the great disadvantage that the blades are fenestrated, and consequently allow the vibrissae in the nasal vestibule to obstruct the view. Duplay's speculum is also much used. It consists of a bivalve, which is introduced closed, and opened by means of a screw attached to the side (Fig. 26). This speculum is comfortable to the patient, can be opened slowly to any desired extent, and is almost self-retaining. It is a little difficult to insert, and somewhat cumbersome. It is impossible to say which speculum is really the best; every specialist will prefer the one with which he is accustomed to work. Thudichum's and Lennox Browne's will be generally found the most convenient.

On introducing the speculum whilst the patient is sitting in the ordinary position, the most prominent object to be seen in the nose

is the globular anterior end of the inferior turbinate. It should be possible to see some distance down the inferior meatus, and between the inferior turbinate and the septum. When the turbinate is unduly large it is impossible to see into the inferior meatus at all; when it is small, or when the spongy tissue is temporarily collapsed, it may be possible to see the entire length of the inferior meatus, or even to obtain a view of the posterior wall of the naso-pharynx. By tilting the patient's head backwards, the middle meatus and the middle turbinate come into view; the superior turbinate can only be seen in exceptional circumstances. The colour and contour of the parts having been examined, a little cocaine and suprarenal extract solution should be applied; this acts as a strong astringent to the nasal mucous membrane, and enables the posterior parts of the nose to be more readily examined. Growths situated far back and other forms of obstruction hitherto concealed come readily into sight. This aid to rhino

scopy should never be omitted, but it is especially important when the nasal passages are unduly narrow or distorted.

The Nasal Probe. Probes for use in the nose should be made of soft flexible metal, blunt pointed and mounted upon handles inclined at an angle of 60 degrees (Fig. 27). They should always be used as an adjunct to anterior rhinoscopy. The attachments of growths, their mobility

and consistence can thus be determined. Masses partially concealed from view can often be rolled out from under the concavities of the turbinates. The probe is also useful in detecting foreign bodies, the presence of bare or necrosed bone, and the existence and extent of obstructions, adhesions, perforations of the septum, etc.

Median Rhinoscopy.

By anterior rhinoscopy it is possible to see the anterior end only of the middle turbinate and a small extent of the middle meatus. Attempts have been

made by Zaufal, Krämer and later by Killian, to overcome this deficiency and to explore more fully the middle and superior meatus of the nose by means of a longer speculum. This method of examination has been entitled median rhinoscopy. Killian's speculum is the best: it consists of two thin tapering blades which can be introduced closed and opened when in position (Fig. 28). The middle turbinate and the septum are anaesthetised, and the closed speculum introduced into the cleft between them. The middle turbinate being attached only by a thin lamina of bone to the outer wall of the nose, may be easily bent outwards as on a hinge, by gentle continued pressure. Thus, as the speculum is slowly opened, the turbinate is deflected until the superior meatus, the roof of the nose, and the anterior surface of the sphenoid are brought into view. In a similar way the speculum can be introduced under the middle turbinate into the middle meatus of the nose, and the orifices of the various accessory sinuses which

1 Münchener Medicin. Wochnschr., 1896, xliii. p. 768.

open in this region can be examined. The method has a limited application, but it is certainly useful under some circumstances. It is especially valuable as an aid to the diagnosis of suppuration in the posterior ethmoidal region and in the sphenoidal sinus. Posterior Rhinoscopy.

Posterior rhinoscopy is thus performed. A tongue depressor (the one shown in Fig. 29. will be found most convenient), is held in the left hand, and passed well back on to the centre of the tongue whilst the mouth is opened to about half its full extent. By raising the proximal end of the tongue depressor the base of the tongue is pressed downwards and forwards well away from the uvula. The patient's chin should be steadied and drawn forward by one of the fingers of the left hand. A strong light is now focussed on to the lower part of the posterior wall of the pharynx, and a small laryngeal mirror, a quarter to half an inch in diameter and inclined about 60° to 80° to its handle, is passed to one or other side of the uvula into the posterior part of the pharynx, care being taken not to touch the uvula or tongue. By turning the mirror in various directions all the structures in the post-nasal space can be seen one by one. The posterior ends of the septum and of the three turbinates, the cushions. and orifices of the Eustachian tubes,

FIG. 29.-LACK'S TONGUE DEPRESSOR.

