middle turbinate and passing along its free edge and the corresponding part of the septum. By posterior rhinoscopy the posterior and upper border of the middle and superior turbinates and the roof of the postnasal space were seen covered with dust. The path of the expired air was observed by making the patient, while under observation, exhale ordinary tobacco smoke through the nose. The smoke was seen to pass along the inferior meatus, and in a less degree along the lower part of the middle meatus. This last observation differs from the results obtained by experiments on the dead body, in which the path of the expired air was shown to be similar to that of the inspiration, but to extend less high into the nose. Parker's experiment is probably correct, for if a small piece of wool be placed in the middle meatus, there is great difficulty in expelling it by blowing the nose, but it can quite easily be blown out if placed in the inferior meatus. The same holds true of the nasal secretion which naturally tends to accumulate in the inferior meatus. The experiments on models show that in addition to the main stream of air, one or more whorls are formed, chiefly in the lower part of the nose (Fig. 21). The best model to demonstrate the air currents is obtained by splitting a skull, removing the nasal septum, and replacing it by a glass plate. The nasal passages are blackened, and tobacco smoke is passed through the nose by the aid of an ordinary air pump. The smoke shows up well against the blackened surface. Experiments have been carried out to test the air pressure in the nose in normal respiration. Franke showed that the negative pressure of inspiration was about six millimetres, and the positive pressure of expiration. about four millimetres in quiet breathing. The experiments of Goodale 1 and of Scanes Spicer practically agree with this. Owing to the very slight variations in pressure it is advisable to use a water instead of a mercury manometer. Olfactory Functions. The olfactory sense includes not only smell, but the greater part of what is popularly known as taste. This function is of much greater importance to the organism than is perhaps generally recognised. It not only lends much to the pleasures of life, to the appetite for, and enjoyment of, food, but acts as a sentinel placed at the very entrance of the respiratory and alimentary channels to give immediate warning of the approach of unhealthy foods and atmospheres. For the proper fulfilment of the function it is necessary that the special nerve cells and centres should be intact, that the mucous membrane of the nose should be slightly moist, and that the inspired air should have free access to the olfactory region. The Respiratory Functions of the nasal mucous membrane are extremely important. 1 Boston Medical and Surgical Journal, 1896, cxxxv. pp. 457 and 487. 2 Proceedings of the Laryngological Society of London, 1902, x. pp. 7 and 30. 1. The inspired air is warmed, being raised approximately to the body temperature. It is obvious that the large extent and the arrangement of the venus plexuses of the mucous membrane are peculiarly adapted to the fulfilment of this function. The importance and action of these plexuses may be best studied clinically. On examining the normal nose the inferior turbinate appears large, round and plump, but if a little cocaine or other astringent be applied, it soon presents a sharp thin edge, and the mucous membrane becomes pale and wrinkled. In health the turbinated bodies vary in size according to the atmospheric conditions. Thus they swell when cold air is breathed so as to provide a larger warm it, and they diminish in size when warmer air is inspired. blood supply to 2. The air is saturated with moisture. The fluid is probably secreted by the glands of the nose and, to a less extent, by those of the accessory cavities and by the superficial beaker cells in the mucous membrane. It may also be partly due to exudation through the small canaliculi in the basement membrane. These two functions, for which the convoluted surfaces render the nose specially adapted, save the other respiratory organs a great amount of work. When the functions of the nose are in abeyance there is a great tendency to a dry condition of the pharnyx, larynx, and trachea, and a liability to catarrh of these regions, and probably also to pulmonary diseases. 