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´╗┐Title: Bronchoscopy and Esophagoscopy - A Manual of Peroral Endoscopy and Laryngeal Surgery
Author: Jackson, Chevalier, 1865-1958
Language: English
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Copyright Status: Not copyrighted in the United States. If you live elsewhere check the laws of your country before downloading this ebook. See comments about copyright issues at end of book.

*** Start of this Doctrine Publishing Corporation Digital Book "Bronchoscopy and Esophagoscopy - A Manual of Peroral Endoscopy and Laryngeal Surgery" ***

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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.





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