By A DE LABORDETTE, Surgeon to the Hospital of Laisieux, Knight of the Legion of Honour.

 THE laryngoscope has been the subject of a favourable report made to the Imperial Academy of Medicine by Professor Robin on behalf of a commission on which. MM. TROUSSEAU and GOSSELIN were appointed.

In this report the facts proved by as on the living and on the dead subject were set forth, and their exactitude was confirmed, not only by the members of the Commission, but by several hos- pital surgeons and students. The following are the results obtained :—

' 1. The instrument may be easily introduced, and is supported without nausea by the majority of subjects, either in good health or asphyxiated.

1. Extracted from the Journal of Public Health and i Medical Jurisprudence.* Second series, vol. xxix., 1868, 

2.' ROBIN, Report,' (Journal of the Academy of Medicine, ; 1865, vol. xxx., p. 721.) 

2. It allows of the easy examination of the epiglottis, the aryteno-epiglottic folds, the supe- rior opening of the larynx, the portions of the back of the throat placed at this level, and the condition of these parts, either directly, or in the mirror with which some laryngoscopes are furnished, 3. It consequently facilitates the introduction of instruments intended to act on these organs, or to free them from the mucus, the false mem- branes, &o,, which may adhere to them.

4. It renders the catheterism of the trachea particularly certain and rapid, by allowing the eye to follow the extremity of the sound as far as the superior orifice of the larynx; and it may consequently be of use in this point of view in measures adopted for the recovery of drowned and asphyxiated persons.

The opinion given by the Commission of the Imperial Academy of Medicine encouraged a$ to urge upon the Prefect of Police the necessity of adding to the apparatus of recovery our laryngo- scope.

Our request, submitted to the Council of Pub- lic Health of the Department of the Seine, was sent to Professor TARDIEU , who proposed to intrust to Dr. AUGUSTE VOISIN, director of the Humane Society, the performance of experiments which should be suitable for demonstrating the nature of the services which our instrument might afford in the recovery of drowned and asphyxiated persons.

Dr. VOISIN handed in his report to the Prefect of Police on the 11th September, 1885, and the following passage is an extract from it; "I have just employed the laryngoscope of DR M DE LABORDETTE on a drowned man at Issy.

The man had his teeth very tightly compressed, in consequence of a trismuss of the jaws. The instrument could not be introduced into the mouth without the aid of a box-wood lever; but when since introduced, it was of great service to me in the cleansing of the back of the throat, and was of great advantage in assisting the entrance of air into the air passages and the recovery of life/' In default of drowned persons on whom the experiment might be repeated, M. AUGUSTS VOISIN tried it while in attendance on epileptics at Bicetre.

From these experiments it was found that during the first period of the fit certain persons have their teeth very firmly compressed, and are almost in the same condition as drowning persons.

With them also the introduction can only be effected by the use of a boxwood lever; but when once in its place, the laryngoscope main- tains the mouth open and the tongue depressed, perfectly and painlessly, so as to permit the easy penetration of air into the air passages.

The facts observed by M. Voisin, although they were few in number, appeared sufficiently con- elusive to M» TARDIEU to enable him to declare hi» authoritative conelusioa that " the laryngo- scope easily maintains the tongue depressed and the respiratory passages open." This double con- dition is so important in all cases where it is necessary to revive persons threatened with death through having bees submerged, hanged, or visited by any other description of asphyxia, that nothing but advantage can accrue by adding this speculum to the different instruments for restoring life.

The Board of Public Health approved of the opinion given by its learned referee, and the Prefect of Police, by a decree, dated Feb. 28th, 1867, ordered that the laryngoscope should be adopted among the apparatus for drowned per- sons.

I have recorded, in reference to the drowned man recovered by M. AUGUSTE Voisin, the co- incidence of a violent contraction of the jaws and the recovery of life. This is a very important detail, to which it is well to call the attention of the reader. Among authors who have made a special study of asphyxia by submersion, I have only found BEAU' giving special attention to the contraction of the jaws.

