plication of caustic solutions. If proper care is exer-
cised no bad efl^ects can follow from this mischief in
the end.
Owing to the severity and rapidity of its action, gal-
vano-cautery is with difliculty applied to a small cir-^
cumscribed superficial spot, as is readily done with solid
caustic. Suppuration, following the application, is also
more extensive in the former than the latter applica-
tion.
It follows then, that as advantageous an agent as gal-
vano-cautery is for the entire destruction of morbid
Digitized by
Google
LARYNGOSCOPY AND RHINOSCOPY. 125
growths of considerable size within the larynx, the re-
moval of which on account of form, nature, etc., is ren-
dered impossible in any other way, it is not applicable
to the extirpation of small neoplasms situated on the
vocal cords.
No known cautery is so powerful, yet its work is
done without blood, particularly if the platinum-wire
is but gently heated, while the pain caused by the opera-
tion is hardly felt.
The last and most indispensable condition for the
success of the operation requires, that the application
of the platinum-wire or chain to the part to be de-
stroyed be distinctly seen and watched by the operator.
Of the instruments for galvano- cautery, among the
few that have been constructed, those of Briins are the
most serviceable and simple. They ought not
to be used for the purposes above indicated, except in
the hands of a ready and practised laryngoscopist. In
such hands, from the very fact of the exceptional cases
in which it is employed and the difficulty of its appli-
cation, laryngoscopal surgery will achieve its greatest
triumph, (von Briins.)
Very few cases have thus far been reported whereon
Galvano-Cautery has been successfully applied. The
difficulty of the subject has undoubtedly deterred many
from using it, besides the rare opportunity which is but
granted to few in practise, to have under treatment such
cases as require the application of this agent. When
more numerous data shall be at hand from different
observers, it will then be possible to compare the result
of this operative procedure with others employed under
similar circumstances.
Digitized by
Google
126 THE PRINCIPLES AND PRACTICE OF
CHAPTER IV.
THE APPLICATION OF GALVANISM TO THE LARYNX IN
TEMPORARY OR PERMANENT APHONIA.
The deviations of the human voice from its normal
condition are so numerous and subject to so many-
causes, that 'the study of the rational treatment of these
has received a new impulse with the era of the laryngo-
scope.
In the language of Dr. Stokes:* " The field is open
and promises a rich harvest." The field has been en-
tered by many observers. That wonderful and beauti-
ful mechanism whiqh gives rise to phonation is now
capable of being studied in its healthy as well as in its
diseased conditions. The various complaints classed
under the name of ^^Aphonia^^ have to yield to the
well directed efforts of the hand guided by sight.
In discussing the application of galvanism to the
treatment of aphonia, exception is made to organic
aphonia, arising from inflammation, whether acute or
chronic, induration or thickening, oedema above or
below the glottis, ulceration, growths and tumours, or
disease of the brain.
On the other hand galvanism deals with functional
aphonia, which is manifested by certain modifications
of the voice, that may vary from inconsiderable hoarse-
ness, (partial aphonia), to that of a total loss of voice,
(total aphonia).
* Diseases of the Chest.
Digitized by
Google
LARYNGOSCOPY AND RHINOSCOPY. 117
To illustrate this more clearly, the subject, instead of
having the power to give utterance to sounds at the
same pitch, high or low or both, as before, can utter
or sing only a few notes of the register or scale, pecu-
liarly circumscribed (oligotonic), or he may be able to
sound a single note (monotonic), or the register of his
voice may be higher or lower than before, in the latter
case often acquiring a peculiar timbre^ as for example the
falzetto voice of some artists ; or the voice, in addition
to its register becoming circumscribed, sounds harsh,
hoarse and fatiguing, its purity and strength gradually
diminishes, till in the place of the former sonorous
tones we only hear a gentle feeble effort to speak.
