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diff --git a/.gitattributes b/.gitattributes new file mode 100644 index 0000000..6833f05 --- /dev/null +++ b/.gitattributes @@ -0,0 +1,3 @@ +* text=auto +*.txt text +*.md text diff --git a/19261.txt b/19261.txt new file mode 100644 index 0000000..4631b55 --- /dev/null +++ b/19261.txt @@ -0,0 +1,9176 @@ +The Project Gutenberg eBook, Bronchoscopy and Esophagoscopy, by Chevalier +Jackson + + +This eBook is for the use of anyone anywhere at no cost and with +almost no restrictions whatsoever. You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + + + + +Title: Bronchoscopy and Esophagoscopy + A Manual of Peroral Endoscopy and Laryngeal Surgery + + +Author: Chevalier Jackson + + + +Release Date: September 13, 2006 [eBook #19261] + +Language: English + +Character set encoding: ISO-646-US (US-ASCII) + + +***START OF THE PROJECT GUTENBERG EBOOK BRONCHOSCOPY AND ESOPHAGOSCOPY*** + + +This book is one of the pioneering works in laryngology. The original text +is from the library of Indiana University Department of +Otolaryngology-Head and Neck Surgery, Bruce Matt, MD. It was scanned, +converted to text, and proofed by Alex Tawadros. + + + +BRONCHOSCOPY AND ESOPHAGOSCOPY + +A Manual of Peroral Endoscopy and Laryngeal Surgery + +by + +CHEVALIER JACKSON, M.D., F.A.C.S. +Professor of Laryngology, Jefferson Medical College, Philadelphia; +Professor of Bronchoscopy and Esophagoscopy, Graduate School of +Medicine, University of Pennsylvania; Member of the American +Laryngological Association; Member of the Laryngological, +Rhinological, and Otological Society; Member of the American Academy +of Ophthalmology and Oto-Laryngology; Member of the American +Bronchoscopic Society; Member of the American Philosophical Society; +etc., etc. + +With 114 Illustrations and Four Color Plates + + + + + + + +Philadelphia And London +W. B. Saunders Company +1922 +Copyrights 1922, by W. B. Saunders Company +Made in U.S.A. + + + + +TO MY MOTHER TO WHOSE INTEREST IN MEDICAL SCIENCE THE AUTHOR OWES +HIS INCENTIVE, AND TO MY FATHER WHOSE CONSTANT ADVICE TO "EDUCATE +THE EYE AND THE FINGERS" SPURRED THE AUTHOR TO CONTINUAL EFFORT, +THIS BOOK IS AFFECTIONATELY DEDICATED. + + + + +PREFACE + +This book is based on an abstract of the author's larger work, +Peroral Endoscopy and Laryngeal Surgery. The abstract was prepared +under the author's direction by a reader, in order to get a reader's +point of view on the presentation of the subject in the earlier book. +With this abstract as a starting point, the author has endeavored, so +far as lay within his limited abilities, to accomplish the difficult +task of presenting by written word the various purely manual +endoscopic procedures. The large number of corrections and revisions +found necessary has confirmed the wisdom of the plan of getting the +reader's point of view; and these revisions, together with numerous +additions, have brought the treatment of the subject up to date so far +as is possible within the limits of a working manual. +Acknowledgment is due the personnel of the W. B. Saunders Company for +kindly help. + +CHEVALIER JACKSON. +OCTOBER, 1922. +II + + + +CONTENTS PAGE + + CHAPTER I INSTRUMENTARIUM 17 + CHAPTER II ANATOMY OF LARYNX, TRACHEA, BRONCHI AND + ESOPHAGUS, ENDOSCOPICALLY CONSIDERED 52 + CHAPTER III PREPARATION OF THE PATIENT FOR PERORAL + ENDOSCOPY 63 + CHAPTER IV ANESTHESIA FOR PERORAL ENDOSCOPY 65 + CHAPTER V BRONCHOSCOPIC OXYGEN INSUFFLATION 71 + CHAPTER VI POSITION OF THE PATIENT FOR PERORAl ENDOSCOPY 73 + CHAPTER VII DIRECT LARYNGOSCOPY 82 + CHAPTER VIII DIRECT LARYNGOSCOPY (Continued) 91 + CHAPTER IX INTRODUCTION OF THE BRONCHOSCOPE 97 + CHAPTER X INTRODUCTION OF THE ESOPHAGOSCOPE 106 + CHAPTER XI ACQUIRING SKILL 117 + CHAPTER XII FOREIGN BODIES IN THE AIR AND FOOD PASSAGES 126 + CHAPTER XIII FOREIGN BODIES IN THE LARYNX AND + TRACHEOBRONCHIAL TREE 149 + CHAPTER XIV REMOVAL OF FOREIGN BODIES FROM THE LARYNX 156 + CHAPTER XV MECHANICAL PROBLEMS OF BRONCHOSCOPIC + FOREIGN BODY EXTRACTION 158 + CHAPTER XVI FOREIGN BODIES IN THE BRONCHI FOR + PROLONGED PERIODS 177 + CHAPTER XVII UNSUCCESSFUL BRONCHOSCOPY FOR FOREIGN BODIES 181 + CHAPTER XVIII FOREIGN BODIES IN THE ESOPHAGUS 183 + CHAPTER XIX ESOPHAGOSCOPY FOR FOREIGN BODY 187 + CHAPTER XX PLEUROSCOPY 199 + CHAPTER XXI BENIGN GROWTHS IN THE LARYNX 201 + CHAPTER XXII BENIGN GROWTHS IN THE LARYNX (Continued) 203 + CHAPTER XXIII BENIGN GROWTHS PRIMARY IN THE + TRACHEOBRONCHIAL TREE 207 + CHAPTER XXIV BENIGN NEOPLASMS OF THE ESOPHAGUS 209 + CHAPTER XXV ENDOSCOPY IN MALIGNANT DISEASE OF THE LARYNX 210 + CHAPTER XXVI BRONCHOSCOPY IN MALIGNANT GROWTHS OF + THE TRACHEA 214 + CHAPTER XXVII MALIGNANT DISEASE OF THE ESOPHAGUS 216 + CHAPTER XXVIII DIRECT LARYNGOSCOPY IN DISEASES OF + THE LARYNX 221 + CHAPTER XXIX BRONCHOSCOPY IN DISEASES OF THE TRACHEA + AND BRONCHI 224 + CHAPTER XXX DISEASES OF THE ESOPHAGUS 235 + CHAPTER XXXI DISEASES OF THE ESOPHAGUS (Continued) 245 + CHAPTER XXXII DISEASES OF THE ESOPHAGUS (Continued) 251 + CHAPTER XXXIII DISEASES OF THE ESOPHAGUS (Continued) 260 + CHAPTER XXXIV DISEASES OF THE ESOPHAGUS (Continued) 268 + CHAPTER XXXV GASTROSCOPY 273 + CHAPTER XXXVI ACUTE STENOSIS OF THE LARYNX 277 + CHAPTER XXXVII TRACHEOTOMY 279 + CHAPTER XXXVIII CHRONIC STENOSIS OF THE LARYNX AND TRACHEA 300 + CHAPTER XXXIX DECANNULATION AFTER CURE OF LARYNGEAL + STENOSIS 309 + BIBLIOGRAPHY 311 + INDEX 315 + + + +[17] CHAPTER I--INSTRUMENTARIUM + +Direct laryngoscopy, bronchoscopy, esophagoscopy and gastroscopy +are procedures in which the lower air and food passages are +inspected and treated by the aid of electrically lighted tubes +which serve as specula to manipulate obstructing tissues out of the +way and to bring others into the line of direct vision. +Illumination is supplied by a small tungsten-filamented, electric, +"cold" lamp situated at the distal extremity of the instrument in a +special groove which protects it from any possible injury during the +introduction of instruments through the tube. The bronchi and the +esophagus will not allow dilatation beyond their normal caliber; +therefore, it is necessary to have tubes of the sizes to fit +these passages at various developmental ages. Rupture or even +over-distention of a bronchus or of the thoracic esophagus is almost +invariably fatal. The armamentarium of the endoscopist must be +complete, for it is rarely possible to substitute, or to improvise +makeshifts, while the bronchoscope is in situ. Furthermore, the +instruments must be of the proper model and well made; otherwise +difficulties and dangers will attend attempts to see them. + +_Laryngoscopes_.--The regular type of laryngoscope shown in Fig. I +(A, B, C) is made in adult's, child's, and infant's sizes. The +instruments have a removable slide on the top of the tubular +portion of the speculum to allow the removal of the laryngoscope +after the insertion of the bronchoscope through it. The infant size +is made in two forms, one with, the other without a removable slide; +with either form the larynx of an infant can be exposed in but a few +seconds and a definite diagnosis made, without anesthesia, general or +local; a thing possible by no other method. For operative work on the +larynx of adults, such as the removal of benign growths, particularly +when these are situated in the anterior portion of the larynx, a +special tubular laryngoscope having a heart-shaped lumen and a +beveled tip is used. With this instrument the anterior commissure is +readily exposed, and because of this it is named the anterior +commissure laryngoscope (Fig. 1, D). The tip of the anterior +commissure laryngoscope can be used to expose either ventricle of the +larynx by lifting the ventricular band, or it may be passed through +the adult glottis for work in the subglottic region. This instrument +may also be used as an esophageal speculum and as a pleuroscope. A +side-slide laryngoscope, used with or without the slide, is +occasionally useful. + +_Bronchoscopes_.--The regular bronchoscope is a hollow brass tube +slanted at its distal end, and having a handle at its proximal or +ocular extremity. An auxiliary canal on its under surface contains +the light carrier, the electric bulb of which is situated in a recess +in the beveled distal end of the tube. Numerous perforations in the +distal part of the tube allow air to enter from other bronchi when the +tube-mouth is inserted into one whose aerating function may be +impaired. The accessory tube on the upper surface of the bronchoscope +ends within the lumen of the bronchoscope, and is used for the +insufflation of oxygen or anesthetics, (Fig. 2, A, B, C, D). + +For certain work such as drainage of pulmonary abscesses, the lavage +treatment of bronchiectasis and for foreign-body or other cases with +abundant secretions, a drainage-bronchoscope is useful The drainage +canal may be on top, or on the under surface next to the light-carrier +canal. For ordinary work, however, secretion in the bronchus is best +removed by sponge-pumping (Q.V.) which at the same time cleans the +lamp. The drainage bronchoscope may be used in any case in which the very +slightly-greater area of cross section is no disadvantage; but in +children the added bulk is usually objectionable, and in cases of +recent foreign-body, secretions are not troublesome. + +As before mentioned, the lower air passages will not tolerate +dilatation; therefore, it is necessary never to use tubes larger than +the size of the passages to be examined. Four sizes are sufficient +for any possible case, from a newborn infant to the largest adult. +For infants under one year, the proper tube is the 4 mm. by 30 cm.; +the child's size, 5 mm. by 30 cm., is used for children aged from one +to five years. For children six years or over, the 7 mm. by 40 cm. +bronchoscope (the adolescent size) can be used unless the smaller +bronchi are to be explored. The adult bronchoscope measures 9 mm. +by 40 cm. + +The author occasionally uses special sizes, 5 mm. x 45 cm., 6 mm. x 35 +cm., 8 mm. x 40 cm. + +_Esophagoscopes_.-The esophagoscope, like the bronchoscope, is a +hollow brass tube with beveled distal end containing a small +electric light. It differs from the bronchoscope in that it has no +perforations, and has a drainage canal on its upper surface, or next +to the light-carrier canal which opens within the distal end of the +tube. The exact size, position, and shape of the drainage outlets is +important on bronchoscopes, and to an even greater degree on +esophagoscopes. If the proximal edge of the drainage outlet is too +near the distal end of the endoscopic tube, the mucosa will be drawn +into the outlet, not only obstructing it, but, most important, +traumatizing the mucosa. If, for instance, the esophagoscope were to +be pushed upon with a fold thus anchored in the distal end, the +esophageal wall could easily be torn. To admit the largest sizes of +esophagoscopic bougies (Fig. 40), special esophagoscopes (Fig. 5) are +made with both light canal and drainage canal outside the lumen of the +tube, leaving the full area of luminal cross-section unencroached +upon. They can, of course, be used for all purposes, but the slightly +greater circumference is at times a disadvantage. The esophageal and +stomach secretions are much thinner than bronchial secretions, and, if +free from food, are readily aspirated through a comparatively small +canal. If the canal becomes obstructed during esophagoscopy, the +positive pressure tube of the aspirator is used to blow out the +obstruction. Two sizes of esophagoscopes are all that are required--7 +mm. X 45 cm. for children, and 10 mm. X 53 cm. for adults (Fig. 3, A +and B); but various other sizes and lengths are used by the author for +special purposes.* Large esophagoscopes cause dangerous dyspnea in +children. If, it is desired to balloon the esophagus with air, the +window plug shown in Fig. 6, is inserted into the proximal end of the +esophagoscope, and air insufflated by means of the hand aspirator or +with a hand bulb. The window can be replaced by a rubber diaphragm +with a perforation for forceps if desired. It will be noted that none +of the endoscopic tubes are fitted with mandrins. They are to be +introduced under the direct guidance of the eye only. Mandrins are +obtainable, but their use is objectionable for a number of reasons, +chief of which is the danger of overriding a foreign body or a lesion, +or of perforating a lesion, or even the normal esophageal wall. The +slanted end on the esophagoscope obviates the necessity of a mandrin +for introduction. The longer the slant, with consequent acuting of the +angle, the more the introduction is facilitated; but too acute an +angle increases the risk of perforating the esophageal wall, and +necessitates the utmost caution. In some foreign-body cases an acute +angle giving a long slant is useful, in others a short slant is +better, and in a few cases the squarely cut-off distal end is best. To +have all of these different slants on hand would require too many +tubes. Therefore the author has settled upon a moderate angle for the +end of both esophagoscopes and bronchoscopes that is easy to insert, +and serves all purposes in the version and other manipulations +required by the various mechanical problems of foreign-body +extraction. He has, however, retained all the experimental models, for +occasional use in such cases as he falls heir to because of a problem +of extraordinary difficulty. + +* A 9 mm. X 45 cm. esophagoscope will reach the stomach of almost all +adults and is somewhat easier to introduce than the 10 mm. X 53 cm., +which may be omitted from the set if economy must be practiced. + +[FIG. I.--Author's laryngoscopes. These are the standard sizes and +fulfill all requirements. Many other forms have been devised by the +author, but have been omitted from the list as unnecessary. The infant +diagnostic laryngoscope (C) is not for introducing bronchoscopes, +and is not absolutely necessary, as the larynx of any infant can be +inspected with the child's size laryngoscope (B). + +A Adult's size; B, child's size; C, infant's diagnostic size; D, +anterior commissure laryngoscope; E, with drainage canal; 17, +intubating laryngoscope, large lumen. All the laryngoscopes are +preferred without drainage canals.] + +[FIG. 2.--The author's bronchoscopes of the sizes regularly used. +Various other lengths and diameters are on hand for occasional use +for special purposes. With the exception of a 6 mm. X 35 cm. size +for older children, these special bronchoscopes are very rarely +used and none of them can be regarded as necessary. For special +purposes, however, special shapes of tube-mouth are useful, as, +for instance, the oval end to facilitate the getting of both +points of a staple into the tube-mouth The illustrated instruments +are as follows: + +A, Infant's size, 4 mm. X 30 cm.; B, child's size, 5 mm. X 30 cm.; +C, adolescent's size, 7 mm. X 40 cm.; D, adult's size, 9 mm. X 40 cm.; +E, aspirating bronchoscope made in all the foregoing sizes, and in a +special size, 5 mm. X 45 cm.] + +[FIG. 3.--The author's esophagoscopes of the sizes he has standardized +for all ordinary requirements. He uses various other lengths and sizes +for special purposes, but none of them are really necessary. A +gastroscope, 10 mm. X 70 cm., is useful for adults, especially in +cases of gastroptosis. Drainage canals are placed at the top or at the +side of the tube, next to the light-carrier canal. + +A, Adult's size, 10 mm. X 53 cm.; B, child's size, 7 mm. X 45 cm.; C +and D, full lumen, with both light canal and drainage canal outside +the wall of the tube, to be used for passing very large bougies. This +instrument is made in adult, child, and adolescent (8 mm. by 45 cm.) +sizes. Gastroscopes and esophagoscopes of the sizes given above (A) +and (B), can be used also as gastroscopes. A small form of C, 5 mm. X +30 cm. is used in infants, and also as a retrograde esophagoscope in +patients of any age. E, window plug for ballooning gastroscope, F.] + +[FIG. 4.--Author's short esophagoscopes and esophageal specula +A, Esophageal speculum and hypopharyngoscope, adult's size; B, +esophageal speculum and hypopharyngoscope, child's size; C, heavy +handled short esophagoscope; D, heavy handled short esophagoscope with +drainage.] + +[FIG. 5.--Cross section of full-lumen esophagoscope for the use of +largest bourgies. The canals for the light carrier and for drainage +are so constructed that they do not encroach upon the lumen of the +tube.] + +[25] The special sized esophagoscopes most often useful are the 8 mm. +X 30 cm., the 8 mm. X 45 cm., and the 5 mm. X 45 cm. These are made +with the drainage canal in various positions. + +For operations on the upper end of the esophagus, and particularly for +foreign body work, the esophageal speculum shown at A and B, in Fig. +4, is of the greatest service. With it, the anterior wall of the +post-cricoidal pharynx is lifted forward, and the upper esophageal +orifice exposed. It can then be inserted deeper, and the upper third +of the esophagus can be explored. Two sizes are made, the adult's and +the child's size. These instruments serve, very efficiently as +pleuroscopes. They are made with and without drainage canals, the +latter being the more useful form. + +[FIG. 6.--Window-plug with glass cap interchangeable with a cap having +a rubber diaphragm with a perforation so that forceps may be used +without allowing air to escape. Valves on the canals (E, F, Fig. 3) +are preferable.] + +_Gastroscopes_.--The gastroscope is of the same construction as the +esophagoscope, with the exception that it is made longer, in order to +reach all parts of the stomach. In ordinary cases, the regular +esophagoscopes for adults and children respectively will afford a good +view of the stomach, but there are cases which require longer tubes, +and for these a gastroscope 10 mm. X 70 cm. is made, and also one 10 +mm. X 80 cm., though the latter has never been needed but once. + +[26] _Pleuroscopes_.--As mentioned above the anterior commissure +laryngoscope and the esophageal specula make very efficient +pleuroscopes; but three different forms of pleuroscopes have been +devised by the author for pleuroscopy. The retrograde esophagoscope +serves very well for work through small fistulae. + +_Measuring Rule_ (Fig. 7).--It is customary to locate esophageal +lesions by denoting their distance from the incisor teeth. This is +readily done by measuring the distance from the proximal end of the +esophagoscope to the upper incisor teeth, or in their absence, to the +upper alveolar process, and subtracting this measurement from the +known length of the tube. Thus, if an esophagoscope 45 cm. long be +introduced and we find that the distance from the incisor teeth to the +ocular end of the esophagoscope as measured by the rule is 20 cm., we +subtract this 20 cm. from the total length of the esophagoscope (45 +cm.) and then know that the distal end of the tube is 25 cm. from the +incisor teeth. Graduation marks on the tube have been used, but are +objectionable. + +[FIG. 7.--Measuring rule for gauging in centimeters the depth of any +location by subtraction of the length of the uninserted portion of the +esophagoscope or bronchoscope. This is preferable to graduations +marked on the tubes, though the tubes can be marked with a scale if +desired.] + +_Batteries_.--The simplest, best, and safest source of current is a +double dry battery arranged in three groups of two cells each, +connected in series (Fig. 8). Each set should have two binding posts +and a rheostat. The binding posts should have double holes for two +additional cords, to be kept in reserve for use in case a cord becomes +defective.* The commercial current reduced through a rheostat should +never be used, because there is always the possibility of "grounding" +the circuit through the patient; a highly dangerous accident when we +consider that the tube makes a long moist contact in tissues close to +the course of both the vagi and the heart. The endoscopist should +never depend upon a pocket battery as a source of illumination, for it +is almost certain to fail during the endoscopy. The wires connecting +the battery and endoscopic instrument are covered with rubber, so that +they may be cleansed and superficially sterilized with alcohol. They +may be totally immersed in alcohol for any length of time without +injury. + +* When this is done care is necessary to avoid attempting to use +simultaneously the two cords from one pair of posts. + +[FIG 8.--The author's endoscopic battery, heavily built for +reliability. + +It contains 6 dry cells, series-connected in 3 groups of 2 cells each. +Each group has its own rheostat and pair of binding posts.] + +_Aspirating Tubes_.--Independent aspirating tubes involve delay in +their use as compared to aspirating canals in the wall of the +endoscopic tube; but there are special cases in which an independent +tube is invaluable. Three forms are used by the author. The "velvet +eye" cannot traumatize the mucosa (Fig. 9). To hold a foreign body by +suction, a squarely cut off end is necessary. For use through the +tracheotomic wound without a bronchoscope a malleable tube (Fig. 10) +is better. + +[FIG. 9.--The author's protected-aperture endoscopic aspirating tube +for aspiration of pharyngeal secretions during direct laryngoscopy and +endotracheobronchial secretions at bronchoscopy, also for draining +retropharyngeal abscesses. The laryngoscopes are obtainable with +drainage canals, but for most purposes the independent aspirating tube +shown above is more satisfactory. The tubes are made in 20 30, 40, and +60 cm. lengths. An aperture on both sides prevents drawing in the +mucosa. It can be used for insufflation of ether if desired. An +aspirating tube of the same design, but having a squarely cut off end, +is sometimes useful for removing secretions lying close to a foreign +body; for removing papillomata; and even for withdrawing foreign +bodies of a soft surface consistency. It is not often that the foreign +bodies can be thus withdrawn through the glottis, but closely fitting +foreign bodies can at least be withdrawn to a higher level at which +ample forceps spaces will permit application of forceps. Such +aspirating tubes, however, are not so safe to use as the protected, +double aperture tubes.] + +[FIG. 10.--The author's malleable tracheotomic aspirating tube for +removal of secretions, exudates, crusts, etc., from the +tracheobronchial tree through the tracheotomic wound without a +bronchoscope. The tube is made of copper so that it can be bent to any +curve, and the copper wire stylet prevents kinking. The stylet is +removed before using the tube for aspiration.] + +[28] _Aspirators_.--The various electric aspirators so universally +used in throat operations should be utilized to withdraw secretions in +the tubes fitted with drainage canals. They, however, have the +disadvantages of not being easily transported, and of occasionally +being out of order. The hand aspirator shown in Fig. 11 is, therefore, +a necessary part of the instrumental equipment. It never fails to +work, is portable, and affords both positive and negative pressures. +The positive pressure is sometimes useful in clearing the drainage +canal of any particles of food, tissue, clots, or secretion which may +obstruct it; and it also serves to fill the stomach or esophagus with +air when the ballooning procedure is used. The mechanical aspirator +(Fig. 12) is highly efficient and is the one used in the Bronchoscopic +Clinic. The positive pressure will quickly clear obstructed drainage +canals, and may be used while the esophagoscope is in situ, by simply +detaching the minus pressure tube and attaching the plus pressure. In +the lungs, however, high plus pressures are so dangerous that the +pressure valve must be lowered. + +[Fig. 11--Portable aspirator for endoscopy with additional tube +connected with the plus pressure side for use in case of occlusion of +the drainage canal. This aspirator has the advantage of great power +with portability. Where portability is not required the electrically +operated aspirator is better.] + +[FIG. 12.--Robinson mechanical aspirator adapted for bronchoscopic and +esophagoscopic aspiration by the author. The positive pressure is used +for clearing obstructed drainage canals and tubes.] + +[FIG. 13.--Apparatus for insufflation of ether or chloroform during +bronchoscopy, for those who may desire to use general anesthesia. The +mechanical methods of intratracheal insufflation anesthesia +subsequently developed by Meltzer and Auer, Elsberg, Geo. P. Muller +and others have rightly superseded this apparatus for all general +surgical purposes.] + +_Sponge-pumping_.--While the usually thin, watery esophageal and +gastric secretions, if free from food, are readily aspirated through a +drainage canal, the secretions of the bronchi are often thick and +mucilaginous and aspirated with difficulty. Further-more, bronchial +secretions as a rule are not collected in pools, but are distributed +over the walls of the larger bronchi and continuously well up from +smaller bronchi during cough. The aspirating bronchoscopes should be +used whenever their very slight additional area of cross-section is +unobjectionable. In most cases, however, the most advantageous way to +remove bronchial secretion has been found to be by introducing a gauze +swab on a long sponge carrier (Fig. 14), so that the sponge extends +beyond the distal end of the bronchoscope, causing cough. Then +withdrawal of the sponge carrier will remove all of the secretion in +the tube just as the plunger in a pump will lift all of the water +above it. By this maneuver the walls of the bronchus are wiped free +from secretions, and the lamp itself is cleansed. + +[FIG. 14.--Sponge carrier with long collar for carrying the small +sponges shown in Fig. 15. The collar screws down as in the Coolidge +cotton carrier. About a dozen of these are needed and they should all +be small enough to go through the 4 mm. (diameter) bronchoscope and +long enough to reach through the 53 cm. (length) esophagoscope, so +that one set will do for all tubes. The schema shows method of +sponging. The carrier C, armed with the sponge, S, when rotated as +shown by the dart, D, wipes the field, P, at the same time wiping the +lamp, L. The lamp does not need ever to be withdrawn for cleaning +during bronchoscopy. It is protected in a recess so that it does not +catch in the sponges.] + +[FIG 15.--Exact size to which the bandage-gauze is cut to make +endoscopic sponges. Each rectangle is the size for the tubal diameter +given. The dimensions of the respective rectangles are not given +because it is easier for the nurse or any one to cut a cardboard +pattern of each size directly from this drawing. The gauze rectangles +are folded up endwise as shown at A, then once in the middle as at B, +then strung one dozen on a safety pin. In America gauze bandages run +about 16 threads to the centimeter. Different material might require a +slightly different size and the pattern could be made to suit.] + +[32] The gauze sponges are made by the instrument nurse as directed in +Fig. 15, and are strung on safety pins, wrapped in paper, the size +indicated by a figure on the wrapper, and then sterilized in an +autoclave. The sterile packages are opened only as needed. These +"bronchoscopic sponges" are also made by Johnston and Johnston, of New +Brunswick, N. J. and are sold in the shops. + +_Mouth-gag_.--Wide gagging prevents proper exposure of the larynx by +forcing the mandible down on the hyoid bone. The mouth should be +gently opened and a bite block (Fig. 16) inserted between the teeth on +the left side of the patient's mouth, to prevent closing of the jaws +on the delicate bronchoscope or esophagoscope. + +[FIG. 16.--Bite block to be inserted between the teeth to prevent +closure of the jaws on the endoscopic tube. This is the +McKee-McCready modification of the Boyce thimble with the omission of +the etherizing tube, which is no longer needed. The block has been +improved by Dr. W. F. Moore of the Bronchoscopic Clinic.] + +_Forceps_.--Delicacy of touch and manipulation are an absolute +necessity if the endoscopist is to avoid mortality; therefore, heavily +built and spring-opposed forceps are dangerous as well as useless. For +foreign-body work in the larynx, and for the removal of benign +laryngeal growths, the alligator forceps with roughened jaws shown in +Fig. 17 serve every purpose. + +[FIG. 17.--Laryngeal grasping forceps designed by Mosher. For my own +use I have taken off the ratchet-locking device for all general work, +to be reapplied on the rare occasions when it is required.] + +_Bronchoscopic and esophagoscopic grasping forceps_ are of the tubular +type, that is, a stylet carrying the jaws works in a slender tube so +that traction on the stylet draws the V of the open jaws into the +lumen of the tube, thus causing the blades to approximate. They are +very delicate and light, yet have great grasping power and will +sustain any degree of traction that it is safe to exert. They permit +of the delicacy of touch of a violin bow. The two types of jaws most +frequently used, are those with the forward-grasping blades shown in +Fig. 18, and those having side-grasping blades shown in Fig. 19. The +side-curved forceps are perhaps the most generally useful of all the +endoscopic forceps; the side projection of the jaws makes them readily +visible during their closure on an object; their broader grasp is also +an advantage., The projection of the blades in the side-curved +grasping forceps should always be directed toward the left. If it is +desired that they open in another direction this should be +accomplished by turning the handle and not by adjusting the blade +itself. If this rule be followed it will always be possible to tell by +the position of the handle exactly where the blades are situated; +whereas, if the jaws themselves are turned, confusion is sure to +result. The forward-grasping forceps are always so adjusted that the +jaws open in an up-and-down direction. On rare occasions it may be +deemed desirable to turn the stylet of either forceps in some other +direction relative to the handle. + +[FIG. 18.--The author's forward grasping tube forceps. The handle +mechanism is so simple and delicate that the most exquisite delicacy +of touch is possible. Two locknuts and a thumbscrew take up all lost +motion yet afford perfect adjustability and easy separation for +cleansing. At A is shown a small clip for keeping the jaws together to +prevent injurious bending in the sterilizer, or carrying case. At the +left is shown a handle-clamp for locking the forceps on a foreign body +in the solution of certain rarely encountered mechanical problems. The +jaws are serrated and cupped.] + +[FIG. 19.--Jaws of the author's side-curved endoscopic forceps. These +work as shown in the preceding illustration, each forceps having its +own handle and tube. Originally the end of the cannula and stylet were +squared to prevent rotation of the jaws in the cannula. This was +found to be unnecessary with properly shaped jaws, which wedge +tightly.] + +_Rotation Forceps_.--It is sometimes desired to make traction on an +irregularly shaped foreign body, and yet to allow the object to turn +into the line of least resistance while traction is being made. This +can be accomplished by the use of the rotation forceps (Fig. 20), +which have for blades two pointed hooks that meet at their points and +do not overlap. Rotation forceps made on the model of the laryngeal +grasping forceps, but having opposing points at the end of the blades, +are sometimes very useful for the removal of irregular foreign bodies +in the larynx, or when used through the esophageal speculum they are +of great service in the extraction of such objects as bones, +pin-buttons, and tooth-plates, from the upper esophagus. These forceps +are termed laryngeal rotation forceps (Fig. 31). All the various forms +of forceps are made in a very delicate size often called the +"mosquito" or "extra light" forceps, 40 cm. in length, for use in the +4 mm. and the 5 mm. bronchoscopes. For the 5 mm. bronchoscopes heavier +forceps of the 40 cm. length are made. For the larger tubes the +forceps are made in 45 cm., 50 cm., and 60 cm. lengths. A +square-cannula forceps to prevent turning of the jaws was at one time +used by the author but it has since been found that round cannula +pattern serves all purposes. + +[FIG. 20.--The author's rotation forceps. Useful to allow turning of an +irregular foreign body to a safer relation for withdrawal and for the +esophagoscopic removal of safety pins by the method of pushing them +into the stomach, turning and withdrawal, spring up.] + +_Upper-lobe-bronchus Forceps_.--Foreign bodies rarely lodge in an +upper-lobe bronchus, yet with such a problem it is necessary to have +forceps that will reach around a corner. The upper-lobe-bronchus +forceps shown in Fig. 27 have curved jaws so made as to straighten out +while passing through the bronchoscope and to spring back into their +original shape on up from the lower jaw emerging from the distal end +of the bronchoscopic tube, the radius of curvature being regulated by +the extent of emergence permitted. They are made in extra-light +pattern, 40 cm. long, and the regular model 45 cm. long. The +full-curved model, giving 180 degrees and reaching up into the +ascending branches, is made in both light and heavy patterns. Forceps +with less curve, and without the spiral, are used when it is desired +to reach only a short distance "around the corner" anywhere in the +bronchi. These are also useful, as suggested by Willis F. Manges, in +dealing with safety pins in the esophagus or tracheobronchial tree. + +[FIG. 21.--Tucker jaws for the author's forceps. The tiny lip +projecting down from the upper, and up from the lower jaw prevents +sidewise escape of the shaft of a pin, tack, nail or needle. The shaft +is automatically thrown parallel to the bronchoscopic axis. Drawing +about four times actual size.] + +[36] _Tucker Forceps_--Gabriel Tucker modified the regular side-curved +forceps by adding a lip (Fig. 21) to the left hand side of both upper +and lower jaws. This prevents the shaft of a tack, nail, or pin, from +springing out of the grasp of the jaws, and is so efficient that it +has brought certainty of grasp never before obtainable. With it the +solution of the safety-pin problem devised by the author many years +ago has a facility and certainty of execution that makes it the method +of choice in safety-pin extraction. + +[FIG. 22.--The author's down-jaw esophageal forceps. The dropping jaw +is useful for reaching backward below the cricopharyngeal fold when +using the esophageal speculum in the removal of foreign bodies. +Posterior forceps-spaces are often scanty in cases of foreign bodies +lodged just below the cricopharyngeus.] + +[FIG. 23.--Expansile forceps for the endoscopic removal of hollow +foreign bodies such as intubation tubes, tracheal cannulae, caps, and +cartridge shells.] + +_Screw forceps_.--For the secure grasp of screws the jaws devised by +Dr. Tucker for tacks and pins are excellent (Fig. 21). + +_Expanding Forceps_.--Hollow objects may require expanding +forceps as shown in Fig. 23. In using them it is necessary to be +certain that the jaws are inside the hollow body before expanding them +and making traction. Otherwise severe, even fatal, trauma may be +inflicted. + +[FIG. 24.--The author's fenestrated peanut forceps. The delicate +construction with long, springy and fenestrated jaws give in gentle +hands a maximum security with a minimum of crushing tendency.] + +[FIG. 25--The author's bronchial dilators, useful for dilating +strictures above foreign bodies. The smaller size, shown at the right +is also useful as an expanding forceps for removing intubation tubes, +and other hollow objects. The larger size will go over the shaft of a +tack.] + +[FIG. 26.--The author's self-expanding bronchial dilator. The extent of +expansion can be limited by the sense of touch or by an adjustable +checking mechanism on the handle. The author frequently used smooth +forceps for this purpose, and found them so efficient that this +dilator was devised. The edges of forceps jaws are likely to scratch +the epithelium. Occasionally the instrument is useful in the +esophagus; but it is not very safe, unless used with the utmost +caution.] + +_Tissue Forceps_.--With the forceps illustrated in Fig. 28 specimens +of tissue may be removed for biopsy from the lower air and food +passages with ease and certainty. They have a cross in the outer blade +which holds the specimen removed. The action is very delicate, there +being no springs, and the sense of touch imparted is often of great +aid in the diagnosis. + +[FIG. 27.--The author's upper-lobe bronchus forceps. At A is shown +the full-curved form, for reaching into the ascending branches of the +upper-lobe bronchus A number of different forms of jaws are made in +this kind of forceps. Only 2 are shown.] + +[FIG 28--The author's endoscopic tissue forceps. The laryngeal length +is 30 cm. For esophageal use they are made 50 and 60 cm. long. These +are the best forceps for cutting out small specimens of tissue for +biopsy.] + +The large basket punch forceps shown in Fig. 33 are useful in removing +larger growths or specimens of tissue from the pharynx or larynx. A +portion or the whole of the epiglottis may be easily and quickly +removed with these forceps, the laryngoscope introduced along the +dorsum of the tongue into the glossoepiglottic recess, bringing the +whole epiglottis into view. The forceps may be introduced through the +laryngoscope or alongside the tube. In the latter method a greater +lateral action of the forceps is obtainable, the tube being used for +vision only. These forceps are 30 cm. long and are made in two sizes; +one with the punch of the largest size that can be passed through the +adult laryngoscope, and a smaller one for use through the +anterior-commissure laryngoscope and the child's size laryngoscope. + +[FIG. 29.--The author's papilloma forceps. The broad blunt nose will +scalp off the growths without any injury to the normal basal tissues. +Voice-destroying and stenosing trauma are thus easily avoided.] + +[FIG. 30.--The author's short mechanical spoon (30 cm. long).] + +_Papilloma Forceps_.--Papillomata do not infiltrate; but superficial +repullulations in many cases require repeated removals. If the basal +tissues are traumatized, an impaired or ruined voice will result. The +author designed these forceps (Fig. 29) to scalp off the growths +without injury to the normal tissues. + +[FIG. 31.--The author's laryngeal rotation forceps.] + +[FIG. 32.--Enlarged view of the jaws of the author's vocal-nodule +forceps. Larger cups are made for other purposes but these tiny cups +permit of that extreme delicacy required in the excision of the +nodules from the vocal cords of singers and other voice users.] + +[FIG 33.-Extra large laryngeal tissue forceps. 30 cm. long, for +removing entire growths or large specimens of tissue. A smaller size +is made.] + +_Bronchial Dilators_.--It is not uncommon to find a stricture of the +bronchus superjacent to a foreign body that has been in situ for a +period of months. In order to remove the foreign body, this stricture +must be dilated, and for this the bronchial dilator shown in Fig. 25 +was devised. The channel in each blade allows the closed dilator to be +pushed down over the presenting point of such bodies as tacks, after +which the blades are opened and the stricture stretched. A small and a +large size are made. For enlarging the bronchial narrowing associated +with pulmonary abscess and sometimes found above a bronchiectatic or +foreign body cavity, the expanding dilator shown in Fig. 26 is perhaps +less apt to cause injury than ordinary forceps used in the same way. +The stretching is here produced by the spring of the blades of the +forceps and not by manual force. The closed blades are to be inserted +through the strictured area, opened, and then slowly withdrawn. For +cicatricial stenoses of the trachea the metallic bougies, Fig. 40, are +useful. For the larynx, those shown in Fig. 41 are needed. + +[FIG. 34.--A, Mosher's laryngeal curette; B, author's flat blade +cautery electrode; C, pointed cautery electrode; D, laryngeal knife. +The electrodes are insulated with hard-rubber vulcanized onto the +conducting wires.] + +[FIG. 35.--Retrograde esophageal bougies in graduated sizes devised by +Dr. Gabriel Tucker and the author for dilatation of cicatricial +esophageal stenosis. They are drawn upward by an endless swallowed +string, and are therefore only to be used in gastrostomized cases.] + +[FIG. 36.--Author's bronchoscopic and esophagoscopic mechanical spoon, +made in 40, 50 and 60 cm. lengths.] + +[FIG. 37.--Schema illustrating the author's method of endoscopic +closure of open safety pins lodged point upward The closer is passed +down under ocular control until the ring, R, is below the pin. The +ring is then erected to the position shown dotted at M, by moving the +handle, H, downward to L and locking it there with the latch, Z. The +fork, A, is then inserted and, engaging the pin at the spring loop, K, +the pin is pushed into the ring, thus closing the pin. Slight rotation +of the pin with the forceps may be necessary to get the point into the +keeper. The upper instrument is sometimes useful as a mechanical spoon +for removing large, smooth foreign bodies from the esophagus.] + +_Esophageal Dilators_.--The dilatation of cicatricial stenosis of the +esophagus can be done safely only by endoscopic methods. Blind +esophageal bouginage is highly dangerous, for the lumen of the +stricture is usually eccentric and the bougie is therefore apt to +perforate the wall rather than find the small opening. Often there is +present a pouching of the esophagus above a stricture, in which the +bougie may lodge and perforate. Bougies should be introduced under +visual guidance through the esophagoscope, which is so placed that the +lumen of the stricture is in the center of the endoscopic field. The +author's endoscopic bougies (Fig. 40) are made with a flexible +silk-woven tip securely fastened to a steel shaft. This shaft lends +rigidity to the instrument sufficient to permit its accurate +placement, and its small size permits the eye to keep the silk-woven +tip in view. These endoscopic bougies are made in sizes from 8 to 40, +French scale. The larger sizes are used especially for the dilatation +of laryngeal and tracheal stenoses. For the latter work it is +essential that the bougies be inspected carefully before they are +used, for should a defective tip come off while in the lower air +passages a difficult foreign body problem would be created. +Soft-rubber retrograde dilators to be drawn upward from the stomach by +a swallowed string are useful in gastrostomized cases (Fig. 35). + +[FIG 38.--Half curved hook, 45 cm. and 60 cm. Full curved patterns are +made but caution is necessary to avoid them becoming anchored in the +bronchi. Spiral forms avoid this. The author makes for himself steel +probe-pointed rods out of which he bends hooks of any desired shape. +The rod is held in a pin-vise to facilitate bending of the point, +after heating in an alcohol or bunsen flame.] + +_Hooks_.--No hook greater than a right angle should be used through +endoscopic tubes; for should it become caught in some of the smaller +bronchi its extraction might result in serious trauma. The half curved +hook shown in Fig. 38 is the safest type; better still, a spiral twist +to the hook will add to its uses, and by reversing the turning motion +it may be "unscrewed" out if it becomes caught. Hooks may easily be +made from rods of malleable steel by heating the end in a spirit lamp +and shaping the curve as desired by means of a pin-vise and pliers. +About 2 cm. of the proximal end of the rod should be bent in exactly +the opposite direction from that of the hook so as to form a handle +which will tell the position of the hook by touch as well as by sight. +Coil-spring hooks for the upper-lobe-bronchus (Fig. 39) will reach +around the corner into the ascending bronchus of the +upper-lobe-bronchus, but the utmost skill and care are required to +make their use justifiable. + +[FIG. 39.--Author's coil-spring hook for the upper-lobe, bronchus] + +_Safety-pin Closer_.--There are a number of methods for the endoscopic +removal of open safety-pins when the point is up, one of which is by +closing the pin with the instrument shown in Fig. 37 in the following +manner. The oval ring is passed through the endoscope until it is +beyond the spring of the safety-pin, the ring is then turned upward by +depressing the handle, and by the aid of the prong the pin is pushed +into the ring, which action approximates the point of the pin and the +keeper and closes the pin. Removal is then less difficult and without +danger. This instrument may also be used as a mechanical spoon, in +which case it may be passed to the side of a difficultly grasped +foreign body, such as a pebble, the ring elevated and the object +withdrawn. Elsewhere will be found a description of the +various safety-pin closers devised by various endoscopists. The author +has used Arrowsmith's closer with much satisfaction. + +_Mechanical Spoon_.--When soft, friable substances, such as a bolus of +meat, become impacted in the upper esophagus, the short mechanical +spoon (Fig. 30) used through the esophageal speculum is of great aid +in their removal. The blade in this instrument, as the name suggests, +is a spoon and is not fenestrated as is the safety-pin closer, which +if used for friable substances would allow them to slip through the +fenestration. A longer form for use through bronchoscopes and +esophagoscopes is shown in Fig. 36. + +A laryngeal curette, cautery electrodes, cautery handle, and laryngeal +knife are illustrated in Fig. 34. The cautery is to be used with a +transformer, or a storage battery. + +_Spectacles_.--If the operator has no refractive error he will need +two pairs of plane protective spectacles with very large "eyes." If +ametropic, corrective lenses are necessary, and duplicate spectacles +must be in charge of a nurse. For presbyopia two pairs of spectacles +for 40 cm. distance and 65 cm. distance must be at hand. Hook temple +frames should be used so that they can be easily changed and adjusted +by the nurse when the lenses become spattered. The spectacle nurse has +ready at all times the extra spectacles, cleaned and warmed in a pan +of heated water so that they will not be fogged by the patient's +breath, and she changes them without delay as often as they become +soiled. The operator should work with both eyes open and with his +right eye at the tube mouth. The operating room should be somewhat +darkened so as to facilitate the ignoring of the image in the left +eye; any lighting should be at the operator's back, and should be +insufficient to cause reflections from the inner surface of his +glasses. + +[FIG. 40.--The author's endoscopic bougies. The end consists of a +flexible silk woven tip attached securely to a steel shank. Sizes 8 to +30 French catheter scale. A metallic form of this bougie is useful in +the trachea; but is not so safe for esophageal use.] + +[FIG. 41.--The author's laryngeal bougie for the dilatation of +cicatricial laryngeal stenosis. Made in 10 sizes. The shaded triangle +shows the cross-section at the widest part.] + +[FIG. 42.--The author's bronchoscopic and esophagoscopic table.] + +[46] _Endoscopic Table_.--Any operating table may be used, but the +work is facilitated if a special table can be had which allows the +placing of the patient in all required positions. The table +illustrated in fig. 42 is so arranged that when the false top is drawn +forward on the railroad, the head piece drops and the patient is +placed in the correct (Boyce) position for esophagoscopy or +bronchoscopy, i.e., with the head and shoulders extending over the end +of the table. By means of the wheel the plane of the table may +be altered to any desired angle of inclination or height of head. + +_Operating Room_.--All endoscopic procedures should be performed in a +somewhat darkened operating room where all the desired materials are +at hand. An endoscopic team consists of three persons: the operator, +the assistant who holds the head, and the instrument assistant. +Another person is required to hold the patient's arms and still +another for the changing of the operator's glasses when they become +spattered. The endoscopic team of three maintain surgical asepsis in +the matter of hands and gowns, etc. The battery, on a small table of +its own, is placed at the left hand of the operator. Beyond it is the +table for the mechanical aspirator, if one is used. All extra +instruments are placed on a sterile table, within reach, but not in +the way, while those instruments for use in the particular operation +are placed on a small instrument table back of the endoscopist. Only +those instruments likely to be wanted should be placed on the working +table, so that there shall be no confusion in their selection by the +instrument nurse when called for. Each moment of time should be +utilized when the endoscopic procedure has been started, no time +should be lost in the hunting or separating of instruments. To have +the respective tables always in the same position relative to the +operator prevents confusion and avoids delay. + +[FIG 43.--The author's retrograde esophagoscope.] + +_Oxygen Tank and Tracheotomy Instruments_.--Respiratory arrest may +occur from shifting of a foreign body, pressure of the esophagoscope, +tumor, or diverticulum full of food. Rare as these contingencies are, +it is essential that means for resuscitation be at hand. No endoscopic +procedure should be undertaken without a set of tracheotomy +instruments on the sterile table within instant reach. In respiratory +arrest from the above mentioned causes, respiratory efforts are not +apt to return unless oxygen and amyl nitrite are blown into the +trachea either through a tracheotomy opening or better still by means +of a bronchoscope introduced through the larynx. The limpness of the +patient renders bronchoscopy so easy that the well-drilled +bronchoscopist should have no difficulty in inserting a bronchoscope +in 10 or 15 seconds, if proper preparedness has been observed. It is +perhaps relatively rarely that such accidents occur, yet if +preparations are made for such a contingency, a life may be saved +which would otherwise be inevitably lost. The oxygen tank covered with +a sterile muslin cover should stand to the left of the operating +table. + +_Asepsis_.--Strict aseptic technic must be observed in all endoscopic +procedures. The operator, first assistant, and instrument nurse must +use the same precautions as to hand sterilization and sterile gowns as +would be exercised in any surgical operation. The operator and first +assistant should wear masks and sterile gloves. The patient is +instructed to cleanse the mouth thoroughly with the tooth brush and a +20 per cent alcohol mouth wash. Any dental defects should, if time +permit, as in a course of repeated treatments, be remedied by the +dental surgeon. When placed on the table with neck bare and the +shoulders unhampered by clothing, the patient is covered with a +sterile sheet and the head is enfolded in a sterile towel. The face is +wiped with 70 per cent alcohol. + +It is to be remembered that while the patient is relatively immune to +the bacteria he himself harbors, the implantation of different strains +of perhaps the same type of organisms may prove virulent to him. +Furthermore the transference of lues, tuberculosis, diphtheria, +pneumonia, erysipelas and other infective diseases would be inevitable +if sterile precautions were not taken. + +All of the tubes and forceps are sterilized by boiling. The +light-carriers and lamps may be sterilized by immersion in 95 per cent +alcohol or by prolonged exposure to formaldehyde gas. Continuous +sterilization by keeping them put away in a metal box with formalin +pastilles or other source of formaldehyde gas is an ideal method. +Knives and scissors are immersed in 95 per cent alcohol, and the +rubber covered conducting cords are wiped with the same solution. + +_List of Instruments_.--The following list has been compiled as a +convenient basis for equipment, to which such special instruments as +may be needed for special cases can be added from time to time. The +instruments listed are of the author's design. + 1 adult's laryngoscope. + 1 child's laryngoscope. + 1 infant's diagnostic laryngoscope. + 1 anterior commissure laryngoscope. + 1 bronchoscope, 4 mm. X 30 cm. + 1 bronchoscope, 5 mm. X 30 cm. + 1 bronchoscope, 7 mm. X 40 cm. + 1 bronchoscope, 9 mm. X 40 cm. + 1 esophagoscope, 7 mm. X 45 cm. + 1 esophagoscope, 10 mm. X 53 cm. + 1 esophagoscope, full lumen, 7 mm. X 45 cm. + 1 esophagoscope, full lumen, 9 mm. X 45 cm. + 1 esophageal speculum, adult. + 1 esophageal speculum, child. + 1 forward-grasping forceps, delicate, 40 cm. + 1 forward-grasping forceps, regular, 50 cm. + 1 forward-grasping forceps, regular, 60 cm. + 1 side-grasping forceps, delicate, 40 cm. + 1 side-grasping forceps, regular, 50 cm. + 1 side-grasping forceps, regular, 60 cm. + 1 rotation forceps, delicate, 40 cm. + 1 rotation forceps, regular, 50 cm. + 1 rotation forceps, regular, 60 cm. + 1 laryngeal alligator forceps. + 1 laryngeal papilloma forceps. + 10 esophageal bougies, Nos. 8 to 17 French (larger sizes to No. 36 +may be added). + 1 special measuring rule. + 6 light sponge carriers. + 1 aspirator with double tube for minus and plus pressure. + 2 endoscopic aspirating tubes 30 and 50 cm. + 1 half curved hook, 60 cm. + 1 triple circuit bronchoscopy battery. + 6 rubber covered conducting cords for battery. + 1 box bronchoscopic sponges, size 4. + 1 box bronchoscopic sponges, size 5. + 1 box bronchoscopic sponges, size 7. + 1 box bronchoscopic sponges, size 10. + 1 bite block, 1 adult. + 1 bite block, child. + 2 dozen extra lamps for lighted instruments. + 1 extra light carrier for each instrument.* + 4 yards of pipe-cleaning, worsted-covered wire. + +[* Messrs. George P. Pilling and Sons who are now making these +instruments supply an extra light carrier and 2 extra lamps with each +instrument.] + +_Care of Instruments_.--The endoscopist must either personally care +for his instruments, or have an instrument nurse in his own employ, +for if they are intrusted to the general operating room routine he +will find that small parts will be lost; blades of forceps bent, +broken, or rusted; tubes dinged; drainage canals choked with blood or +secretions which have been coagulated by boiling, and electric +attachments rendered unstable or unservicable, by boiling, etc. The +tubes should be cleansed by forcing cold water through the drainage +canals with the aspirating syringe, then dried by forcing +pipe-cleaning worsted-covered wire through the light and drainage +canals. Gauze on a sponge carrier is used to clean the main canal. +Forceps stylets should be removed from their cannulae, and the +cannulae cleansed with cold water, then dried and oiled with the +pipe-cleaning material. The stylet should have any rough places +smoothed with fine emery cloth and its blades carefully inspected; the +parts are then oiled and reassembled. Nickle plating on the tubes is +apt to peel and these scales have sharp, cutting edges which may +injure the mucosa. All tubes, therefore, should be unplated. Rough +places on the tubes should be smoothed with the finest emery cloth, +or, better, on a buffing wheel. The dry cells in the battery should be +renewed about every 4 months whether used or not. Lamps, light +carriers, and cords, after cleansing, are wiped with 95 per cent +alcohol, and the light-carriers with the lamps in place are kept in a +continuous sterilization box containing formaldehyde pastilles. It is +of the utmost importance that instruments be always put away in +perfect order. Not only are cleaning and oiling imperative, but any +needed repairs should be attended to at once. Otherwise it will be +inevitable that when gotten out in an emergency they will fail. In +general surgery, a spoon will serve for a retractor and good work can +be done with makeshifts; but in endoscopy, especially in the small, +delicate, natural passages of children, the handicap of a defective or +insufficient armamentarium may make all the difference between a +success and a fatal failure. +A bronchoscopic clinic should at all times be in the same state of +preparedness for emergency as is everywhere required of a fire-engine +house. + +[PLATE I--A WORKING SET OF THE AUTHOR'S ENDOSCOPIC TUBES FOR LARYNGOSCOPY, +BRONCHOSCOPY, ESOPHAGOSCOPY, AND GASTROSCOPY: + A, Adult's laryngoscope; B, child's laryngoscope; C, anterior +commissure laryngoscope; D, esophageal speculum, child's size; E, +esophageal speculum, adult's size; F, bronchoscope, infant's size, 4 +mm. X 30 cm.; G, bronchoscope, child's size, 5 mm. X 30 cm.; H, +aspirating bronchoscope for adults, 7 mm. X 40 cm.; I, bronchoscope, +adolescent's size, 7 mm. x 40 cm., used also for the deeper bronchi of +adults; J, bronchoscope, adult size, g mm. x 40 cm.; K, child's size +esophagoscope, 7 mm. X 45 cm.; L, adult's size esophagoscope, full +lumen construction, 9 mm. x 45 cm.; M, adult's size gastroscope. C, +I, and E are also hypopharyngoscopes. C is an excellent esophageal +speculum for children, and a longer model is made for adults. +If the utmost economy must be practised D, E, and M may be omitted. +The balance of the instruments are indispensable if adults and +children are to be dealt with. The instruments are made by Charles J. +Pilling & Sons, Philadelphia.] + + + +[52] CHAPTER II--ANATOMY OF LARYNX, TRACHEA, BRONCHI AND ESOPHAGUS, +ENDOSCOPICALLY CONSIDERED + +The _larynx_ is a cartilaginous box, triangular in cross-section, with +the apex of the triangle directed anteriorly. It is readily felt in +the neck and is a landmark for the operation of tracheotomy. We are +concerned endoscopically with four of its cartilaginous structures: +the epiglottis, the two arytenoid cartilages, and the cricoid +cartilage. The _epiglottis_, the first landmark in direct +laryngoscopy, is a leaf-like projection springing from the +anterointernal surface of the larynx and having for its function the +directing of the bolus of food into the pyriform sinuses. It does not +close the larynx in the trap-door manner formerly taught; a fact +easily demonstrated by the simple insertion of the direct laryngoscope +and further demonstrated by the absence of dysphagia when the +epiglottis is surgically removed, or is destroyed by ulceration. +Closure of the larynx is accomplished by the approximation of the +ventricular bands, arytenoids and aryepiglottic folds, the latter +having a sphincter-like action, and by the raising and tilting of the +larynx. The _arytenoids_ form the upper posterior boundary of the +larynx and our particular interest in them is directed toward their +motility, for the rotation of the arytenoids at the cricoarytenoid +articulations determines the movements of the cords and the production +of voice. Approximation of the arytenoids is a part of the mechanism +of closure of the larynx. + +The _cricoid cartilage_ was regarded by esophagoscopists as the chief +obstruction encountered on the introduction of the esophagoscope. As +shown by the author, it is the cricopharyngeal fold, and the +inconceivably powerful pull of the cricopharyngeal muscle on the +cricoid cartilage, that causes the difficulty. The cricoid is pulled +so powerfully back against the cervical spine, that it is hard to +believe that this muscles is inserted into the median raphe and not +into the spine itself (Fig. 68). + +The _ventricular bands_ or false vocal cords vicariously phonate in +the absence of the true cords, and assist in the protective function +of the larynx. They form the floor of the _ventricles_ of the larynx, +which are recesses on either side, between the false and true cords, +and contain numerous mucous glands the secretion from which lubricates +the cords. The ventricles are not visible by mirror laryngoscopy, but +are readily exposed in their depths by lifting the respective +ventricular bands with the tip of the laryngoscope. The _vocal cords_, +which appear white, flat, and ribbon-like in the mirror, when viewed +directly assume a reddish color, and reveal their true shelf-like +formation. In the subglottic area the tissues are vascular, and, in +children especially, they are prone to swell when traumatized, a fact +which should be always in mind to emphasize the importance of +gentleness in bronchoscopy, and furthermore, the necessity of avoiding +this region in tracheotomy because of the danger of producing chronic +laryngeal stenosis by the reaction of these tissues to the presence of +the tracheotomic cannula. + +The _trachea_ just below its entrance into the thorax deviates +slightly to the right, to allow room for the aorta. At the level of +the second costal cartilage, the third in children, it bifurcates into +the right and left main bronchi. Posteriorly the bifurcation +corresponds to about the fourth or fifth thoracic vertebra, the +trachea being elastic, and displaced by various movements. The +endoscopic appearance of the trachea is that of a tube flattened on +its posterior wall. In two locations it normally often assumes a more +or less oval outline; in the cervical region, due to pressure of the +thyroid gland; and in the intrathoracic portion just above the +bifurcation where it is crossed by the aorta. This latter flattening +is rhythmically increased with each pulsation. Under pathological +conditions, the tracheal outline may be variously altered, even to +obliteration of the lumen. The mucosa of the trachea and bronchi is +moist and glistening, whitish in circular ridges corresponding to the +cartilaginous rings, and reddish in the intervening grooves. + +The right bronchus is shorter, wider, and more nearly vertical than +its fellow of the opposite side, and is practically the continuation +of the trachea, while the left bronchus might be considered as a +branch. The deviation of the right main bronchus is about 25 degrees, +and its length unbranched in the adult is about 2.5 cm. The deviation +of the left main bronchus is about 75 degrees and its adult length is +about 5 cm. The right bronchus considered as a stem, may be said to +give off three branches, the epiarterial, upper- or superior-lobe +bronchus; the middle-lobe bronchus; and the continuation downward, +called the lower- or inferior-lobe bronchus, which gives off dorsal, +ventral and lateral branches. The left main bronchus gives off first +the upper-or superior-lobe bronchus, the continuation being the +lower-or inferior-lobe bronchus, consisting of a stem with dorsal, +ventral and lateral branches. + +[FIG. 44.