Complete Text (Part 24)

1 -g „ - v .; ^18 i.2'3 0.53 .2 hn 1^.5 ^ |3|o|pgo » p P -o -rH -^ -p a 2 o cb — c» p ^ a ° "S rS 33 - -P ^ O ® 8 • m P « "pm C'5 r S'p o ^ o a . >» o o> 5 ^r <^ ,P P fill »!■!--§ =1^ S p 3-- a .s a t * £ r= o> I 6c o -3 g 5? a p a a § "S ; P cSq'J — c 3 ? 2 J— $ — . o '"5 3 fe "3 s cs y — "J .p a 3 ® S'.S 50 .2-b n .-S-S a S— «u _ rr - a: p if > 3 .2 3 3 y — s.2a 3 o 3 2 "3 3 ESS^oo Ct2 3 a a+2 S S H ■ «M P*' 51 13— Eye. 193 THE NOSE AND ITS DISEASES. ANATOMY OF THE NOSE. Describe the external nose. The external nose is made up of two portions — a bony and a cartilag- inous portion. It is covered externally by integument, internally by mucous membrane, and is supplied with muscles, blood-vessels, and nerves. Name the bones entering into its formation. The bones are the two nasal bones and the nasal processes of the superior maxillary. Name the cartilages. The cartilages are five in number : two upper, two lower lateral car- tilages, and the cartilage of the septum. These are held together by means of strong connective tissue, and by the action of muscles upon them the openings of the nose can be dilated or narrowed. Besides these, are also found smaller sesamoid cartilages. These are usually imbedded in a fibrous mass. Describe the integument of the external nose. The integument is rich in sebaceous glands, the contents of which form the well-known comedones. It extends inside the nose as far as the anterior end of the inferior turbinated bones, and at the entrances of the nares is covered, chiefly in men, with short, thick hairs. Describe the mucous membrane. The mucous membrane is continuous with the integument externally, and with that which lines the nasal fossae within. Name the muscles of the external nose. The muscles are the levator alas nasi, depressor alae nasi, levator alae nasi propr., and the m. apicis. These by their action dilate or make narrow the openings of the nose. Give the blood-supply. The blood-supply is furnished by the lateralis nasi from the facial, and 195 196 THE NOSE. the nasal artery of the septum from the superior coronary, which supplies the al;e and septum, the sides and dorsum being supplied also from the nasal branch of the ophthalmic and the infraorbital. What are the nerves? The nerves are branches from the facial, infraorbital, and infratrochlear, and from the nasal branch of the ophthalmic. How are the nasal cavities formed? By means of various bones which form an upper wall or roof, a lower wall or floor, and an internal and an external wall. How is the upper wall or roof formed ? It is formed anteriorly by both nasal bones (Fig. 76), in the middle by the ethmoidal cribriform plate, and posteriorly by the anterior wall of the sphenoidal sinus. How is the lower wall or floor formed? It is formed by the palatal processes of the superior maxillary, and by the horizontal plates of the palate-bones. The floor is smooth and some- what sloping posteriorly. How is the inner wall formed ? The inner wall is formed by the septum. Its osseous portion is formed by the vomer, by the vertical plate of the ethmoid, by the crista palatina and crista nasalis anter. ; the cartilaginous portion is formed by the car- tilago septi, which shows much variation in form. How is the external wall formed ? The external wall is formed by the superior maxillary, the perpendic- ular portion of the palate-bone, and the pterygoid process of the sphenoid. On the external wall are seen several openings which vary in size and form. The most important of these is called the hiatus semilunaris or bulla ethmoidalis. This leads into a funnel-shaped cavity, the infundib- ulum. The infundibulum in its anterior and upper part stands in con- nection with the frontal sinus, and in its lower and posterior portion with the maxillary sinus by means of the middle meatus and ostium maxillare. What structures are found on the lateral wall ? Describe them. The most important structures are the turbinated bodies. These are three in number — an inferior, a middle, and a superior. The inferior turbinated lies on the inner surface of the upper jaw. It is irregularly curved, and is covered with mucous membrane. On its surface are some- times seen depressions and grooves. The space lying between it and the floor of the nose and the septum is called the inferior turbinated space or meatus. Under the roof of this space — viz. the inferior turbinated body — is situated outwardly and anteriorly a small opening, the excretory opening of the tear-duet. The middle turbinated is a portion of the ANATOMY OF THE NOSE. , v / Fig. 76. 