There is already provided in the "boites de se- cours " a boxwood lever for the purpose of sepa- rating the jaws of drowned persons. Several in-struments have been invented calculated to facili- tate the separation of the jaws. In the " Practical Instruction in the Treatment of the Drowned," edited by FODERE, we read: " If the mouth be found closed by the tonic contraction of the mus- cles of the lower jaw, which sometimes takes place, we must seek to open it with a spatula or the handle of a spoon used as a lever. It will be kept half opened by a piece of cork placed between the teeth, which will also prevent the convulsive closing of the jaws which often happens at the com- mencement of recovery, and which may cut through the tongue if it be protruding." * More or less precise recommendations of the same kind are found in the Instructions published lately by the Board of Health of the Department of the Seine, and of other departments, &c.

These instructions insist, and with reason, upon the means of recovering persons, upon the employment of heat, friction, inspiration of air, suitable movements for causing the entrance of air into the chest, &c., upon the probable causes of death, the incidents, and the complications which accompany asphyxia; in none of them is any weight attached to the fact, so important in my eyes, of the contraction of the jaws.

I shall rapidly relate the principal symptoms regarded as inseparable from asphyxia by sub- mersion, and I shall connect them with the three circumstances noted in the experiment of M. AUGUSTE VOISIN, that is, 1. the constriction of the jaws, 2. the necessity of opening the entrance to the air passages to facilitate the penetration of air into them, and consequently, 3. the recovery of the sufferer to life.

When a person falls into the water he either re- mains at the bottom, or rises to the surface by swimming. What takes place in these two cases as far as the respiratory organs are concerned ? If the body remains under the water does the subject attempt to breathe ? Several authors assert that he does, and some of them have attempted to support this assertion by experimental proofs.

Thus VOISIN says: " Persons in the act of drown- ing, when they have plunged under water, pre- serve for a longer or shorter time the faculty of contracting the thoracic cavity, and in inspira- tion fill the trachea, the bronchi and the lungs with water."3 ALBERT gives the same opinion, and adds that he does not see why an animal which can only live in the midst of atmospheric air should not try to breathe under water, since nothing opposes the mechanical execution of this function, the water is drawn in by the efforts at respiration.' The observations recorded by this clever experimenter, who drowned a large 1 BEAU'S ' Experimental Researches on Deaths by Sub- mersion.' (Archives of Medicine, I860, Fifth series, vol. xvi, p. 16.) 2 FODERE, ' Dictionary of Medical Sciences,' vol. xxxvi. (1819), p. 442, article Noye.

« MARC'S • Fresh Researches into the Recovery of As- phyxiated and Drowned Persons.' Paris, 1835, p. 147.

4 MACC, as above, p. 148.

: number of animals of various species in pure or coloured water, leave no doubt about the pene- tration during submersion of a portion of these | liquids into the tracheal artery and the lungs.1 M. PIORRV, in his experiments on submersion, arrived at the same result.2 Finally, we owe to BLUMHARDT the knowledge ' of a fact of the same description, but altogether | exceptional. It has reference to a man subject to attacks of epilepsy, who was found drowned in a brook about a foot deep, with his face turned towards the ground. The trachea and the two large bronchi contained gray and schistous sand and gravels of different sizes; some particles were even extracted from the pulmonary vesicles.3 All the authors who have just been quoted admit, as we have seen, the presence of a certain quantity of water in the air passages of the drowned man. Nevertheless, they remark this fact, that the quantity of water introduced into the lungs is less when the subject has not come to breathe at the surface. There are even cases, but these form exceptions, in which no trace of liquid is found in the air passages. These cases constitute the variety of asphyxia by submersion, which is called nervous or immaterial, due to a syncope produced at the moment of the fall into water. This form DESGRANGES was the first to distinguish from ordinary or material asphyxia.4 After discussing at length this fact of the introduction of water into the bronchi, the same authors pass in review different methods, having for their object the recovery of drowned or as- phyxiated persons. Among these methods, in- spiration and insufflation of air are placed in the ' first rank. ALBERT speaks highly in favour of inspiration, and in support of his opinion adduces his successes obtained with animals which he had drowned. He relates fifteen observations on animals submerged for five or ten minutes and recovered by means of inspiration. MARC" says that his experiments have not given him such brilliant results as those of ALBERT: nevertheless, in some cases inspiration has been proved to be evidently useful, but so much cannot be said of insufflation. This latter method also has its prose- lytes and detractors. MARC and LEROY D'ETIOLLES have made numerous experiments tending to show the dangers of rough and violent insufflation through the mouth. Quite recently, M. MAR- CHANT has extolled insufflation; but he practises it with the aid of a sound introduced into the nostrils, as MARC, PORTAL, RIGAL, &c., had pre- viously advised or acted on.

