CHAPTER III. SYMPTOMATOLOGY; METHODS OF EXAMINATION AND APPEARANCES OF NOSE AND PHARYNX ; METHODS OF TREATMENT IN NASAL AND PHARYNGEAL AFFECTIONS. 19. Subjective Symptoms.-Pain.-Most nasal diseases do not cause pain. Abscess of the septum and gummatous tumors under the periosteum may, however, give rise to severe suffering, the pain not being correctly localized, but described as headache. In neurasthenic persons various nasal diseases may be attended with much discomfort, especially in the form of diffuse headache, while neuralgia of the supra-orbital or infraorbital nerves, sometimes of great severity, can be caused by inflammation of the accessory sinuses. Acute inflammation of any of the structures in the pharynx is always painful, particularly during swallowing, and to a degree commensurate with the intensity of the disease. If the upper part of the faucial tonsil or the recess behind the posterior pillar of the fauces is involved, the pain is said to shoot into the ear. In chronic pharyngeal inflammations patients describe the sensation less as pain, but rather as an irritation or tickling. 20. The most common complaint of patients with nasal disease is obstruction of the nasal passage. This may be present at all times-if due to a structural narrowing of the nasal caliber-or transient, if caused by temporary distention of the vascular plexus in the mucous membrane or by the presence of viscid secretion. The stuffy feeling may be limited to one side of the nose or may exist on both, while if due to excessive vascularity, it often passes abruptly from one side to the other. Nasal obstruction is also very characteristic of any encroach ment upon the capacity of the vault of the pharynx by enlargement of the pharyngeal tonsil or by a retropharyngeal abscess, even if the nasal passages themselves are clear. This obstruction, too, is intensified when the vascularity is increased by the reclining position. Hence during sleep mouth-breathing occurs, even if nasal respiration is possible during waking hours. Whenever the tongue is arched during mouth-breathing so as to leave merely a narrow passage between itself and the soft palate, the current of air starts vibration of the soft palate and causes snoring. The patency of the nasal passages can be gauged objectively by the sound produced by breathing. The air passes through a normal nose both during inspiration and expiration without any sound whatever, except when a most forcible effort is made. In proportion to the narrowness of the passage breathing yields a rustling or whistling noise. In order to test one side at a time the other side of the nose must be closed with the thumb without pressure on the flexible septum. Interference with nasal respiration is also indicated by the nasal "twang" of the voice. The voice is not affected by a one-sided obstruction if the other side is entirely clear, but whenever both halves of the nose are narrowed, the normal resonance of speech is changed and the voice sounds "dead.” The most characteristic change in the voice is found with enlarged pharyngeal tonsil. 21. Nasal Secretions.-In the normal condition the nasal mucus is never secreted in sufficient quantity to require removal either by blowing the nose or by aspiration into the pharynx. Hence whenever there is any discharge from the nose it is an abnormal occurrence. The discharge is glairy, clear mucus if due to mechanical or chemical irritation of a non-inflamed inucous membrane, but more or less turbid, or pure pus, if caused by inflammation. The secretion from the rear third of the nasal passage is blown out only with difficulty, but either drops into the pharynx from time to time, or is drawn back by forcible inspiration. Discharge from the nasal sinuses may also drop into the throat under some circumstances, especially in the recumbent position. If scant nasal discharge dries in the form of crusts, the patients will sometimes remove them only at long intervals. If inspection does not satisfy the surgeon as to the kind or quantity of discharge, the douche can be used (see 25), whereupon any nasal secretion can be seen floating in the basin. Purulent nasal secretion has a pronounced odor only if pent up and decomposed or dried in the form of crusts. The two most characteristic odors are those of ozena and of syphilitic necrosis, which may enable an expert to make a diagnosis. Foul, too, but different is the odor in sinus suppuration with retained pus and in concretions. and foreign bodies. In any form of nasal obstruction with secretion the breath through the mouth is likely to be offensive, especially on awakening. 22. Sneezing is a normal reflex action whenever the nasal lining is irritated. It is a prominent symptom during acute nasal catarrh so long as the nose is not entirely occluded. In chronic nasal diseases sneezing, sometimes in uncontrollable fits, is an annoying feature in proportion to the "nervous" disposition of the patient. It occurs least whenever the mucous membrane is either much hypertrophied or atrophied. Coughing is not, as a rule, produced by nasal disease, but may accompany pharyngeal lesions, especially hypertrophy of the adenoid tissue at the root of the tongue. The cough of pharyngeal patients is, however, commonly due to extension of the disease into some of the structures of the larynx or to coexisting bronchitis. 23. Methods of Examination of the Nose. The objective examination begins with the external shape of the nose. A flattened bridge is often seen in patients with Decided sinking in of the bridge of the nose is due to cicatricial shrinkage of the septum, almost always ozena. the result of syphilis, either acquired or inherited. Deflection of the nose to one side indicates asymmetry of the septum, caused either by unequal growth or by an injury. On watching the alæ nasi during forcible inspiration it is to be noted whether they remain normally rigid or collapse and are drawn in with every breath, thereby indicating obstruction. In order to see the interior of the nose light must be thrown in. This is done with a concave mirror with a central perforation through which the surgeon looks. The mirror is held in the hand or is attached by means of a ball-and-socket joint to a strap around the forehead or to a metallic spring clasping the head. There are some handles made that may be held between the teeth. The source of light should be the strongest one available. Sunlight can be used advantageously, with a plane mirror in summer to avoid burning. The light from bright white clouds is perhaps the best of any. A blue sky gives an insufficient light. Of all artificial lights the Welsbach incandescent burner is the whitest, but any gas-jet, preferably an Argand burner, or a broad kerosene flame will answer. Of electric lights, one with spirally wound filament is the best. The various forms of condensers placed in the market offer no practical advantage over the naked flame. If artificial light is used, the eye is more sensitive when daylight is excluded by windowshades. A very convenient arrangement is an electric headlight, of which various forms are in the market (Fig. 11). A 6 or 8 candle-power miniature lamp inclosed within a tube with condenser lens is attached to the forehead just above the eye. This is connected by means of a flexible and easily detachable cord to the source of electricity. A street current of not over 110 volts is the most convenient source of energy if its intensity is suitably reduced by a proper resistance in the form of a walllamp furnished by the maker. An additional device found by the author to be useful is that of putting a resistance (a lamp of 210 ohms) into the same circuit as a (parallel) shunt, whereby the shock felt by the hand when the exposed metallic connectors are touched is reduced to a minimum. If no street current is available, resort must be had to a battery or a storage-cell, which requires attention and gives rise to some annoyance. FIG. 11. Electric head-light. With the electric head-lamp the observer is more at liberty to move his head than when he reflects the light by means of a mirror. It is rarely possible to see any distance into a nose. without separating the flexible walls of the vestibule by means of a speculum. Additional space is gained by raising the tip of the nose by upward pressure. A bivalve speculum (Fig. 12) can be handled with the least SHARP SMITH FIG. 12.-Pynchon's bivalve nasal speculum. annoyance to the patient, and, on account of the broadness of its blades and the control that the hand can exert over it, it permits the most satisfactory view. It has the disadvantage, however, of not being self-retaining, a requisite in most operations. Of the various spring specula, the author has found Goodwillie's (Fig. 13) and Palmer's |