Chapter II: Part 2

AUTO-LARYNGOSCOPY.--There is perhaps no better method for the beginner to overcome the difficulties besetting laryngoscopy than to practise the art on himself, for then only will he be able to appreciate to its full extent the necessity of observing all the minute details described above, as the pain and inconvenience which he inflicts upon himself by his false movements will teach him better, and enable him to attain proficiency in the use of his instruments quicker than any other method of practice. Nothing need, for auto-laryngoscopy, be added to the stock of instruments necessary for the examination of others, except a stand to which the reflector is fastened and a small toilet-mirror. The observer seats himself beside a table upon which, at his left, is placed the lamp a little behind his head and the centre of the flame on a level with his eyes. The stand, an ordinary retort-stand, is placed in front of him, and to it is fastened at the proper height the reflector. On the same stand, and immediately above the reflector, is attached the plane mirror in such a manner that it can be inclined at an angle. Inclining the head slightly backward, the observer then by watching his face in the plane mirror directs the light upon his mouth by moving the reflector upon its ball-and-socket joint until the circle falls upon his mouth. He then opens his mouth as wide as possible, grasps his protruded tongue between the folds of a towel or {30} napkin held between the thumb and fore finger of the left hand, and introduces the laryngeal mirror with the right hand in the manner described above. The laryngeal image as it appears on the surface of the laryngeal mirror is reflected by the toilet-glass above the reflector, and can be seen in all its details by the person practising auto-laryngoscopy. By substituting a perforated mirror for the toilet-glass the student can demonstrate the image to others in his own person if the observers look through the perforation in the mirror.

Before giving a description of the laryngeal image it will be well, for the sake of completeness, to mention the fact that of late photography has been employed to reproduce this image, both in this country by T. R. French of Brooklyn[17] and by Lennox Browne of London, England, with very gratifying results. The writer himself several years ago made experiments in this direction, which, however, were not very satisfactory in their results. The method employed by French is a very simple one, and it will be best to give his own description of the process:

"The camera consists of a box 4½ inches long, 1-7/8 inches wide, and ¾ of an inch in thickness. The back opens upon hinges, and admits of the introduction of either the ground glass or the plate-holder. On the anterior face a tube 1-1/8 inches long is attached, in the outer end of which the lens is placed. This lens has a focus of 1¼ inches. At the side of the tube a part of the handle of a throat mirror is fixed, and into that the shank of the throat mirror is passed and fastened by a thumb-screw. The shank of the mirror is somewhat curved, and is attached to the side of the frame holding the mirror. The object of this is to allow the lens being held opposite any part of the opening of the mouth, and also to prevent the possibility of a shadow being cast upon the mirror. In the front part of the box is a shutter made of lead and perforated with a hole just the size of the lens. The shutter is held in position by a lever acting as a key on the anterior face of the camera.

"The apparatus is used in the following manner: A reflector, either plane or concave, attached to a head band, is arranged over the left eye so that the pencil of sunlight from the solar condenser is received upon it and thrown into the mouth. The patient, with the head inclined slightly backward, now protrudes the tongue and holds it well out between the fore finger and thumb of the right hand. The throat mirror with the camera attached, held in the right hand of the observer, is placed in position in the fauces, and the light adjusted so that the larynx can be seen with the observer's left eye to be well illuminated. If, now, the tongue does not mount above the level of the lower edge of the lens and the lower edge of the mirror, it may be taken for granted that when the plate is exposed the picture received upon it will be nearly the same as that seen with the left eye in the throat mirror. The photograph is taken by pressing upon the key with the index finger; this releases the shutter, which in falling makes an instantaneous exposure amounting to perhaps one-seventh of a second.

"In using condensed sunlight with a small camera it is important to throw the circle of light from the inner side of the reflector, that nearest the nose; for in this way a part of the larynx exposed to the lens of the camera may be illuminated which cannot be seen with the eye. To ensure this it is best to cover the outer half of the reflector with black silk. On account of the parallax or displacement of the image due to the difference in point of view between the eye and the camera, some skill is necessary in managing the illumination so that the part which it is desired to bring out will be exposed to the lens if not to the eye."

[Footnote 17: _Archives of Laryngology_, vol. iv. No. 4.]

THE LARYNGEAL IMAGE.--When the mirror is introduced and is held in the proper place, and the light is reflected downward, the laryngeal image {31} will appear on the surface of the mirror. As it is, however, so different from what might be expected after having examined a larynx removed from the body, it requires a detailed description, and the student will do well to refer to the diagrams frequently while examining patients, to make himself familiar with the details he sees, and to recognize them when they are altered by disease or when they are slightly different in shape in different individuals. Figs. 7 and 8 represent the image of the larynx in the act of respiration and of phonation as it appears on the surface of the mirror, while Figs. 9 and 10 are diagrammatic, and are intended to represent the same.