the depression behind them known as Rosenmüller's fossa and the roof of the nasopharynx should be examined in regular order (Fig. 30). This method of c examination may be extremely easy or so difficult as to be almost impossible. The chief trouble arises from the tendency of the patient to raise the soft palate so as to bring it in contact with the posterior pharyngeal wall. To prevent this his attention should be distracted by conversation, or he should be directed to breathe gently through the nose or to hold the breath. Sometimes this object may be obtained by asking the patient to say the word "hang." By these manœuvres a view, if only a momentary one, can usually be obtained. The mirror should never be retained in position very long at a time; it should be removed on the first sign of retching, but may be introduced repeatedly. In a few cases the examination may be facilitated by spraying or painting the parts with cocaine, but this often increases the patient's

FIG. 30. THE POST-NASAL SPACE AS SEEN BY POSTERIOR RHINOSCOPY. a, uvula; b, inferior turbinate; c, middle turbinate; d, superior turbinate; e, septum;, Eustachian tube.

tendency to retch. Formerly a hook to draw the palate and uvula forward was much used as an aid to posterior rhinoscopy; but it is a clumsy instrument and rarely necessary. The best form is White's, which is retained automatically in position (Fig. 31). As a rule it is necessary to apply cocaine to the palate before using it, but in spite of this it frequently

excites violent reflex movements, and thus defeats the end in view. The retractor is chiefly of value when operating upon the post-nasal space, under guidance of the mirror.

Objects seen. As seen by posterior rhinoscopy, the posterior end of the septum is usually in the middle line, and presents a thin sharp edge with more or less symmetrical spindle shaped thickenings near its centre (Fig. 30). The inferior turbinates appear small, the middle turbinates comparatively large, and above these the small superior turbinates can be seen. The Eustachian cushion can be brought into view by rotating the mirror towards the side of the space. It forms a large reddish projection with a central yellowish-white depression, which denotes the orifice of the tube. The vault of the pharynx should be smooth, and the upper part of the · septum where it joins on to it seems to widen out into a triangular Should adenoid growths be present they may be recognised as a reddish mass occupying the vault of the pharynx, and their amount may be more or less accurately gauged by the extent to which they conceal the upper part of the septum and posterior choanae from view.

Digital Examination. Exploration with the finger is especially useful for the examination of the post-nasal space. When a view of this region is not readily obtainable, as in the case of young children, the finger may be used to ascertain the existence of adenoids, hypertrophies of the posterior ends of the turbinates, etc. The consistence and place of attachment of post-nasal tumours, or of a nasal polypus projecting posteriorly, should also be determined by this means. The finger is thus introduced. The surgeon stands behind and on the right side of the patient, passes his left arm round the patient's head, the thumb of the same hand presses in the mucous membrane of the cheek between the patient's teeth, while the fingers steady the lower jaw. The patient is directed to breathe slowly in and out, the right forefinger is passed back over the tongue until it comes in contact with the posterior wall of the pharynx to one side of the uvula; it is then quickly slipped up into the post-nasal space until the posterior edge of the nasal septum is felt. The tip of the finger should

be passed into the choana on either side, and then the back of the finger swept over the vault and posterior wall of the pharynx. If the examination be carried out gently and rapidly, as may easily be done with practice, little pain is produced; but the finger should never be retained long in position, as it always gives rise to a choking sensation and more or less discomfort. If these precautions be adopted, and if the mouth be kept open by pressing the thumb between the patient's teeth, whilst his head is fixed, there is no risk of the surgeon being bitten. Occasionally, when a general anaesthetic has been administered, the finger may be also introduced into the anterior nares to explore the ethmoidal region, to ascertain the existence of bare or broken-down bone, etc.

Other means of examination of the nose, such as transillumination of the cheek by means of an electric lamp placed in the mouth, will be described later (see Chap. XVIII.).

Transillumination should never be omitted when there is a mucopurulent or purulent discharge from the nose, or even when the patient merely complains of such symptoms, although no abnormal secretion can be seen. Quite recently a patient has been under my care complaining only of a bad smell in the nose, with slightly excessive discharge from one nostril. In spite of this, transillumination, which was carried out as a routine practice, revealed the fact that the cheek on the opposite side was darkened, and perforation of this antrum gave exit to much foetid discharge. This patient had been under treatment at various hospitals for over six months, and the cause of the parosmia had remained undiscovered. Another patient complained only of a bad smell in the nose, and yet antrum suppuration was also found. Such cases

illustrate in a striking manner the importance of carrying out transillumination as a routine measure.