_Read Before the Baltimore City Medical Society,
Section on Medicine and Surgery,
February, 1909._
Direct laryngoscopy, as the name implies, is the inspection of the
larynx through a hollow tube without the use of a mirror. The
examination is made with the patient in the sitting position, under
local anesthesia, or in the prone position, under general anesthesia. To
examine the larynx in the sitting position it is practically always
necessary to give a hypodermic injection of morphia and atropia a half
hour beforehand, to relax the muscles and to prevent excessive
secretion. The patient is seated upon a low stool with the head extended
and supported by an assistant. With curved forceps 20% cocaine or 25%
alypin solution is quickly passed into the throat, anesthetizing
pharynx, tongue and epiglottis. Jackson's slide speculum is then
introduced and the base of the tongue, with the epiglottis, gently
pulled forward. At this point it is usually necessary to use more
cocaine directly in the larynx, which is introduced by means of special
cotton carriers. In a few minutes anesthetization is complete, and the
examination can be made at leisure. It will be found easier to inspect
the different parts of the larynx if the head is held about halfway
between the erect position and complete extension. In some patients with
short, thick necks and large middle incisor teeth the slide will have to
be removed from the speculum to enable one to see well. The examination
in the prone position under general anesthesia is made with the
patient's head over the end of the table supported by an assistant. The
speculum is introduced and the base of the tongue and the epiglottis
pulled upward forcibly. In this position direct laryngoscopy, even in
children, is unsatisfactory, and operative procedures are well-nigh
impossible on account of the muscular rigidity. The force required to
lift the tissues is so great and the position of the arm is so cramped
that it is difficult to get a clear view of the field. The difficulty
has impressed all who have worked in this particular line. It remained
for Dr. H. P. Mosher, of Boston, to discover a method of direct
laryngoscopy which makes it as simple under ether anesthesia as in the
sitting position. In April, 1908, he described in the _Boston Medical
and Surgical Journal_ the "left lateral position" for examining the
larynx and the upper end of the esophagus. He designed certain
instruments which I believe are too cumbersome to meet with popular
favor. In Mosher's position the patient lies on the table with the head
turned toward the left until the cheek almost rests on the table; the
chin is flexed on the chest. In our work at the Presbyterian Hospital we
have found a modified Mosher's position and Jackson's child speculum the
ideal combination for the examination in the prone patient. In children
the procedure is carried out with or without anesthesia. Without
anesthesia the head, hands and feet are held, the chin is flexed on the
chest in a normal position by placing a pillow under the head, the
speculum is introduced and the larynx inspected. In adults under
anesthesia the same procedure is used, and will be found much simpler
than the extended position. In adults, after the speculum is in
position, if the anterior part of the larynx is not seen, gentle
pressure on the thyroid cartilage will bring the anterior commissure
into view. Operations can be done through the tube satisfactorily. With
the different methods of direct laryngoscopy it is possible to remove
any growth from the larynx.