be observed during deep sleep, it will be found that at each inspiration there is recession of the anterior triangles of the neck, of the supra-sternal and supra-clavicular fossae, of the lower part of the sternum and of the lower ribs. The more marked the nasal obstruction the deeper the sinking in of these regions. The effect of this in time becomes permanent. If the bones are strong there will probably be a depression in the lower. sternal region and around the chest near the insertion of the diaphragm.

If, on the other hand, the bones are soft,-and rickets from malnutrition is a common complication of adenoids in infants,-there will be flattening of the sides of the chest and the well-known " pigeon" breast. The association of "pigeon" breast with enlarged tonsils was pointed out long ago by Dupuytren. Of course adenoids were unknown at that time, and it is now well recognised that the "pigeon" breast is not due to the enlarged tonsils, which by themselves would produce little if any obstruction to respiration, but to the adenoids, which are almost invariably present when the tonsils are much enlarged. These deformities are among the most serious results of nasal obstruction. It can easily be understood

that, acting in association with the general ill-health and the constant catarrhs of the upper air passages, they render the patient susceptible to diseases of the chest.

(6) Symptoms of Reflex or Obscure Origin. Nocturnal Enuresis. It is generally recognised that nocturnal enuresis is often associated with adenoids or other form of nasal obstruction in children, and that the removal of the latter condition frequently effects a cure. Grönbech records 23 cases, of which 12 were cured at once and five were improved. The exact factors in the production of the enuresis are open to dispute. It is probably the result of the deficient oxygenation of the blood during sleep leading to mild asphyxia which, as is well known, produces contraction of the involuntary muscular fibres. But whatever the relationship may be the frequent association of nocturnal enuresis with nasal obstruction is undoubted. It is of course not the only cause. In many cases of enuresis there is no nasal obstruction, and even when the latter condition is present in a marked degree its removal may have no beneficial effect.

Laryngeal Spasm. If a child with severe nasal obstruction be observed during sleep it may sometimes be noted that as the snoring increases and becomes louder and louder a distinct laryngeal note is added to the stertor. It is probable that the partial asphyxia induces some laryngeal spasm. The stridor subsides immediately the child wakes and breathes through the mouth. Occasionally severe attacks of laryngeal spasm occur during sleep. These probably depend upon mild forms of laryngitis or so-called laryngitis stridulosa. Thus the nasal obstruction is only an indirect cause.2

Laryngismus Stridulus is primarily due to rickets or to some other cause of instability of the general nervous system, although it is possibly more frequent in children who suffer from nasal obstruction than in others.

3

Congenital Laryngeal Stridor was first ascribed to adenoids by Eustace Smith, whose views were at once contradicted by McBride. I have elsewhere, in association with Dr. Sutherland, demonstrated the pathology of this affection, and have shown that it depends upon a congenital deformity of the larynx and is in no way due to nasal obstruction. These views have been confirmed by John Thomson and Logan Turner.5

Hay Fever and Asthma may be met with in association with nasal obstruction, but their exact relationship is difficult to understand. Many cases of hay fever may undoubtedly be cured by removing the nasal obstruction, and the affection may recur when for any reason the

1 Archiv für Laryngol., 1895, ii. p. 214.

2 Lack, Journ. of Laryngol., 1898, xiii. p. 303, also Hutchison, Clinical Journal, 1903-4, xxiii. p. 361.

3 Lancet, 1898, i. p. 783.

Lanet, 1897, ii. p. 653, and Lancet, 1898, i. p. 894.

Brit. Med. Journal, 1900, ii. p. 1561.

obstruction returns. The same sequence of events may be observed in asthma. Thus I have seen a case in which the removal of adenoids completely relieved severe asthma until recurrence of the adenoids took place. A second operation again afforded complete relief until nasal obstruction returned as a result of hypertrophic rhinitis. A third time free nasal respiration was restored with complete relief to the asthma. Bosworth went so far as to ascribe all cases of asthma to nasal obstruction. This view cannot be accepted, although it seems certain that nasal obstruction may be an occasional factor. This important subject will be fully discussed later (see Chap. XIV.).

Cough. A persistent, dry, irritable, or barking cough unaccompanied by expectoration is a frequent symptom of adenoids or other form of nasal obstruction. The cough may recur every minute or so and be extremely annoying to the patient and to his friends. It has been ascribed to a reflex, but very probably it depends upon some. irritation of the pharynx or larynx as the result of mouth breathing. It is usually cured immediately the obstruction is removed.

Stammering. Stammering and stuttering are frequently seen in association with nasal obstruction from any cause, and are extremely difficult to cure until the obstruction is removed. The nasal condition is however only one of the factors in the production of the stammering, and removal of the obstruction alone will not effect a cure.

