A system of practical medicine. By American authors. Vol. 3

Chapter I: Part 1

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A SYSTEM OF PRACTICAL MEDICINE.

BY AMERICAN AUTHORS.

EDITED BY WILLIAM PEPPER, M.D., LL.D.,

PROVOST AND PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE AND OF CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA.

ASSISTED BY LOUIS STARR, M.D.,

CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA.

VOLUME III.

DISEASES OF THE RESPIRATORY, CIRCULATORY, AND HÆMATOPOIETIC SYSTEMS.

PHILADELPHIA: LEA BROTHERS & CO. 1885.

Entered according to Act of Congress, in the year 1885, by

LEA BROTHERS & CO.,

WESTCOTT & THOMSON, _Stereotypers and Electrotypers, Philada._

WILLIAM J. DORNAN, _Printer, Philada._

CONTENTS OF VOLUME III.

DISEASES OF THE RESPIRATORY SYSTEM. PAGE LARYNGOSCOPY AND RHINOSCOPY. By CARL SEILER, M.D. . . . . . . . . 19

DISEASES OF THE NASAL PASSAGES. By HARRISON ALLEN, M.D. . . . . . 41

NEUROSES OF THE LARYNX. By HOSMER A. JOHNSON, M.D., LL.D. . . . . 59

ACUTE CATARRHAL LARYNGITIS (FALSE OR SPASMODIC CROUP).
By ABRAHAM JACOBI, M.D. . . . . . . . . . . . . . . . . . . . . 92

PSEUDO-MEMBRANOUS LARYNGITIS. By ABRAHAM JACOBI, M.D. . . . . . . 100

DISEASES OF THE LARYNX. By LOUIS ELSBERG, A.M., M.D. . . . . . . 109

DISEASES OF THE TRACHEA. By LOUIS ELSBERG, A.M., M.D. . . . . . . 133

TRACHEOTOMY. By GEORGE M. LEFFERTS, A.M., M.D. . . . . . . . . . 145

DISEASES OF THE BRONCHI. By N. S. DAVIS, M.D., LL.D. . . . . . . 164

BRONCHIAL ASTHMA. By W. H. GEDDINGS, M.D. . . . . . . . . . . . . 184

HAY ASTHMA. By W. H. GEDDINGS, M.D. . . . . . . . . . . . . . . . 210

DILATATION OF THE BRONCHIAL TUBES, CIRCUMSCRIBED AND DIFFUSED.
By SAMUEL C. CHEW, M.D. . . . . . . . . . . . . . . . . . . . . 227

EMPHYSEMA. By SAMUEL C. CHEW, M.D. . . . . . . . . . . . . . . . 232

COLLAPSE OF THE LUNG (ATELECTASIS). By SAMUEL C. CHEW, M.D. . . . 250

CONGESTION AND OEDEMA OF THE LUNGS (HYPOSTATIC PNEUMONIA).
By SAMUEL C. CHEW, M.D. . . . . . . . . . . . . . . . . . . . . 258

HÆMOPTYSIS. By WILLIAM CARSON, M.D. . . . . . . . . . . . . . . . 266

PULMONARY APOPLEXY. By WILLIAM CARSON, M.D. . . . . . . . . . . . 293

ABSCESS OF THE LUNG. By WILLIAM CARSON, M.D. . . . . . . . . . . 296

GANGRENE OF THE LUNG. By WILLIAM CARSON, M.D. . . . . . . . . . . 301

CROUPOUS PNEUMONIA. By ALFRED L. LOOMIS, M.D., LL.D. . . . . . . 307

CATARRHAL PNEUMONIA. By WILLIAM PEPPER, M.D., LL.D. . . . . . . . 353

PULMONARY EMBOLISM. By BEVERLEY ROBINSON, M.D. . . . . . . . . . 373

PULMONARY PHTHISIS (FIBROID PHTHISIS OR CHRONIC INTERSTITIAL
PNEUMONIA). By AUSTIN FLINT, M.D. . . . . . . . . . . . . . . . 391

SYPHILITIC DISEASE OF THE LUNG. By EDWARD T. BRUEN, M.D. . . . . 447

PNEUMONOKONIOSIS. By EDWARD T. BRUEN, M.D. . . . . . . . . . . . 454

CANCER OF THE LUNGS. By EDWARD T. BRUEN, M.D. . . . . . . . . . . 460

PULMONARY HYDATIDS. By EDWARD T. BRUEN, M.D. . . . . . . . . . . 466

ACUTE MILIARY TUBERCULOSIS. By JOHN S. LYNCH, M.D. . . . . . . . 472

DISEASES OF THE PLEURA. By FRANK DONALDSON, M.D. . . . . . . . . 483

DISEASES OF THE CIRCULATORY SYSTEM.

DISEASES OF THE SUBSTANCE OF THE HEART. By WILLIAM OSLER, M.D. . 601

ENDOCARDITIS AND CARDIAC VALVULAR DISEASES.
By ALFRED L. LOOMIS, M.D., LL.D. . . . . . . . . . . . . . . . 639

CYANOSIS AND CONGENITAL ANOMALIES OF THE HEART AND GREAT VESSELS.
By MORRIS LONGSTRETH, M.D. . . . . . . . . . . . . . . . . . . 687

CARDIAC THROMBOSIS. By BEVERLEY ROBINSON, M.D. . . . . . . . . . 718

NEUROSES OF THE HEART. By AUSTIN FLINT, M.D. . . . . . . . . . . 747

DISEASES OF THE PERICARDIUM. By J. M. DACOSTA, M.D., LL.D. . . . 769

THE OPERATIVE TREATMENT OF PERICARDIAL EFFUSIONS.
By JOHN B. ROBERTS, A.M., M.D. . . . . . . . . . . . . . . . . 794

DISEASES OF THE AORTA. By G. M. GARLAND, M.D. . . . . . . . . . . 800

DISEASES OF THE CORONARY, PULMONARY, SUPERIOR MESENTERIC,
INFERIOR MESENTERIC, AND HEPATIC ARTERIES, AND OF THE COELIAC
AXIS. By ELBRIDGE G. CUTLER, M.D. . . . . . . . . . . . . . . . 828

DISEASES OF THE VEINS. By ANDREW HEERMANCE SMITH, M.D. . . . . . 843

THE CAISSON DISEASE. By ANDREW HEERMANCE SMITH, M. D. . . . . . . 854

DISEASES OF THE MEDIASTINUM. By EDWARD T. BRUEN, M.D. . . . . . . 861

DISEASES OF THE BLOOD AND OF THE HÆMATOPOIETIC SYSTEM.