The first detail to attract the eye is the epiglottis, which appears as a yellowish-red arch reaching from side to side across the image. It is thicker in the middle than at either end, and a protuberance is usually seen in the centre pointing forward. This arch is the upper margin of the epiglottis, and the protuberance is the tubercle, situated near the insertion of the epiglottis into the thyroid cartilage. The shape as well as the color of the epiglottis is very variable in different individuals, being sometimes rounded as in the drawings, sometimes rolled up like a dried leaf, sometimes notched in the centre, and sometimes presenting a point at this place. However, all these variations in shape have nothing to do with any pathological process, and may therefore be termed normal. The color of the organ also varies from a bluish-yellow to a pink-red, and these variations are also normal, being due to a greater or less thickness of the tissue covering the cartilage, which by shining through imparts its bluish color to the tissue. The superficial blood-vessels also are more prominent in some individuals than in others, and may not be noticeable in some cases.

{32} Immediately behind the epiglottis we see two pit-like depressions, separated from each other in the middle by a fold of mucous membrane and bounded on either side by similar folds less prominent. These folds are the glosso-epiglottic ligaments, and serve to connect the tongue with the epiglottis, while the depressions are the glosso-epiglottic grooves, in which we usually find the foreign bodies which have accidentally been swallowed.

The ends of the epiglottic arch are lost in folds of mucous membrane, which run forward and inward to meet in the median line some distance in front of the epiglottis. Along their course several nodules of different size are noticed, which are symmetrically situated on either side. The one nearest to the epiglottis is the cartilage of Wrisberg, a small cartilaginous nodule imbedded in the tissue. The larger one, situated at the end of the fold of mucous membrane, is the arytenoid cartilage, and a third small nodule is noticed close to the arytenoid cartilage between it and the cartilage of Wrisberg, which is called the capitulum Santorini. The folds of mucous membrane are termed the aryteno-epiglottidean or ary-epiglottic folds. Their color is normally of a pinkish-red, and does not vary much in different individuals.

The arytenoid cartilages forming the ends of the ary-epiglottic folds are movable, approaching and separating alternately during the act of respiration, while during phonation they are pressed against each other, thus obliterating the space between them which is seen when they are separated. This space is the inter-arytenoid space or commissure, and is formed by the lateral walls of the arytenoid cartilages and the upper margin of the posterior portion of the cricoid cartilage. The mucous membrane in this commissure is very loosely attached to the deeper structures, and is thrown into folds by the approximation of the arytenoid cartilages. Its color is much lighter than that of the ary-epiglottic folds, due to the shining through of the cricoid cartilage. Outside of the ary-epiglottic folds and the inter-arytenoid commissure is the tissue forming the posterior and lateral walls of the oesophagus (not shown in the diagrams), and near the epiglottis a space called the pyriform sinus is noticed between the ary-epiglottic folds and the wall of the oesophagus.

Running from the epiglottis to the ary-epiglottic folds are two broad bands, one on either side, covered with mucous membrane and of a pinkish-red color, which are lost on either side in the tissue forming the walls of the laryngeal cavity, while toward the middle of the image they present concave and tolerably sharp edges. These are the ventricular bands, which were formerly termed the false vocal cords, and which form the lip to the opening of the ventricle of the larynx. Between the ventricular bands filling up the central portion of the image are seen the vocal cords, two bands of a pearl-white color which are attached to a cartilaginous process of the arytenoid cartilages, and run from these parallel with each other to the angle of the thyroid cartilage immediately below the tubercle of the epiglottis. These present sharp edges toward each other, and follow the motions of the arytenoid cartilages to which they are attached, so that when in inspiration the cartilages are separated the edges of the vocal cords are also some distance apart, forming, together with the inter-arytenoid commissure, a triangular opening called the glottis. That portion of the opening which is bounded on either side by the edges of the vocal cords alone is called the membranous portion, while the base of the triangle is termed the cartilaginous portion, being bounded on either side by the vocal processes of the arytenoid cartilages. This portion is readily distinguished from the membranous portion by its slightly yellow color, and by the fact that a very obtuse angle is formed at the junction of the two portions when the glottis is wide open during respiration. Through the open glottis the lower edge of the cricoid cartilage and several of the rings of the trachea can usually be seen, and there are a few cases in which even the bifurcation of the trachea can be dimly illuminated, showing in the {33} laryngeal image the openings of the bronchi. The distance is, however, too great for bright illumination, and nothing can be seen distinctly, so that it is of little value in a diagnostic point of view. During phonation the glottis is narrowed to a slit by the approximation of the arytenoid cartilages and inner edges of the vocal cords, and, as has already been stated, the inter-arytenoid space becomes obliterated. In the higher notes of the female voice, the so-called head tones, the cartilaginous portion of the glottis remains closed entirely, while the membranous portion appears as an elliptical opening which is diminished in its longitudinal diameter with each rise in pitch. This becomes possible because of the presence in the vocal cords of a slender rod-like cartilage attached to the end of the vocal process, which can readily be seen in the female larynx, but which is only rudimentary in the male.

This description, intentionally, has been made without reference to the anatomical relation of the parts, but to give a clear idea of what is seen in the laryngeal mirror. The reader should therefore always bear in mind that the laryngeal image, being a reflected one, is reversed, and that, on account of giving a bird's-eye view of the larynx from a point above and behind the organ, distances are materially diminished; and the image is also reversed in an antero-posterior direction, so that the epiglottis appears to be posterior when in reality it is anterior.

