Fig. 257. Tube-spatulæ used for Laryngoscopy. A, Killian’s. B, Bruenings’. A, Handle; B, Collar to allow rotation; C, Fixation spring; D, Switch; E, Socket for lamp; F, Focus; G, Lamp; H, Lens; I, Aperture for eye; K, Reflector.
(a) The tube-spatulæ. The tube originally suggested by Killian was made of straight metal and circular in section, the distal end being cut obliquely with the projecting portion fashioned like a spatula. A strong handle, at right angles to the tube, was used for manipulation. Different sizes were required for children and adults. Various modifications of these tubes are now in use, notably those of Mosher and Bruenings: the instrument recommended by the latter is easier to manipulate and gives a better view than the earlier forms described.
(b) The lamp for illumination. Different forms of head-lamp (Killian’s, Kirstein’s) and hand-lamp (Caspar’s) have been devised for illumination from the outside, and Chevalier Jackson has invented a lamp which is sufficiently small to pass to the distal end of the tube, where it lies in a compartment of its own lest it should be broken and fall into the trachea. Recently these electroscopes have been improved upon by Bruenings, in whose instrument (Fig. 257) the lamp is more powerful and is attached to the handle in such a manner that it can be easily swung into position when required. A condensing lens has also been added and the light can be focused to any desired distance. If preferred, an ordinary forehead-mirror reflecting the light from a powerful Nernst lamp (100 c.p.) can be employed.
(c) The instruments for operation. Various forms of forceps for removal of tumours have been devised by Killian, von Eicken, Bruenings, Patterson, and others. In any form that is employed it is necessary, in order to allow of clear vision, that the handle should be set at an angle with the shaft. For foreign bodies, hooks of different shapes are also useful. Other requirements include a gag for opening the mouth, a tongue depressor, tongue forceps, suitable cotton-wool carriers, the requisites for tracheotomy, and a darkened room.
Operation. The operation can be performed with local or general anæsthesia. With patients who are intolerant chloroform is more reliable, and is preferable to other drugs, which tend to excite secretion. Chloroform should always be employed for children. It should be given slowly and in the smallest possible quantity, the head of the patient being kept lower than the body to allow blood and mucus to drain away from the trachea. To make the parts more tolerant, cocaine can also be applied to the vocal cords, or a dose of morphine (codeine is advised in children) can be given half an hour before the operation. The importance of a skilled anæsthetist cannot be too strongly emphasized. With chloroform, the patient should lie upon the back or right side, with the head projecting beyond the end of the table, so that the neck can be extended as required. With cocaine the upright position is often preferred, and the patient should sit on a low stool facing the surgeon. When the patient is recumbent, the surgeon should sit or kneel behind the head (Fig. 258). He should observe the strictest antiseptic precautions, and should introduce no instrument which has not been properly sterilized; further, the tubes should be previously warmed to prevent ‘fogging’, and oiled with sterilized liquid paraffin before introduction. There should be two assistants, one (the chloroformist) to support the head and watch the respiration and pulse, the other to help with instruments.
Fig. 258. Removal of Multiple Papillomata by Direct Laryngoscopy