DISEASES OF THE BLOOD AND BLOOD-GLANDULAR SYSTEM.
By WILLIAM OSLER, M.D. . . . . . . . . . . . . . . . . . . . . 882

DISEASES OF THE SPLEEN. By I. EDMONDSON ATKINSON, M.D. . . . . . 951

DISEASES OF THE THYROID GLAND. By D. HAYES AGNEW, M.D., LL.D. . . 974

SIMPLE LYMPHANGITIS. By SAMUEL C. BUSEY, M.D. . . . . . . . . . . 983

INDEX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 993

CONTRIBUTORS TO VOLUME III.

AGNEW, D. HAYES, M.D., LL.D.,
Professor of Principles and Practice of Surgery in the University of
Pennsylvania, Philadelphia.

ALLEN, HARRISON, M.D.,
Emeritus Professor of Physiology in the University of Pennsylvania,
Philadelphia.

ATKINSON, I. EDMONDSON, M.D.,
Professor of Pathology and Clinical Medicine and Clinical Professor
of Dermatology in the University of Maryland, Baltimore.

BRUEN, EDWARD T., M.D.,
Assistant Professor of Physical Diagnosis in the University of
Pennsylvania; Physician to Philadelphia (Blockley) Hospital; Lecturer
on Pathology in the Woman's Medical College, Philadelphia.

BUSEY, SAMUEL C., M.D.,
Attending Physician and Chairman of the Board of Hospital
Administration of the Children's Hospital, Washington, D.C.

CARSON, WILLIAM, M.D.,
Physician to and Clinical Lecturer at the Cincinnati Hospital,
Cincinnati.

CHEW, SAMUEL C., M.D.,
Professor of Materia Medica, Therapeutics, and Clinical Medicine in
the University of Maryland, Baltimore.

CUTLER, ELBRIDGE G., M.D.,
Clinical Instructor in Auscultation in the Harvard Medical School;
Physician to Out-Patients, Massachusetts General Hospital.

DACOSTA, J. M., M.D., LL.D.,
Professor of Theory and Practice of Medicine in the Jefferson Medical
College, Philadelphia.

DAVIS, N. S., M.D., LL.D.,
Professor of Principles and Practice of Medicine in the Chicago
Medical College, Chicago.

DONALDSON, FRANK, M.D.,
Clinical Professor of Diseases of the Throat and Chest in the
University of Maryland, Baltimore.

ELSBERG, LOUIS, A.M., M.D.,
Late Professor of Laryngology and Rhinology in the New York
Polyclinic and in Dartmouth Medical College; Physician to Charity
Hospital, Blackwell's Island (Throat Wards), New York.

FLINT, AUSTIN, M.D.,
Professor of the Principles and Practice of Medicine and Clinical
Medicine in the Bellevue Hospital Medical College, New York.

GARLAND, G. M., M.D.,
Formerly Professor of Thoracic Diseases in the University of Vermont,
and Assistant in Clinical Medicine in Harvard Medical School.

GEDDINGS, W. H., M.D.,
Aiken, South Carolina, and Bethlehem, N.H.

JACOBI, ABRAHAM, M.D.,
Clinical Professor of Diseases of Children in the College of
Physicians and Surgeons, New York, etc.

JOHNSON, HOSMER A., M.D., LL.D.,
Emeritus Professor of Practical Medicine in the Chicago Medical
College, Chicago.

LEFFERTS, GEORGE M., A.M., M.D.,
Professor of Laryngoscopy and Diseases of the Throat in the College
of Physicians and Surgeons, New York; Consulting Laryngoscopic
Surgeon to St. Luke's Hospital, etc.

LONGSTRETH, MORRIS, M.D.,
Physician to the Pennsylvania Hospital, Philadelphia.

LOOMIS, ALFRED L., M.D., LL.D.,
Professor of Pathology and Practice of Medicine in the University of
the City of New York.

LYNCH, JOHN S., M.D.,
Professor of Principles and Practice of Medicine in the College of
Physicians and Surgeons, Baltimore.

OSLER, WILLIAM, M.D.,
Professor of Clinical Medicine in the University of Pennsylvania;
formerly Professor of the Institutes of Medicine in McGill
University, Montreal.

PEPPER, WILLIAM, M.D., LL.D.,
Professor of the Theory and Practice of Medicine and of Clinical
Medicine in the University of Pennsylvania, Philadelphia.

ROBERTS, JOHN B., A.M., M.D.,
Professor of Applied Anatomy and Operative Surgery in the
Philadelphia Polyclinic and College for Graduates in Medicine.

ROBINSON, BEVERLEY, M.D.,
Clinical Professor of Medicine in the Bellevue Hospital Medical
College, New York.

SEILER, CARL, M.D.,
Instructor in Laryngoscopy in the University of Pennsylvania;
Professor of Acoustics and Vocal Physiology at the National School of
Oratory, Philadelphia.

SMITH, ANDREW HEERMANCE, M.D.,
Professor of Therapeutics and Clinical Medicine in the New York
Post-Graduate Medical School; Physician to the Presbyterian Hospital,
New York.

ILLUSTRATIONS.

