The Nasal Septal Reflex

C. A. FRANCIS, London

There is extensive clinical evidence that, for a short time before, during,
and for a short time after an attack of bronchial asthma there are changes
in the systemic circulation due to disturbance of its vasomotor control.
Thus in asthma a chilliness of the extremities often occurs during the paroxysm
of dyspnoea, and this chilliness of, for instance, the hands, is a frequent
prodromal sign, occurring before any apparent dyspnoea occurs. Accompany-
ing the peripheral vasoconstriction, there is, during the attack of asthma,
undoubtedly a vasodilation of the small blood-vessels of the mucous membrane
of the bronchial tree. The congestion of the mucous membrane of the larger
bronchi during asthma has been frequently noted by bronchoscopists Che-
valier lackson and Ewart Martin.
I t is reasonable to assume that there is a similar congestion of the mucous
membrane of the smaller bronchi, narrowing their lumen and thus causing a
large part of the obstructive dyspnoea.
The vascular changes during asthma are widespread, and in severe and
prolonged paroxysms the coldness of the surface of the body, the hollow
cheeks and sunken eyes are signs of the extensive fluid depletion of the cuta-
neous tissues. These signs are quickly removed when the asthmatic paroxysm
is relieved.
I t follows that the fundamental factor to be considered in treating asthma
is an improvement in the vasomotor control of the circulation as a whole;
and it was indeed found in the two world wars that the regular physical
exercise of the man in the services, if graduated to the individuals capabilities,
so improved his vasomotor tone that the one time asthmatic could tolerate
with impunity the common causes of an attack of asthma such as changes in
temperature, cold winds and dampness, emotional upsets, fatigue, a cold in
the head, inhalation or ingestion of allergens, or that very common cause of
decreased vasomotor tone, lying down at night.
As regards the nose and throat in asthma, certain operations, such as
drainage of infected sinuses and resection of a deflected septum have in some
cases benefited asthma. On the other hand, radical operations on the sinuses
with removal of nasal polypi have, in aspirin sensitive asthmatics, not in-
frequently made the asthma worse.
The most beneficial effects of intra-nasal treatment can be obtained in
asthma when there is no intra-nasal abnormality. An extremely delicate
touch on the nasal septum with a fine galvano-cautery point, can, in the ma-
jority of cases of asthma, as also in vasomotor rhinitis and migraine, produce
a marked improvement in the symptoms, and if repeated a few times can
often produce complete relief from all symptoms for a considerable period,
sometimes for many years even in cases with a long history of persistent
asthma.
That extreme delicacy of application is essential was emphasized by
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Alexander Francis many years ago in his original publication in 1903, and

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this observation has been confirmed by experienced rhinologists such as
C. A. Parker, W. N. Robertson, Dan Mackenzie and recently R. Scott Steven-
son. In his Presidential address to the section of otorhinolaryngology of the
Australian Medical Association, W. N. Robertson spoke enthusiastically of
the results that could be obtained in asthma by the method under discussion.
That the effect produced by lightly cauterising the nasal septum is a
general systemic effect rather than a local one seems evident from a number
of clinical observations, for, apart from the effect produced on the asthma,
vasomotor rhinitis, migraine or other allergic condition, previously cold hands
and feet often become appreciably and persistently warmer. This effect is so
frequent as to rule out coincidence. In most cases the increase in warmth is
a gradual one extending over several weeks from the time that the septum
is first cauterised but occasionally the effect is dramatically sudden. A woman
of 75 whose left septum had just been very lightly touched with a galvano
cautery point for her vasomotor rhinitis cried out "my hands have become
warm". She then said that for many years past her hands had always been
icy cold, but that instantaneously with her septum being cauterised her hands
became warm. When seen again several weeks later there was no sign of
the Raynauds condition returning from which she had suffered for many
years. I have another case of Raynauds disease attending my Allergy
Clinic at present, and in her case also, her hands have become and remained
warm after three cauterisations of the septum. This case relapsed after her
first child was born, but has again recovere(after further cauterisation and
has now remained symptom free of Raynauds disease for two years.
A previously raised systolic blood-pressure will often come down as much
as 30 mm. Hg (provided that there is no albuminuria) immediately the septum
is cauterised, and the reduction often persists for several months.
The additional fact that in some cases the respiratory excursion becomes
freer, and previously existing rhonchi cease immediately the septum is touched
is further evidence that the effect on the asthma is entirely a reflex one and
is in no way connected with the removal of sensitive or asthmogenous areas
in the nose.
The late Professor W. E. Dixon, the Cambridge pharmacologist, considered,
mainly as the result of experimental work on cats, that the undoubted benefit
to many cases of asthma produced by cauterisation of the nasal septum, was
due to the removal of hypersensitive areas.
But the clinical observations I have described, which are easily verifiable
in many cases, seem to me to point to the effect being a reflex one on the nerve
endings in the septal mucosa and thence to the sympathetic system as a whole.
The technique of the method which I am discussing is comparatively
simple. I t consists in lightly painting, under inspection, a small area of the
nasal septum with a cotton wool tipped probe wrung out of 10% cocaine
solution. The part of the septum to be cauterised is not important. Apparently
any portion of the septal mucous membrane is suitable on which to obtain
the reflex effect but I usually choose that part of the septum immediately
anterior to the anterior margin of the middle turbinate. If however there is a
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marked septal deflection in this area an adjacent level portion should be