This is evidence manifested to us through the organ
of hearing of the presence of aphonia or phonetic par-
alysis, to which we must now add the evidence afforded
us by the laryngoscope. Through the latter we learn,
(having excepted all cases of organic aphonia as above),
that the causes of the various stages of aphonia, both
temporary or permanent, are owing to either a partial
or complete paralytic condition of the muscles of ten-
sion and motion of the vocal cords and arytenoid car-
tilages, more directly shown in the greater or less
degree of perfect approximation of the vocal cords.
The cause of this abnormal condition must, there-
fore, be situated either in the muscles which immedi-
ately govern the degree of tension and motion of the
vocal cords, inasmuch as these muscles have lost the
power of receiving the nerve-action necessary to pro-
duce contraction, or the power to react promptly to
the nerve-influence ; or the cause may be inherent in
Digitized by
Google
128 THE PRINCIPLES AND PRACTICE OF
the nerves supjflying these muscles, particularly the
inferior and superior laryngeal nerves, the power of
which, to conduct the cerebral impulse necessary to
speech to the respective muscles, is either diminished
or weakened, or entirely suspended. To one or both
of these abnormal conditions we may trace back all
those cases of functional aphonia as may arise from the
emotions, such as joy, anger or fright, from hysteria,
impaired innervation, certain local influences, conges-
tions and strains, exhausting diseases, pressure on
nerve-trunks, poisons, as the narcotics lead, antimony,
and arsenic.
To remedy such conditions as enumerated above, the
application of the galvanic current is rationally indi-
cated as one of the most powerful means to stimulate
and restore the action of nerves and muscles.
For this purpose the inducted current (more rarely
the constant current) is used. The extremity of the
poles attached by the wires to the proper apparatus
is olive-shaped, as advised by Duchenne. Dr. Mac-
kenzie has substituted an improved laryngeal galvanizer,
in which the current does not pass beyond the handle,
till the sponge is in contact with the vocal cords, the
handle is pressed down at the proper moment by the
index finger.
This admirable instrument has supplanted nearly all
others. Being constructed on the same principle as all
of Mackenzie's instruments, its use will be readily ac-
quired and its advantages appreciated. We use this
instrument with one of Stohrer's (of Dresden) coal and
zinc batteries.
Digitized by
Google
LARYNGOSCOPY AND RHINOSCOPY.
129
Fig. 53 represents Mackenzie's Laryngeal Galvanizer.
S
2
c
c
CO
Co
•s
fti
jq
.s
a.
to
â– g
•^
•T3
i-i
1
•s
>
^*
8
t
g
w
^
^
-^
•«
j5
Ctf
^
^
to
U3
>-
a.
3
c
IS
N
J3
TJ
4-t
p
<
C
>
-^
u
eu
g
<
cu
jq
•J
.2
-5
i
<
1
?
C
CTJ
••"•
<
C
Si
-s
'5
w
>
i-i
c
na
C
4>
4-1
3
.2
g
jq
.5
ftf
C4
CO
Os
>s
ftj
TJ
C
c
J3
1
to
.S
V
^
2
jq
1
2
.s
.2
B
(^
V
^
h
4>
g
CO
2
.5
h
.s
It is held in the hand between the thumb and second
finger ; when the sponge is in contact with the vocal
cords, the operator presses with his index-finger on the
12
Digitized by
Google
I30 THE PRINCIPLES AND PRACTICE OF
spring in the handle and the electric current passes
through the larynx to the skin externally.* To facili-
tate the application to the vocal cords, Mackenzie sug-
gests to the patient the wearing of a kind of elastic
necklet, in the centre of which is a piece of metal cov-
ered with sponge. This plate of metal, which is
inclosed in cotton, is about three inches long and one
and a half broad, and is bent back in the centre, so
that, when applied, it corresponds to the thyroid carti-
lage. Projecting forward from the centre of this thy-
roid pad is a metal eye, by which it may be connected
with the electric machine. The pad should be wetted
before it is put on the patient's neck. The employ-
ment of this necklet enables the operator to dispense
with assistants. When the point of the galvanizer is
placed on the vocal cords, the electric current passes
right through them in all directions, to reach the pole
over the thyroid cartilage.
