PRACTICAL CONSIDERATIONS: THE NASAL CAVITIES. 1419 



the alie and along the side of the nose, again dividing the bone. The flap thus 

 formed can be turned upward, after breaking the bridge of bone between the upper 

 ends of the two incisions, exposing the nasal fossa. 



The finger can be passed backward through the nostril far enough to meet the 

 finger of the other hand passed to the posterior nares through the mouth. 



The posterior nares can be examined by the rhinoscopic mirror or by the finger 

 introduced through the mouth. Posterior rhinoscopy, like laryngoscopy, is carried 

 out with difficulty, because the region of the naso-pharynx is sensitive and is intol- 

 erant of intrusion. In the act of swallowing, the epiglottis protects the larynx by 

 closing the laryngeal opening, and the soft palate rises against the posterior wall of 

 the pharynx, preventing regurgitation into the nose. When the rhinoscopic mirror 

 is used the same thing occurs, so that the view of the larynx and naso-pharynx is 

 shut of5. Considerable difficulty is sometimes experienced in training the patient to 

 overcome this tendency. The employment of the nasal douche is based upon the 

 same mechanism. When the stream of fluid passed through one nostril reaches the 

 posterior part of the nose, its progress toward the mouth is obstructed by the elev^ated 

 soft palate, and it therefore passes around the posterior edge of the septum and back 

 through the opposite nasal fossa. 



With the rhinoscopic mirror in good position, and the soft palate quiet, one 

 may see the posterior nares divided by the septum, the turbinated bones, and the 

 meati (especially the middle turbinate and the middle meatus), the roof of the naso- 

 pharynx and the orifices of the Eustachian tubes. The finger introduced through 

 the mouth can feel the same structures, and can recognize naso-pharyngeal adenoids, 

 tumors, or abscesses. 



The mucous membrane over the turbinates, owing to the presence of a rich 

 venous plexus, is one of the most vascular in the body, and resembles erectile tissue 

 (page 1968). This and the general vascularity of the nose partly explain the great 

 frequency of epistaxis. The excessive supply of blood to the mucosa may be (a) for 

 the purpose of enabling it to raise the temperature and add to the moisture of the 

 inspired air ; (d) to favor the activity of the numerous mucous glands, the free secre- 

 tion of which together with the action of the cilia of the epithelial cells is required to 

 remove the dust and the micro-organisms that are filtered from the air during inspi- 

 ration by the vibrissas and the cilia themselves ; (^) to endow it with sufficient vitality 

 to resist the pathogenic action of such micro-organisms. In spite of this defensive 

 quality, the constant exposure to atmospheric irritants often leads to congestions and 

 coryzas, w^hich if long continued and frequently repeated result in hypertrophy of 

 the mucous membrane. This may require removal by cauterization or excision to 

 relieve the consequent obstruction. The mucous membrane is somewhat less closely 

 attached to the septum than to the neighboring parts, and hence haematomata of the 

 septal submucosa are not infrequent after an injury to the nose. Such haematomata 

 are almost invariably infected and proceed to suppuration forming septal abscesses, 

 the constitutional symptoms (to.xaemia) of which may give rise to anxiety if their 

 local cause is overlooked. 



Epistaxis is common not only because of (a) this vascularity of the mucosa, but 

 also by reason of {d) the frequency of trauma to the nose ; the relation of its veins 

 (r) to the general venous current so that they may be congested in cardiac or in pul- 

 monary disease, or in straining, or in paroxysms of coughing, as in whooping cough ; 

 and (d) to the intracranial sinuses, so that nose-bleed may be a symptom of cerebral 

 congestion or tumor ; (e) the bleeding may be vicarious, as in cases of suppressed 

 menstruation (an illustration of the sexual relations of the nasal apparatus); (/) 

 it not uncommonly follows ulceration — simple, tuberculous or syphilitic — and in 

 obstinate cases such ulcers should always be sought for. 



The source of hemorrhage from the nose is most frequently in the anterior part, 

 particularly on the septum, and is then ordinarily controlled with ease. L^sually the 

 patient should be kept upright, with the head back, (not in the usual position lean- 

 ing over a basin, increasing the tension of the vessels of the neck and head) and 

 should be made to take deep breaths with the arms raised, thus fully expanding the 

 thorax and depleting the cervical veins and, indirectly, the facial and ophthalmic into 

 which the veins of the nose empty. If ordinary means fail, and this is more likely 



