The stem is withdrawn while the finger fixes the tube. (Lejars.)
Standing in front of the patient the operator identifies the tip of the epiglottis with the forefinger of the left hand in the pharynx, this finger being used at the same time to raise and fix the epiglottis and also to serve as a guide to the tip of the tube, which is passed downward alongside it, by a maneuver similar to that by which the laryngoscopic mirror is used in the pharynx ([Fig. 487]). When the tip of the tube reaches the location behind the epiglottis the finger may be passed a little farther downward, plugging the entrance to the esophagus, while at the same time the handle of the instrument is so manipulated as to bring the tube forward. With gentle movement in the right direction it passes into the larynx ([Fig. 488]). It is then pressed downward until the flanged upper end has passed the epiglottis, after which the tube is disengaged, the handle and the obturator withdrawn, and the upper end of the tube pressed gently into place by the finger which still rests in the pharynx ([Figs. 488], [489] and [490]). During the manipulation there is almost complete obstruction of the glottis for two or three seconds. The effort, therefore, should be to shorten the procedure, and at no time should it occupy more than two or three seconds. If the landmarks are not easily recognized, and the tube is not placed at the expiration of three seconds, the operator should discontinue for a few more seconds in order that a few inspirations may be taken, after which he should try again.
Fig. 490
The finger pushes the tube into place. (Lejars.)
Fig. 491
Withdrawal of the thread. (Lejars.)
When the tube is in place there will come ease of respiration, at the same time violent coughing efforts, because of the irritation thus suddenly produced. So soon as it is apparent, both to the finger in the pharynx and from the relief of obstructive symptoms, that the tube is in its proper place, the finger may be once more passed into the pharynx, the tube pressed down, while the silk thread is withdrawn, since it is not intended to leave it for more than the time necessary to be assured that the tube will not have at once to come out again ([Fig. 491]). Before removing the thread the gag should be removed for a few moments, so that the effect of the excitement may pass, after which it may be re-introduced for the purpose of withdrawing the thread.
The procedure is by no means a simple nor necessarily easy one, and it should be practised with the instruments upon the cadaver before resorting to it on the living child.