CHAPTER III. SOME GENERAL CONSIDERATIONS ON TREATMENT. Methods of Cleansing the Nose. Fluids may be introduced into the nose by sniffing them up or by means of the nasal irrigator, douche, syringe, or spray. The best method for cleansing purposes in ordinary cases is to sniff the lotion up through the nose from the palm of the hand, or from a small cup or glass, letting it pass into the throat and returning it by the mouth. The special cup shown in Fig. 32 is very convenient. This is the most pleasant and satisfactory method, and, though a little difficult at first, it can be easily practised after a few trials. It should be carried out before rather than after meals, as it may cause retching or even vomiting. About two ounces of fluid should be used each time, and the washing may be repeated once, twice, or more often daily. If performed with ordinary care, no ill FIG. 32.-NASAL CUP. results can follow. MAYER&MELTZER DR 16 Nasal Irrigators. If the above method is found inconvenient, the fluid may be introduced into the nose by means of a nasal irrigator (Fig. 33). This is a small, glass, bottle-shaped receptacle. It is filled with MAYER & MELTZER. FIG. 33.-NASAL IRRIGATOR. lotion, the finger or thumb applied to the opening at the end, and the nozzle inserted into the nostril; when the finger is removed the fluid flows gently into the nose. The lotion should then be drawn backwards into the throat and returned through the mouth. This method is easier than the previous one, and equally free from danger. Syringing. When it is necessary to inject fluids into the nose with some force, as when crusts have to be detached, the above methods are ineffective and syringing should be employed. A small rubber ball syringe with a blunt nozzle is the most convenient form (Fig. 34). The patient should stand with the head bent well forward over a receiver, and open and breathe through his mouth. The fluid should be injected along the inferior meatus, never toward the roof of the nose. It will pass into the post-nasal space and will come out through the mouth or down the other nostril. The fluid must be injected with care and in small quantities at a time, or it may be forced through the Eustachian tubes into the ears and set up acute otitis media. This is especially liable to occur if one nostril be narrowed and the fluid is injected down the wider one. In using the syringe there is always some danger that down the Eustachian tubes, but when it is necessary cleanse the nose-e.g. when tenacious crusts are present it is the best available method. MAYER & MELTZER LONDON FIG. 34. NASAL SYRINGE fluids may be forced to employ force to Nasal Douche. This apparatus is well known and frequently employed. Its use is, however, dangerous because of the continuous pressure with which fluid is injected. It is extremely liable to It is extremely liable to cause acute otitis, and as it has no advantage over the syringe its use should be entirely abandoned. Sprays. Nasal lotions may be applied by spraying, but this is never such an effective method of cleansing the nose as those above mentioned, MAVER & MELTZER FIG. 35.-GOTTSTEIN'S WOOL INTRODUCER. MATER & MELTZER LONDON FIG. 36.-WOOL CARRIER. and gives rise to more discomfort. The spray may, however, be used for the application of medicaments, such as cocaine. For the latter purpose nent giving a very fine spray is required: when used for cleansing coarser the spray the better. an in ren. In children who cannot be taught the method of ids may be introduced into the nose with the nasal irrigator aspoon, but in most cases it is better to employ syringing, ith the greatest gentleness. In children even more of force is to be strongly deprecated. ! pledgets of wool applied with forceps or with special wool carriers (Fig. 36) are extremely useful as an additional method of cleansing the nose. They are employed especially for detaching crusts, for which purpose they may with advantage be soaked in hydrogen peroxide solution. These mops are also necessary for cleansing the nose in cases of sinus suppuration and for removing blood during various operations. Packing the Nose. This is a most useful aid in cleansing the nose when there is unusual dryness of the mucous membrane, or when adherent crusts are present. The method was first advocated by Gottstein, who introduced a large roll of wool into the inferior meatus with a special screw introducer (Fig. 35). Gottstein's object was to irritate the mucous membrane and excite increased secretion. The method was painful, and it was difficult to get patients to carry it out. It is quite sufficient to pack the nose lightly either with wool, or, better still, with strips of gauze. If the air be excluded the nasal secretion will remain fluid as the formation of crusts is invariably the result of evaporation, and on removing the packing the nose may appear quite clean, or, if any fluid secretion be present, it may be easily cleansed by syringing. The value of this method will be again referred to when speaking of the treatment of ozaena (see Chap. X.). Nasal Lotions. Nasal lotions should be of about the same density as blood serum and should be used at, or just below, the body temperature. When simple cleansing is required and a large quantity of fluid is necessary ordinary salt solution (one drachm of sodium chloride to a pint of warm water) may be used. To this a few drops of sanitas or of liquid permanganate of potash may be added. All nasal lotions are improved by the addition of carbonate or sulphate of soda, as these salts dissolve or mix with the nasal mucus and make the lotions more effective (Wyatt Wingrave). One of the best lotions is Dobell's, or some modification of it. A useful formula is: Sodii Bicarb. Sodii Biborat. āā. gr. xv. Sacch. Alb. gr. xx. or Glycerin. m xxx. Add one tablespoonful to two ounces of warm water for use. Dobell's original solution was nearly twice this strength. This lotion is capable of various modifications. Thus the carbolic may be omitted when it seems too irritating; chloride of sodium may be added as a mild, or chloride of ammonium as a stronger stimulant; chlorate or iodide of potassium