RHINOSCOPY.--Rhinoscopy, or the art of inspecting the nasal cavities and the naso-pharyngeal space, is divided into two portions--viz. anterior and posterior rhinoscopy; and it will be convenient to observe this division in the following description of the methods employed. But before proceeding with the description it will be well to briefly review the topographic anatomy of the parts, because in most works on general anatomy the nasal and naso-pharyngeal cavities are discussed in a few sentences, and they are rarely if ever examined in the dissecting-room, so that the student has but a very imperfect knowledge of the relation of the parts belonging to these cavities. (See Fig. 11.) The nasal cavities, which are wedge-shaped, with a narrow arched roof, extend from the nostrils to the upper portion of the vault of the pharynx. Their outer walls are formed by the nasal process of the superior maxillary and lachrymal bones in front; in the middle, by the ethmoid and inner surface of the superior maxillary bones; behind, by the vertical plate of the palate bone and the internal pterygoid process of the sphenoid and the turbinated bones. These latter run before backward, three on each side, and are designated as the inferior, middle, and superior, the latter being the smallest of the three. The sinuses or spaces between these turbinated bones are called meatuses; so that the space between the floor of the nose and the lower turbinated bone is called the inferior meatus, the one between the lower and middle turbinated bones is the middle meatus, and the one between the middle and superior turbinated bones is the superior meatus.

The nasal cavities are separated from each other by a septum or division wall composed of the perpendicular plate of the ethmoid bone and the vomer posteriorly and the cartilaginous septum anteriorly, thus presenting a smooth surface as the inner wall of each cavity. The floor is formed by the palatine process of the superior maxillary bone and by the palate bone, and runs in a slanting, downward direction from before backward. The roof is formed by the nasal bones and nasal spine of the frontal in front, in the middle by the cribriform plate of the ethmoid, and posteriorly by the under surface of the body of the sphenoid bone. Directly communicating with the nasal cavities are other cavities situated in the bones of the skull, the lining mucous membrane of which no doubt is largely affected by the pathological processes in nasal diseases: these are the antra of Highmore, large triangular cavities situated in the body of the superior maxillary bone and communicating with the nasal cavities by an irregularly-shaped opening in the middle meatus; {34} then the frontal sinuses, two irregular cavities situated between the two tables of the frontal bone. The communication between them and the nasal cavities is established by the infundibulum, a round opening in the middle meatus, and finally the sphenoidal cells or sinuses, found in the body of the sphenoid bone, communicating with the nasal cavities by small openings in the superior meatus. That portion of the nasal cavities which projects beyond the end of the nasal bone is surrounded by cartilages forming the alæ of the nose.

In the cartilaginous septum of the lower animals we find a small cavity lined with mucous membrane, called after its discoverer Jacobson's organ, the minute anatomy of which has lately been described by Klein.[18] This {35} organ in man is, however, only rudimentary. The nasal cavities are lined with mucous membrane, which varies greatly in thickness in different localities, and which materially decreases the size of the cavities in the living subject from that seen in the denuded skull. This mucous membrane is covered by ciliated epithelium in man, with the exception of that portion which lines the vestibule--_i.e._ that portion of the cavity of the nose surrounded by cartilage only--which is covered by pavement epithelium.

[Footnote 18: _Quarterly Journal of Mic. Science_, January, 1881.]

In the lower animals we find that in the olfactory region the ciliated epithelium is either absent, or that ciliated and non-ciliated epithelium alternates in patches.[19] The author has not been able to find a statement in the literature on the subject as to the kind of epithelium found in the accessory cavities in man, but it is very probable that the mucous membrane of the frontal sinuses and the antra of Highmore is covered with ciliated epithelium; otherwise it would be difficult, if not impossible, for the secretions of that mucous membrane to pass through the narrow channels into the nasal cavities. The color of the normal nasal mucous membrane is of a light pink shade in what is termed the respiratory portion, while it is of a yellowish hue in the olfactory region, that portion of the mucous membrane which covers the roof and the outer walls of the nasal cavities down to the upper margin of the middle turbinated bone and the septum down to about the same level. It is in this region that the nerve-ends of the olfactory nerve are distributed. Immediately beneath the mucous membrane, and between it and the periosteum of the bony walls and the perichondrium of the cartilaginous portion of the septum, we find a tissue which bears a striking resemblance to the erectile tissue of the genital organs.[20] It is composed of a network of fibrous tissue, the trabeculæ of which contain a few organic muscular fibres. Its meshes of various sizes and shapes are occupied by venous sinuses lined with endothelium. These are supplied with blood by small arterioles and capillaries, which are quite numerous in the fibrous tissue and can readily be demonstrated under the microscope. In this arrangement of elements of the nasal mucous membrane we find a ready explanation of the fact that liquids of greater or less density than the serum of the blood when introduced into the nasal cavities produce pain, for we have here the most favorable conditions for osmosis, which will cause either a contraction or a distension of the sinuses. In the larger masses of fibrous tissue between the sinuses or caverns we find imbedded the glands, with their ducts opening out between the epithelial cells of the mucous membrane. There are two kinds of glands in this region, which have been described by Klein[21]--viz. serous and mucous glands.

[Footnote 19: Haenle, _Anatomy des Menschen_, vol. ii.]