Epilepsy.. Epileptiform convulsions, in some cases SO severe as to simulate epilepsy, have been ascribed to nasal obstruction. These spasmodic attacks occur only during sleep and are undoubtedly due to partial asphyxia. True epilepsy may of course be associated with nasal obstruction, and it is quite probable that, owing to the beneficial effect upon the general health resulting from the removal of the adenoids or other obstruction, the epilepsy will be benefited, although the affections are entirely distinct and independent of each other. Some remarkable examples of this are upon record. Jousset1 records two cases cured by the removal of nasal obstruction due in one to a septal spur, in the other to hypertrophic rhinitis. Root reports a similar case, and Grosskopf cured a man with epilepsy of 16 months' duration by the removal of nasal polypi. Lennox Browne records two cases in which small doses of potassium bromide completely controlled the fits after removal of nasal obstruction, although larger doses had previously been given without effect. St Clair Thomson 5 records a cure of chronic epilepsy by the removal of adenoids. The fits ceased shortly after the operation, and had not recurred for three years (see also Chap. XXIV.).

1 Rev. Hebd. de Laryngol., 1902, xxii. p. 305.

2 New York Medical Journal, 1898, lxvii. p. 716.

3 Arch. für Laryngol., 1902, xiii. p. 140.

*Journal of Laryngology, 1900, xv. p. 661.
5 Practitioner, 1905, lxxiv. p. 630.

Chorea is another of the nervous affections, cures of which have been reported by the removal of nasal obstruction. The affection has certainly no direct connection with nasal obstruction, and the benefit which is often obtained by nasal operation, may most probably be ascribed to the resulting improvement of the general health.

Deformities of Jaws and Teeth.

References.

TOMES. A System of Dental Surgery. London, 1873, pp. 117-239.
HOPMAN. Deutsch. med. Wochenschr., 1885, xi. p. 572.

SCHAUS. Archiv für klin. Chir., Bd. xxxv. p. 147.

ZIEM. Monatschr. für Ohrenheilk, 1888.

WATSON WILLIAMS. Journ. of Laryngol., 1897, xii. p. 74.

ESCAT. Archiv Internat. de Laryngol., 1896.

BLOCH. Die Path. u. Therap. der Mundathmung, 1889, pp. 66-68.

PARKER. Post-nasal Growths. London, 1894.

MAYO COLLIER. Lancet, 1895, ii. pp. 1170 and 1189, and 1902, ii. p. 1038. WALDOW. Archiv für Laryngol., 1895, iii. p. 233.

GLEITSMANN. Journ. of Laryngol., 1897, xii. p. 357.

SIEBENMANN.

Münchener med. Wochenschr., 1897, xliv. p. 983.

GROSSHEINTZ. Archiv für Laryngol., 1898, viii. p. 395.

HAAG. Archiv für Laryngol., 1899, ix. p. 1.

ALKAN. Archiv für Larnygol., 1900, x. p. 441.

LANE and discussion. Brit. Med. Journ., 1902, ii. pp. 687 and 692.
BARTH. Archiv für Laryngol., 1903, xiv. p. 89.

BENTZEN. Archiv für Laryngol., 1903, xiv. p. 203.

BUSER. Archiv für Laryngol., 1904, xv. p. 503.

SWAIN.

Boston Med. and Surg. Journ., 1904, cli. p. 273.

LACK and discussion. Proc. Laryngol. Soc. of London, 1905, April.
KÖRNER. Zeitschr. für Ohrenheilk, 1891, xxi. p. 116.
Löwy. Berlin. klin. Woch., 1886, p. 816.

CHAPTER V.

GENERAL CONSIDERATION OF SOME SYMPTOMS OF
NASAL DISEASE.

Alterations in the nasal secretion-Cerebro-spinal Rhinorrhoea—Rhinitis Caseosa-Collapse of the Alae Nasi and its treatment-Epistaxis, its varieties, etiology and treatment-Headache and Neuralgia-Influence of nasal disease on the adjacent organs, Pharynx, Ears, Larynx, Lungs, Eyes, etc.-Anosmia, its varieties, etiology and treatment— Parosmia-Hyperosmia.

APART from local symptoms, diseases of the nose may produce far-reaching effects on other organs and on the general health and development of the whole body. In view of their importance these effects demand somewhat detailed consideration. Other symptoms require discussion as to their etiology and treatment quite apart from the diseases which cause them. Again, some symptoms only remotely suggest their origin in a nasal affection, and thus their true cause is in danger of being overlooked. For these reasons, and also to save repetition, it seems advisable to consider in a general way some of the more prominent symptoms of nasal diseases.

ALTERATIONS IN THE NASAL SECRETION.

The nasal secretion in disease may be altered in character or in amount. In health whilst pure air is breathed the secretion is almost unnoticeable: the little that forms is swept by ciliary movement backwards towards the post-nasal space and swallowed. If the secretion becomes

deficient the nasal mucosa is often covered with mucous crusts and dust deposited from the inspired air. This condition is met with in rhinitis sicca, and occasionally in hypertrophic rhinitis. It may also be produced by the too free use of the galvano-cautery, or follow operations on the turbinates or septum in which much mucous membrane has been removed.

Much more commonly the nasal discharge in disease is increased. It may be clear and watery, as in the early stages of an acute cold, in