In reference to what is said about the contrac- tion of the jaws with drowned persons, M. MAR- CHANT attaches no importance to it; and con- sequently he repels in the following words at- tempts calculated to overcome it before the ap- paratus intended for the re-establishment of re- spiration has been duly employed: " At the third period of asphyxia, every trace of external life has disappeared, and authors who speak of it all agree in comparing individuals who have arrived at this stage to corpses, and in considering the re- turn of life to them like a resurrection. .. . All parts of the body except the heart are asphyxiated; 1 MARC, as above, p. 152.

" MABC, as above, p. 153.

3 MARC, as above, p. 154.

* DESGRANGES, ' Treatise on the Means of Perfecting the Treatment of the Drowned.' Lyons, 1791).

5 MARC, as above, p. 191. 6 MARC, as above, p. 223.

7 This is how MARC expresses himself in relation to insufflation:—"Of different methods of aspiring or In- sufflating air, the best is that in which they are performed by one of the nostrils; the other, as well as the mouth.

being kept closed."—MARC, as above, p. 220.

 

the muscles which play an active part in respira- tion are indifferent alike to contraction as well as to relaxation. This passive state of the muscles as soon sis death becomes complete, will be re- placed by the rigor mortis, which, according to LODIS and SYSTEM, is of great value as a certain sign of death. It is then clear that it is useless to seek to open violently a mouth which offers no resistance, asd the boxwood lever supplied for the means of rescue serves to give no sign."1 The assertions which conclude ths passage just quoted are in diametrica! opposition to the facts observed by the most careful and creditable ex- perimenters, We hare quoted several of them in the course of this notice. We think we ought to add 'to it the opinion expressed by BEAU on the subject which we are now considering, dettaeed from his own experiments : " In the state of sub- mersion," says this learned and skilful observer, " the stoppage of the respiratory motions depends on an instinctive and irresistible horror for the inspiration of water. The animal convulsively closes his month and nostrils with the view of preventing the penetration of water,"2 BEAD relates that a medical student who was drawn out of the water at the moment of impending death told him that in the state of submersion he performed no respirator/ motion in the fear of inspiring water.

These differences of opinion among learned men of repute prove that facts obtained experi- mentally are frequently complex, and that in submersion particularly, the circumstances which lead to death are not always identically the same.

