made, page 128 et seq. Some persons find it impos-
sible to hold the tongue out any length of time. As
soon as an attempt is made to introduce the mirror or
any other instrument, up it rises to the roof of the
mouth and remains there with wonderful pertinacity.
Again, some have more than their just proportion of
that unruly member, and even when firmly pulled over
the under lip, the arch formed is so high as to render
it almost impossible to laryngoscope. Such subjects
are generally quite nervous too, patience becomes, there-
fore, the golden rule with these. The expectant mode
of treatment, so popular with some confrireSy answers
well for a couple of days, but then the attempt must
be renewed, and repeated till all nervousness is more
or less overcome, and the tongue under control. 1 am
in the habit, as also recommended by Dr. Watson, of
directing irritable patients to practice by sitting in
front of a looking glass with the mouth open, for the
purpose of acquiring the habit of controlling the move-
ments of the tongue whilst inspecting it. It is of
great assistance at times.
{b.) The Epiglottis^ which, next to the tongue, pre-
sents many obstacles to the successful examination of
the larynx, varies much in appearance in different
individuals. It may be large or small, broad or narrow
long or short. Its free border often projects obliquely
downwards and backwards, rendering it sometimes im-
possible to throw the light beneath it. Sometimes its
arch is contracted, sometimes one half literally folded
over the other half; at other times depressed (ap-
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LARYNGOSCOPY AND RHINOSCOPY.
57
preaching each to the centre) resembling a bonnet tied
with ribbons under the chin. In fact, the greatest
variation exists.
Fig. 10.
Fig. II.
Fig. 12.
Fig. 13.
Fig. 10 Represents the Epiglottis bent backwards,
depressed.
Fig. II. Omega-shaped Epiglottis, laterally con-
tracted.
Fig 12. The border of the Epiglottis depressed and
rolled backwards.
Fig. 13. Epiglottis depressed, but partially raised
so as to show the arytenoid cartilages with those of
Santorini and Wrisberg, and part of the vocal cords.*
The tubercule of the epiglottis, reaching into the
larynx at the anterior junction of the true vocal cords
interferes with the sight of that part, even when the
epiglottis is in its usual straight position.
The correct position of the head and tongue goes far
* Copied from TUrck's Clinic.
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38 THE PRINCIPLES AND PRACTICE OF
towards remedying any deviation in the position of
the epiglottis. In many cases success is insured when
after the laryngeal mirror is introduced, the patient is
requested to pronounce the diphthong "se'* several
times in succession, each time striking a higher pitch,
for instance, the first, third, fifth and eighth note
of the scale, when at each successive change of the
pitch of the voice, the epiglottis rises step by step>
is straightened often at the same time at the base, so
that, at a glance, the entire surface of the glottis from
the anterior angle to the base can be inspected. With
other patients, .pronouncing the letter ** e " secures the
object, whilst again in another class we have to resort
to repeated forcible and abrupt inspirations. For
exceptional cases means have been devised by Voi>
Bruns . and others, to raise the epiglottis, by advo-
cating the use of the epiglottic pincette, or a covered
epiglottic hook, which, though extremely rarely re-
quired, can be applied without suffering, and renders
good service at times.
Dr. Gibb, of London, presented a paper before the
British Association for the Advancement of Science, at
a meeting at Cambridge in 1862, and at Newcastle in
1863,* wherein he disproved the hitherto received opin-
ion, that the epiglottis is naturally in the correct or
vertical position, but on the contrary demonstrated,
that in eleven per cent, of mankind it was found to be
oblique, very much or semi-pendent, or nearly quite
* Archives of Medicine for 1863 and 1864, and various journal*
and papers.
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LARYNGOSCOPY AND RHINOSCOPY.
3'>
horizontal in persons apparently healthy. His argu-
ments were founded upon an examination, with the
laryngoscope, of six hundred and eighty healthy per-
sons, up to September 1863.
By the last census the population of Great Britain
was determined to be 28,887,519; eleven per cent,
gives the number of 3,177,627 persons who have not a
vertical or erect epiglottis. "Can it be wondered at,'*
the author asks, " that diseases of the throat are very
prevalent among mankind, when the key-stone to the
respiratory arch is shifted in its position ? "
It is probable in some countries, those within the
tropics for example, the percentage might be even more
than has been found to prevail in England."* It would
be both useful and interesting, if we possessed some
statistics in the United States, in reference to the above
fact, particularly in regard to the New England States,
where pulmonary and throat diseases are very prevalent
Semelderf states, that in about 25 per cent, of adults
he got a perfect view of the larynx easily at the first ex-
amination ; in about 5 per cent, it was impossible to
see the larynx at all ; in the remainder he succeeded
more or less completely after repeated examinations.