[Footnote 20: Haenle, _loc. cit._]

[Footnote 21: _Loc. cit._]

This cavernous erectile tissue is most abundant at the lower portion of the septum and of the lower turbinated bones; and, although it has been recognized and described as true erectile tissue by Haenle, Virchow, and others, yet to Bigelow of Boston belongs the honor of having first called attention to the part which this tissue plays in nasal diseases. He gave to it the name turbinated corpora cavernosa.[22] The expansion of the nasal cavities formed by the alæ of the nose is termed the vestibule, which is lined with pavement epithelium and forms the entrance to the cavities proper. The naso-pharyngeal cavity extends from the posterior ends of the turbinated bones and the edge of the vomer to the line where the velum palati touches the pharyngeal wall during the act of deglutition or phonation. In this cavity we find the openings of the Eustachian tubes, two crater-like elevations, with a pit-like depression of variable size and shape, one on either side; and a collection of glands with a central duct-like opening disposed on the roof and posterior wall of the cavity. This gland was named by Luschka[23] the pharyngeal {36} tonsil. The openings between the edge of the vomer and the lateral walls of the naso-pharyngeal cavity are termed the posterior nares.

[Footnote 22: _Boston Med. and Surg. Journal_, April, 1875.]

[Footnote 23: _Der Schlundkopf des Menschen_.]

ANTERIOR RHINOSCOPY.--Anterior rhinoscopy is a very easy and simple procedure, and is practised as follows: The patient is placed in position as for laryngoscopy, and the light directed upon his face so that the centre of the circle of reflection from the head mirror falls upon the tip of the nose. The examiner then elevates the tip of the nose with his left hand, resting the fingers on the forehead of the patient, and lifts the ala away from the septum with a slightly bent probe, when he will be enabled to see a considerable distance into the nasal cavity. It is, however, better to employ a speculum instead of the bent probe, because the parts then are seen in their usual relation to each other, and are not distorted by the forcible traction necessary when the probe or a dilator is employed. The nasal speculum (Fig. 12) is best made of hard rubber and shaped like the ordinary ear speculum, except that the narrow end is oval instead of round. This instrument is to be introduced by a sort of rotatory motion until the end has passed the edge of the vestibule, when it will remain in position, displaying the interior of the nose. Great care should be exercised, when introducing the speculum, not to scratch the mucous membrane of the septum, for this will give rise to pain and start hemorrhage, both of which are to be avoided as much as possible. When applications are to be made to the mucous membrane of the septum or turbinated bones, or when operations are to be performed within the cavity, it is best to employ an instrument called a nasal dilator, of which there are a large number of different forms, the most satisfactory of which is shown in Fig. 13. The dilator is introduced by compressing the blades between the thumb and fore finger, and pushing them into the nostril until their ends have passed the edge of the vestibule. The pressure is then removed, and the spring separating the blades holds the nostril open; the handle or stem of the instrument, hanging down, need not be held or supported, as the blades press sufficiently upon the tissues to retain the instrument in position. If the pressure is too great, however, it will soon produce pain, and the patient will object to the use of the instrument.

The view obtained both by the speculum and the dilator is rather limited, and usually comprises only the anterior portions of the lower and middle turbinated bones, together with the cartilaginous portion of the septum. In order to get a good view of the lower and middle meatus and of the floor of the nose the patient's head should be inclined forward or backward as occasion requires. The student should, however, not be satisfied by simply inspecting the parts, but should aid the eye by the sense of touch, for pathological changes are of common occurrence, and their nature, whether soft and fleshy or hard and bony, erosions of the mucous membrane, or deep ulcerations, can often only be determined by the aid of the probe. In the same manner can the permeability of the meatuses be determined better than by inspection {37} only. In cases where it becomes necessary to determine whether the anterior portion of the septum is of normal thickness, or whether a projection seen through the speculum is due to localized deflection, an instrument called the septometer is of great assistance (Fig. 14). This instrument is similar to the one used by mechanics to determine the diameter of a piece of wood or iron being turned on the lathe. In using it the long straight shanks are introduced one in each nostril, and, being closed upon the septum, the rounded points are gently moved up and down and backward and forward over the bulging portion of the septum. The motion of the index attached to the curved shanks of the instrument accurately indicates the relative thickness of tissue grasped between the points in the nose. By means of this instrument we can thus ascertain whether we have to deal with a deviation or a localized thickening of the septum; for if it is a deviation the index will move but slightly, while it will travel a considerable distance when the points pass over a thickened portion.

Although simple in its details, anterior rhinoscopy is often made difficult or altogether prevented by obstacles which are mostly due to malformation of the parts, such as deviation of the cartilaginous portion of the septum, exostoses from the superior maxillary bones reaching into the nasal cavity, adhesion between the anterior portion of the lower turbinated bone and the septum, nasal polypi, anterior hypertrophies of the mucous membrane, and so forth; or they may be due to faulty instruments, as too much pressure in the spring of the dilator; or, finally, they may be caused by want of care in the handling of the instruments, as when the septum is scratched by the edge of the speculum and hemorrhage ensues.