BEAU,* in the experiments which he performed, made this important remark ; that with submerged animals he has found the lips closed and fixed one against another, and the glottis closed so as to close the passage of air. Much more, these same conditions of closing of the mouth and glottis existed equally with a dog into whose trashes a canula had been fitted; although this cannula afforded a free entrance for the water into the air-passages during the immersion of the animal, it abstained after the first respiration from any retpiratory movement, and then there was no more liquid in- spired. At the post-mortem examination, no more frothy water was found in the lower part of the bronchi than in cases where the submersion had taken place without the previous introduction into the trachea of a canula communicating freely with the outer air. OB the contrary, a dog prepared in the game manner as the preceding was plunged into water, with the exception of the head, which was kept above the surface of the liquid. After a first inspiration fallowed by coughing, and the vomiting of water and air babbles through the canula, respiratory move- ments ceased and afterwards reappeared. The submerged animal made inspirations and expira- tions alternating in the most regular manner, and without coughing. At each expiration bubbles of air proceeded from the canula, and the quantity of them went on diminishing more a»d wore, in proportion as the quantity of water inspired in- creased. At the end of five minutes, the animal was taken out of the water. " It was found that the trachea, and the bronchi were literally filled with water; the water was not frothy; the lips aud the glottis were sot closed convulsively as they had been in the preceding experiments." r, * Asphyxia and Pnlmonary IssaSteUon,* (ArcMre»of Medicine, Sixth series, vol. fct, 18«, p. S30.) 2 BKAU, ' Experimental Researehes OB BeaBi by Sa6- BrerstoB." (Aretees of Medicine, Fifth series, vol. xvi., iseo, p, w.) 3 BSAC, a» abew, p, 54, From this experiment BBAO draws the conclusion " that immersion of the natural orifices of respira- tion is an imperative warning to the animal that respiration will cause the water to penetrate into the air-passages, and that consequently it ought to be stopped." He admits, finally, as a result of his experiments, that " in ordinary and complete submersion the occlusion of the respiratory open- ings and the forcible stoppage of the movements of respiration are the cause of death, and esta- blish a great analogy between this kind of death aftd that which supervenes in. the case of lock- jaw." Professor TARDIEST, in the careful analysis which he has made of the researches and experi- ments undertaken In England by some of the members of the Medieo-Chirurgical Society of London, gives, oa the contrary, his opinion that among drowned persons death is the consequence of the entrance of the water into the lungs and the formation of froth by means of this water, of the air, and of the bronchial mucus, under the influenee of violent efforts at inspiration daring the first minutes of submersion. " ft is," says ibe learned professor, " the penetration of the water into the respiratory passages and into the lungs which is the essential if not the exclusive element in death by submersion, and which sccoaats for the rapidity with which it takes place, as well as the excessive difficulties which are experienced in restoring drowned persons to life; difficulties which neither simple privation of air, strangula- tion, banging, not asphyxia by carbon yapoar present in tha same Jegre« " (p. SSO).' I cannot pretend to set myself up as a judge between the contradictory opinions asserted by the eminent men whose worka I have just been quoting. Bat I must confess that the theory of BEAB seems to me to correspond more completely than the other with the facts which I have had occasion to observe myself. Beside*, those who share the opinion which, in death li y sabmeisioa, makes the water &ad the frothy and bloody mucus play the principal part in the obstruction of the air-passages, appear to me to have lost sight of the refutation addressed by Goodwyn to Haller, who held the same opinion. Goodwyn intro- duced tijreetiy, through an opening made in the trachea of m cat, which was kept in an upright position, » quantity of water estimated at two ounces. ** Immediately the animal experienced a difficulty of breathing, and its pulse became feeble. But in a short time these symptoms subsided; it lived several hours without per- ceptible suffering. Finally it was killed, and I found 2J ounces of water in its lungs." * The same experiment repeated OB two other eats gave identical results. " From this we may conclude," says Goodwyn, "that even if a greater quantity of water were to be introduced into the fuagg than that which was fsuad there, in these tot experi- ments, that quantity would not still produce effects similar to those which result from »nb- mersion." In the experiments which I have myself per- formed, and of which I am now going to give gome account, I particularly applied myself to follow step by step the progress of the aspbyxial symptoms, and specially to observe the produc- tion of the contraction of the jaws.

Aa animal plunged under water and prevented ?, '"Sent Medico-Legal Investigation apon Sub- meratoa and Suffocation,' &e., la reference to the ex- periments of the Medfco43 lnirgleal Society of London.

(Journal of PoWio Hygiene and Medical Jurisprudence, vol. six., Second serfe*. 1883, p. 312.) * EBHCKB GOODWTK, ' The Connexion of Life with Bespiratioa.' London, 1789; translated by J. If.

