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.

FIG. 29.-LACK'S TONGUE DEPRESSOR.

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, the depression behind them known as Rosenmüller's fossa and the roof of the naso-pharynx 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 manoeuvres 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 SERN BY POSTERIOR RHINOSCOPY. a, uvula; b, inferior turbinate; c, middle turbinate; d, superior turbinate; e, septum; f, 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

MAYER SMELTZER

FIG. 31.-WHITE'S PALATE RETRACTOR.

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 surface. 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.

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

results can follow.

MAYER & MELTZER

OZ.

DR

8 200

P

FIG. 32.-NASAL Cup.

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

MAVER & MELTZEA

LONDON

It will pass into out through the

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. the post-nasal space and will come 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. 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.

FIG. 34.

NASAL SYRINGE FOR PATIENT'S USE.

fluids may be forced

to employ force to

In

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 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,

and gives rise to more discomfort. The spray may, however, be used for the application of medicaments, such as cocaine. For the latter purpose an instrument giving a very fine spray is required: when used for cleansing purposes the coarser the spray the better.

For Children. In children who cannot be taught the method of "sniffing", fluids may be introduced into the nose with the nasal irrigator or with a teaspoon, but in most cases it is better to employ syringing, injecting the fluids with the greatest gentleness. In children even more than in adults the use of force is to be strongly deprecated.

Wool Mops. Small pledgets of wool applied with forceps or with