197 Vertical Section of Head, slightly diagrammatic : 1, superior turbinated bone ; 2, middle turbinated bone ; 3, lower turbinated bone ; 4, floor of nasal cavity ; 5, vestibule ; 6, sec- tion of hyoid bone ; 7, ventricular baud ; 8, vocal cord ; 9 and 23, section of thyroid car- tilage ; 10 and 24, section of cricoid cartilage ; 11, section of first tracheal ring ; 12, frontal sinus; 13, sphenoidal cells; 14, pharyngeal opening of Eustachian tube; 15, Rosen- miiller's groove; 16, velum palati; 17, tonsil; 18, epiglottis ; 19, adipose tissue behind tongue; 20, arytenoid cartilage; 21, tubercle of epiglottis; 22, section of arytenoid muscle (Seiler). 198 THE NOSE. ethmoid, and is situated higher and farther back than the inferior tur- binated. The space lying between it and the inferior turbinated body is called the middle turbinated space or meatus. The narrow space lying between it and the septum is called the rima olfactoria, which contains in its mucous membrane the endings of the olfactory nerve. In the middle turbinated space are situated the openings of the maxil- lary and frontal sinuses. The superior turbinated, also a portion of the ethmoid, is the smallest of the turbinated bones. The space between it and the middle turbinated is known as the superior turbinated space. The several openings of the ethmoidal cells are seen in this space. Be- tween the posterior ends of the middle and superior turbinated bodies is situated the foramen spheno-palatinum. Above the posterior portion of the superior turbinated is seen the entrance into the cavity of the sphenoid. Describe the mucous membrane of the nasal cavity. The mucous membrane is continuous anteriorly with the integument and posteriorly with the mucous membrane of the pharynx. It covers the septum, the turbinated bodies, and sinuses. In some places it is so Fig. Distribution of Nerves in the Nasal Passages (Dalton) : 1, olfactory bulb, with its nerve3 ; 2, nasal branch of the fifth pair; 3, sphenopalatine ganglion (Seiler). intimately connected with the periosteum that it is difficult to separate them. The mucous membrane in the upper portion, the regio olfacto- ria, has columnar epithelium. The lower portion, the regio respiratoria, has ciliated and columnar epithelium. It is rich in nerves, blood-vessels, and glands. RHINOSCOPY. 199 Name the nerves of the nasal cavity. The nerves are divided into three sets : the nerves of sensibility, nerves of secretion, and the nerve of smell (Fig. 77). The nerves of sensibility arise chiefly from the first and second branches of the trigeminus. The secretory nerves arise from the spheno -palatine ganglion. The nerve of smell is the olfactory nerve. Name the arteries of the nasal cavity. The arteries are the anterior and posterior ethmoidal, from the oph- thalmic, which supply the ethmoidal cells, frontal sinuses, and roof of the nose ; the spheno-palatine, from the internal maxillary, which sup- plies the mucous membrane covering the turbinated bones, the mea- tuses, and the septum ; and the alveolar branch of the internal maxil- lary, which supplies the lining membrane of the antrum. What are the veins? The veins accompany the arteries, and communicate with the facial and ophthalmic veins. One of these passes through the plate of the ethmoid and the foramen caecum into the longitudinal sinus. What are the physiological functions of the nose as an organ of respiration ? The inspired air is freed to some extent from dust, there is a certain proportion of moisture added to it, and it is also made warmer. RHINOSCOPY. What is rhinoscopy ? Rhinoscopy is the examination of the nasal cavities, and is divided into anterior and posterior rhinoscopy. What instruments are necessary for an examination of the nasal cavities? (1) A nasal speculum. Various specula have been recommended; those chiefly in use are Frankel's, Duplay's, Charriere's, Kramer's, and Bosworth's. (2) A head mirror. (3) Tongue-depressor (Tiirck). (4) A small rhinoscopic mirror. What is seen on an examination of the anterior nares ? On the inner side is seen the septum, which is red in