FIGURE PAGE 1. LARYNGEAL MIRROR . . . . . . . . . . . . . . . . . . . . . . . 21

2. HEAD REFLECTOR . . . . . . . . . . . . . . . . . . . . . . . . 23

3. SEILER'S ELECTRIC ILLUMINATOR FOR THE LARYNGOSCOPE . . . . . . 24

4. POSITION OF HAND IN HOLDING THE LARYNGEAL MIRROR . . . . . . . 27

5. SECTION OF THE HEAD, SHOWING THE POSITION OF LARYNGEAL MIRROR
IN THE PHARYNX . . . . . . . . . . . . . . . . . . . . . . . 27

6. ELSBERG'S SPONGE-HOLDER AND EPIGLOTTIS FORCEPS . . . . . . . . 29

7. LARYNGEAL IMAGE DURING RESPIRATION . . . . . . . . . . . . . . 31

8. LARYNGEAL IMAGE DURING PHONATION . . . . . . . . . . . . . . . 31

9. LARYNGOSCOPIC DIAGRAM, SHOWING VOCAL CORDS WIDELY DRAWN APART,
AND THE POSITION OF THE VARIOUS PARTS DURING QUIET BREATHING 31

10. THE SAME, SHOWING APPROXIMATION OF VOCAL CORDS AND POSITION OF
THE VARIOUS PARTS DURING VOCALIZATION . . . . . . . . . . . 31

11. VERTICAL SECTION OF THE HEAD . . . . . . . . . . . . . . . . . 33

12. NASAL SPECULUM . . . . . . . . . . . . . . . . . . . . . . . . 36

13. BOSWORTH'S NASAL DILATOR . . . . . . . . . . . . . . . . . . . 36

14. SEPTOMETER FOR MEASURING THICKNESS OF NASAL SEPTUM . . . . . . 37

15. FOLDING TONGUE DEPRESSOR . . . . . . . . . . . . . . . . . . . 38

16. COHEN'S TONGUE DEPRESSOR . . . . . . . . . . . . . . . . . . . 38

17. JARVIS'S RHINOSCOPIC MIRROR AND TONGUE DEPRESSOR . . . . . . . 39

18. RHINOSCOPIC IMAGE . . . . . . . . . . . . . . . . . . . . . . 39

19. SHOWING ANTERO-POSTERIOR SECTION OF BONES OF THE FACE IN
POSITION . . . . . . . . . . . . . . . . . . . . . . . . . . 48

20. BELLOCQ'S CANULA . . . . . . . . . . . . . . . . . . . . . . . 52

21. ALLEN'S NASAL FORCEPS . . . . . . . . . . . . . . . . . . . . 54

22. THE GALVANO-CAUTERY SNARE . . . . . . . . . . . . . . . . . . 56

23. DOUBLE BATTERY AND FLEMING ELECTRODE FOR USE IN NASAL DISEASES 56

24. TWO ELECTRODES OF PECULIAR SHAPE, FOR USE IN NASAL DISEASES . 58

25. ACUTE TRACHEITIS: ANTERIOR WALL . . . . . . . . . . . . . . . 135

26. SAME CASE AS FIG. 25: POSTERIOR WALL . . . . . . . . . . . . . 135

27. TUBERCULOUS ULCERATION OF THE TRACHEA, AS SEEN DURING LIFE . . 137

28. SAME CASE AS FIG. 27: POST-MORTEM APPEARANCE . . . . . . . . . 137

29. SYPHILITIC ULCERATION OF TRACHEA, AS SEEN DURING LIFE . . . . 137

30. SAME CASE AS FIG. 29: POST-MORTEM APPEARANCE . . . . . . . . . 138

31. PAPILLOMA OF TRACHEA . . . . . . . . . . . . . . . . . . . . . 141

32. INVOLUTION OF TRACHEA, DUE TO ANEURISM . . . . . . . . . . . . 142

33. A TYPICAL CASE OF LOBAR PNEUMONIA IN THE ADULT: RECOVERY . . . 324

34. LOBAR PNEUMONIA, WITH CRISIS MARKED BY EVENING EXACERBATIONS
REACHING NEARLY THE HIGHEST PYREXIA OF THE SECOND STAGE . . 325

35. A TYPICAL CASE OF LOBAR PNEUMONIA IN A CHILD: RECOVERY . . . . 326

36. A CASE OF LOBAR PNEUMONIA IN A BOY TEN YEARS OLD, IN WHICH
TEMPERATURE WAS TAKEN EVERY FOUR HOURS . . . . . . . . . . . 327

37. A TYPICAL CASE OF SENILE LOBAR PNEUMONIA . . . . . . . . . . . 327

38. CROUPOUS PNEUMONIA IN THE ADULT, TERMINATION OF, IN PURULENT
INFILTRATION . . . . . . . . . . . . . . . . . . . . . . . . 333

39. ACUTE LOBAR (CROUPOUS) PNEUMONIA IN A CHILD: RECOVERY . . . . 341

40. ACUTE LOBULAR (CATARRHAL) PNEUMONIA IN A CHILD: RECOVERY . . . 341

41. SPHYGMOGRAPHIC TRACING OF AORTIC OBSTRUCTION (AFTER FOSTER) . 656

42. SPHYGMOGRAPHIC TRACING OF AORTIC REGURGITATION . . . . . . . . 662

43. SPHYGMOGRAPHIC TRACING OF AORTIC OBSTRUCTION AND REGURGITATION 662

44. SPHYGMOGRAPHIC TRACING OF MITRAL OBSTRUCTION . . . . . . . . . 667

45. SPHYGMOGRAPHIC TRACING OF MITRAL AND AORTIC OBSTRUCTION AND
REGURGITATION . . . . . . . . . . . . . . . . . . . . . . . 669

