The foregoing applies to cases in which a pulmotor would be used, such as apnea from electric shocks, etc. For obstructive dyspnea and asphyxia, tracheotomy is the procedure of choice, and the skillful tracheotomist would be justified in preferring tracheotomy for the other cla.s.s of cases, insufflating the oxygen and amyl nitrite through the tracheotomic wound. The pulmotor and similar mechanisms are, perhaps, the best things the use of which can be taught to laymen; but as compared to bronchoscopic oxygen insufflation they are woefully inefficient, because the intraoral pressure forces the tongue back over the laryngeal orifice, obstructing the airway in this "death zone." By the introduction of the bronchoscope this death zone is entirely eliminated, and a free airway established for piping the oxygen directly into the lungs.

[73] CHAPTER VI--POSITION OF THE PATIENT FOR PERORAL ENDOSCOPY

It is the author's invariable practice to place the patient in the dorsally rec.u.mbent position. The sitting position is less favorable.

While lying on a well-padded, flat table the patient is readily controlled, the head is freely movable, secretions can be easily removed, the view obtained by the endoscopist is truly direct (without reversal of sides), and, most important, the employment of one position only favors smoother and more efficient team work, and a better endoscopic technic.

_General Principles of Position_.--As will be seen in Fig. 47 the trachea and esophagus are not horizontal in the thorax, but their long axes follow the curves of the cervical and dorsal spine. Therefore, if we are to bring the buccal cavity and pharynx in a straight line with the trachea and esophagus it will be found necessary to elevate the whole head above the plane of the table, and at the same time make extension at the occipito-atloid joint. By this maneuver the cervical spine is brought in line with the upper portion of the dorsal spine as shown in Fig. 55. It was formerly taught, and often in spite of my better knowledge I am still unconsciously p.r.o.ne to allow the head and cervical spine to a.s.sume a lower position than the plane of the table, the so-called Rose position. With the head so placed, it is impossible to enter the lower air or food pa.s.sages with a rigid tube, as will be shown by a study of the radiograph shown in Fig. 49. Extension of the head on the occipito-atloid joint is for the purpose of freeing the tube from the teeth, and the amount required will vary with the degree to which the mouth can be opened. Whether the head be extended, flexed, or kept mid-way, the fundamental principle in the introduction of all endoscopic tubes is the anterior placing of the cervical spine and the high elevation of the head. The esophagus, just behind the heart, turns ventrally and to the left. In order to pa.s.s a rigid tube through this ventral curve the dorsal spine is now extended by lowering the head and shoulders below the plane of the table. This will be further explained in the chapter on esophagoscopy. In all of these procedures, the nose of the patient should be directed toward the zenith, and the a.s.sistant should _prevent rotation of the head_ as well as _prevent lowering of the head_. The patient should be urged as follows: "Don't hold yourself so rigid."

"Let your head and neck go loose."

"Let your head rest in my hand."

"Don't try to hold it."

"Let me hold it."

"Relax."

"Don't raise your chest."

[FIG. 47.--Schematic ill.u.s.tration of normal position of the intra-thoracic trachea and esophagus and also of the entire trachea when the patient is in the correct position for peroral bronchoscopy.

When the head is thrown backward (as in the Rose position) the anterior convexity of the cervical spine is transmitted to the trachea and esophagus and their axes deviated. The anterior deviation of the lower third of the esophagus shows the anatomical basis for the "high low" position for esophagoscopy]

[FIG. 48.--Correct position of the cervical spine for esophagoscopy and bronchoscopy. (_Ill.u.s.tration reproduced from author's article Jour.

Am. Med. a.s.soc., Sept. 25, 1909_)]

[FIG. 49.--Curved position of the cervical spine, with anterior convexity, in the Rose position, rendering esophagoscopy and bronchoscopy difficult or impossible. The devious course of the pharynx, larynx and trachea are plainly visible. The extension is incorrectly imparted to the whole cervical spine instead of only to the occipito-atloid joint. This is the usual and very faulty conception of the extended position. (_Ill.u.s.tration reproduced from author's article, Jour. Am. Med. a.s.soc., Sept. 25, 1909._)]

[76] For _direct laryngoscopy_ the patient's head is raised above the plane of the table by the first a.s.sistant, who stands to the right of the patient, holding the bite block on his right thumb inserted in the left corner of the patient's mouth, while his extended right hand lies along the left side of the patient's cheek and head, and prevents rotation. His left hand, placed under the patient's occiput, elevates the head and maintains the desired degree of extension at the occipito-atloid joint (Fig. 50).