color and which may be straight or deviated. On the outer side is seen a rod-like prom- inence, which is the inferior turbinated body. Between this, the floor of the nose, and the septum is a space, the inferior turbinated space. Above the inferior turbinated is seen the middle turbinated space. Then comes into view the middle turbinated, with the rima olfactoria lying between it and the septum. Sometimes the superior turbinated can be 200 THE NOSE. seen through the rirna olfactoria. The head, of course, must be tilted in different directions to bring into view the various structures. How is a posterior rhinoscopic examination made ? The tongue-depressor, held in the left hand, is introduced into the mouth and placed upon the dorsum of the tongue, depressing it as gently as possible. The small rhinoscopic mirror is then heated, and in- troduced with its reflecting surface upward, beneath and beyond the soft palate. If there be no obstacles present, a view of the posterior nares is then obtained. What is seen in a posterior rhinoscopic examination ? The parts visible are the posterior margins of the turbinated bodies (Fig. 78), the septum, the orifices of the Eustachian tubes, the grooves of Fig. 78. Rhinoscopic Image: 1, vomer or nasal septum; 2, floor of nose; 3. superior meatus; 4, middle meatus; 5, superior turbinated bone; 6, middle turbinated bone; 7, inferior turbinated bone; 8, pharyngeal orifice of Eustachian tube ; 9, upper portion of Rosen- miiller's groove ; 11, glandular tissue at the anterior portion of vault of pharynx ; 12, posterior surface of velum (Seiler). Rosenmiiller, the Eustachian prominences, and the vault of the pharynx, on which is seen Luschka's tonsil. What are the obstacles which prevent an examination of the posterior nares ? How are they overcome ? An irritable throat or irritability of the fauces. The palate often con- tracts on introduction of the mirror. To overcome this the patient should be directed to breathe quietly through his nose. The irritability of the parts may be overcome by brushing or spraying them with a 10 per cent, solution of cocaine. RHINOSCOPY. Fig. 79. 201 Sass's Atomizing Tubes. What other instruments are necessary for examination and treatment ? A sound made of silver to detect the consistency of the parts, as well as new growths and foreign bodies ; a cotton-applicator for the appli- Fig. 80. The Burgess Atomizer. 202 THE NOSE. cation of the various . solutions used in the treatment of nasal diseases ; a brush for application to the posterior * 1G- 8 nares and vault of the pharynx ; atom- izer, of which there are a number in use, for the application of medicaments in the form of spray : a hand-atomizer can be used or the condensed-spray appara- tus; powder-insufflators for the insuffla- tion of powders. (Figs. 79 and 80 show Reservoir Insufflator. forms of atomizers, while Fig. 81 sllOWS a powder-insufflator. ) INFLAMMATIONS OF THE NOSE. What is acute rhinitis? It is an acute inflammation of the nasal mucous membrane. What are the other names usually applied to it? Cold in the head, acute nasal catarrh, and coryza. What is the etiology of acute rhinitis? Exposure to cold, sudden changes of temperature, inhalation of dust and irritating vapors, such as the vapors of ammonia, chlorine, iodine, hydrochloric acid, etc. It often occurs in iodism, and is sometimes the result of sexual irritation. It is a constant complication of measles, and is often seen with scarlet fever, small-pox, and typhus. In some persons there is a predisposition to repeated attacks of acute rhinitis. What are the symptoms of acute rhinitis ? There may be prodromal symptoms preceding the outbreak, lasting several hours or days, such as a sense of fulness in the head, fatigue, and an indisposition to work. These are followed by a tickling sensation in the nose, sneezing, violent frontal headache, and increased secretion. These symptoms increase rapidly, the secretion becoming so profuse that the patient is forced to use his handkerchief continuously. The secre- tion is at first thin, watery, and irritating, owing to the presence of so- dium chloride and ammonia. The senses of taste and smell are dimin- ished or completely lost, respiration through the nose is difficult or wholly impossible, and the voice assumes a nasal tone. The inflammation may spread to the conjunctiva through the tear-duct, or to the ear through the Eustachian tubes. The discharge after two to three days becomes thicker, gelatinous, and muco-purulent, and finally becomes normal in character again. The obstruction in the nose gradually disappears and the senses of taste and smell return. The objective changes consist in more or less intense redness of the mucous membrane and swelling, which is chiefly diffuse, but more marked on the anterior and posterior margins of the inferior turbinated body. INFLAMMATIONS. 