Methods Of Examination And Diagnosis In Affections Of The Nose And Throat

By JOHN W. FARLOW, M. D.,
OF BOSTON, MASS.

BEFORE proceeding to the examination of the interior of the nose and throat, it is always of importance to look critically at the face and neck of the patient and also to try to get as much preliminary information as possible by external palpation. This often furnishes valuable clues and hints which are quite likely to be overlooked if they are left until after the internal examination. Look at the region of the frontal sinuses and see if there is any prominence or tenderness on either side; look at the conjunctiva feel of the nasal bones with reference to depression or abnormalities of any kind. The degree of mobility of the cartilaginous septum and the presence of deviations and large perforations can be felt by the fingers on the outside.

The ale nasi should also be tested as to their strength or flaccidity. The folds and creases about the nose are often indications of muscular action which has for its object the opening of the nostril by drawing the ala away from the obstructing septum. Notice whether the mouth is habitually closed, the shape of its aperture, the dryness of the lips, whether the teeth or jaws overlap. Always feel for enlarged glands of the neck both in front of and behind the sterno mastoid muscle. The neck should be thoroughly, relaxed, otherwise the glands are not easily reached.

Inform yourself as to the condition of the cars, especially as regards the existence of suppuration. The hyoid bone and the thyroid and cricoid cartilages are to be examined and any enlargement of the thyroid gland noted. Move the larynx from side to side to test its mobility and the amount of creaking on the prevertebral structures and also to see if there is any tenderness. The finger placed lightly on the crico thyroid membrane detects the narrowing of the crico thyroid space when the pitch of an emitted note is raised.

According to Gerhardt, very important deductions can be drawn as to paralysis of the larynx by external palpation alone ; but it is not my purpose here to do more than point out the advantages of a thorough external examination as a matter of routine practice before beginning internal examination.

As regards the latter, the nose should always be examined first, then the mouth and post nasal space, and lastly the larynx.

EXAMINATION OF THE NARES.

For illuminating the nose and throat we have at our disposal diffused daylight, sunlight, candle, oil lamp, gas, the Welsbach burner, electric light, oxyhdrogen light, and perhaps acetylene gas. Ordinary daylight is not strong enough for the nose or post nasal space, and is too uncertain and variable. Sunlight has the merit of bringing out in their natural colors the various structures examined, but it also has many drawbacks. Its change of position, intervening clouds, and various obstructions on the earth render it very unreliable. With the concave head mirror the rays are easily brought to a focus, and a burn may 'result unless we are careful to keep the illuminated area beyond the focal distance. In order to change the direction of the rays and make them more horizontal and thus better adapted for reflection by the head mirror it is well to have them caught by a plane mirror at the window, which will reflect them at any required angle to the head mirror. The power of the sun's rays is so great that, in spite of many drawbacks, it certainly illuminates and brings out most vividly the various tissues under examination.

The electric light is used either as a small lamp attached to the bead or as a lamp fastened to the wall or table and the rays are reflected by the bead mirror. The bead lamps have always seemed to me to be heavy and cumbersome and to have no special advantage. In the other form of lamp the light is often not bright enough and the film casts a disturbing shadow.

I have seen the oxyhydrogen light is some European clinics, but it is bulky, expensive, and not easily managed. It is used as a direct illuminant and not reflected by a head mirror, and we shall see particularly as we examine the nose, that it is very essential to focus the light quickly at varying depths, and that in so small a space the axis of vision and of illumination should be the same and a head mirror is indispensable.

An oil lamp with a bright flame, such as the Rochester burner, or even the ordinary student's lamp, is to be recommended where there is no gas, the principal objection being the heat; but for everyday work nothing has proved itself so well suited for our purpose as gas with the Argand burner. Gas has also an advantage over the electric light in that with it we can warm our mirrors and instruments, fuse medicines upon probes, etc. The Welsbach burner gives a very brilliant light, and it is unfortunate that it is so fragile, especially when used with adjustable fixtures. The light from acetylene gas is very powerful, and objects illuminated by it look more as they do by daylight than when ordinary gas is used, but it is hardly yet available.

One of the best fixtures for gas is the adjustable arm bracket attached firmly to the wall. This can be raised or lowered and moved in any direction. Where the light is to be on a table at a distance from the wall a movable gas lamp with an adjustable arm is excellent. A very good little portable lamp, very compact, easily carried, and well adapted for use at the bedside is the one figured (Fig. 552).

It is advisable to have a dark chimney with a bull's eye condenser to concentrate the light and make it more powerful, and I have found the Mackenzie condenser very satisfactory (see Fig. 553). The room need not be dark, but no strong light should shine on the patient's face. He should sit in a wooden chair with a fairly straight high back without arms. For operation, a head rest can be attached to the back, against which the head can be pressed. Women sometimes like to have a small cushion behind the shoulders or back of the head, especially if the examination is at all prolonged. The clothing about the neck should be loose, and there should always be a handkerchief in the hand and nothing else. The use of instruments is so likely to cause a flow of mucus, sneezing, gagging, etc., that a handkerchief may be needed suddenly at any moment. The hands should be in the lap, and the arm should not rest on the table, because this force up one shoulder and makes the examination harder. The position should be an easy, natural one and without any tendency to rigidity of the neck.