[FIG 50.--Direct laryngoscopy, rec.u.mbent patient. The second a.s.sistant is sitting holding the head in the Boyce position, his left forearm on his left thigh his left foot on a stool whose top is 65 cm. lower than the table-top. His left hand is on the patient's sterile-covered scalp, the thumb on the forehead, the fingers under the occiput, making forced extension. The right forearm pa.s.ses under the neck of the patient, so that the index finger of the right hand holds the bite-block in the left corner of the patient's mouth. The fingers of the operator's right hand pulls the upper lip out of all danger of getting pinched between the teeth and the laryngoscope. This is a precaution of the utmost importance and the trained habit of doing it must be developed by the peroral endoscopist.]

_Position for Bronchoscopy and Esophagoscopy_.--The dorsally rec.u.mbent patient is so placed that the head and shoulders extend beyond the table, the edge of which supports the thorax at about the level of the scapulae. During introduction, the head must be maintained in the same relative position to the table as that described for direct laryngoscopy, that is, elevated and extended. The first a.s.sistant, in this case, sits on a stool to the right of the patient's head, his left foot resting on a box about 14 inches in height, the left knee supporting the a.s.sistant's left hand, which being placed under the occiput of the patient maintains elevation and extension. The right arm of the a.s.sistant pa.s.ses under the neck of the patient, the bite block being carried on the middle finger of the right hand and inserted into the left side of the patient's mouth. The right hand also prevents rotation of the head (Fig. 51). As the bronchoscope or esophagoscope is further inserted, the head must be placed so that the tube corresponds to the axis of the lumen of the pa.s.sage to be examined. If the left bronchus is being explored, the head must be brought strongly to the right. If the right middle lobe bronchus is being searched, the head would require some left lateral deflection and a considerable degree of lowering, for this bronchus, as before mentioned, extends anteriorly. During esophagoscopy when the level of the heart is reached, the head and upper thorax must be strongly depressed below the plane of the table in order to follow the axis of the lumen of the ventrally turning esophagus; at the same time the head must be brought somewhat to the right, since the esophagus in this region deviates strongly to the left.

[FIG. 51.--Position of patient and a.s.sistant for introduction of the bronchoscope and esophagoscope. The middle of the scapulae rest on the edge of the table; the head and shoulders, free to move, are supported by the a.s.sistant, whose right arm pa.s.ses under the neck; the right middle finger inserts the bite block into the left side of the mouth.

The left hand, resting on the left knee maintains the desired degree of elevation, extension and lateral deflection required by the operator. The patient's vertex should be 10 cm. higher than the level of the top of the table. This is the Boyce position, which has never been improved upon for bronchoscopy and esophagoscopy.]

[FIG. 52.--Schema of position for endoscopy.

A. Normal rec.u.mbency on the table with pillow supporting the head.

The larynx can be directly examined in this position, but a better position is obtainable.

B. Head is raised to proper position with head flexed. Muscles of front of neck are relaxed and exposure of larynx thus rendered easier; but, for most endoscopic work, a certain amount of extension is desired. The elevation is the important thing.

C. The neck being maintained in position B, the desired amount of extension of the head is obtained by a movement limited to the occipito-atloid articulation by the a.s.sistant's hand placed as shown by the dart (B).

D. Faulty position. Unless prevented, almost all patients will heave up the chest and arch the lumbar spine so as to defeat the object and to render endoscopy difficult by bringing the chest up to the high-held head, thus a.s.suming the same relation of the head to the chest as exists in the Rose position (a faulty one for endoscopy) as will be understood by a.s.suming that the dotted line, E, represents the table. If the pelvis be not held down to the table the patient may even a.s.sume the opisthotonous position by supporting his weight on his heels on the table and his head on the a.s.sistant's hand.]

In obtaining the position of high head with occipito-atloid extension, the easiest and most certain method, as pointed out to me by my a.s.sistant, Gabriel Tucker, is first to raise the head, strongly flexed, as shown in Fig. 52; then while maintaining it there, make the occipito-atloid extension. This has proven better than to elevate and extend in a combined simultaneous movement.

If the patient would relax to limpness exposure of the larynx would be easily obtained, simply by lifting the head with the lip of the laryngoscope pa.s.sed below the tip of the epiglottis (as in Fig. 55) and no holding of the head would be necessary. But only rarely is a patient found who can do this. This degree of relaxation is of course, present in profound general ether anesthesia, which is not to be thought of for direct laryngoscopy, except when it is used for the purpose of insertion of intratracheal insufflation anesthetic tubes.

For this, of course, the patient is already to be deeply anesthetized.

The muscular tension exerted by some patients in a.s.suming and holding a faulty position is almost as much of a hindrance to peroral endoscopy as is the position itself. The tendency of the patient to heave up his chest and a.s.sume a false position simulating the opisthotonous position (Fig. 52) must be overcome by persuasion. This position has all the disadvantages of the Rose position for endoscopy.

[FIG. 53.--The author's position for the removal of foreign bodies from the larynx or from any of the upper air or food pa.s.sages. If dislodged, the intruder will not be aided by gravity to reach a deeper lodgement.]