--Tracheo-bronchial tree. LM, Left main bronchus; SL, +superior lobe bronchus; ML, middle lobe bronchus; IL, inferior lobe +bronchus.] + +The septum between the right and left main bronchi, termed the carina, +is situated to the left of the midtracheal line. It is recognized +endoscopically as a short, shining ridge running sagitally, or, as the +patient lies in the recumbent position, we speak of it as being +vertical. On either side are seen the openings of the right and left +main bronchi. In Fig. 44, it will be seen that the lower border of the +carina is on a level with the upper portion of the orifice of the +right superior-lobe bronchus; with the carina as a landmark and by +displacing with the bronchoscope the lateral wall of the right main +bronchus, a second, smaller, vertical spur appears, and a view of the +orifice of the right upper-lobe bronchus is obtained, though a lumen +image cannot be presented. On passing down the right stem bronchus +(patient recumbent) a horizontal partition or spur is found with the +lumen of the middle-lobe bronchus extending toward the ventral surface +of the body. All below this opening of the right middle-lobe bronchus +constitutes the lower-lobe bronchus and its branches. + +[FIG. 45.--Bronchoscopic views. +S; Superior lobe bronchus; SL, superior lobe bronchus; I, inferior +lobe bronchus; M, middle lobe bronchus.] + +[56] Coming back to the carina and passing down the left bronchus, the +relatively great distance from the carina to the upper-lobe bronchus +is noted. The spur dividing the orifices of the left upper- and +lower-lobe bronchi is oblique in direction, and it is possible to see +more of the lumen of the left upper-lobe bronchus than of its +homologue on the right. Below this are seen the lower-lobe bronchus +and its divisions (Fig. 45). + +_Dimensions of the Trachea and Bronchi_.--It will be noted that the +bronchi divide monopodially, not dichotomously. While the lumina of +the individual bronchi diminish as the bronchi divide, the sum of the +areas shows a progressive increase in total tubular area of +cross-section. Thus, the sum of the areas of cross-section of the two +main bronchi, right and left, is greater than the area of cross +section of the trachea. This follows the well known dynamic law. The +relative increase in surface as the tubes branch and diminish in size +increases the friction of the passing air, so that an actual increase +in area of cross section is necessary, to avoid increasing resistance +to the passage of air. + +The cadaveric dimensions of the tracheobronchial tree may be +epitomized approximately as follows: + Adult + Male Female Child Infant +Diameter trachea, 14 X 20 12 X 16 8 X 10 6 X 7 +Length trachea, cm. 12.0 10.0 6.0 4.0 +Length right bronchus 2.5 2.5 2.0 1.5 +Length left bronchus 5.0 5.0 3.0 2.5 +Length upper teeth to trachea 15.0 23.0 10.0 9.0 +Length total to secondary bronchus 32.0 28.0 19.0 15.0 + +In considering the foregoing table it is to be remembered that in life +muscle tonus varies the lumen and on the whole renders it smaller. In +the selection of tubes it must be remembered that the full diameter of +the trachea is not available on account of the glottic aperture which +in the adult is a triangle measuring approximately 12 X 22 X 22 mm. +and permitting the passage of a tube not over 10 mm. in diameter +without risk of injury. Furthermore a tube which filled the trachea +would be too large to enter either main bronchus. + +The normal movements of the trachea and bronchi are respiratory, +pulsatory, bechic, and deglutitory. The two former are rhythmic while +the two latter are intermittently noted during bronchoscopy. It is +readily observed that the bronchi elongate and expand during +inspiration while during expiration they shorten and contract. The +bronchoscopist must learn to work in spite of the fact that the +bronchi dilate, contract, elongate, shorten, kink, and are dinged and +pushed this way and that. It is this resiliency and movability that +make bronchoscopy possible. The inspiratory enlargement of lumen opens +up the forceps spaces, and the facile bronchoscopist avails himself of +the opportunity to seize the foreign body. + +THE ESOPHAGUS + +A few of the anatomical details must be kept especially in mind when +it is desired to introduce straight and rigid instruments down the +lumen of the gullet. First and most important is the fact that the +esophageal walls are exceedingly thin and delicate and require the +most careful manipulation. Because of this delicacy of the walls and +because the esophagus, being a constant passageway for bacteria from +the mouth to the stomach, is never sterile, surgical procedures are +associated with infective risks. For some other and not fully +understood reason, the esophagus is, surgically speaking, one of the +most intolerant of all human viscera. The anterior wall of the +esophagus is in a part of its course, in close relation to the +posterior wall of the trachea, and this portion is called the party +wall. It is this party wall that contains the lymph drainage system of +the posterior portion of the larynx, and it is largely by this route +that posteriorly located malignant laryngeal neoplasms early +metastasize to the mediastinum. + +[58] [FIG 46.--Esophagoscopic and Gastroscopic Chart + +BIRTH 1 yr. 3 yrs. 6 yrs. 10 yrs. 14 yrs.ADULTS +23 27 30 33 36 43 53 Cm. GREATER CURVATURE +18 20 22 25 27 34 40 Cm. CARDIA +19 21 23 24 25 31 36 Cm. HIATUS +13 15 16 18 20 24 27 Cm. LEFT BRONCHUS +12 14 15 16 17 21 23 Cm. AORTA +7 9 10 11 12 14 16 Cm. CRICOPHARYINGEUS +0 0 0 0 0 0 0 Cm. INCISORS +FIG. 46.--The author's esophagoscopic chart of approximate distances +of the esophageal narrowings from the upper incisor teeth, arranged +for convenient reference during esophagoscopy in the dorsally +recumbent patient.] + +The lengths of the esophagus at different ages are shown +diagrammatically in Fig. 46. The diameter of the esophageal lumen +varies greatly with the elasticity of the esophageal walls; its +diameter at the four points of anatomical constriction is shown in the +following table: + +Constriction Diameter Vertebra + +Cricopharyngeal Transverse 23 mm. (1 in.) Sixth cervical + Antero-posterior 17 mm. (3/4 in.) +Aortic Transverse 24 mm. (1 in.) Fourth thoracic + Antero-posterior 19 mm. (3/4 in.) +Left-bronchial Transverse 23 mm. (1 in.) Fifth thoracic + Antero-posterior 17 mm. (3/4 in.) +Diaphragmatic Transverse 23 mm. (1 in+) Tenth thoracic + Antero-posterior 23 mm. (in.--) + +For practical endoscopic purposes it is only necessary to remember +that in a normal esophagus, straight and rigid tubes of 7 mm. diameter +should pass freely in infants, and in adults, tubes of 10 mm. + +The 4 demonstrable constrictions from above downward are at + 1. The crico-pharyngeal fold. + 2. The crossing of the aorta. + 3. The crossing of the left bronchus. + 4. The hiatus esophageus. +There is a definite fifth narrowing of the esophageal lumen not easily +demonstrated esophagoscopically and not seen during dissection, but +readily shown functionally by the fact that almost all foreign bodies +lodge at this point. This narrowing occurs at the superior aperture of +the thorax and is probably produced by the crowding of the numerous +organs which enter or leave the thorax through this orifice. + +_The crico-pharyngeal constriction_, as already mentioned, is produced +by the tonic contraction of a specialized band of the orbicular fibers +of the lowermost portion of the inferior pharyngeal constrictor +muscle, called the cricopharyngeal muscle. As shown by the author it +is this muscle and not the cricoid cartilage alone that causes the +difficulty in the insertion of an esophagoscope. + +This muscle is attached laterally to the edges of the signet of the +cricoid which it pulls with an incomprehensible power against the +posterior wall of the hypopharynx, thus closing the mouth of the +esophagus. Its other attachment is in the median posterior raphe. +Between these circular fibers (the cricopharyngeal muscle) and the +oblique fibers of the inferior constrictor muscle there is a weakly +supported point through which the esophageal wall may herniate to form +the so-called pulsion diverticulum. It is at this weak point that +fatal esophagoscopic perforation by inexperienced operators is most +likely to occur. + +_The aortic narrowing_ of the esophagus may not be noticed at all if +the patient is placed in the proper sequential "high-low" position. It +is only when the tube-mouth is directed against the left anterior wall +that the actively pulsating aorta is felt. + +The bronchial narrowing of the esophagus is due to backward +displacement caused by the passage of the left bronchus over the +anterior wall of the esophagus at about 27 cm. from the upper teeth in +the adult. The ridge is quite prominent in some patients, especially +those with dilatation from stenoses lower down. + +The hiatal narrowing is both anatomic and spasmodic. The peculiar +arrangement of the tendinous and muscular structure of the diaphragm +acts on this hiatal opening in a sphincter-like fashion. There are +also special bundles of muscle fibers extending from the crura of the +diaphragm and surrounding the esophagus, which contribute to tonic +closure in the same way that a pinch-cock closes a rubber tube. The +author has called the hiatal closure the "diaphragmatic pinchcock." + +_Direction of the Esophagus_.--The esophagus enters the chest in a +decidedly backward as well as downward direction, parallel to that of +the trachea, following the curves of the cervical and upper dorsal +spine. Below the left bronchus the esophagus turns forward, passing +through the hiatus in the diaphragm anterior to and to the left of the +aorta. The lower third of the esophagus in addition to its anterior +curvature turns strongly to the left, so that an esophagoscope +inserted from the right angle of the mouth, when introduced into the +stomach, points in the direction of the anterior superior spine of the +left ileum. + +It is necessary to keep this general course constantly in mind in all +cases of esophagoscopy, but particularly in those cases in which there +is marked dilatation of the esophagus following spasm at the diaphragm +level. In such cases the aid of this knowledge of direction will +greatly simplify the finding of the hiatus esophageus in the floor of +the dilatation. + +The extrinsic or transmitted movements of the esophagus are +respiratory and pulsatory, and to a slight extent, bechic. The +respiratory movements consist in a dilatation or opening up of the +thoracic esophageal lumen during inspiration, due to the negative +intrathoracic pressure. The normal pulsatory movements are due to the +pulsatile pressure of the aorta, found at the 4th thoracic vertebra +(24 cm. from the upper teeth in the adult), and of the heart itself, +most markedly felt at the level of the 7th and 8th thoracic vertebrae +(about 30 cm. from the upper teeth in adults). As the distances of all +the narrowings vary with age, it is useful to frame and hang up for +reference a copy of the chart (Fig. 46). + +The intrinsic movements of the esophagus are involuntary muscular +contractions, as in deglutition and regurgitation; spasmodic, the +latter usually having some pathologic cause; and tonic, as the normal +hiatal closure, in the author's opinion may be considered. Swallowing +may be involuntary or voluntary. The constrictors are anatomically not +considered part of esophagus proper. When the constrictors voluntarily +deliver the bolus past the cricopharyngeal fold, the involuntary or +peristaltic contractions of the esophageal mural musculature carry the +bolus on downward. There is no sphincter at the cardiac end of the +esophagus. The site of spasmodic stenosis in the lower third, the +so-called cardiospasm, was first demonstrated by the author to be +located at the hiatus esophageus and the spasmodic contractions are of +the specialized muscle fibers there encircling the esophagus, and +might be termed "phrenospasm," or "hiatal esophagismus." Regurgitation +of food from the stomach is normally prevented by the hiatal muscular +diaphragmatic closure (called by the author the "diaphragmatic +pinchcock") plus the kinking of the abdominal esophagus. + +In the author's opinion there is no spasm in the disease called +"cardiospasm." It is simply the failure of the diaphragmatic pinchcock +to open normally in the deglutitory cycle. A better name is functional +hiatal stenosis. + +At retrograde esophagoscopy the cardia and abdominal esophagus do not +seem to exist. The top of the stomach seems to be closed by the +diaphragmatic pinchcock in the same way that the top of a bag is +closed by a puckering string. + + + +[63] CHAPTER III--PREPARATION OF THE PATIENT FOR PERORAL ENDOSCOPY + +The suggestions of the author in the earlier volumes in regard to +preparation of the patient, as for any operation, by a bath, laxative, +etc., and especially by special cleansing of the mouth with 25 per +cent alcohol, have received general endorsement. Care should be taken +not to set up undue reaction by vigorous scrubbing of gums +unaccustomed to it. Artificial dentures should be removed. Even if no +anesthetic is to be used, the patient should be fasted for five hours +if possible, even for direct laryngoscopy in order to forestall +vomiting. Except in emergency cases every patient should be gone over +by an internist for organic disease in any form. If an endolaryngeal +operation is needed by a nephritic, preparatory treatment may prevent +laryngeal edema or other complications. Hemophilia should be thought +of. It is quite common for the first symptom of an aortic aneurysm to +be an impaired power to swallow, or the lodgment of a bolus of meat or +other foreign body. If aneurysm is present and esophagoscopy is +necessary, as it always is in foreign body cases, "to be fore-warned +is to be forearmed." Pulmonary tuberculosis is often unsuspected in +very young children. There is great danger from tracheal pressure by +an esophageal diverticulum or dilatation distended with food; or the +food maybe regurgitated and aspirated into the larynx and trachea. +Therefore, in all esophageal cases the esophagus should be emptied by +regurgitation induced by titillating the fauces with the finger after +swallowing a tumblerful of water, pressure on the neck, etc. Aspiration +will succeed in some cases. In others it is absolutely necessary to +remove food with the esophagoscope. If the aspirating tube becomes +clogged by solid food, the method of swab aspiration mentioned under +bronchoscopy will succeed. Of course there is usually no cough to aid, +but the involuntary abdominal and thoracic compression helps. Should a +patient arrive in a serious state of water-hunger, as part of the +preparation the patient must be given water by hypodermoclysis and +enteroclysis, and if necessary the endoscopy, except in dyspneic +cases, must be delayed until the danger of water-starvation is past. + +As pointed out by Ellen J. Patterson the size of the thymus gland +should be studied before an esophagoscopy is done on a child. + +Every patient should be examined by indirect, mirror laryngoscopy as a +preliminary to peroral endoscopy for any purpose whatsoever. This +becomes doubly necessary in cases that are to be anesthetized. + + + +[65] CHAPTER IV--ANESTHESIA FOR PERORAL ENDOSCOPY + +A dyspneic patient should never be given a general anesthetic. Cocaine +should not be used on children under ten years of age because of its +extreme toxicity. To these two postulates always in mind, a third one, +applicable to both general and local anesthesia, is to be added--total +abolition of the cough-reflex should be for short periods only. +General anesthesia is never used in the Bronchoscopic Clinic for +endoscopic procedures. The choice for each operator must, however, be +a matter for individual decision, and will depend upon the personal +equation, and degree of skill of the operator, and his ability to +quiet the apprehensions of the patient. In other words, the operator +must decide what is best for his particular patient under the +conditions then existing. + +_Children_ in the Bronchoscopic Clinic receive neither local nor +general anesthesia, nor sedative, for laryngoscopic operations or +esophagoscopy. Bronchoscopy in the older children when no dyspnea is +present has in recent years, at the suggestion of Prof. Hare, been +preceded by a full dose of morphin sulphate (i.e., 1/8 grain for a +child of six years) or a full physiologic dose of sodium bromide. The +apprehension is thus somewhat allayed and the excessive cough-reflex +quieted. The morphine should be given not less than an hour and a half +before bronchoscopy to allow time for the onset of the soporific and +antispasmodic effects which are the desiderata, not the analgesic +effects. Dosage is more dependent on temperament than on age or body +weight. Atropine is advantageously added to morphine in bronchoscopy +for foreign bodies, not only for the usual reasons but for its effect +as an antispasmodic, and especially for its diminution of +endobronchial secretions. True, it does not diminish pus, but by +diminishing the outpouring of normal secretions that dilute the pus +the total quantity of fluid encountered is less than it otherwise +would be. In cases of large quantities of pus, as in pulmonary abscess +and bronchiectasis, however, no diminution is noticeable. No food or +water is allowed for 5 hours prior to any endoscopic procedure, +whether sedatives or anesthetics are to be given or not. If the +stomach is not empty vomiting from contact of the tube in the pharynx +will interfere with work. + +With _adults_ no anesthesia, general or local, is given for +esophagoscopy. For laryngeal operation and bronchoscopy the following +technic is used: + +One hour before operation the patient is given hypodermatically a full +physiologic dose of morphin sulphate (from 1/4, to 3/8 gr.) guarded +with atropin sulphate (gr. 1/150). Care must be taken that the +injection be not given into a vein. On the operating table the +epiglottis and pharynx are painted with 10 per cent solution of +cocain. Two applications are usually sufficient completely to +anesthetize the exterior and interior of the larynx by blocking of the +superior laryngeal nerve without any endolaryngeal applications. The +laryngoscope is now introduced and if found necessary a 20 per cent +cocain solution is applied to the interior of the larynx and +subglottic region, by means of gauze swabs fastened to the sponge +carriers. Here also two applications are quite sufficient to produce +complete anesthesia in the larynx. If bronchoscopy is to be done the +gauze swab is carried down through the exposed glottis to the carina, +thus anesthetizing the tracheal mucosa. If further anesthetization of +the bronchial mucosa is required, cocain may be applied in the same +manner through the bronchoscope. In all these local applications +prolonged contact of the swab is much more efficient than simply +painting the surface. + +[67] In cases in which cocain is deemed contraindicated morphin alone +is used. If given in sufficient dosage cocain can be altogether +dispensed with in any case. + +It is perhaps _safer for the beginner_ in his early cases of +esophagoscopy to have the patient relaxed by an ether anesthesia, +provided the patient is not dyspneic to begin with, or made so by +faulty position or by pressure of the esophagoscopic tube mouth on the +tracheoesophageal "party wall." As proficiency develops, however, he +will find anesthesia unnecessary. Local anesthesia is needless for +esophagoscopy, and if used at all should be limited to the +laryngopharynx and never applied to the esophagus, for the esophagus +is without sensation, as anyone may observe in drinking hot liquids. + +_Direct laryngoscopy in children_ requires neither local nor general +anesthesia, either for diagnosis or for removal of foreign bodies or +growths from the larynx. General anesthesia is contraindicated because +of the dyspnea apt to be present, and because the struggles of the +patient might cause a dislodgment of the laryngeal intruder and +aspiration to a lower level. The latter accident is also prone to +follow attempts to cocainize the larynx. + +_Technic for General Anesthesia_.--For esophagoscopy and gastroscopy, +if general anesthesia is desired, ether may be started by the usual +method and continued by dropping upon folded gauze laid over the mouth +after the tube is introduced. Endo-tracheal administration of ether +is, however, far safer than peroral administration, for it overcomes +the danger of respiratory arrest from pressure of the esophagoscope, +foreign body, or both, on the trachea. Chloroform should not be used +for esophagoscopy or gastroscopy because of its depressant action on +the respiratory center. + +For bronchoscopy, ether or chloroform may be started in the usual way +and continued by insufflating through the branch tube of the +bronchoscope by means of the apparatus shown in Fig. 13. + +In case of paralysis of the larynx, even if only monolateral, a +general anesthetic if needed should be given by intratracheal +insufflation. If the apparatus for this is not available the patient +should be tracheotomized. Hence, every adult patient should be +examined with a throat mirror before general anesthesia for any +purpose, and the necessity becomes doubly imperative before goiter +operations. A number of fatalities have occurred from neglect of this +precaution. + +_Anesthetizing a tracheotomized patient_ is free from danger so long +as +the cannula is kept free from secretion. Ether is dropped on gauze +laid over the tracheotomic cannula and the anesthesia watched in the +usual manner. If the laryngeal stenosis is not complete, +ether-saturated gauze is to be placed over the mouth as well as over +the tracheotomy tube. + +_Endo-tracheal anesthesia_ is by far the safest way for the +administration of ether for any purpose. By means of the silk-woven +catheter introduced into the trachea, ether-laden air from an +insufflation apparatus is piped down to the lungs continuously, and +the strong return-flow prevents blood and secretions from entering the +lower air-passages. The catheter should be of a size, relative to that +of the glottic chink, to permit a free return-flow. A number 24 French +is readily accommodated by the adult larynx and lies well out of the +way along the posterior wall of the larynx. Because of the little room +occupied by the insufflation catheter this method affords ideal +anesthesia for external laryngeal operations. Operations on the nose, +accessory sinuses and the pharynx, apt to be attended by considerable +bleeding, are rendered free from the danger of aspiration pneumonia by +endotracheal anesthesia. It is the safest anesthesia for goiter +operations. Endo-tracheal anesthesia has rendered needless the +intricate negative pressure chamber formerly required for thoracic +surgery, for by proper regulation of the pressure under which the +ether ladened air is delivered, a lung may be held in any desired +degree of expansion when the pleural cavity is opened. It is indicated +in operations of the head, neck, or thorax, in which there is danger +of respiratory arrest by centric inhibition or peripheral pressure; in +operations in which there is a possibility of excessive bleeding and +aspiration of blood or secretions; and in operations where it is +desired to keep the anesthetist away from the operating field. Various +forms of apparatus for the delivery of the ether-laden vapor are +supplied by instrument makers with explicit directions as to their +mechanical management. + +We are concerned here mainly with the technic of the insertion of the +intratracheal tube. The larynx should be examined with the mirror, +preferably before the day of operation, for evidence of disease, and +incidentally to determine the size of the catheter to be introduced, +though the latter can be determined after the larynx is +laryngoscopically exposed. The following list of rules for the +introduction of the catheter will be of service (see Fig. 59). + +RULES FOR INSERTION OF THE CATHETER FOR INSUFFLATION +ANESTHESIA + + 1. The patient should be fully under the anesthetic by the open +method so as to get full relaxation of the muscles of the neck. + 2. The patient's head must be in full extension with the vertex +firmly pushed down toward the feet of the patient, so as to throw the +neck upward and bring the occiput down as close as possible beneath +the cervical vertebrae. + 3. No gag should be used, because the patient should be sufficiently +anesthetized not to need a gag, and because wide gagging defeats the +exposure of the larynx by jamming down the mandible. + 4. The epiglottis must be identified before it is passed. + 5. The speculum must pass sufficiently far below the tip of the +epiglottis so that the latter will not slip. + 6. Too deep insertion must be avoided, as in this case the speculum +goes posterior to the cricoid, and the cricoid is lifted, exposing the +mouth of the esophagus, which is bewildering until sufficient +education of the eye enables the operator to recognize the landmarks. + 7. The patient's head is lifted off the table by the spatular tip of +the laryngoscope. Actual lifting of the head will not be necessary if +the patient is fully relaxed; but the idea of lifting conveys the +proper conception of laryngeal exposure (Fig. 55). + + + +[71] CHAPTER V--BRONCHOSCOPIC OXYGEN INSUFFLATION + +Bronchoscopic oxygen insufflation is a life-saving measure equalled by +no other method known to the science of medicine, in all cases of +asphyxia, or apnea, present or impending. Its especial sphere of +usefulness is in severe cases of electric shock, hanging, smoke +asphyxia, strangulation, suffocation, thoracic or abdominal pressure, +apnea, acute traumatic pneumothorax, respiratory arrest from absence +of sufficient oxygen, or apnea from the presence of quantities of +irrespirable or irritant gases. Combined with bronchoscopic aspiration +of secretions it is the best method of treatment for poisoning by +chlorine gas, asphyxiating, and other war gases. + +Bronchoscopic oxygen insufflation should be taught to every interne in +every hospital. The emergency or accident ward of every hospital +should have the necessary equipment and an interne familiar with its +use. The method is simple, once the knack is acquired. The patient +being limp and recumbent on a table, the larynx is exposed with the +laryngoscope, and the bronchoscope is inserted as hereinafter +described. The oxygen is turned on at the tank and the flow regulated +before the rubber tube from the wash-bottle of tank is attached to the +side-outlet of the bronchoscope. It is necessary to be certain that +the flow is gentle, so that, with a free return flow the introduced +pressure does not exceed the capillary pressure; otherwise the blood +will be forced out of the capillaries and the ischemia of the lungs +will be fatal. Another danger is that overdistension causes inhibition +of inspiration resulting in apnea continuing as long as the distension +is maintained, if not longer. The return flow from the bronchoscope +should be interrupted for 2 or 3 seconds several times a minute to +inflate the lungs, but the flow must not be occluded longer than 3 +seconds, because the intrapulmonary pressure would rise. A pearl of +amyl nitrite may be broken in the wash bottle. Slow rhythmic +artificial respiratory movements are a useful adjunct, and unless the +operator is very skillful in gauging the alternate pressures and +releases with the thumb according to the oxygen pressure, it is +vitally necessary to fill and deflate the lungs rhythmically by one of +the well known methods of artificial respiration. Anyone skilled in +the introduction of the bronchoscope can do bronchoscopy in a few +seconds, and it is especially easy in cases of respiratory arrest, +because of the limp condition of the patient. + +The foregoing applies to cases in which a pulmotor would be used, such +as apnea from electric shocks, etc. For obstructive dyspnea and +asphyxia, tracheotomy is the procedure of choice, and the skillful +tracheotomist would be justified in preferring tracheotomy for the +other class of cases, insufflating the oxygen and amyl nitrite through +the tracheotomic wound. The pulmotor and similar mechanisms are, +perhaps, the best things the use of which can be taught to laymen; but +as compared to bronchoscopic oxygen insufflation they are woefully +inefficient, because the intraoral pressure forces the tongue back +over the laryngeal orifice, obstructing the airway in this "death +zone." By the introduction of the bronchoscope this death zone is +entirely eliminated, and a free airway established for piping the +oxygen directly into the lungs. + + + +[73] CHAPTER VI--POSITION OF THE PATIENT FOR PERORAL ENDOSCOPY + +It is the author's invariable practice to place the patient in the +dorsally recumbent position. The sitting position is less favorable. +While lying on a well-padded, flat table the patient is readily +controlled, the head is freely movable, secretions can be easily +removed, the view obtained by the endoscopist is truly direct (without +reversal of sides), and, most important, the employment of one +position only favors smoother and more efficient team work, and a +better endoscopic technic. + +_General Principles of Position_.--As will be seen in Fig. 47 the +trachea and esophagus are not horizontal in the thorax, but their long +axes follow the curves of the cervical and dorsal spine. Therefore, if +we are to bring the buccal cavity and pharynx in a straight line with +the trachea and esophagus it will be found necessary to elevate the +whole head above the plane of the table, and at the same time make +extension at the occipito-atloid joint. By this maneuver the cervical +spine is brought in line with the upper portion of the dorsal spine as +shown in Fig. 55. It was formerly taught, and often in spite of my +better knowledge I am still unconsciously prone to allow the head and +cervical spine to assume a lower position than the plane of the table, +the so-called Rose position. With the head so placed, it is impossible +to enter the lower air or food passages with a rigid tube, as will be +shown by a study of the radiograph shown in Fig. 49. Extension of the +head on the occipito-atloid joint is for the purpose of freeing the +tube from the teeth, and the amount required will vary with the degree +to which the mouth can be opened. Whether the head be extended, +flexed, or kept mid-way, the fundamental principle in the introduction +of all endoscopic tubes is the anterior placing of the cervical spine +and the high elevation of the head. The esophagus, just behind the +heart, turns ventrally and to the left. In order to pass a rigid tube +through this ventral curve the dorsal spine is now extended by +lowering the head and shoulders below the plane of the table. This +will be further explained in the chapter on esophagoscopy. In all of +these procedures, the nose of the patient should be directed toward +the zenith, and the assistant should _prevent rotation of the head_ as +well as _prevent lowering of the head_. The patient should be urged as +follows: + "Don't hold yourself so rigid." + "Let your head and neck go loose." + "Let your head rest in my hand." + "Don't try to hold it." + "Let me hold it." + "Relax." + "Don't raise your chest." + +[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. + +[FIG. 53.--The author's position for the removal of foreign bodies +from the larynx or from any of the upper air or food passages. If +dislodged, the intruder will not be aided by gravity to reach a deeper +lodgement.] + +The one exception to these general positions is found in procedures +for the removal of foreign bodies from the larynx. In such cases, +while the same relative position of the head to the plane of the table +is maintained, the whole table top is so inclined as to elevate the +feet and lower the head, known as Jackson's position. This +semi-inversion of the patient allows the foreign body to drop into the +pharynx if it should be dislodged, or slip from the forceps (Fig. 53). + + + +[82] CHAPTER VII--DIRECT LARYNGOSCOPY + +_Importance of Mirror Examination of the Larynx_.--The presence of +the direct laryngoscope incites spasmodic laryngeal reflexes, and the +traction exerted somewhat distorts the tissues, so that accurate +observations of variations in laryngeal mobility are difficult to +obtain. The function of the laryngeal muscles and structures, +therefore, can best be studied with the laryngeal mirror, except in +infants and small children who will not tolerate the procedure of +indirect laryngoscopy. A true idea of the depth of the larynx is not +obtained with the mirror, and a view of the ventricles is rarely had. +With the introduction of the direct laryngoscope it is found that the +larynx is funnel shaped, and that the adult cords are situated about 3 +cm. below the aryepiglottic folds; the cords also assume their true +shelf-like character and take on a pinkish or yellowish tinge, rather +than the pearly white seen in the mirror. They are not to any extent +differentiated by color from the neighboring structures. Their +recognition depends almost wholly on form, position and movement. + +Accurate observation is stimulated in all pathologic cases by making +colored crayon sketches, however crude, of the mirror image of the +larynx. The location of a growth may be thus graphically recorded, so +that at the time of operation a glance will serve to refresh the +memory as to its site. It is to be constantly kept in mind, however, +that in the mirror image the sides are reversed because of the facing +positions of the examiner and patient. Direct laryngoscopy is the only +method by which the larynx of children can be seen. The procedure need +require less than a minute of time, and an accurate diagnosis of the +condition present, whether papilloma, foreign body, diphtheria, +paralysis, etc., may be thus obtained. The posterior pharyngeal wall +should be examined in all dyspneic children for the possible existence +of retropharyngeal abscess. + +[PLATE II--DIRECT AND INDIRECT LARYNGEAL VIEWS FROM AUTHOR'S OIL-COLOR +DRAWINGS FROM LIFE: + 1, Epiglottis of child as seen by direct laryngoscopy in the +recumbent position. + 2, Normal larynx spasmodically closed, as is usual on first exposure +without anesthesia. + 3, Same on inspiration. + 4, Supraglottic papillomata as seen on direct laryngoscopy in a +child of two years. + 5, Cyst of the larynx in a child of four years, seen on direct +laryngoscopy without anesthesia. + 6, Indirect view of larynx eight weeks after thyrotomy for cancer of +the right cord in a man of fifty years. + 7, Same after two years. An adventitious band indistinguishable from +the original one has replaced the lost cord. + 8, Condition of the larynx three years after hemilaryngectomy for +epithelioma in a patient fifty-one years of age. Thyrotomy revealed +such extensive involvement, with an open ulceration which had reached +the perichondrium, that the entire left wing of the thyroid cartilage +was removed with the left arytenoid. A sufficiently wide removal was +accomplished without removing any part of the esophageal wall below +the level of the crico-arytenoid joint. There is no attempt on the +part of nature to form an adventitious cord on the left side. The +normal arytenoid drew the normal cord over, approximately to the edge +of the cicatricial tissue of the operated side. The voice, at first a +very hoarse whisper, eventually was fairly loud, though slightly husky +and inflexible. + 9, The pharynx seen one year after laryngectomy for endothelioma in +a man aged sixty-eight years. The purple papilla; anteriorly are at +the base of the tongue, and from this the mucosa slopes downward and +backward smoothly into the esophagus. There are some slight folds +toward the left and some of these are quite cicatricial. The +epiglottis was removed at operation. The trachea was sutured to the +skin and did not communicate with the pharynx. (Direct view.)] + + +_Contraindications to Direct Laryngoscopy_.--There are no absolute +contraindications to direct laryngoscopy in any case where direct +laryngoscopy is really needed for diagnosis or treatment. In extremely +dyspneic patients, if the operator is not confident in his ability for +a prompt and sure introduction of a bronchoscope, it may be wise to do +a tracheotomy first. + +_Instructions to the Patient_.--Before beginning endoscopy the +patient should be told that he will feel a very disagreeable pressure +on his neck and that he may feel as though he were about to choke. He +must be gently but positively made to understand (1) that while the +procedure is alarming, it is absolutely free from danger; (2) that you +know just how it feels; (3) that you will not allow his breath to be +shut off completely; (4) that he can help you and himself very much by +paying close attention to breathing deeply and regularly; (5) and that +he must not draw himself up rigidly as though "walking on ice," but +must be easy and relaxed. + +_Direct Laryngoscopy. Adult Patient_.--Before starting, every detail +in regard to instrumental equipment and operating room assistants, +(including an assistant to hold the arms and legs of the patient) must +be complete. Preparation of the patient and the technic of local +anesthesia have been discussed in their respective chapters. The +dorsally recumbent patient is draped with (not pinned in) a sterile +sheet. The head, covered by sterile towels, is elevated, and slight +extension is made at the occipitoatloid joint by the left hand of the +first assistant. The bite block placed on the assistant's right thumb +is inserted into the left angle of the patient's open mouth (see Fig. +50). + +The laryngoscope must always and invariably be held in the left hand, +and in such a manner that the greatest amount of traction is made at +the swell of the horizontal bar of the handle, rather than on the +vertical bar. + +The right hand is then free for the manipulation of forceps, and the +insertion of the bronchoscope or other instrument. During +introduction, the fingers of the right hand retract the upper lip so +as to prevent its being pinched between the laryngoscope and the +teeth. The introduction of the direct laryngoscope and exposure of the +larynx is best described in two stages. + 1. Exposure and identification of the epiglottis. + 2. Elevation of the epiglottis and all the tissues attached to the +hyoid bone, so as to expose the larynx to direct view. + +_First Stage_.--The spatular end of the laryngoscope is introduced in +the right side of the patient's mouth, along the right side of the +anterior two-thirds of the tongue. It was the German method to +introduce the laryngoscope over the dorsum of the tongue but in order +to elevate this sometimes powerful muscular organ considerable force +may be required, which exercise of force may be entirely avoided by +crowding the tongue over to the left. When the posterior third stage +of the tongue is reached, the tip of the laryngoscope is directed +toward the midline and the dorsum of the tongue is elevated by a +lifting motion imparted to the laryngoscope. The epiglottis will then +be seen to project into the endoscopic field, as seen in Fig. 54. + +[FIG. 54.--End of the first of direct laryngoscopy, recumbent adult +patient. The epiglottis is exposed by a lifting motion of the spatular +tip on the tongue anterior to the epiglottis.] + +_Second Stage_.--The spatular end of the laryngoscope should now be +tipped back toward the posterior wall of the pharynx, passed posterior +to the epiglottis, and advanced about 1 cm. The larynx is now exposed +by a motion that is best described as a suspension of the head and all +the structures attached to the hyoid bone on the tip of the spatular +end of the laryngoscope (Fig. 55). Particular care must be taken at +this stage not to pry on the upper teeth; but rather to impart a +lifting motion with the tip of the speculum without depressing the +proximal tubular orifice. It is to be emphasized that while some +pressure is necessary in the lifting motion, great force should never +be used; the art is a gentle one. The first view is apt to find the +larynx in state of spasm, and affords an excellent demonstration of +the fact that the larynx can he completely closed without the aid of +the epiglottis. Usually little more is seen than the two rounded +arytenoid masses, and, anterior to them, the ventricular bands in more +or less close apposition hiding the cords (Fig. 56). With deep +general anesthesia or thorough local anesthesia the spasm may not be +present. By asking the patient to take a deep breath and maintain +steady breathing, or perhaps by requesting a phonatory effort, the +larynx will open widely and the cords be revealed. If the anterior +commissure of the larynx is not readily seen, the lifting motion and +elevation of the head should be increased, and if there is still +difficulty in exposing the anterior commissure the assistant holding +the head should with the index finger externally on the neck depress +the thyroid cartilage. If by this technic the larynx fails to be +revealed the endoscopist should ask himself which of the following +rules he has violated. + +[FIG. 55.--Schema illustrating the technic of direct laryngoscopy on +the recumbent patient. The motion is imparted to the tip of the +laryngoscope as if to lift the patient by his hyoid hone. The portion +of the table indicated by the dotted line may be dropped or not, but +the back of the head must never go lower than here shown, for direct +laryngoscopy; and it is better to have it at least 10 cm. above the +level of the table. The table may be used as a rest for the operator's +left elbow to take the weight of the head. (Note that in bronchoscopy +and esophagoscopy the head section of the table must be dropped, so as +to leave the head and neck of the patient out in the air, supported by +the second assistant.)] + +[FIG. 56.--Endoscopic view at the end of the second stage of direct +laryngoscopy. Recumbent patient. Larynx exposed waiting for larynx to +relax its spasmodic contraction.] + +RULES FOR DIRECT LARYNGOSCOPY + 1. The laryngoscope must always be held in the left hand, never in +the right. + 2. The operator's right index finger (never the left) should be used +to retract the patient's upper lip so that there is no danger of +pinching the lip between the instrument and the teeth. + 3. The patient's head must always be exactly in the middle line, not +rotated to the right or left, nor bent over sidewise; and the entire +head must be forward with extension at the occipitoatloid joint only. + 4. The laryngoscope is inserted to the right side of the anterior +two-thirds of the tongue, the tip of the spatula being directed toward +the midline when the posterior third of the tongue is reached. + 5. The epiglottis must always be identified before any attempt is +made to expose the larynx. + 6. When first inserting the laryngoscope to find the epiglottis, +great care should be taken not to insert too deeply lest the +epiglottis be overridden and thus hidden. + 7. After identification of the epiglottis, too deep insertion of the +laryngoscope must be carefully avoided lest the spatula be inserted +back of the arytenoids into the hypo-pharynx. + 8. Exposure of the larynx is accomplished by pulling forward the +epiglottis and the tissues attached to the hyoid bone, and not by +prying these tissues forward with the upper teeth as a fulcrum. + 9. Care must be taken to avoid mistaking the ary-epiglottic fold for +the epiglottis itself. (Most likely to occur as the result of rotation +of the patient's head.) + 10. The tube should not be retained too long in place, but should be +removed and the patient permitted to swallow the accumulated saliva, +which, if the laryngoscope is too long in place, will trickle down the +trachea and cause cough. (Swallowing is almost impossible while the +laryngoscope is in position.) The secretions may be removed with the +aspirator. + 11. The patient must be instructed to breathe deeply and quietly +without making a sound. + +[88] _Difficulties of Direct Laryngoscopy_.--The larynx can be +directly exposed in any patient whose mouth can be opened, although +the ease varies greatly with the type of patient. Failure to expose +the epiglottis is usually due to too great haste to enter the speculum +all the way down. The spatula should glide slowly along the posterior +third of the tongue until it reaches the glossoepiglottic fossa, while +at the same time the tongue is lifted; when this is done the +epiglottis will stand out in strong relief. The beginner is apt to +insert the speculum too far and expose the hypopharynx rather than the +larynx. The elusiveness of the epiglottis and its tendency to retreat +downward are very much accentuated in patients who have worn a +tracheotomic cannula; and if still wearing it, the patient can wait +indefinitely before opening his glottis. Over extension of the +patient's head is a frequent cause of difficulty. If the head is held +high enough extension is not necessary, and the less the extension the +less muscular tension there is in the anterior cervical muscles. Only +one arytenoid eminence may be seen. The right and the left look +different. Practice will facilitate identification, so that the +endoscopist will at once know which way to look for the glottis. + +Of the difficulties that pertain to the operator himself the greatest +is lack of practice. He must learn to recognize the landmarks even +though a high degree of spasm be present. The epiglottis and the two +rounded eminences corresponding to the arytenoids must be in the +mind's eye, for it is only on deep, relaxed inspiration that anything +like a typical picture of the larynx will be seen. He must know also +the right from the left arytenoid when only one is seen in order to +know whether to move the lip of the laryngoscope to the right or the +left for exposure of the interior of the larynx. + +_Instruments for Direct Laryngoscopy_.--In undertaking direct +laryngoscopy one must always be prepared for bronchoscopy, +esophagoscopy, and tracheotomy, as well. Preparations for bronchoscopy +are necessary because the pathological condition may not be found in +the larynx, and further search of the trachea or bronchi may be +required. A foreign body in the larynx may be aspirated to a deeper +location and could only be followed with the bronchoscope. Sudden +respiratory arrest might occur, from pathology or foreign body, +necessitating the inserting of the bronchoscope for breathing +purposes, and the insufflation of oxygen and amyl nitrite. Trachectomy +might be required for dyspnea or other reasons. It might be necessary +to explore the esophagus for conditions associated with laryngeal +lesions, as for instance a foreign body in the esophagus causing +dyspnea by pressure. In short, when planning for direct laryngoscopy, +bronchoscopy, or esophagoscopy, prepare for all three, and for +tracheotomy. A properly done direct laryngoscopy would never +precipitate a tracheotomy in an unanesthetized patient; but direct +laryngoscopy has to deal so frequently with laryngeal stenosis, that +routine preparation for tracheotomy a hundred unnecessary times is +fully compensated for by the certainty of preparedness when the rare +but urgent occasion arises. + +_Direct Laryngoscopy in Children_.--The epiglottis in children is +usually strongly curled, often omega shaped, and is very elusive and +slippery. The larynx of a child is very freely movable in the neck +during respiration and deglutition, and has a strong tendency to +retreat downward during examination, and thus withdraw the epiglottis +after the arytenoids have been exposed. In following down with the +laryngoscope the speculum is prone to enter the hypopharynx. Lifting +in this location will expose the mouth of the esophagus and shut off +the larynx, and may cause respiratory arrest. Practice, however, will +soon develop a technic and ability to recognize the landmarks in state +of spasm, so that on exposing the approximated arytenoid eminences the +endoscopist will maintain his position and wait for the larynx to +open. The procedure should be done without any form of anesthesia for +the following reasons: + 1. Anesthesia is unnecessary. + 2. It is extremely dangerous in a dyspneic patient. + 3. It is inadmissable in a patient with diphtheria. + 4. If anesthesia is to be used, direct laryngoscopy will never reach +its full degree of usefulness, because anesthesia makes a major +procedure out of a minor one. + 5. Cocain in children is dangerous, and its application more +annoying than the examination. + +_Inducing a Child to Open its Mouth (Author's Method)_.--The wounding +of the child's mouth, gums, and lips, in the often inefficacious +methods with gags, hemostats, raspatories, etcetera, are entirely +unnecessary. The mouth of any child not unconscious can be opened +quickly and without the slightest harm by passing a curved probe +between the clenched jaws back of the molars and down back of the +tongue toward the laryngopharynx. This will cause the child to gag, +when its mouth invariably opens. + + + +[91] CHAPTER VIII--DIRECT LARYNGOSCOPY (_Continued_) + +_Technic of Laryngeal Operations_.--Preparation of the patient and +anesthesia have been mentioned under their respective chapters. The +prime essential of successful laryngeal operations is perfect mastery +of continuous left-handed laryngeal exposure. The right hand must be +equally trained in the manipulation of forceps, and the right eye to +gauge depth. Blood and secretions are best removed by a suction tube +(Fig. 9) inserted through the laryngoscope, or directly into the +pharynx outside the laryngoscope. + +_For the removal of benign growths_ the author's papilloma forceps, +Fig. 29, or the laryngeal grasping forceps shown in Fig. 17 will prove +more satisfactory than any form of cutting forceps. These growths +should be removed superficially flush with the normal structure. The +crushing of the base incident to the plucking off of the growth causes +its recession. By this conservative method damage to the cords and +impairment of the voice are avoided. For growths in the anterior +portion of the larynx, and in fact for the removal of most small +benign growths, the anterior commissure laryngoscope is especially +adapted. Its shape allows its introduction into the vestibule of the +larynx, and if desired it may be introduced through the glottic chink +for the treatment of subglottic conditions. It will not infrequently +be observed that a pedunculated subglottic growth which is found with +difficulty will be pulled upward into view by the gauze swab +introduced to remove secretions. The growth is then often held tightly +between the approximated cords for a few seconds--perhaps long enough +to grasp it with forceps. + +[92] _Removal of Growth from the Laryngeal Ventricle_.--After exposing +the larynx in the usual manner, if the head is turned strongly to the +right, the tip of the laryngoscope, directed from the right side of +the mouth, may be used to lift the left ventricular hand and thus +expose the ventricle, from which a growth may be removed in the usual +manner (Fig. 57). The right ventricle is exposed by working from the +left side of the mouth. + +[FIG. 57.-Schema illustrating the lateral method of exposing a growth +in the ventricle of Morgagni, by bending the patient's head to the +opposite side, while the second assistant externally fixes the larynx +with his hand. M, Patient's mouth; T, thyroid cartilage; R, right +side; L, left. V, B, ventricular band. C, C, vocal cord. The circular +drawing indicates the endoscopic view obtainable by this method. The +tube, E, is dropped to the corner of the mouth, B, and the tube is +inserted down to R. The lip of the spatula can then be used to lift +the ventricular band so as to expose more of the ventricle. The +drawing shows an unusually shallow ventricle.] + +_Taking a Laryngeal Specimen for Diagnosis_.--The diagnosis of +carcinoma, sarcoma, and some other conditions can be made certain only +by microscopic study of tissue removed from the growth. The specimen +should be ample but will necessarily be small. If the suspected growth +be small it should be removed entire, together with some of the basal +tissues. If it is a large growth, and there are objections to its +entire removal, the edge of the growth, including apparently normal as +well as neoplastic tissue, is necessary. If it is a diffuse +infiltrative process, a specimen should be taken from at least two +locations. Tissue for biopsy is to be taken with the punch forceps +shown in Fig. 28 or that in Fig. 33. The forceps may be inserted +through the tube or from the angle of the mouth; the "extubal" method +(see Fig. 58). + +[FIG. 58.--Schema illustrating removal of a tumor from the upper part +of the larynx by the author's "extubal" method for large tumors. The +large alligator basket punch forceps, F, is inserted from the right +corner of the mouth and the jaws are placed over the tumor, T, under +guidance of the eye looking through the laryngoscope, L. This method +is not used for small tumors. It is excellent for amputation of the +epiglottis with these same punch forceps or with the heavy snare.] + +_Removal of large benign tumors above the cords_ may be done with the +snare or with the large laryngeal punch forceps. Both are used in the +extubal method. + +_Amputation of the epiglottis_ for palliation of odynophagia or +dysphagia in tuberculous or malignant disease, is of benefit when the +ulceration is confined to this region; though as to tuberculosis the +author feels rather conservatingly inclined. Early malignancy of the +extreme tip can be cured by such means. The function of the epiglottis +seems to be to split the food bolus and direct its portions laterally +into the pyriform sinuses, rather than to take any important part in +the closure of the larynx. Following the removal of the epiglottis +there is rarely complaint of food entering the larynx. The projecting +portion of the epiglottis may be amputated with a heavy snare, or by +means of the large laryngeal punch forceps (Fig. 33). + +_Endoscopic Operations for Laryngeal Stenosis_.--Web formations may be +excised with sliding punch forceps, or if the web is due to +contraction only, incision of the true band may allow its retraction. +In some instances liberation of adhesions will favor the formation of +adventitious vocal cords. A sharp anterior commissure is a large +factor in good phonation. + +_Endoscopic evisceration of the larynx_ will cure a few cases of +laryngeal cicatricial stenosis, and should be tried before resorting +to laryngostomy. A sliding punch forceps is used to remove all the +tissue in the larynx out to the perichondrium, but care should be +taken in cicatricial cases to avoid removing any part of either +arytenoid cartilage. In cases of posticus paralysis the excision may +include portions of the vocal processes of the arytenoids. +Ventriculocordectomy is preferable to evisceration. The ventricular +floor is removed with punch forceps (Fig. 33) first on one side, then +after two months, on the other. + +_Vocal Results_.--A whispering voice can always be had as long as air +can pass through the larynx, and this may be developed to a very loud +penetrating stage whisper. If the arytenoid motility has been +uninjured the repeated pulls on the scar tissue may draw out +adventitious bands and develop a loud, useful, though perhaps rough +and inflexible voice. + +_Galvano-cauterization_ is the best method of treatment for chronic +subglottic edema or hyperplasia such as is seen in children following +diphtheria, when the stenosis produced prevents extubation or +decannulation. The utmost caution should be used to avoid deep +cauterizations; they are almost certain to set up perichondritis which +will increase the stenosis. Some of the most difficult cases that have +come to the author have been previously cauterized too deeply. + +_Galvano-cautery puncture_ of tuberculous infiltrations of the larynx +at times yields excellent results in cases with mild pulmonary +lesions, and has quite replaced the use of the curette, lactic acid, +and other caustics. The direct method of exposing the larynx renders +the application of the cautery point easy and accurate. In severely +stenosed tuberculous larynges a tracheotomy should first be done, for +though the reaction is slight it might be sufficient to close a +narrowed glottis. The technic is the usual one for laryngeal +operations. Local anesthesia suffices. The larynx is exposed. The +rheostat having been previously adjusted to heat the electrode to +nearly white heat, the circuit is broken and the electrode introduced +cold. When the point is in contact with the desired location the +current is turned on and the point thrust in as deeply as desired. +Usually it should penetrate until a firm resistance is felt; but care +must be used not to damage the cricoarytenoid joint. The circuit is +broken at the instant of withdrawal. Punctures should be made as +nearly as possible perpendicular to the surface, so as to minimize the +destruction of epithelium and thus lessen the reaction. A minute gray +fibrous slough detaches itself in a few days. Cautery puncture should +be repeated every two or three weeks, selecting a new location each +time, until the desired result is obtained. Great caution, as +mentioned above, must be used to avoid setting up perichondritis. Many +cases of laryngeal tuberculosis will recover as quickly by silence and +a general antituberculous regime. + +_Radium_, in form of capsules or of needles inserted in the tissues +may be applied with great accuracy; but the author is strongly +impressed with pyriform sinus applications by the Freer method. + +_After-care of endolaryngeal operations_ includes careful cleansing of +the teeth and mouth; and if the extrinsic area of the larynx is +involved in the wound, sterile liquid food and water should be given +for four days. The patient should be watched for complications by a +special nurse who is familiar with the signs of laryngeal dyspnea +(q.v.). _Complications during endolaryngeal operations_ are rare. +Dyspnea may require tracheotomy. Idiosyncrasy to cocain, or the sight +or taste of blood may nauseate the patient and cause syncope. Serious +hemorrhage could occur only in a hemophile. The careless handling of a +bite block might damage a frail tool or dental fixture. + +_Complications after endolaryngeal operations_ are unusual. +Carelessness in asepsis has been known to cause cervical cellulitis. +Emphysema of the neck has occurred. Edema of the larynx occasionally +occurs, and might necessitate tracheotomy. Serious bleeding after +operation is very rare except in bleeders. Hemorrhage within the +larynx can be stopped by the introduction of a roll of gauze from +above, tracheotomy having been previously performed. Morphin +subcutaneously administered, has a constricting action on the vessels +which renders it of value in controlling hemorrhage. + + + +[97] CHAPTER IX--INTRODUCTION OF THE BRONCHOSCOPE + +No one should do bronchoscopy until he is able to expose the glottis +by left-handed direct laryngoscopy in less than one minute. When he +has mastered this, one minute more should be sufficient to introduce +the bronchoscope into the trachea. + +TECHNIC OF BRONCHOSCOPY + +Local anesthesia is usually employed in the adult. The patient is +placed in the Boyce position shown in Fig. 51, with head and shoulders +projecting over the edge of the table and supported by an assistant. +The glottis is exposed by left-handed laryngoscopy. The +instrument-assistant now inserts the distal end of the bronchoscope +into the lumen of the laryngoscope, the handle being directed to the +right in a horizontal position. The operator now grasps the +bronchoscope, his eye is transferred from the laryngoscope to the +bronchoscope, and the bronchoscope is advanced and so directed that a +good view of the glottis is obtained. The slanted end of the +bronchoscope should then be directed to the left, so as clearly to +expose the left cord. In this position it will be found that the tip +of the slanted end is in the center of the glottic chink and will slip +readily into the trachea. No great force should be used, because if +the bronchoscope does not go through readily, either the tube is too +large a size or it is not correctly placed (Fig. 60). Normally, +however, there is some slight resistance, which in cases of subglottic +laryngitis may be considerable. The trained laryngologist will readily +determine by sense of touch the degree of pressure necessary to +overcome it. When the bronchoscope has been inserted to about the +second or third tracheal ring, the heavy laryngoscope is removed by +rotating the handle to the left, removing the slide, and withdrawing +the instrument. Care must be taken that the bronchoscope is not +withdrawn or coughed out during the removal of the laryngoscope; this +can be avoided by allowing the ocular end to rest against the +gown-covered chest of the operator. If preferred the operator may +train his instrumental assistant to take off the laryngoscope, while +the operator devotes his attention to preventing the withdrawal of the +bronchoscope by holding the handle with his right hand. At the moment +of insertion of the bronchoscope through the glottis, an especially +strong upward lift on the beak of the spatula will facilitate the +passage. It is necessary to be certain that the axis of the +bronchoscope corresponds to the axis of the trachea, in order to avoid +injury to the subglottic tissue which might be followed by subglottic +edema (Fig. 47). If the subglottic region is already edematous and +causes resistance, slight rotation to the laryngoscope, and +bronchoscope will cause the bronchoscope to enter more easily. + +[FIG. 59.