Drs. Smyley, Johnson, Tobold, Fauvel and many
others have borne testimony to the value of this instru-
ment and we cannot but join gladly in their commen-
dations. We use it in preference to any other of its
kind, with and without the necklet.
It remains now to be stated where the current is to
be applied.
I St. Both poles of the battery may be directly
applied to the mucous membrane of the larynx, being
placed in close proximity to one another in the space
selected for the purpose.
* Mackenzie, page loi, c. 103.
Digitized by
Google
LARYNGOSCOPY AND RHINOSCOPY. 131
2d. One pole only may be placed upon the mucous
membrane of the larynx, whilst the other is applied to
the skin covering the larynx from without ; thus, by
placing the sponge of the galvanizer on the arytenoid
cartthat it is even unnecessary
sometimes to have his head held in proper position by
assistants during the operation.
CHAPTER VIII.
CONCLUDING REMARKS.
CzERMAK Stated somewhere, that many attempts
at laryngoscopy and rhinoscopy had failed in the hands
of students and physicians, because, discouraged by the
failure of their first experiments in the art, they were
disappointed and dropped the whole subject as un-
worthy of future investigation. This however is no
more true in regard to our art than is illustrated daily
in every difficult undertaking. He who lacks, therefore,
* Hypodermic injection has been tried by von BrGns to allay irritability of the
larynx, but we have thus far no satis^ctory data of the result.
Digitized by
Google
LARYNGOSCOPY AND RHINOSCOPY. 143
that important requisite ^^perseverance^* had better not
attempt to walk along its crooked paths. But to him,
who possesses that sine qua non, will be opened a rich
store-house of knowledge just beginning to be explored
and the fruit ripe for gathering.
Many instruments have been described in this essay
(we say this for the encouragement of beginners), that
are not positively necessary to the simple practice of
our art. A good light, a reflector and laryngeal mir-
ror, with a few brushes, will suffice for first attempts,
but he who desires to make laryngoscopy a study, let
him not hesitate to get the best and ample instruments
at once, regardless of expense, and disdain the idea of
reducing everything connected with it to the " cheap
principleJ*^ A man cannot work well in this or any
other useful calling without good tools. When he has
these, it is only after the eye and hand have been much
practiced in applying remedies to the larynx, that in-
struments such as the forceps or lancet, or porte-caus-
tique can be used with safety.
Time accomplishes these things.
Is there however no danger of too much medication
being applied to the larynx ? There is indeed danger
of being too meddlesome, as well as not doing enough
in this direction. For neither fault is there, however,
now-a-days an excuse, since the laryngoscope has
* All the instruments mentioned in connection with the subject discussed are to be
obtained of the well known and obliging firm of Messrs. Otto & Reynders, No. 64
Chatham street^ New Tork, to whose ability and readiness to serve me, as I have no
doubt they will other laryngoscopists, I bear most willing testimony.
Digitized by
Google
144 LARYNGOSCOPY AND RHINOSCOPY.
brought these parts so completely within our reach that
" to see" is almost "to do."
The most valuable additions to the diagnosis and
treatment of the diseases of the larynx and trachea have
been made since the discovery of the art of laryngo-
scopy and rhinoscopy. With its advent commenced a
proud era in the history of practical medicine, from
which we may reasonably expect still more flattering re-
sults in the future.
â– Digitized by
Google
APPENDIX
To page 56. — Infra-Glottic
Tracheoscopy.
Laryngoscopy or
We append Fig. 56, the small mirror of Dr. Neu-
dorfer, and also the fenestrated canula, into which, after
tracheotomy has been performed and the canula prop-
erly adjusted, the mirror is introduced with its re-
flecting face directed upward and forward.