The one exception to these general positions is found in procedures for the removal of foreign bodies from the larynx. In such cases, while the same relative position of the head to the plane of the table is maintained, the whole table top is so inclined as to elevate the feet and lower the head, known as Jackson's position. This semi-inversion of the patient allows the foreign body to drop into the pharynx if it should be dislodged, or slip from the forceps (Fig. 53).

[82] CHAPTER VII--DIRECT LARYNGOSCOPY

_Importance of Mirror Examination of the Larynx_.--The presence of the direct laryngoscope incites spasmodic laryngeal reflexes, and the traction exerted somewhat distorts the tissues, so that accurate observations of variations in laryngeal mobility are difficult to obtain. The function of the laryngeal muscles and structures, therefore, can best be studied with the laryngeal mirror, except in infants and small children who will not tolerate the procedure of indirect laryngoscopy. A true idea of the depth of the larynx is not obtained with the mirror, and a view of the ventricles is rarely had.

With the introduction of the direct laryngoscope it is found that the larynx is funnel shaped, and that the adult cords are situated about 3 cm. below the aryepiglottic folds; the cords also a.s.sume their true shelf-like character and take on a pinkish or yellowish tinge, rather than the pearly white seen in the mirror. They are not to any extent differentiated by color from the neighboring structures. Their recognition depends almost wholly on form, position and movement.

Accurate observation is stimulated in all pathologic cases by making colored crayon sketches, however crude, of the mirror image of the larynx. The location of a growth may be thus graphically recorded, so that at the time of operation a glance will serve to refresh the memory as to its site. It is to be constantly kept in mind, however, that in the mirror image the sides are reversed because of the facing positions of the examiner and patient. Direct laryngoscopy is the only method by which the larynx of children can be seen. The procedure need require less than a minute of time, and an accurate diagnosis of the condition present, whether papilloma, foreign body, diphtheria, paralysis, etc., may be thus obtained. The posterior pharyngeal wall should be examined in all dyspneic children for the possible existence of retropharyngeal abscess.

[PLATE II--DIRECT AND INDIRECT LARYNGEAL VIEWS FROM AUTHOR'S OIL-COLOR DRAWINGS FROM LIFE: 1, Epiglottis of child as seen by direct laryngoscopy in the rec.u.mbent position.

2, Normal larynx spasmodically closed, as is usual on first exposure without anesthesia.

3, Same on inspiration.

4, Supraglottic papillomata as seen on direct laryngoscopy in a child of two years.

5, Cyst of the larynx in a child of four years, seen on direct laryngoscopy without anesthesia.

6, Indirect view of larynx eight weeks after thyrotomy for cancer of the right cord in a man of fifty years.

7, Same after two years. An advent.i.tious band indistinguishable from the original one has replaced the lost cord.

8, Condition of the larynx three years after hemilaryngectomy for epithelioma in a patient fifty-one years of age. Thyrotomy revealed such extensive involvement, with an open ulceration which had reached the perichondrium, that the entire left wing of the thyroid cartilage was removed with the left arytenoid. A sufficiently wide removal was accomplished without removing any part of the esophageal wall below the level of the crico-arytenoid joint. There is no attempt on the part of nature to form an advent.i.tious cord on the left side. The normal arytenoid drew the normal cord over, approximately to the edge of the cicatricial tissue of the operated side. The voice, at first a very hoa.r.s.e whisper, eventually was fairly loud, though slightly husky and inflexible.

9, The pharynx seen one year after laryngectomy for endothelioma in a man aged sixty-eight years. The purple papilla; anteriorly are at the base of the tongue, and from this the mucosa slopes downward and backward smoothly into the esophagus. There are some slight folds toward the left and some of these are quite cicatricial. The epiglottis was removed at operation. The trachea was sutured to the skin and did not communicate with the pharynx. (Direct view.)]

_Contraindications to Direct Laryngoscopy_.--There are no absolute contraindications to direct laryngoscopy in any case where direct laryngoscopy is really needed for diagnosis or treatment. In extremely dyspneic patients, if the operator is not confident in his ability for a prompt and sure introduction of a bronchoscope, it may be wise to do a tracheotomy first.

_Instructions to the Patient_.--Before beginning endoscopy the patient should be told that he will feel a very disagreeable pressure on his neck and that he may feel as though he were about to choke. He must be gently but positively made to understand (1) that while the procedure is alarming, it is absolutely free from danger; (2) that you know just how it feels; (3) that you will not allow his breath to be shut off completely; (4) that he can help you and himself very much by paying close attention to breathing deeply and regularly; (5) and that he must not draw himself up rigidly as though "walking on ice," but must be easy and relaxed.