46. SPHYGMOGRAPHIC TRACING OF MITRAL REGURGITATION . . . . . . . . 672

47. SPHYGMOGRAPHIC TRACING OF MITRAL AND AORTIC REGURGITATION . . 672

48. SPHYGMOGRAPHIC TRACING OF TRICUSPID REGURGITATION . . . . . . 679

49. ROBERTS'S PERICARDIAL ASPIRATING TROCAR . . . . . . . . . . . 797

50. SPHYGMOGRAPHIC TRACING OF NORMAL PULSE . . . . . . . . . . . . 809

51. SPHYGMOGRAPHIC TRACING OF RIGHT AND LEFT RADIAL PULSE IN
ANEURISM OF THE AORTA . . . . . . . . . . . . . . . . . . . 810

52. ARCH OF AORTA DURING EARLY FOETAL LIFE . . . . . . . . . . . . 826

53. SARCOMATOUS TUMOR OF ANTERIOR MEDIASTINUM . . . . . . . . . . 866

54. SECONDARY MYELOID SARCOMA OF MEDIASTINUM . . . . . . . . . . . 868

55. RESECTION OF STERNUM FOR REMOVAL OF ENCHONDROMA . . . . . . . 880

DISEASES OF THE RESPIRATORY SYSTEM.

{19}

LARYNGOSCOPY AND RHINOSCOPY.

BY CARL SEILER, M.D.

The laryngoscope is a combination of instruments designed for the examination of the interior of the larynx and upper part of the trachea, while the rhinoscope is a similar combination of instruments designed to explore the posterior nasal cavity; and both are comparatively recent inventions.

HISTORY OF THE LARYNGOSCOPE.--In medical literature before the middle of the eighteenth century no mention is made of an instrument or apparatus resembling the laryngoscope, but recent excavations at Pompeii have brought to light small polished metal mirrors attached to slender handles which are supposed to have been used to inspect the cavities of the human body. The first authenticated attempt at laryngoscopy and rhinoscopy was made by the distinguished French accoucheur M. Levret in the year 1743, who invented, among other surgical instruments, an apparatus by means of which polypoid growths in the cavities of the nose, throat, ear, etc. could be seen, and a ligature be passed around them for their removal.[1] This apparatus consisted mainly of a polished metal mirror which "reflected the luminous rays in the direction of the tumor," and on whose surface the image of the growth was seen to be reflected. The great value of this apparatus for the diagnosis and treatment of nasal and laryngeal diseases was, however, not recognized, and it shared the fate of many other valuable discoveries which were made before the world was ready to receive them: it was forgotten.

[Footnote 1: _Mercure de France_, 1743, p. 2434.]

In 1807 a certain Dr. Bozzini, living in Frankfort-on-the-Main, published a work describing an apparatus which he had invented for the illumination and examination of the cavities of the human body.[2] This apparatus consisted of a peculiarly-shaped lamp and of a number of metal tubes, polished on their inner surface, of various shapes and sizes adapted for the different cavities of the body. The one intended for the examination of the larynx was bent near its end at a right angle, and had a mirror placed at the bend, which served to throw the light downward toward the opening of the larynx when the tube was inserted into the mouth. When reflected light was to be used, the interior of the tube or speculum was divided into two portions by a longitudinal septum, and two mirrors were inserted at the bend--one for the reflection of the light downward, and the other for receiving the reflected image. This invention of Bozzini was treated, however, with derision by the medical profession, probably on account of the extravagant descriptions given of it in the papers, which were not verified by its performances.

[Footnote 2: "Der Lichtleiter," Philipp Bozzini, _Med. und Chir. Dr._, Weimar, 1807.]

In 1825, Cagniard de Latour, an investigator of the physiology of the voice, made some unsuccessful attempts to examine the living larynx.[3]

[Footnote 3: _Physiologie de la Voix_, par Ed. Tournié, Paris, 1865.]

{20} Senn of Geneva in 1827 endeavored to examine the larynx of a little girl suffering from an affection of the throat by means of a small mirror which he had made and which he inserted into the pharynx, but he failed to see the glottis, because, as he says, the mirror was too small, and because he used neither direct nor reflected light to illuminate the cavity below the mirror.[4]

[Footnote 4: _Journal de Progrès des Sciences, etc._, 1829.]

In the year 1829, Benjamin Guy Babington published[5] an account of what he called the glottiscope, an apparatus which consisted mainly of two mirrors. One of these was small and attached to a slender stem, and was used to receive the image, while the other, an ordinary hand-glass, was used to reflect the rays of the sun or ordinary daylight upon the smaller mirror in the fauces. This combination was essentially the same as is used at the present day in the laryngoscope, with the difference that we now use artificial light in most instances, and a concave mirror instead of a plane one for reflecting the light.

[Footnote 5: _Lond. Med. Gazette_, 1829, vol. iii.]

While Babington was still engaged in perfecting his instruments, a mechanic named Selligue, who suffered from an affection of the throat, in 1832 invented a speculum for his physician, Bennati of Paris, with which the latter was able, as he asserted,[6] to see the vocal cords. This instrument was similar to the one invented by Bozzini, and consisted of a double speculum bent at right angles and carrying two mirrors--one for illuminating the cavity, and the other for reflecting the image. Selligue was rewarded for his efforts by a complete cure of his affection.

[Footnote 6: _Recherches sur le Mécanisme de la Voix humane_.]

A number of others worked in the same direction, and endeavored to see the interior of the larynx in the living subject by employing different apparatus and methods of illumination. Thus, in 1838, Baumès of Lyons described a mirror the size of a two-franc piece (1-1/8 inches in diameter) as useful in examining the larynx and posterior nares.[7] Then Liston in 1840 used a dentist's mirror,[8] and Warden of Edinburgh employed a prism of flint glass attached to a long stem as a laryngeal mirror.[9] In the latter part of the same year Avery of London employed a speculum with a mirror in its end for examining the larynx, using as an illuminator a concave reflector with a central opening, which was supported by a frame to be worn on the head of the operator.[10]

[Footnote 7: _Compte Rendu des Travaux de la Société de Médecine de Lyons_, 1836-38.]

