ing may be so intense that nothing can be made out. Of course, such extreme swelling is by itself highly suspicious of fracture of the bridge of the nose. If the fracture is complicated by tearing of the mucous surface, gaseous distention-emphysema of the face-may happen when the patient sneezes. The interior of the nose should be promptly examined whenever the bridge is broken. A fracture of the septum involves always the cartilaginous part. The ethmoid perpendicular plate will break only from intense violence; the vomer, never. The line of fracture is usually nearly horizontal, rarely vertical, sometimes multiple. As a rule, the fracture is a simple one with intact mucous membrane. The fragments of

the septum may override more or less. There may also be dislocation and lateral.displacement of the cartilaginous plate at its junction with the vomer. Occasionally a fracture of the nasal bones causes only bending, but no fracture of the septum. In the bony septum the reunion is ultimately due to callus, while the cartilaginous fragments are merely joined by connective tissue. Unless a broken septum heals with accurate adaptation of the fragments, there will always remain more or less nasal obstruction. Fracture of the nasal bones leaves flattening of the bridge of the nose proportionate to the dislocation of the fragments. Not infrequently disfiguring asymmetry of the external nose results from a break of the bridge and septum.

When the patient is seen before firm union of the fractured bones has taken place, every effort should be made to restore the plane of the septum and the shape of the external nose. Immediate firm tamponing of the nasal passages with gauze has, on the whole, given the best results. The bridge should be lifted from the interior with the largest rod or thickest probes, which can be introduced and the septum straightened in the same manner. Broad forceps, especially the Asch pattern, used in the operation for deflected septum (Fig. 66), may aid in reducing the dislocation of the septal fragments. Narco

sis should be used if necessary. The nasal passages should then be firmly packed with gauze on both sides, necessitating, of course, mouth-breathing. After a few days the Asch or Meyer rubber tube (119) may be substituted for the gauze in the lower part of the passage. If the comminution and impaction of the bridge of the nose are such that the normal shape cannot be restored by manipulation, the tendency of modern surgery is to reach the fragments by an external incision-of course, under asepsis and to retain them in place, if necessary by wiring. In the interior no incisions are ever required. When a faulty union has begun, it is better to await the final (partial) absorption of the callus than to refracture at the time. The later appearances of a fractured septum have been described in ¶ 116.

257. Cicatricial changes after ulceration may interfere with the function of the pharynx to a variable, sometimes an extreme extent. The most common lesion is adhesion of one or even both posterior pillars to the posterior wall, possibly to an extent separating practically the nasopharynx from the oral pharynx. In other instances the anterior pillars may be so contracted that the palate cannot reach the posterior wall. Scars in the region of the lingual tonsil may narrow the fauces. A variable part of the palate may, besides, have been lost, which, however, is not so common as a mere perforation. Narrowing of the pharynx by cicatricial changes in the posterior wall is less common. In the nasopharynx there may be adhesions between the Eustachian prominence and the posterior wall, bridging over or obliterating the fossa of Rosenmüller. The two Eustachian orifices have been seen united by a transverse bridge.

The most frequent cause of pharyngeal shrinkage is said to be scleroma in those countries where it is prevalent, especially Poland. With us, tertiary syphilis ranks first. Tuberculosis is rare and heals even less frequently. Diphtheria can do much damage in exceptional instances of deep ulceration. Shrinkage from swallowing

The disturbances may be

caustics is very uncommon. insignificant in case of moderate deformity, especially after the patient has become accustomed to the annoyance, or they may be extreme and of vital importance. Partial or total shutting-off of the nasopharynx gives the voice a nasal twang and enforces mouth-breathing. If suppuration is started, it persists practically incurable until the patency of the postnasal space is restored. The ears may suffer from persistent exudative catarrh or suppurative otitis. Swallowing is made difficult by any constriction of the fauces or pharynx. In extreme cases starvation threatens. Even breathing may be interfered with to an extent requiring tracheotomy, although this is very exceptional unless the cicatricial shrinkage involves the larynx.

