The Advantages of Extension of 
tie Head During Anesthesia 
and Other Conditions. 
by v 
CEPHAS L. BARD, M.D., 
VENTURA, CAL. 
R.EPRINT FROM 
Southern Calif. Practitioner 
July, 1893. THE ADVANTAGES 
OF 
Extension of the Head During Anesthesia 
AND SOME OTHER CONDITIONS.* 
CEPHAS L BARD, M.D., VENTURA, CAL. 
President of the Southern California Medical Society. 
In the construction of the human economy, Nature has in no 
other portion so signally exhibited her predilection for curves and 
abhorrence of straight lines than in that of the air-passage. 
Regarded from a purely mechanical point of view, it presents a 
rigid tube, the trachea and larynx, surmounted by the oro-naso- 
pharyngeal cavity which MacKenzie has so aptly compared to the 
hood of a carriage. A vertical section reveals what is usually 
described as a curvature, but which, owing to the abrupt junction 
of the pharynx with the larynx, might properly be designated as 
an angle; the degree of angularity, as modified by flexion and 
extension of the head during repose, physical activity, and disease, 
is ever-varying, and is well expressed externally by the correspond- 
ing distance between the chin and sternum, which ranges from 
actual contact to that of seven or eight inches. In its inclination 
toward acuteness or obtuseness, the flexible pharynx, controlled 
by the muscles associated with the movements of the head, is the 
sole factor, the unbending laryngo-tracheal cylinder (which, how- 
ever, has an up-and-down motion in respiration and deglutition) 
in no way participating. 
The power of extension, or dorsal bending, of the head is 
*Read at the Eleventh Semi-annual Meeting of the Southern California Medical 
Society, San Bernardino, Cal., June 7 and 8, 1893, 2 
possessed in the most marked degree by man, and is one of the 
chief physical distinctions of his superiority over the brute 
creation. That it has not escaped the attention of the poet is 
evidenced by the following allusion from Ovid: 
"Thus, while the mute creation downwards bend 
Their sight, and to their earthly mother tend, 
Man looks aloft and with erected eyes 
Beholds his own hereditary skies." 
Mrs. Browning; in "Aurora Leigh" also refers to it: 
"Men define a man, 
The creature who stands frontward to the stars." 
In repose, and in moderate bodily activity, the curvature or 
angularity of the air-tube is physiological and functional. 
The friction to which it is subjected as it flows toward the lungs 
favors the retardation and calorification of the inspired air. This 
friction is increased by the heat-expansion of the air passing 
through the nose. The inflow by the mouth contributes but little 
to this warmth; in fact, we usually find that avenue closed when 
the body is at rest, or in very moderate action. The physiological 
uses of the mouth are those concerned with taste, mastication, 
insalivation and phonation. Never intended as a respiratory 
organ, it is, however, called into requisition as such in occlusion 
of the nose, an attendant evil of advanced civilization. Primitive 
man, like the horse, cow, sheep, and some other animals, breathed 
solely through the nose. The breath of life was blown into the 
nostrils of Adam, and in the many biblical references to it, there 
is no single mention of the mouth. 
In excessive muscular exertion and in most diseases, when the 
more active tissue-changes create a pressing demand for an unim- 
peded supply of oxygen and an unhindered elimination of carbonic 
acid gas, we observe a marked alteration in the geometrical config- 
uration of this air-supplying channel. By a voluntary, often 
involuntary, extension of the head the curve assumes an approach 
to a straight line, and in strenuous exertion, as well as in some 
forms of dyspnea, an almost complete abolition of Hogarth's line 
of beauty occurs, and a direct iindeviating passage is provided for 
the free passage of air to and from the lungs. A study of the 
shifting phases of this respiratory curve or angle in animal life is 
most interesting and instructive. The first inspiration in the 
new-born, its presentation being what it may, is usually through a 
straightened air-tube. The last breath of life, especially if death 
be due to pulmonary disease, is through a passage as straight as 
a retracted head can make it. If evolution is correct, our quad- 3 
ruped ancestors, their gaze in locomotion being necessarily di- 
rected forward, respired through a straight horizontal air-tract. 