203 Erosions are sometimes seen. Besides these changes, the skin of the nose may appear red, shining, and swollen. The skin of the upper lip and entrance of the nares is often eroded, sometimes covered with an eczema or herpetic vesicles. Where there is complete obstruction of the nose the tongue is dry and fissured. The secretion contains innumerable des- quamated cylindrical and ciliated epithelial cells, white blood-corpuscles, and mucous cells. Occasionally red blood, blood-corpuscles, and bacteria are found. What is the course of the disease ? The course of the disease is from three to eight days ; in severe cases it may last fourteen days or even longer. The disease may become chronic or result in the development .of polypi. The complications that may arise are inflammations of the neighboring cavities, chiefly the frontal sinus ; occasionally empyema of these cavities may occur. Give the diagnosis. The diagnosis is, as a rule, easy, except where the prodromal symp- toms are so violent as to make one suspicious of a more serious affection — e. g. acute exanthemata. What is the prognosis? The prognosis is favorable. A fatal termination is seen only in the aged or in very young children. What is the treatment of acute rhinitis ? The treatment must be both prophylactic and abortive. In those predisposed to this affection an avoidance of the causes that lead to it is necessary. Those who work among chemicals must protect the mucous membrane by means of cotton tampons. Where it occurs as a symptom of iodism the administration of the iodide should at once be discontinued. To abort the disease many remedies have been recom- mended. _ A Dover's powder at bedtime, followed by a laxative in the morning, is useful. Hot foot-baths, diaphoretics, the Turkish bath, are all beneficial. The use of menthol in the form of spray is said to abort an acute coryza. It may be used in the following form : B. Menthol, gr. xv; Fl. albaline, |j.— M. Sig. To be used in the Kesson-Robbins albaline atomizer. The application of cocaine in a 3 per cent, to 10 per cent, solution is often effective, and relieves the very troublesome .symptom of obstruc- tion. Steam inhalations of tinct. benz. co., oil of tar, and eucalyptus often give relief. 204 THE NOSE. What is purulent nasal catarrh ? An acute inflammation in which the secretion is from the beginning purulent in character. What are the causes? The causes are specific and infectious in their nature. Infection of the nose with the secretion of gonorrhoea by means of the fingers or hand- kerchief is a frequent cause. It occurs in new-born infants. - It also occurs in the course of acute infectious diseases, chiefly measles, scarlet fever, diphtheria, variola, or as the result of the spreading of a puru- lent catarrh of the conjunctiva. What are the symptoms? From the beginning of the disease the secretion is purulent in character, and is foetid, cheesy-like, and may be tinged with blood. The skin covering the upper lip and entrances to the nostrils may be ex- coriated. The mucous membrane is swollen, reddened, and covered with superficial ulcers. What is the diagnosis ? The diagnosis rests upon determining one of the above causes. It may be confounded with diphtheria, syphilitic catarrh, and the catarrh produced by irritation from a foreign body. What is the prognosis? The prognosis is favorable ; only in infants is it serious. Various com- plications, such as purulent inflammation of the neighboring cavities, erysipelas of the face, etc., may arise. What is the treatment of purulent nasal catarrh? The most essential point in the treatment is the cleansing of the nose by means of the nasal douche. The disinfectants recommended are boric acid, carbolic acid, and resorcin, and insufflations of nitrate of silver, alum, iodoform, etc. In children and