may be used in cases of unusual dryness of the mucous membrane. Astringents such as antipyrin, hazelin or the extract of hamamelis may also be added, but always in small doses as the nose is very intolerant of irritants. For other formulae see Appendix. The Use of Oils. Oily solutions may be applied to the nose with a suitable spray such as an atomizer, with a small camel's hair brush, or with the wool mops above described. The latter methods are preferable when it is desired to make the application to the anterior part of the nose only; if a more general application be required it is better to use an atomizer. The best basis for oily preparations consists of equal parts of almond (or olive) oil and paroleine (or fluid vaseline). To this basis may be added various medicaments such as eucalyptus oil (one part to 20 or 30), unguentum hydrargyri nitratis (one part in 10), morphinae sulphatis (2 to 4 grains to the ounce), menthol (5 to 15 grains to the ounce) etc., as circumstances require. As the result of experiments made for me it was found that an ointment such as the ung. hydrarg. nitrat. formed a more stable mixture with this basis than with either almond oil or fluid vaseline used separately. This mixture should be used as the basis of most ointments for nasal use, as it is sufficiently fluid to be applied as above directed. a great advantage to make them simple lanolin may be used with advantage. In special circumstances The Steam Inhalations. Hot medicated employed in nasal diseases, but are useful in some acute conditions. steam inhalations are rarely water should be of a temperature of about 140° F. and the steam should be inhaled through the nose for 5 to 6 minutes two or three times a day. The patient should remain in one room at an equable temperature while this treatment is being carried out; otherwise he runs a risk of catching cold. One of the best inhalations in nasal diseases is menthol which may be prepared by adding one teaspoonful of a five to ten per cent. solution of menthol in rectified spirit to a pint of hot water (130° F.). Tincture of benzoin (one drachm to a pint) may also be used. formulae see Appendix. For other NASAL OPERATIONS. A large number of operations upon the nose come under the heading of minor surgery, and can be performed under local anaesthesia. has perhaps been a tendency in late years to operate somewhat too There freely; in many conditions relief may be obtained operative than by other methods of local treatment, and it is to be feared more quickly by also that many trivial abnormalities which produced no definite symptoms have been operated upon by enthusiasts. Therefore it is well to bear in mind that there are certain risks attached even to slight operations. The chief dangers attending nasal operations are, shock, haemorrhage, sepsis, and the toxic effects of cocaine or other anaesthetics. results the most important is permanent injury to the mucous membrane Of late with more or less impairment of the nasal functions. All nasal operations are apt to be accompanied by a certain amount of shock, which may prove dangerous in the old and infirm. Occasionally even slight operations in the upper part of the nose seem to be attended with considerable shock. Nasal operations are often followed by serious loss of blood. For this reason they are dangerous in the young and in the aged; and should never be performed, when from any local or general cause there is special reason to fear haemorrhage. Thus operations on the nose should be avoided during pregnancy, during the menstrual periods, and when the patient suffers from any of the general haemorrhagic conditions such as haemophilia, purpura, etc. Sepsis after nasal operations cannot be altogether avoided. It may show itself as a purulent rhinitis which may spread into one of the accessory cavities and produce sinus suppuration, or spread back through the post-nasal space into the Eustachian tubes and set up acute otitis media. A septic follicular tonsillitis is also frequently seen. The more severe nasal operations, especially those performed under general anaesthesia, may be followed by septic pneumonia or bronchitis. Even slight operations in the upper part of the nose, such as the application of the galvano-cautery to the middle turbinate, or the simple removal of a nasal polypus with a snare, have been followed by septic venous thrombosis, and fatal meningitis. One observer, Rethi, has recorded four deaths, two following the application of the cautery, and two following the removal of polypi. The dangers arising from cocaine will shortly be pointed out. This drug must be used with especial care in the very old and in the young; besides which, it must be remembered that some patients are peculiarly susceptible to cocaine poisoning. In children the nasal passages are very narrow, operations are difficult to carry out, and are liable to be followed by synechiae. It is probable also that they may interfere with the proper development of the parts. Another untoward but fortunately very rare result of nasal operations is optic atrophy and blindness. Packard records a case of total amaurosis lasting 30 minutes after removal of the anterior end of the middle turbinate. Ziem, Lermoyez, and Rethi record similar cases, as well as more severe ones, in which permanent optic atrophy followed. Other cases are related by Killian, and one has been privately communicated to me. In most of these the operation was attended by excessive haemorrhage, and the optic atrophy was probably due to thrombosis of the ophthalmic vein. Still, considering the close relationship of the posterior ethmoidal region and the sphenoidal sinuses to the optic nerves, their occasional involvement in septic inflammations starting in this region would not seem improbable. Lastly, it must be borne in mind that the nasal mucous membrane has an important respiratory function, and that the destruction or removal of too much of it may be followed by disastrous consequences to the upper air passages, and to the general health. This applies chiefly to operations upon the inferior turbinate, the whole of which body should rarely if ever |