This per centage is too large, as, according to Gibb, the
epiglottis deviates from its true position in only 1 1 per
cent., which must interfere with the examination. Add
to this 5 per cent, more for other causes, and we then
have only a total of 16 per cent.
* Gibb. Throat and Windpipe, pages 53 and 54.
f Dr. S. Semeldcr. Vienna, 1863.
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40 THE PRINCIPLES AND PRACTICE OF
It is safe to assert, that in three-quarters of all the
patients I have examined, and they number hundreds,
I have been able to obtain a good view of the larynx.
This estimate does not include children below six years
of age.
(c.) Great sensitiveness and excitability of the fauces^ at
the touch of the mirror during examination is a further
obstacle, as it excites contraction of the pharynx and
retching. In some patients this is natural and unavoid-
able, in the majority however it is owing to a congested
state of the mucous membrane of the fauces. Hence,
when a throat appears at first sight red and engorged,
difficulty may be anticipated in the examination of the
larynx. Special care must be taken by the operator to
avoid any unnecessary increase of that already trouble-
some excitability.
After eating or drinking, this is always increased,
therefore irritable persons ought to be examined either
fasting, or a few hours after breakfast. Again, an in-
crease of sensitiveness is noticeable during the continu-
ance of catarrhal affections of the upper portions of the
respiratory and digestive organs, in the same individual
in different degrees at different times of the day, accord-
ing to the general feeling, especially in nervous individ-
uals, so that, when the examination has been made
suceessfuUy one day, it has to be abandoned the follow-
ing, for the above reasons. Various modes have been
suggested for lessening the sensibility of the throat in
such cases. One is, to direct the patient to take a
piece of ice into the mouth and let it dissolve before ex-
amination. This works well.
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LARYNGOSCOPY AND RHINOSCOPY. 41
Bromide of Potassiumy either swallowed or used as a
gargle — a solution o( Morphine in chloroform y hydrochloric
^ther and tannin have all been tried. Of these the last
mentioned, in a solution of 1 6, 20, 30 grains to the ounce
of distilled water, and administered through a pulveri-
sateur (such as Lewin's), has rendered the best service,
whilst the bromide has disappointed expectations^
Morphine with chloroform is exceedingly painful when
applied toirritable membranes ; and lastly, hydrochloric
aether in diminishing the great sensitiveness causes
burning and produces an irresistible desire to cough,
A more successful way is to put 10 to ao drops of
chloroform on a handkerchief, and let the patient inhale
it for a minute. I find it quiets the most irritable
throats. The number of drops used is too small to
render the patient drowsy. Yet none of these appli-
ances are so effective as the repeated introduction of the
faucial mirror at intervals of a day or two.
(^.) Hypertrophy of the Tonsils may render the exami-
nation of the larynx difficult or impossible. In pro-
portion to this enlargement, the mirror must be adapted
to the examination. When the tonsils are, however,
so much enlarged as to touch each other, laryngoscopic
examination is impracticable. They ought first to be
removed by the guillotine, or by the application of
Vienna paste.
(^.) Irregularity of Respiration must finally be men-
tioned as one of the causes upon which failure of
laryngoscopic examination sometimes depends. Most
patients think, that after the head and tongue are fixed,
it is also necessary for them to retain as long as possi-^
4
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42 THE PRINCIPLES AND PRACTICE OF
ble their breath, instead of breathing quietly and regu-
larly without exertion. Nothing but a careful explan-
ation of the respective steps to be gone through
with, on the part of the operator, can insure success ;
whilst at the same time it will be found that patients
laboring under serious diseases — such as are attended
'with suffering — bear the examination better than those
who have but trifling ailments or none at all.
CHAPTER III.
Auto-Laryngoscopy.
To enable us to judge of the sensations of others
when examined, to acquire skill and confidence in our
manipulations of the larynx, and for the purpose of
gratifying our patients and our curiosity, Auto-Laryn-
goscopy ought to be practised by every one who wishes
to be proficient in this art. The methods of examina-
tion are various.
Garcia' s, the father of auto-laryngoscopy, is very sim-
ple. Turning his back toward the sun, he received the
solar rays by means of a small mirror held before the
face, and directed them upon the laryngeal mirror placed
against the uvula, which reflected again the image into
the other mirror.