POSTERIOR RHINOSCOPY.--Posterior rhinoscopy is much more difficult than laryngoscopy or anterior rhinoscopy, and requires more patience and dexterity on the part of the examiner than either of the former, because but very few persons have control over the movements of the velum palati, and in most of these the upper portion of the pharyngeal wall is so sensitive that the slightest touch with an instrument gives rise to reflex cough and to gagging. In many cases, however, with patience and skill the naso-pharyngeal cavity and the posterior portion of the nasal cavities can be illuminated and inspected. To do this the patient is placed in the same position as for laryngoscopy, except that the head is not inclined backward, and after the mouth is opened as wide as possible the light from the reflector is thrown into the oral cavity. The tongue is then depressed with a tongue depressor. This instrument in its simplest form in which it is daily used by the practitioner for examining the fauces is the handle of a spoon. For laryngoscopic or rhinoscopic purposes, however, the spoon is not to be recommended, because the hand holding it must be on a level with the mouth, thus obstructing the view and light. An instrument has therefore been constructed which obviates this difficulty. It consists of a leaf-shaped blade of silver or German silver bent at right angles and inserted into a flat wooden handle. The lower surface of the blade is slightly concave, and ribbed so as to take a better hold of the slippery back of the tongue, and from the bend is about 3 inches in length. It is introduced into the mouth as far back as possible, and pressed upon the back of the tongue while the hand of the examiner is below the chin of the patient. For the sake of convenience in carrying the instrument the blade has been so hinged to the handle that it will fold up against the latter and will {38} open at a right angle with it (Fig. 15). A more elegant and lighter instrument of the same description has lately been introduced in which the handle is also made of metal, and, like the blade, is heavily nickel-plated, and which when folded can be carried in a pocket-case. Soon, however, the metal tongue depressor becomes tarnished by the secretions of the mouth or by the substances used for applications to the throat, and then presents an appearance disgusting to many patients, who will not on that account submit to its use. For the sake of greater cleanliness, J. Solis Cohen devised a tongue depressor made of hard rubber, which is known as Cohen's tongue depressor (Fig. 16). It consists of a piece of ebonite bent upon itself, either end being a little over 3 inches long. The bend being more than at right angles, the hand holding the instrument rests underneath the chin of the patient; but if a different curve be desired for any particular case it can easily be obtained by placing the instrument for a little while in hot water. When soft it can be bent into any shape, which it will retain when cooled by immersion in cold water. Great care should be exercised not to carry the blade of the instrument too far back, as then gagging will at once set in. In cases where the tongue resists the pressure of the tongue depressor, it is better to exert but a gentle pressure upon the back of the organ, under which it will slowly recede, than to try to subdue it by force, for in the latter case it will unavoidably slip from under the blade of the instrument, and the desired space in the fauces is not obtained. With children the writer has found the fore finger of the left hand to be the best means of depressing the tongue, for the little patients as a rule have a horror of the formidable-looking instrument.

After the tongue has subsided into the floor of the mouth a small laryngoscopic mirror is introduced into the pharyngeal space behind the velum palati, with the reflecting surface upward, and is held there without touching the wall of the pharynx. The handle of the mirror, as in laryngoscopy, is brought into the angle of the mouth, so as to be out of the line of vision. As is usually the case, the velum palati at the approach of the mirror will rise and apply itself to the posterior wall of the pharynx, when of course the naso-pharyngeal space, being shut off, cannot be illuminated. Under these circumstances the velum must be made to hang down as in the act of nasal respiration, which is most easily accomplished by telling the patient to breathe through his nose. It is of course impossible to do so when the mouth is open, but the patient, not being cognizant of the fact, will make the attempt, and the palate will come down, permitting illumination and inspection of the naso-pharyngeal space and the posterior nares. In those cases in which this {39} expedient fails it becomes necessary to forcibly pull down the velum by means of a blunt hook made by bending a silver laryngeal probe, or to tie it down by passing small elastic bands through the anterior nares and bringing the ends through the mouth and tying them over the upper lip. The smallest black rubber tubing is admirably suited for this purpose, as it can be introduced without an instrument. When the palate is pulled down with the palate hook, or when operations in the naso-pharyngeal space are to be performed, the patient must hold the tongue depressor himself, so as to leave the other hand of the operator free. Few persons can do this, however, satisfactorily, and it will be found more convenient to use Jarvis's tongue depressor and rhinoscope, as modified by the writer (Fig. 17). The instrument consists of a stout wire, which, after having been forked or divided at some distance from its insertion into the handle, forms the loop for the tongue depressor. The two branches then cross each other, and are bent to form another loop at an angle to the larger one. The ends of the wire are somewhat flattened and press against each other, thus closing the smaller loop and forming a sort of pincette, which can be opened by pressing the sides of the larger loop toward each other. The ends of the pincette are perforated by a small hole, which receives a pin attached at right angles to the short shaft of a small mirror, thus forming a hinge, so that the mirror can be placed at any desired angle with the handle or stem. The spring of the pincette cannot be made strong enough to prevent a change of the angle of the mirror by coming in contact with the pharyngeal wall, and therefore a ratchet was placed at the shaft of the mirror where it hinged to the end of the pincette, and a small steel spring, coming from one of the branches of the wire where they cross each other to form the small loop, by engaging in the teeth of the ratchet holds the mirror at the angle given to it before introducing. The large loop acts as a tongue depressor, so that with this admirable instrument the examination of the post-nasal cavity can be made with one hand, leaving the other free for the manipulation of other instruments. In order to be able to exert more pressure upon the tongue and to bring the hand out of the line of vision, the handle may be attached to the stem at an angle like the one in the folding tongue depressor. Except in cases of cleft palate the naso-pharyngeal cavity cannot be illuminated in its whole extent, and must be studied in parts, which when placed together in the mind of the examiner form the rhinoscopic image, a slightly diagrammatic drawing of which is seen in Fig. 18.