The light should be on the right of the patient, on a level and about on a line with his mouth, and far enough away from the bead so that the beat is not annoying about nine inches and when not actually in use had better be turned down. On the left hand, at a convenient height, should be some form of spittoon. The doctor sits directly opposite the patient on a light, but firm stool, with his knees outside those of the patient.

I have already spoken briefly of what we should look for externally. Notice the size and shape of the nostrils; see if the fleshy septum is directly tinder the cartilaginous septum, or if the latter projects anteriorly into one or the other nostril. Look for dilated capillaries where the septum presses against the skin, for cracks, fissures, skin eruptions. Try the strength of the aloe and see if there is a tendency for them to collapse or fall in and block the nose by a valve like action:

In testing the potency of the nostrils place the finger under the opening in such a way as not to displace the parts. The sound made by the expelled air shows more or less accurately the amount of obstruction in the nose. if an oily liquid is blown into one nostril by a Vaseline atomizer it should come out of the other in nearly equal volume if both nostrils and the postnasal space are free, but obstructions in or behind the nose diminish the amount of the escaping vapor in proportion to the degree of obstruction. If a piece of finely frayed out absorbent cotton is held lightly in front of each nostril the amount of motion imparted to the cotton by the air as it comes out of the nose will show to a certain extent the pervious ness of the nose. This method is often of use to demonstrate that, for instance, in the case of a child asleep with mouth wide open, most of the air goes through the nose and very little through the mouth. Hold the cotton in front of the mouth and then near the nostrils, and the movement of the cotton may be much less by the air from the mouth than from the nose, even when the post nasal space is much blocked and the mouth is wide open. This is a very forcible way of' showing to parents that the mouth is Dot doing the work of the nose.

A graphic idea of the pervious ness of the nostrils can be obtained by holding a cold glass mirror horizontally under the nostrils on a level with the upper lip and noting the size and shape of the moisture which condenses on the glass on exhaling through the nose. The length of time that it requires for the moisture to disappear is also a factor in determining the degree of obstruction, the vapor from the narrow side disappearing first.

The sense of smell is tested in a general way by holding to the nostrils various volatile substances of different strengths as regards their odor and noting how they are perceived by the patient. For more accurate measurement, an instrument devised by Zwaardemaker and called an olfactometer can be used. This consists of a glass tube 0 (see Fig. 554), whose bent end fits into the nostril. This slides in a cylinder I, which is made of the odorous substance or is impregnated with it. When the tube C is pushed to the end of the tube T, the inspired air contains no vapor, but the more the tube C is drawn out of the tube T, the more the inspired air will be exposed to the inner side of T, which is odorous. The distance to which C has to be drawn out before the odor is perceived, and which is indicated by the scale marked on the glass, gives the measure of the acuteness of smell. Tubes impregnated with different volatile substances are used, and the temperature of the air should be borne in mind, as the warmer the air the more volatile the substance. The perception of an irritation of the nasal mucous membrane by vapors, such as ammonia, or powders, should not be confounded with the sense of smell.

For illuminating the interior of the nose it is necessary to have a concave mirror to concentrate the light and project it in any required direction. The early mirrors were larger than many of those now in use, but possessed no advantages from their size. One with a diameter of 3 1/2 inches is large enough, and the lighter it is the better. Thin glass and an aluminum back diminish the weight. A large open eye hole gives a much better view than a small one. The bead band should be firm but not elastic. The Schrotter band with the two knobs to rest on the nose causes an unpleasant feeling of weight and pressure, and to my mind is much inferior to the simpler ones which have a padded piece to rest on the forehead over the eye. One that gives a firm support, is light, and can be folded together and over the mirror, making it safely portable, is to be preferred. An open wire band to go over the vertex and take support under the occiput is thought by some to cause less heat and fatigue than the solid bands. The perforated hard rubber band, shaped to the head, made by Pfau of Berlin, has the advantage of being clean, and the weight of the mirror is distributed over the whole circumference of the head. The ordinary band absorbs the perspiration and in warm weather can become foul and irritate the skin.

The mirror is usually worn over the right eye, although some prefer it over the left, claiming that it thus protects the examiner's eyes better from the glare of the lamp. It can be attached to a rod fastened to the lamp, and its weight is then entirely removed from the head (see Fig. 553). This is not a good arrangement for examining the nose, because it is necessary to move the patient's head up and down and in various directions, and the opening of the nose is so small that a slight movement of the head throws the light away from the nose and the position of the mirror has to be changed constantly by the hand. For the tonsils and pharynx and also for the larynx, when the latter is easy to see, it is more useful, because slight movements of the patients head do not remove the light from the throat.

The nasal specula most commonly used are those of the bivalve, duck bill, and the open wire type, with their various modifications. The open wire specula have certain disadvantages; they do not hold the hairs out of the way, they have almost no reflecting surfaces, and they cut into the nose. Some of them, Bosworth's, for example (one of the best), are self retaining in certain cases, and are useful as refractors in operating in the front of the nose, but are not so well adapted for examining the middle and posterior parts.

The duckbill specula, of which Duprey's is one of the most generally used, are light, have good reflecting surfaces, thus lighting up well the deeper portions of the nostrils, hold the aloe and the hairs well out of the way, and do not cut into the nose. They do not allow the passage of large instruments through them, and in some cases are not well adapted for operations, but for examinations they are excellent.