Cicatricial adhesions cannot be prevented during the healing of ulcers spreading over opposed surfaces. It is, of course, worse in neglected cases on account of the extent of the ulceration. The treatment which gives the most and immediate relief is the division of any folds of mucous membrane-for instance, the pillars, which are made tense by the shrinkage without being involved in the cicatrix. When space can be gained by such liberating incisions in healthy tissue, the problem is an easy one. In all other cases treatment is tedious and often unsatisfactory. The division of adhering surfaces does not prevent their ultimate reunion. Plastic operations are rarely possible. Partial success can generally be obtained by persistent dilatation, at first with sponge-tents, later on by means of hard-rubber appliances, sometimes fastened to the teeth according to dental methods. Fuller details can be found in the larger treatises on diseases of the larynx.

CHAPTER XXIX.

INFLUENCE OF NASAL AND PHARYNGEAL AFFECTIONS UPON OTHER PARTS OF THE ORGANISM.

258. Affections of the nose and pharynx are not rarely the starting-point of disturbances in adjacent orgaus, or even distant parts of the body. The majority of cases of disease of the middle ear, various ocular troubles, some systemic disturbances, rare instances of pyogenic affections of the brain or its membranes, and quite often certain functional nervous derangements, can be traced etiologically to the upper air-passages. The routes through which nasal or pharyngeal anomalies may involve other organs can be summarized as

Extension of tumors;

Extension of infection;

Absorption of poisonous products;

Mechanical influences partly exerted through the blood and lymph circulation, partly through impeded breathing;

Nervous or so-called reflex disturbances.

In some of the cases of distant disturbances the exact mode of origin is not entirely clear; in some others nasal anomalies exert their influence through several of the above-mentioned routes. For most purposes, however, this analysis of morbid influences suffices for an understanding of the pathogenesis.

259. Tumors originating in the nasal passages or accessory sinuses may invade the orbits or extend through the ethmoid or sphenoid bone into the cranial cavity. This is true as well of malignant carcinoma and sarcoma as of benign but encroaching vascular tumors and fibromata. There is, however, not a large number of such occurrences on record.

260. The most frequent mode in which nasal affections involve other organs is by extension of infection.

This is quite rare in an ordinary uncomplicated coryza, rather more likely in the acute rhinitis of influenza or measles, but especially so when a purulent process occurs in nostrils previously stenotic. Less of a menace to the ear, but more so to the orbit and brain, are affections of the sinuses. It is not so much the continued chronic condition which is liable to extend as the subacute exacerbation when a fresh coryza is added. The organ most likely to suffer by extension of nasopharyngeal disease is the ear, in the form of purulent otitis or serous catarrh. The ear is endangered as much by pharyngeal inflammations, even though not suppurative, such as tonsillitis, pharyngitis, or diphtheria, as by purulent processes in the nose itself. Pharyngeal affections are all the more dangerous to the ear if the pharyngeal or faucial tonsils are permanently enlarged. Whether the common plastic form of middle-ear disease (dry catarrh) comes under the head of infection is not known. Acute inflammatory processes in the nose and pharynx are likely to extend likewise into the larynx and bronchial tubes, and if the disease becomes chronic in the upper air-passages, it is also likely to persist in the lower. is not positively known, however, that disease of the nose may directly lead to involvement of the lungs themselves, and various statements to this effect have not been adequately supported by proof. An occasional complication of chronic purulent disease of the nose is facial erysipelas, sometimes in recurring attacks.

It

Affections of the tear-passages are, as a rule, due to extension of nasal disease. This is true of hypertrophic inflammation causing stricture, as well as of purulent involvement of the tear-sac. Disease of the frontal sinus and of the ethmoid cells may invade the orbit, causing either a circumscribed abscess or a diffused phlegmon. The eye itself may suffer in the course of purulent rhinitis or affections of the sinuses. Acute