--Insufflation anesthesia with Elsberg apparatus. Anesthetist +has exposed the larynx and is about to introduce the silk-woven +catheter. Note the full extension of the head on the table.] + +[FIG. 60.--Schema illustrating the introduction of the bronchoscope +through the glottis, recumbent patient. The handle, H, is always +horizontally to the right. When the glottis is first seen through the +tube it should be centrally located as at K. At the next inspiration +the end B, is moved horizontally to the left as shown by the dart, M, +until the glottis shows at the right edge of the field, C. This means +that the point of the lip, B, is at the median line, and it is then +quickly (not violently) pushed through into the trachea. At this same +moment or the instant before, the hyoid bone is given a quick +additional lift with the tip of the laryngoscope.] + +[FIG. 61.--Schema illustrating oral bronchoscopy. The portion of the +table here shown under the head is, in actual work, dropped all the +way down perpendicularly. It appears in these drawings as a dotted +line to emphasize the fact that the head must be above the level of +the table during introduction of the bronchoscope into the trachea. A, +Exposure of larynx; B, bronchoscope introduced; C, slide removed; D, +laryngoscope removed leaving bronchoscope alone in position.] + +_Difficulties in the Introduction of the Bronchoscope_.--The beginner +may enter the esophagus instead of the trachea: this might be +a dangerous accident in a dyspneic case, for the tube could, by +pressure on the trachea, cause respiratory arrest. A bronchoscope thus +misplaced should be resterilized before introducing it into the air +passages, for while the lower air passages are usually free from +bacteria, the esophagus is a septic canal. If the given technic is +carefully carried out the bronchoscope will not be contaminated with +mouth secretions. The trachea is recognized as an open tube, with +whitish rings, and the expiratory blast can be felt and tubular +breathing heard; while if by mistake the bronchoscope has entered the +gullet it will be observed that the cervical esophagus has collapsed +walls. A puff of air may be felt and a fluttering sound heard when the +tube is in the esophagus, but these lack the intensity of the tracheal +blast. Usually a free flow of secretion is met with in the esophagus. +In diseased states the tracheal rings may not be visible because of +swollen mucosa, or the trachea itself may be in partial collapse from +external pressure. The true expiratory blast will, however, always be +recognized when the tube is in the trachea. Wide gagging of the mouth +renders exposure of the larynx difficult. + +[FIG. 62.--Insertion of the bronchoscope. Note direction of the +trachea as indicated by the bronchoscope. Note that the patient's head +is held above the level of the table. The assistant's left hand should +be at the patient's mouth holding the bite-block. This is removed and +the assistant is on the wrong side of the table in the illustration in +order not to hide the position of the operator's hands. Note the +handle of the bronchoscope is to the right.] + +[FIG. 63.--The heavy laryngoscope has been removed leaving the light +bronchoscope in position. The operator is inserting forceps. Note how +the left hand of the operator holds the tube lightly between the thumb +and first two fingers of the left hand, while the last two fingers are +hooked over the upper teeth of the patient "anchoring" the tube to +prevent it moving in or out or otherwise changing the relation of the +distal tube-mouth to a foreign body or a growth while forceps are +being used. Thus, also, any desired location of the tube can be +maintained in systematic exploration. The assistant's left hand is +dropped out of the way to show the operator's method. The assistant +during bronchoscopy holds the bite-block like a thimble on the index +finger of the left hand, and the assistant should be on the right side +of the patient. He is here put wrongly on the left side so as not to +hide the instruments and the manner of holding them.] + +_Examination of the Trachea and Bronchi_.--All bronchial orifices must +be identified _seriatim_; because this is the only way by which the +bronchoscopist can know what part of the tree he is examining. +Appearances alone are not enough. It is the order in which they are +exposed that enables the inexperienced operator to know the orifices. +After the removal of the laryngoscope, the bronchoscope is to be held +by the left hand like a billiard cue, the terminal phalanges of the +left middle and ring fingers hooking over the upper teeth, while the +thumb and index finger hold the bronchoscope, clamping it to the teeth +tightly or loosely as required (Fig. 63). Thus the tube may be +anchored in any position, or at any depth, and the right hand which +was directing the tube may be used for the manipulation of +instruments. The grasp of the bronchoscope in the right hand should be +similar to that of holding a pen, that is, the thumb, first, and +second fingers, encircle the shaft of the tube. The bronchoscope +should never be held by the handle (Fig. 64) for this grasp does not +allow of tactile sense transmission, is rigid, awkward, and renders +rotation of the tube a wrist motion instead of but a gentle finger +action. Any secretion in the trachea is to be removed by sponge +pumping before the bronchoscope is advanced. The inspection of the +walls of the trachea is accomplished by weaving from side to side and, +if necessary, up and down; the head being deflected as required during +the search of the passages, so that the larynx be not made the fulcrum +in the lever-like action. + +[FIG. 64.--At A is shown an incorrect manner of holding the +bronchoscope. The grasp is too rigid and the position of the hand is +awkward. B, Correct manner, the collar being held lightly between the +finger and the thumb The thumb must not occlude the tube mouth.] + +_The Fulcrum of the Bronchoscopic Lever is at the Upper Thoracic +Aperture; Never at the Larynx_.--Disregard of this rule will cause +subglottic edema and will limit the lateral motion of the tip of the +bronchoscope. It is the function of the assistant to make the head and +neck follow the direction of the proximal end of the bronchoscope and +thus avoid any pressure on the larynx (see Peroral Endoscopy, Fig. +135, p. 164). + +In passing down the trachea the following two rules must be kept in +mind: + 1. Before attempting to enter either main bronchus the carina must +be identified. + 2. Before entering either main bronchus the orifices of both should +be identified and inspected. + _The carina_ is identified as a sharp vertical spur (recumbent +patient) at the distal end of the trachea, on either side of which are +the openings of the main bronchi. As the carina is situated to the +left of the midline of the trachea, the lip of the bronchoscope should +be turned toward the left, and slight lateral pressure should be made +on the left tracheal wall while the head of the patient is held +slightly to the right. This will expose the left bronchial orifice and +carina. + +_Entering the Bronchi_.--The lip of the bronchoscope should be turned +in the direction of the bronchus to be explored, and the axis of the +bronchoscope should be made to correspond as nearly as possible to the +axis of this bronchus. The position of the lip is designated by the +direction taken by the handle. Upon entering the right bronchus, the +handle of the bronchoscope is turned horizontally to the right, and at +the same time the assistant deflects the head to the left. + +_The right upper-lobe bronchus_ is recognized by its vertical spur; +the orifice is exposed by displacing the right lateral wall of the +right main bronchus at the level of the carina. Usually this orifice +will be thus brought into view. If not the bronchoscope may be +advanced downward 1 or 2 cm., carefully to avoid overriding. This +branch is sometimes found coming off the trachea itself, and even if +it does not, the overriding of the orifice is certain if the right +bronchus is entered before search is made for the upper-lobe-bronchial +orifice. The head must be moved strongly to the left in order to view +the orifice. A lumen image of the right upper-lobe bronchus is not +obtainable because of the sharp angles at which it is given off. _The +left upper-lobe bronchus_ is entered by keeping the handle of the +bronchoscope (and consequently the lip) to the left, and, by keeping +the head of the patient strongly to the right as the bronchoscopist +goes down the left main bronchus. This causes the lip of the +bronchoscope to bear strongly on the left wall of the left main +bronchus, consequently the left upper-lobe-bronchial orifice will not +be overridden. The spur separating the upper-lobe-bronchial orifice +from the stem bronchus is at an angle approximately from two to eight +o'clock, as usually seen in the recumbent patient. A lumen image of a +descending branch of the upper-lobe bronchus is often obtained, if the +patient's head be borne strongly enough to the right. + +[FIG. 65.--Schema illustrating the entering of the anteriorly +branching middle lobe bronchus. T, Trachea; B, orifice of left main +bronchus at bifurcation of trachea. The bronchoscope, S, is in the +right main bronchus, pointing in the direction of the right inferior +lobe bronchus, I. In order to cause the lip to enter the middle lobe +bronchus, M, it is necessary to drop the head so that the bronchoscope +in the trachea TT, will point properly to enable the lip of the tube +mouth to enter the middle lobe bronchus, as it is seen to have done at +ML.] + +Branches of the stem bronchus in either lung are exposed, or their +respective lumina presented, by manipulation of the lip of the +bronchoscope, with movement of the head in the required direction. +Posterior branches require the head quite high. A large one in the +left stem just below the left upper-lobe bronchus is often invaded by +foreign bodies. Anterior branches require lowering the head. The +_middle-lobe bronchus_ is the largest of all anterior branches. Its +almost horizontal spur is brought into view by directing the lip of +the bronchoscope upward, and dropping the head of the patient until +the lip bears strongly on the anterior wall of the right bronchus (see +Fig. 65). + + + +[106] CHAPTER X--INTRODUCTION OF THE ESOPHAGOSCOPE + +The esophagoscope is to be passed only with ocular guidance, never +blindly with a mandrin or obturator, as was done before the +bevel-ended esophagoscope was developed. Blind introduction of the +esophagoscope is equally as dangerous as blind bouginage. It is almost +certain to cause over-riding of foreign bodies and disease. In either +condition perforation of the esophagus is possible by pushing a sharp +foreign body through the normal wall or by penetrating a wall weakened +by disease. Landmarks must be identified as reached, in order to know +the locality reached. The secretions present form sufficient +lubrication for the instrument. A clear conception of the endoscopic +anatomy, the narrowings, direction, and changes of direction of the +axis of the esophagus, are necessary. The services of a trained +assistant to place the head in the proper sequential "high-low" +positions are indispensible (Figs. 52 and 70). Introduction may be +divided into four stages. + 1. Entering the right pyriform sinus. + 2. Passing the cricopharyngeus. + 3. Passing through the thoracic esophagus. + 4. Passing through the hiatus. + +The patient is placed in the Boyce position as described in Chapter +VI. As previously stated, the esophagus in its upper portion follows +the curves of the cervical and dorsal spine. It is necessary, +therefore, to bring the cervical spine into a straight line with the +upper portion of the dorsal spine and this is accomplished by +elevation of the head--the "high" position (Figs. 66-71). + +[PLATE III--ESOPHAGOSCOPIC VIEWS FROM OIL-COLOR DRAWINGS FROM LIFE, BY +THE AUTHOR: +1, Direct view of the larynx and laryngopharynx in the dorsally +recumbent patient, the epiglottis and hyoid bone being lifted with the +direct laryngoscope or the esophageal speculum. The spasmodically +adducted vocal cords are partially hidden by the over-hang of the +spasmodically prominent ventricular hands. Posterior to this the +aryepiglottic folds ending posteriorly in the arytenoid eminences are +seen in apposition. The esophagoscope should be passed to the right of +the median line into the right pyriform sinus, represented here by the +right arm of the dark crescent. 2, The right pyriform sinus in the +dorsally recumbent patient, the eminence at the upper left border, +corresponds to the edge of the cricoid cartilage. 3, The +cricopharyngeal constriction of the esophagus in the dorsally +recumbent patient, the cricoid cartilage being lifted forward with the +esophageal speculum. The lower (posterior) half of the lumen is closed +by the fold corresponding to the orbicular fibers of the +cricopharyngeus which advances spasmodically from the posterior wall. +(Compare Fig. 10.) This view is not obtained with an esophagoscope. 4, +Passing through the right pyriform sinus with the esophagoscope; +dorsally recumbent patient. The walls seem in tight apposition, and, +at the edges of the slit-like lumen, bulge toward the observer. The +direction of the axis of the slit varies, and in some instances it is +like a rosette, depending on the degree of spasm. 5, Cervical +esophagus. The lumen is not so patulent during inspiration as lower +down; and it closes completely during expiration. 6, Thoracic +esophagus; dorsally recumbent patient. The ridge crossing above the +lumen corresponds to the left bronchus. It is seldom so prominent as +in this patient, but can always be found if searched for. 7, The +normal esophagus at the hiatus. This is often mistaken for the cardia +by esophagoscopists. It is more truly a sphincter than the cardia +itself. In the author's opinion there is no truly sphincteric action +at the cardia. It is the failure of this hiatal sphincter to open as +in the normal deglutitory cycle that produces the syndrome called +"cardiospasm." 8, View in the stomach with the open-tube gastroscope. +The form of the folds varies continually. 9, Sarcoma of the posterior +wall of the upper third of the esophagus in a woman of thirty-one +years. Seen through the esophageal speculum, patient sitting. The +lumen of the mouth of the esophagus, much encroached upon by the +sarcomatous infiltration, is seen at the lower part of the circle. 10, +Coin (half-dollar) wedged in the upper third of the esophagus of a boy +aged fourteen years. Seen through the esophageal speculum, recumbent +patient. Forceps are retracting the posterior lip of the esophageal +"mouth" preparatory to removal. 11, Fungating squamous-celled +epithelioma in a man of seventy-four years. Fungations are not always +present, and are often pale and edematous. 12, Cicatricial stenosis of +the esophagus due to the swallowing of lye in a boy of four years. +Below tile upper stricture is seen a second stricture. An ulcer +surrounded by an inflammatory areola and the granulation tissue +together illustrates the etiology of cicatricial tissue. The +fan-shaped scar is really almost linear, but it is viewed in +perspective. Patient was cured by esophagoscopic dilatation. 13, +Angioma of the esophagus in a man of forty years. The patient had +hemorrhoids and varicose veins of the legs. 14, Luetic ulcer of the +esophagus 26 cm. from the upper teeth in a woman of thirty-eight +years. Two scars from healed ulcerations are seen in perspective on +the anterior wall. Branching vessels are seen in the livid areola of +the ulcers. 15, Tuberculosis of the esophagus in a man of thirty-four +years. 16, Leukoplakia of the esophagus near the hiatus in a man aged +fifty-six years.] + +The hypopharynx tapers down to the gullet like a funnel, and the +larynx is suspended in its lumen from the anterior wall. The larynx is +attached only to the anterior wall, but is held closely against the +posterior pharyngeal wall by the action of the inferior constrictor of +the pharynx, and particularly by its specialized portion--the +cricopharyngeus muscle. A bolus of food is split by the epiglottis and +the two portions drifted laterally into the pyriform sinuses, the +recesses seen on either side of the larynx. But little of the food +bolus passes posterior to the larynx during the act of swallowing. It +is through the pyriform sinus that the esophagoscope is to be +inserted, thereby following the natural food passage. To insert the +esophagoscope in the midline, posterior to the arytenoids, requires a +degree of force dangerous to exert and almost certain to produce +damage to the cricoarytenoid joint or to the pharyngeal wall, or to +both. + +The esophagoscope is steadied by the left hand like a billiard cue, the +terminal phalanges of the left middle and ring fingers hooked over the +upper teeth, while the left index finger and thumb encircle the tube +and retract the upper lip to prevent its being pinched between the +tube and upper teeth. The right hand holds the tube in pen fashion at +the collar of the handle, not by the handle. During introduction the +handle is to be pointed upward toward the zenith. + +_Stage I. Entering the Right Pyriform Sinus_.--The operator standing +(as in Fig. 66), inserts the esophagoscope along the right side of the +tongue as far as and down the posterior pharyngeal wall. A lifting +motion imparted to the tip of the esophagoscope by the left thumb will +bring the rounded right arytenoid eminence into view (A, Fig. 69). +This is the landmark of the pyriform sinus, and care must be taken to +avoid injury by hooking the tube mouth over it or its fellow. The tip +of the tube should now be directed somewhat toward the midline, +remembering the funnel shape of the hypopharynx. It will then be found +to glide readily through the right pyriform sinus for 2 or 3 cm., when +it comes to a full stop, and the lumen disappears. This is the +spasmodically closed cricopharyngeal constriction. + +[FIG. 66.--Esophagoscopy by the author's "high-low" method. First +stage. "High" position. Finding the right pyriform sinus. In this and +the second stage the patient's vertex is about 15 cm. above the level +of the table.] + +_Stage 2. Passing the cricopharyngeus_ is the most difficult part of +esophagoscopy, especially if the patient is unanesthetized. Local +anesthesia helps little, if at all. The handle of the esophagoscope is +still pointing upward and consequently we are sure that the lip of the +esophagoscope is directed anteriorly. Force must not be used, but +steady firm pressure against the tonically contracted cricopharyngeus +is made, while at the same time the distal end of the esophagoscope is +lifted by the left thumb. At the first inspiration a lumen will +usually appear in the upper portion of the endoscopic field. The tip +of the esophagoscope enters this lumen and the slanted end slides over +the fold of the cricopharyngeus into the cervical esophagus. There is +usually from 1 to 3 cm. of this constricted lumen at the level of the +cricopharyngeus and the subjacent orbicular esophageal fibers. + +[109] [FIG. 67.--Schematic illustration of the author's "high-low" +method of esophagoscopy. In the first and second stages the patient's +head fully extended is held high so as to bring it in line with the +thoracic esophagus, as shown above. The Rose position is shown by way +of accentuation.] + +[FIG. 68.--Schematic illustration of the anatomic basis for difficulty +in introduction of the esophagoscope. The cricoid cartilage is pulled +backward against the cervical spine, by the cricopharyngeus, so +strongly that it is difficult to realize that the cricopharyngeus is +not inserted into the vertebral periosteum instead of into the median +raphe.] + +[FIG. 69.--The upper illustration shows movements necessary for +passing the cricopharyngeus. + +The lower illustration shows schematically the method of finding the +pyriform sinus in the author's method of esophagoscopy. The large +circle represents the cricoid cartilage. G, Glottic chink, +spasmodically closed; VB, ventricular band; A, right arytenoid +eminence; P, right pyriform sinus, through which the tube is passed in +the recumbent posture. The pyriform sinuses are the normal food +passages.] + +_Stage 3. Passing Through the Thoracic Esophagus_.--The thoracic +esophagus will be seen to expand during inspiration and contract +during expiration, due to the change in thoracic pressure. The +esophagoscope usually glides easily through the thoracic esophagus if +the patient's position is correct. After the levels of the aorta and +left bronchus are passed the lumen of the esophagus seems to have a +tendency to disappear anteriorly. The lumen must be kept in axial view +and the head lowered as required for this purpose. + +_Stage 4. Passing Through the Hiatus Esophageus_.--When the head is +dropped, it must at the same time be moved horizontally to the right +in order that the axis of the tube shall correspond to the axis of the +lower third of the esophagus, which deviates to the left and turns +anteriorly. The head and shoulders at this time will be found to be +considerably below the plane of the table top (Fig. 71). The hiatal +constriction may assume the form of a slit or rosette. If the rosette +or slit cannot be promptly found, as may be the case in various +degrees of diffuse dilatation, the tube mouth must be shifted farther +to the left and anteriorly. When the tube mouth is centered over the +hiatal constriction moderately firm pressure continued for a short +time will cause it to yield. Then the tube, maintaining this same +direction will, without further trouble glide into and through the +abdominal esophagus. The cardia will not be noticed as a constriction, +but its appearance will be announced by the rolling in of reddish +gastric mucosal folds, and by a gush of fluid from the stomach. + +[FIG. 70.--Schematic illustration of the author's "high-low" method of +esophagoscopy, fourth stage. Passing the hiatus. The head is dropped +from the position of the 1st and 2nd stages, CL, to the position T, +and at the same time the head and shoulders are moved to the right +(without rotation) which gives the necessary direction for passing the +hiatus.] + +[FIG. 71.--Esophagoscopy by the author's "high-low" method. Stage 4. +Passing the hiatus The patient's vertex is about 5 cm. below the top +of the table.] + +_Normal esophageal mucosa_ under proper illumination is glistening and +of a yellowish or bluish pink. The folds are soft and velvety, +rendering infiltration quickly noticeable. The cricoid cartilage shows +white through the mucosa. The gastric mucosa is a darker pink than +that of the esophagus and when actively secreting, its color in some +cases tends toward crimson. + +_Secretions_ in the esophagus are readily aspirated through the +drainage canal by a negative pressure pump. Food particles are best +removed by "sponge pumping," or with forceps. Should the drainage +canal become obstructed positive pressure from the pump will clear the +canal. + +_Difficulties of Esophagoscopy_.--The beginner may find the +esophagoscope seemingly rigidly fixed, so that it can be neither +introduced nor withdrawn. This usually results from a wedging of the +tube in the dental angle, and is overcome by a wider opening of the +jaws, or perhaps by easing up of the bite block, but most often by +correcting the position of the patient's head. If the beginner cannot +start the tube into the pyriform sinus in an adult, it is a good plan +to expose the arytenoid eminence with the laryngoscope and then to +insert the 7 mm. esophagoscope into the right pyriform sinus by direct +vision. Passing the cricopharyngeal and hiatal spasmodically +contracted narrowings will prove the most trying part of +esophagoscopy; but with the head properly held, and the tube properly +placed and directed, patient waiting for relaxation of the spasm with +gentle continuous pressure will usually expose the lumen ahead. In his +first few esophagoscopies the novice had best use general anesthesia +to avoid these difficulties and to accustom himself to the esophageal +image. In the first favorable subject--an emaciated individual with no +teeth--esophagoscopy without anesthesia should be tried. + +In cases of kyphosis it is a mistake to try to straighten the spine. +The head should be held correspondingly higher at the beginning, and +should be very slowly and cautiously lowered. + +Once inserted, the esophagoscope should not be removed until the +completion of the procedure, unless respiratory arrest demands it. +Occasionally in stenotic conditions the light may become covered by +the upwelling of a flood of fluid, and it will be thought the light +has gone out. As soon as the fluid has been aspirated the light will +be found burning as brightly as before. If a lamp should fail it is +unnecessary to remove the tube, as the light carrier and light can be +withdrawn and quickly adjusted. A complete instrument equipment with +proper selection of instruments for the particular case are necessary +for smooth working. + +_Ballooning Esophagoscopy_.--By inserting the window plug shown in +Fig. 6 the esophagus may be inflated and studied in the distended +state. The folds are thus smoothed out and constrictions rendered more +marked. Ether anesthesia is advocated by Mosher. The danger of +respiratory arrest from pressure, should the patient be dyspneic, is +always present unless the anesthetic be given by the intratracheal +method. If necessary to use forceps the window cap is removed. If the +perforated rubber diaphragm cap be substituted the esophagus can be +reballooned, but work is no longer ocularly guided. The fluoroscope +may be used but is so misleading as to render perforation and false +passage likely. + +_Specular Esophagoscopy_.--Inspection of the hypopharynx and upper +esophagus is readily made with the esophageal speculum shown in Fig. +4. High lesions and foreign bodies lodged behind the larynx are thus +discovered with ease, and such a condition as a retropharyngeal +abscess which has burrowed downward is much less apt to be overlooked +than with the esophagoscope. High strictures of the esophagus may be +exposed and treated by direct visual bouginage until the lumen is +sufficiently dilated to allow the passage of the esophagoscope for +bouginage of the deeper strictures. + +_Technic of Specular Esophagoscopy_.--Recumbent patient. Boyce +position. The larynx is to be exposed as in direct laryngoscopy, the +right pyriform sinus identified, the tip of the speculum inserted +therein, and gently insinuated to the cricopharyngeal constriction. +Too great extension of the head is to be avoided--even slight flexion +at the occipito-atloid joint may be found useful at times. Moderate +anterior or upward traction pulls the cricoid away from the posterior +pharyngeal wall and the lumen of the esophagus opens above a +crescentic fold (the cricopharyngeus). The speculum readily slides +over this fold and enters the cervical esophagus. In searching for +foreign bodies in the esophagus the speculum has the disadvantage of +limited length, so that should the foreign body move downward it could +not be followed. + +_Complications Following Esophagoscopy_.--These are to be avoided in +large measure by the exercise of gentleness, care, and skill that are +acquired by practice. If the instructions herein given are followed, +esophagoscopy is absolutely without mortality apart from the +conditions for which it is done. + +Injury to the crico-arytenoid joint may simulate recurrent paralysis. +Posticus paralysis may occur from recurrent or vagal pressure by a +misdirected esophagoscope. These conditions usually recover but may +persist. Perforation of the esophageal wall may cause death from +septic mediastinitis. The pleura may be entered,--pyopneumothorax will +result and demand immediate thoracotomy and gastrostomy. Aneurysm of +the aorta may be ruptured. Patients with tuberculosis, decompensating +cardiovascular lesions, or other advanced organic disease, may have +serious complications precipitated by esophagoscopy. + +_Retrograde Esophagoscopy_.--The first step is to get rid of the +gastric secretions. There is always fluid in the stomach, and this +keeps pouring out of the tube in a steady stream. Fold after fold is +emptied of fluid. Once the stomach is empty, the search begins for the +cardial opening. The best landmark is a mark with a dermal pencil on +the skin at a point corresponding to the level of the hiatus +esophageus. When it is desired to do a retrograde esophagoscopy and +the gastrostomy is done for this special purpose, it is wise to have +it very high. Once the cardia is located and the esophagus entered, +the remainder of the work is very easy. Bouginage can be carried out +from below the same as from above and may be of advantage in some +cases. Strictural lumina are much more apt to be concentric as +approached from below because there has been no distortion by pressure +dilatation due to stagnation of the food operating through a long +period of time. At retrograde esophagoscopy there seems to be no +abdominal esophagus and no cardia. The esophagoscope encounters only +the diaphragmatic pinchcock which seems to be at the top of the +stomach like the puckering string at the top of a bag. + +Retrograde esophagoscopy is sometimes useful for "stringing" the +esophagus in cases in which the patient is unable to swallow a string +because he is too young or because of an epithelial scaling over of +the upper entrance of the stricture. In such cases the smallest size +of the author's filiform bougies (Fig. 40) is inserted through the +retrograde esophagoscope (Fig. 43) and insinuated upward through the +stricture. When the tip reaches the pharynx coughing, choking and +gagging are noticed. The filiform end is brought out the mouth +sufficiently far to attach a silk braided cord which is then pulled +down and out of the gastrostomic opening. The braided silk "string" +must be long enough so that the oral and the abdominal ends can be +tied together to make it "endless;" but before doing so the oral end +should be drawn through nose where it will be less annoying than in +the mouth. The purpose of the "string" is to pull up the retrograde +bougies (Fig. 35) + + + +[117] CHAPTER XI--ACQUIRING SKILL + +Endoscopic ability cannot be bought with the instruments. As with all +mechanical procedures, facility can be obtained only by educating the +eye and the fingers in repeated exercise of a particular series of +maneuvers. As with learning to play a musical instrument, a +fundamental knowledge of technic, positions, and landmarks is +necessary, after which only continued manual practice makes for +proficiency. For instance, efficient use of forceps requires that they +be so familiar to the grasp that their use is automatic. Endoscopy is +a purely manual procedure, hence to know how is not enough: manual +practice is necessary. Even in the handling of the electrical +equipment, practice in quickly locating trouble is as essential as +theoretic knowledge. There is no mystery about electric lighting. No +source of illumination other than electricity is possible for +endoscopy. Therefore a small amount of electrical knowledge, rendered +practical by practice, is essential to maintain the simple lighting +system in working order. It is an insult to the intelligence of the +physician to say that he cannot master a simple problem of electric +testing involving the locating of one or more of five possibilities. +It is simply a matter of memorizing five tests. It is repeated for +emphasis that a commercial current reduced by means of a rheostat +should never be used as a source of current for endoscopy with any +kind of instrument, because of the danger to the patient of a possible +"grounding" of the circuit during the extensive moist contact of a +metallic endoscopic tube in the mediastinum. The battery shown in Fig. +8 should be used. The most frequent cause of trouble is the mistake of +over-illuminating the lamps. _The lamp should not be over-illuminated +to the dazzling whiteness usually used in flash lights_. Excessive +illumination alters the proper perception of the coloring of the +mucosa, besides shortening the life of the lamps. The proper degree of +brightness is obtained when, as the current is increased, the first +change from yellow to white light is obtained. Never turn up the +rheostat without watching the lamp. + +_Testing for Electric Defects_.--These tests should be made +beforehand; not when about to commence introduction. + +If the first lamp lights up properly, use it with its light-carrier to +test out the other cords. + +If the lamp lights up, but flickers, locate the trouble before +attempting to do an endoscopy. If shaking the carrier cord-terminal +produces flickering there may be a film of corrosion on the central +contact of the light carrier that goes into the carrier cord-terminal. + +If the lamp fails to show a light, the trouble may be in one of five +places which should be tested for in the following order and manner. + 1. The lamp may not be firmly screwed into the light-carrier. +Withdraw the light-carrier and try screwing it in, though not too +strongly, lest the central wire terminal in the lamp be bent over. + 2. The light-carrier may be defective. + 3. The cord may be defective or its terminals not tight in the +binding posts. If screwing down the thumb nuts does not produce a +light, test the light-carrier with lamp on the other cords. Reserve +cords in each pair of binding posts are for use instead of the +defective cords. The two sets of cords from one pair of binding posts +should not be used simultaneously. + 4. The lamp may be defective. Try another lamp. + 5. The battery may be defective. Take a cord and light-carrier with +lamp that lights up, detaching the cord-terminals at the binding +posts, and attach the terminals to the binding posts of the battery to +be tested. + +_Efficient use of forceps_ requires previous practice in handling of +the forceps until it has become as natural and free from thought as +the use of knife and fork. Indeed the coordinate use of the +bronchoscopic tube-mouth and the forceps very much resembles the use +of knife and fork. Yet only too often a practitioner will telegraph +for a bronchoscope and forceps, and without any practice start in to +remove an entangled or impacted foreign body from the tiny bronchi of +a child. Failure and mortality are almost inevitable. A few hundred +hours spent in working out, on a bit of rubber tubing, the various +mechanical problems given in the section on that subject will save +lives and render easily successful many removals that would otherwise +be impossible. + +It is often difficult for the beginner to judge the distance the +forceps have been inserted into the tube. This difficulty is readily +solved if upon inserting the forceps slowly into the tube, he observes +that as the blades pass the light they become brightly illuminated. By +this _light reflex_ it is known, therefore, that the forceps blades +are at the tube-mouth, and distance from this point can be readily +gauged. Excellent practice may be had by picking up through the +bronchoscope or esophagoscope black threads from a white background, +then white threads from a black background, and finally white threads +on a white background and black threads on a black background. This +should be done first with the 9 mm. bronchoscope. It is to be +remembered that the majority of foreign body accidents occur in +children, with whom small tubes must be used; therefore, practice +work, after say the first 100 hours, should be done with the 5 mm. +bronchoscope and corresponding forceps rather than adult size tubes, +so that the operator will be accustomed to work through a small +calibre tube when the actual case presents itself. + +[120] _Cadaver Practice_.--The fundamental principles of peroral +endoscopy are best taught on the cadaver. It is necessary that a +specially prepared subject be had, in order to obtain the required +degree of flexibility. Injecting fluid of the following formula worked +out by Prof. J. Parsons Schaeffer for the Bronchoscopic Clinic +courses, has proved very satisfactory: + Sodium carbonate--1 1/2 lbs. + White arsenic--2 1/2 lbs. + Potassium nitrate--3 lbs. + Water--5 gal. + +Boil until arsenic is dissolved. When cold add: + Carbolic acid 1500 c.c. + Glycerin 1250 c.c. + Alcohol (95%) 1250 c.c. + +For each body use about 3 gal. of fluid. + +The method of introduction of the endoscopic tube, and its various +positions can be demonstrated and repeatedly practiced on the cadaver +until a perfected technic is developed in both the operator and +assistant who holds the head, and the one who passes the instruments +to the operator. In no other manner can the landmarks and endoscopic +anatomy be studied so thoroughly and practically, and in no other way +can the pupil be taught to avoid killing his patient. The +danger-points in esophagoscopy are not demonstrable on the living +without actually incurring mortality. Laryngeal growths may be +simulated, foreign body problems created and their mechanical +difficulties solved and practice work with the forceps and tube +perfected. + +_Practice on the Rubber-tube Manikin_.--This must be carried out in +two ways. + 1. General practice with all sorts of objects for the education of +the eye and the fingers. + 2. Before undertaking a foreign body case, practice should be had +with a duplicate of the foreign body. + +It is not possible to have a cadaver for daily practice, but +fortunately the eye and fingers may be trained quite as effectually by +simulating foreign body conditions in a small red rubber tube and +solving these mechanical problems with the bronchoscope and forceps. +The tubing may be placed on the desk and held by a small vise (Fig. +72) so that at odd moments during the day or evening the fascinating +work may be picked up and put aside without loss of time. Complicated +rubber manikins are of no value in the practice of introduction, and +foreign body problems can be equally well studied in a piece of rubber +tubing about 10 inches long. No endoscopist has enough practice on the +living subject, because the cases are too infrequent and furthermore +the tube is inserted for too short a space of time. Practice on the +rubber tube trains the eye to recognize objects and to gauge distance; +it develops the tactile sense so that a knowledge of the character of +the object grasped or the nature of the tissues palpated may be +acquired. Before attempting the removal of a particular foreign body +from a living patient, the anticipated problem should be simulated +with a duplicate of the foreign body in a rubber tube. In this way the +endoscopist may precede each case with a practical experience +equivalent to any number of cases of precisely the same kind of +foreign body. If the object cannot be removed from the rubber tube +without violence, it is obvious that no attempt should be made on the +patient until further practice has shown a definite method of harmless +removal. During practice work the value of the beveled lip of the +bronchoscope and esophagoscope in solving mechanical problems will be +evidenced. With it alone, a foreign body may be turned into favorable +positions for extraction, and folds can always be held out of the way. +Sufficient combined practice with the bronchoscope and the forceps +enable the endoscopist easily to do things that at first seem +impossible. It is to be remembered that lateral motion of the long +slender tube-forceps cannot be controlled accurately by the handle, +this is obtained by a change in position of the endoscopic tube, the +object being so centered that it is grasped without side motion of the +forceps. When necessary, the distal end of the forceps may be pushed +laterally by the manipulation of the bronchoscope. + +[FIG. 72.--A simple manikin. The weight of the small vise serves to +steady the rubber tubing. By the use of tubing of the size of the +invaded bronchus and a duplicate of the foreign body, any mechanical +problem can he simulated for solution or for practice, study of all +possible presentations, etc.] + +_Practice on the Dog_.--Having mastered the technic of introduction on +the cadaver and trained the eye and fingers by practice work on the +rubber tube, experience should be had in the living lower air and food +passages with their pulsatory, respiratory, bechic and deglutitory +movements, and ever-present secretions. It is not only inhuman but +impossible to obtain this experience on children. Fortunately the dog +offers a most ready subject and need in no way be harmed nor pained by +this invaluable and life-saving practice. A small dog the size of a +terrier (say 6 to 10 pounds in weight) should be chosen and +anesthetized by the hypodermic injection of morphin sulphate in dosage +of approximately one-sixth of a grain per pound of body weight, given +about 45 minutes before the time of practice. Dogs stand large doses +of morphin without apparent ill effect, so that repeated injection may +be given in smaller dosage until the desired degree of relaxation +results. The first effect is vomiting which gives an empty stomach for +esophagoscopy and gastroscopy. Vomiting is soon followed by relaxation +and stupor. The dog is normal and hungry in a few hours. Dosage must +be governed in the clog as in the human being by the susceptibility to +the drug and by the temperament of the animal. Other forms of +anesthesia have been tried in my teaching, and none has proven so safe +and satisfactory. Phonation may be prevented during esophagoscopy by +preventing approximation of the cords, through inserting a silk-woven +cathether in the trachea. The larynx and trachea may be painted with +cocain solution if it is found necessary for bronchoscopy. A very +comfortable and safe mouth gag is shown in Fig. 73. Great gentleness +should be exercised, and no force should be used, for none is required +in endoscopic work; and the endoscopist will lose much of the value of +his dog practice if he fails to regard the dog as a child. He should +remember he is not learning how to do endoscopy on the dog; but +learning on the dog how safely to do bronchoscopy on a human being. +The degree of resistance during introduction can be gauged and the +color of the mucosa studied, while that interesting phenomenon, the +dilatation and lengthening of the bronchi during inspiration and their +contraction and shortening during expiration, is readily observed and +always forms subject for thought in its possible connection with +pathological conditions. Foreign body problems are now to be solved +under these living conditions, and it is my feeling that no one should +attempt the removal of a foreign body from the bronchus of a child +until he has removed at least 100 foreign bodies from the dog without +harming the animal. Dogs have the faculty of easily ridding their +air-passages of foreign objects, so that one need not be alarmed if a +foreign body is lost during practice removal. It is to be remembered +that dogs swallow very large objects with apparent ease. The dog's +esophagus is relatively much larger than that of human beings. +Therefore a small dog (of six to eight pounds' weight) must be used +for esophagoscopic practice, if practice is to be had with objects of +the size usually encountered in human beings. The bronchi of a dog of +this weight will be about the size of those of a child. + +[FIG. 73.--Author's mouth gag for use on the dog. The thumb-nut serves +to prevent an uncomfortable degree of expansion of the gag. A bandage +may be wound around the dog's jaws to prevent undue spread of the +jaws.] + +_Endoscopy on the Human Being_.--Dog work offers but little practice +in laryngoscopy. Because of the slight angle at which the dog's head +joins his spine, the larynx is in a direct line with the open mouth; +hence little displacement of the anterior cervical tissues is +necessary. Moreover the interior of the larynx of the dog is quite +different from that of the human larynx. The technic of laryngoscopy +in the human subject is best perfected by a routine direct examination +of the larynx of anesthetized patients after such an operation as, for +instance, tonsillectomy, to see that the larynx and laryngopharynx are +free of clots. To perform a bronchoscopy or esophagoscopy under these +conditions would be reprehensible; but direct laryngoscopy for the +seeking and removal of clots serves a useful purpose as a preventative +of pulmonary abscess and similar complications.* Diagnosis of +laryngeal conditions in young children is possible only by direct +laryngoscopy and is neglected in almost all of the cases. No +anesthesia, general or local, is required. Much clinical material is +neglected. All cases of dyspnea or dysphagia should be studied +endoscopically if the cause of the condition cannot be definitely +found and treated by other means. Invaluable practice in esophagoscopy +is found in the treatment of strictures of the esophagus by weekly or +biweekly esophagoscopic bouginage. + +* Dr. William Frederick Moore, of the Bronchoscopic Clinic, has +recently collected statistics of 202 cases of post-tonsillectomic +pulmonary abscess that point strongly to aspiration of infected clots +and other infective materials as the most frequent etiologic mechanism +(Moore, W. F., Pulmonary Abscess. Journ. Am. Med. Assn., April 29, +1922, Vol. 78, pp. 1279-1281). + +In acquiring skill as an endoscopist the following paraphrased +aphorisms afford food for thought. + +APHORISMS + + Educate your eye and your fingers. + Be sure you are right, but not too sure. + Follow your judgment, never your impulse. + Cry over spilled milk enough to memorize how you spilled it. + Let your mistakes worry you enough to prevent repetition. + Let your left hand know what your right hand does and how +to do it. + Nature helps, but she is no more interested in the survival of your +patient than in the survival of the attacking pathogenic bacteria. + + + +[126] CHAPTER XII--FOREIGN BODIES IN THE AIR AND FOOD PASSAGES + +The air and food passages may be invaded by any foreign substance of +solid, liquid or gaseous nature, from the animal, vegetable, or +mineral kingdoms. Its origin may be from within the body (blood, pus, +secretion, broncholiths, sequestra, worms); introduced from without by +way of the natural passages (aspirated or swallowed objects); or it +may enter by penetration (bullet, dart, drainage tube from the neck). + +_Prophylaxis_.--If one put into his mouth nothing but food, foreign +body accidents would be rare. The habit of holding tacks, pins and +whatnot in the mouth is quite universal and deplorable. Children are +prone to follow the bad example of their elders. No small objects such +as safety pins, buttons, and coins should be left within a baby's +reach; children should be watched and taught not to place things in +their mouths. Mothers should be specially cautioned not to give nuts +or nut candy of any kind to a child whose powers of mastication are +imperfect, because the molar teeth are not erupted. It might be made a +dictum that: "No child under 3 years of age should be allowed to eat +nuts, unless ground finely as in peanut butter." Digital efforts at +removal of foreign bodies frequently force the object downward, or may +hook it forward into the larynx, whereas if not meddled with digitally +the intruder might be spat out. Before general anesthesia the mouth +should be searched for loose teeth, removable dentures, etc., and all +unconscious individuals should be likewise examined. When working in +the mouth precautions should be taken against the possible inhalation +or swallowing of loose objects or instruments. + +[126] Objects that have lodged in the esophagus, larynx, trachea, or +bronchi should be endoscopically removed. + +_Foreign Bodies in the Insane_.--Foreign bodies may be introduced +voluntarily and in great numbers by the insane. Hysterical individuals +may assert the presence of a foreign body, or may even volitionally +swallow or aspirate objects. It is a mistake to do a bronchoscopy in +order to cure by suggestion the delusion of foreign body presence. +Such "cures" are ephemeral. + +_Foreign Bodies in the Stomach_.--Gastroscopy is indicated in cases of +a foreign body that refuses to pass after a month or two. Foreign +bodies in very large numbers in the stomach, as in the insane, may be +removed by gastrostomy. + +_The symptomatology of foreign bodies_ may be epitomized as given +below; but it must be kept in mind, that certain symptoms may not be +manifest immediately after intrusion, and others may persist for a +time after the passage, removal, or expulsion of a foreign body. + +ESOPHAGEAL FOREIGN BODY SYMPTOMS + + 1. There are no absolutely diagnostic symptoms. + 2. Dysphagia, however, is the most constant complaint, varying with +the size of the foreign body, and the degree of inflammatory or +spasmodic reaction produced. + 3. Pain may be caused by penetration of a sharp foreign body, by +inflammation secondary thereto, by impaction of a large object, or by +spasmodic closure of the hiatus esophageus. + 4. The subjective sensation of foreign body is usually present, but +cannot be relied upon as assuring the presence of a foreign body for +this sensation often remains for a time after the passage onward of +the intruder. + 5. All of these symptoms may exist, often in the most intense +degree, as the result of previous violent attempts at removal; and the +foreign body may or may not be present. + +SYMPTOMS OF LARYNGEAL FOREIGN BODY + + 1. Initial laryngeal spasm followed by wheezing respiration, croupy +cough, and varying degrees of impairment of phonation. + 2. Pain may be a symptom. If so, it is usually located in the +laryngeal region, though in some cases it is referred to the ears. + 3. The larynx may tolerate a thin, flat, foreign body for a +relatively long period of time, a month or more; but the development +of increasing dyspnea renders early removal imperative in the majority +of cases. + +SYMPTOMS OF TRACHEAL AND BRONCHIAL FOREIGN BODY + + 1. Tracheal foreign bodies are usually movable and their movements +can usually be felt by the patient. + 2. Cough is usually present at once, may disappear for a time and +recur, or may be continuous, and may be so violent as to induce +vomiting. In recent cases fixed foreign bodies cause little cough; +shifting foreign bodies cause violent coughing. + 3. Sudden shutting off of the expiratory blast and the phonation +during paroxysmal cough is almost pathognomonic of a movable tracheal +foreign body. + 4. Dyspnea is usually present in tracheal foreign bodies, and is due +to the bulk of the foreign body plus the subglottic swelling caused by +the traumatism of the shiftings of the intruder. + 5. Dyspnea is usually absent in bronchial foreign bodies. + 6. The respiratory rate is increased only if a considerable portion +of lung is out of function, by the obstruction of a main bronchus, or +if inflammatory sequelae are extensive. + 7. The asthmatoid wheeze is usually present in tracheal foreign +bodies, and is often louder and of lower pitch than the asthmatoid +wheeze of bronchial foreign bodies. It is heard at the open mouth, not +at the chest wall; and prolonged expiration as though to rid the lungs +of all residual air, may be necessary to elicit it. + 8. Pain is not a common symptom, but may occur and be accurately +localized by the patient, in case of either tracheal or bronchial +foreign body. + +EARLY SYMPTOMS OF IRRITATING FOREIGN BODY SUCH AS A PEANUT KERNEL IN +THE BRONCHUS + + 1. Initial laryngeal spasm is almost invariably present with foreign +bodies of organic nature, such as nut kernels, peas, beans, maize, +etc. + 2. A diffuse purulent laryngo-tracheo-bronchitis develops within 24 +hours in children under 2 years. + 3. Fever, toxemia, cyanosis, dyspnea and paroxysmal cough are +promptly shown. + 4. The child is unable to cough up the thick mucilaginous pus +through the swollen larynx and may "drown in its own secretions" +unless the offender be removed. + 5. "Drowned lung," that is to say natural passages idled with pus +and secretions, rapidly forms. + 6. Pulmonary abscess develops sooner than in case of mineral foreign +bodies. + 7. The older the child the less severe the reaction. + +SYMPTOMS OF PROLONGED FOREIGN BODY SOJOURN IN THE BRONCHUS + + 1. The time of inhalation of a foreign body may be unknown or +forgotten. + 2. Cough and purulent expectoration ultimately result, although +there may be a delusive protracted symptomless interval. + [130] 3. Periodic attacks of fever, with chills and sweats, and +followed by increased coughing and the expulsion of a large amount of +purulent, usually more or less foul material, are so nearly diagnostic +of foreign body as to call for exclusion of this probability with the +utmost care. + 4. Emaciation, clubbing of the fingers and toes, night sweats, +hemoptysis, in fact all of the symptoms of tuberculosis are in most +cases simulated with exactitude, even to the gain in weight by an +out-door regime. + 5. Tubercle bacilli have never been found, in the cases at the +Bronchoscopic Clinic, associated with foreign body in the bronchus.