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selected. A second application of 10% cocaine solution should be made after
an interval of aminute and this gives ample anaesthesia. I t is quite unnecessary
to pack the nostril with wool or gauze soaked in cocaine solution. If, with the
cocainising as described, the subsequent cauterisation causes the least dis-
comfort, an incorrect technique has been employed. The cauterisation is
performed by introducing a fine cautery point into the nose, heating to a dull
red heat, then allowing it almost to cool and then, gently touching the surface
of the septal mucosa, drawing the cautery point downwards and forwards
for half an inch. I find it a great help to rest the shaft of the cautery point
against the side of the ring-finger of the left hand. An extremely superficial
burn should be made which on inspection resembles a fine silk thread.

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With the correct technique the moment of cauterisation is imperceptible
to the patient. If any slough is visible on the septum after an interval of a
week, the application has been considerably too heavy or the cautery point
too hot. Depending on the progress of the case, a second application can be
made a week later on the opposite side of the septum. Jf however there is
by then, as not infrequently happens, a considerable improvement in symp-
toms, the second application should be postponed until such time as the im-
provement ceases. Subsequent cauterisations depend on progress, but should
never be attempted when the patient has a cold, during a severe paroxysm
of asthma or after an interval of less than a week. The maximum benefit is
usually obtained after one to four treatments; but 13 % of cases require
6 or more treatments.
The systolic blood-pressure should be taken before and after each cauteris-
ation. Experience has shown that when there is an immediate reduction in
the systolic pressure of 10-30 mm. Hg., marked improvement in the asthma
usually results. It is also noteworthy that it is the extremely light touch on
the septum which results in a reduction in blood-pressure, whereas tlte deeper
wider burn has no such effect. If the first burn is not satisfactory, a second can
be done at the same sitting, on the same septum slightly above or below the
first burn.
The following diagram illustrates this point. The patient was a man of
35 with systolic blood-pressure of 140 mm. Hg. The first burn which was too
short, wide, and deep, produced no reduction of blood-pressure. The second
burn, done aminute later, being longer and more superficial, immediately
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reduced the blood-pressure to 125 mm. Hg.

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 Indications
The treatment is effective in asthma, hay fever, va so motor rhinitis and
migraine, and as there are no contraindications I employ it as a routine in all
such cases in hospital and private practice. It is, however, on the whole more
effective in asthma than in the other allergic conditions, and in hay fever it is
my experience less effective than specific pollen desensitisation, with which I
usually combine it, as I find that such patients then obtain relief from their
symptoms with a lower pollen dosage than would otherwise be needed.
The results are poor in those cases who give a history of aspirin sensitivity,
which is a sign of worse prognostic significance than the length of asthmatic
history or the severity and frequence of attacks. If the systolic blood-pressure
is normal or above normal, the pro gnosis is better than in cases with a sub-
normal blood-pressure. The prognosis in children is on the whole better than
in adults. The improvement in children is more gradual than in adults, but
a higher proportion of children than of adults eventually become symptom
free without relapse.
Resume
L'asthme est ramene a une defaillance du contröle des vasomoteurs, le
retrecissement bronchiolique a une vasodilatation. Une amelioration du con-
tröle des vasomoteurs constitue le facteur essentiel de tout traitement. Elle
est realisable par une cauterisation prudente dy. septum nasal. L'intervention
est suivie d'une baisse de la pression systolique, d'une amelioration de la
circulation generale et d'un accroissement de la resistance vis-a-vis des agents
asthmatogenes. Les criteres d'evaluation du pronostic sont exposes.

Zusammenfassung
Das Asthma wird auf ein Versagen der Vasomotorenkontrolle, die Ver-
engerung des Bronchiallumens auf eine Vasodilation zurückgeführt. Eine
Verbesserung der Vasomotorenkontrolle ist dementsprechend die Grundlage
jeder Behandlung. Das kann durch eine vorsichtige Kauterisierung des
Nasenseptums erreicht werden. Der Eingriff ist von einer Abnahme des
systolischen Druckes, einer Verbesserung der allgemeinen Zirkulation und
einer Resistenzsteigerung gegenüber asthmatogenen Faktoren gefolgt. Die
prognostischen Zeichen werden erläutert.

Bibliography
Dixon, W. E.: Practitioner 1929, CXXIII, 35. - Franeis, Alexander: Asthma in Relation
to the Nose, London 1903. - Franeis, Clement: Asthma, London 1950. - Jaekson, Chevalier:
Am. Journ. Dis. Children, XXXVII, 331, 1929. - McKenzie, Dan: Diseases of the Nose,
Throat and Ear, London, 1927, p.319. - Martin, Ewart: Edin. Med. Journ. XXXVI, 153,
1929; Journ. Laryngol. and Otol. XLVI, 256, 1931. - Parker, C. A.: The Nose and Throat
and their Treatment, London 1906. - Robertson, W. N.:Australasian Med. Gazette XXIV,
1,1906; Australasian Med. Gazette XXX, 637,1911. - Stevenson, R. Seott: The Ear, Nose and
Throat in the Services, 1943.
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Clement Francis, M.B., 75, Wimpole Street, London, W. I, England

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