Of bivalve specula there are many varieties. I have always considered that Hartmann's (Fig. 555) answered its purpose very well. A firm even expansion of the nasal orifice can be made with it, and it, has good reflecting surfaces and allows the passage and manipulation of good sized instruments. The blades are sometimes made too thick.

As a simple retractor of the ala a bent hairpin can be used and can 'be held in place by a tape fastened to it and then tied around the bead. A nasal probe is indispensable for exploring the cavities and estimating the density and mobility of the various structures. It should be long enough to reach the posterior pharyngeal wall easily through the nose and fairly stiff. I have used with satisfaction one like Fig. 556. It is five inches long from the tip to where it bends downward at the handle. All instruments should be warm and used very gently.

In order to get better access to the interior of the nose its tip should be lifted up by the finger so as to get a view over the anterior projection of the floor of the nose. The speculum is introduced closed, one blade resting against the septum and the other against the ala, and gradually opened. The anterior septum should be looked at while the speculum is being put in, otherwise the blade may cover small cracks, vessels, or ulcers. Students often overlook small perforations for this very reason. The thin mucous membrane of the septum can be made to bleed very easily by pressure of the end of the speculum, a thing to be carefully avoided.

When the patient's head is straight (see Fig. 555) the most prominent object on the outer wall of the nostril is the red rounded end of the inferior turbinal body, underneath which is the inferior meatus. The opening of the tear passage into this meatus is not seen, being concealed by the turbinal. We should be able to follow this body along to near its middle and sometimes even to its posterior end, and may even see a portion of the posterior pharyngeal wall. By getting the patient to say K, we Dot infrequently see the soft palate lifted, and if the turbinal is very small, we may see the Eustachian eminence; and the act of swallowing shows the mouth of the tube brought nearer the median line and more into view.

The turbinal is subject to great variations in size from vaso motor influences, as well as from hypertrophy and atrophy of its tissues. Sometimes it is so large as to fill the whole anterior part of' the nostril, and a mere touching with the probe may cause it to diminish perceptibly. Spraying also may have the same effect. We must distinguish between a true and an apparent hypertrophy. The former is quite firm to the probe and does not diminish appreciably in size under the influence of cocain. The turbinal may also be very small, in which case the inferior meatus is usually large and the posterior pharyngeal wall may be plainly seen. It is important to determine, whether this smallness is natural or due to an atrophy. If normal, the membrane over it will have the normal color and moisture, and the rest of the nose will be found in good condition. If atrophic, the membrane will be a dull, lusterless red, perhaps rather dry, and there may be crusts or muco purulent secretions over it or in the rest of the nose. The posterior end of the turbinal is liable to great swelling, which can be determined by the probe from the front, or often better by posterior rhinoscopy, as we shall see.

The head should now be tipped farther back, which brings into view the middle meatus, the usual seat of polypi and the place where the openings of the antrum, frontal sinus, and ethmoid cells are found. Above this is the middle turbinal body, which begins farther back than the inferior, is less rounded in shape, and with its mucous membrane more closely adherent to the bone. It is not seen to such an extent as the inferior, as a general rule, and great hypertrophy of the latter or deviations of the septum may conceal it altogether. If the head is tipped still farther back, we can see the roof of the nose and the olfactory fissure; but the superior turbinal is not visible. The tipper regions of the nose are narrow and sensitive, and the probe should be carefully used. As the olfactory nerve is distributed on the upper part of the septum and over the superior and middle turbinates we should notice whether there are any obstructions which would prevent the air from having free access to these important regions and also whether the membrane in which the nerve is distributed is normal or atrophic or covered with crusts or abnormal secretions.

Foreign bodies are usually in the inferior meatus and cause a purulent or even bloody discharge. A unilateral discharge, especially in a child, should always awaken a suspicion of a foreign body, and with the probe we are able to feel and locate it. Necrosis may also cause a bloody, purulent discharge with the characteristic odor, and should be carefully hunted for with the probe, in the Lipper part of the nose particularly.

On the inner side of the nostril is the septum, made up of the anterior or cartilaginous septum, the perpendicular plate of the ethmoid and the vomer. It is very uncommon to find the septum straight, dividing the nose into two equal nostrils. The cartilage is very frequently bent so as to encroach upon one nostril, or it may have a sigmoid deviation which occludes both nares. Thickenings in the shape of ridges and spurs are common. These may press against the turbinals in such a way as to make it very difficult or even impossible to see far into the nose.

To determine the thickness of the septum we can introduce the little finger into each nostril and estimate the amount of intervening cartilage; or we can make use of the septometer, such as Seiler's, whose scale gives an accurate measure of the thickness of the structures between the ends of the blades.

If the light is thrown into one nostril, especially if it is sunlight, the color of' the septum when viewed through the other nostril is much lighter where the septum is thin than in its thickened portions. A probe bent at the end when slid along a ridge or spur will show when the posterior edge has been reached.

The anterior vulnerable septal cartilage is the usual seat of epistaxis, and here we should look for dilated vessels, ulcers, and perforations.

