There can be no question but that the sun gives the
clearest and purest light — more desirable for our purpose
than any other — provided we could have its benefit at
all times and in all places, could ward oflT the great heat
from the patient's head, which a lengthy examination
renders insupportable, and could stay his course for the
time, so as to abolish the necessity, both for patient and
^Professor Turck^s reflector, with spring-supporter, seemingly belonging here, will
be spoken of hereafter under caput << light.**
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LARYNGOSCOPY AND RHINOSCOPY. 19
doctor, for changing position every few minutes, for the
purpose of keeping pace with his constant progress.
Dependent then as we are upon the sun's favor, and
rarely — especially within our city walls — the recipients
of his benefactions, we are mostly, if not entirely,
obliged to rely upon artificial light in the application of
our art.
The simplest contrivance in this respect for our pur-
pose is the German student's lamp, or an Argand-gas
burner, where the luxury of gas is enjoyed. Of the
lamp and its position we have already spoken, which,
with the reflector is all that is needed to make illumi-
nation perfect.
Our description of the reflector (on page 17) would
be incomplete, did we not here introduce Prof. Tiirck's
simple, ingenious, and eminently practical combination
of both reflector and supporter.
With this reflector on the forehead, its position
capable of being changed in an instant, both hands of
the operator remain free to depress the tongue, to
apply caustic or other local remedies, or to perform
various operations. In cases of diptheria and scarlatina
especially, an examination can be made in a more tho-
rough manner, with less loss of time than in the ordinary
way, and without obliging the patient to raise the head
from the pillow. There being more or ess risk of inhal-
ing the patient's breath under such circumstances, and
of having some morbid secretions coughed into the
face, the physician is thus less exposed to infection
than otherwise.
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20 THE PRINCIPLES AND PRACTICE OF
Fig. 4.
Turck's Reflector supporttd by a Spring.
a. Steel-spring projecting at both ends, upholstered with Qannel and covered with
black silk.
b. A narrower, quite strong somewhat bent steel-spring, bearing considerable resis-
tance, inserted at right angles into spring a.
c. A round strong metal plate at the point of union, to the anterior side of which
is attached an elastic band with buckle, which serves as head band.
d. Square upholstered saddle, attached to the lower, broader extremity of the des-
cending spring, (b) which is to be placed at the apex of the nose.
e. Socket joint at the anterior surface of the saddle into which is inserted the ball
attached to the posterior surface of the reflector.
/. Screw to render the joint more or less firm, or to remove the mirror altogether.
g. Reflector of 3 J-4 inches diameter taken from Tiirck^s apparatus fcr illumination.
k. The handle can be used to change the position of the mirror.
This supporter will readily adapt itself to the fore-
head, is very light, and presses therefore, not uncom-
fortably upon the root of the nose, a great objection to
all similar contrivances.
Rotation is easily accomplished, and the reflector
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LARYNGOSCOPY AND RHINOSCOPY. 21
placed readily in the middle above the eyes, or replaced
before either of them.
To Professor Tiirck also belongs the credit of
having first used for illumination in laryngoscopic ex-
aminations the so-called Schuster-Kugel, (Shoemaker's
globe). Both globes and lenses have been used with-
out reflectors.
Mourds Pharyngoscope difl^ers from the above simply
in the fact, that a lens is substituted in the apparatus
for the glass globe.
A simple, compact apparatus appeared in France
some two years ago, but not generally in use, in which
a metallic reflector is placed posteriorly to the light,
and a bull's-eye lens or condensor anteriorly to the
same, giving a good volume of light, besides being
easily managed.
By fastening a second mirror to the bull's-eye lens, the
apparatus answers perfectly for auto-laryngoscopic pur-
poses. I n examinations at the bedside, where gas is not to
be had, we are able, if we can obtain simply a candle or
a common lamp, to accomplish all we desire with it.
To speak of all the instruments which have been con-
structed to direct and intensify the volume of ligni
such as Czermak's, Lewin's, Von Bruns', Winterich's,
and those of several others not less active experimen-
ters, would occupy too much space. We shall only
describe two, those of Tiirck and Tobold, which are
in daily requisition in our operating room, the practi-
cal merits of which in daily use for a long time, we
have fully learned to appreciate above all others that
have been tried from time to time by us.
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Fig. 5.