* +In cases of prolonged sojourn this has been the only element lacking +in a complete clinical picture of advanced tuberculosis. One point of +difference was the almost invariably rapid recovery after removal of +the foreign body. The statement in all of the text-books, that foreign +body is followed by phthisis pulmonalis is a relic of the days when +the bacillary origin of true tuberculosis was unknown, hence the +foreign-body phthisis pulmonalis, or pseudo tuberculosis, was confused +with the true pulmonary tuberculosis of bacillary origin. + 6. The subjective sensation of pain may allow the patient accurately +to localize a foreign body. + 7. Foreign bodies of metallic or organic nature may cause their +peculiar taste in the sputum. + 8. Offensive odored sputum should always suggest bronchial foreign +body; but absence of sputum, odorous or not, should not exclude +foreign body. + 9. Sudden complete obstruction of one main bronchus does not cause +noticeable dyspnea provided its fellow is functionating. + [131] 10. Complete obstruction of a bronchus is followed by rapid +onset of +symptoms. + 11. The physical signs usually show limitation of expansion on the +affected side, impairment of percussion, and lessened trans-mission or +absence of breath-sounds distal to the foreign body. + +* The exceptional case has at last been encountered. A boy with a tack +in the bronchus was found to have pulmonary tuberculosis. + +SYMPTOMS OF GASTRIC FOREIGN BODY + +Foreign body in the stomach ordinarily produces no symptoms. The +roentgenogram and the fluoroscopic study with an opaque mixture are +the chief means of diagnosis. + +DIAGNOSIS OF FOREIGN BODY IN THE AIR OR FOOD PASSAGES + +The questions arising are: + I. Is a foreign body present? + 2. Where is it located? + 3. Is a peroral endoscopic procedure indicated? + 4. Are there any contraindications to endoscopy? + +In order to answer these questions the definite routine given below is +followed unvaryingly in the Bronchoscopic Clinic. + 1. History. + 2. Complete physical examination, including mirror laryngoscopy. + 3. Roentgenologic study. + 4. Endoscopy. + +The history should note the date of, and should delve into the details +of the accident; special note being made of the occurrence of +laryngeal spasm, wheezing respiration heard by the patient or others +(asthmatoid wheeze), fever, cough, pain, dyspnea, dysphagia, +odynphagia, regurgitation, etc. The amount, character and odor of +sputum are important. Increasing amounts of purulent, foul-odored, +sometimes blood-tinged sputum strongly suggest prolonged bronchial +foreign body sojourn. The mode of onset of the persisting symptoms, +whether immediately following the supposed accident or delayed in +their occurrence, is to be noted. Do attacks of sudden dyspnea and +cyanosis occur? What has been the previous treatment and what attempts +at removal have been made? The nature of the foreign body is to be +determined, and if possible a duplicate thereof obtained. + +_General physical examination_ should be complete including inspection +of the eyes, ears, nose, pharynx, and mirror inspection of the +naso-pharynx and larynx. Special attention is paid to the chest for +the localization of the object. In order to discover conditions +rendering endoscopy unusually hazardous, all parts of the body are to +be examined. Aneurysm of the aorta, excessive blood pressure, serious +cardiac and renal conditions, the presence of a hernia and the +existence of central nervous disease, as tabes dorsalis, should be at +least known before attempting any endoscopic procedure. Dysphagia +might result from the pressure of an unknown aneurysm, the symptoms +being attributed to a foreign body, and aortic aneurysm is a definite +contraindication to esophagoscopy unless there be foreign body present +also. There is no absolute contraindication to the endoscopic removal +of a foreign body, though many conditions may render it wise to +post-pone endoscopy. Laryngeal crises of tabes might, because of their +sudden onset, be thought due to foreign body. + +PHYSICAL SIGNS IN ESOPHAGEAL FOREIGN BODY + +There are no constant physical signs associated with uncomplicated +impaction of a foreign body in the esophagus. Should perforation of +the cervical esophagus occur, subcutaneous emphysema, and perhaps +cellulitis, may be found; while a perforation of the thoracic region +causing mediastinitis is manifested by toxemia, fever, and rapid +sinking. Perforation of the pleura, with the development of +pyopneumothorax, is manifested by the usual signs. It is to be +emphasized that blind bouginage has no place in the diagnosis of any +esophageal condition. The roentgenologist will give the information we +desire without danger to the patient, and with far greater accuracy. + +FOREIGN BODIES IN THE LARYNX + +Laryngeally lodged foreign bodies produce a wheezing respiration, the +quality of which is peculiar to the larynx and is readily localized to +this organ. If swelling or the size of the foreign body be sufficient +to produce dyspnea, inspiratory indrawing of the suprasternal notch, +supraclavicular fossae, costal interspaces and lower sternum will be +present. Cyanosis is only an accompaniment of suddenly produced +dyspnea; the facies will therefore usually be anxious and pale, unless +the patient is seen immediately after the aspiration of the foreign +body. If labored breathing has been prolonged, and exhaustion +threatened, the heart's action will be irregular and weak. The foreign +body can be seen with the mirror, but a roentgenograph must +nevertheless be made, for the object may be of another nature than was +first thought. The roentgenograph will show its position, and from +this knowledge the plan of removal can be formulated. For example, a +straight pin may be so placed in the larynx that only a portion of its +shaft will be visible, the roentgenogram will tell where the head and +point are located, and which of these will be the more readily +disengaged. (See Chapter on Mechanical Problems.) + +PHYSICAL SIGNS OF TRACHEAL FOREIGN BODY + +If fixed in the trachea the only objective sign of foreign body may be +a wheezing respiration, the site of which may be localized with the +stethoscope, by the intensity of the sound. Movable foreign bodies may +produce a palpatory thrill, and the rumble and sudden stop can be +heard with the stethoscope and often with the naked ear. The lungs +will show equal aeration, but there may be marked dyspnea without the +indrawing of the fossae, if the object be of large size and located +below the manubrium. + +To the peculiar sound of the sudden subglottic, expiratory or bechic +arrest of the foreign body the author has given the name "audible +slap;" when felt by the thumb on the trachea he calls it the +"palpatory thud." These signs can be produced by no condition other +than the arrest of some substance by the subglottic taper. Once heard +and felt they are unmistakable. + +PHYSICAL SIGNS OF BRONCHIAL FOREIGN BODY + +In most cases there will be limitation of expansion on the invaded +side, even though the foreign body is of such a shape as to cause no +bronchial obstruction. It has been noted frequently in conjunction +with the presence of such objects as a common straight pin in a small +branch bronchus. This peculiar phenomenon was first noted by Thomas +McCrae in one of the author's cases and has since been abundantly +corroborated by McCrae and others as one of the most constant physical +signs. + +To understand the peculiar physical findings in these cases it is +necessary to remember that the bronchi are not tubes of constant +caliber; there occurs a dilatation during inspiration, and a +contraction of the lumen during expiration; furthermore, the lumen may +be narrowed by swollen mucosa if the foreign body be of an irritant +nature. The signs vary with the degree of obstruction of the bronchus, +and with the consequent degree of interference with aeration and +drainage of the subjacent portion of the lung. We have three definite +types which show practically constant signs in the earlier stages of +foreign body invasion. + + 1. Complete bronchial occlusion. + 2. Obstruction complete during expiration, but allowing the passage +of air during the bronchial dilatation incident to inspiration, +constituting an expiratory valve-like obstruction. + 3. Partial bronchial obstruction, allowing to-and-fro passage of +air. + + 1. _Complete bronchial obstruction_ is manifested by limitation of +expansion, markedly impaired percussion note, particularly at the +base, absence of breath-sounds, and rales on the invaded side. An +atelectasis here exists; the air imprisoned in the lung is soon +absorbed, and secretions rapidly accumulate. On the free side a +compensatory emphysema is present. + + 2. _Expiratory Valve-like Obstruction_.--The obstructed side shows +marked limitation of expansion. Percussion is of a tympanitic +character. The duration of the vibrations may be shortened giving a +muffled tympany. Various grades and degrees of tympany may be noted. +Breath sounds are markedly diminished or absent. No rales are heard on +the invaded side, although rales of all types may be present on the +free side. In some cases it is possible to hear a short inspiratory +sound. Vocal resonance and fremitus are but little altered. The heart +will be found displaced somewhat to the opposite side. These signs are +explained by the passage of some air past the foreign body during +inspiration with its trapping during expiration, so that there is air +under pressure constantly maintained in the obstructed area. This type +of obstruction is most frequently observed when the foreign body is of +an organic nature such as nut kernels, beans, corn, seed, etc. The +localized swelling about the irritating foreign body completes the +expiratory obstruction. It may also be present with any foreign body +whose size and shape are such as to occlude the lumen of the bronchus +during its contracted expiratory phase. It was present in cases of +pebbles, cylindrical metallic objects, thick tough balls of secretion +etcetera. The valvular action is here produced most often by a change +in the size of the valve seat and not by a movement of the foreign +body plug. In other cases I have found at bronchoscopy, a regular +ball-valve mechanism. Pneumothorax is the only pathologic condition +associated with signs similar to those of expiratory, valve-like +bronchial obstruction by a foreign body. + +3. _Partial bronchial obstruction_ by an object such as a nail allows +air to pass to and fro with some degree of retardation, and impairs +the drainage of the subjacent lung. Limitation of expansion will be +found on the invaded side. The area below the foreign body will give +an impaired percussion note. Breath-sounds are diminished in the area +of dullness, and vocal resonance and fremitus are impaired. Rales are +of great diagnostic import; the passage of air past the foreign body +is accompanied by blowing, harsh breathing, and snoring; snapping +rales are heard usually with greatest intensity posteriorly over the +site of the foreign body (usually about the scapular angle). + +A knowledge of the topographical lung anatomy, the bronchial tree, and +of endoscopic pathology* should enable the examiner of the chest to +locate very accurately a bronchial foreign body by physical signs +alone, for all the significant signs occur distal to the foreign body +lodgment. + +* Jackson, Chevalier. Pathology of Foreign Bodies in the Air and Food +Passages. Mutter Lecture, 1918. Surgery, Gynecology and Obstetrics, +March, 1919. Also, by the same author, Mechanism of the Physical Signs +of Foreign Bodies in the Lungs. Proceedings of the College of +Physicians, Philadelphia, 1922. + +_The asthmatoid wheeze_ has been found by the author a valuable +confirmatory sign of bronchial foreign body. It is a wheezing heard by +placing the observer's ear at the open mouth of the patient (not at +the chest wall) during a prolonged forced expiration. Thomas McCrae +elicits this sign by placing the stethoscope bell at the patient's +open mouth. The quality of the sound is dryer than that heard in +asthma and the wheeze is clearest after all secretion has been removed +by coughing. The mechanism of production is, probably, the passage of +air by a foreign body which narrows the lumen of a large bronchus. As +the foreign body works downward the wheeze lessens. The wheeze is +often so loud as to be heard at some distance from the patient. It is +of greatest value in the diagnosis of non-roentgenopaque foreign body +but its absence in no way negates foreign body. Its presence or +absence should be recorded in every case. + +_Prolonged bronchial obstruction_ by foreign body is followed by +bronchiectasis and lung abscess usually in a lower lobe. The symptoms +may with exactitude simulate tuberculosis, but this disease should be +readily excluded by the basal, unilateral site of the lesion, absence +of tubercle bacilli in the sputum, and roentgenographic study. Chest +examination in the foreign body cases reveals limitation of expansion, +often some retraction, flat percussion note, and greatly diminished or +absent breath-sounds over the site of the pulmonary lesion. Rales vary +with the amount of secretion present. These physical signs suggest +empyema; and rib resection had been done before admission in a number +of cases only to find the pleura normal. + +ROENTGENRAY STUDY IN FOREIGN BODY CASES + +_Roentgenography_.--All cases of chest disease should have the benefit +of a roentgenologic study to exclude bronchial foreign body as an +etiological factor. Negative opinions should never be based upon any +plates except the best that the wonderful modern development of the +art and science of roentgenology can produce. In doubtful cases, the +negative opinion should not be conclusive until a roentgenologist of +long experience in chest work, and especially in foreign body cases, +has been called in consultation. Even then there will be an occasional +case calling for diagnostic bronchoscopy. Antero-posterior and lateral +roentgenograms should always be made. In an antero-posterior film a +flat foreign body lying in the lateral body plane might be invisible +in the shadow of the spine, heart, and great vessels; but would be +revealed in the lateral view because of the greater edgewise density +of the intruder and the absence of other confusing shadows. +Fluoroscopic examination will often discover the best angle from which +to make a plate; but foreign bodies casting a very faint shadow on a +plate may be totally invisible on the fluoroscopic screen. The value +of a roentgenogram after the removal of a foreign body cannot be too +strongly emphasized. It is evidence of removal and will exclude the +presence of a second intruder which might have been overlooked in the +first study. + +Fluoroscopic study of the swallowing function with barium mixture, or +a barium-filled capsule, will give the location of a nonroentgenopaque +object (such as bone, meat, etc.) in the esophagus. If a flat or +disc-shaped object located in the cervical region is seen to be lying +in the lateral body plane, it will be found to be in the esophagus, +for it assumed that position by passing down flatwise behind the +larynx. If, however, the object is seen to be in the sagittal plane it +must lie in the trachea. This position was necessary for it to pass +through the glottic chink, and can be maintained because of the +yielding of the posterior membranous wall of the trachea. + +THE ROENTGENOGRAPHIC SIGNS OF EXPIRATORY-VALVE-LIKE BRONCHIAL +OBSTRUCTION + +The roentgenray signs in expiratory valve-like obstruction of a +bronchus are those of _an acute obstructive emphysema_ (Fig. 74), +namely, + 1. Greater transparency on the obstructed side (Iglauer). + 2. Displacement of the heart to the free side (Iglauer). + 3. Depression and flattening of the dome of the diaphragm on the +invaded side (Iglauer). + 4. Limitation of the diaphragmatic excursion on the obstructed side +(Manges). + +It is very important to note that, as discovered by Manges, the +differential emphysema occurs at the end of expiration and the plate +must be exposed at that time, before inspiration starts. He also noted +that at fluoroscopy the heart moved laterally toward the uninvaded +side during expiration.* + +* Dr. Manges has developed such a high degree of skill in the +fluoroscopic diagnosis of non-opaque foreign bodies by the obstructive +emphysema they produce that he has located peanut kernels and other +vegetable substances with absolute accuracy and unfailing certainty in +dozens of cases at the Bronchoscopic Clinic. + +[FIG. 74--Expiratory valve-like bronchial obstruction by +non-radiopaque foreign body, producing an acute obstructive emphysema. +Peanut kernel in right main bronchus. Note (a) depression of right +diaphragm; (b) displacement of heart and mediastinum to left; (c) +greater transparency of the invaded side. Ray-plate made by Willis F. +Manges.] + +_Complete bronchial obstruction_ shows a density over the whole area +the aeration and drainage of which has been cut off (Fig. 75). +Pulmonary abscess formation and "drowned lung" (accumulated secretion +in the bronchi and bronchioli) are shown by the definite shadows +produced (Fig. 76). + +[140] Dense and metallic objects will usually be readily seen in the +roentgenograms and fluoroscope, but many foreign bodies are of a +nature which will produce no shadow; the roentgenologist should, +therefore, be prepared to interpret the pulmonary pathology, and +should not dismiss the case as negative for foreign body because one +is not seen. Even metallic objects are in rare cases exceedingly +difficult to demonstrate. + +[FIG. 75.--Radiograph showing pathology resulting from complete +obstruction of a bronchus with atelectasis and drowned lung resulting. +Foot of an alarm clock in left bronchus of 4 year old child. Present +25 days. Plate made by Johnston and Grier.] + +_Positive Films of the Tracheo-bronchial Tree as an Aid to +Localization_.--In order to localize the bronchus invaded by a small +foreign body the positive film is laid over the negative of the +patient showing the foreign body. The shadow of the foreign body will +then show through the overlying positive film. These positive films +are made in twelve sizes, and the size selected should be that +corresponding to the size of the patient as shown by the +roentgenograph. The dome of the diaphragm and the dome of the pleura +are taken as visceral landmarks for placing the positive films which +have lines indicating these levels. If the shadow of the foreign body +be faint it may be strengthened by an ink mark on the +uncoated side of the plate. + +[FIG. 76.--Partial bronchial obstruction for long period of time +Pathology, bronchiectasis and pulmonary abscess, produced by the +presence for 4 years of a nail in the left lung of a boy of 10 years] + +_Bronchial mapping_ is readily accomplished by the author's method of +endobronchial insufflation of a roentgenopaque inert powder such as +bismuth subnitrate or subcarbonate (Fig. 77). The roentgenopaque +substance may be injected in a fluid mixture if preferred, but the +walls are better outlined with the powder (Fig. 77). + +[FIG. 77.--Roentgenogram showing the author's method of bronchial +mapping or lung-mapping by the bronchoscopic introduction of opaque +substances (in this instance powdered bismuth subnitrate) into the +lung of the patient. Plate made by David R. Bowen. (Illustration, +strengthened for reproduction, is from author's article in American +Journal of Roentgenology, Oct., 1918.)] + +ERRORS TO AVOID IN SUSPECTED FOREIGN BODY CASES + + 1. Do not reach for the foreign body with the fingers, lest the +foreign body be thereby pushed into the larynx, or the larynx be thus +traumatized. + 2. Do not hold up the patient by the heels, lest a tracheally lodged +foreign body be dislodged and asphyxiate the patient by becoming +jammed in the glottis. + [143] 3. Do not fail to have a roentgenogram made, if possible, +whether the foreign body in question is of a kind dense to the ray or +not. + 4. Do not fail to search endoscopically for a foreign body in all +cases of doubt. + 5. Do not pass blindly an esophageal bougie, probang, or other +instrument. + 6. Do not tell the patient he has no foreign body until after +roentgenray examination, physical examination, indirect examination, +and endoscopy have all proven negative. + +SUMMARY + +SYMPTOMATOLOGY AND DIAGNOSIS OF FOREIGN BODIES IN THE AIR AND FOOD +PASSAGES + +_Initial symptoms_ are choking, gagging, coughing, and wheezing, often +followed by a symptomless interval. The foreign body may be in the +larynx, trachea, bronchi, nasal chambers, nasopharynx, fauces, tonsil, +pharynx, hypopharynx, esophagus, stomach, intestinal canal, or may +have been passed by bowel, coughed out or spat out, with or without +the knowledge of the patient. Initial choking, etcetera may have +escaped notice, or may have been forgotten. + +_Laryngeal Foreign Body_.--One or more of the following laryngeal +symptoms may be present: Hoarseness, croupy cough, aphonia, +odynphagia, hemoptysis, wheezing, dyspnea, cyanosis, apnea, subjective +sensation of foreign body. Croupiness in foreign body cases, as in +diphtheria, usually means subglottic swelling. Obstructive foreign +body may be quickly fatal by laryngeal impaction on aspiration, or on +abortive bechic expulsion. Lodgement of a non-obstructive foreign body +may be followed by a symptomless interval. Direct laryngoscopy for +diagnosis is indicated in every child having laryngeal diphtheria +without faucial membrane. (No anesthetic, general or local is needed.) +In the presence of laryngeal symptoms, think of the following: + 1. A foreign body in the larynx. + 2. A foreign body loose or fixed in the trachea. + 3. Digital efforts at removal. + 4. Instrumentation. + 5. Overflow of food into the larynx from esophageal obstruction due +to the foreign body. + 6. Esophagotracheal fistula from ulceration set up by a foreign body +in the esophagus, followed by the leakage of food into the +air-passages. + 7. Laryngeal symptoms may persist from the trauma of a foreign body +that has passed on into the deeper air or food passages or that has +been coughed or spat out. + 8. Laryngeal symptoms (hoarseness, croupiness, etcetera) may be due +to digital or instrumental efforts at the removal of a foreign body +that never was present. + 9. Laryngeal symptoms may be due to acute or chronic laryngitis, +diphtheria, pertussis, infective laryngotracheitis, and many other +diseases. + 10. Deductive decisions are dangerous. + 11. If the roentgenray is negative, laryngoscopy (direct in +children, indirect in adults) without anesthesia, general or local, is +the only way to make a laryngeal diagnosis. + 12. Before doing a diagnostic laryngoscopy, preparation should be +made for taking a swab-specimen and for bronchoscopy and +esophagoscopy. + +_Tracheal Foreign Body_.--(1) "Audible slap," (2) "palpatory thud," +and (3) "asthmatoid wheeze" are pathognomonic. The "tracheal flutter" +has been observed by McCrae in a case of watermelon seed. Cough, +hoarseness, dyspnea, and cyanosis are often present. Diagnosis is by +roentgenray, auscultation, palpation, and bronchoscopy. Listen long +for "audible slap," best heard at open mouth during cough. The +"asthmatoid wheeze" is heard with the ear or stethoscope bell (McCrae) +at the patient's open mouth. History of initial choking, gagging, and +wheezing is important if elicited, but is valueless negatively. + +_Bronchial Foreign Body_.--Initial symptoms are coughing, choking, +asthmatoid wheeze, etc. noted above. There may be a history of these +or of tooth extraction. At once, or after a symptomless interval, +cough, blood-streaked sputum, metallic taste, or special odor of +foreign body may be noted. Non-obstructive metallic foreign bodies +afford few symptoms and few signs for weeks or months. Obstructive +foreign bodies cause atelectasis, drowned lung, and eventually +pulmonary abscess. Lobar pneumonia is an exceedingly rare sequel. +Vegetable organic foreign bodies as peanut-kernels, beans, watermelon +seeds, etcetera, cause at once violent laryngotracheobronchitis, with +toxemia, cough and irregular fever, the gravity and severity being +inversely to the age of the child. Bones, animal shells and inorganic +bodies after months or years produce changes which cause chills, +fever, sweats, emaciation, clubbed fingers, incurved nails, cough, +foul expectoration, hemoptysis, in fact, all the symptoms of chronic +pulmonary sepsis, abscess, and bronchiectasis. These symptoms and some +of the physical signs may suggest pulmonary tuberculosis, but the +apices are normal and bacilli are absent from the sputum. Every acute +or chronic chest case calls for the exclusion of foreign body. + +_The physical signs_ vary with conditions present in different cases +and at different times in the same case. Secretions, normal and +pathologic, may shift from one location to another; the foreign body +may change its position admitting more, less, or no air, or it may +shift to a new location in the same lung or even in the other lung. A +recently aspirated pin may produce no signs at all. The signs of +diagnostic importance are chiefly those of partial or complete +bronchial obstruction, though a non-obstructive foreign body, a pin +for instance, may cause limited expansion (McCrae) or, rarely, a +peculiar rale or a peculiar auscultatory sound. The most nearly +characteristic physical signs are: (1) Limited expansion; (2) +decreased vocal fremitus; (3) impaired percussion note; (4) diminished +intensity of the breath-sounds distal to the foreign body. Complete +obstruction of a bronchus followed by drowned lung adds absence of +vocal resonance and vocal fremitus, thus often leading to an erroneous +diagnosis of empyema. Varying grades of tympany are obtained over +areas of obstructive or compensatory emphysema. With complete +obstruction there may be tympany from the collapsed lung for a time. +Rales in case of complete obstruction are usually most intense on the +uninvaded side. In partial obstruction they are most often found on +the invaded side distal to the foreign body, especially posteriorly, +and are most intense at the site corresponding to that of the foreign +body. A foreign body at the bifurcation of the trachea may give signs +in both lungs. Early in a foreign body case, diminished expansion of +one side, with dulness, may suggest pneumonia in the affected side; +but absence of, or decreased, vocal resonance, and absence of typical +tubular breathing should soon exclude this diagnosis. Bronchial +obstruction in pneumonia is exceedingly rare. + +Memorize these signs suggestive of foreign body: + 1. Expansion--diminished. + 2. Percussion note--impaired (except in obstructive emphysema). + 3. Vocal fremitus--diminished. + 4. Breath sounds--diminished. + +The foregoing is only for memorizing, and must be considered in the +light of the following fundamental note by Prof. McCrae "There is no +one description of physical signs which covers all cases. If the +student will remember that complete obstruction of a bronchus leads to +a shutting off of this area, there should be little difficulty in +understanding the signs present. The diagnosis of empyema may be made, +but the outline of the area of dulness, the fact that there is no +shifting dulness, and the greater resistance which is present in +empyema nearly always clear up any difficulty promptly. The absence of +the frequent change in the voice sounds, so significant in an early +small empyema, is of value. A large empyema should give no difficulty. +If difficulty remains the use of the needle should be sufficient. In +thickened pleura vocal fremitus is not entirely absent, and the +breath-sounds can usually be heard, even if diminished. In case of +partial obstruction of a bronchus, it is evident that air will still +be present, hence the dulness may be only slight. The presence of air +and secretion will probably result in the breath-sounds being somewhat +harsh, and will cause a great variety of rales, principally coarse, +and many of them bubbling. Difficulty may be caused by signs in the +other lung or in a lobe other than the one affected by the foreign +body. If it is remembered that these signs are likely to be only on +auscultation, and to consist largely in the presence of rales, while +the signs in the area supplied by the affected bronchus will include +those on inspection, palpation, and percussion, there should be little +difficulty." + +_The roentgenray_ is the most valuable diagnostic means; but careful +notation of physical signs by an expert should be made in all cases +preferably without knowledge of ray findings. Expert ray work will +show all metallic foreign bodies and many of less density, such as +teeth, bones, shells, buttons, etcetera. If the ray is negative, a +diagnostic bronchoscopy should be done in all cases of unexplained +bronchial obstruction. + +Peanut kernels and watermelon seeds and, rarely, other foreign bodies +in the bronchi produce obstructive emphysema of the invaded side. +Fluoroscopy shows the diaphragm flattened, depressed and of less +excursion on the invaded side; at the end of expiration, the heart and +the mediastinal wall move over toward the uninvaded side and the +invaded lung becomes less dense than the uninvaded lung, from the +trapping of the air by the expiratory, valve-like effect of +obliteration of the "forceps spaces" that during inspiration afford +air ingress between the foreign body and the swollen bronchial wall. +This partial obstruction causes obstructive emphysema, which must be +distinguished from compensatory emphysema, in which the ballooning is +in the unobstructed lung, because its fellow is wholly out of function +through complete "corking" of the main bronchus of the invaded side. + +_Esophageal Foreign Body_.--After initial choking and gagging, or +without these, there may be a subjective sense of a foreign body, +constant or, more often, on swallowing. Odynphagia and dysphagia or +aphagia may or may not be present. Pain, sub-sternal or extending to +the back is sometimes present. Hematemesis and fever may occur from +the foreign body or from rough instrumentation. Symptoms referable to +the air-passages may be present due to: (1) Overflow of the secretions +on attempts to swallow through the obstructed esophagus; (2) erosion +of the foreign body through from the esophagus into the trachea; or +(3) trauma inflicted on the larynx during attempts at removal, digital +or instrumental, the foreign body still being present or not. + +Diagnosis is by the roentgenray, first without, then, if necessary, +with a capsule filled with an opaque mixture. Flat objects, like +coins, always lie with their greatest diameter in the coronal plane of +the body, when in the esophagus; in the sagittal plane, when in the +trachea or larynx. Lateral, anteroposterior, and sometimes also +quartering roentgenograms are necessary. One taken laterally, low down +on the neck but clear of the shoulder, will often show a bone or other +semiopaque object invisible in the anteroposterior exposure. + + + +[149] CHAPTER XIII--FOREIGN BODIES IN THE LARYNX AND TRACHEOBRONCHIAL +TREE + +The protective reflexes preventing the entrance of foreign bodies into +the lower air passages are: (1) The laryngeal closing reflex and (2) +the bechic reflex. Laryngeal closing for normal swallowing consists +chiefly in the tilting and the closure of the upper laryngeal orifice. +The ventricular bands help but slightly; and the epiglottis and the +vocal cords little, if at all. The gauntlet to be run by foreign +bodies entering the tracheobronchial tree is composed of: + 1. Epiglottis. + 2. Upper laryngeal orifice. + 3. Ventricular bands. + 4. Vocal cords. + 5. Bechic blast. + +The epiglottis acts somewhat as a fender. The superior laryngeal +aperture, composed of a pair of movable ridges of tissue, has almost a +sphincteric action, in addition to a tilting movement. The ventricular +bands can approximate under powerful stimuli. The vocal cords act +similarly. The one defect in the efficiency of this barrier, is the +tendency to take a deep inspiration preparatory to the cough excited +by the contact of a foreign body. + +_Site of Lodgment_.--The majority of foreign bodies in the air +passages occur in children. The right bronchus is more frequently +invaded than the left because of the following factors: I. Its greater +diameter. 2. Its lesser angle of deviation from the tracheal axis. 3. +The situation of the carina to the left of the mid-line of the +trachea. 4. The action of the trachealis muscle. 5. The greater volume +of air going into the right bronchus on inspiration. + +The middle lobe bronchus is rarely invaded by foreign body, and, +fortunately, in less than one per cent of the cases is the object in +an upper lobe bronchus. + +_Spontaneous Expulsion of Foreign Bodies from the Air Passages_. A +large, light, foreign body in the larynx or trachea may occasionally +be coughed out, but the frequent newspaper accounts of the sudden +death of children known to have aspirated objects should teach us +never to wait for this occurrence. The cause of death in these cases +is usually the impaction of a large foreign body in the glottis +producing sudden asphyxiation, and in a certain proportion of these +cases the impaction has occurred on the reverse journey, when cough +forced the intruder upward from below. The danger of subglottic +impaction renders it imperative that attempts to aid spontaneous +expulsion by inverting the patient should be discouraged. Sharp +objects, such as pins, are rarely coughed out. The tendency of all +foreign bodies is to migrate down and out to the periphery as their +size and shape will allow. Most of the reported cases of bechic +expulsion of bronchially lodged foreign bodies have occurred after a +prolonged sojourn of the object, associated which much lung pathology; +and in some cases the object has been carried out along with an +accumulation of pus suddenly liberated from an abscess cavity, and +expelled by cough. This is a rare sequence compared to the usual +formation of fibrous stricture above the foreign body that prevents +the possibility of bechic expulsion. To delay bronchoscopy with the +hope of such a solution of the problem is comparable to the former +dependence on nature for the cure of appendiceal abscess. + +We do our full duty when we tell the patient or parents that while the +foreign body may be coughed up, it is very dangerous to wait; and, +further, that the difficulty of removal usually increases with the +time the foreign body is allowed to remain in the air passages. + +_Mortality and morbidity of bronchoscopy_ vary directly with the +degree of skill and experience of the operator, and the conditions for +which the endoscopies are performed. The simple insertion of the +bronchoscope is devoid of harm if carefully done. The danger lies in +misdirected efforts at removal of the intruder and in repeating +bronchoscopies in children at too frequent intervals, or in prolonging +the procedure unduly. In children under one year endoscopy should be +limited to twenty minutes, and should not be repeated sooner than one +week after, unless urgently indicated. A child of 5 years will bear 40 +to 60 minutes work, while the adult offers no unvarying time limit. +More can be ultimately accomplished, and less reaction will follow +short endoscopies repeated at proper intervals than in one long +procedure. + +_Indications for bronchoscopy for suspected foreign body_ may be thus +summarized: + 1. The appearance of a suspicious shadow in the radiograph, in the +line of a bronchus. + 2. In any case in which lung symptoms followed a clear history of +the patient having choked on a foreign body. + 3. In any case showing signs of obstruction in the trachea or of a +bronchus. + 4. In suspected bronchiectasis. + 5. Symptoms of pulmonary tuberculosis with sputum constantly +negative for tubercle bacilli. If the physical signs are at the base, +particularly the right base, the indication becomes very strong even +in the absence of any foreign body circumstance in the history. + 6. In all cases of doubt, bronchoscopy should be done anyway. + +There is no absolute _contraindication to bronchoscopy for foreign +bodies_. Extreme exhaustion or reaction from previous efforts at +removal may call for delay for recuperation, but pulmonary abscess and +even the rarer complications, bronchopneumonia and gangrene of the +lung, are improved by the early removal of the foreign body. + +_Choice of Time to do Bronchoscopy for Foreign Body_.--The +difficulties of removal usually increase from the time of aspiration +of the object. It tends to work downward and outward, while the mucosa +becomes edematous, partly closing over the foreign body, and even +completely obliterating the lumen of smaller bronchi. Later, +granulation tissue and the formation of stricture further hide the +object. The patient's health deteriorates with the onset of pulmonary +pathology, and renders him a less favorable subject for bronchoscopy. +Organic foreign bodies, which produce early and intense inflammatory +reaction and are liable to swell, call for prompt bronchoscopy. When a +bronchus is completely obstructed by the bulk of the foreign body +itself immediate removal is urgently demanded to prevent serious lung +changes, resulting from atelectasis and want of drainage. In short, +removal of the foreign body should be accomplished as soon as possible +after its entrance. This, however, does not justify hasty, +ill-planned, and poorly equipped bronchoscopy, which in most cases is +doomed to failure in removal of the object. The bronchoscopist should +not permit himself to be stampeded into a bronchoscopy late at night, +when he is fatigued after a hard day's work. + +_Bronchoscopic finding of a foreign body_ is not especially difficult +if the aspiration has been recent. If secondary processes have +developed, or the object be small and in a bronchus too small to admit +the tube-mouth, considerable experience may be necessary to discover +it. There is usually inflammatory reaction around the orifice of the +invaded bronchus, which in a measure serves to localize the intruder. +We must not forget, however, that objects may have moved to another +location, and also that the irritation may have been the result of +previous efforts at removal. Care must be exercised not to mistake the +sharp, shining, interbronchial spurs for bright thin objects like new +pins just aspirated; after a few days pins become blackened. If these +spurs be torn pneumothorax may ensue. If a number of small bronchi are +to be searched, the bronchoscope must be brought into the line of the +axis of the bronchus to be examined, and any intervening tissue gently +pushed aside with the lip of the bronchoscope. Blind probing for +exploration is very dangerous unless carefully done. The straight +forceps, introduced closed, form the best probe and are ready for +grasping if the object is felt. Once the bronchoscope has been +introduced, it should not be withdrawn until the procedure is +completed. The light carrier alone may be removed from its canal if +the illumination be faulty. + +COMPLICATIONS AND AFTER-EFFECTS OF BRONCHOSCOPY + +All foreign body cases should be watched day and night by special +nurses until all danger of complications is passed. Complications are +rare after careful work, but if they do occur, they may require +immediate attention. This applies especially to the subglottic edema +associated with arachidic bronchitis in children under 2 years of age. + +_General Reaction_.--There is usually no elevation in temperature +following a short bronchoscopy for the removal of a recently lodged +metallic foreign body. If, however, an inflammatory condition of the +bronchi existed previous to the bronchoscopy, as for instance the +intense diffuse, purulent laryngotracheobronchitis associated with +the aspiration of nut kernels, or in the presence of pulmonary abscess +from long retained foreign bodies, a moderate temporary rise of +temperature may be expected. These cases almost always have had +irregular fever before bronchoscopy. Disturbance of the epithelium in +the presence of pus without abscess usually permits enough absorption +to elevate the temperature slightly for a few days. + +_Surgical shock_ in its true form has never followed a carefully +performed and time-limited bronchoscopy. Severe fatigue resulting in +deep sleep may be seen in children after prolonged work. + +_Local reaction_ is ordinarily noted by slight laryngeal congestion +causing some hoarseness and disappearing in a few days. If dyspnea +occur it is usually due to (1) Drowning of the patient in his own +secretions. (2) Subglottic edema. (3) Laryngeal edema. + +_Drowning of the Patient in His Own Secretions_.--The accumulation of +secretions in the bronchi due to faulty bechic powers and seen most +frequently in children, is quickly relievable by bronchoscopic +sponge-pumping or aspiration through the tracheotomic wound, in cases +in which the tracheotomy may be deemed necessary. In other cases, the +aspirating bronchoscope with side drainage canal (Fig. 1, E) may be +used through the larynx. Frequent peroral passage of the bronchoscope +for this purpose is contraindicated only in case of children under 3 +years of age, because of the likelihood of provoking subglottic edema. +In such cases instead of inserting a bronchoscope the aspirating tube +(Fig. 9) should be inserted through the direct laryngoscope, or a low +tracheotomy should be done. + +_Supraglottic edema_ is rarely responsible for dyspnea except when +associated with advanced nephritis. + +_Subglottic edema_ is a complication rarely seen except in children +under 3 years of age. They have a peculiar histologic structure in +this region, as is shown by Logan Turner. Even at the predisposing age +subglottic edema is a very unusual sequence to bronchoscopy if this +region was previously normal. The passage of a bronchoscope through an +already inflamed subglottic area is liable to be followed by a +temporary increase in the swelling. If the foreign body be associated +with but slight amount of secretion, the child can usually obtain +sufficient air through the temporarily narrowed lumen. If, however, as +in cases of arachidic bronchitis, large amounts of purulent secretion +must be expelled, it will be found in certain cases that the decreased +glottic lumen and impaired laryngeal motility will render tracheotomy +necessary to drain the lungs and prevent drowning in the retained +secretions. Subglottic edema occurring in a previously normal larynx +may result from: 1. The use of over-sized tubes. 2. Prolonged +bronchoscopy. 3. Faulty position of the patient, the axis of the tube +not being in that of the trachea. 4. Trauma from undue force or +improper direction in the insertion of the bronchoscope. 5. The +manipulation of instruments. 6. Trauma inflicted in the extraction of +the foreign body. + +_Diagnosis_ must be made without waiting for cyanosis which may never +appear. Pallor, restlessness, startled awakening after a few minutes +sleep, occurring in a child with croupy cough, indrawing around the +clavicles, in the intercostal spaces, at the suprasternal notch and at +the epigastrium, call for tracheotomy which should always be low. Such +a case should not be left unwatched. The child will become exhausted +in its fight for air and will give up and die. The respiratory rate +naturally increases because of air hunger, accumulating secretions +that cannot be expelled because of impaired glottic motility give +signs wrongly interpreted as pneumonia. Many children whose lives +could have been saved by tracheotomy have died under this erroneous +diagnosis. + +_Treatment_.--Intubation is not so safe because the secretions cannot +easily be expelled through the tube and postintubational stenosis may +be produced. Low tracheotomy, the tracheal incision always below the +second ring, is the safest and best method of treatment. + + + +[156] CHAPTER XIV--REMOVAL OF FOREIGN BODIES FROM THE LARYNX + +_Symptoms and Diagnosis_.--The history of a sudden choking attack +followed by impairment of voice, wheezing, and more or less dyspnea +can be usually elicited. Laryngeal diphtheria is the condition most +frequently thought of when these symptoms are present, and antitoxin +is rightly given while waiting for a positive diagnosis. Extreme +dyspnea may render tracheotomy urgently demanded before any attempts +at diagnosis are made. Further consideration of the symptomatology and +diagnosis of laryngeal foreign body will be found on pages 128, 133 +and 143. + +_Preliminary Examination_.--In the adult, mirror examination of the +larynx should be done, the patient being placed in the recumbent +position. Whenever time permits roentgenograms, lateral and +anteroposterior, should be made, the lateral one as low in the neck as +possible. One might think this an unnecessary procedure because of the +visibility of the larynx in the mirror; but a child's larynx cannot +usually be indirectly examined, and even in the adult a pin may be so +situated that neither head nor point is visible, only a portion of the +shaft being seen. The roentgenogram will give accurate information as +to the position, and will thus allow a planning of the best method for +removal of the foreign body. A bone in the larynx usually is visible +in a good roentgenogram. Accurate diagnosis in children is made by +direct laryngoscopy without anesthesia, but direct laryngoscopy should +not be done until one is prepared to remove a foreign body if found, +to follow it into the bronchus and remove it if it should be dislodged +and aspirated, and to do tracheotomy if sudden respiratory arrest +occur. + +[157] _Technic of Removal of Foreign Bodies from the Larynx_.--The +patient is to be placed in the author's position, shown in Fig. 53. No +general anesthesia should be given, and the application of local +anesthesia is usually unnecessary and further, is liable to dislodge +and push down the foreign body.* Because of the risk of loss downward +it is best to seize the foreign body as soon as seen; then to +determine how best to disimpact it. The fundamental principles are +that a pointed object must either have its point protected by the +forceps grasp or be brought out point trailing, and that a flat object +must be so rotated that its plane corresponds to the sagittal plane of +the glottic chink. The laryngeal grasping forceps (Fig. 53) will be +found the most useful, although the alligator rotation forceps (Fig. +31) may occasionally be required. + +* In adolescents or adults a few drops of a 4 per cent solution of +cocain applied to the laryngopharynx with an atomizer or a dropper +will afford the minimum risk of dislodgement; but the author's +personal preference is for no anesthesia, general or local. + + + +[158] CHAPTER XV--MECHANICAL PROBLEMS OF BRONCHOSCOPIC FOREIGN BODY +EXTRACTION* + +* For more extensive consideration of mechanical problems than is here +possible the reader is referred to the Bibliography, page 311, +especially reference numbers 1, 11, 37 and 56. + +The endoscopic extraction of a foreign body is a mechanical problem +pure and simple, and must be studied from this viewpoint. Hasty, +ill-equipped, ill-planned, or violent endoscopy on the erroneous +principle that if not immediately removed the foreign body will be +fatal, is never justifiable. While the lodgement of an organic foreign +body (such as a nut kernel) in the bronchus calls for prompt removal +and might be included under the list of emergency operations, time is +always available for complete preparation, for thorough study of the +patient, and localization of the intruder. The patient is better off +with the foreign body in the lung than if in its removal a +mediastinitis, rupture into the pleura, or tearing of a thoracic blood +vessel has resulted. The motto of the endoscopist should be "I will do +no harm." If no harm be inflicted, any number of bronchoscopies can be +done at suitable intervals, and eventually success will be achieved, +whereas if mortality results, all opportunity ceases. + +The first step in the solution of the mechanical problem is the study +of the roentgenograms made in at least three planes; (1) +anteroposterior, (2) lateral, and (3) the plane corresponding to the +greatest plane of the foreign body. The next step is to put a +duplicate of the foreign body into the rubber-tube manikin previously +referred to, and try to simulate the probable position shown by the +ray, so as to get an idea of the bronchoscopic appearance of the +probable presentation. Then the duplicate foreign body is turned into +as many different positions as possible, so as to educate the eye to +assist in the comprehension of the largest possible number of +presentations that may be encountered at the bronchoscopy on the +patient. For each of these presentations a method of disimpaction, +disengagement, disentanglement or version and seizure is worked out, +according to the kind of foreign body. Prepared by this practice and +the radiographic study, the bronchoscope is introduced into the +patient. The location of the foreign body is approached slowly and +carefully to avoid overriding or displacement. A _study of the +presentation_ is as necessary for the bronchoscopist as for the +obstetrician. It should be made with a view to determining the +following points: + 1. The relation of the presenting part to the surrounding tissues. + 2. The probable position of the unseen portion, as determined by the +appearance of the presenting part taken in connection with the +knowledge obtained by the previous ray study, and by inspection of the +ray plate upside down on view in front of the bronchoscopist. + 3. The version or other manipulation necessary to convert an +unfavorable into a favorable presentation for grasping and +disengagement. + 4. The best instruments to use, and which to use first, as, hook, +pincloser, forceps, etc. + 5. The presence and position of the "forceps spaces" of which there +must be two for all ordinary forceps, one for each jaw, or the +"insertion space" for any other instrument. + +Until all of these points are determined it is a grave error to insert +any kind of instrument. If possible even swabbing of the foreign body +should be avoided by swabbing out the bronchus, when necessary, before +the region of the intruder is reached. When the operator has +determined the instrument to be used, and the method of using it, the +instrument is cautiously inserted, under guidance of the eye. + +[160] _The lip of the bronchoscope_ is one of the most valuable aids +in the solution of foreign-body problems. With it partial or complete +version of an object can be accomplished so as to convert an +unfavorable presentation into one favorable for grasping with the +forceps; edematous mucosa may be displaced, angles straightened and +space made at the side of the foreign body for the forceps' jaw. It +forms a shield or protector that can be slipped under the point of a +sharp foreign body and can make counterpressure on the tissues while +the forceps are disembedding the point of the foreign body. With the +bronchoscopic lip and the forceps or other instrument inserted through +the tube, the bronchoscopist has bimanual, eye-guided control, which +if it has been sufficiently practiced to afford the facility in +coordinate use common to everyone with knife and fork, will accomplish +maneuvers that seem marvelous to anyone who has not developed facility +in this coordinate use of the bronchoscopic instruments. + +_The relation of the tube mouth and foreign body_ is of vital +importance. Generally considered, the tube mouth should be as near the +foreign body as possible, and the object must be placed in the center +of the bronchoscopic field, so that the ends of the open jaws of the +forceps will pass sufficiently far over the object. But little lateral +control is had of the long instruments inserted through the tube; +sidewise motion is obtained by a shifting of the end of the +bronchoscope. When the foreign body has been centered in the +bronchoscopic field and placed in a position favorable for grasping, +it is important that this position be maintained by anchoring the tube +to the upper teeth with the left, third, and fourth fingers hooked +over the patient's upper alveolus (Fig. 63) + +_The Light Reflex on the Forceps_.--It is often difficult for the +beginner to judge to what depth an instrument has been inserted +through the tube. On slowly inserting a forceps through the tube, as +the blades come opposite the distal light they will appear brightly +illuminated; or should the blades lie close to the light bulb, a +shadow will be seen in the previously brilliantly lighted opposite +wall. It is then known that the forceps are at the tube mouth, and the +endoscopist has but to gauge the distance from this to the foreign +body. This assistance in gauging depth is one of the great advances in +foreign body bronchoscopy obtained by the development of distal +illumination. + +_Hooks_ are useful in the solution of various mechanical problems, and +may be turned by the operator himself into various shapes by heating +small probe-pointed steel rods in a spirit lamp, the proximal end +being turned over at a right angle for a controlling handle. Hooks +with a greater curve than a right angle are prone to engage in small +orifices from which they are with difficulty removed. A right angle +curve of the distal end is usually sufficient, and a corkscrew spiral +is often advantageous, rendering removal easy by a reversal of the +twisting motion (Bib. 11, p. 311). + +_The Use of Forceps in Endoscopic Foreign Body Extraction_.--Two +different strengths of forceps are supplied, as will be seen in the +list in Chapter 1. The regular forceps have a powerful grasp and are +used on dense foreign bodies which require considerable pressure on +the object to prevent the forceps from slipping off. For more delicate +manipulation, and particularly for friable foreign bodies, the lighter +forceps are used. Spring-opposed forceps render any delicacy of touch +impossible. Forceps are to be held in the right hand, the thumb in one +ring, and the third, or ring finger, in the other ring. These fingers +are used to open and close the forceps, while all traction is to be +made by the right index finger, which has its position on the forceps +handle near the stylet, as shown in Fig. 78. It is absolutely +essential for accurate work, that the forceps jaws be seen to close +upon the foreign body. The impulse to seize the object as soon as it +is discovered must be strongly resisted. A careful study of its size, +shape, and position and relation to surrounding structures must be +made before any attempt at extraction. The most favorable point and +position for grasping having been obtained, the closed forceps are +inserted through the bronchoscope, the light reflex obtained, the +forceps blades now opened are turned in such a position that, on +advancing, the foreign body will enter the open V, a sufficient +distance to afford a good grasp. The blades are then closed and the +foreign body is drawn against the tube mouth. Few foreign bodies are +sufficiently small to allow withdrawal through the tube, so that tube, +forceps and foreign body are usually withdrawn together. + +[FIG. 78.--Proper hold of forceps. The right thumb and third fingers +are inserted into the rings while the right index finger has its place +high on the handle. All traction is made with the index finger, the +ring fingers being used only to open and close the forceps. If any +pushing is deemed safe it may be done by placing the index finger back +of the thumb-nut on the stylet.] + +_Anchoring the Foreign Body Against the Tube Mouth_.--If withdrawal be +made a bimanual procedure it is almost certain that the foreign body +will trail a centimeter or more beyond the tube mouth, and that the +closure of the glottic chink as soon as the distal end of the +bronchoscope emerges will strip the foreign body from the forceps +grasp, when the foreign body reaches the cords. This is avoided by +anchoring the foreign body against the tube mouth as soon as the +foreign body is grasped, as shown in Fig. 79. The left index finger +and thumb grasp the shaft of the forceps close to the ocular end of +the tube, while the other fingers encircle the tube; closure of the +forceps is maintained by the fingers of the right hand, while all +traction for withdrawal is made with the left hand, which firmly +clamps forceps and bronchoscope as one piece. Thus the three units are +brought out as one; the bronchoscope keeping the cords apart until the +foreign body has entered the glottis. + +[FIG. 79--Method of anchoring the foreign body against the tube mouth +After the object has been drawn firmly against the lip of the +endoscopic tube the left finger and thumb grasp the forceps cannula +and lock it against the ocular end of the tube, the other fingers of +the left hand encircle the tube. Withdrawal is then done with the left +hand; the fingers of the right hand maintaining closure of the +forceps.] + +[164] _Bringing the Foreign Body Through the Glottis_.--Stripping of +the foreign body from the forceps at the glottis may be due to: + 1. Not keeping the object against the tube mouth as just mentioned. + 2. Not bringing the greatest diameter of the foreign body into the +sagittal plane of the glottic chink. + 3. Faulty application of the forceps on the foreign body. + 4. Mechanically imperfect forceps. + +Should the foreign body be lost at the glottis it may, if large become +impacted and threaten asphyxia. Prompt insertion of the laryngoscope +will usually allow removal of the object by means of the laryngeal +grasping forceps. The object may be dropped or expelled into the +pharynx and be swallowed. It may even be coughed into the naso-pharynx +or it may be re-aspirated. In the latter event the bronchoscope is to +be re-inserted and the trachea carefully searched. Care must be used +not to override the object. If much inflammatory reaction has occurred +in the first invaded bronchus, temporarily suspending the aerating +function of the corresponding lung, reaspiration of a dislodged +foreign body is liable to carry it into the opposite main bronchus, by +reason of the greater inspiratory volume of air entering that side. +This may produce sudden death by blocking the only aerating organ. + +_Extraction of Pins, Needles and Similar Long Pointed Objects_.--When +searching for such objects especial care must be taken not to override +them. Pins are almost always found point upward, and the dictum can +therefore be made, "Search not for the pin, but for the point of the +pin." If the point be found free, it should be worked into the lumen +of the bronchoscope by manipulation with the lip of the tube. It may +then be seized with the forceps and withdrawn. Should the pin be +grasped by the shaft, it is almost certain to turn crosswise of the +tube mouth, where one pull may cause the point to perforate, +enormously increasing the difficulties by transfixation, and perhaps +resulting fatally (Fig. 80). + +[FIG. 80.--Schematic illustration of a serious phase of the error of +hastily seizing a transfixed pin near its middle, when first seen as +at M. Traction with the forceps in the direction of the dart in Schema +B will rip open the esophagus or bronchus inflicting fatal trauma, and +probably the pin will be stripped off at the glottic or the +cricopharyngeal level, respectively. The point of the pin must be +disembedded and gotten into the tube mouth as at A, to make forceps +traction safe.] + +[FIG. 81.--Schema illustrating the mechanical problem of extracting a +pin, a large part of whose shaft is buried in the bronchial wall, B. +The pin must be pushed downward and if the orifice of the branches, C, +D, are too small to admit the head of the pin some other orifice (as +at A) must be found by palpation (not by violent pushing) to admit the +head, so that the pin can be pushed downward permitting the point to +emerge (E). The point is then manipulated into the bronchoscopic +tube-mouth by means of co-ordinated movements of the bronchoscopic lip +and the side-curved forceps, as shown at F.] + +_Inward Rotation Method_.--When the point is found to be buried in the +mucosa, the best and usually successful method is to grasp the pin as +near the point as possible with the side-grasping forceps, then with a +spiral motion to push the pin downward while rotating the forceps +about ninety degrees. The point is thus disengaged, and the shaft of +the pin is brought parallel with that of the forceps, after which the +point may be drawn into the tube mouth. The lips added to the +side-curved forceps by my assistant Dr. Gabriel Tucker I now use +exclusively for this inward rotation method. They are invaluable in +preventing the escape of the pin during the manipulation. A hook is +sometimes useful in disengaging a buried point. The method of its use +is illustrated in Fig. 82. + +[FIG. 82.--Mechanical problem of pin, needle, tack or nail with +embedded point. If the forceps are pulled upon the pin point will be +buried still deeper. The side curved forceps grasp the pin as near the +point as possible then with a corkscrew motion the pin is pushed +downward and rotated to the right when the pin will be found to be +parallel with the shaft of the forceps and can be drawn into the tube. +If the pin is prevented by its head from being pushed downward the +point may be extracted by the hook as shown above The side curved +forceps may be used instead of the hook for freeing the point, the +author's "inward rotation" method. The very best instrument for the +purpose is the forceps devised by my assistant, Dr. Gabriel Tucker +(Fig. 21). The lips prevent all risk of losing the pin from the grasp, +and at the same time bring the long axis of the pin parallel to that +of the bronchoscope.] + +Pins are very prone to drop into the smaller bronchi and disappear +completely from the ordinary field of endoscopic exploration. At other +times, pins not dropping so deeply may show the point only during +expiration or cough, at which times the bronchi are shortened. In such +instances the invaded bronchial orifice should be clearly exposed as +near the axis of its lumen as possible; the forceps are now inserted, +opened, and the next emergence watched for, the point being grasped as +soon as seen. + +_Extraction of Tacks, Nails and Large Headed Foreign Bodies from the +Tracheobronchial Tree_.--In cases of this sort the point presents the +same difficulty and requires solution in the same manner as mentioned +in the preceding paragraphs on the extraction of pins. The author's +inward-rotation method when executed with the Tucker forceps is ideal. +The large head, however, presents a special problem because of its +tendency to act as a mushroom anchor when buried in swollen mucosa or +in a fibrous stenosis (Fig. 83). The extraction problems of tacks are +illustrated in Figs. 84, 85, and 86. Nails, stick pins, and various +tacks are dealt with in the same manner by the author's "inward +rotation" method. + +_Hollow metallic bodies_ presenting an opening toward the observer may +be removed with a grooved expansile forceps as shown in Figs 23 and +25, or its edge may be grasped by the regular side-grasping forceps. +The latter hold is apt to be very dangerous because of the trauma +inflicted by the catching of the free edge opposite the forceps; but +with care it is the best method. Should the closed end be uppermost, +however, it may be necessary to insert a hook beyond the object, and +to coax it upward to a point where it may be turned for grasping and +removal with forceps. + +[FIG. 83.--"Mushroom anchor" problem of the upholstery tack. If the +tack has not been _in situ_ more than a few weeks the stenosis at the +level of the darts is simply edematous mucosa and the tack can be +pulled through with no more than slight mucosal trauma, _provided_ +axis-traction only be used. If the tack has been in situ a year or +more the fibrous stricture may need dilatation with the divulsor. +Otherwise traction may rupture the bronchial wall. The stenotic tissue +in cases of a few months' sojourn maybe composed of granulations, in +which case axis-traction will safely withdraw it. The point of a tack +rarely projects freely into the lumen as here shown. More often it is +buried in the wall.] + +[168] [FIG. 84.