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

by Unknown

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

FIG. 5.

Diagram of Section of Head, showing the Position of Laryngeal Mirror in the Pharynx.

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

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

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

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

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

FIG. 6.

Elsberg's Sponge-holder and Epiglottis Forceps.