Paris, H98, p. It.

from coming to breathe at the surface executes respiratory movements which cause bubbles of air to rise to the surface of the liquid. While keeping the mouth closed, it swims, goes to the bottom, and attempts to rise to the surface again; at the end of about a minute the limbs cease to move and seem to contract. It falls again to the bottom, afresh attempts to swim, half opens its mouth, and again shuts it in an instant; its limbs stiffen, it falls, to rise only once more at the end of about a minute and a-half.

In spite of the greatest attention, I have not seen the slightest dilatation of the chest pro- duced. The animal, drawn out of water under the circumstances just related, presented a very firm contraction of the jaws. It was with diffi- culty that I kept them open with the aid of pincers; the limbs were stiff and the eyes start- ing out of the sockets. By keeping the mouth open and causing movements to be executed simulating those which are produced in the act of respiration, I saw the subject recover life in proportion as the air penetrated into the lungs.

This experiment, repeated upon twelve animals of the same age and the same species (namely, rats), gave me the following results: nine were restored to life, only three died.

By prolonging the stay of the animal under water to two or three minutes, the limbs by degrees spread out and the jaws were no longer con- tracted. In the case of twelve animals taken out of the water after remaining in it two or three minutes, I found the jaws not fixed together and the limbs not contracted. After having tried for a long time to recall them to life with the methods which had succeeded so well in the preceding cases, I was only able to restore to life three, and that not without difficulty; the other nine were dead.1 The dead animals in the preceding experiments, having been left in the open air or placed under water for twelve hours, I found that their jaws and limbs had become rigid. I executed on them attempts at resuscitation, but they were in vain.

The stiffness which follows death cannot be con- founded with that which is produced in the sub- ject whose stay under water has lasted only for some moments. In the latter case, with subjects restored to life, the rigidity was the result of the contraction of the muscles; in the other case, it was due to the rigor mortis. The section of the medulla oblongata immediately caused the first species of contraction to give way; but it re- mained without any effect on the second—that is to say, on the rigor mortii. Eight animals (two rats, two dogs, and four rabbits), presenting, after a short immersion in water, a strong contraction of the jaws, were submitted by M. LEQROS and myself to section of the medulla oblongata, and immediately the contraction disappeared.

It is well-known that it is possible to oppose the entrance of air into the bronchi by contracting the muscles of the jaws, the pharynx, and the roof of the palate. By the use of this contraction we can very well plunge into water without the liquid penetrating into the air-passages. But can these muscles which protect the respiratory pas- sages contract equally without our will? We shall arrive at an affirmative answer, if we con- sider the part which the nerves proceeding from the tenth pair play in the act of respiration. The mucous membrane of the larynx, the trachea, the bronchi, &c., is traversed by numerous ramifica- tions of the pneumo-gastric nerve—a nerve ex- i These experiments, which I made together with Dr.

Legros, were made In the laboratory of Professor ROBIN, at the Practical School, on the 15th, 21st, 25th, 26th, and 28th October, 1867.

clusively one of sensation. The spinal nerve on its. part presides over the movements of the glottis, animates the muscles of the larynx, the con- tractile tissue of the trachea and the bronchi, the constrictors of the pharynx, &c. "There is not," says M, LONGET, " in the animal economy a single motor nerve on which depend movements as directly necessary to the support of life as are those which are influenced by the spinal nerve." Struck with the exceptional peculiarity which the medullary origins of this nerve present, the length of which is out of proportion to the other nervous pairs, this learned physiologist adds: " Convinced that nature, always foreseeing and faithful to the aim of conservation which pre- dominates in her works, has multiplied in pro- portion to the importance of the functions the resources and means suited to ensure the free and easy exercise of them, I thought that if the spinal nerve takes insertions in so great an extent of the medullary axis, it must be in order that its func- tional integrity may be better preserved, and that the sudden interruption to the influence of the nerve may be less easy."' Let any cause or agent Intervene to threaten the respiratory function in its physiological conditions, the sensitive disturbance which the pneumo-gastric nerve receives from it immediately causes the motor nerves, the spinal, hypoglossal, the laryngeal nerves to enter into action, and immediately the muscles of the mouth, of the back of the throat, and of the larynx, &c., in contracting shut out the access of any other agent than the atmospheric air; and this air must be in a normal quantity and arrive in a regular manner. We see, in fact, that a large quantity of air arriving too quickly produces symptoms analogous to those which re- sult from the introduction into the bronchi of a deleterious gas or a liquid.