-Schema illustrating the "mushroom anchor" problem of +the brass headed upholstery tack. At A the tack is shown with the head +bedded in swollen mucosa. The bronchoscopist, looking through the +bronchoscope, E, considering himself lucky to have found the point of +the tack, seizes it and starts to withdraw it, making traction as +shown by the dart in drawing B. The head of the tack catches below a +chondrial ring and rips in, tearing its way through the bronchial wall +(D) causing death by mediastinal emphysema. This accident is still +more likely to occur if, as often happens, the tack-head is lodged in +the orifice of the upper lobe bronchus, F. But if the bronchoscopist +swings the patient's head far to the opposite side and makes +axis-traction, as shown at C, the head of the tack can be drawn +through the swollen mucosa without anchoring itself in a cartilage. If +necessary, in addition, the lip of the bronchoscope can be used to +repress the angle, h, and the swollen mucosa, H. If the swollen +mucosa, H, has been replaced by fibrous tissue from many months' +sojourn of the tack, the stenosis may require dilatation with the +divulsor.] + +[FIG. 85.--Problem of the upholstery tack with buried point. If pulled +upon, the imminent perforation of the mediastinum, as shown at A will +be completed, the bronchus will be torn and death will follow even if +the tack be removed, which is of doubtful possibility. The proper +method is gently to close the side curved forceps on the shank of the +tack near the head, push downward as shown by the dart, in B, until +the point emerges. Then the forceps are rotated to bring the point of +the tack away from the bronchial wall.] + +[169] _Removal of Open Safety Pins from the Trachea and Bronchi_.-- +Removal of a closed safety pin presents no difficulty if it is grasped +at one or the other end. A grasp in the middle produces a "toggle +and ring" action which would prevent extraction. When the +safety pin is _open with the point downward_ care must be exercised +not to override it with the bronchoscope or to push the point through +the wall. The spring or near end is to be grasped with the side-curved +or the rotation forceps (Figs. 19, 20 and 31) and pulled into the +bronchoscope, thus closing the pin. An open safety pin lodged point up +presents an entirely different and a very difficult problem. If +traction is made without closing the pin or protecting the point +severe and probably fatal trauma will be produced. The pin may be +closed with the pin-closer as illustrated in Fig. 37, and then removed +with forceps. Arrowsmith's pin-closer is excellent. Another method +(Fig. 87) consists in bringing the point of the safety pin into the +bronchoscope, after disengaging the point with the side curved +forceps, by the author's "inward rotation" method. The forceps-jaws +(Fig. 21) devised recently by my assistant, Dr. Gabriel Tucker, are +ideal for this maneuver. As the point is now protected, the spring, +seen just off the tube mouth, is best grasped with the rotation +forceps, which afford the securest hold. The keeper and its shaft are +outside the bronchoscope, but its rounded portion is uppermost and +will glide over the tissues without trauma upon careful withdrawal of +the tube and safety pin. Care must be taken to rotate the pin so that +it lies in the sagittal plane of the glottis with the keeper placed +posteriorly, for the reason that the base of the glottic triangle is +posterior, and that the posterior wall of the larynx is membranous +above the cricoid cartilage, and will yield. A small safety-pin may be +removed by version, the point being turned into a branch bronchial +orifice. No one should think of attempting the extraction of a safety +pin lodged point upward without having practiced for at least a +hundred hours on the rubber tube manikin. This practice should be +carried out by anyone expecting to do endoscopy, because it affords +excellent education of the eye and the fingers in the endoscopic +manipulation of any kind of foreign body. Then, when a safety pin case +is encountered, the bronchoscopist will be prepared to cope with its +difficulties, and he will be able to determine which of the methods +will be best suited to his personal equation in the particular case. + +[FIG. 86.--Schema illustrating the "upper-lobe-bronchus problem," +combined with the "mushroom-anchor" problem and the author's method +for their solution. The patient being recumbent, the bronchoscopist +looking down the right main bronchus, M, sees the point of the tack +projecting from the right upper-lobe-bronchus, A. He seizes the point +with the side-curved forceps; then slides down the bronchoscope to the +position shown dotted at B. Next he pushes the bronchoscopic +tube-mouth downward and medianward, simultaneously moving the +patient's head to the right, thus swinging the bronchoscopic level on +its fulcrum, and dragging the tack downward and inward out of its bed, +to the position, 1). Traction, as shown at C, will then safely and +easily withdraw the tack. A very small bronchoscope is essential. The +lip of the bronchoscopic tube-mouth must be used to pry the forceps +down and over, and the lip must be brought close to the tack just +before the prying-pushing movement. S, right stem-bronchus.] + +[FIG. 87.--One method of dealing with an open safety pin without +closing it.] + +_Removal of Double Pointed Tacks_.--If the tack or staple be small, +and lodged in a relatively large trachea a version may be done. That +is, the staple may be turned over with the hook or rotation forceps +and brought out with the points trailing. With a long staple in a +child's trachea the best method is to "coax" the intruder along gently +under ocular guidance, never making traction enough to bury the point +deeply, and lifting the point with the hook whenever it shows any +inclination to enter the wall. Great care and dexterity are required +to get the intruder through the glottis. In certain locations, one or +both points may be turned into branch bronchi as illustrated in Fig. +88, or over the carina into the opposite main bronchus. Another method +is to get both points into the tube-mouth. This may be favored, as +demonstrated by my assistant, Dr. Gabriel Tucker, by tilting the +staple so as to get both points into the longest diameter of the +tube-mouth. In some cases I have squeezed the bronchoscope in a vise +to create an oval tube-mouth. In other cases I have used expanding +forceps with grooved blades. + +[FIG. 88.-Schema illustrating podalic version of bronchially-lodged +staples or double-pointed tacks. H, bronchoscope. A, swollen mucosa +covering points of staple. At E the staple has been manipulated upward +with bronchoscopic lip and hooks until the points are opposite the +branch bronchial orifices, B, C. Traction being made in the direction +of the dart (F), by means of the rotation forceps, and counterpressure +being made with the bronchoscopic lip on the points of the staple, the +points enter the branch bronchi and permit the staple to be turned +over and removed with points trailing harmlessly behind (K).] + +_The Extraction of Tightly Fitting Foreign Bodies from the Bronchi. +Annular Edema_.--Such objects as marbles, pebbles, corks, etc., are +drawn deeply and with force by the inspiratory blast into the smallest +bronchus they can enter. The air distal to the impacted foreign body +is soon absorbed, and the negative pressure thus produced increases +the impaction. A ring of edematous mucosa quickly forms and covers the +presenting part of the object, leaving visible only a small surface in +the center of an acute edematous stenosis. A forceps with narrow, +stiff, expansive-spring jaws may press back a portion of the edema and +may allow a grasp on the sides of the foreign body; but usually the +attempt to apply forceps when there are no spaces between the +presenting part of the foreign body and the bronchial wall, will +result only in pushing the foreign body deeper.* A better method is to +use the lip of the bronchoscope to press back the swollen mucosa at +one point, so that a hook may be introduced below the foreign body, +which then can be worked up to a wider place where forceps may be +applied (Fig. 89). Sometimes the object may even be held firmly +against the tube mouth with the hook and thus extracted. For this the +unslanted tube-mouth is used. + +* The author's new ball forceps are very successful with ball-bearing +balls and marbles. + +[FIG. 89.--Schema illustrating the use of the lip of the bronchoscope +in disimpaction of foreign bodies. A and B show an annular edema above +the foreign body, F. At C the edematous mucosa is being repressed by +the lip of the tube mouth, permitting insinuation of the hook, H, past +one side of the foreign body, which is then withdrawn to a convenient +place for application of the forceps. This repression by the lip is +often used for purposes other than the insertion of hooks. The lip of +the esophagoscope can be used in the same way.] + +_Extraction of Soft Friable Foreign Bodies from the Tracheobronchial +Tree_.--The difficulties here consist in the liability of crushing or +fragmenting the object, and scattering portions into minute bronchi, +as well as the problem of disimpaction from a ring of annular edema, +with little or no forceps space. There is usually in these cases an +abundance of purulent secretion which further hinders the work. The +great danger of pushing the foreign body downward so that the swollen +mucosa hides it completely from view, must always be kept in mind. +Extremely delicate forceps with rather broad blades are required for +this work. The fenestrated "peanut" forceps are best for large pieces +in the large bronchi. The operator should develop his tactile sense +with forceps by repeated practice in order to acquire the skill to +grasp peanut kernels sufficiently firmly to hold them during +withdrawal, yet not so firmly as to crush them. Nipping off an edge by +not inserting the forceps far enough is also to be avoided. Small +fragments under 2 mm. in diameter may be expelled with the secretions +and fragments may be found on the sponges and in the secretions +aspirated or removed by sponge pumping. It is, however, never +justifiable deliberately to break a friable foreign body with the hope +that the fragments will be expelled, for these may be aspirated into +small bronchi, and cause multiple abscesses. A hook may be found +useful in dealing with round, friable, foreign bodies; and in some +cases the mechanical spoon or safety-pin closer may be used to +advantage. The foreign body is then brought close to, but not crushed +against the tube mouth. + +[174] _Removal of animal objects from the tracheobronchial tree_ is +readily accomplished with the side-curved forceps. Leeches are not +uncommon intruders in European countries. Small insects are usually +coughed out. Worms and larvae may be found. Cocaine or salt solution +will cause a leech to loosen its hold. + +_Foreign bodies in the upper-lobe bronchi_ are fortunately not common. +If the object is not too far out to the periphery it may be grasped by +the upper-lobe-bronchus forceps (Fig. 90), guided by the collaboration +of the fluoroscopist. These forceps are made so as to reach high into +the ascending branches of the upper-lobe bronchus. Full-curved +coil-spring hooks will reach high, but must be used with the utmost +caution, and the method of their disengagement must be practiced +beforehand. + +_Penetrating Projectiles_.--Foreign bodies that have penetrated the +chest wall and lodged in the lung may be removed by oral bronchoscopy +if the intruder is not larger than the lumen of the corresponding main +bronchus (see Bibliography, 43) + +[FIG. 90.--Schematic illustration of the author's upper-lobe-bronchus +forceps in position grasping a pin in an anteriorly ascending branch +of the upper-lobe bronchus. T, Trachea; UL, upper-lobe bronchus; LB, +left bronchus; SB, stem bronchus. These forceps are made to extend +around 180 degrees.] + +RULES FOR ENDOSCOPIC FOREIGN BODY EXTRACTION + + 1. Never endoscope a foreign body case unprepared, with the idea of +taking a preliminary look. + 2. Approach carefully the suspected location of a foreign body, so +as not to override any portion of it. + [175] 3. Avoid grasping a foreign body hastily as soon as seen. + 4. The shape, size and position of a foreign body, and its relations +to surrounding structures, should be studied before attempting to +apply the forceps. (Exception cited in Rule 10.) + 5. Preliminary study of a foreign body should be from a distance. + 6. As the first grasp of the forceps is the best, it should be well +planned beforehand so as to seize the proper part of the intruder. + 7. With all long foreign bodies the motto should be "Search, not for +the foreign body, but for its nearer end." With pins, needles, and the +like, with point upward, _search always for the point_. Try to see it +first. + 8. Remember that a long foreign body grasped near the middle +becomes, mechanically speaking, a "toggle and ring." + 9. Remember that the mortality to follow failure to remove a foreign +body does not justify probably fatal violence during its removal. + 10. _Laryngeally lodged_ foreign bodies, because of the likelihood +of dislodgment and loss, may be seized by any part first presented, +and plan of withdrawal can be determined afterward. + 11. For similar reasons, laryngeal cases should be dealt with only +in the author's position (Fig. 53). + 12. An esophagoscopy may be needed in a bronchoscopic case, or a +bronchoscopy in an esophageal case. In every case both kinds of tubes +should be sterile and ready before starting. It is the unexpected that +happens in foreign body endoscopy. + 13. Do not pull on a foreign body unless it is properly grasped to +come away readily without trauma. Then do not pull hard. + 14. Do no harm, if you cannot remove the foreign body. + 15. Full-curved hooks are to be used in the bronchi with greatest +caution, if used at all, lest they catch inextricably in branch +bronchi. + [176] 16. Don't force a foreign body downward. Coax it back. The +deeper it gets the greater your difficulties. + 17. The watchword of the bronchoscopist should be, "If I can do no +good, I will at least do no harm." + +_Fluoroscopic bronchoscopy_ is so deceptively easy from a superficial, +theoretical, point of view that it has been used unsuccessfully in +cases easily handled in the regular endoscopic way with the eye at the +proximal tube-mouth. In a collected series of cases by various +operators the object was removed in 66.7 per cent with a mortality of +41.6 per cent. In the problem of a pin located out of the field of +bronchoscopic vision, the fluoroscopist will yield invaluable aid. An +extremely delicate forceps is to be inserted closed into the invaded +bronchus, the grasp on the object being confirmed by the +fluoroscopist. It is to be kept in mind that while the object itself +may be in the grasp of the forceps, the fluoroscope will not show +whether there may not be included in the forceps' grasp a bronchial +spur or other tissue, the tearing of which may be fatal. Therefore +traction must not be sufficient to lacerate tissue. If the foreign +body does not come readily it must be released, and a new grasp may +then be taken. All of the cautions in faulty seizure already +mentioned, apply with particular force to fluoroscopic bronchoscopy. +The fluoroscope is of aid in finding foreign bodies held in abscess +cavities. The fluoroscope should show both the lateral and +anteroposterior planes. To accomplish this quickly, two Coolidge tubes +and two screens are necessary. Fluoroscopic bronchoscopy, because of +its high mortality and low percentage of successes, should be tried +only after regular, ocularly guided, peroral bronchoscopy has failed, +and only by those who have had experience in ocularly guided +bronchoscopy. + + + +[177] CHAPTER XVI--FOREIGN BODIES IN THE BRONCHI FOR PROLONGED PERIODS + +The sojourn of an inorganic foreign body in the bronchus for a year or +more is followed by the development of bronchiectasis, pulmonary +abscess, and fibrous changes. The symptoms of tuberculosis may all be +presented, but tubercle bacilli have never been found associated with +any of the many cases that have come to the Bronchoscopic Clinic.* The +history of repeated attacks of malaise, fever, chills, and sweats +lasting for a few days and terminated by the expulsion of an amount of +foul pus, suggests the intermittent drainage of an abscess cavity, and +special study should be made to eliminate foreign body as the cause of +the condition, in all such cases, whether there is any history of a +foreign body accident or not. Bronchoscopy for diagnosis is to be done +unless the etiology can be definitely proven by other means. In all +cases of chronic chest disease foreign body should be eliminated as a +matter of routine. + +* One exception has recently come to the Clinic. 12 + +_The time of aspiration of a foreign body_ may be unknown, having +possibly occurred in infancy, during narcosis, or the object may even +enter the lower air passages without the patient being aware of the +accident, as happened with a particularly intelligent business man who +unknowingly aspirated the tip of an atomizer while spraying his +throat. In many other cases the accident had been forgotten. In still +others, in spite of the patient's statement of a conviction that the +trouble was due to a foreign body he had aspirated, the physician did +not consider it worthy of sufficient consideration to warrant a +roentgenray examination. It is curious to note the various opinions +held in regard to the gravity of the presence of a bronchial foreign +body. One patient was told by his physician that the presence of a +staple in his bronchus was an impossibility, for he would not have +lived five minutes after the accident. Others consider the presence of +a foreign body in the bronchus as comparatively harmless, in spite of +the repeated reports of invalidism and fatality in the medical +literature of centuries. The older authorities state that all cases of +prolonged bronchial foreign body sojourn died from phthisis +pulmonalis, and it is still the opinion of some practitioners that the +presence of a foreign body in the lung predisposes to the development +of true tuberculosis. With the dissemination of knowledge regarding +the possibility of bronchial foreign body, and the marvellous success +in their removal by bronchoscopy, the cases of prolonged foreign body +sojourn should decrease in number. It should be the recognized rule, +and not the exception, that all chest conditions, acute or chronic, +should have the benefit of roentgenographic study, even apart from the +possibility of foreign body. + +Often even with the clear history of foreign-body aspiration, both +patient and physician are deluded by a relatively long period of +quiescence in which no symptoms are apparent. This symptomless +interval is followed sooner or later by ever increasing cough and +expectoration of sputum, finally by bronchiectasis and pulmonary +abscess, chronic sepsis, and invalidism. + +_Pathology_.--If the foreign body completely obstructs a main +bronchus, preventing both aeration and drainage, such rapid +destruction of lung tissue follows that extensive pathologic changes +may result in a few months, or even in a few weeks, in the case of +irritating foreign bodies such as peanut kernels and soft rubber. Very +minute, inorganic foreign bodies may become encysted as in +anthracosis. Large objects, however, do not become encysted. The +object is drawn down by gravity and aspirated into the smallest +bronchus it can enter. Later the negative pressure below from +absorption of air impacts it still further. Swelling of the bronchial +mucosa from irritation plus infection completes the occlusion of the +bronchus. Retention of secretions and bacterial decomposition thereof +produces first a "drowned lung" (natural passages full of pus); then +sloughing or ulceration in the tissues plus the pressure of the pus, +causes bronchiectasis; further destruction of the cartilaginous rings +results in true abscess formation below the foreign body. The +productive inflammation at the site of lodgement of the foreign body +results in cicatricial contraction and the formation of a stricture at +the top of the cavity, in which the foreign body is usually held. The +abscess may extend to the periphery and rupture into the pleural +cavity. It may drain intermittently into a bronchus. Certain +irritating foreign bodies, such as soft rubber, may produce gangrenous +bronchitis and multiple abscesses. For observations on pathology (see +Bibliography, 38). + +_Prognosis_.--If the foreign body be not removed, the resulting +chronic sepsis or pulmonary hemorrhage will prove fatal. Removal of +the foreign body usually results in complete recovery without further +local treatment. Occasionally, secondary dilatation of a bronchial +stricture may be required. All cases will need, besides removal of the +foreign body, an antituberculous regimen, and offer a good prognosis +if this be followed. + +_Treatment_.--Bronchoscopy should be done in all cases of chronic +pulmonary abscess and bronchiectasis even though radiographic study +reveals no shadow of foreign body. The patient by assuming a posture +with the head lowered is urged to expel spontaneously all the pus +possible, before the bronchoscopy. The aspirating bronchoscope (Fig. +2, E) is often useful in cases where large amounts of secretion may be +anticipated. Granulations may require removal with forceps and +sponging. Disturbed granulations result in bleeding which further +hampers the operation; therefore, they should not be touched until +ready to apply the forceps, unless it is impossible to study the +presentation without disturbing them. For this reason secretions +hiding a foreign body should be removed with the aspirating tube (Fig. +9) rather than by swabbing or sponge-pumping, when the bronchoscopic +tube-mouth is close to the foreign body. It is inadvisable, however, +to insert a forceps into a mass of granulations to grope blindly for a +foreign body, with no knowledge of the presentation, the forceps +spaces, or the location of branch-bronchial orifices into which one +blade of the forceps may go. Dilatation of a stricture may be +necessary, and may be accomplished by the forms of bronchial dilators +shown in Fig. 25. The hollow type of dilator is to be used in cases in +which the foreign body is held in the stricture (Fig. 83). This +dilator may be pushed down over the stem of such an object as a tack, +and the stricture dilated without the risk of pushing the object +downward. It is only rarely, however, that the point of a tack is +free. Dense cicatricial tissue may require incision or excision. +_Internal bronchotomy_ is doubtless, a very dangerous procedure, +though no fatalities have occurred in any of the three cases in the +Bronchoscopic Clinic. It is advisable only as a last resort. + + + +[181] CHAPTER XVII--UNSUCCESSFUL BRONCHOSCOPY FOR FOREIGN BODIES + +The limitations of bronchoscopic removal of foreign bodies are usually +manifested in the failure to find a small foreign body which has +entered a minute bronchus far down and out toward the periphery. When +localization by means of transparent films, fluoroscopy, and +endobronchial bismuth insufflation has failed, the question arises as +to the advisability of endoscopic excision of the tissue intervening +between the foreign body and bronchoscope with the aid of two +fluoroscopes, one for the lateral and the other the vertical plane. +With foreign bodies in the larger bronchi near the root of the lung +such a procedure is unnecessary, and injury to a large vessel would be +almost certain. At the extreme periphery of the lung the danger is +less, for the vessels are smaller and serious hemorrhage less +probable, through the retention and decomposition of blood in small +bronchi with later abscess formation is a contingency. The nature of +the bridge of tissue is to be considered; should it be cicatricial, +the result of prolonged inflammatory processes, it may be carefully +excised without very great risk of serious complications. The blood +vessels are diminished in size and number by the chronic productive +inflammation, which more than offsets their lessened contractility. + +The possibility of the foreign body being coughed out after +suppurative processes have loosened its impaction is too remote; and +the lesions established may result fatally even after the expulsion of +the object. Pulmonary abscess formation and rupture into the pleura +should not be awaited, for the foreign body does not often follow the +pus into the pleural cavity. It remains in the lung, held in a bed of +granulation tissue. Furthermore, to await the development is to +subject the patient to a prolonged and perhaps fatal sepsis, or a +fatal pulmonary hemorrhage from the erosion of a vessel by the +suppurative process. The recent developments in thoracic surgery have +greatly decreased the operative mortality of thoracotomy, so that this +operation is to be considered when bronchoscopy has failed. +Bronchoscopy can be considered as having failed, for the time being, +when two or more expert bronchoscopists on repeated search have been +unable to find the foreign body or to disentangle it; but the art of +bronchoscopy is developing so rapidly that the failures of a few years +ago would be easy successes today. Before considering thoracotomy +months of study of the mechanical problem are advisable. It is +probable that any foreign body of appreciable size that has gone down +the natural passages can be brought back the same way. + +In the event of a foreign body reaching the pleura, either with or +without pus, it should be removed immediately by pleuroscopy or by +thoracotomy, without waiting for adhesive pleuritis. + +The problem may be summarized thus: + 1. Large foreign bodies in the trachea or large bronchi can always +be removed by bronchoscopy. + 2. The development of bronchoscopy having subsequently solved the +problems presented by previous failures, it seems probable that by +patient developmental endeavor, any foreign body of appreciable size +that has gone down through the natural passages, can be +bronchoscopically removed the same way, provided fatal trauma is +avoided. + +At the author's Bronchoscopic Clinics 98.7 per cent of foreign bodies +have been removed. + + + +CHAPTER XVIII--FOREIGN BODIES IN THE ESOPHAGUS + +_Etiology_.--The lodgement of foreign bodies in the esophagus is +influenced by: + 1. The shape of the foreign body (disc-shaped, pointed, irregular). + 2. Resiliency of the object (safety pins). + 3. The size of the foreign body. + 4. Narrowing of the esophagus, spasmodic or organic, normal, or +pathologic. + 5. Paralysis of the normal esophageal propulsory mechanism. + +The lodgement of a bolus of ordinary food in the esophagus is strongly +suggestive of a preexisting narrowing of the lumen of either a +spasmodic or organic nature; a large bolus of food, poorly masticated +and hurriedly swallowed, may, however, become impacted in a perfectly +normal esophagus. + +Carelessness is the cause of over 80 per cent of the foreign bodies in +the esophagus (see Bibliography, 29). + +_Site of Lodgement_.--Almost all foreign bodies are arrested in the +cervical esophagus at the level of the superior aperture of the +thorax. A physiologic narrowing is present at this level, produced in +part by muscular contraction, and mainly by the crowding of the +adjacent viscera into the fixed and narrow upper thoracic aperture. If +dislodged from this position the foreign body usually passes downward +to be arrested at the next narrowing or to pass into the stomach. The +esophagoscopist who encounters the difficulty of introduction at the +cricopharyngeal fold expects to find the foreign body above the fold. +Such, however, is almost never the case. The cricopharyngeus muscle +functionates in starting the foreign body downward as if it were food; +but the narrowing at the upper thoracic aperture arrests it because +the esophageal peristaltic musculature is feeble as compared to the +powerful inferior constrictor. + +_Symptoms_.--_Dysphagia_ is the most frequent complaint in cases of +esophageally lodged foreign bodies. A very small object may excite +sufficient spasm to cause aphagia, while a relatively large foreign +body may be tolerated, after a time, so that the swallowing function +may seem normal. Intermittent dysphagia suggests the tilting or +shifting of a foreign body in a valve-like fashion; but may be due to +occlusion of the by-passages by food arrested by the foreign body. +_Dyspnea_ may be present if the foreign body is large enough to +compress the trachea. _Cough_ may be excited by reflex irritation, +overflow of secretions into the larynx, or by perforation of the +posterior tracheal wall, traumatic or ulcerative, allowing leakage of +food or secretion into the trachea. (See Chapter XII for discussion of +symptomatology and diagnosis.) + +_Prognosis_.--A foreign body lodged in the esophagus may prove quickly +fatal from _hemorrhage_ due to perforation of a large vessel; from +_asphyxia_ by pressure on the trachea; or from _perforation_ and +_septic mediastinitis_. Slower fatalities may result from suppuration +extending to the trachea or bronchi with consequent edema and +asphyxia. Sooner or later, if not removed, the foreign body causes +death. It may be tolerated for a long period of time, causing abscess, +cervical cellulitis, fistulous tracts, and ultimately extreme stenosis +from cicatricial contraction. Perichondritis of the laryngeal or +tracheal cartilages may follow, and result in laryngeal stenosis +requiring tracheotomy. The damage produced by the foreign body is +often much less than that caused by blind and ill-advised attempts at +removal. If the foreign body becomes dislodged and moves downward, the +danger of intestinal perforation is encountered. The _prognosis_, +therefore, must be guarded so long as the intruder remains in the +body. + +_Treatment_.--It is a mistake to try to force a foreign body into the +stomach with the stomach tube or bougie. Sounding the esophagus with +bougies to determine the level of the obstruction, or to palpate the +nature of the foreign body, is unnecessary and dangerous. +Esophagoscopy should not be done without a previous roentgenographic +and fluoroscopic examination of the chest and esophagus, except for +urgent reasons. The level of the stenosis, and usually the nature of +the foreign body, can thus be decided. Blind instrumentation is +dangerous, and in view of the safety and success of esophagoscopy, +reprehensible. + +If for any reason removal should be delayed, bismuth sub-nitrate, +gramme 0.6, should be given dry on the tongue every four hours. It +will adhere to the denuded surfaces. The addition of calomel, gramme +0.003, for a few doses will increase the antiseptic action. Should +swallowing be painful, gramme 0.2 of orthoform or anesthesin will be +helpful. Emetics are inefficient and dangerous. Holding the patient up +by the heels is rarely, if ever, successful if the foreign body is in +the esophagus. In the reported cases the intruder was probably in the +pharynx. + +_External esophagotomy_ for the removal of foreign bodies is +unjustifiable until esophagoscopy has failed in the hands of at least +two skillful esophagoscopists. It has been the observation in the +Bronchoscopic Clinic that every foreign body that has gone down +through the mouth into the esophagus can be brought back the same way, +unless it has already perforated the esophageal wall, in which event +it is no longer a case of foreign body in the esophagus. The mortality +of external esophagotomy for foreign bodies is from twenty to +forty-two per cent, while that of esophagoscopy is less than two per +cent, if the foreign body has not already set up a serious +complication before the esophagoscopy. Furthermore, external +esophagotomy can be successful only with objects lodged +in the cervical esophagus and, moreover, it has happened that after +the esophagus has been opened, the foreign body could not be found +because of dislodgement and passage downward during the relaxation of +the general anesthesia. Should this occur during esophagoscopy, the +foreign body can be followed with the esophagoscope, and even if it is +not overtaken and removed, no risk has been incurred. + +Esophagoscopy is the one method of removal worthy of serious +consideration. Should it repeatedly fail in the hands of two skillful +endoscopists, which will be very rarely, if ever, then external +operation is to be considered in cervically lodged foreign bodies. + + + +[187] CHAPTER XIX--ESOPHAGOSCOPY FOR FOREIGN BODY + +_Indications_.--Esophagoscopy is demanded in every case in which a +foreign body is known to be, or suspected of being, in the esophagus. + +_Contraindications_.--There is no absolute contraindication to careful +esophagoscopy for the removal of foreign bodies, even in the presence +of aneurism, serious cardiovascular disease, hypertension or the like, +although these conditions would render the procedure inadvisable. +Should the patient be in bad condition from previous ill-advised or +blind attempts at extraction, endoscopy should be delayed until the +traumatic esophagitis has subsided and the general state improved. It +is rarely the foreign body itself which is producing these symptoms, +and the removal of the object will not cause their immediate +subsidence; while the passage of the tube through the lacerated, +infected, and inflamed esophagus might further harm the patient. +Moreover, the foreign body will be difficult to find and to remove +from the edematous and bleeding folds, and the risk of following a +false passage into the mediastinum or overriding the foreign body is +great. Water starvation should be relieved by means of proctoclysis +and hypodermoclysis before endoscopy is done. The esophagitis is best +treated by placing dry on the tongue at four-hour intervals the +following powder: + Rx. Anesthesin...gramme 0.12 + Bismuth subnitrate...gramme 0.6 + Calomel, gramme 0.006 to 0.003 may be added to each powder for a few +doses to increase the antiseptic effect. If the patient can swallow +liquids it is best to wait one week from the time of the last attempt +at removal before any endoscopy for extraction be done. This will give +time for nature to repair the damage and render the removal of the +object more certain and less hazardous. Perforation of the esophagus +by the foreign body, or by blind instrumentation, is a +contraindication to esophagoscopy. It is manifested by such signs as +subcutaneous emphysema, swelling of the neck, fever, irritability, +increase in pulsatory and respiratory rates, and pain in the neck or +chest. Gaseous emphysema is present in some cases, and denotes a +dangerous infection. Esophagoscopy should be postponed and the +treatment mentioned at the end of this chapter instituted. After the +subsidence of all symptoms other than esophageal, esophagoscopy may be +done safely. Pleural perforation is manifested by the usual signs of +pneumothorax, and will be demonstrated in the roentgenogram. + +ESOPHAGOSCOPIC EXTRACTION OF FOREIGN BODIES + +It is unwise to do an endoscopy in a foreign-body case for the sole +purpose of taking a preliminary look. Everything likely to be needed +for extraction of the intruder should be sterile and ready at hand. +Furthermore, all required instruments for laryngoscopy, bronchoscopy +or tracheotomy should be prepared as a matter of routine, however +rarely they may be needed. + +Sponging should be done cautiously lest the foreign body be hidden in +secretions or food accumulation, and dislodged. Small food masses +often lodge above the foreign body and are best removed with forceps. +The folds of the esophagus are to be carefully searched with the aid +of the lip of the esophagoscope. If the mucosa of the esophagus is +lacerated with the forceps all further work is greatly hampered by the +oozing; if the laceration involve the esophageal wall the accident may +be fatal: and at best the tendency of the tube-mouth to enter the +laceration and create a false passage is very great. + +_"Overriding" or failure to find a foreign body known to be present_ +is explained by the collapsed walls and folds covering the object, +since the esophagoscope cannot be of sufficient size to smooth out +these folds, and still be of small enough diameter to pass the +constricted points of the esophagus noted in the chapter on anatomy. +Objects are often hidden just distal to the cricopharyngeal fold, +which furthermore makes a veritable chute in throwing the end of the +tube forward to override the foreign body and to interpose a layer of +tissue between the tube and the object, so that the contact at the +side of the tube is not felt as the tube passes over the foreign body +(Fig. 91). The chief factors in overriding an esophageal foreign body +are: + 1. The chute-like effect of the plica cricopharyngeus. + 2. The chute-like effect of other folds. + 3. The lurking of the foreign body in the unexplored pyriform sinus. + 4. The use of an esophagoscope of small diameter. + 5. The obscuration of the intruder by secretion or food debris. + 6. The obscuration of the intruder by its penetration of the +esophageal wall. + 7. The obscuration of the intruder by inflammatory sequelae. + +[FIG. 91.--Illustrating the hiding of a coin by the folding downward +of the plica cricopharyngeus. The muscular contraction throws the beak +of the esophagoscope upward while the interposed tissue prevents the +tactile appreciation of contact of the foreign body with the side of +the tube after the tip has passed over the foreign body. Other folds +may in rare instances act similarly in hiding a foreign body from +view. This overriding of a foreign body is apt to cause dangerous +dyspnea by compression of the party wall.] + +_The esophageal speculum for the removal of foreign bodies_ is useful +when the object is not more than 2 cm. below the cricoid in a child, +and 3 cm. in the adult. The fold of the cricopharyngeus can be +repressed posteriorward by the forceps which are then in position to +grasp the object when it is found. The author's down-jaw forceps (Fig. +22) are very useful to reach down back of the cricopharyngeal fold, +because of the often small posterior forceps space. The speculum has +the disadvantage of not allowing deeper search should the foreign body +move downward. In infants, the child's size laryngoscope may be used +as an esophageal speculum. General anesthesia is not only unnecessary +but dangerous, because of the dyspnea created by the endoscopic tube. +Local anesthesia is unnecessary as well as dangerous in children; and +its application is likely to dislodge the foreign body unless used as +a troche. Forbes esophageal speculum is excellent. + +MECHANICAL PROBLEMS OF ESOPHAGOSCOPIC REMOVAL OF FOREIGN BODIES + +The bronchoscopic problems considered in the previous chapter should +be studied. + +_The extraction of transfixed foreign bodies_ presents much the same +problem as those in the bronchi, though there is no limit here to the +distance an object may be pushed down to free the point. Thin, sharp +foreign bodies such as bones, dentures, pins, safety-pins, etcetera, +are often found to lie crosswise in the esophagus, and it is +imperative that one end be disengaged and the long axis of the object +be made to correspond to that of the esophagus before traction for +removal is made (Fig. 92). Should the intruder be grasped in the +center and traction exerted, serious and perhaps fatal trauma might +ensue. + +[191] [FIG. 92.--The problem of the horizontally transfixed foreign +body in the esophagus. The point, D, had caught as the bone, A, was +being swallowed. The end, E, was forced down to C, by food or by blind +attempts at pushing the bone downward. The wall, F, should be +laterally displaced to J, with the esophagoscope, permitting the +forceps to grasp the end, M, of the bone. Traction in the direction of +the dart will disimpact the bone and permit it to rotate. The rotation +forceps are used as at K.] + +[FIG. 93.--Solution of the mechanical problem of the broad foreign +body having a sharp point by version. If withdrawn with plain forceps +as applied at A, the point B, will rip open the esophageal wall. If +grasped at C, the point, D, will rotate in the direction of F and will +trail harmlessly. To permit this version the rotation forceps are used +as at H. On this principle flat foreign bodies with jagged or rough +parts are so turned that the potentially traumatizing parts trail +during withdrawal.] + +The extraction of broad, flat foreign bodies having a sharp point or a +rough place on part of their periphery is best accomplished by the +method of rotation as shown in Fig. 93. + +_Extraction of Open Safety-pins from the Esophagus_.--An open safety +pin with the point down offers no particular mechanical difficulty in +removal. Great care must be exercised, however, that it be not +overridden or pushed upon, as either accident might result in +perforation of the esophagus by the pin point. The coiled spring is to +be sought, and when found, seized with the rotation forceps and the +pin thus drawn into the esophagoscope to effect closure. An open +safety-pin lodged point upward in the esophagus is one of the most +difficult and dangerous problems. A roentgenogram should always be +made in the plane showing the widest spread of the pin. It is to be +remembered that the endoscopist can see but one portion of the pin at +a time (except in cases of very small safety-pins) and that if he +grasps the part first showing, which is almost invariably the keeper, +fatal trauma will surely be inflicted when traction is made. It may be +best to close the safety pin with the safety-pin closer, as +illustrated in Fig. 37. For this purpose Arrowsmith's closer is +excellent. In other cases it may prove best to disengage the point of +the pin and to bring the pointed shaft into the esophagoscope with the +Tucker forceps and withdraw the pin, forceps, and esophagoscope, with +the keeper and its shaft sliding alongside the tube. The rounded end +of the keeper lying outside the tube allows it to slip along the +esophageal walls during withdrawal without inflicting trauma; however, +should resistance be felt, withdrawal must immediately cease and the +pin must be rotated into a different plane to release the keeper from +the fold in which it has probably caught. The sense of touch will aid +the sense of sight in the execution of this maneuver (Fig. 87). When +the pin reaches the cricopharyngeal level the esophagoscope, forceps, +and pin should be turned so that the keeper will be to the right, not +so much because of the cricopharyngeal muscle as to escape the +posteriorly protuberant cricoid cartilage. In certain cases in which +it is found that the pointed shaft of a small safety pin has +penetrated the esophageal wall, the pin has been successfully removed +by working the keeper into the tube mouth, grasping the keeper with +the rotation forceps or side-curved forceps, and pulling the whole pin +into the tube by straightening it. This, however, is a dangerous +method and applicable in but few cases. It is better to disengage the +point by downward and inward rotation with the Tucker forceps. + +_Version of a Safety Pin_.--A safety pin of very small size may be +turned over in a direction that will cause the point to trail. An +advancing point will puncture. This is a dangerous procedure with a +large safety pin. + +_Endogastric Version_.--A very useful and comparatively safe method is +illustrated in Figs. 94 and 95. In the execution of this maneuver the +pin is seized by the spring with a rotation forceps, and thus passed +along with the esophagoscope into the stomach where it is rotated so +that the spring is uppermost. It can then be drawn into the tube mouth +so as to protect the tissues during withdrawal of the pin, forceps, +and esophagoscope as one piece. Only very small safety-pins can be +withdrawn through the esophagoscope. + +_Spatula-protected Method_.--Safety-pins in children, point upward, +when lodged high in the cervical esophagus may be readily removed with +the aid of the laryngoscope, or esophageal speculum. The keeper end is +grasped with the alligator forceps, while the spatular tip of the +laryngoscope is worked under the point. Instruments and foreign body +are then removed together. Often the pin point will catch in the +light-chamber where it is very safely lodged. If the pin be then +pulled upon it will straighten out and may be withdrawn through the +tube. + +[FIG. 94.--Endogastric version. One of the author's methods of removal +of upward pointed esophageally lodged open safety-pins by passing them +into stomach, where they are turned and removed. The first +illustration (A) shows the rotation forceps before seizing pin by the +ring of the spring end. (Forceps jaws are shown opening in the wrong +diameter.) At B is shown the pin seized in the ring by the points of +the forceps. At C is shown the pin carried into the stomach and about +to be rotated by withdrawal. D, the withdrawal of the pin into the +esophagoscope which will thereby close it. If withdrawn by flat-jawed +forceps as at F, the esophageal wall would be fatally lacerated.] + +_Double pointed tacks and staples_, when lodged point upward, must be +turned so that the points trail on removal. This may be done by +carrying them into the stomach and turning them, as described under +safety-pins. + +_The extraction of foreign bodies of very large size_ from the +esophagus is greatly facilitated by the use of general anesthesia, +which relaxes the spasmodic contractions of the esophagus often +occurring when attempt is made to withdraw the foreign body. General +anesthesia, though entirely unnecessary for introduction of the +esophagoscope, in any case may be used if the body is large, sharp, +and rough, in order to prevent laceration through the muscular +contractions otherwise incident to withdrawal.* In exceptional cases +it may be necessary to comminute a large foreign body such as a tooth +plate. A large smooth foreign body may be difficult to seize with +forceps. In this case the mechanical spoon or the author's safety-pin +closer may be used. + +* It must always be remembered that large foreign bodies are very +prone to cause dyspnea that renders general anesthesia exceedingly +dangerous especially in children. + +[FIG. 95.--Lateral roentgenogram of a safety-pin in a child aged 11 +months, demonstrating the esophageal location of the pin in this case +and the great value of the lateral roentgenogram in the localization +of foreign bodies. The pin was removed by the author's method of +endogastric version. (Plate made by George C. Johnston )] + +_The extraction of meat and other foods from the esophagus_ at the +level of the upper thoracic aperture is usually readily accomplished +with the esophageal speculum and forceps. In certain cases the +mechanical spoon will be found useful. Should the bolus of food be +lodged at the lower level the esophagoscope will be required. + +_Extraction of Foreign Bodies from the Strictured Esophagus_.--Foreign +bodies of relatively small size will lodge in a strictured esophagus. +Removal may be rendered difficult when the patient has an upper +stricture relatively larger than the lower one, and the foreign body +passing the first one lodges at the second. Still more difficult is +the case when the second stricture is considerably below the first, +and not concentric. Under these circumstances it is best to divulse +the upper stricture mechanically, when a small tube can be inserted +past the first stricture to the site of lodgement of the foreign body. + +_Prolonged sojourn of foreign bodies in the esophagus_, while not so +common as in the bronchi is by no means of rare occurrence. Following +their removal, stricture of greater or less extent is almost certain +to follow from contraction of the fibrous-tissue produced by the +foreign body. + +_Fluoroscopic esophagoscopy_ is a questionable procedure, for the +esophagus can be explored throughout by sight. In cases in which it is +suspected that a foreign body, such as pin, has partially escaped from +the esophagus, the fluoroscope may aid in a detailed search to +determine its location, but under no circumstances should it be the +guide for the application of forceps, because the transparent but +vital tissues are almost certain to be included in the grasp. + +[197] Complications and Dangers of Esophagoscopy for Foreign Bodies. +Asphyxia from the pressure of the foreign body, or the foreign body +plus the esophagoscope, is a possibility (Fig. 91). Faulty position of +the patient, especially a low position of the head, with faulty +direction of the esophagoscope may cause the tube mouth to press the +membranous tracheo-esophageal wall into the trachea, so as temporarily +to occlude the tracheal lumen, creating a very dangerous situation in +a patient under general anesthesia. Prompt introduction of a +bronchoscope, with oxygen and amyl nitrite insufflation and artificial +respiration, may be necessary to save life. The danger is greater, of +course, with chloroform than with ether anesthesia. Cocain poisoning +may occur in those having an idiosyncrasy to the drug. Cocain should +never be used with children, and is of little use in esophagoscopy in +adults. Its application is more annoying and requires more time than +the esophagoscopic removal of the foreign bodies without local +anesthesia. Traumatic esophagitis, septic mediastinitis, cervical +cellulitis, and, most dangerous, gangrenous esophagitis may be +present, caused by the foreign body itself or ill-advised efforts at +removal. Perforation of the esophagus with the esophagoscope is rare, +in skillful hands, if the esophageal wall is sound. The esophageal +wall, however, may be weakened by ulceration, malignant disease, or +trauma, so that the possibility of making a false passage should +always deter the endoscopist from advancing the tube beyond a visible +point of weakening. To avoid entering a false passage previously +created, is often exceedingly difficult, and usually it is better to +wait for obliterative adhesive inflammation to seal the tissue layers +together. + +_Treatment_.--Acute esophagitis calls for rest in bed, sterile liquid +food, and the administration of bismuth powder mentioned in the +paragraph on contraindications. An ice bag applied to the neck may +afford some relief. The mouth should be hourly cleansed with the +following solution: + Dakin's solution 1 part + Cinnamon water 5 parts. + Emphysema unaccompanied by pyogenic processes usually requires no +treatment, though an occasional case may require punctures of the skin +to liberate the air. Gaseous emphysema and pus formation urgently +demand early external drainage, preferably behind the sternomastoid. +Should the pleura be perforated by sudden puncture pyo-pneumothorax is +inevitable. Prompt thoracotomy for drainage may save the patient's +life if the mediastinum has not also been infected. Foreign bodies +ulcerating through may reach the lung without pleural leakage because +of the sealing together of the visceral and parietal pleurae. In the +serious degrees of esophageal trauma, particularly if the pleura be +perforated, gastrostomy is indicated to afford rest of the esophagus, +and for alimentation. A duodenal feeding tube may be placed through an +esophagoscope passed into the stomach in the usual way through the +mouth, avoiding by ocular guidance the perforation into which a +blindly passed stomach tube would be very likely to enter, with +probably dangerous results. + + + +[199] CHAPTER XX--PLEUROSCOPY + +_Foreign bodies in the pleural cavity_ should be immediately removed. +The esophageal speculum inserted through a small intercostal incision +makes an excellent pleuroscope, its spatular tip being of particular +value in moving the lung out of the way. This otherwise dark cavity is +thus brilliantly illuminated without the necessity of making a large +flap resection, an important factor in those cases in which there is +no infection present. The pleura and wound may be immediately closed +without drainage, if the pleura is not infected. Excessive plus +pressure or pus may require reopening. In one case in which the author +removed a foreign body by pleuroscopy, healing was by first intention +and the lung filled in a few days. Drainage tubes that have slipped up +into the empyemic cavity are foreign bodies. They are readily removed +with the retrograde esophagoscope even through the smallest fistula. +The aspirating canal keeps a clear field while searching for the +drain. + +_Pleuroscopy for Disease_.--Most pleural diseases require a large +external opening for drainage, and even here the pleuroscope may be of +some use in exploring the cavities. Usually there are many adhesions +and careful ray study may reveal one or more the breaking up of which +will improve drainage to such an extent as to cure an empyema of long +standing. Repeated severing of adhesions, aspiration and sometimes +incision of the thickened visceral pleura may be necessary. The author +is so strongly imbued with the idea that local examination under full +illumination has so revolutionized the surgery of every region of the +body to which it has been applied, that every accessible region should +be thus studied. The pleural cavity is quite accessible with or +without rib-resection, and there is practically no risk in careful +pleuroscopy. + + + +[201] CHAPTER XXI--BENIGN GROWTHS IN THE LARYNX + +Benign growths in the larynx are easily and accurately removable by +direct laryngoscopy; but perhaps no method has been more often misused +and followed by most unfortunate results. It should always be +remembered that benign growths are benign, and that hence they do not +justify the radical work demanded in dealing with malignancy. The +larynx should be worked upon with the same delicacy and respect for +the normal tissues that are customary in dealing with the eye. + +_Granulomata in the larynx_, while not true neoplasms, require +extirpation in some instances. + +_Vocal nodules_, when other methods of cure such as vocal rest, +various vocal exercises, etcetera have failed may require surgical +excision. This may be done with the laryngeal tissue forceps or with +the author's vocal nodule forceps. Sessile vocal nodules may be cured +by touching them with a fine galvanocautery point, but all work on the +vocal cords must be done with extreme caution and nicety. It is +exceedingly easy to ruin a fine voice. + +_Fibromata_, often of inflammatory genesis, are best removed with the +laryngeal grasping forceps, though the small laryngeal punch or tissue +forceps may be used. If very large, they may be amputated with the +snare, the base being treated with galvanocautery though this is +seldom advisable. Strong traction should be avoided as likely to do +irreparable injury to the laryngeal motility. + +_Cystomata_ may get well after simple excision or galvanopuncture of a +part of the wall of the sac, but complete extirpation of the sac is +often required for cure. The same is true of _adenomata._ + +[202] Angiomata, if extensive and deeply seated, may require deep +excision, but usually cure results from superficial removal. Usually +no cauterization of the vessels at the base is necessary, either to +arrest hemorrhage or to lessen the tendency to recurrence. A diffuse +telangiectasis, should it require treatment, may be gently touched +with a needle-pointed galvanocaustic electrode at a number of +sittings. The galvanonocautery is a dangerous method to use in the +larynx. Radium offers the best results in this latter form of angioma, +applied either internally or to the neck. + +_Lymphoma, enchondroma and osteoma_, if not too extensively involving +the laryngeal walls, may be excised with basket punch forceps, but +lymphoma is probably better treated by radium.* _True myxomata and +lipomata_ are very rare. _Amyloid tumors_ are occasionally met with, +and are very resistant to treatment. _Aberrant thyroid tumors_ do not +require very radical excision of normal base, but should be removed as +completely as possible. + +In a general way, it may be stated that with benign growths in the +larynx the best functional results are obtained by superficial rather +than radical, deep extirpation, remembering that it is easier to +remove tissue than to replace it, and that cicatrices impair or ruin +the voice and may cause stenosis. + +* In a case reported by Delavan a complete cure with perfect +restoration of voice resulted from radium after I had failed to cure +by operative methods. (Proceedings American Laryngological +Association, 1921.) + + + +[203] CHAPTER XXII--BENIGN GROWTHS IN THE LARYNX (Continued) + +PAPILLOMATA OF THE LARYNX IN CHILDREN + +Of all benign growths in the larynx papilloma is the most frequent. It +may occur at any age of childhood and may even be congenital. The +outstanding fact which necessarily influences our treatment is the +tendency to recurrences, followed eventually in practically all cases +by a tendency to disappearance. In the author's opinion multiple +papillomata constitute a benign, self-limited disease. There are two +classes of cases. 1. Those in which the growth gets well +spontaneously, or with slight treatment, surgically or otherwise; and, +2, those not readily amenable to any form of treatment, recurrences +appearing persistently at the old sites, and in entirely new +locations. In the author's opinion these two classes of case represent +not two different kinds of growths, but stages in the disease. Those +that get well after a single removal are near the end of the disease. +Papillomata are of inflammatory origin and are not true neoplasms in +the strictest sense. + +_Methods of Treatment_.--Irritating applications probably provoke +recurrences, because the growths are of inflammatory origin. Formerly +laryngostomy was recommended as a last resort when all other means had +failed. The excellent results from the method described in the +foregoing paragraph has relegated laryngostomy to those cases that +come in with a severe cicatricial stenosis from an injudicious +laryngofissure; and even in these cases cure of the stenosis as well +as the papillomata can usually be obtained by endoscopic methods +alone, using superficial scalping off of the papillomata with +subsequent laryngoscopic bouginage for the stenosis. Thyrotomy for +papillomata is mentioned only to be condemned. Fulguration has been +satisfactory in the hands of some, disappointing to others. It is +easily and accurately applied through the direct laryngoscope, but +damage to normal tissues must be avoided. Radium, mesothorium, and the +roentgenray are reported to have had in certain isolated cases a +seemingly beneficial action. In my experience, however, I have never +seen a cure of papillomata which could be attributed to the radiation. +I have seen cases in which no effect on the growths or recurrence was +apparent, and in some cases the growths seemed to have been stimulated +to more rapid repullulations. In other most unfortunate cases I have +seen perichondritis of the laryngeal cartilages with subsequent +stenosis occurring after the roentgenotherapy. Possibly the disastrous +results were due to overdosage; but I feel it a duty to state the +unfavorable experience, and to call attention to the difference +between cancer and papillomata. Multiple papillomata involve no danger +to life other than that of easily obviated asphyxia, and it is +moreover a benign self-limited disease that repullulates on the +surface. In cancer we have an infiltrating process that has no limits +short of life itself. + +_Endolaryngeal extirpation_ of papillomata in children requires no +anesthetic, general or local; the growths are devoid of sensibility. +If, for any reason, a general anesthetic is used it should be only in +tracheotomized cases, because the growths obstruct the airway. +Obstructed respiration introduces into general anesthesia an enormous +element of danger. Concerning the treatment of multiple papillomata it +has been my experience in hundreds of cases that have come to the +Bronchoscopic Clinic, that repeated superficial removals with blunt +non-cutting forceps (see Chapter I) will so modify the soil as to make +it unfavorable for repullulation. The removals are superficial and do +not include the subjacent normal tissue. Radical removal of a +papilloma situated, for instance, on the left ventricular band or +cord, can in no way prevent the subsequent occurrence of a similar +growth at a different site, as upon the epiglottis, or even in the +fauces. Furthermore, radical removal of the basal tissues is certain +to impair the phonatory function. Excellent results as to voice and +freedom from recurrence have always followed repeated superficial +removal. The time required has been months or a year or two. Only +rarely has a cure followed a single extirpation. + +If the child is but slightly dyspneic, the obstructing part of the +growth is first removed without anesthesia, general or local; the +remaining fungations are extirpated subsequently at a number of brief +seances. The child is thus not terrified, soon loses dread of the +removals, and appreciates the relief. Should the child be very +dyspneic when first seen, a low tracheotomy is immediately done, and +after an interim of ten days, laryngoscopic removal of the growth is +begun. Tracheotomy probably has a beneficial effect on the disease. +Tracheal growths require the insertion of the bronchoscope for their +removal. + +_Papillomata in the larynx of adults_ are, on the whole, much more +amenable to treatment than similar growths in children. Tracheotomy is +very rarely required, and the tendency to recurrence is less marked. +Many are cured by a single extirpation. The best results are obtained +by removal of the growths with the laryngeal grasping-forceps, taking +the utmost care to avoid including in the bite of the forceps any of +the subjacent normal tissue. Radical resection or cauterization of the +base is unwise because of the probable impairment of the voice, or +cicatricial stenosis, without in anyway insuring against +repullulation. The papillomata are so soft that they give no sensation +of traction to the forceps. They can readily be "scalped" off without +any impairment of the sound tissues, by the use of the author's +papilloma forceps (Fig. 29). Cutting forceps of all kinds are +objectionable because they may wound the normal tissues before the +sense of touch can give warning. A gentle hand might be trusted with +the cup forceps (Fig. 32, large size.) + +Sir Felix Semon proved conclusively by his collective investigations +that cancer cannot be caused by the repeated removals of benign +growths. Therefore, no fear of causing cancer need give rise to +hesitation in repeatedly removing the repullulations of papillomata or +other benign growths. Indeed there is much clinical evidence elsewhere +in the body, and more than a little such evidence as to the larynx, to +warrant the removal of benign growths, repeated if necessary, as a +prophylactic of cancer (Bibliography, 19). + + + +[207] CHAPTER XXIII--BENIGN GROWTHS PRIMARY IN THE TRACHEOBRONCHIAL +TREE + +Extension of papillomata from the larynx into the cervical trachea, +especially about the tracheotomy wound, is of relatively common +occurrence. True primary growths of the tracheobronchial tree, though +not frequent, are by no means rare. These primary growths include +primary papillomata and fibromata as the most frequent, aberrant +thyroid, lipomata, adenomata, granulomata and amyloid tumors. +Chondromata and osteochondromata may be benign but are prone to +develop malignancy, and by sarcomatous or other changes, even +metaplasia. Edematous polypi and other more or less tumor-like +inflammatory sequelae are occasionally encountered. + +_Symptoms of Benign Tumors of the Tracheobronchial Tree_.