more practiced observer settled the matter by means of
a rhinoscopic examination. The superior turbinated
bones, small and somewhat triangular in shape, are dis-
tinctly seen. The inferior turbinated bones are seen
as two pale, roundish, solid-looking tumors at the
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56 THE PRINCIPLES AND PRACTICE OF
base of the nasal fossae. Of the three, the middle pro-
jects the furthest. Of the three meati^ the superior one
is the largest, whilst the inferior one appears only as
a thin dark line.
The orifices of the Eustachian tubes are two irregular
openings, looking downward and outward, on each
side of the turbinated bones, though further back and
in a different plane. Buried in the pharyngeal wall, of
a lighter color and more yellow tinge than the sur-
rounding mucous membrane, the opening of the
Eustachian tube is trumpet-shaped and bevelled off et
the upper and posterior edge. Beneath the nasal fossas
is the soft palate, uvula, etc.
As in certain cases it is impossible to make a rhin-
oscopic examination, which can be easily determined by
examining the fauces, so on the other hand this examina-
tion is much facilitated in cases of fissure of the soft
or hard palate, or loss of the former by ulceration.
Occasionally small mirrors are introduced into the
front of the nose, in order to examine the nasal cavity
and inferior turbinated bones. It is stated, also, that
in persons with capacious nostrils, the nasal orifice of
the lachrymal canal can be seen.
Though rather difficult of application and limited
in extent, very valuable information may sometimes be
obtained by rhinoscopy, in cases of ozana^ the various
forms of ulceration of the hard and soft farts at the back of
the nose J in obstruction of the nasal passages by polypi or
thickened mucous membrane. It also enables us in cases
of deafness dependent on obstruction of the Eustachian
orifice, to diagnose the affection correctly, and to in-
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LARYNGOSCOPY AND RHINOSCOPY. 57
troduce the Eustachian catheter with safety and pre-
cision.
We shall embrace the opportunity to introduce here
a few cases, to illustrate the practical value of rhino-
scopy.
Case i . — Obstruction of the right nasal passage from
thickening of the mucous membrane of the right middle tur-
binated bone. The right nostril closed for twenty months.
Relief by local treatment.
Mr. C, aet. 34, merchant, presented himself in Janu-
ary, 1866, on account of a constant stopping up of the
right side of his nose, accompanied at times with a very
troublesome sensation of dryness, and at times again
by a free watery discharge. He felt as if he had con-
stantly a cold in the head, and sniffed incessantly.
Took medicine internally, and solutions of zinc, alum,
nitrate of silver were sniffed and also injected into the
affected parts without benefit.
Condition for rhinoscopic examination favorable.
Result of Inspection. — The mucous membrane of both
nostrils was of a red color, of deeper red on the right
side, where that part of it covering the right turbinated
bone was so much swollen as to nearly block up the
entire right nasal passage. I applied solutions of ni-
trate of silver, sulphate of copper and tannin with a
curved brush, for some time, with little result, when
I resorted to iodine and glycerine, equal parts, which
proved successful in a comparatively short time. The
swelling disappeared, and there has been no return of
the disease.
5
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58 THE PRINCIPLES AND PRACTICE OF
Case 2. — Ulcers onthevomery the rights middle and left
inferior turbinated bones ^ resulting in ozana of three years*
standing.
Mr. F., act. ^^^ salesman, had been subject to a very
offensive discharge from the nose and throat for nearly
three years, which latterly grew so offensive as to be in-
tolerable. Being of strumous habit, the tonsils moder-
ately enlarged, but not so as to obstruct the space be-
tween the velum-palati and pharynx, rhinoscopic exam-
ination showed the existence of an ulcer near the base of
the vomer and inferior turbinated bone on the left side,
one on the middle and right turbinated bone. The
mucous membrane was of a dirty gray color near the
ulcers, for the rest, red.
Treatment. — Solutions of nitrate of silver applied with
a sponge fastened to a curved holder, the internal use
of iodide of potassium, and regulation of diet. A
complete cure in eight weeks.
Case 3. — Lodgement of a glass bead in the left nostril
of a girl four and a half years old. Removal by forceps.
A little girl was brought to me, November 1866,
who, whilst playing with other children with beads,
stuck one into her left nostril. Unable to expel it,
she was subjected to a rhinoscopic examination. It was
found to have lodged firmly back in the middle meatus.
By the aid of the mirror and forceps it was successfully
removed.