Olsten the
sund made
which may
crcd accord-
n, or to at-
to the back
^ and and
tubes of
«cd in c and
>ed or short-
: to desire,
ut through
ifined with-
ible.
the prisma.
flat joint
For the at-
magnifying
I and socket
attach the
ipring sup-
icle with a
eception of
TiiRCK's Independent Apparatus for iUumi- [^J ."tdbV^m^r
nation. reflector.
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LARYNGOSCOPY AND RHINOSCOPY. 23
The same apparatus is also manufactured with three
brass tubes fitting into one another, instead of only
two, as in the accompanying drawing. This is called
the large apparatus ; both from the fact that the brass
tubes fit into one another, are very compact, and the
reflector being separated, the whole is easily packed and
carried about.
Modus Operandi. — The Lamp and its position.
Any lamp, from a study to a common house lamp,
answers the purpose, provided the flame be white, which
can be regulated through a glass-chimney of proper
dimension and sufficient draught.^'
The lamp is to be placed behind, and on the right
of the patient's head, who is seated on a chair. Its
flame ought to be about an equal distance behind the
ear, as the latter is distant from the angle of the mouth.
This may serve as a rule when the concave mirror — the
reflector used, — is 6i inches in diameter. In proportion
as the diameter of the reflector is increased the lamp
must be moved further back.
The apparatus itself is in front of the patient and to
his right. In the absence of a special stand it can be
screwed to the back of a chair, upon which a person is
seated to steady the same. The operator seated in
front of the patient, adjusts now witfa his left hand the
brass tubes to the required height, — the prisma remain-
ing undisturbed, turns the concave mirror by careful
rotations towards the lamp and directs the concentrated
* Cusco in Paris, 1861, increased intensity of light, by incorporating Oxygen gas
with the flame of a common lamp.
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24 THE PRINCIPLES AND PRACTICE OF
rays of light into the cavity of the mouth to illumine
the palate and uvula.
A few well directed motions of the reflector, executed
immediately after the laryngeal mirror is introduced,
will afford a perfect view of the parts to be examined.
It is but just to state, in this connection, that to
acquire the dexterity to examine patients promptly and
accurately with this apparatus, demands more than ordi-
nary application and tact, as compared with the inven-
tions of other observers ; but once the difficulty over-
come, and the left hand practised in the rotation of the
reflector, the least motion of which will also result in
a change of the picture presented to the eye of the
observer — the patient student will be amply rewarded
by the result of his investigations, as the tourist who has
been climbing a steep mountain-path, after many priva-
tions and exposures, is rewarded by the sight of a majes-
tic and unsurpassingly grand landscape.
Dr. Tobold's apparatus, remaining yet to be
described, has proved itself in our daily practice as the
most easily managed, simple in its construction, com-
pact in form, and answering all requirements. It can
safely be recommended to beginners in the art, and can-
not be dispensed with when once used. For this, as
well as much other valuable labor in laryngoscopy, we
are indebted to Tobold.
His apparatus, a representation of which we give
below, consists of three convex lenses, r, d^ gy (vide
figure 6), enclosed in a brass tube tf, which is screwed
to a common study-lamp, and at i has a movable arm
supplied with a screw, whereby the lens can be brought
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LARYNGOSCOPY AND RHINOSCOPY.
25
in close proximity with the flame of the lamp, thereby
increasing the intensity of light. The lenses c and d
are in close proximity to one another, and can, for the
purpose of cleaning, be removed at /, as also can lens
g^ by unscrewing the tube at A ; w, is a brass arm with
three joints fastened to the lamp, to the extremity {$)
of which the handle attached to the reflector (/) is
screwed ; at <? is a simple Charnier joint, by which to
move the mirror back and forward.
It is unnecessary to move the reflector itself, as any
side motion of it is easily gained by the movable arm,
which acts with perfect facility. A brass rod with screw,
an Argand gas-burner, and suflicient rubber tubing,
enables us to dispense with the lamp altogether, and to
set up and employ this apparatus anywhere where gas
has been introduced. Such is the apparatus (besides
that of Prof. Tiirck) we daily employ, and which we
recommend.
Fig. 6.
Tobold's Apparatus for Illumination. ^
„.c*
26 THE PRINCIPLES AND PRACTICE OF
Section II.