Any exertion beyond that incidental to ordinary respiration during 
repose calls extension of the head into play, its extent varying 
with the amount. 
A ramble through the by-ways of Nature reveals it on every 
side; in the carol of our feathered songsters; m the challenge of 
chanticleer; in the halloo of the hunter; in the bay of the hound; 
in the neighing of the horse, and in the lowing of the cow. We 
observe it in the of the bird; in the gallop of the horse; in 
the bound of the deer, and in the scud of the hare. It is well 
displayed in the dash of the sprinter; the stroke of the swimmer; 
the pull of the rower; the glide of the skater, and the rush of the 
bicyclist. It is a conspicuous accompaniment of the acts of 
yawning, sighing, crying and laughing. Not well marked in man 
during deglutition, it is to the greatest degree in the horse and 
those ot^er animals which breathe solely through the nose. It is 
well exhibited also in such animals during grazing and browsing. 
It is a significant fact that since the disuse of the stock, or stiff 
collar, which surmounted the coats of the Guards of Wellington 
and the Grenadiers of Napoleon, and which, if not favoring ex- 
tension to any very marked extent,^prevented flexion of the head, 
the record of military marches has-been lowered Sherman, in 
his march to the sea, with his foot-soldiers clad in blouses, with 
their blankets slung over their shoulder, averaged fourteen miles 
a day. The bewildering movements of Stonewall Jackson with 
his " foot-cavalry " were made at a rate not exceeding eighteen or 
twenty miles in a single day. The Prussians advancing on Vienna 
in 1866, did not display any greater rapidity. MacMahon's army 
hurrying to relieve Bazaine at Metz did not average more than 
ten miles a day, and the German Crown-Prince, in hot pursuit, 
was not much more rapid. After Sedan, the Prussians pushed on 
to Paris at the rate of about twenty-one miles a day. In contrast 
to these modern forced marches, we have the historic one of 
MacKenzie, who, on his way to join Wellington at Talavera, with 
the chins of his Guards well held up by their stocks, completed 
sixty-two miles in twenty six hours. The Russian foot-guards 
advancing to Paris, in 1814, marched forty-eight miles in twenty- 
six hours. In 1709, in order to secure the passage of the Haine, 
the Prince of Hesse-Cassel made a march of forty-nine miles in 
fifty-six hours. 
Some original study, the result of which I desire to record, of 
that form of locomotion known as the trot, in connection with 
extension of the head, contributes much interesting information 4 
having a direct bearing upon the subject under discussion. In the 
horse, it is an acquired gait which has required years to perfect. 
Before his subjugation, it was unknown. Forced, or urged, to 
this artificial gait, he does not display, and never will, the speed 
which he does in the natural one of running. Being an unnatural 
gait, the trotter breaks down quicker than the racer. In the 
evolution of the trotting horse, it has been found useful, in order 
to develop his greatest speed, to raise his head and effect its 
extension. The lowering of the trotting record, which had re- 
mained practically unchanged for years, is coincident with the 
introduction of the much abused over-draw check rein. This 
device, by placing the head in an elevated extended position, not 
only changes his center of gravity, but furnishes the animal with 
a straight unobstructed and unimpeded air-passage. 
Indispensable in a burst of speed on the track when it is desired 
to make the fastest time, it is, when drawn too tightly, in ordinary 
driving, an instrument of torture which should be loosened by the 
heavy hand of the law. 
In the slow trot, or jog, where there is no pressing demand for 
a prompt unimpeded supply of oxygen, such a degree of extension 
is not only unnecessary but barbarous. In the fast trot, however, 
owing to the more rapid tissue change and urgent need for an 
unstinted amount of air, it is absolutely essential. In the consid- 
eration of my subject, I take the original position, which I shall 
endeavor to maintain, that, if the trot, especially the fast trot, in 
the horse was a natural instead of an acquired gait, he would, by 
nature, be supplied with some method of accomplishing or assum- 
ing the position of an elevated extended head, which furnishes 
him with an unembarrassed respiration and develops the greatest 
perfection of this particular form of locomtion. 