Case 4. — Examined Mr. F., aet. 52, May 14, 1867.
His right nostril was obstructed and he had been told that
he had a polypus which was the cause of the obstruction, and
was advised to have it removed. Inspected the fauces
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LARYNGOSCOPY AND RHYNOSCOPY. 59
and found this patient well adapted for rhinoscopic
examination. Without any difficulty whatever gained
a perfect view of the posterior nasal fossae and turbinat-
ed bones. No polypus was found, but the right middle
turbinated bone was thickened and diseased, being the
sole cause of the obstruction.
Dr. G.Johnson, in his lectures on the Laryngoscope,*
relates a case similar to the foregoing, where the sur-
geon had already made an unsuccessful attempt to
remove a supposed polypus with the forceps, when
rhinoscopy proved it to be an affection of the turbinat-
ed bone and not a polypus. Another good illustration
of the value of rhinoscopy in correcting an erroneous
diagnosis is given by Czermak in the last German edi-
tion of his monograph^ on the subject. A young man
had a tumor at the back of his left nostril, which to
the touch gave the impression of a polypus, and render-
ed him deaf on that side. An operation was contem-
plated, but a rhinoscopic examination discovered a
temporary swelling of the mucous membrane nearly as
thick as the finger, surrounding the orifice of the Eust-
achian tube, also great swelling of the middle and
inferior turbinated bones, but no polypus, nor any
tumor which an operation could have removed or
lessened.
The foregoing cases will suffice to illustrate the im-
portance of acquiring the art of rhinoscopy, both as an
unfailing guide in diagnosis and in treatment. Be it
* London, Hardwicke, 132 Piccadilly, 1864.
t Opus cit., pp. 127-8. Leipzic, 1863.
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6o THE PRINCIPLES AND PRACTICE OF
however remembered, that it requires even more pa-
tience in this than to practice laryngoscopy. AsCzermak
justly remarks : " Many a physician and student has
thrown down in despair his mirrors, and quitted the
study of this art, on account of a want of patience, so
necessary in all great things."
CHAPTER VII.
CONCLUDING REMARKS ON THE PRECEDING CHAPTERS.
1st. It is absolutely necessary, in order to study
practical Laryngoscopy and Rhinoscopy with success,
that the student should be perfectly familiar with the
anatomy of the parts he has so constantly to deal with
of their appearance in a healthy condition, before he is
able to judge of their diseased state. A description of
the larynx, its functions, and the parts intimately con-
nected with it, can be found in every good work on
anatomy and physiology. It has therefore been con-
sidered unnecessary to introduce the subject here.
Better, however, than the study of plates is it, to
familiarize oneself on the dead subject, with the parts
in situ ; to introduce the mirror, and to dissect the sep-
arate parts. Where this cannot be done, a larynx, with
tongue and oesophagus attached, will answer the pur-
pose.
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LARYNGOSCOPY AND RHINOSCOPY. 6i
2d. The best method, and one not less essential, to
familiarize oneself with the shape, position, color and
movements of the throat, larynx or nose, and relative
connection of all component parts, is to embrace every
possible opportonity to examine the throat and larynx
of every healthy person, old and young — even chil-
dren — who can be induced to submit to it, which gen-
erally can be done without much persuasion. It is
surprising how easy a self-interest can be awakened in
unprofessional persons. For over two years I have
made it a business to examine the larynx of every per-
son that comes sufficiently long within my presence to
enable me to do so. Thus I have examined some days
from 2 to 6 persons, including children (exclusive of
patients), and noted the condition of the larynx, throat,
and particularly the epiglottis, in over three hundred
persons. I know of no more beautiful object than the
vocal apparatus, particularly that of children. An
interest, nay a passion, is developed during these exam-
inations, executed con am ore, which will overcome all
difficulties.
3d. The color of the parts differs, as described by
Gibb.* In a healthy condition, the epiglottis is of a
pale salmon or buff color ; the interior of the larynx
above the glottis is of a pale rose ; the true vocal
cords are white with a gray shade ; the part immediately
below the glottis is pale fawn, which in the trachea
shades off into a drab ; the ring of the cricoid, and the
rings of the trachea, appearing of a lighter and almost
*■ Gibby op. cit.
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62 THE PRINCIPLES AND PRACTICE OF
white color through the transparent membrane. In
some persons the arytenoid cartilages are of a yellow
pink, and those of Wrisberg, when present, (almost
always in negroes), have a yellowish tinge like a small
abscess.