[Footnote 8: _Practical Surgery_, 1840.]

[Footnote 9: _Lond. Med. Gazette_, vol. xxiv. p. 256.]

[Footnote 10: _Med. Circ._, June, 1862.]

Up to this time all efforts at laryngoscopy had been made with a view to diagnose diseases of the larynx, with the exception of those made by Latour. In the year 1854, however, Signor Manuel Garcia of London, without any knowledge of previous efforts, conceived the idea of studying the changes in the larynx during phonation in his own throat. For this purpose he placed a small dentist's mirror against the uvula and reflected the rays of the sun into his mouth and upon the small mirror by means of a hand-glass held in the other hand. By arranging his position in relation to the sun in such a manner that he could see the reflected image of the small mirror in his throat in the hand-glass, and in it the illuminated image of his larynx, after a few ineffectual attempts his efforts at auto-laryngoscopy were crowned with such success that he was enabled to study the movements of the vocal cords during phonation, and accurately describe the registers of the voice in a paper read before the Royal Society of London in 1855.[11] Although Garcia was the first who practised laryngoscopy successfully, his communication to the Royal Society attracted little attention, and would have been forgotten if it had not been that, in 1857, Tuerk of Vienna, having heard of Garcia's paper, began to use the laryngeal mirror on the patients in the K. K. Algem. Krankenhaus for {21} diagnostic purposes.[12] At first he was not very successful in his attempts, and began to experiment with laryngeal mirrors of different sizes and shapes. While thus engaged Czermak borrowed Tuerk's mirrors, and modified them until he succeeded in the greater number of cases in seeing the vocal cords,[13] using artificial light for illuminating the larynx. Meanwhile, Tuerk continued his experiments, and also succeeded in almost all cases of throat disease which came to his department of the hospital in seeing the interior of the larynx and in treating the lesions. Both Tuerk and Czermak improved their apparatus, and especially the latter, who by substituting artificial light for sunlight, and by inventing a number of different illuminating apparatuses, has given us the laryngoscope in the form in which it is used at the present day. It is but natural that Tuerk should have claimed priority in the successful use of this instrument, and in consequence of this claim a controversy was carried on for a number of years in the medical press between him and Czermak, which at times became quite spirited, but which left Czermak master of the field. In the winter of 1858-59, Madam E. Seiler, having heard of Czermak's experiments, had a laryngeal mirror constructed from his description, practised laryngoscopy successfully on herself and others, among them the writer, with a view to study the physiology of the voice. Her efforts being crowned with success, she was able not only to verify Garcia's observations in regard to the registers, but also discovered the so-called head register of the female voice, as well as two small cartilages in the vocal cords.[14]

[Footnote 11: _Proc. Royal Society of London_, vol. vii. No. 13, 1855.]

[Footnote 12: _Zeitschrift der Ges. der Aerzte zu Wien_, April, 1858.]

[Footnote 13: _Wien. Medicin. Wochenschrift_, March, 1858.]

[Footnote 14: _Altes und Neues_, Leipzig, 1861.]

HISTORY OF THE RHINOSCOPE.--Rhinoscopy, or the art of viewing the naso-pharyngeal space by placing a small mirror behind the velum palati, naturally suggested itself almost as soon as any attempts at laryngoscopy were made, but in the literature we find that Bozzini was the first to clearly express the idea.[15]

[Footnote 15: _Loc. cit._]

A number of years later Wilde endeavored to see the opening of the Eustachian tubes by means of a small mirror: an account of these experiments he published in his famous work on the diseases of the ear.

In 1836, Baumès used the rhinoscope, and claimed to have seen ulcerations in the naso-pharyngeal cavity.[16] It remained, however, for modern times to develop this field of research, and it is again Czermak whom we have to thank for the perfection of this valuable means of diagnosis.

[Footnote 16: _Loc. cit._]

THE LARYNGOSCOPE.--The laryngoscope as it is used at the present day, both by the specialist and the general practitioner of medicine, consists of a so-called laryngeal mirror and of an illuminating apparatus more or less complicated. The laryngeal mirror is a small circular glass mirror mounted in a metal frame varying in size from ¾ inch to 1½ inches in diameter, and attached to a wire stem at an angle of 120°. This stem, about 4 inches in length and about 1/10 inch in thickness, should be soldered to the back of the mirror in such a manner that the rim of the frame forms the angle with the stem, and should not be below it, as this would increase the diameter of the instrument without increasing its reflecting surface. The stem is made to slide into a hollow handle of wood, ivory, or ebonite, and is clamped at any desired length by a set-screw. This arrangement is preferable to having the stem permanently fixed in the handle, inasmuch as the stem can be pushed entirely into it, thus economizing space and rendering the instrument more portable, and also allowing an adjustment of the length of the stem when in use. The handle should be 4 inches in length, and of the thickness of an ordinary lead-pencil (Fig. 1).

Mirrors of various shapes have been used, but it has been found that the circular form is the one most easily borne by the patient, and can be used in {22} a greater number of cases than any other shape, at the same time giving the largest reflecting surface for its size. However, in cases where an hypertrophy of the tonsils is present an oval mirror can be introduced between the protruding glands more easily than a round one.

This laryngeal mirror, however, would be of little or no value as an instrument of diagnosis if used by itself, for in order to see the cavity of the larynx it must be illuminated, lying as it does far below the level of the back of the tongue; and this cannot be done satisfactorily by merely allowing ordinary daylight to fall into the oral cavity. It becomes, therefore, necessary to use a stronger light to illuminate the larynx, and for this purpose either direct or reflected artificial or sunlight may be used.