My assumption is strengthened by the evidence furnished by 
another animal, the reindeer, which is a natural trotter and the 
only one encountered in nature which does not resort to other 
gaits in its movements. Many others, as the dog, cow, hog, and 
sheep, display a jog, or slow trot, but recoursing to a greater 
speed they immediately exchange it for the faster one of running. 
The American moose, or European elk, does not gallop but 
shuffles or ambles along. Increasing its speed, the hind feet 
straddle to avoid treading on its fore-heels; his nose is held well 
up by his antlers which rest horizontally backward. 
The American elk exhibits a trot which he relinquishes for the 
gallop when desirous of increasing the rapidity of his flight. 
The trot of the reindeer, on the contrary, is a perfect gait dis- 
playing a poetry of motion which the horse, in spite of his educa- 5 
tion, can never be expected to attain. Splint, spavin, wind-galls, 
sprung knees and stiffened shoulders which, sooner or later, mar 
the symmetry of the limbs of the equine trotter and consign him 
to the paddock, are never seen in this servitor of Arctic man. 
Statements of its speed and endurance are almost incredible. 
Journeys of 150 miles in nineteen hours are said to be common. 
One is said to have drawn an officer, bearing important dispatches, 
in 1669, 800 English miles in forty-eight hours and the portrait of 
the poor deer, which fell dead at the end of the marvelous jour- 
ney, is still preserved in the Palace of Drotningholm in Sweden. 
Of the fifty-two species of Cervidse, the reindeer is the only one 
of which the female is provided with antlers. The generally 
accepted opinion of their use, derived from Darwin, is that of 
ornamentation, and as weapons for fighting purposes. My inves- 
tigations concerning this animal in connection with the gait of 
trotting embolden me to submit an opinion opposite to that of 
the illustrious naturalist, whose observations, it may be said, were 
made prior to the trotting era. Interlocking of antlers may occur 
occasionally between males contending for supremacy, but these 
appendages are not used on such occasions any more freely than 
their feet. It is not a pugnacious animal, and when exposed to 
danger, usually resorts to flight. Fleeing from wolves, its greatest 
source of danger, it elevates its head, and its antlers resting hori- 
zontally backward produce marked extension of the head and 
steady its upturned nose. This attitude provides a straight 
undeviating passage for the entrance of air to the lungs. By their 
weight and the rearwardly extending traction which the antlers 
exert, they, especially in long continued flight, reinforce the 
strained ligamentum nuchae and the weary muscles of the neck. 
In othei- words, the antlers are Nature's over-draw check-rein, the 
prototype of the much abused modern one, which cannot be 
loosened at will, and which, as we have seen, is useful in develop- 
ing speed in the horse when driven to a gait which is acquired 
but which in the fleeter reindeer is natural. 
A convincing argument in favor of this view is presented by a 
feature connected with the shedding of the antlers. Formed in 
the early Spring, they are dropped by both sexes in November. 
If at that time the doe should happen to be pregnant, she retains 
hers until she brings forth her fawn, which event may not occur 
until the following Spring. This is apparently a wonderful pro- 
vision of Nature, by which she is permitted to retain appurte- 
nances useful in flight, so that when in peril, they may contribute 
to the preservation and safety of what Leigh Hunt, in speaking 
of the gravid woman, designates as "the living treasure contain- ing treasure about to live." Darwin, in accounting for this remark- 
able phenomenon, says: "that horns must have been transferred 
to the female at a period subsequent to the divergence of the 
various species from a common stock, and that this was not effected 
for the sake of giving her any special advantages." In the light 
of what has been said of the relations of the modern check-rein 
with the gait of trotting, his opinion cannot be accepted without 
serious doubts of its accuracy. Considering that these antlers are 
developed in very early life, much earlier than in the other species; 
that both sexes are supplied with them; that, at least as far as I 
can ascertain, they are less exposed to danger and incapable of 
manifesting their greatest speed during that portion of the year 
when they are dehorned; it would appear that Nature has dis- 
played a wonderful partiality for the preservation and perpetua- 
tion of this particular species, without which the boreal regions of 
both hemispheres would be uninhabitable. 