Moura Bourouillion's laryngoscope is available for
these examinations, though little used.
Dr. G. Johnson proposed the following simple and
satisfactory plan : " Sitting at a table of a convenient
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LARYNGOSCOPY AND RHINOSCOPY. 4J
** height," he says, " I can place a looking-glass at a
" distance of about eighteen inches in front of me, and
** a moderator lamp on one side of the glass, but two
** or three inches further back, so that the light may
** not pass directly from the lamp to the mirror. Now,
** with the reflector on my forehead, I direct the light
** as it were into the open mouth of my own image in
" the looking-glass ; then, introducing the laryngeal
** mirror into my mouth, I see the reflection of my lar-
" ynx and trachea in the glass before me, and any one
" looking over my head can see the image at the same
** time. By this method the experimenter can see his
" own larynx and show it to others." We have tried
the above method and found it as successful as it is sim-»-
pie, so that it can be carried out with facility by begin-
ners. Omitting to speak of several other apparatuses for
Auto-laryngoscopy, we shall only refer to Prof. Czer-
mak's, as by its use in his own hands the art has become,
so to speak, naturalized in every foreign land. It con-
sists of a mahogany box, at the bottom of which is a
sliding panel, to which is screwed a brass tube, which
permits of the attachment of a large illuminating con-
cave perforated reflector, at any height most suitable.
Opposite to this is a receptacle for another tube, which
latter receives the stem of an oblong mirror, attached
by means of a hinge. The light is placed to one side
of the experimenter, and throws its rays into the large
mirror, which reflects him in the laryngeal mirror held
against the uvula in the right hand. The observer
looks through the perforation, or around the margin
of the large mirror, whilst the experimenter looks into
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44 THE PRINCIPLES AND PRACTICE OF
the oblong mirror ; both see the laryngoscopic image
in the laryngeal mirror, although not precisely alike to
each, as their visual axes do not form the same angles
with the reflecting surface of the mirror. From the
position of the lamp the eyes are completely protected
from the glare.*
This apparatus has this advantage, that a large party
of persons can see the laryngoscopic image by cluster-
ing around the reflecting^mirror, and at the same time
others, by looking into the oblong mirror, will see
nearly the same object. For general convenience,
handiness of arrangement, regulation of light, elegance,
and simplicity, this apparatus is to be recommended as
preferable to any other, at a cost which places it within
reach of all.
For lecturers on physiology, Czermak's Auto-laryn-
goscope is most indispensable, and should have the
preference over every other instrument. Such is the
language of commendationj[of Dr. Gibb, one most able
to judge in such matters.
* Gibb on the Throat and Windpipe, p. 458 et seq., Sect.'Auto-Laiyngotcopf.
Medical Times and Gazette^ Feb. I4,''i863» p. 157.
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LARYNGOSCOPY AND RHINOSCOPY. 45
CHAPTER IV.
RECIPRO-LARYNGOSCOPY.
This, the art of demonstrating a patient's larynx to
others, was^first pointed out by Dr. Smyly, of Dublin.*
He has contrived to overcome the difficulty of show-
ing the larynx to a third person in the ordinary way.
To quote his own words: "In the ordinary method,
when the examiner has a full view of the vocal cords
of the examinee, he calls upon his colleague to view
the parts, who when he places his head beside that of the
examiner, only gets a partial view — a portion of the
epiglottis, one arytenoid, and perhaps a vocal cord.
In endeavoring to see more he pushes the examiner's
head, so as to displace the light, or shakes his hand, so
as to bring on nausea. Many other inconveniences
will occur to the mind of the practical laryngoscopist,
which I shall not here allude to.
" My addition consists of a simple square piece of
very good plate-glass mirror, set in brass, like the or-
dinary concave mirror. A second split tube is solder-
ed on close to the tube, which exists on all Weiss' fron-
♦ Dublin Quarterly Journal, Vol. XXXVI., Aug. 1863.
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46 THE PRINCIPLES AND PRACTICE OF
tal bands,'*' and a brass rod, the ends of which are bent
in opposite directions, at an angle of 45^.
*' The mode of using this glass is as follows : The
lar)mgoscope is fixed, as usual, before either the left or
right eye. The brass rod is fixed in the tube, beside
that which holds the rod supporting the reflector, and
my square glass is fixed on the other end, as is very
well shown in the engraving.