THE RHINOSCOPIC IMAGE.--In the middle of the drawing we see a triangular plate with its apex downward; this is the posterior margin of the vomer or nasal septum. On either side we notice curtain-like folds projecting against the septum; these are the posterior aspects of the turbinated bones. On either side of these and on the margin of the drawing we notice pointed elevations projecting toward the interior of the cavity, with a crater-like {40} depression on their apices; these are the lateral pharyngeal walls with the orifices of the Eustachian tubes. Above we see the vault of the pharynx, and below the posterior surface of the velum palati with the uvula.

Another method of examining the laryngeal and naso-pharyngeal cavities, which is especially valuable in cases where neoplasms or impacted foreign bodies hide the parts forming the laryngoscopic and rhinoscopic images, is by means of digital palpation. Even where no obstruction is present the beginner will do well to resort to this method in all cases, for he will thus become better acquainted with the topography of the parts than by inspection only. The procedure is not as difficult nor as disagreeable to the patient as might be imagined, and needs but little description.

When the laryngeal cavity is to be examined by palpation, the head of the patient is thrown back, and steadied in that position by the left hand of the examiner while he introduces the index finger of the right hand into the mouth and slides it along the back of the tongue until the tip comes in contact with the upper margin of the epiglottis. Passing downward along its lateral margin on either side, the ary-epiglottic folds and the tips of the arytenoid cartilages can be felt, and likewise the upper surfaces of the ventricular bands. The vocal cords are, as a rule, too low down to be reached by the tip of the finger. An examination of this kind should of course be made quickly while the patient is holding his breath, so as not to obstruct respiration too long, which in cases of narrowed glottis by neoplasms might give rise to serious results. When the naso-pharyngeal space is to be explored by the finger, the patient's head is bent forward, and the index finger is gently pushed upward between the velum and the pharyngeal wall. When this is accomplished, the velum is drawn forward and the finger pushed along its posterior aspect until the different portions forming the rhinoscopic image are reached and explored by the sense of touch.

{41}

DISEASES OF THE NASAL PASSAGES.

BY HARRISON ALLEN, M.D.

Coryza.

Coryza is an acute inflammation of the mucous membrane of the nasal chambers. The disease is ordinarily idiopathic, but may be produced by irritative vapors, pollen, or dust. In the idiopathic form the symptoms of coryza are often preceded by malaise, with chilly sensations, and in severe attacks with headache. The attack itself is divided into two stages: that of determination or congestion, and that of exudation. In the first stage the excessive quantity of blood flowing into the arterio-venous network and the capillaries of the nasal mucous membrane distend them and obstruct the nasal chambers.

The symptoms are referable either to such obstruction of nasal respiration--in which group are included oral respiration, sensations of distension, and throbbing in the nose--or to reflexes, such as frontal headache, attacks of sneezing, and dull aching pain in the teeth.

The first stage lasts for a period varying from a few hours to several days, and is followed by the stage of exudation. This is characterized by a free watery or mucoid discharge from the nasal chambers, and by the cessation of the symptoms due directly or indirectly to pressure of the layers of swollen mucous membrane against each other. The discharge at first is watery, and is doubtless composed of transuded liquor sanguinis. It is followed by a mucoid fluid, which in severe or neglected cases may assume a purulent character. In many instances, even in mild cases, the discharge becomes muco-purulent toward recovery. The second stage is associated in children and adults of delicate constitution with excoriations of the nostrils.

Suppuration may take place in nurslings and in old people. It would appear that in coryza, as it exists in the northern countries of Europe, the beginning of the second stage is apt to be marked by free suppuration.

Acute coryza may involve the sinuses of the face, particularly the maxillary sinus. The involvement of the frontal and sphenoidal sinuses, while possible, is infrequent. Pharyngitis, laryngitis, and occasionally acute aural catarrh, often coexist with the disease.

The symptoms of coryza are so distinctive that the diagnosis is easily made. But since any obstructive or catarrhal state of the nose is described by patients as a cold in the head, it is necessary for the medical attendant to distinguish the various diseases so denominated. Acute coryza may be confounded with angiose hypertrophy; with the obstruction to nasal respiration due to deflection of the nasal septum or to an inflamed soft polypus; with catarrhal irritation affecting surfaces which are already enlarged by hyperplasia or which are undergoing atrophy; or with the effects of operative interference in the nose.

In angiose hypertrophy the swollen membranes will contract under a mild {42} current of electricity or by change in the position of the body. Both chambers are rarely involved at the same time. Reflexes are of infrequent occurrence. Obstruction to nasal respiration due to a deflected septum arises from causes which are insignificant and do not affect the constitution. The genuine influenzal or catarrhal element is absent. In an inflamed soft nasal polypus an attempt at inspiration will, as a rule, detect the presence of the growth. In diffuse multiple polypi the case is different. Many persons who are reputed to take cold readily, or who may be said never to be free from cold, are really sufferers from neglected polypi. Persons suffering from atrophic catarrh always speak of an exacerbation of their symptoms as a fresh cold, and describe the disease itself as a cold. The sense of fulness, the throbbing, the heat, and the characteristic discharge of coryza are absent. A fresh cold in atrophic catarrh is an attack of inflammation (often catarrhal in character, it is true) which affects the involved surfaces, but is attended with an increase of plastic exudation and accompanying fetor.