In sleep, parturition, the many fevers, cerebral diseases, croup, 
spasm of the glottis, fogeign bodies in the air-passage, asthma, 
pneumonia, and other affections of the respiratory tract, in both 
man and animals extension of the head exists, the subject assum- 
ing that attitude which is most conducive to unobstructed respira- 
tion. By facilitating the inflow of the needed oxygen, it con- 
tributes in most diseases no little to the recovery of the patient, 
and in fatal cases the last struggle by vanquished nature is made 
with an extended head. 
Its absence from the description of the Facies Hippocijata 
detracts from the reputation of the " Old Man of Cos " as an acute 
observer. 
In this connection, note should be taken of the comparative 
immunity to pulmonary diseases enjoyed by the natives of China, 
Japan, and other countries of the Orient, to whom the modern 
form of pillow is unknown, and who sleep with a block beneath 
the neck, their heads, in consequence, being in a state of extension. 
That the ancient Romans and other nations adhered to the same 
custom is evident from a study of the definition of some of their 
words pertaining to the neck and its support in repose. Thus, 
while collum is applied to the entire neck, or pedicle of the head, 
cervix refers to the posterior portion, or nape, and cervical trans- 
lated, is a pillow. That distortion of the thorax and air-passage, 
incidental to the use of the pillow with its accompanying flexion, 
is conducive, especially in children, to deformities of the chest 
and diminished pulmonary capacity, there can be no doubt. In 
my own practice cases of asthma have been benefited by its disuse, 
and the improvement observed in the treatment of the disease by 
camping out is really often due to its absence. 
6 7 
Of the twelve methods of artificial respiration suggested in the 
treatment of asphyxia neonatorum by Howard, Sylvester, Hall, 
Pacini, Bain, Schuckling, Byrd, Schuller, Schroeder, Schultz, 
Forest and Dew, resort is made in all, with hardly an exception, to 
extension of the head. In the neonatus, before it has breathed, 
'there is no air cavity in the thorax, no pharynx, larynx, mouth, or 
njyes. The walls are all in close apposition; the base of the 
tongue lies against the posterior wall of the pharynx and its 
upper surface against the palate; the uvula lies behind and 
against the epiglottis; and the soft walls of the nares lined with 
mucus are in close contact. The first reflex action, or inspiration, 
has for its object, the opening up of these cavities by forcible 
separation of their respective walls through the aid of pneumatic 
pressure, and, as already mentioned, it is facilitated by the pres- 
ence of a tube made straight by an extended head. The knowledge 
of this association of head extension with the first inspiration is 
not confined to the profession. The all-observant Shakespeare 
makes King Lear say: 
" Thou know'st the first time that we smell the air, we wawl and cry." 
Sir Walter Scott also speaks of "the helpless infant coming waul- 
ing and crying into the world." To ivaul defined is to cry like a 
cat, and a retracted head is always associated in our minds with 
the midnight serenade of rampant Grimalkin on the garden fence. 
Having thus shown the connection of extension of the head with 
the ordinary phenomena of animal life in health and disease, we 
can logically conclude and analogously infer that the attitude 
would be the proper one to resort to in anesthesia, a condition in 
which provision for an unembarrassed respiration is imperative. 
The standard surgical authorities, such as Gross, Agnew, Lister, 
Wyeth, Roberts, and others, are singularly reticent as to the sub- 
ject of position, simply enjoining recumbency and the loosening 
of constricting clothing. Nor is it referred to in special works 
devoted to anesthesia, such as Lyman's and that of Sir James Y. 