The normal secretion of the nose is clear mucus, more copious in cold weather than in summer. The character and seat of the secretions of the nose should be carefully noted before they are removed by spray, swab, or forceps. Occasionally we meet a case where there is a very profuse and annoying flow of clear mucus which binders our examination. A small dose of atropin about four hours before the visit serves to check this. Our great resource for obtaining a better view of the interior of the nose is cocain. This causes the turbinals to diminish in size; the amount of blood in the mucous membrane is lessened. This is of special value in hypertrophic con¬ditions where, without it, we could see only the anterior part of the inferior turbinal. The nose should be carefully dried with cotton and a small quan¬tity of a weak solution, say 4 per cent., placed against the tissues which it is desired to diminish in size. This is much wiser than spraying the solution, indiscriminately into the nose. When the anterior obstruction is diminished, another application can be made farther in. The nose should be first exam¬ined as thoroughly as possible without the cocain; for this, while rendering the deeper structures visible, blanches the tissues and so changes their aspect that we might be entirely misled unless we knew the condition before the cocain was applied.

Yet, even with the help of cocain, we shall find some nostrils so narrow and tortuous and the external orifice so small and even pointing downward that we can get but a very imperfect view of the interior.

ACCESSORY CAVITIES.

Within the last few years the accessory cavities have begun to attract the attention they deserve. The antrum, frontal sinus, and anterior ethmoidal cells open into the middle meatus (see Fig. 556); the posterior ethmoidal cells and the sphenoidal sinus open into the superior meatus. If a discharge of pus is seen in the upper part of the nasal chamber, when not due to necrosis or a foreign body, it probably comes from one of these cavities. In early life they are very imperfectly developed; but in later life, especially since the epidemics of influenza, their diseases are seen to be not uncommon.

The largest and most frequently affected cavity is the maxillary antrum, which has its outlet at the top and empties into the middle meatus by an opening which is usually concealed by the middle turbinal, under which pus from the antrum makes its appearance. If this pus is thoroughly removed and the head bent forward and downward, with the side of the face corresponding to the suspected antrum uppermost, pus will thus more readily run out of the natural opening and can be seen under the middle turbinal when the patient again sits upright.

Transillumination often gives a certain amount of information as to whether the pus is located in the antrum, and should always be tried before making an exploratory puncture. Unless the room can be made absolutely dark, it is well to use a piece of black cloth, such as photographers use in focussing, or a black rubber sheet which can cover the beads of examiner and patient, and when tightly held under the chin shuts out effectually every ray of light. A small electric light (Heryng's is good, but there are a number of others) is placed in the mouth above the tongue and the lips are tightly closed. All tooth plates should be removed. When the electric light is turned on, the healthy antrum should allow the light to pass through it and show a crescentic bright area under the eye, and sometimes the pupil is lighted tip (see Plate 14). The patient should also have the subjective sensation of light in the eye with the eyes closed. In case the antrum is filled with pus or any opaque substance, this area and sensation of light are, entirely wanting. This method is often of great value as corroborative evidence; but too much reliance should not be placed on it, because there are cases in which the face fails to be lighted up when the antrum is empty, even when the bony walls are not abnormally thick. But I think we may safely say that where there is a discharge of pus under the middle turbinal and that side of the face remains absolutely dark without sensation of light in the eye, while the other side is brightly illuminated with sensation of light, the chances are very greatly in favor of our having to deal with empyema of the antrum (see page 970).

To make sure that the antrum is the part affected we can wash it out in various ways. A hollow cannula, such as Hartmann's, can be passed along under the middle turbinal till it comes to the neighborhood of the natural opening and then turned outward, and it can sometimes be felt to enter the opening. A syringe attached to the cannula may be used to suck the pus out, or warm water may be forced in, and the stringy flocculent pus which appears shows its antra origin.

In case the opening is not found, it is possible to perforate the outer wall of the middle meatus with a trocar and wash out through this artificial opening, the pus escaping through the natural opening or one or more accessory openings which may exist. Care should be taken not to puncture too deep for fear of entering the orbit. Cocain should be used for these manipulations, both to produce anesthesia and also to cause a shrinking of the tissues and gain room. It may be necessary to remove the anterior end of the middle turbinate to gain greater freedom for the cannula. Pieces of polypi and granulations, if present, should also be removed.

I have preferred to make the exploratory puncture in the outer wall of the inferior meatus, about the middle third, where the bone is usually thin. For this the curved trocar, such as Krause's or Myles's can be used, or the straight hollow needle of Hajek (see Fig. 557). This is passed along under the inferior turbinate to the proper spot, and is then pointed outward and pushed through the bone into the antrum, when the washing out follows, as above described. If a tooth has recently been extracted, the alveolar socket may be so thin that a cannula can be passed easily through it into the antrum. The alveolar process can be perforated through the socket of the bicuspids or molars or between the roots of the teeth. These latter places, as well as the canine fossa, are generally chosen in carrying out treatment rather than for simple diagnostic purpose.

In case we find that the pus in the middle meatus does not come from the antrum, we should look to the frontal sinus and the anterior ethmoidal cells. The former is reached through the infundibulum by a small hollow sound or cannula (see Fig. 556). This is often difficult, and it may be necessary to remove the anterior end of the middle turbinate. If pus is brought away on the sound when it enters the infundibulum, or if washing out the cavity through the cannula shows pus, the frontal sinus is presumably the seat of disease, as it may be when the antrum is filled by its discharge.