Direct illumination, by allowing a strong artificial light or sunlight to fall into the patient's mouth, although it is used by several of the eminent laryngologists of Europe, is both inconvenient and unsatisfactory, because the observer must either place his head in the path of the light in order to be able to see the surface of the laryngeal mirror, as in the case when sunlight is used, or he must place the lamp, candle, or other source of light between himself and the patient, which materially interferes with the freedom of his motions. For these reasons reflected light is now almost universally employed in laryngoscopy.

Reflected light may be obtained by throwing the light of a lamp, candle, gas-jet, or light from any other source into the mouth of the patient by means of a round concave reflector. This concave mirror--which, when made of glass, should be silvered and not backed with amalgam--is from 3 to 4 inches in diameter, and should have a focus of from 12 to 14 inches. The metal frame in which it is mounted is attached by means of a ball-and-socket joint to some contrivance by which it can be supported on the observer's head or be attached to the source of illumination if a stationary artificial light, such as a gas-lamp, is used at the physician's office.

A variety of devices for fastening the reflector on the head of the observer is in use, among which the head band, introduced by Cramer, will be found the most serviceable. It consists of a broad strap of some strong material which passes around the head and is fastened at the back by a buckle. To the part of the band or strap resting on the forehead is attached a padded plate, to which the reflector is fastened with its ball-and-socket joint (Fig. 2). The reflector usually either has a small hole in the centre or a small space in the centre is left unsilvered. This opening is intended to be brought before the pupil of one or the other eye of the observer in such a manner that the line of vision and that of light have exactly the same direction. Using the reflector in this way like the reflector of the ophthalmoscope, it is easier to obtain the image of the larynx well illuminated, but with the great disadvantage of {23} monocular vision, which makes all objects appear on the same plane and prevents a correct interpretation of distances--a very important point in laryngoscopy. It will therefore be found more advantageous to place the reflector on the forehead, and from thence reflect the light into the patient's larynx. Both eyes may thus be employed in viewing the laryngeal image, and a correct idea of the relations of parts in regard to distance may be formed.

The line of vision and the path of the beam of light in order to obtain the best results should be in the same plane as though the light emanated from the pupil of the observer; but practically the position of the reflector upon the forehead is nearly as good as when the hole in it is brought before the eye, because a line drawn from the pupil of the eye to the laryngeal mirror, and a line from the reflector upon the forehead to the mirror, do not form an angle sufficient to make any very great difference in the reflection of the light downward, and very little difficulty will be experienced in obtaining the desired image.

The head reflector should be concave when artificial light or ordinary daylight is used, but be plane when direct sunlight is employed, for the concentration of the sun's rays by a concave reflector produces so much heat as to become painful to the patient.

THE SOURCE OF LIGHT.--As an artificial source of light a candle, coal oil lamp, gas-flame, or incandescent electric lamp suffices for ordinary purposes. But frequently it is desirable to have a much stronger light than can be obtained without concentration, and several forms of apparatus for concentrating artificial light have been constructed and are in use. Among these, Tobold's lamp and Mackenzie's light concentrator are the most convenient and most universally used.

Tobold's lamp consists of a brass tube containing several lenses, which are placed, one before the other, at such distances as to give the greatest possible amount of concentration of light. The back part of the tube is closed, while near the end two large holes are cut in its sides opposite to each other, through which the chimney of the lamp projects. The whole is fastened by means of clamps to a stand, to which is also attached a jointed arm bearing the reflector. This apparatus is used either in connection with a student's lamp or with an argand gas-lamp, and it will be found very convenient to have it mounted upon a gas-bracket which can be raised and lowered and swung from side to side.

Mackenzie's light concentrator consists of a cylinder of sheet iron about 6 inches long by 2½ in diameter. Near one end a hole is cut in the side of the cylinder, and a short piece of tube holding a condensing lens is attached to the edge of the hole. This lens, which is plano-convex with a spherical curve, and of 2½ inches diameter, is placed with the plane side toward the light. {24} This concentrator is intended to be slipped over the chimney of an argand burner, and should be so adjusted that the centre of the flame corresponds with the centre of the lens. It may, however, be used in connection with a student's lamp, incandescent electric lamp, or even a candle, giving in all cases a very satisfactory light, which, however, must be reflected from the head mirror into the patient's mouth.

The best light, however, when the examinations are conducted in the office of the physician, is the electric incandescent light, which presents numerous advantages over the gas or oil lamp. It is more brilliant and whiter than any other suitable artificial light, giving off neither gases nor heat, nor does it consume the oxygen in the room; and since the introduction and perfection of storage batteries it has become available and convenient for use in private houses. Numerous experiments which the author has carried on for some time have resulted in the application of this form of light for laryngoscopy in two ways which are both very satisfactory. The incandescent lamp is mounted upon the universal gas-bracket in place of the argand burner, and either the Tobold lamp or Mackenzie's light concentrator is slipped over it, so that it comes opposite the centre of the lens. In fact, the electric lamp is substituted for the gas-burner, and the whole apparatus is used as described above. The arc light may also be used in the same manner, but does not give as satisfactory results on account of its unsteadiness.

The second method is to mount the electric lamp on the head mirror in such a way that it projects a little from the surface and is a little to one side of the centre of the reflector (Fig. 3). The light is then thrown forward in a cone, and can be directed with great ease into the mouth of the patient. Since thus the source of the light moves with the mirror, the observer can follow the motions of the patient more easily; and if, in the first place, an easy position of the head has been assumed when adjusting the light, much less {25} fatigue is experienced by the examiner with this apparatus than when the light is reflected from a stationary source. Still another mode of using the incandescent lamp, which was suggested by Trouvé, is to mount the lamp within a tube one end of which is closed by a plano-convex lense, while the other end is covered by a metal cap carrying in its centre a ball-and-socket joint, by means of which it is fastened to the frontal plate of the head band. In this way the light with its condensing apparatus is carried on the forehead like the head mirror.