DIRECT LARYNGOSCOPIC EXAMINATIONS.
Having already considered laryngoscopic examina-
tions by direct sunlight, both with and without re-
flection, let the room be sufficiently darkened, by dAw-
ing down the curtains, and the examination be made by
artificial light, for which purpose we shall employ To-
bold's instrument.
The following progressive steps will claim our atten-
tion.
I St. Position of patient y fhysician^ and arrangement of
the apparatus. — ^When artificial light is employed, it is
stationed to the right, and somewhat in front of the
patient ; the centre of the flame being in direct line with
the mouth, in order that the rays of light from the
reflector may fall in a horizontal line directly over the
back of the tongue, upon the laryngeal mirror, held
against the palate by the operator. In order, moreover,
that the light may fall exactly into the median line,
the face of the patient must be turned slightly to the
right. The examining physician, with his legs in
proximity and outside those of his patient, sits close
in front, his eyes in a line of equal height with the upper
lips of the former. Then approaching the border of the
reflector, he looks into the throat of the patient ; when,
in order to inspect more critically particular positions
of the cavity of the larynx, he bends his head to the side.
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LARYNGOSCOPY AND RHINOSCOPY. 27
and makes the examination through the central perfora-
tion in the reflector. Intensity of light is thereby
gained.
Some laryngoscopists use the centrum seldom, others
constantly and exclusively. It is a matter of practice
and habit only.
2d. Position of the head and tongue of the patient. — The
position of the head is important. Bent somewhat
backwards, the lower border of the upper lip ought to
be in a line with the insertion of the velum palati.
Most patients will readily hold the head as directed
when it is explained to them, and when they are assured
that they are not going to be hurt. Nevertheless, at
the first attempt (sometimes oftener), to introduce the
laryngeal mirror into the mouth,* they involuntarily
recede, sometimes quite violently, and a second trial
has to be made.
To remedy this evil, a head-rest, an arrangement
like that attached to photographers' chairs, has been
adopted by some; an admirable contrivance when
operations are to be performed within the throat. Ex-
cept for operations and exceptional cases it will be
found, that the physician's left hand supporting tongue
and chin, and a little patience on both sides, will suflice
to accomplish the object.
The head in proper position, let the patient open the
mouth and protrude the tongue as far as possible ; then
take a towel or soft handkerchief, held in readiness for
the purpose,' dry the protruded tongue, lay the cloth on
it, place the index-finger of the left hand over and
across it, and the thumb under it, hold^and draw it
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£8 THE PRINCIPLES AND PRACTICE OF
firmly yet gently over the underlip so as to depress the
root of it, whilst the mirror is introduced into the
throat. If the patient is fretful and moves the head,
let the operator hold the tongue as described ; other-
wise it is best to let the former go through this man-
oeuvre, as it gives confidence, occupies the mind, and
last, but not least, leaves the physician's left hand free.
We very rarely assist the patient, and then only at the
first examination. A few individuals possess sufficient
control over the tongue to hold it down by a voluntary
effort, while the laryngoscopic examination is made.
Sometimes this power is acquired after considerable
practice.
A metallic tongue depressor may be used where the
tongue shows great resistance ; it may be depressed
with one or two fingers of the operator's left hand. We
have, however, invariably found that any attempt to
depress the tongue is usually less successful than its
gentle and steady traction forward, for the reason that
when it is depressed in front with force, it is also at the
same time pushed backward at the base, and upwards
too, touching nearly the back of the pharynx. Some-
times it arches upwards so as to touch the roof of the
mouth. The result is, that the passage of light into
the larynx is obstructed, brings the tongue in contact
with the laryngeal mirror, and thus excites nausea.
To depress the tongue with finger or instrument should
therefore be avoided.
3d. Manner of holdingy introduction^ position^ and
changes of the laryngeal mirror J^ — When the patient and
* The laryngeal mirror ha« already been described at length.
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LARYNGOSCOPY AND RHINOSCOPY. 29
the operator have taken the requisite positions, the
apparatus for illumination properly adjusted, the pa-
tient's head placed rightly, the tongue protruded and
fixed, the physician takes hold of the mirror, which,
before being introduced, is first to be warmed by hold-
ing it over a lamp or by dipping it into warm water (of
50"^ or 60"^ R., for, if the water is too hot, the silver coat-
ing of the glass mirror is easily spoiled, and the mirror
rendered useless*), so that the patient's breath may not
dim it. Its temperature should, however, every time
be carefully tested by the operator, by bringing it in
contact with the cheek or the hand, for the reasons,
that an over-heated mirror will burn the patient's
mouth and spoil the silvering.
