[FIG. 47.—Schematic illustration 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. (Illustration reproduced from author's article Jour.
Am. Med. Assoc., 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. (Illustration reproduced from author's article, Jour. Am. Med. Assoc., Sept. 25, 1909.)]
[76] For direct laryngoscopy the patient's head is raised above the plane of the table by the first assistant, 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, recumbent patient. The second assistant 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 passes 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 recumbent 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 assistant, 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 assistant's left hand, which being placed under the occiput of the patient maintains elevation and extension. The right arm of the assistant passes 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 passage 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 assistant 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 assistant, whose right arm passes 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 recumbency 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 assistant'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 assuming 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 assuming that the dotted line, E, represents the table. If the pelvis be not held down to the table the patient may even assume the opisthotonous position by supporting his weight on his heels on the table and his head on the assistant'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 assistant, 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 passed 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 assuming 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 assume 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.