Wfien we are thoroughly convinced of the reality of this protecting function entrusted to the organs anterior to the air-passages, it is easy to survey their exercise when chloroform is breathed, in view of a surgical operation. The patient has to make an effort to overcome what is called spasm; his will is sometimes incapable of acting, and when he is already subject to the effect of the anaesthetic, the operator must bring all his energy to bear, in order that he may continue to keep up his respiration by raising his sides.

If we analyse the sensation which is experienced when we fall into water, we remember that we suffered for some time a violent constraint in the throat. We may swallow, but not breathe, and when we come out of the water, we still preserve for a long time the sensation of contraction and constriction of the throat.

I believe I have established, in my experiments on animals, that the contraction of the jaws, far from being a sign of death, established rather the continuance of life. Let us see if, in reference to drowned men restored to life, this contraction of the jaws has been made out. Independently of my personal observations, I have gained informa- tion among many Humane Society men and per- sons who have rescued and restored drowned persons to life. All of them agreed in declaring to me the existence, among drowned persons, of the contraction of the jaws.

1. " On board the Citizen, a whaler, two men were taken out of the water after having been immersed several minutes, their boat having been destroyed by a whale; I was compelled to unclose their jaws with a bar, and I afterwards restored them to life." i LOSOET, ' Anatomy and Physiology of tlie Hervous System of Man and the Vertebrited Animals,' vol. ii., p. 267.

 

2. "On board the Vermont, an American whaler, I restored a sailor who had remained several minutes under water, and whose teeth I had unclosed with a knife." 3. M. CORDIER (of Tronville) told me that he had resuscitated three drowned men, who all had their teeth contracted.

4. L , a child five years of age, had been underwater about three minutes; his teeth were closely fastened; he was a long time unconscious, and it was only after having opened bis mouth that his uncle succeeded in reviving him.

5. Dr. BIDAULT (of Evreux) being called to see an asphyxiated person, had to unclose his teeth with the handle of a steel fork, before being able to make him breathe and restore him to life.

6. Dr. POTTIER (of Rouen) had occasion to resuscitate a drowned man; his jaws were con- tracted.

7. M. LECTOR,president of the Humane Society, Rouen, took the trouble to inquire of a large num- ber of his men, and he told me that he recollected perfectly, as well as his colleagues, that the drowned men who had been resuscitated under their efforts all had their teeth closed.

FIG. 1.

Fig. 1. Laryngoscope closed. A, mirror; B, the Fig. 2. Laryngoscope open. A, mirror in which lower valve; C, the upper valve; D, joint between the larnyx is reflected; B, lower valve keeping the parts of the instrument; £, handle of the | the tongue depressed; C, valve fixed along the lower valve; F, handle of the upper valve; G, curvature of the pharynx, spring, closing the instrument. • When we have a drowned man to deal with, after having properly placed and covered him to keep him from the influence of the cold, and after having freed him from every constricting bandage, we ought at once to take measures to overcome the obstacles which the contraction of the jaws opposes to the entrance of air into the air passages and to secure the opening of the mouth and the back of the throat. We then proceed with the administration of other means; as insufflation, exterior application of heat, friction, &c. Would a subject taken out of the water, and left to him- self, return to life if he were not stimulated, and his back throat cleared ? The thing is not abso- lutely impossible, and perhaps some example of it might be found in the records of science. " It is certain," says FODERE, " that several drowned persons owe their restoration to life to simple exposure to the rays of the sun."1 But we must ' -Dictionary of Medical Science,' vol. xxxvi. (1819), article Noyes, p. 411.

make allowance for heat: this agent, whatever source it come from, is, as is well known, one of the most powerful in accomplishing the restora- tion of drowned persons. Besides, those are ex- ceptional cases, by which it would be imprudent to regulate one's conduct. I even believe that one of the causes of want of success in the use of such simple and such really good measures as those of MARSHALL HALL and SYLVESTER' results from the fact that in making exclusive applica- tion of them without any other aid, too little attention is paid to the contraction of the jaws, to overcome which immediate attempts ought to be made, in order to permit the air to penetrate through the larnyx into the lungs.- This contraction is so much the more precious an indication to rescuers, as it is, as we have said, an almost certain sign of the persistence of life. I confidently and emphatically express 1 See Ih; 'Journal of Public Health,' Second series.