Fig. 14.
Dr. Smyly's Rccipro-Laryngoscope.
" As the angles of incidence and reflection are equal,
the mirror may be turned to such an angle that the
second examiner may be placed at such a distance from
both the patient and operator, that his presence cannot
disturb the steadiness of either. The view the second
examiner has of the larynx in the square mirror is not
* Also to be had at Otto & Reynders*, Chatham street, New York.
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LARYNGOSCOPY AND RHINOSCOPY. 47
inverted, being twice reflected. The right vocal cord
of the examinee is to the right-hand side of examiner
number two.
** The glass employed in the manufacture must be as
perfect and parallel as possible, so that the loss of light
may be a minimum.
'* In conclusion, I may add that the additional
weight of the square glass, when made in an artistic
manner, is scarcely perceptible." — Dublin Sluarterly
Journal, Vol. XXXVI., Aug. 1863.
CHAPTER V.
INFRA-GLOTTIC LARYNGOSCOPY OR TRACHEOSCOPY.
First suggested by Dr. Neudorfer in 1858, but first
carried out in practice by Prof. Czermak in 1859. It
consists in the introduction of a very minute mirror
through the opening made for the insertion of the
canula in tracheotomy. The face of the mirror being
directed upward, a view of the larynx is obtained from
below. Several cases, one by Semeleder, of this suc-
cessful mode of operating, have been reported. We
had, about a year ago, the rare opportunity of examin-
ing a discharged soldier, on whom, two and a half years
before, tracheotomy had been performed in consequence
of a gunshot wound received in battle, and who wore a
canula. Having introduced our little mirror of Neu-
dorfer, by very strong reflected light we could see per-
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48 THE PRINCIPLES AND PRACTICE OF
fcctly the lower surface of the vocal cords, of a reddish
color, in contradistinction from the upper surface,
which was pearly white, and could be distinctly seen ;
ats the epiglottis was not bound down by cicatrices, as
ordinarily happens.
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LARYNGOSCOPY AND RHINOSCOPY. 49
Rhinoscopy.
CHAPTER VI.
Although Bozzini in 1807, Baumes in 1838, and
Avery in 1 846, practiced the art of examining the pos-
terior recesses of the nostrils and of the pharyngo-^
nasal recess, yet it was not until Czermak,* in 1859, in
his first publication on the laryngoscope, called atten-
tion to the fact that the same method of examination
was applicable to the posterior surface of the soft
palate, the posterior openings of the nasal fossae, and
the superior parts of the larynx. He also contrived
various useful instruments for this purpose. Prof..
Tiirck, Semeleder, Storck, Voltolini, Wagner and oth-
ers, have since made many valuable contributions to
and improvements in this art.
To accomplish what is claimed for Rhinoscopy
requires patience and perseverance, and more so than
laryngoscopy, as its practice is more difficult. Unsatis-
factory results, especially in beginners in the art, are
generally, with few exceptions, owing to want of perse-
verance, sometimes, however, to lack of skill.
We shall describe the instruments necessary and the
modus operandi during examination.
There are required :
* Wiener Med. Wochenschrift, Aug. 6, 1859.
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THE PRINCIPLES AND PRACTICE OF
1st. A small mirror of glass, smaller than usual for
laryngoscopic purposes, about five-eights of an inch in
diameter, and placed at a right angle to the shank.
ad. A reflectory which may be the same as used in
laryngoscopy.
3d. A tonguespatulay which has been made of \rarious
lengths and at different angles. Prof. Turck's spatula,
recommended especially for rhinoscopic purposes, has
proved itself the most practical adopted, from the fact
that the stem or handle is separable from the spatula
blade itself, so that a larger or smaller-sized blade can
be screwed to the handle, and the point of distance of
the blade from the handle can be regulated at option.
Thus it can be used for children and adults. It is also
easily packed and carried about.
[See Figures 15, 16, 17, 18 and 19 on the following page.]
4th. A palate-hooky for raising the uvula and pull-
ing it forward, about four inches long, narrow at its
fixed end, broader and somewhat curved at the oppo-
site end. Recommended by Czermak. This instrument
is now seldom used. Tiirck advises the use of a loop,
devised by himself, to secure and keep the uvula out of
the way. Figure 20 is a representation of his palate
lasso, or loop.
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LARYNGOSCOPY AND RHINOSCOPY. ji
6
ON
6
Tiirck's Tongue-Spatula.
o
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52 THE PRINCIPLES AND PRACTICE OF
Fig. 20.