--Cough, +wheezing respiration, and dyspnea, varying in degree with the size of +the tumor, indicate obstruction of the airway. Associated with +defective aeration will be the signs of deficient drainage of +secretions. Roentgenray examination may show the shadow of +enchondromata or osteomata, and will also show variations in aeration +should the tumor be in a bronchus. + +_Bronchoscopic removal of benign growths_ is readily accomplished with +the endoscopic punch forceps shown in Figs. 28 and 33. Quick action +may be necessary should a large tumor producing great dyspnea be +encountered, for the dyspnea is apt to be increased by the congestion, +cough, and increased respiration and spasm incidental to the presence +of the bronchoscope in the trachea. General anesthesia, as in all +cases showing dyspnea, is contraindicated. The risks of hemorrhage +following removal are very slight, provided fungations on an +aneurismal erosion be not mistaken for a tumor. + +Multiple papillomata when very numerous are best removed by the +author's "coring" method. This consists in the insertion of an +aspirating bronchoscope with the mechanical aspirator working at full +negative pressure. The papillomata are removed like coring an apple; +though the rounded edge of the bronchoscope does not even scratch the +tracheal mucosa. Many of the papillomata are taken off by the holes in +the bronchoscope. Aspiration of the detached papillomata into the +lungs is prevented by the corking of the tube-mouth with the mass of +papillomata held by the negative pressure at the canal inlet orifice. + + + +CHAPTER XXIV--BENIGN NEOPLASMS OF THE ESOPHAGUS + +As a result of prolonged inflammation edematous polypi and granulomata +are not infrequently seen, but true benign tumors of the esophagus are +rare affections. Keloidal changes in scar tissue may occur. Cases of +retention, epithelial and dermoid cysts have been observed; and there +are isolated reports of the finding of papillomata, fibromata, +lipomata, myomata and adenomata. The removal of these is readily +accomplished with the tissue forceps (Fig. 28), if the growths are +small and projecting into the esophageal lumen. The determination of +the advisability of the removal of keloidal scars would require +careful consideration of the particular case, and the same may be said +of very large growths of any kind. The extreme thinness of the +esophageal walls must be always in the mind of the esophagoscopist if +he would avoid disaster. + + + +[210] CHAPTER XXV--ENDOSCOPY IN MALIGNANT DISEASE OF THE LARYNX + +The general surgical rule applying to individuals past middle life, +that benign growths exposed to irritation should be removed, probably +applies to the larynx as well as to any other epithelialized +structure. The facility, accuracy and thoroughness afforded by +skilled, direct, laryngeal operation offers a means of lessening the +incidence of cancer. To a much greater extent the facility, accuracy, +and thoroughness contribute to the cure of cancer by establishing the +necessary early diagnosis. Well-planned, careful, external operation +(laryngofissure) followed by painstaking after-care is the only +absolute cure so far known for malignant neoplasms of the larynx; and +it is a cure only in those intrinsic cases in which the growth is +small, and is located in the anterior two-thirds of the intrinsic +area. By limiting operations strictly to this class of case, +eighty-five per cent of cures may be obtained.* In determining the +nature of the growth and its operability the limits of the usefulness +of direct endoscopy are reached. It is very unwise to attempt the +extirpation of intrinsic laryngeal malignancy by the endoscopic +method, for the reason that the full extent of the growth cannot be +appreciated when viewed only from above, and the necessary radical +removal cannot be accurately or completely accomplished. + +* The author's results in laryngofissure have recently fallen to 79 +per cent of relative cures by thyrochondrotomy. + +_Malignant disease of the epiglottis_, in those rare cases where the +lesion is strictly limited to the tip is, however, an exception. If +amputation of the epiglottis will give a sufficiently wide removal, +this may be done en masse with a heavy snare, and has resulted in +complete cure. Very small growths may be removed sufficiently widely +with the punch forceps (Fig. 33); but piece meal removal of malignancy +is to be avoided. + +_Differential Diagnosis of Laryngeal Growths in the Larynx of +Adults_.--Determination of the nature of the lesion in these cases +usually consists in the diagnosis by exclusion of the possibilities, +namely, + 1. Lues. + 2. Tuberculosis, including lupus. + 3. Scleroma. + 4. Malignant neoplasm. + +In the Bronchoscopic Clinic the following is the routine procedure: + 1. A Wassermann test is made. If negative, and there remains a +suspicion of lues, a therapeutic test with mercury protoiodid is +carried out by keeping the patient just under the salivation point for +eight weeks; during which time no potassium iodid is given, lest its +reaction upon the larynx cause an edema necessitating tracheotomy. If +no improvement is noticed lues is excluded. If the Wassermann is +positive, malignancy and the other possibilities are not considered as +excluded until the patient has been completely cured by mercury, +because, for instance, a leutic or tuberculous patient may have +cancer; a tuberculous patient may have lues; or a leutic patient, +tuberculosis. + 2. Pulmonary tuberculosis is excluded by the usual means. If present +the laryngeal lesion may or may not be tuberculous; if the +laryngoscopic appearances are doubtful a specimen is taken. Lupoid +laryngeal tuberculosis so much resembles lues that both the +therapeutic test and biopsy may be required for certainty. + 3. In all cases in which the diagnosis is not clear a specimen +is taken. This is readily accomplished by direct laryngoscopy under +local anesthesia, using the regular laryngoscope or the anterior +commissure laryngoscope. The best forceps in case of large growths are +the alligator punch forceps (Fig. 33). Smaller growths require tissue +forceps (Fig. 28). In case of small growths, it is best to remove the +entire growth; but without any attempt at radical extirpation of the +base; because, if the growth prove benign it is unnecessary; if +malignant, it is insufficient. + +_Inspection of the Party Wall in Cases of Suspected Laryngeal +Malignancy_.--When taking a specimen the party wall should be +inspected by passing a laryngoscope or, if necessary, an esophageal +speculum down through the laryngopharynx and beyond the +cricopharyngeus. If this region shows infiltration, all hope of cure +by operation, however radical, should be abandoned. + +_Radium and the therapeutic roentgenray_ have given good results, but +not such as would warrant their exclusive use in any case of +malignancy in the larynx operable by laryngofissure. With inoperable +cases, excellent palliative results are obtained. In some cases an +almost complete disappearance of the growth has occurred, but +ultimately there has been recurrence. The method of application of the +radium, dosage, and its screening, are best determined by the +radiologist in consultation with the laryngologist. Radium may be +applied externally to the neck, or suspended in the larynx; +radium-containing needles may be buried in the growth, or the +emanations, imprisoned in glass pearls or capillary tubes, may be +inserted deeply into the growth by means of a small trocar and +cannula. For all of these procedures direct laryngoscopy affords a +ready means of accurate application. Tracheotomy is necessary however, +because of the reactionary swelling, which may be so great as to close +completely the narrowed glottic chink. Where this is the case, the +endolaryngeal application of the radium may be made by inserting the +container through the tracheotomic wound, and anchoring it to the +cannula. + +The author is much impressed with Freer's method of radiation from the +pyriform sinus in such cases as those in which external radiation +alone is deemed insufficient. + +The work of Drs. D. Bryson Delavan and Douglass M. Quick forms one of +the most important contributions to the subject of the treatment of +radium by cancer. (See Proceedings of the American Laryngological +Association, 1922; also Proceedings of the Tenth International +Otological Congress, Paris, 1922.) + + + +[214] CHAPTER XXVI--BRONCHOSCOPY IN MALIGNANT GROWTHS OF THE TRACHEA + +The trachea is often secondarily invaded by malignancy of the +esophagus, thyroid gland, peritracheal or peribronchial glands. +Primary malignant neoplasms of the trachea or bronchus have not +infrequently been diagnosticated by bronchoscopy. Peritracheal or +peribronchial malignancy may produce a compressive stenosis covered +with normal mucosa. Endoscopically, the wall is seen to bulge in from +one side causing a crescentic picture, or compression of opposite +walls may cause a "scabbard" or pear shaped lumen. Endotracheal and +endobronchial malignancy ulcerate early, and are characterized by the +bronchoscopic view of a bleeding mass of fungating tissue bathed in +pus and secretion, usually foul. The diagnosis in these cases rests +upon the exclusion of lues, and is rendered certain by the removal of +a specimen for biopsy. Sarcoma and carcinoma of the thyroid when +perforating the trachea may become pedunculated. In such cases +aberrant non-pathologic thyroid must be excluded by biopsy. +Endothelioma of the trachea or bronchus may also assume a pedunculated +form, but is more often sessile. + +_Treatment_.--Pedunculated malignant growths are readily removed with +snare or punch forceps. Cure has resulted in one case of the author +following bronchoscopic removal of an endothelioma from the bronchus; +and a limited carcinoma of the bronchus has been reported cured by +bronchoscopic removal, with cauterization of the base. Most of the +cases, however, will be subjects for palliative tracheotomy and radium +therapy. It will be found necessary in many of the cases to employ the +author's long, cane-shaped tracheal cannula (Fig. 104, A), in order to +pipe the air down to one or both bronchi past the projecting neoplasm. + +It has recently been demonstrated that following the intravenous +injection of a suspension of the insoluble salt, radium sulphate, that +the suspended particles are held in the capillaries of the lung for a +period of one year. Intravenous injections of a watery suspension, and +endobronchial injections of a suspension of radium sulphate in oil, +have had definite beneficial action. While as yet, no relatively +permanent cures of pulmonary malignancy have been obtained, the +amelioration and steady improvement noted in the technic of radium +therapy are so encouraging that every inoperable case should be thus +treated, if the disease is not in a hopelessly advanced stage. + +In a case under the care of Dr. Robert M. Lukens at the Bronchoscopic +Clinic, a primary epithelioma of the trachea was retarded for 2 years +by the use of radium applied by Dr. William S. Newcomet, +radium-therapist, and Miss Katherine E. Schaeffer, technician. + + + +[216] CHAPTER XXVII--MALIGNANT DISEASE OF THE ESOPHAGUS + +Cancer of the esophagus is a more prevalent disease than is commonly +thought. In the male it usually develops during the fourth and fifth +decades of life. There is in some cases the history of years of more +or less habitual consumption of strong alcoholic liquors. In the +female the condition often occurs at an earlier age than in the male, +and tends to run a more protracted course, preceeded in some cases by +years of precancerous dysphagia. + +Squamous-celled epithelioma is the most frequent type of neoplasm. In +the lower third of the esophagus, cylindric cell carcinoma may be +found associated with a like lesion in the stomach. Sarcoma of the +esophagus is relatively rare (Bibliography 1, p. 449). + +The sites of the lesion are those of physiologic narrowing of the +esophagus. The middle third is most frequently involved; and the lower +third, near the cardia, comes next in frequency. Cancer of the lower +third of the esophagus preponderates in men, while cancer of the upper +orifice is, curiously, more prevalent in women. The lesion is usually +single, but multiple lesions, resulting from implantation metastases +have been observed (Bibliography 1, p. 391). Bronchoesophageal fistula +from extension is not uncommon. + +_Symptoms_.--Malignant disease of the esophagus is rarely seen early, +because of the absence, or mildness, of the symptoms. Dysphagia, the +one common symptom of all esophageal disease, is often ignored by the +patient until it becomes so marked as to prevent the taking of solid +food; therefore, the onset may have the similitude of abruptness. Any +well masticated solid food can be swallowed through a lumen 5 +millimeters in diameter. The inability to maintain the nutrition is +evidenced by loss of weight and the rapid development of cachexia. +When the stenosis becomes so severe that the fluid intake is limited, +rapid decline occurs from water starvation. Pain is usually a late +symptom of the disease. It may be of an aching character and referred +to the vertebral region or to the neck; or it may only accompany the +act of swallowing. Blood-streaked, regurgitated material, and the +presence of odor, are late manifestations of ulceration and secondary +infection. In some cases, constant oozing of blood from the ulcerated +area adds greatly to the cachexia. If the recurrent laryngeal nerves +are involved, unilateral or bilateral paralysis of the larynx may +complicate the symptoms by cough, dyspnea, aphonia, and possibly +septic pneumonia. + +_Diagnosis_.--It has been estimated that 70 per cent of stenoses of +the esophagus in adults are malignant in nature. This should stimulate +the early and careful investigation of every case of dysphagia. When +all cases of persistent dysphagia, however slight, are endoscopically +studied, precancerous lesions may be discovered and treated, and the +limited malignancy of the early stages may be afforded surgical +treatment while yet there is hope of complete removal. Luetic and +tuberculous ulceration of the esophagus are to be eliminated by +suitable tests, supplemented in rare instances by biopsy. Aneurysm of +the aorta must in all cases of dysphagia be excluded, for the dilated +aorta may be the sole cause of the condition, and its presence +contraindicates esophagoscopy because of the liability of rupture. +Foreign body is to be excluded by history and roentgenographic study. +Spasmodic stenosis of the esophagus may or may not have a malignant +origin. Esophagoscopy and removal of a specimen for biopsy renders the +diagnosis certain. It is to be especially remembered, however, that it +is very unwise to bite through normal mucosa for the purpose of taking +a specimen from a periesophageal growth. Fungations and polypoid +protuberances afford safe opportunities for the removal of specimens +of tissue. + +_The esophagoscopic appearances of malignant disease_, varying with +the stage and site of origin of the growth, may present as follows:-- + 1. Submucosal infiltration covered by perfectly normal membrane, +usually associated with more or less bulging of the esophageal wall, +and very often with hardness and infiltration. + 2. Leucoplakia. + 3. Ulceration projecting but little above the surface at the edges. + 4. Rounded nodular masses grouped in mulberry-like form, either dark +or light red in color. + 5. Polypoid masses. + 6. Cauliflower fungations. + +In considering the esophagoscopic appearances of cancer, it is +necessary to remember that after ulceration has set in, the cancerous +process may have engrafted upon it, and upon its neighborhood, the +results of inflammation due to the mixed infections. Cancer invading +the wall from without may for a long time be covered with perfectly +normal mucous membrane. The significant signs at this early stage are: + 1. Absence of one or more of the normal radial creases between the +folds. + 2. Asymmetry of the inspiratory enlargement of lumen. + 3. Sensation of hardness of the wall on palpation with the tube. + 4. The involved wall will not readily be made to wrinkle when pushed +upon with the tube mouth. + +In all the later forms of lesions the two characteristics are (a) the +readiness with which oozing of blood occurs; and (b) the sense of +rigidity, or fixation, of the involved area as palpated with the +esophagoscope, in contrast to the normally supple esophageal wall. +Esophageal dilatation above a malignant lesion is rarely great, +because the stenosis is seldom severely obstructive until late in the +course of the disease. + +_Treatment_.--The present 100 per cent mortality in cancer of the +esophagus will be lowered and a certain percentage of surgical cures +will be obtained when patients with esophageal symptoms are given the +benefit of early esophagoscopic study. The relief or circumvention of +the dysphagia requires early measures to prevent food and water +starvation. _Bouginage_ of a malignant esophagus to increase +temporarily the size of the stenosed lumen is of questionable +advisability, and is attended with the great risk of perforating the +weakened esophageal wall. + +_Esophageal intubation_ may serve for a time to delay gastrostomy but +it cannot supplant it, nor obviate the necessity for its ultimate +performance. The Charters-Symonds or Guisez esophageal intubation tube +is readily inserted after drawing the larynx forward with the +laryngoscope. The tube must be changed every week or two for cleaning, +and duplicate tubes must be ready for immediate reinsertion. +Eventually, a smaller, and then a still smaller tube are needed, until +finally none can be introduced; though in some cases the tube can be +kept in the soft mass of fungations until the patient has died of +hemorrhage, exhaustion, complications or intercurrent disease. + +_Gastrostomy_ is always indicated as the disease progresses, and it +should be done before nutrition is greatly impaired. Surgeons often +hesitate thus to "operate on an inoperable case;" but it must be +remembered that no one should be allowed to die of hunger and thirst. +The operation should be done before inanition has made serious +inroads. As in the case of tracheotomy, we always preach doing it +early, and always do it late. If postponed too long, water starvation +may proceed so far that the patient will not recover, because the +water-starved tissues will not take up water put in the stomach. + +_Radiotherapy_.--Radium and the therapeutic roentgenray are today our +only effective means of retarding the progress of esophageal malignant +neoplasms. No permanent cures have been reported, but marked temporary +improvement in the swallowing function and prolongation of life have +been repeatedly observed. The combination of radium treatment applied +within the esophageal lumen and the therapeutic roentgenray through +the chest wall, has retarded the progress of some cases. + +The dosage of radium or the therapeutic ray must be determined by the +radiologist for the particular individual case; its method of +application should be decided by consultation of the radiologist and +the endoscopist. Two fundamental points are to be considered, however. +The radium capsule, if applied within the esophagus, should be so +screened that the soft, irritating, beta rays, and the secondary rays, +are both filtered out to prevent sloughing of the esophageal mucosa. +The dose should be large enough to have a lethal effect upon the +cancer cells at the periphery of the growth as well as in the center. +If the dose be insufficient, development of the cells at the outside +of the growth is stimulated rather than inhibited. It is essential +that the radium capsule be accurately placed in the center of the +malignant strictured area and this can be done only by visual control +through the esophagoscope (Fig. 95) + +Drs. Henry K. Pancoast, George E. Pfahler and William S. Newcomet have +obtained very satisfactory palliative effects from the use of radium +in esophageal cancer. + + + +[221] CHAPTER XXVIII--DIRECT LARYNGOSCOPY IN DISEASES OF THE LARYNX + +The diagnosis of laryngeal disease in young children, impossible with +the mirror, has been made easy and precise by the development of +direct laryngoscopy. No anesthetic, local or general, should be used, +for the practised endoscopist can complete the examination within a +minute of time and without pain to the patient. The technic for doing +this should be acquired by every laryngologist. Anesthesia is +absolutely contraindicated because of the possibility of the presence +of diphtheria, and especially because of the dyspnea so frequently +present in laryngeal disease. To attempt general anesthesia in a +dyspneic case is to invite disaster (see Tracheotomy). It is to be +remembered that coughing and straining produce an engorgement of the +laryngeal mucosa, so that the first glance should include an +estimation of the color of the mucosa, which, as a result of the +engorgement, deepens with the prolongation of the direct laryngoscopy. + +_Chronic subglottic edema_, often the result of perichondritis, may +require linear cauterization at various times, to reduce its bulk, +after the underlying cause has been removed. + +_Perichondritis and abscess_, and their sequelae are to be treated on +the accepted surgical precepts. They may be due to trauma, lues, +tuberculosis, enteric fever, pneumonia, influenza, etc. + +_Tuberculosis of the larynx_ calls for conservatism in the application +of surgery. Ulceration limited to the epiglottis may justify +amputation of the projecting portion or excision of only the ulcerated +area. In either case, rapid healing may be expected, and relief from +the odynphagia is sometimes prompt. Amputation of the epiglottis is, +however, not to be done if ulceration in other portions of the larynx +coexist. The removal of tuberculomata is sometimes indicated, and the +excision of limited ulcerative lesions situated elsewhere than on the +epiglottis may be curative. These measures as well as the +galvanocautery are easily executed by the facile operator; but their +advisability should always be considered from a conservative +viewpoint. They are rarely justifiable until after months of absolute +silence and a general antituberculous regime have failed of benefit. + +_Galvanopuncture_ for laryngeal tuberculosis has yielded excellent +results in reducing the large pyriform edematous swellings of the +aryepiglottic folds when ulceration has not yet developed. Deep +punctures at nearly a white heat, made perpendicular to the surface, +are best. Care must be exercised not to injure the cricoarytenoid +joint. Fungating ulcerations may in some cases be made to cicatrize by +superficial cauterization. Excessive reactions sometimes follow, so +that a light application should be made at the first treatment. + +_Congenital laryngeal stridor_ is produced by an exaggeration of the +infantile type of larynx. The epiglottis will be found long and +tapering, its lateral margins rolled backward so as to meet and form a +cylinder above. The upper edges of the aryepiglottic folds are +approximated, leaving a narrow chink. The lack of firmness in these +folds and the loose tissue in the posterior portion of the larynx, +favors the drawing inward of the laryngeal aperture by the inspiratory +blast. The vibration of the margins of this aperture produces the +inspiratory stridor. Diagnosis is quickly made by the inspection of +the larynx with the infant diagnostic laryngoscope. No anesthetic, +general or local, is needed. Stridorous respiration may also be due to +the presence of laryngeal papillomata, laryngeal spasm, thymic +compression, congenital web, or an abnormal inspiratory bulging into +the trachea of the posterior membranous tracheo-esophageal wall. The +term "congenital laryngeal stridor" should be limited to the first +described condition of exaggerated infantile larynx. + +_Treatment of congenital laryngeal stridor_ should be directed to the +relief of dyspnea, and to increasing the nutrition and development of +the infant. The insertion of a bronchoscope will temporarily relieve +an urgent dyspneic attack precipitated by examination; but this rarely +happens if the examination is not unduly prolonged. Tracheotomy may be +needed to prevent asphyxia or exhaustion from loss of sleep; but very +few cases require anything but attention to nutrition and hygiene. +Recovery can be expected with development of the laryngeal structures. + +_Congenital webs of the larynx_ require incision or excision, or +perhaps simply bouginage. Congenital goiter and congenital laryngeal +paralysis, both of which may cause stertorous breathing, are +considered in connection with other forms of stenosis of the air +passages. + +_Aphonia_ due to cicatricial webs of the larynx may be cured by +plastic operations that reform the cords, with a clean, sharp anterior +commissure, which is a necessity for clear phonation. The laryngeal +scissors and the long slender punch are often more useful for these +operations than the knife. + + + +[224] CHAPTER XXIX--BRONCHOSCOPY IN DISEASES OF THE TRACHEA AND +BRONCHI + +_The indications for bronchoscopy in disease_ are becoming +increasingly numerous. Among the more important may be mentioned: + 1. Bronchiectasis. + 2. Chronic pulmonary abscess. + 3. Unexplained dyspnea. + 4. Dyspnea unrelieved by tracheotomy calls for bronchoscopic search +for deeper obstruction. + 5. Paralysis of the recurrent laryngeal nerve, the cause of which is +not positively known. + 6. Obscure thoracic disease. + 7. Unexplained hemoptysis. + 8. Unexplained cough. + 9. Unexplained expectoration. + +_Contraindications to bronchoscopy in disease_ do not exist if the +bronchoscopy is really needed. Serious organic disease such as +aneurysm, hypertension, advanced cardiac disease, might render +bronchoscopy inadvisable except for the removal of foreign bodies. + +_Bronchoscopic Appearances in Disease_.--The first look should note +the color of the bronchial mucosa, due allowance being made for the +pressure of tubal contact, secretions, and the engorgement incident to +continued cough. The carina trachealis normally moves slowly forward +as well as downward during deep inspiration, returning quickly during +expiration. Impaired movement of the carina indicates peritracheal and +peribronchial pathology, the fixation being greatest in advanced +cancer. In children and in the smaller tubes of the adult, the +lengthening and dilatation of the bronchi during inspiration, and +their shortening and contraction during expiration are readily seen. + +_Anomalies of the Tracheobronchial Tree_.--Tracheobronchial anomalies +are relatively rare. Congenital esophagotracheal and esophagobronchial +fistulae are occasionally seen, and cases of cervicotracheal fistulae +have been reported. Congenital webs and diverticula of the trachea are +cited infrequently. Laryngoptosis and deviation of the trachea may be +congenital. Substernal goitre, aneurysm, malignant growths, and +various mediastinal adenopathies may displace the trachea from its +normal course. The emphysematous chest fixed in the deep voluntary +inspiratory position produces in some cases an elevation of the +superior thoracic aperture simulating laryngoptosis (Bibliography r, +pp. 468, 594). + +_Compression Stenosis of the Trachea and Bronchi_.--Compression of the +trachea is most commonly caused by goiter, substernal or cervical, +aneurysm, malignancy, or, in children, by enlarged thymus. Less +frequently, enlarged mediastinal tuberculous, leukemic, leutic or +Hodgkin's glands compress the airway. The left bronchus may be +stenosed by pressure from a hypertrophied cardiac auricle. Compression +stenosis of the trachea associated with pulmonary emphysema accounts +for the dyspnea during attacks of coughing. + +The endoscopic picture of compression stenosis is that of an +elliptical or scabbard-shaped lumen when the bronchus is at rest or +during inspiration. Concentric funnel-like compression stenosis, while +rare, may be produced by annular growths. + +_Treatment of Compression Stenoses of the Trachea_.--If the thymus be +at fault, rapid amelioration of symptoms follows roentgenray or radium +therapy. Tracheotomy and the insertion of the long cane-shaped cannula +(Fig. 104) past the compressed area is required in the cases caused by +conditions less amenable to treatment than thymic enlargement. +Permanent cure depends upon the removability of the compressive mass. +Should the bronchi be so compressed by a benign condition as to +prevent escape of secretions from the subjacent air passages, +bronchial intubation tubes may be inserted, and, if necessary, worn +constantly. They should be removed weekly for cleansing and oftener if +obstructed. + +_Influenzal Laryngotracheobronchitis_.--Influenzal infection, not +always by the same organism, sweeps over the population, attacking the +air passages in a violent and quite characteristic way. Bronchoscopy +shows the influenzal infection to be characterized by intense +reddening and swelling of the mucosa. In some cases the swelling is so +great as to necessitate tracheotomy, or intubation of the larynx; and +if the edema involve the bronchi, occlusion may be fatal. Hemorrhagic +spots and superficial erosions are commonly seen, and a thick, +tenacious exudate, difficult of expectoration, lies in patches in the +trachea. Infants may asphyxiate from accumulation of this secretion +which they are unable to expel. The differential diagnosis from +diphtheria is sometimes difficult. The absence of true membrane and +the failure to find diphtheria bacilli in smears taken from the +trachea are of aid but are not infallible. In doubtful cases, the +administration of diphtheria antitoxin is a wise precaution pending +the establishment of a definite diagnosis. The pseudomembrane +sometimes present in influenzal tracheobronchitis is thinner and less +pulpy than that of the earlier stages of diphtheria. The casts of the +later stages do not occur in influenzal tracheobronchitis +(Bibliography I, p. 480). + +_Edematous Tracheobronchitis_.--This is chiefly observed in children. +The most frequently encountered form is the epidemic disease to which +the name "Influenza" has been given (q.v. supra). The only noticeable +difference between the epidemic and the sporadic cases is in the more +general susceptibility to the infective agent, which gives the +influenzal form an appearance of being more virulently infective. +Possibly the sporadic form is simply the attack of children not +immunized by a previous attack during an epidemic. + +There is another form of edematous tracheobronchitis often of great +severity and grave prognosis, that results from the aspiration of +irritating liquids or vapors, or of certain organic substances such as +peanut kernels, watermelon seeds, etcetera. Tracheotomy should be done +if marked dyspnea be present. Secretions can then be easily removed +and medication in the form of oily solutions be instilled at will into +the trachea. In the Bronchoscopic Clinic many children have been kept +alive for days, and their lives finally saved by aspiration of thick, +tough, sometimes clotted and crusted secretions, with the aspirating +tube (Fig. 10). It is better in these cases not to pass the +bronchoscope repeatedly. If, however, evidences of obstruction remain, +after aspiration, it is necessary to see the nature of the obstruction +and relieve it by removal, dilatation, or bronchial intubation as the +case may require. It is all a matter of "plumbing" i.e., clearing out +the "pipes," and maintaining a patulous airway. + +_Tracheobronchial Diphtheria_.--Urgent dyspnea in diphtheria when no +membrane and but slight lessening of the laryngeal airway is seen, +calls for bronchoscopy. Many lives have been saved by the +bronchoscopic removal of membrane obstructing the trachea or bronchi. +In the early stages, pulpy masses looking like "mother" of vinegar are +very obstructive. Later casts of membrane may simulate foreign bodies. +The local application of diphtheria antitoxin to the trachea and +bronchi has also been recommended. A preparation free from a chemical +irritant should be selected. + +_Abscess of the Lung_.--If of foreign-body origin, pulmonary abscess +almost invariably heals after the removal of the object and a regime +of fresh air and rest, without local measures of any kind. Acute +pulmonary abscess from other causes may require bronchoscopic drainage +and gentle dilatation of the swollen and narrowed bronchi leading to +it. Some of these bronchi are practically fistulae. Obstructive +granulations should be removed with crushing, not biting forceps. The +regular foreign-body forceps are best for this purpose. Caution should +be used as to removal of the granulations with which the abscess +"cavity" is filled in chronic cases. The term "abscess" is usually +loosely applied to the condition of drowned lung in which the pus has +accumulated in natural passages, and in which there is neither a new +wall nor a breaking down of normal walls. Chronic lung-abscess is +often successfully treated by weekly bronchoscopic lavage with 20 cc. +or more of a warm, normal salt solution, a 1:1000 watery potassium +permanganate solution, or a weak iodine solution as in the following +formula: + Rx. Monochlorphenol (Merck) .12 + Lugol's solution 8.00 + Normal salt solution 500. + +Perhaps the best procedure is to precede medicinal applications by the +clearing out of the purulent secretions by aspiration with the +aspirating bronchoscope and the independent aspirating tube, the +latter being inserted into passages too small to enter with the +bronchoscope, and the endobronchial instillation of from 10 to 30 cc. +of the medicament. The following have been used: Argyrol, 1 per cent +watery solution; Silvol, 1 per cent watery solution; Iodoform, oil +emulsion 10 per cent; Guaiacol, 10 per cent solution in paraffine oil; +Gomenol, 20 per cent solution in oil; or a bismuth subnitrate +suspension in oil. Robert M. Lukens and William F. Moore of the +Bronchoscopic Clinic report excellent results in post-tonsillectomy +abscesses from one tenth of one per cent phenol in normal salt +solution with the addition of 2 per cent Lugol's solution. Chlorinated +solutions are irritating, and if used, require copious dilution. +Liquid petrolatum with a little oil of eucalyptus has been most often +the medium. + +_Gangrene of the Lung_.--Pulmonary gangrene has been followed by +recovery after the endobronchial injection of oily solutions of +gomenol and guaiacol (Guisez). The injections are readily made through +the laryngoscope without the insertion of a bronchoscope. A silk woven +catheter may be used with an ordinary glass syringe or a long-nozzled +laryngeal syringe, or a bronchoscopic syringe may be used. + +_Lung-mapping_ by a roentgenogram taken promptly after the +bronchoscopic insufflation of bismuth subnitrate powder or the +injection of a suspension of bismuth in liquid petrolatum is advisable +in most cases of pulmonary abscess before beginning any kind of +treatment. + +_Bronchial Stenosis_.--Stenosis of one or more bronchi results at +times from cicatricial contraction following secondary infection of +leutic, tuberculous or traumatic lesions. The narrowing resulting from +foreign body traumatism rarely requires secondary dilatation after the +foreign body has been removed. Tuberculous bronchial stenoses rarely +require local treatment, but are easily dilated when necessary. Luetic +cicatricial stenosis may require repeated dilatation, or even +bronchial intubation. Endobronchial neoplasms may cause a subjacent +bronchiectasis, and superjacent stenosis; the latter may require +dilatation. Cicatricial stenoses of the bronchi are readily +recognizable by the scarred wall and the absence of rings at or near +the narrowing. + +_Bronchiectasis_.--In most cases of bronchiectasis there are strong +indications for a bronchoscopic diagnosis, to eliminate such +conditions as foreign body, cicatricial bronchial stenosis, or +endobronchial neoplasm as etiologic factors. In the idiopathic types +considerable benefit has resulted from the endobronchial lavage and +endobronchial oily injections mentioned under lung abscess. It is +probable that if bronchoscopic study were carried out in every case, +definite causes for many so-called "idiopathic" cases would be +discovered. Lung-mapping as elsewhere herein explained is invaluable +in the study of bronchiectasis. + +_Bronchial asthma_ affords a large field for bronchoscopic study. As +yet, sufficient data to afford any definite conclusions even as to the +endoscopic picture of this disease have not been accumulated. Of the +cases seen in the Bronchoscopic Clinic some showed no abnormality of +the bronchi in the intervals between attacks, others a chronic +bronchitis. In cases studied bronchoscopically during an attack, the +bronchi were found filled with bubbling secretions and the mucosa was +somewhat cyanotic in color. The bronchial lumen was narrowed only as +much as it would be, with the same degree of cough, in any patient not +subject to asthma. The secretions were removed and the attack quickly +subsided; but no influence on the recurrence of attacks was observed. +It is essential that the bronchoscopic studies be made, as were these, +without anesthesia, local or general, for it is known that the +application of cocain or adrenalin to the larynx, or even in the nose, +will, with some patients, stop the attack. When done without local +anesthesia, allowance must be made for the reaction to the presence of +the tube. In those cases in which other means have failed to give +relief, the endobronchial application of novocain and adrenalin, +orthoform, propaesin or anesthesin emulsion may be tried. Cures have +been reported by this treatment. Argentic nitrate applied at weekly +intervals has proven very efficient in some cases. Associated +infective disease of the bronchial mucosa brings with it the questions +of immunity, allergy, anaphylaxis, and vaccine therapy; and the often +present defective metabolism has to be considered. + +_Autodrownage_.--Autodrownage is the name given by the author to the +drowning of the patient in his own secretions. Tracheobronchial +secretions in excess of the amount required to moisten the inspired +air, become, in certain cases, a mechanical menace to life, unless +removed. The cough reflex, forced expiration, and ciliary action, +normally remove the excess. When these mechanisms are impaired, as in +profound asthenia, laryngeal paralysis, laryngeal or tracheal +stenosis, etc.; and especially when in addition to a mild degree of +glottic stenosis or impaired laryngeal mobility, the secretions become +excessive, the accumulation may literally drown the patient in his own +secretions. This is illustrated frequently in influenza and arachidic +bronchitis. Infants cannot expectorate, and their cough reflex is +exceedingly ineffective in raising secretion to the pharynx; +furthermore they are easily exhausted by bechic efforts; so that age +may be cited as one of the most frequent etiologic factors in the +condition of autodrownage. Bronchoscopic sponge-pumping (_q.v._) and +bronchoscopic aspiration are quite efficient and can save any patient +not afflicted with conditions that are fatal by other pathologic +processes. + +_Lues of the Tracheobronchial Tree_.--Compared to laryngeal +involvement, syphilis of the tracheobronchial tree is relatively rare. +The lesions may be gummatous, ulcerative, or inflammatory, or there +may be compressive granulomatous masses. Hemoptysis may have its +origin from a luetic ulceration. Excision of fungations or of a +portion of the margin of the ulceration for biopsy is advisable. The +Wassermann and therapeutic tests, and the elimination of tuberculosis +will be required for confirmation. Luetic stenoses are referred to +above. + +_Tuberculosis of the Tracheobronchial Tree_.--The bronchoscopic study +of tuberculosis is very interesting, but only a few cases justify +bronchoscopy. The subglottic infiltrations from extensions of +laryngeal disease are usually of edematous appearance, though they are +much more firm than in ordinary inflammatory edema. Ulcerations in +this region are rare, except as direct extensions of ulceration above +the cord. The trachea is relatively rarely involved in tuberculosis, +but we may have in the trachea the pale swelling of the early stage of +a perichondritis, or the later ulceration and all the phenomena +following the mixed pyogenic infections. These same conditions may +exist in the bronchi. In a number of instances, the entire lumen of +the bronchus was occluded by cheesy pus and debris of a peribronchial +gland which had eroded through. As a rule, the mucosa of tuberculosis +is pale, and the pallor is accentuated by the rather bluish streak of +vessels, where these are visible. Erosion through of peri-bronchial or +peri-tracheal lymph masses may be associated with granulation tissue, +usually of pale color, but occasionally reddish; and sometimes oozing +of blood is noticed. A most common picture in tuberculosis is a +broadening of the carina, which may be so marked as to obliterate the +carina and to bulge inward, producing deformed lumina in both bronchi. +Sometimes the lumina are crescentic, the concavity of the crescent +being internal, that is, toward the median line. Absence of the normal +anterior and downward movement of the carina on deep inspiration is +almost pathognomonic of a mass at the bifurcation, and such a mass is +usually tuberculous, though it may be malignant, and, very rarely, +luetic. The only lesion visible in a tuberculous case may be +cicatrices from healed processes. In a number of cases there has been +a discharge of pus coming from the upper-lobe bronchus. + +[Fig. 96.--The author's tampons for pulmonary hemostasis by +bronchoscopic tamponade. The folded gauze is 10 cm. long; the braided +silk cord 60 cm. long.] + +_Hemoptysis_.--In cases not demonstrably tuberculous, hemoptysis may +require bronchoscopic examination to determine the origin. Varices or +unsuspected luetic, malignant, or tuberculous lesions may be found to +be the cause. It is mechanically easy to pack off one bronchus with +the author's packs (Fig. 96) introduced through the bronchoscope, but +the advisability of doing so requires further clinical tests. + +_Angioneurotic Edema_.--Angioneurotic edema manifests itself by a pale +or red swollen mucosa producing stenosis of the lumen. The temporary +character of the lesion and its appearance in other regions confirm +the diagnosis. + +_Scleroma of the trachea_ is characterized by infiltration of the +tracheal mucosa, which greatly narrows the lumen. The infiltration may +be limited in area and produce a single stricture, or it may involve +the entire trachea and even close a bronchial orifice. Drying and +crusting of secretions renders the stenosis still more distressing. +This disease is but rarely encountered in America but is not +infrequent in some parts of Europe. Treatment consists in the +prevention of crusts and their removal. Limited stenotic areas may +yield to bronchoscopic bouginage. Urgent dyspnea calls for +tracheotomy. Radium and roentgenray therapy have been advised, and +cure has been reported by intravenous salvarsan treatment (see article +by S. Shelton Watkins, on Scleroma in Surg. Gynecol. and Obst., July, +1921, p. 47). + +_Atrophic tracheitis_, with symptoms quite similar to atrophic +rhinitis is a not unusual accompaniment of the nasal condition. It may +also exist without nasal involvement. On tracheoscopy the mucosa is +thinned, pale and dry, and is covered with patches of thick +mucilaginous secretion and crusts. Decomposition of secretion produces +tracheal "ozena," while the accumulated crusts give rise to the +sensation of a foreign body and may seriously interfere with +respiration, making bronchoscopic removal imperative. The associated +development of tracheal nodular enchondromata has been described. The +internal administration of iodine and the intratracheal injection of +bland oily solutions of menthol, guaiacol, or gomenol are helpful. + + + +[235] CHAPTER XXX--DISEASES OF THE ESOPHAGUS + +The more frequent causes of the one common symptom of esophageal +disease, dysphagia, are included in the list given below. To avoid +elaboration and to obtain maximum usefulness as a reminder, +overlapping has not been eliminated. + 1. Anomalies. + 2. Esophagitis, acute. + 3. Esophagitis, chronic. + 4. Erosion. + 5. Ulceration. + 6. Trauma. + 7. Stricture, congenital. + 8. Stricture, spasmodic, including cramp of the diaphragmatic +pinchcock. + 9. Stricture, inflammatory. + 10. Stricture, cicatricial. + 11. Dilatation, local. + 12. Dilatation, diffuse. + 13. Diverticulum. + 14. Compression stenosis. + 15. Mediastinal tumor. + 16. Mediastinal abscess. + 17. Mediastinal glandular mass. + 18. Aneurysm. + 19. Malignant neoplasm. + 20. Benign neoplasm. + 21. Tuberculosis. + 22. Lues. + 23. Actinomycosis. + 24. Varix. + 25. Angioneurotic edema. + 26. Hysteria. + 27. Functional antiperistalsis. + 28. Paralysis. + 29. Foreign body in (a) pharynx, (b) larynx, (c) trachea, (d) +esophagus. + + + + +[236] _Diagnosis_.--The swallowing function can be studied only with +the fluoroscope; esophagoscopy for diagnosis, should therefore always +be preceded by a fluoroscopic study of deglutition with a barium or +other opaque mixture and examination of the thoracic organs to +eliminate external pressure on the esophagus as the cause of stenosis. +Complete physical examination and Wassermann reaction are further +routine preliminaries to any esophagoscopy. Special laboratory tests +are done as may be indicated. The physical examination is meant to +include a careful examination of the lips, tongue, palate, pharynx, +and a mirror examination of the larynx when age permits. + +_Indications for Esophagoscopy in Disease_.--Any persistent abnormal +sensation or disturbance of function of the esophagus calls for +esophagoscopy. Vague stomach symptoms may prove to be esophageal in +origin, for vomiting is often a complaint when the patient really +regurgitates. + +_Contraindications to Esophagoscopy_.--In the presence of aneurysm, +advanced organic disease, extensive esophageal varicosities, acute +necrotic or corrosive esophagitis, esophagoscopy should not be done +except for urgent reasons, such as the lodgment of a foreign body; and +in this case the esophagoscopy may be postponed, if necessary, unless +the patient is unable to swallow fluids. Esophagoscopy should be +deferred, in cases of acute esophagitis from swallowing of caustics, +until sloughing has ceased and healing has strengthened the weak +places. The extremes of age are not contraindications to +esophagoscopy. A number of newborn infants have been esophagoscoped by +the author; and he has removed foreign bodies from patients over 80 +years of age. + +_Water starvation_ makes the patient a very bad surgical subject, and +is a distinct contraindication to esophagoscopy. Water must be +supplied by means of proctoclysis and hypodermoclysis before any +endoscopic or surgical procedure is attempted. If the esophageal +stenosis is not readily and quickly remediable, gastrostomy should be +done immediately. _Rectal feeding_ will supply water for a limited +time, but for nutrient purposes rectal alimentation is dangerously +inefficient. + +_Preliminary examination of the pharynx and larynx with tongue +depressor_ should always precede esophagoscopy, for any purpose, +because the symptoms may be due to laryngeal or pharyngeal disease +that might be overlooked in passing the esophagoscope. A high degree +of esophageal stenosis results in retention in the suprajacent +esophagus of the fluids which normally are continually flowing +downward. The pyriform sinuses in these cases are seen with the +laryngeal mirror to be filled with frothy secretion (Jackson's sign of +esophageal stenosis) and this secretion may sometimes be seen +trickling into the larynx. This overflow into the larynx and lower air +passages is often the cause of pulmonary symptoms, which are thus +strictly secondary to the esophageal disease. + +ANOMALIES OF THE ESOPHAGUS + +_Congenital esophagotracheal fistulae_ are the most frequent of the +embryonic developmental errors of this organ. Septic pneumonia from +the entrance of fluids into the lungs usually causes death within a +few weeks. + +_Imperforate esophagus_ usually shows an upper esophageal segment +ending in a blind pouch. A lower segment is usually present and may be +connected with the upper segment by a fistula. + +_Congenital stricture_ of the esophagus may be single or multiple, and +may be thin and weblike, or it may extend over a third or more of the +length of the esophagus. It may not become manifest until solids are +added to the child's diet; often not for many months. The lodgment of +an unusually large bolus of unmasticated food may set up an +esophagitis the swelling of which may completely close the lumen of +the congenitally narrow esophagus. It is not uncommon to meet with +cases of adults who have "never swallowed as well as other people," +and in whom cicatricial and spasmodic stenosis can be excluded by +esophagoscopy, which demonstrates an obvious narrowing of the +esophageal lumen. These cases are doubtless congenital. + +_Webs in the upper third of the esophagus_ are best determined by the +passage of a large esophagoscope which puts the esophagus on the +stretch. The webs may be broken by the insertion of a closed alligator +forceps, which is then withdrawn with opened blades. Better still is +the dilator shown in Fig. 26. This retrograde dilatation is relatively +safe. A silk-woven esophagoscopic bougie or the metallic tracheal +bougie may be used, with proper caution. Subsequent dilatation for a +few times will be required to prevent a reproduction of the stenosis. + +_Treatment of Esophageal Anomalies_.--Gastrostomy is required in the +imperforate cases. Esophagoscopic bouginage is very successful in the +cure of all cases of congenital stenosis. Any sort of lumen can be +enlarged so any well masticated food can be swallowed. Careful +esophagoscopic work with the bougies (Fig. 40) will ultimately cure +with little or no risk of mortality. Any form of rapid dilatation is +dangerous. Congenital stenosis, if not an absolute atresia, yields +more readily to esophagoscopic bouginage than cicatricial stenosis. + +RUPTURE AND TRAUMA OF THE ESOPHAGUS + +These may be spontaneous or may ensue from the passage of an +instrument, or foreign body, or of both combined, as exemplified in +the blind attempts to remove a foreign body or to push it downwards. +Digestion of the esophagus and perforation may result from the +stagnation of regurgitated gastric juice therein. This condition +sometimes occurs in profound toxic and debilitated states. Rupture of +the thoracic esophagus produces profound shock, fever, mediastinal +emphysema, and rapid sinking. Pneumothorax and empyema follow +perforation into the pleural cavity. Rupture of the cervical esophagus +is usually followed by cervical emphysema and cervical abscess, both +of which often burrow into the mediastinum along the fascial layers of +the neck. Lesser degrees of trauma produce esophagitis usually +accompanied by fever and painful and difficult swallowing. + +The treatment of traumatic esophagitis consists in rest in bed, +sterile liquid food, and the administration of bismuth subnitrate +(about one gramme in an adult), dry on the tongue every 4 hours. +Rupture of the esophagus requires immediate gastrostomy to put the +esophagus at rest and supply necessary alimentation. Thoracotomy for +drainage is required when the pleural cavity has been involved, not +only for pleural secretions, but for the constant and copious +esophageal leakage. It is not ordinarily realized how much normal +salivary drainage passes down the esophagus. The customary treatment +of shock is to be applied. No attempt should be made to remove a +foreign body until the traumatic lesions have healed. This may require +a number of weeks. Decision as to when to remove the intruder is +determined by esophagoscopic inspection. + +Subcutaneous emphysema does not require puncture unless gaseous, or +unless pus forms. In the latter event free external drainage becomes +imperative. + +ACUTE ESOPHAGITIS + +This is usually of traumatic or cauterant origin. If severe or +extensive, all the symptoms described under "Rupture of the Esophagus" +may be present. The endoscopic appearances are unmistakable to anyone +familiar with the appearance of mucosal inflammations. The pale, +bluish pink color of the normal mucosa is replaced by a deep-red +velvety swollen appearance in which individual vessels are invisible. +After exudation of serum into the tissues, the color may be paler and +in some instances a typical edema may be seen. This may diminish the +lumen temporarily. Folds of swollen mucosa crowd into the lumen if the +inflammation is intense. These folds are sometimes demonstrable in the +roentgenogram by the bismuth or barium in the creases between which +the prominence of the folds show as islands as beautifully +demonstrated by David R. Bowen in one of the author's cases. If the +inflammation is due to corrosives, a grayish exudate may be visible +early, sloughs later. + +ULCERATION OF THE ESOPHAGUS + +Superficial erosions of the esophagus are by no means an uncommon +accompaniment of the stagnation of food and secretions. From the +irritation they produce, spastic stenosis may occur, thus constituting +a vicious circle; the spasm of the esophagus increases the stagnation +which in turn results in further inflammation and ultimate ulceration. +Healing of such ulcers may result in cicatricial contraction and +organic stenosis. Ulceration may follow trauma by instrument, foreign +body, or corrosive. + +DIFFERENTIAL DIAGNOSIS OF ULCER OF THE ESOPHAGUS + +_Simple ulcer_ requires the exclusion of lues, tuberculosis, +epithelioma, endothelioma, sarcoma, and actinomycosis. Simple ulcer of +the esophagus is usually associated with stenosis, spastic or organic. + +_Luetic ulcers_ commonly show a surrounding inflammatory areola, and +they usually have thickened elevated edges, generally free from +granulation tissue, with a pasty center not bleeding readily when +sponged. The Wassermann reaction may contribute to the diagnosis; but +if negative, a thorough and prolonged test with mercury is imperative. +It must be remembered that a person with lues may have a simple, +mixed, or malignant ulceration of the esophagus, or the three lesions +may even be combined. It may be in some cases possible to demonstrate +the treponema pallidum in scrapings taken from the ulcer. + +The single _tuberculous ulcer_ is usually pale, superficial, and +granular in base. If it is a continuation from more extensive +extra-esophageal tuberculous ulceration, pale cauliflower granulations +may be present. Slight cicatrices may be seen. Tuberculosis in other +organs can almost always be demonstrated by roentgenographic, +physical, or laboratory studies. Tuberculin tests and animal injection +with an emulsion of a specimen of tissue may be required. The specimen +must be taken very superficially to avoid risk of perforation. + +_Sarcomatous ulcers_ do not differ materially in appearance from those +of carcinoma, but they are much more rare. + +_Carcinomatous ulcer_ is usually characterized by the very vascular +bright red zone, raised edges, fungations, granulation tissue that +bleeds freely on the lightest touch, and above all, it is almost +invariably situated on an infiltrated base which communicates a +feeling of hardness to the pressure of sponges or the esophagoscope +itself. A scar may be from the healing of an ulcer from stasis, or one +of specific or precancerous character. It may be a cancerous process +developing on the site of a scar, so that the presence of scar tissue +does not absolutely negative malignancy. As a rule, however, scars are +absent in cancer of the esophagus. The firm and sometimes prominent +ridge of the crossing of the left bronchus must not be mistaken for +infiltration, and the esophagoscopist must be familiar with the normal +rigidity of the cricopharyngeus. + +[242] Mixed infection gives to all esophageal ulceration a certain +uniformity of appearance, so that laboratory studies of smears or +histologic and bacteriologic study of tissue specimens taken from +fungations or thickened edges are often required to confirm the +endoscopic diagnosis. If the edges are thin and flat, the taking of a +specimen involves some risk; fungations can be removed without risk; +so can nodules, but care must be taken that projecting folds are not +mistaken for nodules. It is always wise to push the therapeutic test +with potassium iodid and especially mercury in any case of esophageal +ulceration unassociated with stasis. + +_Treatment of Acute and Subacute Inflammation and Ulceration of the +Esophagus_.