the infundibulum and prevent drainage and ventilation of the sinuses in Series I. Chronic suppin-ative sinuitis, with obstructive lesions, demands the removal of the obstructive lesions, whether they be of septal, turbinal, or of other origin. As there is simple obstruction and no morbid material other than pus, the removal of the obstructive lesions permits of drainage and of the removal of the morl)id material (pus). The foregoing state- ment does not apply, however, to all cases, as the drainage of pus from the cells is not altogether dependent upon free cell openings, as in most of the cells the opening is near their upper limit. The ciliated columnar epithelium lining the cells, though limited in distribution, carries the secretions up to the cell openings, where it is discharged into the nasal cavity. If, therefore, the ciliae are destroyed by the inflammatory process, the removal of the obstructive lesions does not necessarily establish free drainage. In such cases it may be necessary to institute operative ])rocedures to open the cells at their most dependent portion, or to ex- enterate them in dieir entirety (ethmoidal). In some cases the mucous membrane and the ciliated epithelium can be restored to their normal integrity and functional activity by lavage, or by negative air pressure, as recommended by liier. Chronic sup])urative sinuitis wiUiout ()l)structive lesions of the septum (»!• Ilic middle turbinated body implies a degeneration of the mucous m<'nibiane with a loss of the cohunnar ciliated epithelium of the sinuses, at least in certain areas. The treatment shoidd, therefore, either be directed toward the regeneration of the mucous membrane by negative pressure, and die resultant hyj)eremia and increased nutrition, or by o|)ening (lie cells and establishing fre(> drainage by some operative pro- (•('(liire. Chronic suppurative shmitis with granulations, polypi, or bone necrosis GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 193 is only amenable to surgical treatment. No treatment other than this will establish drainage and ventilation and remove the morbid material. Treatment. — The principles of treatment having been given, only the technique of the treatment will be described in this section. Treatment of Acute Catarrhal Sinuitis. — Acute catarrhal sinuitis usually involves all the accessory sinuses, and the indications call for the reduc- tion of the swelling of the mucous membrane for the purpose of opening the ostei of the sinuses. The following technique is usually successful : (a) Apply adrenalin, 1 to 2000, on thin pledgets of cotton, to the swollen middle and inferior turbinals to reduce the swelling. (b) Apply a 4 per cent, solution of cocaine to reduce the swelling and to relieve the hypersensitiveness of the mucous membrane. (c) Apply a 10 per cent, solution of antipyrine over the same area to prolong the ischemic effects of the adrenalin and cocaine. (d) Use a 0.5 per cent, solution of menthol or other bland aromatic oily solution with a nebulizer every two or three hours. The solutions of adrenalin, cocaine, and antipyrine should be used as often as the nasal chambers become stuffy, or the headache and sense of pressure returns. In addition to the foregoing local remedies the internal administration of the usual remedies given in acute coryza may be given, but they are only of value in the early stage. (See Treatment of Coryza.) Heat applied with a 500 candle-power lamp (Fig. 19) over the face sometimes affords immediate relief. The lamp should be passed back and forth before the closed eyes, at a distance of from twelve to eighteen inches, for twenty to thirty minutes. The good effects are due to the in- creased hyperemia and leukocytosis, and to the improvement of the nutri- tional processes. While germicidal properties are claimed for the light of this lamp, the effects may be explained by the increased leukocytosis and nutrition of the tissues. I have treated old chronic cases with the light in which the purulent discharge and pain disappeared, but returned after a few weeks. Whether persistent use of the light will cure these cases I am not prepared to state. Treatment of Chronic Catarrhal Sinuitis. — This is more difficult to suc- cessfully treat on account of its chronicity, which of itself may imply that anatomical barriers existed during the acute stage to prevent resolution. These barriers, if present, must be overcome before a cure can be permanently established. The anatomical barriers to resolution may consist of hypertrophic or hyperplastic changes in the mucous membrane of the nose, especially in the region of the cell openings and the olfactory fissure, or they may be due to cystic formations in the middle turbinal or to deviations of the upper portion of the nasal septum. The swelling of the mucosa may be somewhat reduced by the local applications of adrenalin, cocaine, and antipyrine. In addition to this, the hypertrophic or hyperplastic rhinitis should be treated after the manner described under these diseases. If these measui-es fail, more radical surgical procedures, such as are used in obstinate cases of suppurative sinuitis, may become necessary. 13 104 THE SO SIC A.