At the back of the nose the turbinated bones possess
a pale pink and drab color, but when congested, the
vessels are generally of a vivid pink, and prominent.
The oval trumpet-orifices of the Eustachian tubes gen-
erally are pale yellow.
4th. In order to overcome all the difficulties encoun-
tered in introducing and placing the laryngeal mirror
properly, and to be sure that no part be overlooked
during the inspection, or mistaken one for another, let
the examination be performed in a strictly systematic
order, step by step, as laid down at length in the pre-
ceding chapters.
5th. Do not attempt at the first glance to see the
vocal cords in the depth of the larynx, but observe first
the parts above in succession, and afterward the parts
situated lower.
6th. After the mirror is introduced, observe strictly
the median line from before backward, the condition
of the back of the tongue, the epiglottis, the posterior
wall of the pharynx ; then let the mirror be turned to
the side in order to see the walls of the pharynx, the
aryepiglottic folds, and return again to the pharyngeal
wall and the epiglottis.
7th. Lastly, is to be examined the interior of the
larynx when first its posterior wall is seen ; observe the
form, size, color, position and movability of the
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LARYNGOSCOPY AND RHINOSCOPY. 63
arytenoid cartilages, then lower, the false and true
vocal cords in all their relations and power of motion,
finally, the posterior plane of the anterior wall of the
larynx, from the free border of the epiglottis down into
the trachea.
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64 THE PRINCIPLES AND PRACTICE OF
PART SECOND^
CHAPTER I.
APPLICATION OF REMEDIES TO THE LARYNX AIDED
BY THE LARYNGOSCOPE.
It has been said without exaggeration, that the
laryngoscope has rendered the diagnosis of the diseases
of the larynx more simple and certain than the diagno-
sis of the diseases of any other internal organ; it is
equally true as a consequence, that our treatment of
these complaints has been placed upon a new basis, the
positive basis of a correct diagnosis. When, now-a-days>
as Dr. Tobold remarks, a patient presents himself with
sore-throat, we grope about no longer in the dark; we
are not satisfied with purely subjective appearances, and
prescribe some old-fashioned formula for laryngeal
catarrh and hoarseness, or even, when these fail, send
the patient to a distant water-cure or summer resort,
from whence he probably returns little or not at all re-
lieved ; but we examine first, mirror in hand, the dis-
eased organ, and apply according to indications our
topical remedies, or the knife, where medicines are use-
less. The treatment of the diseased larynx has there-
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LARYNGOSCOPY AND RHINOSCOPY. 6^
fore been transplanted from the field of medicine to that
of surgery.*
Nor is the result of the treatment less satisfactory in
this class of diseases since the introduction of laryngo-
scopy, with the exception, perhaps, of tuberculosis; but
even there laryngo-therapeutics afford, sometimes at
least, temporary relief.
The various degrees of inflammation of the laryngeal
mucous membrane, of the submucous tissues, or the
muscles in hyperaemia, affections of the perichondrium
and of the cartilages, swelling, and extension of the
false vocal cords and aryepiglottic folds, infiltration,,
ulceration, new growths accompanied by disturbed
functions or alteration of voice, all these diseased con-
ditions are amenable to local treatment. Although we
will not deny that internal remedies may now and then
act as valuable adjuvants, yet it can no longer be
questioned, that the local treatment is the principal factor
therein^ since good results are arrived at in much less
time, and a radical cure is brought about only through
their means.f
It is presumed, that the introduction of the mirror
with the left hand has been practiced, so as to be ex-
ecuted with the same care, ease, dexterity and certainty
as with the right hand, which now must be employed
for the brush, or porte-caustic, or any other instrument
called into service. Here again our motion must be
quick and certain.
To avoid any illusion regarding the position of the
♦ Tobold, op. cit., page 57. f Tobold, op. cit.
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€6 THE PRINCIPLES AND PRACTICE OF
parts, their respective distance from each other must be
carefully measured. Let the patient be reassured, and
his head so fixed as to contribute to the success of the
operation.
The remedies applied for the cure of diseases of the
larynx by aid of the laryngoscope may be divided into
three classes : —
I St. We can produce by the direct application of
remedies to the diseased spot or part alterative, astrin-
gent, or sedative effects, or what is more common, we
can cauterize the part, or destroy portions of it alto-
gether.