The mirror is to be held like a pen (see figure) rest-
ing between the thumb and side of the first phalanx of
the middle finger, so that by simple pressure of the
thumb upon the handle, the mirror can be rotated as
little or as much as desired. The index-finger does not
come into requisition.
* The use of warm water has also another advantage, viz., if the mirror is bespat-
tered by sputa, blood, etc., during examination, it can at once be washed, cleansed and
warmed again in one and the same process, instead of washing it first in cold water,
drying it, and then lastly warming it again over a lamp.
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so THE PRINCIPLES AND PRACTICE OF
Fig. 7.
Position of the Hand and Mirror.
The hand should be held naturally, easy, not stiffly
bent backward. This requires patient practice. Held
thus, it is introduced so as to slightly raise the uvula
and soft palate. Take care, lest the uvula project be-
low the mirror, and its image being reflected in the
glass it thus obscures the view of the larynx. Avoid
touching the tongue, and particularly the back of the
pharynx with the mirror, these being the most sensitive
parts within the mouth.
In exceptional cases the pharynx bears the touch of
the mirror as well as the uvula and soft palate. By
resting the third and fourth finger upon the chin of the
patient, the hand of the operator may be kept steady,
and assist him much to carry his mirror undisturbed
over the tongue to its destination. At the same time,
the stem of the mirror must be pressed into the angle
of the mouth, whereby the mirror, held somewhat
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LARYNGOSCOPY AND RHINOSCOPY. 31
obliquely, passes exactly along the median line, and
receives additional support.* Having avoided the back
of the tongue and the pharynx, and placed the mirror
in an oblique position below the soft palate, with the
uvula at its back, we at once obtain a view of the larynx,
at the same time the patient — as instructed beforehand —
is to breathe gently, short and regularly, as if he were
moderately out of breath. Practice enables us readily
to make such changes in the position of the mirror (by
slight rotation executed by the thumb), or of the
patient, or in the direction of the light, as may be
required, to bring the parts fully in view.
It must be remembered, that the picture of the larynx
as it appears in the mirror, is reversed, so that we get
the same view as we do when examining the larynx after
death. We look at it from behind. The epiglottis is
seen first (it shall engage our attention by and by) ;
the arytaenoid cartilages appear nearest to the eye; the
insertion of the vocal cords into the thyroid cartilage is
more distant. The anterior wall of the trachea is seen
* For the benefit of beginners, to train the hand and eye, Dr. Tobold has introduced
a phantom in the shape of a prepared skull fastened to a portable stand with slide and
screw, into which is introduced a plaster of Paris cast of the larynx and trachea, with
the tongue protruding, truthfully painted, and admirably adapted for the first
practice of the art. A second phantom represents the head with open mouth and pro-
truding tongue, into the neck of which is also introduced a larynx, for the purpose of
studying the same inside, and gaining the requisite dexterity with the mirror before
experimenting on individuals. In our demonstrations before pupils these phantoms
are constantly used, and they are found of great advantage. The use of the above-
mentioned phantoms can, however, be dispensed with by procuring a human tongue
and larynx with the upper part of the oesophagus, and placing or arranging them in
a skull with the lower jaw attached. This can readily be done upon a table, the skull
i>eing supported on a few books, or if the above is wanting the head and neck of a sheep
frill answer the same purpose.
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3a THE PRINCIPLES AND PRACTICE OF
as if we were looking into the tube from behind. To
the uninitiated, this reversed picture is, of course, at
first troublesome, as everything, so to speak, has
changed position. This delusion will soon, however,
cease to annoy him, if he constantly remembers, that
the parts are on the same side of the observer on which
the image appears. What, therefore, is copied to the
left of the observer in the mirror picture, is in reality
also to his left. Likewise, as the right eye of the
patient so also the right half of the larynx is to the
left of the observer, and so also appears the right half
of the larynx in the mirror to the left of the observer.*
Figure 8, taken from Prof Turcks' Clinic, repre-
sents the larynx as the parts arc seen in their natural
position ; figure 9 represents the parts as represented
in the laryngeal mirror during examination.
