Frontal Sinus.

KICER. Laryngoscope, 1899, vi. p. 83.

MAX SCHEIER. Archiv Internat. de Laryng., 1901, xiv. p. 321.
ONODI. Archiv für Laryngol., 1903, xiv. p. 375.

LOTHROP. Annals of Surgery, 1898, xxviii. pp. 601, 647; 1899, xxix. pp. 73, 175.

Ethmoidal Cells.

ONODI. (Cells of middle turbinate) Archiv für Laryngol., 1904, XV. p. 307.

HARMER. (Cells of middle turbinate) Archiv für Laryngol., 1902, xiii. p. 163.

ONODI. (Relation of posterior ethmoidal cells to optic nerve) Archiv für Laryngol., 1903, xv. p. 259, and 1903, xiv. p. 360.

Sphenoidal Sinus.

ONODI. Archiv für Laryngol., 1904, xvi. p. 454.

Embryology and Histology.

KILLIAN. (Anat. of nose of human embryo) Archiv für Laryngol., 1894, ii. p. 234; 1895, iii. p. 17; 1896, iv. p. 1.

WINGRAVE. (Histology of accessory sinuses) Journ. of Laryng., 1903, xviii. p. 416.

SCHIEFFERDECKER. Heymann's Handbuch der Laryngol. u. Rhinol., Bd. iii. p. 87. Wien, 1899.

Functions of Nose.

MACDONALD. (Warmth and moisture) Diseases of the Nose. London, 1890.

GOODALE. Boston Med. and Surg. Journ., 1896, cxxxv. pp. 457 and 487. GAULE. Heymann's Handbuch der Larnygol. u. Rhinol., Bd. iii. p. 152. ZWAARDEMACHER. (Olfactory) Journ. of Laryngol., 1900, xv. p. 405. STCLAIR THOMSON and HEWLETT. (Arrest of micro-organisms) Journ.

of Laryngol., 1895, ix. p. 796; Lancet, Jan. 11th, 1896, and Med. ChirTransactions, vol. lxxviii., 1895.

PARK and WRIGHT. Journ. of Laryngol., 1898, xiii. p. 124 (gives full references to preceding papers on subject).

E. FRANKEL. Virchow's Archiv, 1882, xc. p. 499.

LOEWENBERG. Deutsch. med. Wochnschr., 1885, xi. pp. 5 and 22.

HAJEK. Berlin. klin. Wochnschr., 1888, xxv. p. 659.

WURTZ and LERMOYEZ. Annales des Maladies de l'Oreille, etc., 1893, p. 661.

KLEMPERER. Journ. of Laryng., 1896, x. p. 286.

Path of Air Stream,

SCHEFF and KAYSER. Journ. of Laryngol., 1895, ix. p. 64.

FRANKE. Archiv für Laryngol., 1894, i. p. 230.

BURCHARDT. (Variations in, in various forms of nasal obstruction) Archiv

für Laryngol., 1905, xvii. p. 123.

PARKER. Journ. of Laryngol., 1901, xvi. p. 345.

C

CHAPTER II.

THE EXAMINATION OF THE NOSE.

BEFORE examining the interior of the nose the general history of the patient, and the local and remote symptoms of which he complains should be enquired into as carefully as in an ordinary medical case. The attention should then be directed to the general aspect of the patient. The configuration of the face and nose often yields valuable information; a broad nose is likely to be associated with wide nasal fossae, and a long narrow nose with nasal obstruction. The habitual mouth-breather is at once recognised by the shape of his face, and by his general aspect; by the narrowness of the vestibule of the nose, and by the presence of deep folds or creases on the alae nasi. Any prominence or depression of the bridge of the nose or bulging in the region of the accessory sinuses should be observed. The presence of excoriation or of pustules on the skin of the upper lip is evidence of an irritating nasal discharge. The development and arrangement of the teeth, and the formation of the upper jaw, should also be examined; the neck, especially behind the sterno-mastoids, should be explored for enlarged glands. The examination of the chest, of the lungs and other organs, and the investigation of the patient's general history and condition, may be deferred until the local examination has been completed. The nose must be examined both by anterior and posterior rhinoscopy, and if necessary by digital exploration. The pharynx, larynx and ears should then be examined.