Fig. 56.
Mirror of Ncudorfer, with Fenestrated Canula.
The canula must be provided with the largest possi-
ble window. The mirror must be made of thin plates
of steel, about the size of a lentil, and must, of course,
as in laryngoscopic examination, be warmed before
introduction.
Czermak, to prevent the frequent interruption of the
Digitized by
Google
146 APPENDIX.
examination caused by the rapid cooling of these little
mirrors, had them covered with a very thin layer of
dissolved caoutchouc, by means of which the image
remains clear for a longer time.
The procedure is as tedious as it is difficult. In a
healthy condition of the larynx, even, it must be remem-
bered, that the lower surface of the vocal cords is not
white, but reddened, resembling the mucous membrane
of the larynx ; hence they are recognized only by their
motion and not by their color ; the lower surface of
the epiglottis may be seen, if the glottis is open. Thus
Czermak claims to have thrown light into the larynx.
That the difficulties of examination are vastly in-
creased when we have (as is almost always the case)
to deal with pathological changes, is self-evident. The
. space within the larynx is not unfrequently narrowed in
consequence of the swelling of the mucous membrane
below the glottis, after the operation. But as Semel-
eder justly remarks,* the worth of the method lies in
this, that precisely in pathological cases the epiglottis,
either from tumefaction or from the shortening conse-
quent upon the cicatrix, preserves so unfavorable a
position, that the examination from above is very un-
productive. In this way, also, by the aid of the mirror,
the sound and other thin instruments might be intro-
duced.
The same author has reported a remarkable case of
laryngoscopic self-observation from below through the
canula.
Czermak has also reported two observations.
* Dr. Casweirs translation, page 9^.
Digitized by
Google
APPENDIX. 147
The application of this instrument to the examina-
tion of the larynx must of course be very limited, yet
it is exceedingly valuable and interesting. It cannot
be urged too much upon those having an opportunity to
examine the larynx from below, as directed above.
TiOpage 79. — The Syringe or Laryngeal Injector.
In addition to the syringes of Tiirck and Gibb,
given on page 79, we present here Fig. 57, Tobold's
Laryngeal Syringe, with xnirror attached.
Fig. 57.
Tobold's Laryngeal Syringe, with Mirror.
This instrument will be found useful in cases where
the operator desires to observe during the introduction
of fluids into the larynx or trachea the direction the
liquid takes, combining the laryngeal mirror with the
syringe. The only objection is, that the mirror gets
easily bespattered by the fluid injected, which may par-
tially obstruct the view and therefore defeat the object
intended.
Where the quantity of fluid to be injected is how-
ever small, there is nothing to be apprehended from
this objection. The manner of holding the instrument
will also contribute much toward the successful execu-
tion both of the operation and our purpose.
Digitized by
Google
148 APPENDIX.
To page 86. — Spray-Producers or Pulverizers.
To the various spray-producers mentioned page 86,
et seq., must yet be added Schnitzler's Spray-Producer
for the nose and pharynx, represented by Fig. 58.
Fio. 58. It consists of a glass recep-
tacle to receive the fluid to be
pulverized, into the top of which
is inserted a hard rubber tube,
the smaller hollow extremity of
which reaches almost to the
bottom of the glass receiver.
The free larger portion is of
g equal length but bent near its
§ extremity at an obtuse angle
g and terminating into a bulb
c pierced with holes. A little
g above its insertion into the re-
ceiver is placed a short, hollow
arm at right angles, into which
the tube of Clark's hand-ball
anatomizer is inserted. The
surplus air introduced into the
glass reservoir by means of
steady pressure upon the lower
W ball causes the fluid to be ex-
pelled from the numerous holes
[Schnitzler's Spray-Producer. ^^ the bulb in the form of fine
spray.
This instrument will be found principally useful in
the treatment of catarrh.
Digitized by
Google
APPENDIX. 149
To Page 99. — Application of Solid Caustic.