We can also make use of transillumination by covering the electric lamp with a thick piece of rubber open at the end so as to throw the light in one direction only. The rubber is placed against the roof of the orbit, not too near the thick orbital ridge (see Plate 14), and pressed upward, inward, and backward. The healthy sinus may thus be lighted up and show an illumination over quite an area. In case one side is light and the other not, it will give us an intimation that the dark sinus may contain pus. But the frontal sinus is so irregular in contour and size that we must not lay too much stress on this mode of examination.

The anterior ethmoidal cells are entered by passing the' probe upward between the middle turbinal and the outer wall into the hiatus semilunaris (see Fig. 556). The opening is near that of the frontal sinus, and the end of the probe should be bent at a right angle.

The opening of the sphenoidal sinus can sometimes be seen when the turbinals are very much atrophied. The anterior wall is usually about seven centimeters from the anterior nasal spine. A probe passed along the anterior part of the floor of the nose upward and backward between the septum and the middle turbinal, crossing the latter a little posterior to its center, should reach the anterior wall of the sinus (see Fig. 555).

EXAMINATION OF THE PHARYNX.

The lips, checks, teeth, palate, tongue, and floor of the mouth should be carefully examined for ulcers, cicatrices, fissures, swellings, ranula, tonguetic, etc.

For the tonsils, pharynx, and post nasal space a tongue depressor is necessary. It is possible to get something of a look at the fauces by pressing down the tongue with a spoon, pencil, paper cutter, the patient's finger, or even without any instrument, the patient saying "Ah!" during a deep inspiration, but no thorough examination can be thus made. The depressor of Turck is one of the oldest and has the advantage of resting at the corner of the mouth and is easily held by the patient when the examiner desires to use both hands in examining or operating.

The narrow bladed depressor of Frankel is much used and holds down the center of the tongue well and takes up but little room in the mouth. But I have found the sides of the tongue likely to be raised on either side of the instrument, shutting off the sides of the throat and the base of the tonsils from view. It has not seemed to me to take a sufficiently strong hold on enough of the tongue to keep it steady and out of the way. I pre¬fer a broader, thin blade with a fenestrum, somewhat concave from side to side and also from front to back. About an inch in width at its widest part and front 3 3 1/2 inches in length gives a blade which keeps the sides as well as the center of the tongue out of the way (Fig. 558).

In open wire depressors the tongue is very apt to protrude between the wires and obstruct the view; and folding depressors, although portable and convenient, are not always stiff enough.

The proper use of the tongue depressor is of great importance and is the key to a correct examination of the throat and post nasal space. The patient should be told to open the mouth, but not too wide, and to keep the tongue inside the mouth, its tip against the lower front teeth. He should then say "Ah!" in a natural voice without contracting the throat. When he has said this several times the tongue depressor is taken in the hand and carried over the tongue till the end of the blade is well over the dorsum where the tongue begins to curve downward, and while " Ali."' is being spoken the instrument presses downward and pulls forward the base of the tongue. If the handle is held between the thumb and forefinger, the middle finger placed tinder the chin acts as a fulcrum and the third and little fingers pull the handle upward and consequently help to depress the tongue still more. With the tongue, chin, and depressor thus firmly held, the patient's head can be moved tip or down or sideways, and is well under the control of the examiner (Fig. 559).

There are, however, many cases where this is a very difficult undertaking. A short, thick, muscular tongue requires considerable force to make it lie down; a strong but steady pressure should be used. Some patients have such irritable throats that they gag even before the tongue depressor touches the tongue. Great patience is needed and many trials. It is sometimes well to endeavor to turn the patient's attention from what you are trying to do by getting him to say " Ah !" several times in a loud tone while you try the depressor. Immediately after a meal there is a greater tendency to gagging than when the stomach is nearly empty, and the visit should be timed accordingly. If there is secretion on the posterior pharyngeal wall, it should be removed, because it tends to cause gagging when the tongue is held. The nose and post nasal space should be freed from secretions, as free nasal respiration makes it easier to have the tongue held. The gagging of the alcoholic may be almost impossible to overcome, and in such cases it. is well to try a few doses of bromid. Pieces of ice held in the mouth diminish the irritability.

In case we find our patient still unable to allow a satisfactory view of the throat we can generally succeed by painting the posterior pharyngeal wall with a 5 per cent., solution of cocain. The unpleasant sensation of' suffocation and of a foreign body impossible to dislodge soon disappears, and the patient should be told of this. A fairly stiff probe is of great use in examining the tonsils. If passed between the anterior pillar and the tonsil, it shows the presence or absence of adhesions. It should be passed into the crypts to determine whether they contain cheesy secretions or tonsilliths. A dull wire curette is valuable for searching under the anterior pillar and in any deep depressions in or about the tonsil. The probe can also pull the tonsil' from its bed and render it more visible and bring out more clearly the size of its attachment to the side of the throat. During gagging the tonsils are everted, approach the median line, and appear much larger than they really are, consequently they should be examined while at rest and in their natural position. If one forefinger is placed under the angle of the jaw and the other in the mouth against the tonsil or soft palate, we can determine the density of the tonsil, whether it contains a bard concretion or a cyst, and also the presence of fluctuation.

