needle in ordinary cases is the fifth interspace in the lower lateral region.

The mode of procedure is this. The skin is rendered tense by the thumb and forefinger of the left hand; the needle held by its handle between the thumb, fore and middle fingers of the right hand, is pushed gently and gradually into the thorax, a little above the upper edge of the rib. When the needle-point has cleared the pleura it will be felt to move jerkingly onwards. The needle may now be moved a little further, say one line more. If there be any liquid in the cavity of the pleura, a little liquor will be found to issue from the grooved surface of the needle. This occurrence now declares for proceeding to the employment of the trochar.

CHAP. XLV.

The Examination of the Mouth, Fauces, Larynx, &c.- Tongue Depressors. Specula. Illuminated Specula.-Avery's Speculum. — Czermack's Laryngoscope.-Table of Thoracic Regions.

THE EXAMINATION OF THE MOUTH, FAUCES, LARYNX, ETC. This is a very important office. It is one which should never be omitted, if it can be at all conveniently done. The state of the gums, the tongue, fauces, and other parts will greatly assist us in deciding upon the nature and extent of the disease of the patient, as well as in obtaining indications for the treatment.

If, when the patient is only slightly disturbed in his health, and when the thoracic physical signs of phthisis are ill marked, the gums present a fine red border along the edge of union with the teeth, and the fauces are only very slightly congested, or perfectly healthy, the probability of pulmonary disease in an incipient form being the primary complaint is considerable. If, on the other hand, the fauces be highly vascular, granular or granulous, the posterior wall of the pharynx be rough, tuberculated, and covered here and there with thick green mucus, or the tonsils be irritable, large, and projecting, and associated with enlarged cervical glands on the exterior of the neck, and the voice be more or less hoarse or nasal, and no decisive physical signs of phthisis are to be

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obtained by auscultation or percussion, it is highly probable that the primary and chief disease is within sight, and that the thoracic symptoms and signs are only secondary, and very likely to pass off upon the cure of the morbid conditions above referred to.

When the mouth of the patient is to be examined, if in bed, he should be made to sit up. If out of bed, he may stand or sit down, but care should be taken that he is placed before a window or nearly in front of a good light. The physician must endeavour to place his head on a level with that of the patient and move the head of the examinee so that the innermost parts of the pharynx may be brought into view. The sitting posture with the head gently thrown back is very suitable for examining the pharnyx. To have a good view of the interior of the mouth, and to allow of the admission of sufficient light, it is a good plan-though perhaps a somewhat coarse one-to introduce the forefinger of the two hands into the mouth respectively at the two angles, and separate the angles to a convenient distance. This can only be done of course when the hands are not engaged with instruments, or in the management of artificial light.

THE MANAGEMENT OF THE TONGUE.-The behaviour of the tongue of the patient is an important point. Some persons have the happy art of keeping this member easily, and for a considerable period, deep down in the floor of the mouth, thus greatly facilitating ocular inspection. Others, on the other hand, have such a rebellious and obstinate member, that no exertion of the owner and no direction on the part of the physician will succeed in preventing it rising, in the most sight-obscuring manner, between the eye of the observer and the fauces of the patient. If ducked down for a moment, it will rise the next and be proof against any exertion. For such persons various means have been employed, and some instruments have been contrived. The tongue is conveniently and very readily depressed by the forefinger of the physician, but some practitioners would be afraid to risk their reputation for delicacy by adopting this method; and again, some squeamish patients may have a repugnance to it. Yet it has its advantages; the examination is made at once before the spatula and depressor could be introduced, and this is no slight matter when we have to deal with hysterical men or women, and with spoiled naughty children. The latter may possibly complain or cry, but the examination has been already made, and this is satisfactory. When employing the finger we must guard against being bitten.