2d. By the use of instruments, we can bring about
a mechanical separation, a destruction, or an entire re-
moval of the parts affected.
3d. Galvanism may be applied directly to the mucous
membrane of the larynx, for the twofold purpose of
stimulating muscular contraction, and for destroying
a certain grown part by the electric cautery.
Each of the above three classes shall be considered
seriatim.
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LARYNGOSCOPY AND RHINOSCOPY. (>!
CHAPTER II.
Remedies directly applied to the larynx may be in
the form of:
a. Solutions.
b. Powders.
f. Solid caustic.
d. Escharotics.
Section I. — Solutions.
When applied :
1st. In more or less diffused hyperaemia of the mucous
membrane and submucous cellular tissues, especially
in chronic catarrhal conditions which do not yield
to milder remedies in the form of inhalations ;
2d. In pseudo-membraneous formations upon the
free mucous membrane, the well-known exudations
in croup and diphtheria ;
3d. In hypertrophy of the mucous membrane, involv-
ing its whole structure, or only its superficial layer
and the epithelial cells, as has been observed along
the free border of the vocal cords;
4th. In superficial abrasions and ulcerations which
may extend over more or less surface.
In the diseases included in the foregoing four classes,
the question is not one of a deep-seated abnormal condi-
tion, but one of greater or less extent, generally con-
fined to the surface, which through the application of
stimulating and alterative remedies is to be brought
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6S THE PRINCIPLES AND PRACTICE OF
back to its normal condition. (Von Brun's Laryngo-
scopic Surgery.)
Remedies used. — Among the most efficacious of these
must be classed nitrate of silver^ which, from its gen-
eral utility and great importance, deserves more than a
passing notice.
The solutions used vary from i, 2, 4, 5 scruples to
the ounce of distilled water. A two-scruple solution
will be found the most serviceable on all ordinary occa-
sions, for it is unquestionably agreed among all trust-
worthy observers, that for the purpose of application
into the larynx, trachea, fauces, or nose, a solution of
less strength is only trifling with the patient and pro-
duces no satisfactory results. For the treatment of ul-
cerations of the epiglottis or about the larynx, solutions
of greater strength are fully warranted. Whilst, how-
ever, some are timid, and for fear of doing injury
would confine themselves to five or ten-grain solutions,
others are not wanting who advocate the use of the
solid nitrate, and the strongest concentrated solutions to
an ulcerated or otherwise sore throat. These latter
must be warned of the risk they incur of destroying the
tissues by means of their remedies. The larynx is too
delicate a structure and of too great importance to its
possessor, to admit of its being placed in jeopardy by
unsafe and destructive remedies.
Other valuable remedies are tannin, perchloride of
iron, sulphate of zinc and copper, iodine, alum, bro-
mide of ammonium, hydrochlorate of morphia, carbolic
acid. The most useful solvent for these agencies is
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LARYNGOSCOPY AND RHINOSCOPY. 69
glycerine, by reason of its being viscid ; it ad-
heres to the surface of the mucous membrane, and
retains there the remedy it holds in solution. But this
solvent property of glycerine is subject to certain pro-
portions. Tannic acid dissolves in glycerine only in
proportion of two drachms to the ounce. This forms
one of the most useful topical astringents ; with nitrate
of silver, sulphate of zinc and alum, it will combine by
aid of heat in the proportion of two drachms to the
ounce. It dissolves also one-fifth of its weight of hydro-
chlorate of morphia, a weaker solution of which is a
very useful application in irritation of the larynx.
Which of the above remedies to apply in each case is a
matter of judgment.
How applied. — Solutions are applied by means of the
laryngeal brushy the sponge-carriery the syringe or injector ^
and pulverisateurs for inhalation,
1st. The laryngeal brushy which has now mostly su-
perseded the sponge recommended by Watts, Greene,
and others, was first proposed in its present and
most useful form by Professor Tiirck. A large,
full-bellied squirrel's or camel's hair brush, cut
square at the end, is firmly attached to a silver stem
from four to five inches long, of sufficient strength,
:so that said stem can be bent at any convenient
angle between 90** and 102°, according as we wish
to touch the anterior insertion of the vocal cords, or
the arytenoid cartilages, or any other part of the
throat, as circumstances may demand. The stem is
fastened to a handle of a convenient shape and size.