Palate Lasso.
It consists of a small silver tube, about one inch
long, and sufficiently wide to pass a double thread
through; it. Near one end of it is a hole, through
which is: passed a double well-waxed thread, fastened by
its centre. When the other end of the double thread is
again passed through the tube, a sling is formed, the
object of which is to fasten the uvula. This is accom-
plished by holding the tube with the loop in a pair of
forceps, then bringing the loop under and on to the
uvula. It is fastened by pressing the tube firmly toward
the uvula, and holding the thread behind stretched
whilst it is fastened to a hook attached to an elastic
band tied around the patient's forehead. This process,
though at first rather troublesome to be accomplished
with ease, secures the uvula without pain, and keeps it
temporarily out of the operator's way. To remove
the loop and tube, it is simply necessary to pull the
tube with the forceps backward, when the loop drops
from the uvula. Whatever may be said for or against
the employment of a hook, or any other device, to se-
cure the uvula, we must acknowledge that we make our
most successful examinations without a hook or loop.
Sometimes the use of the hook is attended with discom-
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LARYNGOSCOPY AND RHINOSCOPY. 53
fort ; its contact excites contraction of the palate, which
is then drawn upward and backward, so as to obstruct
the view completely.
It will be seen at a glance, in looking into the pa-
tient's mouth, whether the examination can be made
without hook, loop, or any other contrivance to keep
the uvula in its proper position. This depends upon
the space which exists between the palate and the pos-
terior wall of the pharynx. Whenever the interval is a
moderately wide one, the mirror can be introduced
without touching the uvula or palate.
During the examination the patient must sit erect,
without throwing the head back, while the light is
thrown into the mouth by the reflector, illuminated by
a lamp or gas-burner, placed in the same position as in
laryngoscopy. He is then directed to open his mouth
widely, whilst the tongue is pressed forward and down-
ward by a metallic spatula, either held by himself or the
operator. The patient being directed to breathe quietly,
the mirror is then introduced by the side of the uvula,
beneath the palate, with its surface directed upward
and forward, so that the plane of the reflecting surface
forms with the horizon an angle of about 130 degrees.
After introducing the mirror, the observer can steady it
by resting his third and fourth fingers on the patient's
lower jaw. (Dr. Mackenzie and Voltolini of Breslau,
both use an instrument in which the tongue-spatula
and mirror are combined in one.)
The following objects will then be successively pre-
sented to view :
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54 THE PRINCIPLES AND PRACTICE OF
(a.) The septum narium ;
li.) The posterior orifices of the nasal fossse ;
(r.) The middle and lower turbinated bones ;
(d.) The orifices of the Eustachian tubes ;
(e.) The roof of the pharynx, and sometimes
(/.) The floor of the mouth.
Figures 21 and 22, Tiirck's work, are reproduced here
for the sake of illustration.
Fig. 21.
Fig. 21 represents a posterior view, after removal
of the dorsal vertebrae of the anterior wall, and a part
of the side-walls of the naso-pharyngeal space.
a, Tubercule of the left Eustachian tube; ^, its
opening; r, fossa of Rosenmiiller; //, inferior; ^, middle
meatus; /i middle; ^, inferior turbinated bone; A, poste-
rior extremity of the septum between both turbinated
bones ; /, posterior surface of the soft palate ; ky uvula ;
/, dorsum of the tongue.
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LARYNGOSCOPY AND RHINOSCOPY. SS
Fig. 22.
* * Fig. 22. Rhinoscopic
resentation of the
erior and a part of
lateral walls of the
o-pharyngeal space;
josterior plane of the
t palate, with the
ila looped up; ^,
nt of union of the
^ « soft palate; r, septum
between both turbinated bones; //, inferior; ^, mid-
dle left turbinated bone ; /, inferior; g, middle left mea-
tus ; hy tubercule of the Eustachian tube; /, opening of
the tube; ky fossa of Rosenmiiller.
These component parts of the picture presented
deserve a most careful examination and ought to be
vividly impressed upon the memory to avoid mistakes
in diagnosis of disease of those parts. The septum,
seen first, is rarely symmetrical, but slants a little to one
side, usually the left.
The middle turbinated bones y projecting from the outer
wall of the naris on each side toward the septum, are
covered with a pale mucous membrane, resembling
polypi; so much so, owing to their form and color,
they have been mistaken for such until the eye of a