--Bismuth subnitrate in doses of about one gramme, given +dry on the tongue and swallowed without water, has a local antiseptic +and protective action. Its antiseptic power may be enhanced by the +addition of calomel to the powder, in such amount as may be tolerated +by the bowels. If pain be present the combination of a grain or two of +anesthesin or orthoform with the bismuth will be grateful. The local +application of argyrol in 25 per cent watery solution is also of great +value. The mouth and teeth are to be kept clean with a mouth wash of +Dakin's solution, 1 part, to peppermint water, 6 parts. The esophagus +must be placed at rest as far as possible by liquid diet or, if need +be, by gastrostomy. + +CHRONIC ESOPHAGITIS + +This is usually a result of stagnation of food or secretion, and will +be considered under spasmodic stenosis and diffuse dilatation of the +esophagus. + +A very marked case with local distress and pain extending through to +the back was seen by the author in consultation with Dr. John B. +Wright who had made the diagnosis. The patient was a sufferer from +ankylostomiasis. + +[243] COMPRESSION STENOSIS OF THE ESOPHAGUS + +The esophagus may be narrowed by the pressure of any periesophageal +disease or anomaly. The lesions most frequently found are: + 1. Goiter, cervical or thoracic. + 2. Malignancy of any of the intrathoracic viscera. + 3. Aneurysm. + 4. Cardiac and aortic enlargement. + 5. Lymphadenopathies. Hodgkins' disease. + Leukemia. + Lues. + Tuberculosis. + Simple infective adenitis. + 6. Lordosis. + 7. Enlargement of the left hepatic lobe. + +Endoscopically, compression stenosis of the esophagus is manifested by +a slit-like crevice which occupies the place of the lumen and which +does not open up readily before the advancing tube. The long axis of +the slit is almost always at right angles to the compressive mass, if +the esophageal wall be uninvolved. The covering mucosa may be normal +or it may show signs of chronic inflammation. Malignant compressions +are characterized by their hardness when palpated with the tube. +Associated pressure on the recurrent laryngeal nerve often makes +laryngeal paralysis coexistent. The nature of the compressive mass +will require for its determination the aid of the roentgenologist, +internist, and clinical laboratory. Compression by the enlarged left +auricle has been observed a number of times. The presence of aneurysm +is a distinct contraindication to esophagoscopy for diagnosis except +in case of suspected foreign body. + +_Treatment of compressive stenosis of the esophagus_ depends upon the +nature of the compressive lesion and is without the realm of +endoscopy. In uncertain cases potassium iodid, and especially mercury, +should always be given a thorough and prolonged trial; an occasional +cure will result. Esophageal intubation is indicated in all conditions +except aneurysm. Gastrostomy should be done early when necessary. + +DIFFUSE DILATATION OF THE ESOPHAGUS + +This is practically always due to stagnation ectasia, which is +invariably associated with either organic or "spasmodic" stricture, +existing at the time of observation or at some time prior thereto. The +dilating effect of the repeatedly accumulated food results in a +permanent enlargement, so that the esophagus acts as the reservoir of +a large funnel with a very small opening. When food is swallowed the +esophagus fills, and the contents trickle slowly through the opening. +Gases due to fermentation increase the distension and cause substernal +pressure, discomfort, and belching. A very large dilatation of the +thoracic esophagus indicates spastic stenosis. Cicatricial stenoses do +not result in such large dilatations and the dilatation above a +malignant stenosis is usually slight, probably because of its +relatively shorter duration. + +The _treatment of diffuse esophageal dilatation_ consists in dilating +the "diaphragmatic pinchcock" that is, the hiatal esophagus. Chronic +esophagitis is to be controlled by esophageal lavage, the regulation +of the diet to liquefiable foods and the administration of bismuth +subnitrate. The patient can be taught to do the lavage. The local +esophagoscopic application of a small quantity of a 25 per cent watery +solution of argyrol may be required for the static esophagitis. The +redundancy probably never disappears; but functional and subjective +cures are usually obtainable. + + + +[245] CHAPTER XXXI--DISEASES OF THE ESOPHAGUS (_Continued_) + +SPASMODIC STENOSIS OF THE ESOPHAGUS + +_Etiology_.--The functional activity of the esophagus is dependent upon +reflex action. The food is propulsed in a peristaltic wave by the same +mechanism as, and through an innervation (Auerbach and Meissner +plexus) similar to that which controls intestinal movements. The vagus +also is directly concerned with the deglutitory act, for swallowing is +impossible if both vagi are cut. Anything which unduly disturbs this +reflex arc may serve as an exciting cause of spasmodic stenosis. +Bolting of food, superficial erosions, local esophageal disease, or a +small foreign body, may produce spasmodic stenosis. Spasm secondary to +disease of the stomach, liver, gall bladder, appendix, or other +abdominal organ is clinically well recognized. A perpetuating cause in +established cases is undoubtedly "nerve cell habit," and in many cases +there is an underlying neurotic factor. Shock as an exciting cause has +been well exemplified by the number of cases of phrenospasm developing +in soldiers during the World War. + +_Cricopharyngeal spasmodic stenosis_ usually presents the subjective +symptom of difficulty in starting the bolus of food downward. Once +started, the food passes into the stomach unimpeded. Regurgitation, if +it occurs, is immediate. The condition consists in a tonic +contraction, ahead of the bolus, of the circular fibers of the +inferior constrictor known as the cricopharyngeus muscle, or in a +failure of this muscle to relax so as to allow the bolus to pass. In +either case the disorder may be secondary to an organic lesion. Local +malignant disease or foreign bodies may be the cause. Globus +hystericus, "lump in the throat," and the sense of constriction and +choking during emotion are due to the same spasmodic condition. + +_Diagnosis_.--At esophagoscopy there will be found marked exaggeration +of the usual spasm which occurs at the cricopharyngeus during the +introduction of the tube. The lumen may assume various shapes, or be +so tightly closed that the folds form a mammilliform projection in the +center. If the spasm gradually yields, and a full-sized esophagoscope +passes without further resistance, it may be stated that the esophagus +is of normal calibre, and a diagnosis of spasmodic stenosis can be +made. Considerable experience is required to distinguish between +normal and pathologic spasm in an unanesthetized individual. To the +less experienced esophagoscopist, examination under ether anesthesia +is recommended. Deep anesthesia will relax the normal cricopharyngeal +reflex closure as well as any abnormal spasm, thus assisting in the +differentiation between an organic stricture and one of functional +character. Under deep general anesthesia, however, it is impossible to +differentiate between the normal reflex and a spasmodic condition, +since both are abolished. Many cases of intermittent esophageal +stenosis supposed to be spasmodic are due to organic narrowness of +lumen plus lodgement of food, obstructive in itself and in the +esophagitis resulting from its presence. The organic narrowing, +congenital or pathologic, is readily recognizable esophagoscopically. + +_Treatment_.--The fundamental cause of the disturbance of the reflex +should be searched for, and treated according to its nature. Purely +functional cases are often cured by the passage of a large +esophagoscope. Recurrences may require similar treatment. + +[247] FUNCTIONAL HIATAL STENOSIS. HIATAL ESOPHAGISMUS. PHRENOSPASM, +DIAPHRAGMATIC PINCHCOCK STENOSIS. (SO-CALLED CARDIOSPASM) + +There is no sphincteric muscular arrangement at the cardiac orifice of +the esophagus, so that spasmodic stenosis at this level is not +possible and the term cardiospasm is, therefore, a misnomer. It was +first demonstrated by the author that in so-called cardiospasm the +functional closure of the esophagus occurred at the diaphragmatic +level, and that it was due to the "diaphragmatic pinchcock." +Anatomical studies have corroborated this finding by demonstrating a +definite sphincteric mechanism consisting of muscle bands springing +from the crura of the diaphragm and surrounding the esophagus at the +under surface of the hiatus. An inspection of the cadaveric diaphragm +from below will demonstrate an arrangement like double shears +admirably adapted to this "pinchcock" action. Further confirmation is +the fact that all dilatation of the esophagus incident to spasm at its +lower extremity is situated above the diaphragm. In passing it may be +stated that the pinchcock action, plus the kinking of the esophagus +normally prevents regurgitation when a man with a full stomach "stands +on his head" or inverts his body. For the upward escape of food from +the stomach an involuntary co-ordinated antiperistaltic cycle is +necessary. The dilatation resulting from phrenospasm may reach great +size (Fig. 96a), and the capacity of the sac may be as much as two +liters. While the esophagus is usually dilated, the stomach on the +other hand is often contracted, largely from lack of distention by +food, but possibly also because of a spastic state due to the same +causes as the phrenospasm. Recently Mosher has demonstrated that +hepatic abnormality may furnish an organic cause in many cases +formerly considered spasmodic. + +The _symptoms of hiatal esophagismus_ are variable in degree. +Substernal distress, with a feeling of fullness and pressure followed +by eructations of gas and regurgitation of food within a period of a +quarter of an hour to several hours after eating, are present. If the +esophageal dilatation be great, regurgitation may occur only after an +accumulation of several days, when large quantities of stale food will +be expelled. The general nutrition is impaired, and there is usually +the history of weight loss to a certain level at which it is +maintained with but slight variation. This is explained by the +trickling of liquified food from the esophageal reservoir into the +stomach as the spasm intermittently relaxes, this occurring usually +before a serious state of inanition supervenes. At times the hiatal +spasms are extremely violent and painful, the pain being referred from +the xiphoid region to the back, or upward into the neck. Patients are +often conscious of the times of patulency of the esophagus; they will +know the esophagus to be open and will eat without hesitation, or will +refuse food with the certain knowledge that it will not pass into the +stomach. Periods of remission of symptoms for months and years are +noted. The neurotic character of the lesion in some cases is evidenced +by the occasionally sudden and startling cures following a single +dilatation, as well as by the tendency to relapse when the individual +is subject to what is for him undue nervous tension. In a very few +cases, with patients of rather a stolid type, all neurotic tendencies +seem to be absent. + +The _diagnosis of hiatal esophagismus_ requires the exclusion of local +organic esophageal lesions. In the typical case with marked +dilatation, the esophagoscopic findings are diagnostic. A white, +pasty, macerated mucosa, and normally contracted hiatus esophageus +which when found permits the large esophagoscope to pass into the +stomach, will be recognized as characteristic by anyone who has seen +the condition. In the cases with but little esophageal distension the +diagnosis is confirmed by the constancy of the obstruction to a barium +mixture at the phrenic level, while at esophagoscopy the usual +resistance at the hiatus esophageus is found not to be increased, and +no other local lesion is found as the esophagoscope enters the +stomach. It is the failure of the diaphragmatic pinchcock to open, as +in the normal deglutitory cycle, rather than a spasmodic tightness, +that obstructs the food. The presence of organic stenosis at the +hiatus may remove the case altogether from the spasmodic class, or a +cicatricial or infiltrated narrowing may be the result of static +esophagitis. A compressive stenosis due to hepatic abnormality may +simulate spasmodic stenosis as shown by Mosher, who believes that 75 +per cent of so-called cardiospasms are organic. + +_Treatment of hiatal esophagismus (so-called cardiospasm)_ consists in +the over-dilatation of the "diaphragmatic pinchcock" or hiatus +esophageus, and in proper remedial measures for the removal of the +underlying neurosis. The simple passage of the esophagoscope suffices +to cure some cases. Further dilatation by endoscopic guidance may be +obtained by the introduction of Mosher's divulsor through the +esophagoscope, by which accurate placement is obtained. The distension +should not usually exceed 25 mm. Numerous water and air bags have been +devised for stretching the hiatus, and excellent results have been +obtained by their use. Possibly some of the cures have been due to the +dilatation of organic lesions, or to the crowding back of an enlarged +malposed, or otherwise abnormal left lobe of the liver, which Mosher +has shown to be an etiologic factor. + +Certain cases prove very obstinate of cure, and require esophageal +lavage for the esophagitis, and feedings through the stomach tube to +increase nutrition and to dilate the contracted stomach. Gastrostomy +for feeding rarely becomes necessary, for a stomach tube can always be +placed with the esophagoscope if it will not pass otherwise. +Retrograde dilatation with the fingers through a gastrostomy opening +has been done, but seems hardly warranted in view of the excellent +results obtainable from above. Instructions should be given concerning +the proper mastication of food, and during treatment the frequent +partaking of small quantities of liquid foods is recommended. Liquids +and foods should be neither hot nor cold. The neurologist should be +consulted in cases deemed neurotic. + +[96a.-Functional hiatal stenosis. Cramp of the diaphragmatic pinchcock +(so-called cardiospasm).] + +Endocrine imbalance should be investigated and treated, as urged by +MacNab. + +_Esophageal antiperistalsis_ is the name given by the author to a +heretofore undescribed disease associated with regurgitation of food +from the esophagus, the food not having reached the stomach. It may be +continuous or paroxysmal and may be of so serious a degree as to +threaten starvation. The best treatment in severe cases is gastrostomy +to put the esophagus at rest. Milder cases get well under liquid diet, +rest in bed, endocrine therapy, cure of associated abdominal disease, +etcetera. + + + +[251] CHAPTER XXXII--DISEASES OF THE ESOPHAGUS (_Continued_) + +CICATRICIAL STENOSIS OF THE ESOPHAGUS + +_Etiology_.--The accidental swallowing of caustic alkali in solutions +of lye or proprietary washing and cleansing powders, is the most +frequent cause of cicatricial stenosis. Commercial lye preparations +are about 95 per cent sodium hydroxide. The cleansing and washing +powders contain from eight to fifty per cent of caustic alkali, +usually soda ash, and are sold by grocers everywhere. The labels on +their containers not only give no warning of the dangerous nature of +the contents nor antidotal advice, but have such directly misleading +statements as : "Will not injure the most delicate fabric," "Will not +injure the hands," etc. Utensils used to measure or dissolve the +powders are afterward used for drinking, without rinsing, and thus the +residue of the powder remaining is swallowed in strong solution. At +other times solutions of lye are drunk in mistake for water, coffee, +or wine. These entirely preventable accidents would be rare if they +were as conspicuously labelled "Poison" as is required by law in the +case of these and any other poisons, when sold by druggists. The +necessity for such labelling is even greater with the lye preparations +because they go into the kitchen, whereas the drugs go to the medicine +shelf, out of the reach of children. "Household ammonia," "salts of +tartar" (potassium carbonate), "washing soda" (sodium carbonate), +mercuric chloride, and strong acids are also, though less frequently, +the cause of cicatricial esophageal stricture. Tuberculosis, lues, +scarlet fever, diphtheria, enteric fever and pyogenic conditions may +produce ulceration followed by cicatrices of the esophagus. Spasmodic +stenosis with its consequent esophagitis and erosions, and, later, +secondary pyogenic infection, may result in serious cicatrices. Peptic +ulcer of the lower esophagus may be a cause. The prolonged sojourn of +a foreign body is likely to result in cicatricial narrowing. + +[FIG. 97.--Schematic illustration of a series of eccentric strictures +with interstrictural sacculations, in the esophagus of a boy aged four +years. The strictures were divulsed seriatim from above downward with +the divulsor, the esophageal wall, D, being moved sidewise to the +position of the dotted line by means of a small esophagoscope inserted +through the upper stricture, A, after divulsion of the latter.] + +_Location of Cicatricial Esophageal Strictures_.--The strictures are +often multiple and their lumina are rarely either central or +concentric (Fig. 97). In order of frequency the sites of cicatricial +stenosis are: 1. At the crossing of the left bronchus; 2. In the +region of the cricopharyngeus; 3. At the hiatal level. Stricture at +the cardia has rarely been encountered in the Bronchoscopic Clinic. +Stenosis of the pylorus has been noted, but is rare. + +_Prognosis_.--Spontaneous recovery from cicatricial stenosis probably +never occurs, and the mortality of untreated small lumen strictures is +very high. Blind methods of dilatation are almost certain to result in +death from perforation of the esophageal wall, because some pressure +is necessary to dilate a stricture, and the point of the bougie, not +being under guidance of the eye, is certain at sometime or other to be +engaged in a pocket instead of in the stricture. Pressure then results +in perforation of the bottom of the pocket (Fig. 98). This accident is +contributed to by dilatation with the wrinkled, scarred floor which +usually develops above the stricture. Rapid divulsion and internal +esophagotomy are mechanically very easily and accurately done through +the esophagoscope, and would yield a few prompt cures; but the +mortality would be very high. Under certain circumstances, to be +explained below, gentle divulsion of the proximal one of a series of +strictures has to be done. With proper precautions and a gentle hand, +the risk is slight. Under esophagoscopic bouginage the prognosis is +favorable as to ultimate cure, the duration of the treatment varying +with the number of strictures, the tightness, and the extent of the +fibrous tissue-changes in the esophageal wall. Mortality from the +endoscopic procedure is almost nil, and if gastrostomy is done early +in the tightly stenosed cases, ultimate cure may be confidently +expected with careful though prolonged treatment. + +[FIG. 98.--Schema illustrating the mechanism of perforation by blind +bouginage. On encountering resilient resistance the operator, having a +false conception, pushes on the bougie. Perforation results because in +reality the bougie is in a pocket of the suprastrictural eccentric +dilatation.] + +_Symptoms_.--Dysphagia, regurgitation, distress after eating, and loss +of weight, vary with the degree of the stenosis. The intermittency of +the symptoms is sometimes confusing, for the lodgment of relatively +large particles of food often simulates a spasmodic stenosis, and in +fact there is often an element of spasm which holds the foreign body +in the strictured area until it relaxes. Static esophagitis results in +a swelling of the esophageal walls and a narrowing of the lumen, so +that swallowing is more or less troublesome until the esophagitis +subsides. + +_Esophagoscopic Appearances of Cicatricial Stenosis_.--The color of +the cicatricial area is usually paler than the normal mucosa. The +scars may be very white and elevated, or they may be flush with the +normal mucosa, or even depressed. Occasionally the cicatrix is +annular, but more often it is eccentric and involves only a part of +the circumference of the wall. If the amount of scar tissue is small, +the lumen maintains its mobility; opens and closes during respiration, +cough, and vomiturition. Between two strictures there is often a pouch +containing food remnants. It is rarely possible to see the lumen of +the second stricture, because it is usually eccentric to the first. +Stagnation of food results in superjacent dilatation and esophagitis. +Erosions and ulcerations which follow the stagnation esophagitis +increase the cicatricial stenosis in their healing. + +_Differential Diagnosis_.--When the underlying condition is masked by +inflammation and ulceration, these lesions must be removed by frequent +lavage, the administration of bismuth subnitrate with the occasional +addition of calomel powder, and the limitation of the diet to strained +liquids. The cicatricial nature of the stenosis can then be studied to +better advantage. In most cases the cicatrices are unmistakably +conspicuous. Spasmodic stenoses are differentiated by the absence of +cicatrices and the yielding of the stenosis to gentle but continuous +pressure of the esophagoscope. While it is possible that spasmodic +stenosis may supplement cicatricial stenosis, it is certainly +exceedingly rare. Nearly all of the occasions in which a temporary +increase of the stenosis in a cicatricial case is attributed to an +element of spasm, the real cause of the intermittency is not spasm but +obstruction caused by food. This occurs in three ways: 1. Actual +"corking" of the strictured lumen by a fragment of food, in which case +intermittency may be due to partial regurgitation of the "corking" +mass with subsequent sinking tightly into the stricture. 2. The "cork" +may dissolve and pass on through to be later replaced by another. 3. +Reactionary swelling of the esophageal mucosa due to stagnation. Here +again the obstruction may be prolonged, or it may be quite +intermittent, due to a valve-like action of the swollen mucosal +surfaces or folds intermittently coming in contact. Cancerous stenosis +is accompanied by infiltration of the periesophageal tissue, and +usually by projecting bleeding fungations. Cancer may, however, +develop on a cicatrix, favored no doubt by chronic inflammation in +tissue of low resistance. Compression stenosis of the esophagus is +characterized by the sudden transition of the lumen to a linear or +crescentic outline, while the covering mucosa is normal unless +esophagitis be present. The compressive mass can be detected by the +sensation transmitted to the touch by the esophagoscope. + +_Treatment_.--Blind bouginage should be discarded as an obsolete and +very dangerous procedure. If the stenosis be so great as to interfere +with the ingestion of the required amount of liquids, gastrostomy +should be done at once and esophagoscopic treatment postponed until +water hunger has been relieved. Gastrostomy aids in the treatment by +putting the esophagus at rest, and by affording the means of +maintaining a high degree of nutrition unhampered by the variability +or efficiency of the swallowing function. Careful diet and gentle +treatment will, however, usually avoid gastrostomy. The diet in the +gastrostomy-fed patients should be as varied as in oral alimentation; +even solids of the consistency of mashed potatoes, if previously +forced through a wire gauze strainer, may be forced through the tube +with a glass injector. Liquids and readily liquefiable foods are to be +given the non-gastrostomized patient, solids being added when +demonstrated that no stagnation above the stricture occurs. Thorough +mastication and the slow partaking of small quantities at a time are +imperative. Should food accumulation occur, the esophagus should be +emptied by regurgitation, following which a glassful of warm sodium +bicarbonate solution is to be taken, and this also regurgitated if it +does not go through promptly. The esophagus is thus lavaged and +emptied. In all these cases, whether being fed through the mouth or +the gastrostomic tube, it is very important to remember that milk and +eggs are not a complete dietary. A pediatrist should be consulted. +Prof. Graham has saved the lives of many children by solving the +nutritive problems in the cases at the Bronchoscopic Clinic. Fruit and +vegetable juices are necessary. Vegetable soups and mashed fruits +should be strained through a wire gauze coffee strainer. If the saliva +is spat out by the child because it will not go through the stricture +the child should be taught to spit the saliva into the funnel of the +abdominal tube. This method of improving nutrition was discovered by +Miss Groves at the Bronchoscopic Clinic. + +_Esophagoscopic bouginage_ with the author's silk-woven steel-shank +endoscopic bougies (Fig. 40) has proven the safest and most successful +method of treatment. The strictured lumen is to be centered in the +esophagoscopic field, and three successively increasing sizes of +bougies are used under direct vision. Larger and larger bougies are +used at the successive treatments which are given at intervals of from +four to seven days. No anesthesia, general or local, is used for +esophagoscopic bouginage. The tightness of the grasping of the bougie +by the stricture on withdrawal, determines the limitation of sizes to +be used. When the upper stricture is dilated, lower ones in the series +are taken seriatim. If concentric, two or more closely situated +strictures may be simultaneously dilated. For the use of bougies of +the larger sizes, the special esophagoscopes with both the +light-carrier canal and the drainage canal outside the lumen of the +tube are needed. Functional cure is obtained with a relatively small +lumen at the point of stenosis. A lumen of 7 mm. will allow the +passage of any well masticated food. It is unwise and unsafe to +attempt to restore the lumen to its normal anatomic size. In +cicatricial stricture cases it is advisable to examine the esophagus +at monthly periods for a time after a functional cure has been +obtained, in order that tendency to recurrence may be early detected. + +_Divulsion_ of an upper stricture may be deemed advisable in order to +reach others lower down, especially in cases of multiple eccentric +strictures (Fig. 97). This procedure is best done with the author's +esophagoscopic divulser, accurately placed by means of the +esophagoscope; but divulsion requires the utmost care, and a gentle +hand. Even then it is not so safe as esophagoscopic bouginage. + +_Internal esophagotomy_ by the string-cutting instruments and +esophagotome are relatively dangerous methods, and perhaps yield in +the end no quicker results than the slower and safe bouginage per +tubam. + +_Electrolysis_ has been used with varying results in the treatment of +cicatricial stenosis. + +_Thermic bouginage_ with electrically heated bougies has been found +useful in some cases by Dean and Imperatori. + +[258] _String-swallowing_, with the passage of olives threaded over +the string has yielded good results in the hands of some operators. +The string may be used to pull up dilators in increasing sizes, +introduced through a gastrostomic fistula. The string stretched across +the stomach from the cardia to the pylorus, is fished out with the +author's pillar retractor, or is found with the retrograde +esophagoscope (Fig. 43). The string is attached to a dilator (Fig. +35), and a fresh string is pulled in to replace the one pulled out. +This is the safest of the blind methods. It is rarely possible to get +a child under two years of age to swallow and tolerate a string. It is +better after each treatment to draw the upper end of the string +through the nose, as it is not so likely to be chewed off and is less +annoying. With the esophagoscope, the string is not necessary, because +the lumen of the stricture can be exposed to view by the +esophagoscope. + +_Retrograde esophagoscopy_ through a gastrostomy wound offers some +advantages over peroral treatment; but unless the gastrostomy is high, +the procedure is undoubtedly more difficult. The approach to the +lowest stricture from below is usually funnel shaped and free from +dilatation and redundancy. It must be remembered the stricture seen +from below may not be the same one seen from above. Roentgenray +examination with barium mixture or esophagoscopes simultaneously in +situ above and below are useful in the study of such cases. + +_Impermeable strictures_ of the cervical esophagus are amenable to +external esophagotomy, with plastic reformation of the esophagus. +Those in the middle third have not been successfully treated by +surgical methods, though various ingenious operations for the +formation of an extrathoracic esophagus have been suggested as means +of securing relief. Impermeable strictures of the lower third can with +reasonable safety be treated by the Brenneman method, which consists +in passing the esophagoscope down to the stricture while the surgeon, +inserting his finger up into the esophagus from the stomach, can feel +the end of the esophagoscope. An incision through the tissue barrier +is then made from below, passing the knife along the finger as a +guide. A soft rubber stomach-tube is pulled up from below and left in +situ, being replaced at intervals by a fresh one, pulled up from the +stomach, until epithelialization of the new lumen is complete. +Catheters are used in children. In replacing the catheter or stomach +tube the fresh one is attached to the old one by stitching in a loop +of braided silk. Frequent esophagoscopic bouginage will be required to +maintain the more or less fistulous lumen until it is epithelialized, +and in occasional cases, for a long time thereafter. + +In cases of absolute atresia the saliva does not reach the stomach. No +one realizes the quantity of normal salivary drainage, nor its +importance in nutritive processes. Oral insalivation is of little +consequence compared to esophagogastric drainage. Gastrostomized +children with absolute atresia of the esophagus do not thrive unless +they regurgitate the salivary accumulations into the funnel of the +gastrostomic feeding tube. This has been abundantly proven by +observations at the Bronchoscopic Clinic. My attention was first +called to this clinical fact by Miss Frances Groves who has charge of +these cases. + +_Intubation of the esophagus_ with soft rubber tubes has occasionally +proven useful. + + + +[260] CHAPTER XXXIII--DISEASES OF THE ESOPHAGUS (_Continued_) + +DIVERTICULUM OF THE ESOPHAGUS + +Diverticula may, and usually do, consist in a pouching by herniation, +of the whole thickness of the esophageal wall; or they may be +herniations of the mucosa between the muscular layers. They are +classified according to their etiology, as traction and pulsion +diverticula. + +[FIG. 99.--Traction diverticulum of the esophagus rendered visible in +the roentgenogram by a swallowed opaque mixture. Case of H. W. +Dachtler, Am. Journ. Roentgenology.] + +_Traction diverticulum of the esophagus_ (Fig. 99) is a rare +condition, usually occurring in the thorax, and as a rule constituting +a one-sided enlargement of the gullet rather than a true pouch +formation. It is supposed to be formed by the pulling during cough, +respiration, and swallowing, on localized adhesions of the esophagus +to periesophageal structures, such as inflammatory peribronchial +glands. + +_Diagnosis_ is often incidental to examination of the gastrointestinal +tract for other conditions, because traction diverticula usually cause +no symptoms. Unless a very large esophagoscope be used, a traction +diverticulum may easily be overlooked in the mucosal folds. Careful +lateral search, however, will reveal the dilatation, and the localized +periesophageal fixation may be demonstrated. The subdiverticular +esophagus is readily followed, its lumen opening during inspiration +unless very close to the diaphragm, which is very rare. Perhaps most +cases will be discovered by the roentgenologist. It has been said that +traction diverticula are more readily demonstrated in the +roentgenologic examination, if the patient be placed with pelvis +elevated. + +_Pulsion diverticulum of the esophagus_ is an acquired hernia of the +mucosa between the circular and oblique fibers of the inferior +constrictor muscle of the pharynx. A congenital anatomic basic factor +in etiology probably exists. The pouching develops in the middle part +of the posterior wall, between the orbicular and oblique fibers of the +cricopharyngeus muscle, at which point there is a gap, leaving the +mucosa supported only by a not very resistant fascia (Fig. 100). When +small, the sac is in the midline, but with increase in size, it +presents either to the right or the left side, commonly the latter. +The sac may be very small, or it may be sufficiently large to hold a +pint or more, and to cause the neck to bulge when filled. When large, +the pouch extends into the mediastinum. It will be seen that +anatomically the pulsion diverticulum has its origin in the pharynx; +the symptoms, however, are referable to the esophagus and the +subdiverticular esophagus is stenosed by compression of the pouch; +therefore, it is properly classified as an esophageal disease. + +[FIG. 100.--Schema illustrative of the etiology of pressure +diverticula. O, oblique fibers of the cricopharyngeus attached to the +thyroid cartilage, T. The fundiform fibers, F, encircle the mouth of +the esophagus. Between the two sets of fibers is a gap in the support +of the esophageal wall, through which the wall herniates owing to the +pressure of food propelled by the oblique fibers, O, advance of the +bolus being resisted by spasmodic contraction of the orbicular fibers, +F.] + +_Etiology_.--Pressure diverticula occur after middle life, and more +often in men than in women. The hasty swallowing of unmasticated food, +too large a bolus, defective or artificial teeth, flaccidity of +tissues, and spasm of the cricopharyngeus muscle, are etiologic +factors. Cicatricial stenosis below the level of the inferior +constrictor is a contributory cause in some cases. + +_Prognosis_.--After the pouch is formed, it steadily increases in +size, since the swallowed food first fills and distends the sac before +the overflow passes down the esophagus. When a pendulous sac becomes +filled with food, it presses on the subdiverticular esophagus, and +produces compression stenosis; so that there exists a "vicious +circle." The enlargement of the sac produces increasing stenosis with +consequent further distension of the pouch. This explains the +clinically observed fact, that unless treated, pulsion diverticula +increase progressively in size, and consequently in distressing +symptoms. The sac becomes so large in some cases as to contribute to +the occurrence of cerebral apoplexy by interference with venous +return. Practically all cases can be cured by radical operation. The +operative mortality varies with the age, state of nutrition, and +general health of the patient. In general it may be said to have a +mortality of at least 10 per cent, largely due to the fact that most +cases are poor surgical subjects. Recurrences after radical operation +are due to a persistence of the original causes, i.e., bolting of +food; stenosis, spasmodic or organic, of the esophageal lumen; and +weakness in the support of the esophageal wall, which, unsupported, +has little strength of its own. + +_Symptoms_.--Dysphagia, regurgitation, a gurgling sound and subjective +bubbling sensation on swallowing, sour odor to the breath, and cough, +are the chief symptoms. With larger pouches, emaciation, pressure +sensation in the neck and upper mediastinum, and the presence of a +mass in the neck when the sac is filled, are present. Tracheal +compression by the filled pouch may produce dyspnea. The sac may be +emptied by pressure on the neck, this means of relief being often +discovered by the patient. The sac sometimes spontaneously empties +itself by contraction of its enveloping muscular layer, and one of the +most annoying symptoms is the paroxysm of coughing, waking the +patient, when during the relaxation of sleep the sac empties itself +into the pharynx and some of its contents are aspirated into the +larynx. There are no pathognomonic symptoms. Those recited are common +to other forms of esophageal stenosis, and are urgent indications for +diagnostic esophagoscopy. + +_Diagnosis_.--Roentgenray study with barium mixtures, is the first +step in the diagnosis (Fig. 101). This is to be followed by diagnostic +esophagoscopy. Malignant, spasmodic, cicatricial, and compression +stenosis are to be excluded by esophagoscopic appearances. Aneurysm is +to be eliminated by the usual means. The Boyce sign is almost +invariably present, and is diagnostic. It is elicited by telling the +patient to swallow, which action imprisons air in the sac. The +imprisoned air is forced out by finger-pressure on the neck, over the +sac. The exit of the air bubble produces a gurgling sound audible at +the open mouth of the patient. + +_Esophagoscopic Appearances in Pulsion Diverticulum_.--The +esophagoscope will without difficulty enter the mouth of the sac which +is really the whole bottom of the pharynx, and will be arrested by the +blind end of the pouch, the depth of which may be from 4 to 10 cm. In +some cases the bottom of the pouch is in the mediastinum. The walls +are often pasty, and may be eroded, or ulcerated, and they may show +vessels or cicatrices. On withdrawing the tube and searching the +anterior wall, the subdiverticular slit-like opening of the esophagus +will be found, though perhaps not always easily. The esophageal +speculum will be found particularly useful in exposing the +subdiverticular orifice, and through this a small esophagoscope may be +passed into the esophagus, thus completing the diagnosis. Care must be +exercised not to perforate the bottom of the diverticular pouch by +pressure with the esophagoscope or esophageal speculum. The walls of +the sac are surprisingly thin. + +[FIG. 101.--Pulsion diverticulum filled with bismuth mixture in a man +of fifty years.] + +_Treatment of Pulsion Diverticulum_.--If the pouch is small, the +subdiverticular esophageal orifice may be dilated with esophagoscopic +bougies, thus overcoming the etiologic factor of spastic or organic +stenosis. The redundancy remains, however, though the symptoms may be +relieved. Cutting the common wall between the esophagus and the sac by +means of scissors passed through the endoscopic tube, has been +successfully done by Mosher. + +Various methods of external operation have been devised, among which +are: (1) Freeing the sac through an external cervical incision and +suturing its fundus upward against the pharynx, which has proved +successful in some cases. (2) Inversion of the sac into the pharynx +and suture of the mouth of the pouch. In a case so treated the pouch +was blown out again during a fit of sneezing eight months after +operation. (3) Plication of the walls of the sac by catgut sutures, as +in the Matas obliterative operation for aneurysm. (4) Freeing and +removing the sac, with suture of the esophageal wound. (5) Removal of +the sac by a two-stage operation, in which method the initial step is +the deliverance of the sac into the cervical wound, where it remains +surrounded by gauze packing until adhesions have walled off the +mediastinum. The work is completed by cutting off the sac and either +suturing the esophageal wound or touching it with the cautery, and +allowing it to heal by granulation. External exposure and amputation +of the sac has been more frequently done than any other operation. +Unless the pouch is large, it is extremely difficult to find after the +surgeon has exposed the esophagus, for the reasons that at operation +it is empty and that when the adhesions about it are removed the walls +of the sac contract. After removal, the sac is disappointingly small +as compared with its previous size in the roentgenogram, which shows +it distended with opaque material. It has been the chagrin of skilled +surgeons to find the diverticulum present functionally and +roentgenographically precisely the same as before the performance of +the very trying and difficult operation. The time of operation may be +shortened at least by one-half by the aid of the esophagoscopist in +the Gaub-Jackson operation. Intratracheally insufflated ether is the +anesthesia of choice. After the surgeon has exposed the esophagus by +dissection, the endoscopist introduces the esophagoscope into the sac, +and delivers it into the wound, while the surgeon frees it from +adhesions. The esophagoscope is now withdrawn from the pouch and +entered into the esophagus proper, below the diverticulum, while the +surgeon cuts off the hernial sac and sutures the esophagopharyngeal +wound over the esophagoscope. The presence of the esophagoscope +prevents too tight suture and possible narrowing of the lumen (Fig. +102). + +[FIG. 102.--Schematic representation of esophagoscopic aid in the +excision of a diverticulum in the Gaub-Jackson operation. At A the +esophagoscope is represented in the bottom of the pouch after the +surgeon has cut down to where he can feel the esophagoscope. Then the +esophagoscopist causes the pouch to protrude as shown by the dotted +line at B. After the surgeon has dissected the sac entirely loose from +its surroundings, traction is made upon the sac as shown at H and the +esophagoscope is inserted down the lumen of the esophagus as shown at +C. The esophagoscope now occupies the lumen which the patient will +need for swallowing. It only remains for the surgeon to remove the +redundancy, without risk of removing any of the normal wall. The +esophagoscope here shown is of the form squarely cut off at the end. +The standard form of instrument with slanted end will serve as well.] + +_After-care_.--Feeding may be carried on by the placing of a small +nasal feeding tube into the stomach at the time of operation. +Gastrostomy for feeding as a preliminary to the esophageal operation +has been suggested, and is certainly ideal from the viewpoint of +nutrition and esophageal rest. The decision of its performance may +perhaps be best made by the patient himself. Should leakage through +the neck occur, the fistula should be flushed by the intake of sterile +water by mouth. Oral sepsis should, of course, be treated before +operation and combated after operation by frequent brushing of the +teeth and rinsing of the mouth with Dakin's solution, one part, to ten +parts of peppermint water. A postoperative barium roentgenogram should +be made in every case as a matter of record and to make certain the +proper functioning of the esophagus. + + + +[268] CHAPTER XXXIV--DISEASES OF THE ESOPHAGUS (_Continued_) + +PARALYSIS OF THE ESOPHAGUS + +The passage of liquids and solids through the esophagus is a purely +muscular act, controlled, after the propulsive usually voluntary start +given to the bolus by the inferior constrictor, by a reflex arc having +connection with the central nervous system through the vagus nerve. +Gravity plays little or no part in the act of deglutition, and alone +will not carry food or drink to the stomach. Paralysis of the +esophagus may be said to be motor or sensory. It is rarely if ever +unassociated with like lesions of contiguous organs. + +_Motor paralysis of the esophagus_ is first manifested by inability to +swallow. This is associated with the accumulation of secretion in the +pyriform sinuses (the author's sign of esophageal stenosis) which +overflows into the larynx and incites violent coughing. Motor +paralysis may affect the constrictors or the esophageal muscular +fibers or both. + +_Sensory paralysis of the esophagus_ by breaking the continuity of the +reflex arc, may so impair the peristaltic movements as to produce +aphagia. The same filling of the pyriform sinuses will be noted, but +as the larynx is usually anesthetic also, it may be that no cough is +produced when secretions overflow into it. + +_Etiology_.--1. Toxic paralysis as in diphtheria. + 2. Functional paralysis as in hysteria. + 3. Peripheral paralysis from neuritis. + 4. Central paralysis, usually of bulbar origin. + Embolism or thrombosis of the posterior cerebral artery is a +reported cause in two cases. Lues is always to be excluded as the +fundamental factor in the groups 3 and 4. Esophageal paralysis is not +uncommon in myasthenia gravis. + +_Esophagoscopic findings_ are those of absence of the normal +resistance at the cricopharyngeus, flaccidity and lack of sensation of +the esophageal walls, and perhaps adherence of particles of food to +the folds. The hiatal contraction is usually that normally +encountered, for this is accomplished by the diaphragmatic +musculature. In paralysis of sensation, the reflexes of coughing, +vomiturition and vomiting are obtunded. + +_Diagnosis_.--Hysteria must not be decided upon as the cause of +dysphagia, until after esophagoscopy has eliminated paralysis. +Dysphagia after recent diphtheria should suggest paralysis of the +esophagus. The larynx, lips, tongue, and pharynx also, are usually +paralyzed in esophageal paralysis of bulbar origin. The absence of the +cricopharyngeal resistance to the esophagoscope passed without +anesthesia, general or local, is diagnostic. + +_Treatment_.--The internist and neurologist should govern the basic +treatment. Nutrition can be maintained by feeding with the +stomach-tube, which meets no resistance to its passage. Should this be +contraindicated by ulceration of the esophagus, gastrostomy should be +done. + +LUES OF THE ESOPHAGUS + +_Esophageal syphilis_ is a rather rare affection, and may show itself +as a mucous plaque, a gumma, an ulceration, or a cicatrix. Cicatricial +stenosis developing late in life without history of the swallowing of +escharotics or ulcerative lesions is strongly suggestive of syphilis, +though the late manifestation of a congenital stenosis is a +possibility. + +_Esophagoscopic appearances_ of lues are not always characteristic. As +in any ulcerative lesion, the inflammatory changes of mixed infections +mask the basic nature. The mucous plaque has the same appearance as +one situated on the velum, and gummata resemble those seen in the +mucosa elsewhere. There is nothing characteristic in luetic +cicatrices. + +_The diagnosis_ of luetic lesions of the esophagus, therefore, depends +upon the history, presence of luetic lesions elsewhere, the serologic +reaction, therapeutic test, examination of tissue, and the +demonstration of the treponema pallidum. The therapeutic test by +prolonged saturation of the system with mercury is imperative in all +suspected cases and no other negative result should be deemed +sufficient. + +_The treatment_ of luetic esophagitis is systemic, not local. Luetic +cicatrices contract strongly, and are very resistant to treatment, so +that esophagoscopic bouginage should be begun as early as possible +after the healing of a luetic ulceration, in order to prevent +stenosis. A silk-woven endoscopic bougie placed in position by ocular +guidance, and left _in situ_ for from half to one hour daily, may +prevent severe contraction, if used early in the stage of +cicatrization. Prolonged treatment is required for the cure of +established luetic cicatricial stenosis. If gastrostomy has been done +retrograde bouginage (Fig. 35) may be used. + +TUBERCULOSIS OF THE ESOPHAGUS + +_Esophageal tuberculosis_ is not commonly met, but is probably not +infrequently associated with the dysphagia of tuberculous laryngitis. +It may rarely occur as a primary infection, but usually the esophagus +is involved in an extension from a tuberculous process in the larynx, +mediastinal lymphatics, pleura, bronchi, or lungs. + +Primary lesions appear as superficial erosions or ulcerations, with a +surrounding yellowish granular zone, or the granules may alone be +present. The mucosa in tuberculous lesions is usually pallid, the +absence of vascularity being marked. Invasion from the periesophageal +organs produces more or less localized compression and fixation of the +esophagus. The character of open ulceration is modified by the mixed +infections. Healed tuberculous lesions, sometimes resulting from the +evacuation of tuberculous mediastinal lymph nodes into the esophagus +may be encountered. The local fixation and cicatricial contraction may +be the site of a traction diverticulum. Tuberculous esophago-bronchial +fistulae are occasionally seen. + +_Diagnosis_, to be certain, requires the demonstration of the +tubercule bacilli and the characteristic cell accumulation of the +tubercle in a specimen of tissue removed from the lesion. +Actinomycosis must be excluded, and the possibility of mixed luetic +and tuberculous lesions is to be kept in mind. Post-tuberculous +cicatrices have no recognizable characteristics. + +_Treatment_.--The maintenance of nutrition to the highest degree, and +the institution of a strict antituberculous regime are demanded. Local +applications are of no avail. Gastrostomy for feeding should be done +if dysphagia be severe, and has the advantage of putting the esophagus +at rest. The passage of a stomach-tube for feeding purposes may be +done, but it is often painful, and is dangerous in the presence of +ulceration. Pain is not marked if the lesion be limited to the +esophagus, though if it is present orthoform, anesthesin, or +apothesin, in powder form, swallowed dry, may prove helpful. + +VARIX AND ANGIOMA OF THE ESOPHAGUS + +These lesions are sometimes the cause of esophageal hemorrhage, the +regurgitated blood being bright red, and alkaline in reaction, in +contradistinction to the acid "coffee ground" blood of gastric origin. +Esophageal varices may coexist with the common dilatation of the +venous system in which the veins of the rectum, scrotum, and legs are +most conspicuously affected. Cirrhosis and cancer of the liver may, by +interference with the portal circulation, produce dilatation of the +veins in the lower third of the esophagus. Angioma of the esophagus is +amenable to radium treatment. + +ACTINOMYCOSIS OF THE ESOPHAGUS + +_Esophageal actinomycosis_ has been autoptically discovered. Its +diagnosis, and differentiation from tuberculosis, would probably rest +upon the microscopic study of tissue removed esophagoscopically, +though as yet no such case has been reported. + +ANGIONEUROTIC EDEMA + +_Angioneurotic edema_ involving the esophagus, may produce +intermittent and transient dysphagia. The lesions are rarely limited +to the esophagus alone; they may occur in any portion of the +gastrointestinal, genitourinary, or respiratory tracts, and +concomitant cutaneous manifestations usually render the diagnosis +clear. The treatment is general. + +DEVIATION OF THE ESOPHAGUS + +_Deviation of the esophagus_ may be marked in the presence of a +deformed vertebral column, though dysphagia is a very uncommon +symptom. The lack of esophageal symptoms in deviation of spinal +production is probably explained by the longitudinal shortening of the +spine which accompanies the deflection. Compression stenosis of the +esophagus is commonly associated with deviations produced by a +thoracic mass. + +[PLATE IV + +A, Gastroscopic view of a gastrojejunostomy opening drawn patulous by +the tube mouth. (Gastrojejunostomy done by Dr. George L. Hays.) B, +Carcinoma of the lesser curvature. (Patient afterward surgically +explored and diagnosis verified by Dr. John J. Buchanan.) C, Healed +perforated ulcer. (Patient referred by Dr. John W. Boyce.) + +Drawn from a case of postdiphtheric subglottic stenosis cured by the +author's method of direct galvanocauterization of the hypertrophies. +A, Immediately after removal of the intubation tube; hypertrophies +like turbinals are seen projecting into the subglottic lumen. B, Five +minutes later; the masses have now closed the lumen almost completely. +The patient became so cyanotic that a bronchoscope was at once +introduced to prevent asphyxia. C, The left mass has been cauterized +by a vertical application of the incandescent knife. D, Completely and +permanently cured after repeated cauterizations. Direct view; +recumbent patient. + +PHOTOPROCESS REPRODUCTIONS OF THE AUTHOR'S OIL-COLOR DRAWINGS FROM +LIFE] + + + +[273] CHAPTER XXXV--GASTROSCOPY + +The stomach of any individual having a normal esophagus and normal +spine can be explored with an open-tube gastroscope. The adult size +esophagoscope being 53 cm. long will reach the stomach of the average +individual. Longer gastroscopes are used, when necessary, to explore a +ptosed stomach. Various lens-system gastroscopes have been devised, +which afford an excellent view of the walls of the air-inflated +stomach. The optical system, however, interferes with the insertion of +instruments, so that the open-tube gastroscope is required for the +removal of gastric foreign bodies, the palpation of, or sponging +secretions from, gastric lesions. The open-tube gastroscope may be +closed with a window plug (Fig. 6) having a rubber diaphragm with a +central perforation for forceps, when it is desired to inflate the +stomach. + +_Technic_.--Relaxation by general anesthesia permits lateral +displacement of the dome of the diaphragm along with the esophagus, +and thus makes possible a wider range of motion of the distal end of +the gastroscope. All of the recent gastroscopies in the Bronchoscopic +Clinic, however, have been performed without anesthesia. The method of +introduction of the gastroscope through the esophagus is precisely the +same as the introduction of the esophagoscope (q.v.). It should be +emphasized that with the lens-system gastroscopes, the tube should be +introduced into the stomach under direct ocular guidance, without a +mandrin, and the optical apparatus should be inserted through the tube +only after the stomach has been entered. Blind insertion of a rigid +metallic tube into the esophagus is an extremely dangerous procedure. + +The descriptions and illustrations of the stomach in anatomical works +must be disregarded as cadaveric. In the living body, the empty +stomach is usually found, on endoscopic inspection, to be a collapsed +tube of such shape as to fit whatever space is available at the +particular moment, with folds and rugae running in all directions, the +impression given as to form being strikingly like searching among a +mass of earth worms or boiled spaghetti. The color is pink, under +proper illumination, if no food is present. Poor illumination may make +the color appear deep crimson. If food is present, or has just been +regurgitated, the color is bright red. To appreciate the appearance of +gastritis, the eye must have been educated to the endoscopic +appearances under a degree of illumination always the same. The left +two-thirds of the stomach is most easily examined. The stomach wall +can be pushed by the tube into almost any position, and with the aid +of gentle external abdominal manipulation to draw over the pylorus it +is possible to examine directly almost all of the gastric walls except +the pyloric antrum, which is reachable in relatively few cases. A +lateral motion of from 10 to 17 cm. can be imparted to the +gastroscope, provided the diaphragmatic musculature is relaxed by deep +anesthesia. The stomach is explored by progressive traverse. That is, +after exploring down to the greater curvature, the tube-mouth is moved +laterally about 2 centimeters, and the withdrawing travel explores a +new field. Then a lateral movement affords a fresh field during the +next insertion. This is repeated until the entire explorable area has +been covered. Ballooning the stomach with air or oxygen is sometimes +helpful, but the distension fixes the stomach, lessens the mobility of +the arch of the diaphragm, and thus lessens the lateral range of +gastroscopic vision. Furthermore, ballooning pushes the gastric walls +far away from the reach of the tube-mouth. A window plug (Fig. 6) is +inserted into the ocular end of the gastroscope for the ballooning +procedure. + +[275] Like many other valuable diagnostic means, gastroscopy is very +valuable in its positive findings. Negative results are entitled to +little weight except as to the explorable area. + +The gastroscopist working in conjunction with the abdominal surgeon +should be able to render him invaluable assistance in his work on the +stomach. The surgeon with his gloved hand in the abdomen, by +manipulating suspected areas of the stomach in front of the tube-mouth +can receive immediately a report of its interior appearance, whether +cancerous, ulcerated, hemorrhagic, etc. + +_Lens-system ballooning gastroscopy_ may possibly afford additional +information after all possible data from open-tube gastroscopy has +been obtained. Care must be exercised not to exert an injurious degree +of air-pressure. The distended portion of the stomach assumes a +funnel-like form ending at the apex in a depression with radiating +folds, that leads the observer to think he is looking at the pylorus. +The foreshortening produced by the lens system also contributes to +this illusion. The best lens-system gastroscope is that of Henry +Janeway, which combines the open-tube and the lens system. + +_Gastroscopy for Foreign Bodies_.--The great majority of foreign +bodies that reach the stomach unassisted are passed per rectum, +provided the natural protective means are not impaired by the +administration of cathartics, changes in diet, etcetera. This, +however, does not mean that esophageal foreign bodies should be pushed +into the stomach by blind methods, or by esophagoscopy, because a +swallowed object lodged in the esophagus can always be returned +through the mouth. Foreign bodies in the stomach and intestines should +be fluoroscopically watched each second day. If an object is seen to +lodge five days in one location in the intestines, it should be +removed by laparotomy, since it will almost certainly perforate. +Certain objects reaching the stomach may be judged too large to pass +the pylorus and intestinal angles. These should be removed by +gastroscopy when such decision is made. It is to be remembered that +gastric foreign bodies may be regurgitated and may lodge in the +esophagus, whence they are easily removed by esophagoscopy. The +double-planed fluoroscope of Manges is helpful in the removal of +gastric foreign bodies, but there is great danger of injury to the +stomach walls, and even the peritoneum, unless forceps are used with +the utmost caution. + + + +[277] CHAPTER XXXVI--ACUTE STENOSIS OF THE LARYNX + +_Etiology_.--Causes of a relatively sudden narrowing of the lumen of +the larynx and subjacent trachea are included in the following list. +Two or more may be combined. + 1. Foreign body. + 2. Accumulation of secretions or exudate in the lumen. + 3. Distension of the tissues by air, inflammatory products, serum, +pus, etc. + 4. Displacement of relatively normal tissues, as in abductor +paralysis, congenital laryngeal stridor, etcetera. + 5. Neoplasms. + 6. Granulomata. + +_Edema of the larynx_ may be at the glottic level, or in the +supraglottic or subglottic regions. The loose cellular tissue is most +frequently concerned in the process rather than the mucosal layer +alone. In children the subglottic area is very vascular, and swelling +quickly results from trauma or inflammation, so that acute stenosis of +the larynx in children commonly has its point of narrowing below the +cords. Dyspnea, and croupy, barking, cough with no change in the tone +or pitch of the speaking voice are characteristic signs of subglottic +stenosis. Edema may accompany inflammation of either the superficial +or deep structures of the larynx. The laryngeal lesion may be primary, +or may complicate general diseases; among the latter, typhoid fever +deserves especial mention. + +_Acute laryngeal stenosis_ complicating typhoid fever is frequently +overlooked and often fatal, for the asthenic patient makes no fight +for air, and hoarseness, if present, is very slight. The laryngeal +lesion may be due to cordal immobility from either paralysis or +inflammatory arytenoid fixation, in the absence of edema. +Perichondritis and chondritis of the laryngeal cartilages often follow +typhoid ulceration of the larynx, chronic stenosis resulting. + +_Laryngeal stenosis in the newborn_ may be due to various anomalies of +the larynx or trachea, or to traumatism of these structures during +delivery. The normal glottis in the newborn is relatively narrow, so +that even slight encroachment on its lumen produces a serious degree +of dyspnea. The characteristic signs are inspiratory indrawing of the +supraclavicular fossae, the suprasternal notch, the epigastrium, and +the lower sternum and ribs. Cyanosis is seen at first, later giving +place to pallid asphyxia when cardiac failure occurs. Little air is +heard to enter the lungs, during respiratory efforts and the infant, +becoming exhausted by the great muscular exertion, soon ceases to +breathe. Paralytic stenosis of the larynx sometimes follows difficult +forceps deliveries during which stretching or compression of the +recurrent nerves occur. + +_Acute laryngeal stenosis in infants, from laryngeal perichondritis_, +may be a delayed result of traumatism to the laryngeal cartilages +during delivery. The symptoms usually develop within four weeks after +birth. Lues and tuberculosis are possible factors to be eliminated by +the usual methods. + +_Surgical Treatment of Acute Laryngeal Stenosis_.