POST NASAL SPACE.

For the post nasal space we make use of the rhinoscopic mirror, which should have a size corresponding to the distance between the soft palate and the pharynx wall and also between the uvula and the tonsil. The common size is about half an inch in diameter, but for children, especially where the tonsils are large, one half the size is large enough. In some eases where there is plenty of room and the parts not sensitive, we are able to use a laryngoscopic mirror. The usual angle of the mirror to the shank is about 105', but mirrors are also made with a joint by means of which any desired angle can be obtained. The head should be held a little forward. After warming the mirror, to avoid condensation of moisture, it should be held like a pencil, the reflecting surface upward and passed parallel to the surface of the tongue until the uvula is reached. It should then be turned diagonally and passed between the uvula and the tonsil, usually to the right of the uvula and then behind and below the soft palate, with the reflecting surface facing upward and forward. The patient should be directed to breathe through the nose and try to say 'A en “with a strong nasal tone.

The view obtained is of a part only of the post nasal space at a time, and the mirror has to be turned in order to see the different parts in succession. It is very important to have the base of the tongue well pulled forward so as to have plenty of room for this manipulation of the mirror. The landmark¬ for which we look is the back of the vomer, which is of a yellowish gray color, broader at the top than lower down. The middle turbinal is generally more prominent than the inferior, whose lower half and the inferior meatus are often not visible. These structures are lighter colored, more gray, than their anterior ends. High up we may see on one or both sides the small superior turbinals which are not visible through the anterior nares. The mirror has to be turned considerably toward the sides in order to see the Eustachian prominences with their yellowish, crater like openings, over the edge of which a small red vessel is often seen. Behind the prominences are the fossoe of Rosenmuller, perhaps irregular at the bottom, or there may be bands of adhesion stretching across to the prominences. The pharyngeal vault should be dome shaped and is often irregular. In the center we may find a cleft, the median recess, whose depth call be told by passing into it behind the palate a suitably curved probe, which can also give information as to the density and extent of any thickened tissues at the vault. The mirror alone sometimes gives an inadequate idea of the amount of hypertrophy at the vault, as will be readily seen by looking at Figs. 560 and 561.

We will suppose that there is a growth which reaches down to the lower border of the inferior turbinal. When looked at through the anterior nares we see the growth hanging down as far as the inferior meatus, re I presented by the dotted line. The rhinoscopic mirror, however, seems to indicate that its lower margin is on a level with the superior meatus, and is consequently of much less extent than it really is. In such a case it is well to hold the mirror more horizontal and look at the posterior end of the growth, if that is possible, when we may find that it hangs down farther than we had first supposed. But a much better way is to make use of digital exploration, as we often have to do when no post nasal examination is possible. The examiner stands at the side of the sitting patient with his arm around the patient's head, and in the case of a child it is well to press the check in between the teeth, which serves to keep the mouth open and also prevents the biting of the examiner's finger. A metal finger is often used as protection against the sharp lower teeth, or a mouth gag may be employed.

The forefinger of' the doctor's hand, the palmar side up, is then passed along the side of the month to the tonsillar region and then behind the soft palate, being very careful not to carry the uvula or palate with it. The elbow is well depressed and carried in front of the patient and the finger feels for the septum, turbinates, Eustachian eminences, the vault, and can thus estimate very accurately the amount and character of any obstructions, whether central, near the choane how much of each posterior naris is covered, and whether the growths are on the posterior wall. The examination should be short but thorough, and may be unsatisfactory unless the child is firmly held. It should follow and not precede other methods of examination; because the child has usually had all the examination be will submit to when tile finger has once been behind the palate.

Still another way of seeing the post nasal space is advocated by Katzenstein of Berlin,' who calls it autoscopie. The patient lies On his back with the bead banging down as far as possible. The mouth is then opened and the tongue drawn forward, as in laryngoscopy. A palate retractor, resembling an eyelid retractor, is then placed behind the uvula, and by slowly and gradually increasing the force used the palate is drawn so far forward and downward that we are able to see the posterior pharyngeal wall, the vault, the Eustachian eminences and openings, the plica salpingo palatina, the plica salpingo pharyngea, and the fossa of Rosenmuller. The septum, turbinates, and choane are Dot visible. Post nasal tumors and adenoid hypertrophy can be seen and operated on in this way without a mirror, and the catheter can be placed directly in the Eustachian tube without having to pass it through the nose. Strong illumination is necessary here, as in all examinations of the post nasal space.

The obstacles to rhinoscopic examination are many. The tonsils may be so large as to prevent the introduction of even the smallest mirror. A very broad uvula may interfere, in which case we can hold it to one side or lift it by a palate retractor. The distance between the soft palate and the pharynx may be so small that there is no room for the mirror. By using a little cocain on the back of the palate we may be able to pull it forward by the palate hook and gain space enough for a small glass.

Where the fauces are of sufficient size the attempt to pass the mirror behind the palate often causes the latter to be drawn back against the pharynx wall, even when the mirror has Dot touched the tongue, uvula, or pharynx. The mere presence of the mirror, whether by interfering with the passage of the air or by acting on the mind, is enough to excite movements of the palate. A very small mirror may be tolerated when a large one is not. I have sometimes succeeded by passing the tongue depressor on the side of the tongue instead of in the center and pushing the tongue over to the other side. Thus room enough is gained near the tonsil for a small glass, and the patient does not have so much the feeling that the tongue is being held down.