Simpson. Some surgeons do resort to it, but only in a moderate 
degree, whilst others, and possibly the large majority, by the use 
of the pillow, place their patients' heads in a state of flexion. Any 
suggestion which may tend to reduce the mortality incidental to 
the administration of anesthetics is sufficient excuse for present- 
ing it, and I proceed to an explanation of the method of its 
application and the particular benefits to be derived from it. 
The patient is placed in a supine position on a table, unfurnished 
with a pillow, and the chosen agent is administered in conformity 
with the usual unvarying instructions of the text-books. When 8 
the stage of insensibility is reached, the head is extended to its 
fullest limit and held so by the hands of the anesthetize!. An 
additional advantage may be secured by sliding the subject to the 
end of the table and making the head project a little beyond, that 
portion just below the occipital protuberance resting against its 
padded edge. This movement does not increase the extension,' 
which already exists in its greatest extent, but causes the mobile 
cervical vertebrae to participate in the dorsal bending, and thereby, 
as we shall shortly see, increasing the capacity of the thoracic 
cavity. 
As the primary effect of an anesthetic is to increase salivation, 
which might cause some obstruction by the accumulation of mucus 
in the pharynx, this position is not advised in the first stage-, but, 
as the secondary effect is to diminish salivation, no such objection 
holds during the later period. 
What are the advantages of the position as described? It 
diminishes the friction of the inspired and expired air; raises the 
epiglottis; enlarges the glottis; occludes the esophagus; dimin- 
ishes the liability of syncope; prevents stertor; and increases the 
capacity of the thorax. 
From the blending of the skin with the mucous membrane to 
the bifurcation of the trachea the most attainable lumen exists. 
Pneumatics demonstrate that the friction of air through a 
straight tube is much less than through a curved one. Benjamin 
Howard has shown us in his article " A New and Only Way of Rais- 
ing the Epiglottis," British Medical Journal, November, 1888, that 
complete extension of the head is the only means of raising the 
collapsed janitor of the larynx. Its elevation is much assisted by 
combining with it the lifting up of the lower jaw. Traction of the 
tongue, so generally recommended for the purpose in asphyxia 
does not accomplish it, as it simply stretches the connecting 
mucus folds between it and the tongue. Sir Joseph Lister, 
whilst admitting the claims of Howard, insists that very forcible 
traction, to the extent of elevating the hyoid bone and lower jaw, 
as shown by Kappeler's experiments on the cadaver, will produce 
the same effect, and that the method also exercises a reflex action 
similar to that of producing inspiration by tickling the fauces 
which experimental physiology has demonstrated as the last 
refuge* of sensibility during the ultimate period, of anasthesia. 
The anesthetizer by the use of his hands pushing the jaw well 
upward and forward will materially facilitate the elevation of the 
epiglottis. He should also see that the mouth is closed. Mouth 
breathing is no more to be desired in the artificial than in the 
natural sleep. An important reason for a closed mouth is based 9 
upon the observations of Dr. Bowles published in his article, 
" Stertor, Apoplexy, and the Management of the Apoplectic State," 
in Wood's Monographs, September, 1891. He says: "When the 
mouth is closed, the horizontal portion, or body of the jaw, forms 
nearly a right angle wjth the spinal column, from which the 
symphysis is then at its greatest distance. When the mouth is 
opened by the dropping of the jaw, the symphysis describes the 
arc of a circle, and approaches more nearly to the spine where the 
posterior wall of the pharynx is attached. The tongue having its 
chief attachment to the symphysis, would consequently be drawn 
away from the pharynx in the former case, and allowed to rest in 
contact with it in the latter." 
Referring to a dissection which he illustrates by diagrams, he 
says: "When the mouth was open and the subject on his back, 
the road to the larynx was completely obstructed, in consequence 
of the tongue resting in contact with the back of the pharynx. 
When the mouth was closed, the tongue was lifted from the 
pharynx, leaving ample breathing space. But even with the 
mouth closed, if the chin was much bent on the sternum, the base 
of the tongue was almost in contact with the back of the pharynx. 