Paris, 18o5, vol. xxlv., p. 209. this opinion, resting upon the fact, that the : attention given to shipwrecked or drowned per- i sons by their rescuers is usually sufficiently near to } the moment of the accident to prevent the spas- ! modic contraction from being confounded with ! the rigor mortis, which only manifests itself a considerable time after death. The attempts to recover a drowned man from the state of apparent death ought to be so much the more persevering, I repeat, as the fact of the persistence of the i contraction of the jaws is almost tantamount to a certainty of seeing them crowned with success. ; If unfortunately life should prove to be extinct, | we should have a sure sign of the inutility of any ' attempt at resuscitation in the spontaneous un- closing of the teeth and the reopening of the mouth.

Mode of using the laryngoscope: The asphyxia of persons who have been drowned or hanged is occasioned by the suspen- sion of respiration. The introduction of air into the lungs being stopped, the blood is not revivified, and death ensues in a very short time.

The end to be kept in view is, therefore, the re-establishment, as quickly as possible, of re- spiration.

By mentioning some of the difficulties which have to be overcome, the method of employment of the laryngoscope will be better understood.

With asphyxiated or drowned persons: 1. The mouth is closed and often very much contracted.

2. The tongue adheres to the back of the throat, and this adherence is complicated by the presence of a greater or smaller amount of mucus.

3. The mouth is with difficulty kept open, and the epiglottis, which covers the superior portion of the larynx, can only be raised at the cost of great trouble.

It will be seen how the laryngoscope sur- mounts these obstacles.

The body of the subject is placed on the back, a little turned on the right side, and the. head a little raised.

After having unclosed the teeth with the lever, j the laryngoscope, held in the right hand by the j handle F, is introduced into the mouth by the ! rounded extremity of its posterior or superior ! valve C. It is pushed in so that this valve C may follow the course of the roof of the palate, along which its curvature makes it glide without effort, and without any danger of injuring any of the parts by which it passes. The instrument is in- troduced till the joint D almost touches the uppei"j lip. When this first stage of the proceeding has been performed, the handle E of the lower valve is raised with a finger, towards the one already held. The two handles, E and F, now held 1 together, are then taken in the left hand. Great | care will be necessary to keep the instrument j well back in the throat. Its lower valve B j reaches the base of the tongue, which it de- | presses from above downwards, and from beliind j forwards; and thus the back of the throat is j completely opened, the epiglottis which was : covering the larynx is raised, the superior part i of the air passages is by this single move- | ment entirely cleared, and in direct contact j with the air. There is then nothing to hinder j the mucus from being cleared out by a piece of whalebone with a small sponge fixed at the end. The operator has one hand free, with which, if he be a doctor, he can afterwards use such an instrument as may be suitable, whether a sound or insufflator; but it is well understood that only a, doctor should use these means.

If the patient does not gasp immediately after the introduction of the laryngoscope, the instru- ment should be kept in its place, whilst the thoracic movements used" in such cases to induce respira- tion are employed. I particularly recommend pressure exercised by the hand placed flat on the surface of the epigastrium, and sharply drawn away. The effect of this action ought to be so much the more efficacious now that the superior part of the larayx has become more completely free from every obstacle.

The application of the laryngoscope in cases of asphyxia excludes none of the methods re- commended in such cases.

NOTE.—The laryngoscope can be purchased from Messrs.

L. BLAISE and Co., 6T, St. James's Street, London, S.W.