FIG. 14.
Septometer for Measuring
Thickness of Nasal Septum.

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 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.

FIG. 15.
Folding Tongue Depressor.

FIG. 16.
Cohen's Tongue Depressor.

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 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.