I have already spoken of the need and value of a weak solution of cocain in the pharynx, and it is also well to paint a little on the back of the palate.

A good many self retaining palate retractors have been devised to hold refractory palates out of the way, and that of White is probably as good as any. One end goes behind the soft palate and the anterior branches are placed on the outer side of the lip, one on either side of the nose. I have found, however, that eases that needed them generally did not tolerate them; and when they were well borne that they were not necessary. The palate may he held forward by tapes or rubber bands passed through the nose, drawn down behind the palate and out of the mouth, and tied over the upper lip. This method is more commonly used in operating than in examining.

LARYNX.

The lingual tonsil and the glosso epiglottic fossa are not well seen by using the tongue depressor, although it is occasionally possible to pull the tongue sufficiently away from the epiglottis to get a view of part of the region. But we succeed so much better with the laryngoscopic mirror that this examination is generally combined with that of the larynx. The forefinger passed all around the base of the tongue gives a very good idea of the amount of tissue present, its character, whether inflammation or suppuration are present, and can often detect foreign bodies which find here a convenient lodging place.

For looking at the larynx the usual method is to have the patient's bead held well back and the extended tongue held between the thumb and forefinger of the examiner. This lifts the whole larynx. Care must be taken not to pull the tongue too hard, especially when it is sore or the teeth sharp and rough. For a mirror we use a glass about an inch in diameter, although if the fauces are small or the tonsils large, and usually in children, we have to choose a smaller size. On the other hand, in adults we can sometimes use one much larger, and with one the size of a silver dollar I have obtained a very satisfactory view. The shank should be quite stiff, and I have been surprised to find so many slender and flexible ones in the market. Those sold in students' sets are often too flimsy for actual use. A stiff, firm handle, shank, and mirror are much more easily borne by the patient. The mirror figured (Fig. 563) is one that I have found excellent.

The glass should be warmed over the lamp and the metal back tested against the ball of the thumb to insure its not being too hot. The handle is then taken between the extended fingers and thumb. The mirror is intro with the glass side down, above and parallel to the dorsum of the tongue, but without touching the latter. The patient is directed to say “Ah!" and as he does so the base of the tongue is lowered and the soft palate is raised. The mirror is placed under the uvula, which it carries backward and upward, and the glass is pointed downward at ail angle of about 45'. This is the position for looking into the larynx; but it is well before this to look at the base of the tongue. For this purpose we hold the mirror nearly horizontal and near the posterior edge of the hard palate. We can thus look directly down on the base of the tongue, or if we carry the mirror back to the uvula we must slant it farther forward than as if to look into the larynx. We should note the region of the circumvallate papilla and the glosso epiglottic fossa, which should normally be free and rather smooth. If hypertrophy of the lingual tonsil is present, we see red, rounded, raised masses filling the whole or a part of the space or even crowding upon the epiglottis, or we may find it acutely swollen, with yellow or white spots on the surface, or false membrane or ulceration. A smooth atrophy in this region is thought by some to be characteristic of syphilis.

Coursing over the base of the tongue in adults we may see large, dilated, or varicose vessels, looking not unlike rivers in the atlas.

After having examined the region anterior to the epiglottis, we place our mirror to look into the larynx, as spoken of above. The epiglottis is now the great obstacle and the patient should be told to say Ah !" or what is still better, to take a number of deep breaths and say eh !" during the inspiration. This serves to lift the epiglottis. If not successful at first, we are generally rewarded after a number of trials by seeing it gradually lift. We may at need spray a little cocain into the larynx or paint the posterior surface of the epiglottis and hook it forward with a bent probe, the patient holding the tongue.

The epiglottis varies greatly in shape and position. It is usually of a reddish yellow color, and its free edge is thin. It may be erect or pendulous, hanging completely over the larynx, or in any position between these extremes. In children it is generally bent more backward than in adults. It may be rounded, incurved in the center of its free edge, omega shaped, its edge turned over, etc. It is sometimes not symmetrical, and may Dot be in the median line. The mucous membrane is much more closely adherent to the posterior surface than to the anterior, so that swellings, edema, or cysts are more often found on the latter. Low down on the posterior surface we see the projection called the cushion (see Fig. 541), which is at times quite marked. Extending downward from either side of the epiglottis toward the median line and the posterior part of the larynx we see what are called the ary epiglottic folds, which are narrow near' the epiglottis and become wider as they descend. The two rounded projections on either side of the median line are the small cartilages of Santorini and Wrisberg, and below them are the arytenoid cartilages, whose form is not definitely seen. These structures are covered with a reddish membrane in health. Between the arytenoids is the interarytenoid space, where hypertrophies of various kinds are likely to occur.

The vocal cords are the pearly white bands which stretch across from their anterior commissure at the inner angle of the thyroid cartilage to the vocal processes of the arytenoids posteriorly. In respiration the posterior ends separate, leaving a V shaped aperture, but in phonation they lie parallel to and nearly or quite in contact with each other. Just above the cords is a dark space, the opening of the ventricle, more plainly seen when the larynx is thin and relaxed. Just above and outside the months of ventricles are the ventricular bands or false cords, which are of a red color.