Anterior Rhinoscopy. The first requisite is a good artificial light. The electric light, gas, either in the form of an argand or incandescent burner, the oxyhydrogen lime-light, and a good paraffin lamp, are the most generally employed; acetylene gas gives a most brilliant light, but a sufficiently reliable lamp for it has not yet been discovered.

The Electric Light. The electric light is the most generally convenient whenever the current can be obtained. It has the great advantage of being always ready for use; it gives rise to but little heat; the lamp can be held or fixed in any position, and there is no danger of fire even if it be dropped. A burner of about 32 candle-power with a frosted glass

should be employed. A 50 candle-power light is sometimes used, but it is preferable to use the weaker light, and to darken the examining room. The lamp may stand upon the table, or be fixed upon a movable bracket on a wall, and it should be detachable for use as a hand lamp. It should be fitted with a bull's eye to concentrate the light, and should be completely covered in. Several additional plugs should be provided so that the lamp may be available in any house in which the electric light has been installed (see Fig. 22). If this light be used, it is necessary to provide means of warming the mirrors; a small spirit lamp may be used, or a

sterilizer, the latter serves two purposes at once. Lately I have been trying the Nernst lamp: it gives a very bright blue-white light similar to the oxyhydrogen lime-light, which is very pleasant to work with. It is in many respects preferable to the ordinary electric light, and the Throat and Ear department of the London Hospital has been entirely fitted with it.

Gas-light. If gas be chosen, the Argand burner, or a lamp with an incandescent mantle, may be used. The latter gives a powerful but rather unpleasant and patchy, white light. The lamp should be fitted with a metal chimney with reflector and bull's eye, and this again should be enclosed in an asbestos shield, as the flame is apt to give off a great deal of heat. On this account the lamp should be kept at a little distance from the patient's head, and the patient's hat must be removed for fear of burning

it. The lamp must be fixed to an adjustable stand which can be raised or lowered at will (see Fig. 23).

The Oxyhydrogen Lime-light. This gives perhaps the best light of all, but it is troublesome, expensive, and cumbersome. The lamp can be fixed

MAYER & MELTZER

FIG. 23.-ARGAND GAS BURNER WITH MACKENZIE'S ADJUSTABLE WALL BRACKET.

on a portable tripod stand, and erected anywhere. A cylinder containing oxygen, and a supply of ordinary coal gas, are required, with the necessary lengths of tubing.

The illumination shows objects almost in their natural colours, and it is very pleasant to work with. It is suitable only when in constant use, and is not nearly so convenient as the electric light.

When none of these lights are available, Cresswell Baber's incandescent spirit lamp or an ordinary paraffin lamp may be used. The latter may be fitted with reflector and bull's eye; it should have a broad flat bottom, and the top of the oil should be covered by two or three layers of finely-chopped cork, to prevent its being spilt by shaking. Baber's lamp (see Fig. 24) is a great improvement on this, and I now always employ it for examinations in patients' houses.

Position of Patient, etc. The surgeon must wear an ordinary frontal mirror, such as is used for laryngoscopy; it may be attached to the head by a band or by a spectacle frame. The mirror should have a small aperture in its centre, and should always be worn over the eye on the same side as the source of the light, when it will be found to shade both eyes from the glare. In this country the lamp is usually placed just behind and to the left of the patient's head, and consequently the mirror must be worn over the surgeon's right eye. As, however, most surgeons use the right hand in operating, there are many advantages to be obtained by

reversing this position, so that the movement of the operating hand may not interfere with the source of the light. The patient should be seated on a firm chair with a narrow seat and a vertical back, so that he is compelled to sit upright or lean slightly forward. The surgeon sits facing him, and an ordinary music stool, which can be adjusted to any height, will be found a most convenient seat.

Speculum. For anterior rhinoscopy it is necessary to use a speculum to

dilate the anterior nares. Thudichum's or Lennox Browne's (Fig. 25) are the most convenient, as they have solid blades, which prevent the vibrissae obstructing the view. The Thudichum speculum is often painful to the patient if the spring is too strong: it should therefore either be compressed by the fingers, or the spring should be broken. It is an advantage also to bend the speculum so that the outer blade projects a little further back than the blade which lies next the septum. Fränkel's speculum (Fig. 26) is preferred by some; Morell Mackenzie strongly recommended it. It is comfortable to the patient, easy to introduce, and is self-retaining. It has