--Multiple puncture +of acute inflammatory edema, while readily performed with the +laryngeal knife used through the direct laryngoscope, is an uncertain +measure of relief. Tracheotomy, if done low in the neck, will +completely relieve the dyspnea. By its therapeutic effect of rest, it +favors the rapid subsidence of the inflammation in the larynx and is +the treatment to be preferred. Intubation is treacherous and +unreliable except in diphtheritic cases; but in the diphtheritic cases +it is ideal, if constant skilled watching can be had. + + + +[279] CHAPTER XXXVII--TRACHEOTOMY + +_Indications_.--Tracheotomy is indicated in dyspnea of laryngotracheal +origin. The cardinal signs of this form of dyspnea are: + 1. Indrawing at the suprasternal notch. + 2. Indrawing around the clavicles. + 3. Indrawing of the intercostal spaces. + 4. Restlessness. + 5. Choking and waking as soon as the aid of the voluntary +respiratory muscles ceases in falling to sleep. + 6. Cyanosis is a dangerously late symptom. + +As a therapeutic measure in diseases of the larynx its place has been +thoroughly established. Marked improvement of the laryngeal lesions +has been observed to follow tracheotomy in advanced laryngeal +tuberculosis, and in cancer of the larynx. It has proven, in some +cases, a useful adjunct in the treatment of luetic laryngitis, though +it cannot be regarded as indicated, in the absence of dyspnea. +Perichondritis and other inflammations are benefited by tracheotomy. A +marked therapeutic effect on multiple laryngotracheal papillomata in +children has been noted by the author in hundreds of cases. + +_Tracheotomy for foreign body_ is no longer indicated either for the +removal of the intruder, or for the insertion of the bronchoscope. +Tracheotomy may be urgently indicated for foreign body dyspnea, but +not for foreign body removal. + +_Subcutaneous rupture of the trachea_ from external trauma may produce +dyspnea and generalized emphysema, both of which will be relieved by +tracheotomy. + +[280] _Acromegalic stenosis of the larynx_ is a rare but urgent +indication for tracheotomy. + +_Contraindications_.--There are no contraindications to tracheotomy +for dyspnea. + +_The instruments_ required for an orderly tracheotomy are: + Headlight + Scalpels + 2 Retractors + Trousseau dilator + 6 Hemostats + Scissors (dissecting) + Tracheal cannulae (six sizes) + Curved needles + Needle holder + Hypodermic syringe for local anesthesia + No. 1 plain catgut ligatures + Linen tape + Gauze sponges + +These are sterilized and kept in a sterile copper box ready for +instant use. Beside the patient's bed following the tracheotomy the +following sterile materials are placed: + Sterile gloves + 1 Hemostat + Sterile new gauze + Trousseau dilator + Scissors + Duplicate tracheotomy tube + Silver probe + Basin of Bichloride of mercury solution, 1 : 10,000 + +Tracheotomy is one of the oldest operations known to surgery, yet +strange to say, it is probably more often improperly performed today, +and more often followed by needless mortality, than any other +operation. The two chief preventable sequelae are death from improper +routine surgical care and wrongly fitted tube, and stenosis from too +high an operation. The classical descriptions of crico-thyroidotomy +and high and low tracheotomy have been handed down to generations of +medical students without revision. Every medical graduate has been +taught that there are two kinds of tracheotomy, high and low, the low +operation being very difficult, the high operation very easy. When he +is suddenly called upon to do an emergency tracheotomy, this erroneous +teaching is about all that remains in the dim recesses of his memory; +consequently he makes sure of doing the operation high enough, and +goes in through the larynx, usually dividing the cricoid cartilage, +the only complete ring in the trachea. As originally made the +distinction between high and low as applied to tracheotomy referred to +operations above and below the isthmus of the thyroid gland, in a day +when primitive surgery attached too much importance to operations upon +the thyroid gland. The isthmus is entitled to absolutely no +consideration whatever in deciding the location at which to incise so +vital a structure as the trachea. Students are taught different short +skin incisions for these two operations, and it is no wonder that +they, as did their predecessors, find tracheotomy a difficult, bloody, +and often futile operation. The trachea is searched for at the bottom +of a short, deep wound filled with blood, the source of which is +difficult to find and impossible to control. + +_Tracheotomic cannulae_ should be made of sterling silver. German +silver plated with pure silver is good enough for temporary use, but +the plating soon wears off under the galvanic action set up between +the two metals. Aluminum becomes roughened by boiling and contact with +secretions, and causes the formation of granulations which in time +lead to stenosis. Hard rubber tubes cannot be boiled, the walls are so +thick as to leave too little lumen, and the rubber is irritating to +the tissues. All tracheotomy tubes should be fitted with pilots. Many +of the tubes furnished to patients have no pilots to facilitate the +introduction, and the tubes are inserted with somewhat the effect of a +cheese tester, and with great pain and suffering on the part of the +patient. Most of the the tubes in the shops are too short to allow for +the swelling of the tissues of the neck following the operation. They +may reach the trachea at the time of the operation, but as soon as the +reactionary swelling occurs, the end of the tube is pulled out (Fig. +103) of the tracheal incision; the air hissing along the tube is +considered by the attendant to indicate that the tube is still in +place, and the increasing dyspnea and accelerated respiratory rate are +attributed to supposed pneumonia or edema of the lungs, under which +erroneous diagnosis the patient is buried. In all cases in which it is +reported that in spite of tracheotomy the dyspnea was only temporarily +relieved, the fault is the lack of a "plumber." That is, an attendant +who will make sure that there is at all times a clear airway all the +way down to the lungs. With a bronchoscope and aspirator he will see +that the airway is clear. To begin with, a proper sized cannula must +be selected. The series of different sized, full curved tubes, one of +which is illustrated in Fig. 104, will under all conditions reach the +trachea. If the tube seems to be too long in any given case, it will +usually be found that the tracheotomy has been done too high, and a +lower one should be done at once. If the operation has not been done +too high, and the cannula is too long, a pad of gauze under the shield +will take up the surplus length. In cases of tracheal compression from +new growth, thymus or other such cases, in which the ordinary tube +will not pass the obstruction, the author's long cane-shaped cannula +(see Fig. 104) can be inserted past the obstruction, and if necessary +into either bronchus. The fenestrum placed in the cannula in many of +the older tubes, with the supposed function of allowing partial +breathing through the larynx, is a most pernicious thing. A properly +fitted tube should not take up more than half of the cross section of +the trachea, and should allow the passage of sufficient air for free +laryngeal breathing when it is completely corked. The fenestrum is, +moreover, rarely so situated that air can pass through it; the +fenestral edges act as a constant irritant to the wound, producing +bleeding and granulation tissue. + +[FIG. 103.--Schema showing thick pad of gauze dressing, filling the +space, A, and used to hold out the author's full-curved cannula when +too long, prior to reactionary swelling, and after subsidence of the +latter. At the right is shown the manner in which the ordinary cannula +of the shops permits a patient to asphyxiate, though some air is heard +passing through the tracheal opening, H, after the cannula has been +partially withdrawn by swelling of the tissues, T.] + +[FIG. 104.--The author's tracheotomic cannulae. A, shows cane-shaped +cannula for use in intrathoracic compressive or other stenoses. B, +shows full curved cannula for regular use. Pilots are made to fit the +outer cannula; the inner cannula not being inserted until after +withdrawal of the pilot.] + +_Anesthesia_.--No dyspneic patient should be given a general +anesthetic; because any patient dyspneic enough to need a tracheotomy +for dyspnea is depending largely upon the action of the accessory +respiratory muscles. When this action is stopped by beginning +unconsciousness, respiration ceases. If the trachea is not immediately +opened, artificial respiration instituted, and oxygen insufflated, the +patient dies on the table. Skin infiltration along the line of +incision with a very weak cocaine solution (1/10 of 1 per cent), +apothesine (2 per cent), novocaine, Schleich's fluid or other local +anesthetic, suffices to render the operation painless. The deeper +structures have little sensation and do not require infiltration. It +has been advocated that an interannular injection of cocaine solution +with a hypodermic syringe be done just prior to incision of the +trachea for the purpose of preventing cough after the incision of the +trachea and the insertion of the cannula. It would seem, however, that +this introduces the risk of aspiration pneumonia and pulmonary +abscess, by permitting the aspiration and clotting of blood in small +bronchi, followed by subsequent breaking down of the clots. As the +author has so often said, "The cough reflex is the watch dog of the +lungs," and if not drugged asleep by local or general anesthesia can +safely be relied upon to prevent all possibility of the blood or the +pus which nearly always is present in acute or chronic conditions +calling for tracheotomy, being aspirated into the deeper air-passages. +Cocaine in any form, by any method, and in any dosage, is dangerous in +very young children. + +_Technic_.--The patient should be placed in the recumbent position, +with the extended head held in the midline by an assistant. The +shoulders, not the neck, should be slightly raised with a sand bag. +The head should be somewhat lower than the feet, to lessen the danger +of aspiration of blood. A midline incision dividing the skin and +fascia is made from the thyroid notch to just above the suprasternal +notch. The cricoid is now located, and the deeper dissection is +continued from below this point. The ribbon muscles are separated with +dissecting scissors or knife, and held apart with retractors. If the +isthmus of the thyroid gland is in the way, it may be retracted +upward; if large, however, it should be divided and ligated, for it is +apt to slip over the tracheal incision afterward, and render difficult +the quick finding of the incision during after-care. This covering of +the tracheal incision by the slipping back of the drawn-aside +thyroidal isthmus is one of the most frequent avoidable causes of +mortality, because it deflects the cannula off into the tissues when +it is replaced after cleaning during the early postoperative period. +The corrugated surface of the trachea can be felt, and its exact +location can be determined by the index finger. If the tracheotomy is +proceeding in an orderly manner, all bleeding points should be caught +and tied with plain catgut (No. 1) before the trachea is opened. +Because of distension of vessels during cough, all but the tiniest +vessels should be ligated. Side-cut veins are particularly +treacherous. They should be freed of tissue, cut across and the +divided ends ligated. + +The _incision in the trachea_ should be as low as possible, and should +never be made through the first ring. The incision should be through +the third, fourth and fifth rings. Only in cases of laryngoptosis will +it be necessary to incise the trachea higher than this. The incision +must be made in the midline, and in the long axis of the trachea, and +care must be exercised that the point of the knife does not perforate +the posterior tracheal wall. Stab incisions are always to be avoided. +If the incision in the trachea is found to be of insufficient length, +the original incision must be found and elongated. A second incision +must not be made, for the portion of cartilage between the two +incisions will die and will almost certainly make a site of future +tracheal stenosis. The cricoid should never be cut, for stenosis is +almost sure to follow the wearing of a cannula in this position. A +Trousseau dilator should now be inserted in the tracheal incision, its +blades gently separated. With the tracheal lumen thus opened, a +cannula of proper size is introduced with absolute certainty of its +having entered the trachea. A quadruple-folded square of gauze in the +form of a pad about four inches square is moistened with mercuric +chloride solution (1:10,000) and is slit from the lower border to its +midpoint. This pad is slipped from above downward under the tape +holder of the cannula, the slit permitting the tubal part of the +cannula to reach the central part of the pad (Fig. 108), and +completely covers the wound. No attempt should be made to suture the +skin wound, for this tends to form a pocket in which lodge the +bronchial secretions that escape alongside the tube, resulting in +infection of the wound. Furthermore it renders the daily changing of +the tube much more difficult. In fact it prevents the attendant from +being certain that the tube is actually placed in the trachea. +Suturing of the skin to the trachea should never be done, for the +sutures soon tear out and often set up a perichondritis of the +tracheal cartilages, with resulting difficult decannulation. + +[FIG. 105.--Schema of practical gross anatomy to be memorized for +emergency tracheotomy. The middle line is the safety line, the higher +the wider. Below, the safety line narrows to the vanishing point VP. +The upper limit of the safety line is the thyroid notch until the +trachea is bared, when the limit falls below the first tracheal ring. +In practice the two-dark danger lines are pushed back with the left +thumb and middle finger as shown in Fig. 106, thus throwing the safety +line into prominence. This is generally known as Jackson's +tracheotomic triangle.] + +[FIG. 106.--Schema showing the author's method of rapid tracheotomy. +First stage. The hands are drawn ungloved for the sake of clearness. +The upper hand is the left, of which the middle finger (M) and the +thumb are used to repress the sterno-cleido-mastoid muscles, the +finger and thumb being close to the trachea in order to press backward +out of the way the carotid arteries and the jugular vein. This throws +the trachea forward into prominence, and one deep slashing cut will +incise all of the soft tissues down to the trachea.] + +_Emergency Tracheotomy_.--Stabbing of the cricothyroid membrane, or an +attempted stabbing of the trachea, so long taught as an emergency +tracheotomy, is a mistake. The author's "two stage, finger guided" +method is safer, quicker, more efficient, and not likely to be +followed by stenosis. To execute this promptly, the operator is +required to forget his textbook anatomy and memorize the schema (Fig. +105). The larynx and trachea are steadied by the thumb and middle +finger of the left hand, which at the same time push back the +important nerves and vessels which parallel the trachea, and render +the central safety line more prominent (Fig. 106). A long incision is +now made from the thyroid notch almost to the suprasternal notch, and +deep enough to reach the trachea. This completes the first stage. + +[FIG. 107.--Illustrating the author's method of quick tracheotomy. +Second stage. The fingers are drawn ungloved for the sake of +clearness. In operating the whole wound is full of blood, and the +rings of the trachea are felt with the left index which is then moved +slightly to the patient's left, while the knife is slid down along the +left index to exactly the middle line when the trachea is incised.] + +Second stage. The entire wound is full of blood and the trachea cannot +be seen, but its corrugations can be very readily felt by the tip of +the free left index finger. The left index finger is now moved a +little to the patient's left in order that the knife shall come +precisely in the midline of the trachea, and three rings of the +trachea are divided from above downward (Fig. 107). The Trousseau +dilator should now be inserted, the head of the table should be +lowered, and the patient should be turned on the side to allow the +blood to run away from the wound. If respiration has ceased, a cannula +is slipped in, and artificial respiration is begun. Oxygen +insufflation will aid in the restoration of respiration, and a pearl +of amyl nitrite should be crushed in gauze and blown in with the +oxygen. In all such cases, excessive pressure of oxygen should be +avoided because of the danger of producing ischemia of the lungs. Hope +of restoring respiration should not be abandoned for half an hour at +least. One of the author's assistants, Dr. Phillip Stout, saved a +patient's life by keeping up artificial respiration for twenty minutes +before the patient could do his own breathing. + +The _after-care_ of the tracheotomic wound is of the utmost +importance. A special day and night nurse are required. The inner tube +of the cannula must be removed and cleaned as soon as it contains +secretion. Secretion coughed out must be wiped away quickly, but +gently, before it is again aspirated. The gauze dressing covering the +wound must be changed as soon as soiled with secretions from the wound +and the air-passages. Each fresh pad should be moistened with very +weak bichloride of mercury solution (1:10,000). The outer tube must be +changed every twenty-four hours, and oftener if the bronchial +secretion is abundant. Student-physicians who have been taught my +methods and who have seen the cases in care of our nurses have often +expressed amazement at the neglect unknowingly inflicted on such cases +elsewhere, in the course of ordinary routine surgery. It is not +unusual for a patient to be sent to the Bronchoscopic Clinic who has +worn his cannula without a single changing for one or two years. In +some cases the tube had broken and a portion had been aspirated into +the trachea. + +[FIG. 108.--Method of dressing a tracheotomic wound. A broad +quadruple, in-folded pad of gauze is cut to its centre so that it can +be slipped astride of the tube of the cannula back of the shield. No +strings, ravellings or strips of gauze are permissible because of the +risk of their getting down into the trachea.] + +If the respiratory rate increases, instead of attributing it to +pulmonary complications, the entire cannula should be removed, the +wound dilated with the Trousseau forceps, the interior of the trachea +inspected, and all secretions cleaned away. Then the tracheal mucosa +below the wound should be gently touched with a sterile bent probe, to +induce cough to rid the lower air passages of accumulated secretions. +In many cases it is a life-saving procedure to insert a sterile long +malleable aspirating tube to remove secretions from the lower +air-passages. When all is clear, a fresh sterile cannula which has +been carefully inspected to see that its lumen has been thoroughly +cleaned, is inserted, and its tapes tied. Good "plumbing," that is, +the maintenance at all times of a clear, clean passage in all the +"pipes," natural and artificial, is the reason why the mortality in +the Bronchoscopic Clinic has been less than half of one per cent, +while in ordinary routine surgical care in all hospitals collectively +it ranges from 10 to 20 per cent. + +_Bronchial Aspiration_.--As mentioned above, bronchial aspiration is +often necessary. When the patient is unable to get up secretions, he +will, as demonstrated by the author many years ago, "drown in his own +secretions." In some cases bronchoscopic aspiration is required +(Peroral Endoscopy, p. 483). Occasionally, very thick secretions will +require removal with forceps. Pus may become very thick and gummy from +the administration of morphin. Opiates do not lessen pus formation, +but they do lessen the normal secretions that ordinarily increase the +quantity and fluidity of the pus. When to this is added the +dessicating effect of the air inhaled through the cannula, unmoistened +by the upper air-passages, the secretions may be so thick as to form +crusts and plugs that are equivalent to foreign bodies and require +removal with forceps. Diphtheritic membrane in the trachea may require +removal with bronchoscope and forceps. Thinner secretions may be +removed by sponge-pumping. In most cases, however, secretions can be +brought up through an aspirating tube, connected to a bronchoscopic +aspirating syringe (Fig. 11), an ordinary aspirating bottle, or +preferably, a mechanical aspirator such as that shown in Fig. 12. In +this, combined with bronchoscopic oxygen insuflation (q.v.), we have a +life-saving measure of the highest efficiency in cases of poisoning by +chlorine and other irritant and asphyxiating gases. An aspirating tube +for insertion into the deeper air passages should be of copper, so +that it can be bent to the proper curve to reach into the various +parts of the tracheobronchial tree, and it should have a removable +copper-wire core to prevent kinking, and collapse of the lumen. The +distal end should be thickened, and also perforated at the sides, to +prevent drawing-in of the mucosa and trauma thereto. A rubber tube may +be used, but is not so satisfactory. The one shown in Fig. 10 I had +made by Mr. Pilling, and it has proved very satisfactory. + +_Decannulation_.--When the tracheal incision is placed below the first +ring, no difficulty in decannulation should result from the operation +per se. When by temporarily occluding the cannula with the finger it +is evident that the laryngeal aperture has regained sufficient size to +allow free breathing, a smaller-sized tracheotomic tube should be +substituted to allow free passage of air around the cannula in the +trachea. In doing this, the amount of secretion and the handicap of +impaired glottic mobility in the expulsion of thick secretions must be +borne in mind. Babies labor under a special handicap in their +inefficient bechic expulsion and especially in their small cannulae +which are so readily occluded. If breathing is not free and quiet with +the smaller tube; the larger one must be replaced. If, however, there +is no trouble with secretions, and the breathing is free and quiet, +the inner cannula should be removed, and the external orifice of the +outer cannula firmly closed with a rubber cork. If the laryngeal +condition has been acute, decannulation can usually be safely done +after the patient has been able to sleep quietly for three nights with +a corked cannula. If free breathing cannot be obtained when the +cannula is corked, the larynx is stenosed, and special work will be +required to remove the tube. Children sometimes become panic stricken +when the cannula is completely corked at once and they are forced to +breathe through the larynx instead of the easier shortcut through the +neck. In such a case, the first step is partially to cork the cannula +with a half or two-thirds plug made from a pure rubber cord fashioned +in the desired shape by grinding with an emery wheel (Fig. 112). Thus +the patient is gradually taught to use the natural air-way, still +feeling that he has an "anchor to windward" in the opening in the +cannula. When some swelling of the laryngeal structures still exists, +this gradual corking has a therapeutic effect in lessening the +stenosis by exercising the muscles of abduction of the cords and +mobilizing the cricoarytenoid articulation during the inspiratory +effort. The forced respiration keeps the larynx freed from secretions, +which are more or less purulent and hence irritating. After removing +the cannula, in order that healing may proceed from the bottom upward, +the wound should be dressed in the following manner: A single +thickness of gauze should be placed over the wound and the front of +the neck, and a gauze wedge firmly inserted over this to the depths of +the tracheotomic wound, all of this dressing being held in place by a +bandage. If the skin-wound heals before the fibrous union of the +tracheal cartilages is complete, exuberant granulations are apt to +form and occlude the trachea, perhaps necessitating a new tracheotomy +for dyspnea. + +It is so important to fix indelibly in the mind the cardinal points +concerning tracheotomy that I have appended to this chapter the +teaching notes that I have been for years giving my classes of +students and practitioners, hundreds of whom have thanked me for +giving them the clear-cut conception of tracheotomy that enabled them, +when their turn came to do an emergency tracheotomy, to save human +life. + +RESUME OF TRACHEOTOMY + +_Instruments_. + Headlight + Sandbag + Scalpel + Hemostats + Small retractors + Tenaculum + Tracheotomic cannulae (proper kind) + Long. + Half area cross-section trachea. + Proper curve: Radius too short will press ant. tracheal wall; too +long, post. wall. + Sterling Silver + Tracheobronchial aspirator. + Probe. + Tapes for cannulae + Trousseau dilator + Sponges + Infiltration syringe and solution + Oxygen tank. + +_Indications_: Laryngeal dyspnea. + (Indrawing guttural and clavicular fossae and at epigastrium. + Pallor. Restlessness. Drowning in his own secretions.) + + Do it early. Don't wait for cyanosis. + [294] Never use general anesthesia on dyspneic patient. + Forget about "high" and "low" distinctions until trachea is exposed. + Memorize Jackson's tracheotomic triangle. + Patient recumbent, sand bag under shoulders or neck. Nose to zenith. + Infiltration, _Intra_dermatic. + Incise from Adam's apple to guttural fossa. + Hemostasis. + Keep in middle line. + Feel for trachea. + Expose isthmus of thyroid gland. + Draw it upward or downward or cut it. + Ligature, torsion, etc. before incising trachea. + Hold trachea with tenaculum. + Incise trachea below first ring. + Avoid cutting cricoid or first ring. Cut 3 rings vertically. Don't +hack. Don't cut posterior wall which almost touches the anterior wall +during cough. Spread carefully, with Trousseau dilator. + Insert cannula; _see_ it enter tracheal lumen; remove pilot; tie +tapes. + Don't suture wound. Dress with large squares. + Don't give morphine. + Decannulation by corking partially, after changing to smaller +cannula. + Do not remove cannula permanently until patient sleeps without +indrawing with corked cannula. + +RESUME OF EMERGENCY TRACHEOTOMY + +The following notes should be memorized. + 1. Essentials: Knife and pair of hands (but full equipment better). + [295] 2. Don't do a laryngotomy, or stabbing. + 3. "Two stage, finger guided" operation better. + 4. Sand bag or substitute. + 5. Press back danger lines with left thumb and middle finger, making +safety line and trachea prominent. + 6. Memorize Jackson's tracheotomic triangle. + 7. Incise exactly in middle line from Adam's apple to sternum. + 8. Feel for tracheal corrugations with left index in pool of blood, +following trachea with finger downward from superficial Adam's apple. + 9. Pass knife along index and incise trachea (not too deeply, may +cut posterior wall). + 10. Don't mind bleeding; but keep middle line and keep head +straight; keep head low; don't bother about thyroid gland. + 11. Don't expect hiss when trachea is cut if patient has stopped +breathing. + 12. Start artificial respiration. + 13. Amyl nitrite. Oxygen. + 14. Practice palpation of the neck until the tracheal landmarks are +familiar. + 15. Practice above technic, up to point of incision, at every +opportunity. + 16. _Jackson's tracheotomic triangle_: A triangulation of the front +of the neck intended to facilitate a proper emergency tracheotomy. + Apex at suprasternal notch. + Sides anterior edge sternomastoids. + Base horizontal line lower edge cricoid. + +RESUME OF AFTER-CARE OF A TRACHEOTOMIC CASE + + 1. Always bear in mind that tracheotomy is not an ultimate object. +The ultimate object is to pipe air down into the lungs. Tracheotomy is +only a means to that end. + 2. Sterile tray beside bed should contain duplicate (exact) +tracheotomy tube, Trousseau dilator, hemostat, thumb forceps, silver +probe, scissors, scalpel, probe-pointed curved bistoury. Sterile +gloves ready. + 3. Special nursing necessary for safety. + 4. Laxative. + 5. Sponge away secretions before they are drawn in. + 6. Cover wound with wide large gauze square slit so it fits around +cannula under the tape holder. Pull off ravelings. Keep wet with +1 : 10,000 Bichloride solution. + 7. Change dressing every hour or oftener. + 8. Abundance of fresh air, temperature preferably about 70 degrees. + 9. _Nurse should remove inner cannula as often as needed and clean +it with pipe cleaner before boiling._ + 10. Outer cannula should be changed every day by the surgeon or +long-experienced tracheotomy nurse. A pilot should be used and care +should be taken not to injure the cut ends of the tracheal cartilage. + 11. A sterile, bent probe may be inserted downward in the trachea +with both cannulae out to excite cough if necessary to expel +secretions. An aspirating tube should be used, when necessary. + 12. A patient with a properly fitted cannula free of secretions +breathes noiselessly. Any sound demands immediate attention. + 13. If the respiratory rate increase it is much more likely to be +due to obstruction in, malposition of, or shortness of the cannula +than to lung complications. + 14. Be sure that: + (a) The cannula is clear and clean. + (b) The cannula is long enough to reach well down into the +trachea. A cannula that was long enough when the operation was done +may be too short after the cervical tissues swell. + (c) The distal end of the cannula actually is deeply in the +trachea. The only way to be sure is, when inserting the cannula, to +spread the wound and the tracheal incision with a Trousseau dilator, +then _see_ the interior of the tracheal lumen and _see_ the cannula +enter therein. + 15. If after attending to the above mentioned details there are +still signs of obstructive dyspnea, a bronchoscopy should be done for +finding and removal of the obstruction in the trachea or main bronchi. + 16. If all the "pipes," natural and instrumental, are clear there +can be no such thing as obstructive dyspnea. + 17. Pneumonia and pulmonary edema may exist before tracheotomy, but +they are rare sequelae. + 18. Decannulation, in cases of tracheotomy done for temporary +conditions should not be attempted until the patient has slept at +least 3 nights with his cannula tightly corked. A properly fitted +cannula (i.e. one not larger than half the area of cross section of +the trachea) permits the by-passage of plenty of air. A partial cork +should be worn for a few days first for testing and "weaning" a child +away from the easier breathing through the neck. In cases of chronic +laryngeal stenosis a prolonged test is necessary before attempting +decannulation. + 19. A tracheotomic case may be aphonic, hence unable to call for +help. + 20. The foregoing rules apply to the post-operative periods. After +the wound has healed and a fistula is established, the patient, if not +a child, may learn to care for his own cannula. + [298] 21. Do not give cough-sedatives or narcotics. The cough reflex +is the watch dog of the lungs. + +NOTES ON NURSING TRACHEOTOMIZED PATIENTS + +Bedside tray should contain: + Duplicate cannula + Scalpel + Trousseau dilator + Hemostat + Dressing forceps + Sterile vaseline + Scissors + Tape + Probe + Gauze sponges + Gauze squares + Probe-pointed curved bistoury. + + 1. Room should be abundantly ventilated, as free from dust and lint +as possible, and the air should be moistened by steam in winter. + 2. Keep mouth clean. Tooth brush. Rinse alcohol 1:10. + 3. Sponge away secretion after the cough before drawn in. + 4. Remove inner cannula (not outer) as often as needed. Not less +often than every hour. Replace immediately. Never boil a cannula until +you have thoroughly cleaned it. + 5. Obstruction of cannula calling for cleaning indicated by: + Blue or ashy color. + Indrawing at clavicles, sternal notch, epigastrium. + Noisy breathing. (Learn sound.) + 6. Surgeon (in our cases) will change outer cannula once daily or +oftener. + 7. Duplicate cannulae. + 8. Be careful in cleaning cannulae not to damage. + 9. Watch for loose parts on cannula. + 10. Change dressing (in our cases) as often as soiled. Not less +often than every hour. Large squares. Never narrow strips. + 11. Watch color of lips and ears and face. + [299] 12. Report at once if food or water leaks through wound. +(Coughing and choking). + 13. Never leave a tracheotomized patient unwatched during the first +days or weeks, according to case. + 14. Remember Trousseau dilator or hemostat will spread the tracheal +wound or fistula when cannula is out. + 15. Remember life depends on a clear cannula if the patient gets no +air through the mouth. + 16. Remember it takes very little to clog the small cannula of a +child. + 17. Remember a tracheotomized patient cannot call for help. + 18. Decannulation. Testing by corking partially. Watch corks +not too small, or broken. Attach them by braided silk +thread. Pure rubber cord ground down makes best cork. + + + +[300] CHAPTER XXXVIII--CHRONIC STENOSIS OF THE LARYNX AND TRACHEA + +The various forms of laryngeal stenosis for which tracheotomy or +intubation has been performed, and the difficulties encountered in +restoring the natural breathing, may be classified into the following +types: + 1. Panic + 2. Spasmodic + 3. Paralytic + 4. Ankylotic (arytenoid) + 5. Neoplastic + 6. Hyperplastic + 7. Cicatricial + (a) Loss of cartilage + (b) Loss of muscular tissue + (c) Fibrous + +_Panic_.--Nothing so terrifies a child as severe dyspnea; and the +memory of previous struggles for air, together with the greater ease +of breathing through the tracheotomic cannula than through even a +normal larynx, incites in some cases so great a degree of fear that it +may properly be called panic, when attempts at decannulation are made. +Crying and possibly glottic spasm increase the difficulties. + +_Spasmodic stenosis_ may be associated with panic, or may be excited +by subglottic inflammation. Prolonged wearing of an intubation tube, +by disturbing the normal reciprocal equilibrium of the abductors and +adductors, is one of the chief causes. The treatment for spasmodic +stenosis and panic is similar. The use of a special intubation tube +having a long antero-posterior lumen and a narrow neck, which form +allows greater action of the musculature, has been successful in some +cases. Repeated removal and replacement of the intubation tube when +dyspnea requires it may prove sufficient in the milder cases. Very +rarely a tracheotomy may be required; if so, it should be done low. +The wearing of a tracheotomic cannula permits a restoration of the +muscle balance and a subsidence of the subglottic inflammation. +Corking the cannula with a slotted cork (Fig. 111) will now restore +laryngeal breathing, after which the tracheotomic cannula may be +removed. + +[PLATE V--PHOTOPROCESS REPRODUCTIONS OF THE AUTHOR'S OIL-COLOR +DRAWINGS FROM LIFE--LARYNGEAL AND TRACHEAL STENOSES: + +1, Indirect view, sitting position; postdiphtheric cicatricial +stenosis permanently cured by endoscopic evisceration. (See Fig. 5.) +2, Indirect view, sitting position; posttyphoid cicatricial stenosis. +Mucosa was very cyanotic because cannula was re-moved for laryngoscopy +and bronchoscopy. Cured by laryngostomy. (See Fig. 6.) 3, Indirect +view, sitting position; posttyphoid infiltrative stenosis, left +arytenoid destroyed by necrosis. Cured by laryngostomy; failure to +form adventitious band (Fig. 7) because of lack of arytenoid activity. +4, Indirect view, recumbent position; posttyphoid cicatricial +stenosis. Cured of stenosis by endoscopic evisceration with sliding +punch forceps. Anterior commissure twice afterward cleared of +cicatricial tissue as in the other case shown in Fig. 15. Ultimate +result shown in Fig. 8. 5, Same patient as Fig. 1; sketch made two +years after decannulation and plastic. 6, Same patient as Fig. 2; +sketch made four years after decannulation and plastic. 7, Same +patient as Fig. 3; sketch made three years after decannulation and +plastic. 8, Same patient as Fig. 4; sketch made one year after +decannulation, fourteen months after clearing of the anterior +commissure to form adventitious cords. 9, Direct view, recumbent +patient; web postdiphtheric (?) or congenital (?). "Rough voice" since +birth, but larynx never examined until stenosed after diphtheria. Web +removed and larynx eviscerated with punch forceps; recurrence of +stenosis (not of web). Cure by laryngostomy. This view also +illustrates the true depth of the larynx which is often overlooked +because of the misleading flatness of laryngeal illustrations. 10, +Direct laryngoscopic view; postdiphtheric hypertrophic subglottic +stenosis. Cured by galvanocauterization. 11, Direct laryngoscopic +view; postdiphtheric hypertrophic supraglottic stenosis. Forceps +excision; extubation one month later; still well after four years. 12, +Bronchoscopic view of posttracheotomic stenosis following a "plastic +flap" tracheotomy done for acute edema. 13, Direct laryngoscopic view; +anterolateral thymic compression stenosis in a child of eighteen +months. Cured by thymopexy. 14, Indirect laryngoscopic (mirror) view; +laryngostomy rubber tube in position in treatment of post-typhoid +stenosis. 15, Direct view; posttyphoid stenosis after cure by +laryngostomy. Dotted line shows place of excision for clearing out the +anterior commissure to restore the voice. 16, Endoscopic view of +posttracheotomic tracheal stenosis from badly placed incision and +chondrial necrosis. Tracheotomy originally done for influenzal +tracheitis. Cured by tracheostomy.] + +_Paralysis_.--Bilateral abductor laryngeal paralysis causes severe +stenosis, and usually tracheotomy is urgently required. In cadaveric +paralysis both cords are in a position midway between abduction and +adduction, and their margins are crescentic, so that sufficient airway +remains. Efforts to produce the cadaveric position of the cords by +division or excision of a portion of the recurrent laryngeal nerves, +have been failures. The operation of _ventriculocordectomy_ consists +in removing a vocal cord and the portion or all of the ventricular +floor by means of a punch forceps introduced through the direct +laryngoscope. Usually it is better to remove only the portion of the +floor anterior to the vocal process of the arytenoid. In some cases +monolateral ventriculocordectomy is sufficient; in most cases, +however, operation on both sides is needed. An interval of two months +between operations is advisable to avoid adhesions. In almost all +cases, ventriculocordectomy will result in a sufficient increase in +the glottic chink for normal respiration. The ultimate vocal results +are good. Evisceration of the larynx, either by the endoscopic or +thyrotomic method, usually yields excellent results when no lesion +other than paralysis exists. Only too often, however, the condition is +complicated by the results of a faultily high tracheotomy. A rough, +inflexible voice is ultimately obtained after this operation, +especially if the arytenoid cartilage is unharmed. In recent bilateral +recurrent paralysis, it may be worthy of trial to suture the recurrent +to the pneumogastric. Operations on the larynx for paralytic stenosis +should not be undertaken earlier than twelve months from the inception +of the condition, this time being allowed for possible nerve +regeneration, the patient being made safe and comfortable, meanwhile, +by a low tracheotomy. + +_Ankylosis_.--Fixation of the crico-arytenoid joints with an +approximation of the cords may require evisceration of the larynx. +This, however, should not be attempted until after a year's lapse, and +should be preceded by attempts to improve the condition by endoscopic +bouginage, and by partial corking of the tracheotomic cannula. + +_Neoplasms_.--Decannulation in neoplastic cases depends upon the +nature of the growth, and its curability. Cicatricial contraction +following operative removal of malignant growths is best treated by +intubational dilatation, provided recurrence has been ruled out. The +stenosis produced by benign tumors is usually relieved by their +removal. + +_Papillomata_.--Decannulation after tracheotomy done for papillomata +should be deferred at least 6 months after the discontinuance of +recurrence. Not uncommonly the operative treatment of the growths has +been so mistakenly radical as to result in cicatricial or ankylotic +stenoses which require their appropriate treatments. It is the +author's opinion that recurrent papillomata constitute a benign +self-limited disease and are best treated by repeated superficial +removals, leaving the underlying normal structures uninjured. This +method will yield ultimately a perfect voice and will avoid the +unfortunate complications of cicatricial hypertrophic and ankylotic +stenosis. + +_Compression Stenosis of the Trachea_.--Decannulation in these cases +can only follow the removal of the compressive mass, which may be +thymic, neoplastic, hypertrophic or inflammatory. Glandular disease +may be of the Hodgkins' type. Thymic compression yields readily to +radium and the roentgenray, and the tuberculous and leukemic +adenitides are sometimes favorably influenced by the same agents. +Surgery will relieve the compression of struma and benign neoplasms, +and may be indicated in certain neoplasms of malignant origin. The +possible coexistence of laryngeal paralysis with tracheal compression +is frequently overlooked by the surgeon. Monolateral or bilateral +paralysis of the larynx is by no means an uncommon postoperative +sequel to thyroidectomy, even though the recurrent nerves have been in +no way injured at operation. Probably a localized neuritis, a +cicatricial traction, or inclusion of a nerve trunk accounts for most +of these cases. + +_Hyperplastic and cicatricial chronic stenoses_ preventing +decannulation may be classified etiologically as follows: + 1. Tuberculosis + 2. Lues + 3. Scleroma + 4. Acute infectious diseases + (a) Diphtheria + (b) Typhoid fever + (c) Scarlet fever + (d) Measles + (e) Pertussis + 5. Decubitus + (a) Cannular + (b) Tubal + 6. Trauma + (a) Tracheotomic + (b) Intubational + (c) Operative + (d) Suicidal and homicidal + (e) Accidental (by foreign bodies, external violence, bullets, +etc.) + +Most of the organic stenoses, other than the paralytic and neoplastic +forms, are the result of inflammation, often with ulceration and +secondary changes in the cartilages or the soft tissues. + +[304] _Tuberculosis_.--In the non-cicatricial forms, galvanocaustic +puncture applied through the direct laryngoscope will usually reduce +the infiltrations sufficiently to provide a free airway. Should the +pulmonary and laryngeal tuberculosis be fortunately cured, leaving, +however, a cicatricial stenosis of the larynx, decannulation may be +accomplished by laryngostomy. + +_Lues_.--Active and persistent antiluetic medication must precede and +accompany any local treatment of luetic laryngeal stenosis. Prolonged +stretching with oversized intubation tubes following excision or +cauterization may sometimes be successful, but laryngostomy is usually +required to combat the vicious contraction of luetic cicatrices. + +_Scleroma_ is rarely encountered in America. Radiotherapy has been +advocated and good results have been reported from the intravenous +injection of salvarsan. Radium may be tried, and its application is +readily made through the direct laryngoscope. + +_Diphtheria_.--Chronic postdiphtheritic stenosis may be of the panic, +spasmodic or, rarely, the paralytic types; but more often it is of +either the hypertrophic or cicatricial forms. Only too frequently the +stenosis should be called posttracheotomic rather than +postdiphtheritic, since decannulation after the subsidence of the +acute stenosis would have been easy had it not been for the sequelae +of the faulty tracheotomy. Prolonged intubation may induce either a +supraglottic or subglottic tissue hyperplasia. _The supraglottic type_ +consists in an edematous thickening around the base of the epiglottis, +sometimes involving also the glossoepiglottic folds and the +ventricular bands. An improperly shaped or fitted tube is the usual +cause of this condition, and a change to a correct form of intubation +tube may be all that is required. Excessive polypoid tissue +hypertrophy should be excised. The less redundant cases subside under +galvanocaustic treatment, which may be preceded by tracheotomy and +extubation, or the intubation tube may be replaced after the +application of the cautery. The former method is preferable since the +patient is far safer with a tracheotomic cannula and, further, the +constant irritation of the intubation tube is avoided. _Subglottic +hypertrophic stenosis_ consists in symmetrical turbinal-like swellings +encroaching on the lumen from either side. Cautious galvanocauterant +treatment accurately applied by the direct method will practically +always cure this condition. Preliminary tracheotomy is required in +those cases in which it has not already been done, and in the cases in +which a high tracheotomy has been done, a low tracheotomy must be the +first step in the cure. Cicatricial types of postdiphtheritic stenosis +may be seen as webs, annular cicatrices of funnel shape, or masses of +fibrous tissue causing fixation of the arytenoids as well as +encroachment on the glottic lumen. (See color plates.) + +As a rule, when a convalescent diphtheritic patient cannot be +extubated two weeks after three negative cultures have been obtained +the advisability of a low tracheotomy should be considered. If a +convalescent intubated patient cough up a tube and become dyspneic a +low tracheotomy is usually preferable to forcing in an oversized +intubation tube. + +_Typhoid Fever_.--Ulcerative lesions in the larynx during typhoid +fever are almost always the result of mixed infection, though +thrombosis of a small vessel, with subsequent necrosis is also seen. +If the ulceration reaches the cartilage, cicatricial stenosis is +almost certain to follow. + +_Trauma_.--The chief traumatic factors in chronic laryngeal stenosis +are: (a) prolonged presence of a foreign body in the larynx (b) +unskilled attempts at intubation and the wearing of poorly fitting +intubation tubes; (c) a faulty tracheotomy; (d) a badly fitting +cannula; (e) war injuries; (f) attempted suicide; (g) attempted +homicide; (h) neglect of cleanliness and care of either intubation +tubes or tracheotomic cannulae allowing incrustation and roughening +which traumatize the tissues at each movement of the ever-moving +larynx and trachea. + +_Treatment of Cicatricial Stenosis_.--A careful direct endoscopic +examination is essential before deciding on the method of treatment +for each particular case. Granulations should be removed. Intubated +cases are usually best treated by tracheotomy and extubation before +further endoscopic treatment is undertaken. A certain diagnosis as to +the cause of the condition must be made by laboratory and therapeutic +tests, supplemented by biopsy if necessary. Vigorous antiluetic +treatment, especially with protiodide of mercury, must precede +operation in all luetic cases. Necrotic cartilage is best treated by +laryngostomy. Intubational dilatation will succeed in some cases. + +[FIG. 109.--Schema showing the author's method of laryngostomy. The +hollow upward metallic branch (N) of the cannula (C) holds the rubber +tube (R) back firmly against the spur usually found on the back wall +of the trachea. Moreover, the air passing up through the rubber tube +(R) permits the patient to talk in a loud whisper, the external +orifice of the cannula being occluded most of the time with the cork +(K). The rubber tubing, when large sizes are reached may extend down +to the lower end of the cannula, the part C coming out through a large +hole cut in the tubing at the proper distance from the lower end.] + +_Laryngoscopic bouginage_ once weekly with the laryngeal bougies (Fig. +42) will cure most cases of laryngeal stenosis. For the trachea, +round, silk-woven, or metallic bougies (Fig. 40) are better. + +[307] _Laryngostomy_ consists in a midline division of the laryngeal +and tracheal cartilages as low as the tracheotomic fistula, excision +of thick cicatricial tissue, very cautious incision of the scar tissue +on the posterior wall, if necessary, and the placing of the author's +laryngostomy tube for dilatation (Fig. 109). Over the upward branch of +the laryngostomy tube is slipped a piece of rubber tubing which is in +turn anchored to the tape carrier by braided silk thread. +Progressively larger sizes of rubber tubing are used as the laryngeal +lumen increases in size under the absorptive influence of the +continuous elastic pressure of the rubber. Several months of wearing +the tube are required until dilatation and epithelialization of the +open trough thus formed are completed. Painstaking after-care is +essential to success. When dilatation and healing have taken place, +the laryngostomy wound in the neck is closed by a plastic operation to +convert the trough into a trachea by supplying an anterior wall. + +_Intubational treatment of chronic laryngeal stenosis_ may be tried in +certain forms of stenosis in which the cicatrices do not seem very +thick. The tube is a silver-plated brass one of large size (Fig. 110). +A post which screws into the anterior surface of the tube prevents its +expulsion. Over the post is slipped a block which serves to keep open +the tracheal fistula. Detailed discussion of these operative +treatments is outside the scope of this work, but mention is made for +the sake of completeness. Before undertaking any of the foregoing +procedures, a careful study of the complete descriptions in Peroral +Endoscopy is necessary, and a practical course of training is +advisable. + +[FIG. 110.--The author's retaining intubation tube for treatment of +chronic laryngeal stenosis. The tube (A) is introduced through the +mouth, then the post (B) is screwed in through the tracheal wound. +Then the block (C) is slid into the wound, the square hole in the +block guarding the post against all possibility of unscrewing. If the +threads of the post are properly fitted and tightly screwed up with a +hemostat, however, there is no chance of unscrewing and gauze packing +is used instead of the block to maintain a large fistula. The shape of +the intubation tube has been arrived at after long clinical study and +trials, and cannot be altered without risk of falling into errors that +have been made and eliminated in the development of this shape.] + + + +[309] CHAPTER XXXIX--DECANNULATION AFTER CURE OF LARYNGEAL STENOSIS + +In order to train the patient to breathe again through the larynx it +is necessary to occlude the cannula. This is best done by inserting a +rubber cork in the inner cannula. At first it may be necessary to make +a slot in the cork so as to permit some air to enter through the tube +to supplement the insufficient supply obtainable through the +insufficiently patulous glottis, new corks with smaller grooves being +substituted as laryngeal breathing becomes easier. Corking the cannula +is an excellent orthopedic treatment in certain cases where muscle +atrophy and partial inflammatory fixation of the cricoarytenoid joints +are etiological factors in the stenosis. The added pull of the +posterior cricoarytenoid muscles during the slight effort at +inspiration restores their tone and increases the mobility of all the +attached structures. By no other method can panic and spasmodic +stenosis be so efficiently cured. + +[FIG. 111.--Illustration of corks used to occlude the cannula in +training patients to breathe through the mouth again, before +decannulation. The corks allow air leakage, the amount of which is +regulated by the use of different shapes. A smaller and still smaller +air leak is permitted until finally an ungrooved cork is tolerated. A +central hole is sometimes used instead of a slot. A, one-third cork; +B, half cork; C, three-quarter cork; D, whole cork.] + +Following the subsidence of an acute laryngeal stenosis, it is my rule +to decannulate after the patient has been able to breathe through the +larynx with the cannula tightly corked for 3 days and nights. This +rule does not apply to chronic laryngeal stenosis, for while the lumen +under ordinary conditions might be ample, a slight degree of +inflammation might render it dangerously small. In these cases, many +weeks are sometimes required to determine when decannulation is safe. +A test period of a few months is advisable in most cases of chronic +laryngeal stenosis. Recurrent contractions after closure of the wound +are best treated by endoscopic bouginage. The corks are best made of +pure rubber cord, cut and ground to shape, and grooved, if desired, on +a small emery wheel (Fig. 112). The ordinary rubber corks and those +made of cork-bark should not be used because of their friability, and +the possible aspiration of a fragment into the bronchus, where rubber +particles form very irritant foreign bodies. + +[FIG. 112.--This illustration shows the method of making safe corks +for tracheotomic cannulae by grinding pure rubber cord to shape on an +emery wheel. After grinding the taper, if a partial cork is desired, a +groove is ground on the angle of the wheel. If a half-cork is desired +half of the cork is ground away on the side of the wheel. Reliable +corks made in this way are now obtainable from Messers Charles J. +Pilling and Son.] + + + +BIBLIOGRAPHY + +The following list of publications of the author may be useful for +reference: + 1. Peroral Endoscopy and Laryngeal Surgery, Textbook, 1914. +(Contains full bibliography to date of publication.) + 2. Acromegaly of the Larynx. Journ. Amer. Med. Asso., Nov. 30, 1918, +Vol. LXXI, pp. 1787-1789. + 3. A Fence Staple in the Lung. A New Method of Bronchoscopic +Removal. Journ. Amer. Med. Asso., Vol. LXIV, June 5, 1917, pp. 1906-7. + 4. Amalgam Tooth-filling Aspirated into Lung During Extraction. +Dental Cosmos, Vol. LIX, May, 1917, pp. 500-502. + 5. Amalgam Filling Removed from Lung after a Seven Months' Sojourn: +Case Report. Dental Cosmos, April, 1920. + 6. A Mechanical Spoon for Esophagoscopic Use. The Laryngoscope, +January, 1918, PP. 47-48. + 7. An Anterior Commissure Laryngoscope. The Laryngoscope, Vol. XXV, +Aug., 1915, P. 589. + 8. Ancient Foreign Body Cases. Editorial. The Laryngoscope, Vol. +XXVII, July, 1917, PP. 583-584. + 9. An Esophagoscopic Forceps. The Laryngoscope, Jan., 1918, p. 49. + 10. A New Diagnostic Sign of Foreign Body in Trachea or Bronchi, the +"Asthmatoid Wheeze." Amer. Journ. Med. Sciences, Vol. CLVI, No. 5, +Nov., 1918, p. 625. + 11. A New Method of Working Out Difficult Mechanical Problems of +Bronchoscopic Foreign-body Extraction. The Laryngoscope, Vol. XXVII, +Oct., 1917, p. 725. + 12. Arachidic Bronchitis. Journ. Amer. Med. Asso., Aug. 30, 1919, +Vol. LXXIII, pp. 672-677. + 13. Band of a Gold Crown in the Bronchus: Report of a Case. Dental +Cosmos. Vol. LX, Oct., 1918, p. 905. + 14. Bronchiectasis and Bronchiectatic Symptoms Due to Foreign +Bodies. Penn. Med. Journ., Vol. XIX, Aug., 1916, pp. 807-814. + 15. Bronchoscopic and Esophagoscopic Postulates. Annals of Otology, +Rhinology and Laryngology, June, 1916, pp. 414-416. + 16. Bronchoscopic Removal of a Collar Button after Twenty-six Years +Sojourn in the Lung. Annals of Otology, Rhinology and Laryngology, +June, 1913. + 17. Bronchoscopy. Keen's Surgery, 1921, Vol. VIII. + 18. Caisson Bronchoscopy in Lung-abscess Due to Foreign Body. Surg., +Gyn. and Obstet., Oct., 1917, pp. 424-428. + 19. Cancer of the Larynx. Is it Preceded by a Recognizable +Precancerous Condition? Proceedings Amer. Laryngol. Soc., 1922. + 20. Din. Editorial. The Laryngoscope, Vol. XXVI, Dec., 1916, pp. +1385-1387. + 23. Endoscopie Perorale et Chirurgie Laryngienne. Arch. de +Laryngol., T. XXXVII, No. 3, 1914, pp. 649-680. + 24. Endoscopy and the War. Editorial. The Laryngoscope, Vol. XXVI, +June, 1916, p. 992. + 25. Endothelioma of the Right Bronchus Removed by Peroral +Bronchoscopy. Amer. Journ. of Med. Sci., No. 3, Vol. CLII, March, +1917, p. 371. + 26. Esophageal Stenosis Following the Swallowing of Caustic +Alkalies, Journ. Amer. Med. Asso., July 2, 1921, Vol. LXXVII, pp. +22-23. + 27. Esophagoscopic Radium Screens. The Laryngoscope, Feb., 1914. + 28. Foreign Bodies in the Insane. Editorial. The Laryngoscope, Vol. +XXVII, June, 1917, pp. 513-515. + 29. Foreign Bodies in the Larynx, Trachea, Bronchi and Esophagus +Etiologically Considered. Trans. Sec. Laryn., Otol. and Rhin., Amer. +Med. Asso., 1917, pp. 36-56. + 30. Gold Three-tooth Molar Bridge Removal from the Right Bronchus: +Case Report. Dental Cosmos, Oct., 1919. + 31. High Tracheotomy and Other Errors the Chief Causes of Chronic +Laryngeal Stenosis. Surg., Gyn. and Obstet., May, 1921, pp. 392-398. + 32. Inducing a Child to Open Its Mouth. Editorial. The Laryngoscope, +Vol. XXVI, Nov., 1917, p. 795. + 33. Intestinal Foreign Bodies. Editorial. The Laryngoscope, Vol. +XXVI, May, 1916, p. 929. + 34. Laryngoscopic, Esophagoscopic and Bronchoscopic Clinic. +International Clinics, Vol. IV, 1918. J. B. Lippincott Co. + 35. Local Application of Radium Supplemented by Roentgen Therapy +(Discussion). Amer. Journ. of Roentgenology. + 36. Localization of the Lobes of the Lungs by Means of Transparent +Outline Films. Amer. Journ. Roent., Vol. V, Oct., 1918, p. 456. Also +Proc. Amer. Laryn., Rhin. and Otol. Soc., 1918. + 37. Mechanical Problems of Bronchoscopic and Esophagoscopic Foreign +Body Extraction, Journ. Am. Med. Assn., Jan. 27, 1917. + 38. Observation on the Pathology of Foreign Bodies in the Air and +Food Passages Based on the Analysis of 628 Cases. Mutter Lecture, +1917, Surg. Gyn. and Obstet., Mar., 1919, pp. 201-261. + 39. Orthopedic Treatment by Corking. Journ. of Laryn. and Otol., +London, Vol. XXXII, Feb., 1917. + 40. Peroral Endoscopy. Journ. of Laryn. and Otol., Edinburgh, Nov., +1921. + 41. Peroral Endoscopy and Laryngeal Surgery. The Laryngoscope, Feb., +1919. + 42. Postulates on the Cough Reflex in Some of its Medical and +Surgical Phases. Therapeutic Gazette, Sept. 15, 1920. + 43. Prognosis of Foreign Body in the Lung. Journ., Amer. Med. Asso., +Oct. 8, 1921, Vol. LXXVII, pp. 1178-1181. + 44. Pulsion Diverticulum of the Esophagus. Surg., Gyn. and Obstet., +Vol. XXI, July, 1915, PP. 52-55. + 45. Radium. Editorial. The Laryngoscope, Vol. XXVI, Aug., 1916, pp. +1111-1113. + 46. Reaction after Bronchoscopy. Penn. Med. Journ., April, 1919. +Vol. XXII P. 434. + 47. Root-canal Broach Removed from the Lung by Bronchoscopy. The +Dental Cosmos, Vol. LVII, March, 1915, p. 247. + 48. Safety Pins in Stomach, Peroral Gastroscopic Removal without +Anesthesia. Journ. Amer. Med. Asso., Feb. 26, 1921, Vol. LXXVI, pp. +577-579. + 49. Symptomatology and Diagnosis of Foreign Bodies in the Air and +Food Passages. Am. Journ. Med. Sci., May, 1921, Vol. CLXI, No. 5, p. +625. + 50. The Bronchial Tree, Its Study by Insufllation of Opaque +Substances in the Living. Amer. Journ. Roentgenology, Vol. 5, Oct., +1918, p. 454. Also Proc. Amer. Laryn., Rhinol. and Otol. Soc., 1918. + 51. Thymic Death. Editorial. The Laryngoscope, Vol. XXVI, May, 1916, +p. 929. + 52. Tracheobronchitis Due to Nitric Acid Fumes. New York Med. +Journ., Nov. 4, 1916, PP. 898-899. + 53. Treatment of Laryngeal Stenosis by Corking the Tracheotomic +Cannula, The Laryngoscope, Jan., 1919. + 54. Ventriculocordectomy. Proceedings Amer. Laryngol. Soc., 1921. + 55. New Mechanical Problems in the Bronchoscopic Extraction of +Foreign Bodies from the Lungs and Esophagus. Annals of Surgery, Jan., +1922. + 56. The Diaphragmatic Pinchcock in So-called Cardiospasm. +Laryngoscope, Jan., 1922. + + + +***END OF THE PROJECT GUTENBERG EBOOK BRONCHOSCOPY AND ESOPHAGOSCOPY*** + + +******* This file should be named 19261.txt or 19261.zip ******* + + +This and all associated files of various formats will be found in: +http://www.gutenberg.org/dirs/1/9/2/6/19261 + + + +Updated editions will replace the previous one--the old editions +will be renamed. + +Creating the works from public domain print editions means that no +one owns a United States copyright in these works, so the Foundation +(and you!) can copy and distribute it in the United States without +permission and without paying copyright royalties. Special rules, +set forth in the General Terms of Use part of this license, apply to +copying and distributing Project Gutenberg-tm electronic works to +protect the PROJECT GUTENBERG-tm concept and trademark. 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