Sunlight is certainly the best source of light for the illumination of the interior of the larynx and nasal cavities, but, unfortunately, it is not available at all times and in all localities. When it can be obtained, however, the student should not neglect the opportunity, and should not be deterred from using it for examination by the little extra apparatus and trouble necessary.

The most convenient plan is to place a small plane mirror mounted upon a stand in such a manner that it can be turned in any direction, such as a small toilet-glass, in the direct rays of the sun coming through a southern window. Then turn the mirror until the reflection falls upon a second plane mirror supported by a jointed arm and placed in a distant corner of the room, and in front of the chair upon which the patient is seated, with his back to the first mirror. The light from the second mirror is then thrown into the patient's mouth in the same manner as when a light concentrator is used. The second mirror may also be mounted on the head band and used as a head reflector, but this latter plan is not as satisfactory, because the reflected light from the first mirror is apt to strike the observer's eye and temporarily blind him.

Sunlight, as well as the light from the oxyhydrogen and electric-arc lamps, is white, and therefore shows us the parts in their natural coloring, which is claimed as a great advantage over all other sources of light. It is true that the yellow rays which are predominant in all other artificial lights make the mucous membrane appear redder than it really is, and the observer may be led to believe that a congestion exists if the patient be examined by white light first, and then by yellow light on different occasions. But as all our knowledge and appreciation of shades of color depend upon a comparison with a standard, it makes no difference whether this standard, as in the case before us, is a little redder when viewed by yellow light or not so red when seen by white light. This advantage of the white light is, therefore, not of much practical value, and the expense and difficulties connected with the use of the oxyhydrogen or electric arc-light for laryngoscopy fully outweigh any advantage which can be claimed for it.

THE ART OF LARYNGOSCOPY.--Before entering upon a description of the details of the art it will be necessary to clearly understand the optical principle upon which the use of the laryngoscope is based, and, further, to remember that the object to be viewed is situated below the straight path of light and vision. The optical law referred to is, that "The angle of incidence is equal to the angle of reflection," and consequently, in order to illuminate the cavity of the larynx and to see its details, the laryngeal mirror must be placed in such a position in the fauces that the light is reflected downward. The light rays forming the laryngeal image will then be reflected from the surface of the laryngeal mirror into the eye of the observer. It should always be borne in mind that the image seen in the mirror is a reflected one, like the image of one's self seen in a looking-glass, so that what appears to be right is left, and vice versâ. On account of the difference in height of the parts forming the image, and because the mirror must be placed above and slightly behind the opening of the larynx, the picture appears reversed in an antero-posterior direction. The same holds good when viewing a drawing of a laryngeal image.

{26} POSITION OF PATIENT AND OBSERVER.--The relative positions of the patient, observer, and the source of light are of very great importance, especially to the beginner, and a want of proper adjustment will often make it extremely difficult, if not impossible, to obtain the desired view of the larynx. The patient having been seated upon a chair, or better still upon a piano-stool, the source of light is placed upon a table at his right, at such a height that the centre of the flame is on a level with his eyes and a few inches behind. The observer then takes a seat directly in front of the patient, and, separating his knees, places his feet on either side of those of the patient, thus being able to grasp the patient's knees with his own should occasion require him to do so. This position is preferable to the one in which the knees of the observer are either on one side or the other of the patient's knees, because then the observer, in order to throw the light from the head mirror into the mouth of the patient, has to assume a constrained position which very soon becomes fatiguing. Under no circumstances should the patient be allowed to grasp the observer's knees, for then the latter is powerless to restrain the struggles of his patient, and cannot quickly leave his seat should vomiting occur. When the examination is made at the physician's office or wherever it is practicable, it is of advantage to have a head-rest, such as photographers use, for the patient's head.

The positions having been taken, the observer places the head reflector upon his forehead a little above the left eye, and by rotating it upon its ball-and-socket joint reflects the light from the lamp- or gas-flame upon the patient's face so that the circle of light is bounded above by the tip of the nose and below by the tip of the chin. It is of great importance that the adjustment of the reflector should be made by means of its joint, and not by rotating or inclining the head, for it is necessary that the head should have an easy position which can quickly be resumed should it become necessary to move the head. It requires considerable practice to quickly reflect the light from the head mirror in any desired direction, and it is therefore well for the beginner to practise this by throwing the light upon a spot on the wall before he attempts to examine a patient, as he will thus save himself, as well as the patient, unnecessary annoyance. If a light concentrator be used which supports the reflector on the jointed arm, this of course is not necessary, but the practice with the head mirror will even then be found advantageous, because when a patient is to be examined in the sick room a light concentrator cannot usually be employed, and the physician has to fall back upon the head mirror for illuminating the laryngeal cavity.

When the reflector has thus been properly adjusted the patient is required to incline his head backward and open his mouth as wide as possible, when it will be found that the centre of the circle of light falls upon the root of the uvula. A careful examination of the oral cavity, the anterior and posterior pillars, the tonsils, and the wall of the pharynx should be made before the laryngeal mirror is introduced, not only because the condition of these parts often imparts valuable information, but also in order to be sure that no infectious sores be present which might contaminate the instruments to be introduced. The laryngologist cannot be too careful to prevent the carrying of infectious material from one patient to another; and if he should by this preliminary examination discover a specific sore, he should use only such instruments as are reserved for this class of cases, and which are kept in a separate box or drawer of the instrument-case.