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7© THE PRINCIPLES AND PRACTICE OF
similar to that of the laryngeal mirror. To this brush
_, we confine ourselves mostly, satis-
Fig. 23. ^ , , , r
ned that the sponge often pro-
duces irritation, if not injury,
when it comes in contact with
the delicate membrane of the
larynx.
Fig. 23 represents Tiirck's
laryngeal brush. The brush is
firmly attached to the stem, biit I
have had the same made with a
screw at the extremity of the stem,
so as to change the brush whenever
desired.
Dr.Gibb recommends a brush at-
tached to a bent whalebone, as rep-
resented in the annexed Fig. 24.
Fig. 24.
Ttlrck's Laryngeal Brash. Gibb's Laryngeal Brush.
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LARYNGOSCOPY AND RHINOSCOPY. 71
Both Tiirck's and Gibb's brush can be so construct-
ed that it can be attached by means of a screw to the
stem, and thus changed for each patient, and retained
for future use, whilst the stem and holder can be equally
used for all.
An excellent instrument as Gibb's brush is, yet for
certain purposes, I find it objectionable, because the
angle of the whalebone to which the brush is attached^
cannot be changed at will (only by being seated), whea
occasion requires it. It is true, this objection may be
obviated by having on hand brushes inclined at differ-
ent angles and also of different sizes.
It will hardly be necessary to suggest that each pa-
tient be provided with a separate brush, which after
being used is marked with the name of the owner and
laid aside for future use on the same person only.
After using a brush it should be immediately immersed
in water — near at hand — in a glass or bowl, in order to.
free it at once from any mucous or other impurities,
which may attach to it ; and thus it is already prepared
for future use.
The brush is introduced during active respiration,,
or when the epiglottis is depressed and in order to-
raise it, whilst the patient pronounces the sound ^^aey
When we have passed over the root of the tongue^
the brush is then placed against the posterior plane of
the epiglottis and pressed almost vertically deeper, in
order to reach the glottis. This operation is not so
readily performed as it seems, particularly not so-
quickly as requisite ; it requires, therefore, some prac-
tice. It is much easier to get the brush behind the
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72 THE PRINCIPLES AND PRACTICE OF
epiglottis and press that down, instead of getting over
it into the larynx.
When the brush has reached the glottis, violent
spasms, fits of coughing, and shortness of breath,
sometimes seize the patient and frighten him ; but
these sensations are readily suppressed by taking a
drink of cold water immediately after. To illustrate
the result of this simple treatment in acute and chronic
inflammation of the larynx, we shall insert a few in-
structive cases selected from among many. If more
evidence is wanted, medical journals contain suflicient
proof of cases treated successfully by topical remedies.
Be it owing to our climate — the sudden change of
temperature, our mode of heating our houses, our
style of dress, our habits of living— certain it is, that
the various catarrhal affections are most frequently met
with in daily practice. Nor ought it to create surprise,
that the larynx, supplied with nerves and endowed with
exquisite sensibility, the door-keeper of the lungs as
well as the guardian of the vocal apparatus, with its
many intimate connections, the pharynx and nasal
centres above, the trachea and bronchi below, should
be subject to complications, most of which have re-
mained hidden from our view, and thus rendered treat-
ment almost empirical.
Case I. — Rev. J. H. , D.D., L y Kentucky,
«t. 45, short, active, robust, and enjoying good health ;
whilst laboring assiduously in the cause of the Sanitary
Commission in the West during 1862, ^B^t '64, was
attacked in the spring of 1864, with pain in the fauces
and larynx, at times sharply, sometimes dull and
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LARYNGOSCOPY AJSFD RHINOSCOPY. 73
heavy, so that gradually he was obliged to leave the
parish, and concluded to visit Europe for the purpose
of finding medical aid. In Paris, he consulted Dr.
Fauvel, who made local applications to the part, gave
inhalations, and also sent him to the springs. In No-
vember, 1865, the patient returned benefited, but still
complaining of the pain, and inability to speak for any
length of time, he placed himself under my care in
the city of New York.
Laryngoscopic Examination — December 9, 1865. — The
mucous membrane of the fauces is much congested
(presenting the appearance of raw beef), free border of
the epiglottis and its posterior plane are of a rather
subdued red color, the false vocal cords inflamed, and
along the free border of the true vocal cords is a reddish-
yellow margin resembling a seam.
The aryepiglottic folds as well as the mucous mem-
brane covering the arytenoid cartilages have an un-
healthy reddish-yellow appearance ; phlegm is lodged on