Among the many useful instruments for the appli-
cation of solid caustic to the larynx, one of the most
complete is that of Professor Tiirck.
* The large instrument is
represented somewhat re-
duced in size ; figs, e and
d are of natural size.
It has already been stated,
that the Porte-Caustique is
not to be employed indis-
criminately, but is almost
indispensable in healing up
obstinate ulcers, or to de-
stroy growths that cannot
otherwise be removed.
A patient presented him-
self two months ago, with
an old obstinate syphilitic
ulcer on the left aryepi-
glottic fold, which had re-
sisted former treatment,
^ although besides the use of
internal remedies nitrate of
silver in solution had been
faithfully applied. Tiirck's
Porte-Caustique being call-
ed into service six times
in the course of two weeks,
and the constitutional rem-
edies being continued, the
ulcer healed completely, to
the great delight of the
Turck'i Porte-Caustique. patient.
Digitized by
Google
150 APPENDIX.
Magnifying Instruments, Micrometers,
AND Double Mirrors.
No mention has been made in its appropriate place
of the use of magnifying instruments and micrometers
in practical laryngoscopy, for the reason that both these
instruments may safely be regarded as of no practical
use in the treatment of disease.
The former, intended to increase the size of the lar-
yngeal image, and recommended first by Dr. Wertheim
of Vienna, in 1859, the latter constructed by Merkel
of Leipzig, and Mandl of Paris, so as to measure the
exact size of different parts of the larynx, and for esti-
mating distances, both attest the ingenuity of the in-
ventors, without being of use to the practitioner.
The same remark applies to the use of double mir-
rors, first suggested by Czermak, by means of which
views of the floor of the nasal cavity are to be obtained.
Dr. Wagner and Dr. Voltolini alone have thus far tried
double mirrors. Wagner declares this method of ex-
perimenting as very laborious, the illumination does
not always succeed, and the image which is obtained
includes but little.
FINIS.
Digitized by
Google
INDEX
Abscess in the larynx, opening of, 103
at the base of the epiglottis, case of,
108
Anzsthesia, of the larynx, 141
Aphonia, 126
treated by galvanism, 128, 129,
I30> I3i> I3*> 133
Apparatus for illumination, 21
position of, 23
Applications of solutions to larynx, 67
Aryepiglottidean fold, 33
Arytenoid cartilages, 33
Asthma, cases treated by inhalation, 96
Auto-laryngoscopy, 42
Avery, Mr., experiments in laryngoscopy,
4
Babington, Dr., his glottiscope, 2
Bau'mes, Dr., his laryngoscope, 3
Bead, glass, in the left nostril, 58
Bennati, Dr., his laryngoscope, 3
Bozzini, Dr., his laryngoscope, 2
Bromide of potassium, 41
Brush, the laryngeal of Tiirck, 70
Cartilages, Santorini, 33
of Wrisberg, 38
Cases, illustrating the use of the rhino-
scope, 57
Catarrh, cases of, treated, 62, 72
simple, by inhalation, 91
chronic, by inhalation, 93
of larynx and bronchi, 94
Caustic, solid, application of, 99
Cautery, electric, 122
Cauterizer, laryngeal, 99, 148
Color, healthy, of the larynx, 61
of the turbinated bones, 62
of orifices of Eustachian tubes, 62
Cricoid cartilage, 33
Czermak, his first labors, 7
borrows Turck*s mirrors, 7
his claim to priority reviewed, 9
his travels, 1 3
introduced artificial light, 1 3
demonstrated rhinoscopy, 49
apparatus for auto-laryngoscopy, de-
scription of, 43
first practice of tracheoscopy, 47
Changes in position of mirror, 28
Direct light, 18
Direct laryngoscopic examination, 26
Durham, Mr., case of cystic tumor, ixo
Ecraseur, laryngeal, 121
Epiglottis, healthy, 33
deviations from its natural position,
37
illustrations of, 37
position among mankind, 39
Epiglottic pincette, 38
Escharotics, loi
Essentials for laryngoscopic examination,
IS
Face-shield, 88
False vocal cords, 33
Digitized by
Google
152
INDEX.
