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.