♦ Turck's Clinicy 1866. The Author hasoivailed himself principally of the illus-
trations of Prof. Turck*s late work for two reasons, first : that he considers them
superior to any others published ; and secondly, in the hope of directing the attention
of the profession to the able works of the distinguished Professor.
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LARYNGOSCOPY AND RHINOSCOPY. 3$
Fig. 8.
g 1 8 r h n qm k I 1
c d a
Fig. 9.
cd a
Fig. 8 & 9, (tf) Root of the tongue; [b) Anterior surface of the epiglottis; (c) It»
everted border; (d) ligam- glossoepiglottic med. with the well known valleculae (Tour-
tual) on both sides ; (e) Right latteral glossoepiglottic ligament ; (/) Right large cornu
of the hyoid bone; [g) Right wall of the pharynx; (/) Posterior wall of the pharynx;
(I) Left arytenoid cartilage ; (>) The cartilage of Santorini ; (I) Cartilage of Wrisberg ;,
(w) Upper extremity of the posterior wall of the larynx, (musc-transversi) ; (n) Right
true; (o) Right false vocal cord; (p) Opening of the left ventricle of Morgagni; (y)
Glottis, at its anterior extremity the anterior wall of the larynx ; (r) Right thyroid
cartilage, which with the folds of mucous membrane above {s {) represents the outer
wall of the sinus pyriformis, extending into the outer wall of the pharynx the inner
wall of which is formed by the arytenoid cartilage and the ligament aryteno-epiglotticum.
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34 THE PRINCIPLES AND PRACTICE OF
To simplify description, Dr. Gibb (on the Throat
and Windpipe, page 452, sec. editn.,) gives the follow-
ing order of the parts as seen when looking into the
throat with the mirror :
I. The back of the tongue.
a. The valleculae, or fossae at its base.
3. The epiglottis.
4. Posterior part of the cricoid cartilage, with its
mucous membrane.
5. Larynx.
6. The arytenoid cartilages, with their apices, the
cartilages of Santorini.
7. The aryteno-epiglottic folds, or ligaments, with
the cartilages of Wrisberg in the negro.
g. Vestibule of the glottis.
9. Superior thyro-arytenoid ligaments or false vocal
cords.
10. Ventricles of Morgani.
11. The true vocal cords, or glottis.
Beyond the trachea sometimes the bifurcation of
the same is distinctly seen.
When the patient makes a deep inspiration, the
glottis, which during common or regular respiration
is only partially open, is then a wide triangular open-
ing of considerable size, and the vocal cords appear
on each side of a pearly white color. If again the
patient is requested to pronounce the German diph-
thong " ae," the glottis closes, whilst the vocal cords
approach one another closely, and vibrate with the
impulse of the expired air.
Often experiments can be carried very far in this
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LARYNGOSCOPY AND RHINOSCOPY. 35
direction. We have succeeded with patients, partic-
ularly singers, to such an extent — after a positive
tolerance has been established — as to make them
sing (of course without pronouncing the words), short
melodies, during the progress of which the opening
and closing of the glottis, the variable tension of the
cords, and the action which the remaining component
parts of the larynx took therein was most beautifully
exhibited.
It is equally important to practice the introduction
of the laryngeal mirror with the left hand as well as with
the right. The operator, holding the mirror in his left
hand to gain a view of the larynx, — the patient mani-
pulating his own tongue,— can use his right hand for
the introduction of brush or other instrument in situ,
and thus make his applications with discrimination.
4th. Obstacles encountered in laryngoscopic examina-
tion. — It remains yet to speak of the obstacles encountered
and to be overcome in the introduction of the laryngeal
mirror, and during its necessary retention, in the throat.
It is rather singular that those unpleasant sensations,
cough, retching, and dyspnoea, which we should expect
to follow the instant introduction and contact of the
mirror, are very seldom encountered. Among the very
large number of cases that we have examined for several
years we remember but nine — four of retching and five
of cough — that obliged us to give up every further
attempt for the time. Other laryngoscopists speak
equally of the rare occurence of these symptoms.
Others more formidable, we meet often, and have to
devise means to overcome them :
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36 THE PRINCIPLES AND PRACTICE OF
(tf.) The TonguCy reference to which has already been