Everything being in readiness, the laryngeal mirror is held over the lamp, with the glass side down, for a few seconds until it is warm, so as to prevent the condensation of moisture on its reflecting surface, and is then introduced in the following manner: The handle is held between the thumb and fore finger of the right hand like a pen-holder (Fig. 4); the hand is bent {27} backward upon the wrist and held below the chin of the patient. Meanwhile, the protruded tongue is grasped between the folds of a napkin or towel held in the left hand, and gently but firmly pulled out of the mouth. Great care should be exercised to prevent the frænum of the tongue from coming in contact with the sharp edge of the front teeth, for this soon becomes very painful and may prevent a successful examination. Many laryngologists are in the habit of letting the patient hold his tongue, which becomes necessary when operations or applications are to be made to the larynx; but for the purpose of examining only it is better for the observer to hold the tongue, as he thus gains more control over the movements of the head of the patient.

The mirror is now rapidly introduced into the mouth of the patient, without touching the tongue or the palate, and carried backward until its rim touches the wall of the pharynx, when it is lifted upward, carrying on its back the uvula, and the stem is brought into the angle of the mouth, so as to be out of the line of vision (Fig. 5). In this position the light of the reflector will fall upon the reflecting surface of the laryngeal mirror, and will be reflected downward so as to illuminate the laryngeal cavity and reflect the laryngeal image into the eye of the observer.

{28} There are, however, numerous obstacles and difficulties which must be overcome to successfully practise laryngoscopy--obstacles which are partly due to the want of skill on the part of the operator, and partly to over-sensitiveness and want of control of the patient, or, finally, to abnormal positions of the parts. Taking them up one by one, in the order named above, the reader will soon learn to overcome these obstacles by practice and careful attention to details.

As has already been pointed out, a satisfactory view of the laryngeal image cannot be obtained if the position of the light, of the patient's head, and of the observer is not properly arranged; further, if the laryngeal mirror is either too cold or too hot. In the former case the moisture of the breath will condense on its reflecting surface and render it non-reflecting, and in the latter case the patient will feel the heat and will object to the presence of the mirror in the fauces. The examiner should therefore carefully test the temperature of the mirror on the back of his hand before introducing it. Many laryngologists are in the habit of testing the temperature by placing the mirror against the cheek, but this is a dangerous practice, for a slight scratch or abrasion of the skin from shaving may be inoculated with infectious material from a specific sore, and the writer knows of more than one instance in which such infection has occurred; while a scratch on the hand is not so likely to be overlooked, and therefore the danger is much less. Pulling too hard upon the tongue, so that the frænum becomes injured by the edge of the teeth, is another obstacle, for the patient will not bear the pain thus occasioned. Touching the tongue or palate in the act of introducing the mirror, besides coating the reflecting surface with the secretions of the mouth, causes in most patients gagging, and should therefore be avoided. When the mirror has been introduced it should be held very still, and if it becomes necessary to rotate it, this should be done slowly and steadily, because the slightest trembling motion of the rim of the mirror resting against the wall of the pharynx produces gagging and cuts the examination short at once. It is therefore advisable to steady the hand holding the mirror by placing the third finger against the cheek of the patient, or, better still, against the thumb of the hand holding the tongue.

Undue irritability of the fauces is of very rare occurrence, and is almost invariably produced by one or the other of the above-mentioned mistakes of the examiner. When it does exist independently, it can in a measure be overcome by letting the patient drink a large draught of ice-water immediately before introducing the mirror, and by holding the mirror so that it does not touch either the pharyngeal wall or the palate. In this manner but a very unsatisfactory view of the larynx can be obtained, and it is better to overcome the irritability by practice on the part of the patient--_i.e._ by introducing the mirror frequently and removing it before gagging sets in, and by directing the patient to introduce a teaspoon into the fauces before a looking-glass several times a day. Even the most obstinate cases can thus be educated to allow of a lengthy examination. No matter how tolerant a patient may be, however, the mirror should never be left in the fauces after the first symptoms of gagging show themselves, but should at once be removed. It is better in all cases to leave the mirror in the mouth but a short time and to introduce it frequently, thus studying the different parts of the image one after the other, than to attempt to see everything at once. In laryngoscopy, as in many other arts, not only the hand, but also the eye, must be educated to appreciate all the details and the variations from the normal.

Among the malformations of the parts which present obstacles to laryngoscopy are, in the first place, hypertrophied tonsils, which by narrowing the space in the fauces make it impossible to introduce the ordinary-sized mirror. A smaller mirror or one of oval shape can, however, usually be slipped past the {29} enlarged glands and the desired image obtained. An elongated uvula does not exactly prevent a view of the larynx, but it materially interferes with a good image, because its end by hanging below the rim of the mirror is seen in the reflecting surface and obscures part of the image. Removal of the uvula by surgical means is of course the best remedy.

The third and most serious obstacle presented by malformation or malposition of parts is a pendent epiglottis--_i.e._ an epiglottis which by being bent too far over covers the laryngeal opening and prevents a view. This obstacle exists to a certain extent in most cases that come under observation, but is easily overcome by letting the patient sound the vowel sound of _eh_, which causes a rising of the epiglottis and opens the laryngeal cavity to view. There are some cases, however, in which this expedient does not sufficiently raise the epiglottis to obtain a glimpse of the vocal cords, and only the arytenoid cartilages are seen, from the motion and color of which we can often obtain valuable information in regard to pathological processes. In these cases, when it becomes absolutely necessary to see the whole extent of the vocal cords, we may succeed by causing the patient to laugh in a high key, but when this fails the only resource left is to lift the epiglottis by grasping its upper margin with a pair of curved forceps especially designed for this purpose and called epiglottis forceps (Fig. 6). If this instrument is not at hand, the same object may be attained by clasping the edge of the epiglottis with a bull-nose forceps, to which is fastened a string weighted at the other end by a small weight, such as a rifle-bullet. The string with its weight hanging out of the mouth of the patient makes traction upon the forceps, and thus the epiglottis is raised. In cases of operation within the laryngeal cavity this method of raising the epiglottis is even preferable to the epiglottis forceps, because it leaves the hands of the operator free to use the mirror and the instrument to be used in operating.

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A system of practical medicine. By American authors. Vol. 3Chapter I: Part 1

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