CHAPTER XVII. EPISTAXIS-HYDRORRHOEA NASALIS. EPISTAXIS-NOSEBLEED. 125. Bleeding from the nose may depend on various intranasal lesions or different systemic disturbances. As a matter of convenient reference it is well to summarize these different conditions under one head. The loss of blood from the nose may vary from a mere trifle to a flow alarming by its persistence. Yet there are probably no immediate fatal results on record, as the hemorrhage usually stops in the end by reason of fainting. The frequent recurrence of bleeding may, however, cause serious anemia and lessen the resisting power to other diseases. The most common lesion causing nosebleed is ulceration of the septum in the anterior inferior region immediately behind the pyriform aperture, the ulceration being the intermediate stage between anterior dry rhinitis and perforating ulcer (75). If the health is otherwise good, the bleeding from this lesion is generally not copious. When the bleeding spot can be seen, the hemorrhage can be checked by cauterization with a bead of nitrate of silver or a cotton pledget containing (melted) trichloracetic acid. The galvanocautery presents no advantage over chemical cauterization. Either measure may fail for the time being and packing may prove necessary. A comparatively rare lesion, but one which bleeds. freely, is the "bleeding polypus of the septum" (¶ 237). Its site is above the usual location of the septum ulcer. It appears as a small, red polypoid tumor, bleeding freely on touch. If well accessible, it should be snared radically, otherwise its base should be completely cut through with the galvanocaustic burner. Very copious bleeding can be caused by intranasal tumors which are partly made up of cavernous tissue. This applies to benign polypi, suspicious adenomatous tumors, as well as to malignant cancers. Excessive hemorrhage may also be due to an unmixed angiomatous growth. Postnasal fibromata are likewise very prone to bleed freely, more, however, into the pharynx than through the nose. Slight nosebleed occurs to some extent in children with enlarged pharyngeal tonsil. Transient bleeding may be caused by a blow, usually without lasting lesion. Any nasal operation may be followed by secondary bleeding within the first few days. Sudden diminution of air pressure in ascending high mountains starts bleeding from the nose in many persons. Nosebleed with or without visible septal lesion may depend on various systemic conditions. After typhoid fever, in the course of grave anemia, but especially in any form of pernicious anemia, as well as in leukocythemia, it may prove difficult to manage. In scurvy and hemophilia it is more likely trivial if spontaneous, but if traumatic in a bleeder, it gives cause for anxiety. Nosebleed is an early symptom in typhoid fever, less so in measles and scarlatina, in which latter case it is said. to be indicative of severe infection. In middle or advanced life epistaxis may indicate arteriosclerosis and thus prove a forerunner of cerebral softening. The nosebleed referable to the climacteric period in women is probably also dependent on some change in the blood-vessels. Hemorrhage from the nose, vicarious for suppressed menstruation, is occasionally observed, but its frequency has been exaggerated. If epistaxis occurs with symptoms of nasal inflammation, fibrinous rhinitis or nasal diphtheria should be thought of. 126. In any ordinary case of nosebleed the patient should be instructed to sit up, or, better still, stand up, in order to lower the blood pressure and to plug the nostrils. with cotton. Wiping and other useless meddling merely protracts the bleeding. The popular practice of placing anything cold (for instance, a key) on the nape of the neck probably causes reflex action of the vasomotor nerves and is not without some utility. Severe bleeding requires surgical plugging with gauze (or cotton in case of emergency). Slight bleeding is easily controlled by the use of suprarenal solution on cotton. But there has not been enough experience with this agent to state definitely whether it can be relied upon in grave cases and whether it checks hemorrhage permanently. Pledgets wet with antipyrin solution (10 per cent.) often act quicker than mere mechanical plugging, especially if the pledgets are dusted with tannin powder. The latter alone, however, is not of much use. In dangerous cases Monsell's solution of iron is certain in its action, but very disagreeable by reason of the firm clot which it produces. Whenever the blood flows into the pharynx in spite of nasal plugging, a tampon must be placed in the nasopharynx by means of Belloc's sound (or by aid of a rubber drainagetube pushed through the nose) (¶ 29). In all instances the lesion causing the bleeding should be looked for as soon as practicable and treated. 127. Nasal hydrorrhea (or rhinorrhea), a discharge of a clear watery fluid from the nose, is a symptom of variable significance. It is most frequently seen in connection with sneezing fits in nasal irritability. This may depend in some instances on abnormal turgescence of cavernous tissue in neurotic subjects (vasomotor coryza), while in others it is due to the presence of polypi. In cases of this nature the hydrorrhea occurs as a spell of short duration. In less common instances the watery discharge lasts longer and is very profuse. Within less than an hour many handkerchiefs may be saturated. Much less common is a continuous discharge lasting day and night. Its cause can usually not be determined. A few times it has been seen in connection with disease of the fifth nerve, either neuralgia or paraly sis. In some instances the internal use of atropin has proved of service. In other instances the fluid dropping from the nose is cerebrospinal fluid. This diagnosis is favored by finding in it chemically a substance reducing Fehling's (copper sulphate) solution like sugar. An. escape of cerebrospinal fluid may occur as the result of a fracture of the base of the skull. A few fatal cases have been reported in which a continuous flow of clear fluid from the nose accompanied atrophy of the optic nerves with pronounced contraction of the visual fields and with the presence of other cerebral symptoms (headache and vertigo). The autopsies showed a perforation of the roof of the sphenoid sinus due to tumors of the hypophysis cerebri or other basal tumors or hydrocephalus. CHAPTER XVIII. ANATOMY OF THE TONSILS. ACUTE INFLAMMA- (ANGINA). 128. Anatomy of the Adenoid Tissue and Tonsils. -The shape and topographic anatomy of the pharynx have been described in Chap. I., ¶ 6, and Chap. III., 24, the structure of its lining membrane in Chap. I., ¶ The faucial tonsils form' a slightly prominent cushion in the space bounded by the anterior and posterior pillars. The pillars themselves are projecting folds of mucous membrane, practically the downward prolongation of the free border of the soft palate extending down to the tongue. Above each tonsil and underneath the superior junction of the two pillars is a recess, sometimes a deep pocket-the supratonsillar sinus. The tonsil itself is a thickening of the mucous membrane due to the develop |