Below the true cords we see a little of the inner side of the cricoid cartilage, and farther down a number of transverse white bands, the rings of the trachea, and consequently the anterior wall; and occasionally we can even see the bifurcation of the trachea and the opening of the bronchi. Outside of the ary epiglottic folds are the pyriform sinuses; and the cornua of the thyroid cartilage may sometimes be seen as whitish elevations in their floor.

In the mirror these laryngeal structures look as if spread out in one plane; but study of the exsected larynx (Fig. 564) shows very forcibly what should be borne in mind while using the mirror that they are on very different planes, and that from the top of the middle of the ary epiglottic fold down to the top of the vocal cord is about an inch. It is of great service to study a model or a larynx removed from the body as a preliminary to using the mirror.

The objects looked at in the mirror are seen as if inverted ; that is, the anterior commissure of the cords is at the top of' the mirror and apparently points backward, whereas the arytenoids are on the lower side of the mirror and seem to be anterior. The figure (Fig. 563) will illustrate my meaning. In using the probe to touch the different parts of the larynx it is necessary to bear this inversion in mind, and it is well to practise on a model. It has seemed to me that students have more difficulty in passing the probe backward against the anterior face of the interarytenoid space than forward toward the anterior commissure when trying on the exsected larynx.

There are many difficulties in the way of' obtaining a good view of the larynx. A short, thick tongue, perhaps even tongue tied, may be almost impossible to hold with the fingers or may fill up so much of tile mouth as to leave very little room for the mirror and the light. We may then find it better to use the tongue depressor and draw the tongue forward with it so as to make room at its base for the mirror. If the throat is very irritable we can spray cocain into the larynx or paint the pharynx or use pieces of ice.

In children the epiglottis is often bent over the larynx in respiration, and the glottis is difficult to see. To overcome, this the long, curved tonguedepressor of Mount Bleyer can be used, which goes behind the tip of tile epiglottis, lifts it and also the whole larynx to some extent, or the tonguedepressor of Escat may be tried. Its branched ends are placed behind the sides of the' epiglottis in the pyriform fossa, and so pull forward and upward the epiglottis as to open tip the entrance to the larynx, and a view can be obtained with the mirror. A mouth gag may be necessary.

In the ordinary examination with the head thrown well back the face of the mirror is so turned as to show the anterior wall of the trachea. If the head is bent well forward while the patient is standing and the examiner, kneeling in front of the patient, holds the mirror well up against the uvula, a very different view is obtained. Instead of the anterior part of' the larynx and trachea we see the posterior wall, sometimes even as far as the bifurcation. This is the method of Killian, and is valuable for looking at the posterior part of the larynx, the posterior ends of the cords and underneath their surface. It is not always easy to carry out, as the position of the examiner is not a comfortable one. The saliva runs out of the mouth into the doctor's hand and tip his sleeve, so that it is well to have the patient expectorate before we use the mirror. The light does not come in a suitable direction, and the head mirror is usually beyond its focal distance from the throat mirror. If the examiner wears glasses they may also be an obstacle from the unusual position of the head. But in spite of these difficulties the view of the posterior part of the larynx and trachea is often very striking and gives information not to be obtained by the ordinary method.

The larynx can also be viewed by transillumination in a dark room. The electric lamp, such as is used for the frontal sinus, is placed against the front of the Deck in the neighborhood of the cricoid cartilage. The tongue is held and the mirror passed as in ordinary examinations, only Do light is thrown in through the mouth. The larynx is seen in the mirror to be illuminated by a light which traverses the tissues of the Deck and gives a Yellowish red look to the parts quite different from the usual examination. It was hoped that this method would be of great service in determining abnormal densities of the different tissues traversed by the rays of light, but it is not much used for that purpose at present.

Under this name Kirstein has reverted to the oldest method of examining the larynx. No throat mirror is used, but, the base of' tile tongue and the epiglottis are drawn very much forward by a special ly constructed tongue depressor, and the examiner looks directly down into the throat illuminated by an electric lamp or by light reflected from a head mirror and sees the posterior part of the larynx, the arytenoids, perhaps the posterior half of' the cords, and the posterior part of the trachea. The patient should have a yielding tongue and neck to give good results. He should be seated, the upper part of the body thrown forward and the head tilted slightly backward. The physician stands in front, and places the depressor as far back as possible oil the ton tie with firm pressure downward and forward On its root, whereby a deep groove is formed, allowing tile rays of light to fall in line with the laryngo t rac heal axis.

According to Kirstein, in about one fourth of all adults the whole larynx and trachea can be thus conveniently examined, except that the extreme apex of the anterior commissure call be seen in but one tenth of all cases. About one half of all people call be fairly well examined, so that tile posterior region of tile larynx, including sometimes a more or less extensive portion of the trachea, is exposed to view. This method, he claims, is applicable to children .under anesthesia, and sometimes without anesthesia. This needs corroboration, and the method is in no sense a substitute for ordinar y examination with the mirror, which gives us in most cases all needed information.

THE RONTGEN RAYS.

The X ray has served to locate foreign bodies in the air passages and esophagus. 'Pile nose and tipper throat are so accessible by our present means of illumination that it is not of the same help to the laryngologist as to the general surgeon.

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