It would seem from this dissection that the muscles of the 
tongue attaching it to the symphysis of the jaw are too short to 
admit the base of the tongue reaching the back of the throat when 
the mouth is closed. The purpose served by such an arrangement 
would appear to be to keep the base of the tongue away from the 
back of the throat during deglutition. The dissection also sug- 
gests the necessity of caution being used in raising the head with 
pillows; for if the head be too much bent forward on the chest, 
the tongue may lie in dangerous proximity to the pharynx, even 
when the mouth is closed." 
That the patulousness of the rima glottidis can be affected by 
any position of the head is generally regarded as extremely doubt- 
ful. Without attempting any explanation of its action, I can 
assert that it is increased by extension of the head as is plainly 
shown by the comparatively easy accidental passage of foreign 
bodies into the trachea when the head is held in that position. 
There are numerous instances of teeth extracted from an extended 
head, the usual attitude of a patient in the dental chair, dropping 
without apparent contact through the rima glottidis into the 
trachea. Of the many instances of this kind, is the historic one 
of the famous English Engineer Brunel, who, in amusing some 
children, caught in his open mouth a half-sovereign which he had 
tossed in the air. Watching the descent of the coin with a forci- 
bly extended head, it dropped directly into the trachea without, 
seemingly, touching the laryngeal walls. A study of the history of recorded cases would indicate that in 
the vast majority, the accident has occurred as described, or in the 
acts of crying, yawning and laughing, the head being in a state of 
extension in every case. 
In the position under discussion the flaccid esophagus is com- 
pletely occluded by the pressure of the cervical vertebra) which 
are thrown forward, and of the rigid larynx which is drawn back- 
ward. This result diminishes very greatly the liability of the 
occurrence of vomiting. It has been found by Magendie that 
during the nausea which precedes the act of vomiting there is 
always distension of the stomach from deglutition of air. No air 
can pass into the stomach in this position which is always resorted 
to on that account in the mouth to mouth inflation in artificial 
respiration. The experiments of Beclard and of Legallois have 
further shown that in emesis there is a violent and extensive con- 
traction of the longitudinal fibres of the esophagus. The result- 
ing shortening of the tube assists in vomiting as it has a tendency 
to dilate the cardiac orifice of the stomach and to counteract the 
contraction of the pillars of the diaphragm. As there is lengthen- 
ing instead of contraction of the gullet during extension, vomiting 
for this reason also is much less apt to occur. If vomiting should 
occur, the danger of vomited material entering the larynx with its 
elevated epiglottis, is not enhanced, as a straight tube is furnished 
the regurgitant matter, and gravity would direct its flow rather to 
the nares. 
That syncope is less liable to occur in this posture is obvious, as 
gravity assists the flow of blood to the brain. 
Owing to the stretching of the mucous lining of the pharynx 
and larynx, there is in this attitude, especially when the mouth is 
closed, a complete absence of stertor. Its appearance has ever 
been regarded in anesthetics as a "danger-signal." It should not 
be regarded as an alarm but as a danger per se. It should be 
abolished, if possible, not only because it is synonymous with 
obstruction, but because, if absent, reliance would be placed in 
other more valuable indications of impending disaster. A study 
of the history of fatal cases would indicate that it was not present 
in many. In an esthetic point of view its absence is also desirable. 
The palatine form of stertor, or ordinary snoring, cannot exist in 
this position as there can be no vibrations of the velum palati as 
long as no air passes through the mouth. 
Sir Joseph Lister first pointed out that form known as laryngeal, 
produced by the vibrations of the portion of the mucous mem- 
brane surmounting the apices of the arytenoid cartilages and 
which is prevented in the described position by the stretching of 
10 11 
the aryteno-epiglottidean folds. Stertor in those who do not use 
the modern pillow, and especially in those who sleep with an 
extended head, their necks resting on a block of wood, is seldom, 
if ever, observed. Visit the Chinese quarters at midnight and 
compare the quiet placid breathing of the inmates, many of whom 
are in a state of anesthesia produced by opium, with the noisy, 
stertorous snoring observed at the, same hoqr in the ordinary 
American hotel or tePHudydrouseT" 
If when the body is resting supine on a table, the projecting 
head is forcibly extended and the neck is made to participate in 
the movement, the ribs are raised by the action of the muscles 
connecting the head with the sternum, clavicle, and anterior por- 
tion of the ribs, and the thoracic cavity is thereby enlarged. If, 
however, the body should follow the neck in its backward move- 
ment, as it would if a pillow was beneath the shoulders, the action 
of these muscles would be antagonized to a great extent by the 
abdominal recti. 