_Direct Laryngoscopy. Adult Patient_.--Before starting, every detail in regard to instrumental equipment and operating room a.s.sistants, (including an a.s.sistant to hold the arms and legs of the patient) must be complete. Preparation of the patient and the technic of local anesthesia have been discussed in their respective chapters. The dorsally rec.u.mbent patient is draped with (not pinned in) a sterile sheet. The head, covered by sterile towels, is elevated, and slight extension is made at the occipitoatloid joint by the left hand of the first a.s.sistant. The bite block placed on the a.s.sistant's right thumb is inserted into the left angle of the patient's open mouth (see Fig.

50).

The laryngoscope must always and invariably be held in the left hand, and in such a manner that the greatest amount of traction is made at the swell of the horizontal bar of the handle, rather than on the vertical bar.

The right hand is then free for the manipulation of forceps, and the insertion of the bronchoscope or other instrument. During introduction, the fingers of the right hand retract the upper lip so as to prevent its being pinched between the laryngoscope and the teeth. The introduction of the direct laryngoscope and exposure of the larynx is best described in two stages.

1. Exposure and identification of the epiglottis.

2. Elevation of the epiglottis and all the tissues attached to the hyoid bone, so as to expose the larynx to direct view.

_First Stage_.--The spatular end of the laryngoscope is introduced in the right side of the patient's mouth, along the right side of the anterior two-thirds of the tongue. It was the German method to introduce the laryngoscope over the dorsum of the tongue but in order to elevate this sometimes powerful muscular organ considerable force may be required, which exercise of force may be entirely avoided by crowding the tongue over to the left. When the posterior third stage of the tongue is reached, the tip of the laryngoscope is directed toward the midline and the dorsum of the tongue is elevated by a lifting motion imparted to the laryngoscope. The epiglottis will then be seen to project into the endoscopic field, as seen in Fig. 54.

[FIG. 54.--End of the first of direct laryngoscopy, rec.u.mbent adult patient. The epiglottis is exposed by a lifting motion of the spatular tip on the tongue anterior to the epiglottis.]

_Second Stage_.--The spatular end of the laryngoscope should now be tipped back toward the posterior wall of the pharynx, pa.s.sed posterior to the epiglottis, and advanced about 1 cm. The larynx is now exposed by a motion that is best described as a suspension of the head and all the structures attached to the hyoid bone on the tip of the spatular end of the laryngoscope (Fig. 55). Particular care must be taken at this stage not to pry on the upper teeth; but rather to impart a lifting motion with the tip of the speculum without depressing the proximal tubular orifice. It is to be emphasized that while some pressure is necessary in the lifting motion, great force should never be used; the art is a gentle one. The first view is apt to find the larynx in state of spasm, and affords an excellent demonstration of the fact that the larynx can he completely closed without the aid of the epiglottis. Usually little more is seen than the two rounded arytenoid ma.s.ses, and, anterior to them, the ventricular bands in more or less close apposition hiding the cords (Fig. 56). With deep general anesthesia or thorough local anesthesia the spasm may not be present. By asking the patient to take a deep breath and maintain steady breathing, or perhaps by requesting a phonatory effort, the larynx will open widely and the cords be revealed. If the anterior commissure of the larynx is not readily seen, the lifting motion and elevation of the head should be increased, and if there is still difficulty in exposing the anterior commissure the a.s.sistant holding the head should with the index finger externally on the neck depress the thyroid cartilage. If by this technic the larynx fails to be revealed the endoscopist should ask himself which of the following rules he has violated.

[FIG. 55.--Schema ill.u.s.trating the technic of direct laryngoscopy on the rec.u.mbent patient. The motion is imparted to the tip of the laryngoscope as if to lift the patient by his hyoid hone. The portion of the table indicated by the dotted line may be dropped or not, but the back of the head must never go lower than here shown, for direct laryngoscopy; and it is better to have it at least 10 cm. above the level of the table. The table may be used as a rest for the operator's left elbow to take the weight of the head. (Note that in bronchoscopy and esophagoscopy the head section of the table must be dropped, so as to leave the head and neck of the patient out in the air, supported by the second a.s.sistant.)]

[FIG. 56.--Endoscopic view at the end of the second stage of direct laryngoscopy. Rec.u.mbent patient. Larynx exposed waiting for larynx to relax its spasmodic contraction.]

RULES FOR DIRECT LARYNGOSCOPY 1. The laryngoscope must always be held in the left hand, never in the right.

2. The operator's right index finger (never the left) should be used to retract the patient's upper lip so that there is no danger of pinching the lip between the instrument and the teeth.

3. The patient's head must always be exactly in the middle line, not rotated to the right or left, nor bent over sidewise; and the entire head must be forward with extension at the occipitoatloid joint only.

4. The laryngoscope is inserted to the right side of the anterior two-thirds of the tongue, the tip of the spatula being directed toward the midline when the posterior third of the tongue is reached.

5. The epiglottis must always be identified before any attempt is made to expose the larynx.