3. The air is purified from dust and micro-organisms. This function has been studied by Heymann, Kayser, Bloch, Aschenbrand, StClair Thomson, Hewlett, and others. Most observers agree that the interior of the nose and the mucus covering the nasal mucous membrane proper are usually sterile. Thus Thomson and Hewlett found the nasal mucosa sterile in 80 per cent. of their examinations, and only a few organisms were obtained in the remainder. What becomes of the organisms in the inspired air still remains doubtful. It is probable that some of them are arrested by the vibrissae, upon which numerous bacteria are always found, and that those which reach the interior of the nose are entangled in the thin layer of sticky mucus which everywhere covers the nasal mucous membrane, and, thus held, are swept away by the movements of the cilia of the epithelium. It is possible that the nasal mucus, or the serous exudation which exudes from the canaliculi of the basement membrane, possesses a certain amount of bactericidal action as Lermoyez suggested.1 At any rate, when living cultures of non-pathogenic organisms are introduced into the nose, they are found to disappear rapidly. The importance of the ciliated epithelium to the well-being of the nose and to the general health can hardly be over-estimated. The action of a single cilium is extremely slight, but the aggregate effect of the myriads 1 See also Piaget, Annales des Mal. de l'Oreille, etc., 1897, xxiii. p. 117. This observer finds nasal mucus bactericidal to some organisms. of cilia within the nose must be enormous. The whole of the nasal secretion with the dust, organisms, etc., which gain entrance to it, is ceaselessly swept back towards the naso-pharynx, and the secretion of the accessory cavities is also removed entirely by this agency. Ciliated epithelium is a highly specialised cell. Its functions are easily impaired. by catarrh, etc., and if it is destroyed, as by severe purulent catarrhs, by extensive operations or traumatism, its place will be taken by a lower form. of epithelium, either simple cubical or squamous cells. This is an important factor in the causation of that grave disorder known as atrophic rhinitis. The large vascular sinuses which form a peculiar feature of the nasal mucous membrane, together with the bulk of the secreting glands are collected in the inferior turbinate. These structures play the chief part in cleansing, warming and moistening the inspired air. When dust or any other irritating particles gain entrance into the nose, the vascular sinuses dilate, the secretion of the glands is increased, and abundant fluid is poured out to wash the irritant away. Similar physiological responses are constantly made to meet variations in the temperature or dryness of the air. It is most important, therefore, to respect the integrity of the inferior turbinates. Parts of them may often be removed without harm resulting, but as a rule, it is worse than useless to restore nasal breathing by removing the structure upon which the value of nasal respiration mainly depends. The upper air passages will suffer less from respiration. through the healthy mouth than from breathing through a the inferior turbinates have been removed. The following works may be consulted: On Anatomy of the nose generally. nose when ZUCKERKANDL. Normal u. path. Anat. der Nasenhöhle u. ihrer pneumatischen Anhänge. Wien, 1893. QUAIN'S ANATOMY. Arts. by Thane, vol. ii. part i. 1890, and Schäffer, vol. iii. part iii. 1894. LOGAN TURNER. The Accessory Sinuses of the Nose. Edinb. 1901. MIHALKOVICS. Heymann's Handbuch der Laryngol. u. Rhinol., Bd. iii., p. 1-86. Wien, 1899. HAJEK. Path. u. Therap. der entzündl. Erkrank. der Nebenhöhlen der BRAUNE AND CLASEN. Zeitschrift für Anat. u. Entwicklung, 1877, ii. p. 1. GRÜNWALD. Die Lehre von den Naseneiterungen, 2te Aufl., München, 1896. ONODI. The Anatomy of the Nasal Cavity (Trans. by StC. Thomson). London, 1895. CRYER. The Dental Cosmos, 1903, xlv. p. 841. COFFIN. (Development of the Sinuses) Amer. Journ. of Med. Science, 1905, cxxix. p. 297, and Journal of Laryngol., 1904, xix. p. 593. Antrum. DMOCHOWSKI. Archiv für Laryngol., 1895, iii. p. 255. Frontal Sinus. KICER. Laryngoscope, 1899, vi. p. 83. MAX SCHEIER. Archiv Internat. de Laryng., 1901, xiv. p. 321. 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, p. 307. HARMER. p. 163. XV. (Cells of middle turbinate) Archiv für Laryngol., 1902, xiii. 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. Chir Transactions, 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. 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 pos terior 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 |