This paper would be incomplete without reference to the recent 
instructive researches of Drs. Hare and Martin, of Philadelphia, 
who formulated the following rules regarding the position of the 
head, neck, epiglottis and tongue, in connection with the subject 
of artificial respiration: 
"The fingers are pressed behind the angles of the lower jaw 
and the latter is pressed forward; this elevates the epiglottis and 
the base of the tongue about a quarter of an inch from the post- 
pharyngeal wall. Extending the head and pushing it forward so 
that the neck makes an angle of forty-five degrees with the plane 
of the table, draws the base of the tongue and hyoid bone far 
forward, this motion being at the same time imparted to the 
epiglottis, so that the latter stands upright and is separated from 
the posterior walls of the pharynx by an interval of about an inch. 
By tightly closing the jaw the antero posterior space is still 
further increased. The epiglottis may prevent free entrance of 
air to the lungs even though the tongue is pulled forward. Any 
means which accomplish the anterior projection of the hyoid bone 
immediately and infallibly raise the epiglottis and the base of the 
tongue, and the hyoid bone may be made to project anteriorly by 
direct pressure upon its cornua, by direct pressure or traction 
applied to the tongue far back behind the anterior half-arches of 
the palate, and by the action of gravity in the abdominal decubi- 
tus, or by extension of the head upon the neck, although flexion 
of the neck with extension of the head does away with the 
epiglottis as an obstructing factor as completely as any other 
posture 12 
Lately when using anesthetics, I have placed my patients in 
the position as suggested and have been most favorably impressed 
with the easy-xespiration, the absence of stertor and vomiting, 
and, owing t6 unimpeded, unobstructed entrance of the inspired 
agent, the rapidity of its effects and the smaller quantity required 
to produce insensibility. 
Its advantages should be made use of in the sick-room, and our 
patients, especially when unconscious, should be placed in a 
position of extension, to a moderate degree at least, which we have 
seen secures the free passage of oxygen. The time^honored in- 
junction of the lying-in room, "Press your chin dnwn on your 
breast and bear down," enjoined by the gin guzzlSsy/crony, as 
well as by .the modern aseptic obstetrician, is not only unphilo- 
sophical but is absolutely injurious. A woman in the throes of 
labor instinctively assumes the position of an extended head, and 
if she is ever to be granted the free entrance of refreshing, much 
needed air, it should be at such a time. Besides, a full inspiration 
by favoring the descent of the diaphragm to its fullest limit, 
affords no little supplementary aid to the expulsion of the fetus. 
The instructions to flex the head on such occasions is in strict 
harmony with the opposition to the use of chloroform in labor; 
with the washing of the new-born babe; and with the dressing of 
the cord with the foul ill-smelling oiled rag. 
In the bottle-raised infant, it will be found that when its head is 
well flexed during feeding, strangling by the milk passing into 
the larynx is much less apt to occur than when elevation of its 
epiglottis is effected by head extension. In the use of atomized 
liquids when the object is to spray the larynx, the head should be 
placed in the state of extension. If the object is to treat the 
pharynx the head should be flexed and the mouth closed over the 
delivery tube. 
In resorting to inversion of the body in the treatment of chlor- 
oform or ether narcosis, the patient should be suspended by the 
heels and the head placed in a state of complete and forcible 
extension. 
The same position should be made use of for the expulsion of 
foreign bodies from the trachea, as it has been successful in 
numerous cases, notably that of Brunel already referred to. 
Many other practical deductions can be made, but I feel assured 
that I have said sufficient to awaken an interest in this important 
subject.