TONGUE DEPRESSORS.-Instruments so called are in general use, and should be in the possession of every physician called upon to treat much disease of the chest and throat. A very convenient form of depressor is one shaped like the handle of a table-spoon. It is about five inches long. The widest part is about an inch in width. The surface which comes in contact with the tongue is gently concave, so as in part to receive the tongue and thus keep it under. Children require a smaller instrument. To use this depressor the physician takes it in his right hand, and standing or sitting a little to the right of the patient, gently introduces it till the extremity has reached the root of the tongue: he now depresses that organ and keeps it firmly out of the range of vision. A common non-flexible metal or wooden spatula, or even a strong ivory paper-knife, form convenient substitutes. When it is necessary to keep the tongue out of the way some considerable time, or when we have to deal with restless patients, another form of depressor is useful. Connected with the depressing part of the instrument, we have an arm which descends at right angles, and comes in contact with the chin, which forms a convenient point d'appui; and the danger of passing the instrument too far is avoided. A movable joint connects the two parts so that the instrument may be extended or bent, or folded at pleasure.

Tongue Depressors.

By means of the instruments just described, and a good light, a fair view may generally be obtained of the pharynx, tonsils, and even of the epiglottis,

The epiglottis is even occasionally brought into view simply by the efforts of the patient, without any aid from the physician. But it frequently happens that the means indicated above do not succeed in enabling the explorer to see the epiglottis and the rima; it is therefore necessary to employ

others.

Specula have been, of recent years, rather largely employed to bring the epiglottis and the rima glottidis into view. A mirror of glass or metal is introduced into the mouth and

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held so as to reflect an image of the parts upon the retina of the observer. The usual mirror is about half an inch square and is gently bent upon the handle. Liston recommended such an instrument years ago. To employ this instrument, it

is warmed before introduction into the mouth, to prevent condensation of vapour. It is employed gently and brought as little in contact with the patient as is possible. It is moved about until the image is brought into vision. It may be allowed to touch the soft palate and uvula, but it is desirable to avoid contact with the tongue and pharynx. If it touch the latter part, involuntary acts of deglutition take place. To the use of the speculum has been latterly added the advantages of illumination. A metallic reflector has been added to it, by which the interior of the mouth and the larynx have been lighted up. Mr. Avery, I believe, was the first to make use of this instrument. While a speculum consisting of a metal cylinder with a mirror at its further extremity is held in the mouth, the light of a candle lamp is received upon a concave reflector connected with this lamp and made to enter the mouth, through the cylinder, the explorer looking through the speculum in the mouth over the edge of the reflector. This is a very useful instrument, the glottis and the larynx are well seen with it, and it is easily managed. When a good inspection is desired, this instrument may be employed. It is to be borne in mind that, simple as it is, and capable of quick adjustment, it is occasionally found to be irksome to the patient, and it sometimes happens that contact of the speculum with the soft palate, &c., of the patient brings on spasmodic movements which render it necessary to desist

from its employment. The patient is to be seated before the examiner. The latter holds the lamp and reflector in one hand, while he holds the speculum in the mouth of the patient with the other. The mirror in the mouth is to be held above the rima when the larynx is to be inspected. The subjoined figures represent a speculum having a mirror at the smaller extremity, and a candle lamp furnished with a reflector.

The Speculum after Avery.

Within the last few months the ingenious contrivances of Czermack and Dr. Türck of Vienna for inspecting the larynx have been brought before the profession in England, and have excited much interest. The chief improvement over the lamp and speculum above described, and which has been in use in England for some years, consists in an arrangement in respect of the reflector, by means of which the examiner looks through instead of over the reflector. The reflector which is concave, is perforated in the middle, and the eye of the physician inspects through it. This reflector receives its light either from the sun or from a lamp or gas-burner with which may be connected a bi-convex lens. The reflector is held before the eye by the teeth or by means of a common spectacleframe. The speculum or mirror used by these physicians, is fixed to a flexible metal handle, about four inches long. It is held so as to illuminate the parts, and to reflect an image of them into the eye, through the perforation in the concave reflector. The interior of the larynx, and (it is said) the interior of the trachea down to its bifurcation, are to be thus successfully explored.