It is a common occurrence for patients who have had a cautery application made or a polypus removed to return after a few days' absence with the report that they have contracted a cold. While the condition may be an attack of acute coryza, the chances are in favor of the symptoms being excited by the manipulation or the reaction from the operation. The symptoms are mild in character.

TREATMENT.--The treatment of coryza is both local and constitutional. The local treatment consists in applications of agents which tend to constrict the vessels of the nasal mucous membrane. In the first rank of such agents may be named cocaine, which in a 2 per cent. or a 4 per cent. solution will often give notable relief by overcoming the sense of obstruction. Individuals will be found in whom the effect is of short duration, and in some persons I found the medicine to have no effect whatever. In more favorable subjects the relief will be acknowledged for a period varying from four to six hours. Next in rank may be named a current of constant electricity (say from six to ten cells) passed through the cheeks. Should neither of the above-named agents be available, inhalations of iodine vapor, a few drops of chloroform rubbed upon the palms and inhaled, or the inhalation of the spirits of ammonia may be recommended. Toward the later stages of the disease detergents and mild astringents are well borne. The constitutional treatment includes the administration of diaphoretics and minute doses of opium, especially in the early stages of the disease. Coryza is commonly self-limited, and by far the larger number of cases do not come under the care of the physician.

Chronic Nasal Catarrh.

Chronic nasal catarrh embraces those more or less persistent affections of the nasal chambers whose symptoms resemble those of acute coryza. The term catarrh is inexact. It is used to include several diseases associated by a single characteristic--namely, the existence of an increased amount of mucous secretion upon the affected membranes.

In order to understand the varieties of nasal catarrh, it is necessary to have clear conceptions of the uses of the nasal chambers. The normal performance of the function of respiration demands that when the mouth is closed the currents of air should pass through the nose. These currents, however, do not sweep over the entire nasal surfaces, but are confined to those portions which answer to the inferior meatus and the space bounded within by the septum, without by the median surface of the inferior turbinated bone, and above by the under surface of the middle turbinated bone. In the lower mammals this space is separated posteriorly by a transverse bony lamina which {43} effectively excludes the upper portion of the nasal chambers from the tract just named. Anteriorly, at the termination of the inferior meatus and the middle turbinated bone, the tract is in freer communication with the upper spaces. The passage thus briefly defined may be called the respiratory tract, and when it remains patulous no serious interference with nasal respiration can occur.

The transverse diameters of the tract are subject to frequent changes, owing to the erectile character of the mucous membrane in its walls. But as long as the surfaces do not touch one another obstruction cannot exist. The passage, even when narrowed to a chink or line intervening between the median and lateral walls of the tract or between the floor and the roof of the inferior meatus, is sufficient evidence that there is room for the transit of the currents of air. The membranes themselves are subject to changes in form which are dependent upon the degree of development of their erectile tissue.

There is doubtless a disposition on the part of the erectile tissue to grow in the direction of the least resistance, and thus to occupy, by a process of compensative hypertrophy, the spaces left as the result of variations or defects in development in the bones composing the framework of the nasal chambers. The greater development of the erectile tissue may in this way be found on the side answering to the larger respiratory tract, which may therefore be more apt to suffer from changes in the conditions of nasal breathing than the chamber having the smaller tract. The erectile tissue acts as a monitor to the throat and lungs by presenting warm surfaces over which the air passes, thereby having the temperature raised before it enters the throat and lungs. It also acts by occluding the chamber, and thus aids in shutting out irritant vapors and dust. The lower animals possess a higher degree of development of the tissue at the point where the adducted ala presses against the septum. This point answers to the position of the organ of Jacobson. With man, the locality of the adduction corresponds to the junction of the premaxillary with the maxillary portion of the nasal chambers, and is often the seat of a delicate band of mucus extending across from the inferior turbinated bone to the septum.

That portion of the nasal chamber above the respiratory tract may be called the olfactory tract. It does not appear to be involved in the diseases under consideration, or, if it is, no clinical signs or symptoms are presented with which the author is acquainted. It will therefore receive no attention in this article.

For convenience the varieties of chronic catarrh may be classified as follows:

FIRST VARIETY--that dependent on defective nasal respiration.

This variety is caused by--

_(a)_ Osseous obstruction in the nasal chamber.

_(b)_ Membranous obstruction in the nasal chambers from compensatory
hypertrophy of the erectile tissue, alone or with
hyperplasia.

_(c)_ Obstruction arising from hypertrophy of the adenoid tissue in
the pharyngeal vault.

_(d)_ Contracture of the levator palati muscles.

SECOND VARIETY--that dependent on structural changes in the component parts of the nasal chamber.

This variety is associated with--

_(a)_ Chronic inflammation of the nasal mucous membrane without
hypertrophy of the erectile tissue.

_(b)_ Atrophy of the turbinals and their associated mucous membrane.

_(c)_ Necrosis of the bones which enter into the framework of the
nasal chambers.