Fauces, great sensitireness and excitabil-
ity, 40
Fish-bone removed from larynx with for-
ceps, 138
Forceps, laryngeal, 140
Foreign bodies, removal of, 137
Fossa, innominata, 33
Galvanism, application of, to the larynx,
126
Oalvano-cautery, 122
Oalvanizer,' laryngeal, 120
Garcia, Mr., his observations, 5
his auto-laryngoscope, 42
Oibb, graduated laryngeal syringe, 79
laryngeal fluid pulverizer, 86
Glottis, 33
Gymnastic of larynx in aphonia, 133
Head rest, 27
Healthy larynx, 35
History of the invention, i
Hyoid fossa, 33
Hypertrophy of tonsils, 41
Johnson, Dr., his method of practicing
auto-laryngoscopy, 42
Illumination, 18
Inhaling apparatus, Siegle-Bergson, 87
InAra-glottic laryngoscopy, 47
Injector, laryngeal, 86
Lamp, different kinds of, 19
its position, 23
Lancet, laryngeal, 107.
Larynx, healthy, in natural position, 33
as seen in the mirror, 33
Laryngeal mirror, 15
Lewin*s pulverisateur, 84
Light, natural and artificial, 18
reflected, 19
Magnifying instruments, 150
Mackenzie, laryngeal galvanizer, 129
Micrometers, 150
Mirrors, double, 150
laryngeal, 15
Morbid growths, removal of, xzx
' by cutting, 113
by ligation, 121
Morgagni, ventricle of, 33
Morphine in Chloroform, 41
Mou^, his pharyngoscope, 21
Neudorfer, Dr., his canula mirror, 145
Obstacles, encountered in laryngoscopic
examination, 35
Obstruction of nasal passage, 57
CEdema, treated by scarification, case of,
Z08
Palate, hook, 50
lasso, 52
Phthisis, tubercular, treated by inhala-
tion, 97
Position of patient and physician, 26
of head and tongue of patient, 27
of hand and mirror, 30
Powders, the application of, to the la-
rynx, 98
Practice of laryngoscopy, 15
Profile of laryngeal mirrors, 17
Prize Monty on, 1861, 12
Pseudo- Aphonia, 137
Pulverbateurs, 80
Recipro-Laryngoscopy, 45
Reflector, description of, 17
position of, 17, 19
Reflected light, compared with
direct, 18
Rhinal image, 54
Rhinoscopy, history of, 49
by whom first practiced, 49
how practiced, 53
objects seen in examination, 54, 55
cases illustrative of the
practice of, 57
Scarification of the larynx, 103
Sellique, laryngeal speculum, 3
Senn, Dr., his laryngeal mirror, a
Digitized by
Google
INDEX.
«53
Siegle, Dr., his experiments^ 86
his apparatus, 87
Smyly, Dr., his mode of demonstrating a
patient*8 larynx to others, 45
Solutions, when applied, 67
used, 68
how applied, 69
Special difficulties in laryngoscopy, 35
Sunlight, 18
Syphilitic ulcers of larynx and pharynx, 95
Schnitzler, spray-producer, 148
Thyroid cartilage, 33
Tobold, Dr., his apparatus for illum-
ination, 25
phantom, 31
laryngeal syringe, with mirror, 146
polypus instruments for decision,
excision, puncture, 114, 115
Tongue, the, 36
Tracheoscopy (see Infra-glottic laryngosy
copy), 47
Trousseau, laryngeal speculum, 3
Turbinated bones, diseased, 59
TUrck, Dr., revives the laryngoscope in
medicine, 6
first experiment, with laryngeal mir-
ror, 6