\'D ACCESSORY SIX USES rrul)iii<; the frontonasal canal sometimes affords relief, although the removal of the anterior end of the middle tiirbinal and the curettement of the ethmoidal cells may he necessary. Treatment of Chronic Suppurative Sinuitis. — In the simpler form of sinuitis, that is, where there are no granulations and carious bone, the lavage of the affected sinus with antiseptic, alkaline, or stimulating solu- tions is sometimes followed by a cure. The lavage of the frontal sinus may be performed through the frontonasal canal, except in those cases in which it is absolutely closed by an enlarged bulla or by an enlarged middle turbinated body. Lavage of the Frontal Sinus. — An understanding of certain anatomical peculiarities of the region of the infundibulum and the frontonasal canal will materially aid in the lavage of the sinuses. The hiatus semi- lunaris, the infundibulum, and the frontonasal canal will be clearly defined, as much confusion appears in the literature concerning them. The terms are often used as s}iionymous, whereas they are distinct anatomical entities. The hiatus semilunaris is a slit-like crescen tic-shaped opening in the outer wall of the nose. It is the opening of the infimdibulum into the middle meatus of the nose. Its inner lip is the upper margin of the uncinate process of the ethmoid bone. The infundibulum is a deep, narrow groove or gutter in the outer wall of the nose (Fig. 129/), the inner wall of which is the uncinate process. The frontonasal canal drains into the infundibulum in about one-half of the subjects, whereas in the remainder it drains a little anterior to it directly into the middle meatus (Turner). The frontonasal canal is a closed tubular duct extending upward and forward from the middle meatus or the infundibulum, as the case may be, to the frontal sinus. Its opening into the floor of the frontal sinus is known as the ostium frontale. IIa\ing defined the parts concerned in probing or irrigating the frontal sinus, certain anatomical peculiarities which influence the procedure will be given brief notice. The hiatus semilunaris is the key to the probing, as it is the opening into the infundibulum, which must be entered to reach the frontonasal canal in about one-half of the cases. The bulla ethmoidalis is situated just above the hiatus, and when large it encroaches upon the slit-like opening and partially or completely closes it. Occasionally there is an accessory cell in the uncinate process, which also obstructs the hiatus. In other cases the middle turbinal closely hugs the outer wall of the nose and blocks the hiatus (Sluder). When either of these anatomical peculiarities is present the introduction of the probe or the cannula is rendered difficult or impossible. If the frontonasal canal opens in front of the infundibulum the probe or cannula may be passed into it even though the hiatus is closed. Another difficulty sometimes encountered in probing is, that the probe may enter the ostium of one of the anterior ethmoidal cells instead of the frontal sinus. Some of the anterior cells may open into the infun- GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES I95 dibiilum on its outer wall, wliile'others open into the frontonasal canal. The anterior cells are usually located external to the infundibulum and the frontonasal canal and their ostei open into the infundibulum and frontonasal canal, through the outer wall. In probing, therefore, the point of the probe should be kept against the inner or mesial wall of the frontonasal canal in order to avoid the ostei on its outer wall. Probing is generally more difficult in those subjects in which the frontonasal canal empties into the infundibulum than when it empties directly into the middle meatus. In the former case the canal is often tortuous and narrow, while in the latter it is usually straighter and of larger caliber. The middle turbinal is sometimes so close to the hiatus, especially when the turbinal contains an accessory cell, that it is difficult to enter it with a probe or cannula. In this event the removal of the anterior third of the turbinal overcomes the difficulty. The Technique of Probing the Frontal Nasal Canal. — First cocainize the parts. Then introduce a fine silver probe (Fig. 128), bent at its distal end to an angle of about 135 degrees, between the anterior third of the middle^ turbinal and the outer wall of the nose. Keep the tip of Holmes' malleable frontal sinus probe. the probe against the outer surface of the turbinal and pass it forward and upward through the hiatus into the infundibulum, where it readily enters the frontonasal canal even to the osteum frontale (Fig. 129). After engaging in the middle meatus it should be passed into the infun- dibulum and canal for about 6 to S cm. to reach the frontal sinus. The irrigation of the frontal sinus is accomplished through a silver cannula, which is introduced in the same manner as described for the introduction of the probe. The syringe is attached to the cannula (Fig. 130) and the sinus gently irrigated with warm normal salt or boric acid solution. Lavage of the splienoidal sinus is possible when the middle tm-binal, or a deflection of the septinn, does not prevent the introduction of the sphenoidal cannula into its opening. When such an obstruction is present it may become necessary to first remove it by some surgical procedure before the irrigations can be practised. Personally, I am in the habit of using a silver Eustachian catheter in place of a sphenoidal cannula, and find the curve used for the inflation of the ear the correct one for irriga- tion of the sphenoidal sinus. Myles' cannula (Fig. 130) maybe bent to reach any sinus, and is smaller than the Eustachian catheter. 19(j rilE XOSK AXD ACCESSURY SIXUSES Larof/c of the Maxillary Sinus. — Tlris can rarely be effected tlirougb the cell opening on acconnt of its hidden position in the infundibulum, and on acconnt of the forward and downward direction of the antral opening from the infinuHbuluni to die antrum. The opening into the ,f^' Probing the frontal sinus. Tiie anterior half of the middle turbinated body is removed to siiow tlie anatomical landmarks, n n, the probe in the first i)osition beneath the middle turbinal and posterior to the bulla ethnioi