FIRST VARIETY.--Defects in nasal respiration induce hyperæmia, distension of the erectile tissue, hyperplasia of the mucous membrane, and {44} inevitable distress in the nose. A sense of fulness across the bridge of the nose and at its sides is complained of. Frontal headache may be present.

_(a, b)_ When the septum is deflected and the left nasal chamber is narrowed, the labor of sustaining nasal respiration is thrown on the right side. This arrangement invites a flow of blood to the already large turbinals, and creates obstruction which is frequently referred to the right side, although both are alike affected. Thus, subjects in which the initial obstacle is osseous complain of distress caused by cavernous-tissue hypertrophy of the lining membrane of the opposite side. This represents a very common class of cases.

When the septum is not deflected, but projections from it impede the current of air, there may be either unilateral or bilateral obstruction, dependent upon the shape of the septum itself. Hypertrophy of the cavernous layer of the mucous membrane usually coexists. These cases are numerous, but less common than those last described.

Infrequently, cases are seen where the distress is occasioned by defects of the osseous structures not accompanied by cavernous hypertrophy.

Treatment of the above disorders consists in restoring nasal respiration by removing obstructions, whether they be osseous or membranous. The septal projections may be drilled or filed away, or, if marked deflection of the anterior portion be present dependent upon a malposition of the triangular cartilage, an operation simple in character may be performed for its correction. This consists in severing the connection of the lower margin of the cartilage with the maxilla and slipping the partially free cartilage to a new position. The details attendant upon the operation need not be here given. The reduction of the hypertrophied membranes can be best accomplished by cauterization. The most efficient method is by means of the electric cautery. The electrode used should be flexible and of small size. The points which most frequently require cauterization are the premaxillary portion of the inferior turbinated bone, the under surface of the same, and the septum at the maxillary spur. Rarely the inferior surface of the inferior turbinated bone at the palatal region requires attention. The applications are best made over small surfaces at a time, and should be repeated at intervals of from two to three days until all suspected points have been at least once cauterized. Not infrequently, the effect of the cauterization at one spot will cause constriction to take place in the vessels of the entire mucous surface, so that while this condition lasts it is impossible to tell what additional points of the membranous obstruction demand removal. At the following visit, however, the vessels have become relaxed, the membranes are again turgescent, and if obstruction now occurs it can easily be detected.

The galvano-cautery can only be used in the nasal chamber in patients who are earnestly seeking relief and are willing to assist the physician in all his efforts. With the tractable, intelligent subject it can with proper care be limited exactly to the spot intended. It is scarcely necessary to observe that any erratic or unexpected motion of the head will sear unaffected and sensitive surfaces. The interior of the vestibule is perhaps the most sensitive of these, and should always be protected by the use of the nasal speculum. No additional protection is needed, though in the judgment of others, among whom may be mentioned E. Shurly of Detroit, Michigan, an ivory shield passed in the nose parallel to the electrode is a necessary safeguard.

The pain of the application is generally slight, and can be in part annulled by a previous application of a 4 per cent. solution of cocaine. Some annoyance is acknowledged on the following day from the pressure of the eschar. Traumatic congestion of the entire mucous surface of the corresponding chamber is at the same time detected, and is usually sufficiently decided to produce some of the effects of acute coryza. This condition will spontaneously terminate in from thirty-six to forty-eight hours. The most annoying features {45} following an application of the galvano-cautery which has been too freely made do not belong to the group just indicated, but rather to reflex disturbances. Pains are occasionally excited in the teeth, in the temple, eye, nape of the neck, and the middle ear. On one occasion in the writer's experience a unilateral reflex excitation of the entire opposite side of the body occurred, and a prickling sensation, followed by numbness, ensued, which lasted for twenty-four hours. Very rarely a congestion of the pharynx, of the larynx, and the larger bronchial tubes ensues, which can scarcely be directly attributable to the application, yet it has followed in a sufficient number of cases to lead me to believe that the two are in some remote way associated. Perhaps such a condition is analogous to the slight irritation of the respiratory tract following excision of the tonsil. Careful use of the galvano-cautery will obviate the conditions above described. They are important to remember as serving as limitations to the use of this valuable agent.

_(c)_ It will be seen that osseous obstruction in the nasal chamber and hypertrophy of the cavernous nasal tissue often coexist. More rarely, a third element occurs as a complication, or it may be found independently of all other morbid processes. I allude to the presence of hypertrophy of the adenoid tissue in the pharyngeal vault. When this tissue is only moderately developed, it need not, and does not, interfere with nasal respiration; but when it projects downward to such a degree as to lie within the axis of the lower portion of the posterior nares, it produces the same effect upon nasal breathing as though obstruction existed within the chamber. The growths can be easily detected, as a rule, from behind by the aid of the rhinal mirror, but it should not be forgotten that they also can be seen from in front, provided the chamber is free from obstruction along the respiratory tract. In some individuals the ribbed or lobate structure of the mass can be discerned, but more often its presence is revealed by the minute points of light reflected from the lobules. If it be a matter of doubt whether these points of reflection are within the nasal chamber or beyond it in the pharyngeal vault, the patient may be requested to swallow, or to pronounce the letter _e_; when, if the point of reflection is within the nasal chamber, it will not change its position, but if it be within the naso-pharynx, it will be moved slightly from side to side, or it may for a moment disappear.