Bronchoscopy and Esophagoscopy
by Chevalier Jackson · English · Gutenberg #19261 · 511,109 chars · public domain (US)
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Title: Bronchoscopy and Esophagoscopy
Author: Chevalier Jackson
Release date: September 13, 2006 [eBook #19261]
Language: English
Other information and formats: www.gutenberg.org/ebooks/19261
*** START OF THE PROJECT GUTENBERG EBOOK BRONCHOSCOPY AND ESOPHAGOSCOPY ***
This book is one of the pioneering works in laryngology. The original text
is from the library of Indiana University Department of
Otolaryngology-Head and Neck Surgery, Bruce Matt, MD. It was scanned,
converted to text, and proofed by Alex Tawadros.
BRONCHOSCOPY AND ESOPHAGOSCOPY
A Manual of Peroral Endoscopy and Laryngeal Surgery
by
CHEVALIER JACKSON, M.D., F.A.C.S.
Professor of Laryngology, Jefferson Medical College, Philadelphia;
Professor of Bronchoscopy and Esophagoscopy, Graduate School of
Medicine, University of Pennsylvania; Member of the American
Laryngological Association; Member of the Laryngological,
Rhinological, and Otological Society; Member of the American Academy
of Ophthalmology and Oto-Laryngology; Member of the American
Bronchoscopic Society; Member of the American Philosophical Society;
etc., etc.
With 114 Illustrations and Four Color Plates
Philadelphia And London
W. B. Saunders Company
1922
Copyrights 1922, by W. B. Saunders Company
Made in U.S.A.
TO MY MOTHER TO WHOSE INTEREST IN MEDICAL SCIENCE THE AUTHOR OWES
HIS INCENTIVE, AND TO MY FATHER WHOSE CONSTANT ADVICE TO "EDUCATE
THE EYE AND THE FINGERS" SPURRED THE AUTHOR TO CONTINUAL EFFORT,
THIS BOOK IS AFFECTIONATELY DEDICATED.
PREFACE
This book is based on an abstract of the author's larger work,
Peroral Endoscopy and Laryngeal Surgery. The abstract was prepared
under the author's direction by a reader, in order to get a reader's
point of view on the presentation of the subject in the earlier book.
With this abstract as a starting point, the author has endeavored, so
far as lay within his limited abilities, to accomplish the difficult
task of presenting by written word the various purely manual
endoscopic procedures. The large number of corrections and revisions
found necessary has confirmed the wisdom of the plan of getting the
reader's point of view; and these revisions, together with numerous
additions, have brought the treatment of the subject up to date so far
as is possible within the limits of a working manual.
Acknowledgment is due the personnel of the W. B. Saunders Company for
kindly help.
CHEVALIER JACKSON.
OCTOBER, 1922.
II
CONTENTS PAGE
CHAPTER I INSTRUMENTARIUM 17
CHAPTER II ANATOMY OF LARYNX, TRACHEA, BRONCHI AND
ESOPHAGUS, ENDOSCOPICALLY CONSIDERED 52
CHAPTER III PREPARATION OF THE PATIENT FOR PERORAL
ENDOSCOPY 63
CHAPTER IV ANESTHESIA FOR PERORAL ENDOSCOPY 65
CHAPTER V BRONCHOSCOPIC OXYGEN INSUFFLATION 71
CHAPTER VI POSITION OF THE PATIENT FOR PERORAl ENDOSCOPY 73
CHAPTER VII DIRECT LARYNGOSCOPY 82
CHAPTER VIII DIRECT LARYNGOSCOPY (Continued) 91
CHAPTER IX INTRODUCTION OF THE BRONCHOSCOPE 97
CHAPTER X INTRODUCTION OF THE ESOPHAGOSCOPE 106
CHAPTER XI ACQUIRING SKILL 117
CHAPTER XII FOREIGN BODIES IN THE AIR AND FOOD PASSAGES 126
CHAPTER XIII FOREIGN BODIES IN THE LARYNX AND
TRACHEOBRONCHIAL TREE 149
CHAPTER XIV REMOVAL OF FOREIGN BODIES FROM THE LARYNX 156
CHAPTER XV MECHANICAL PROBLEMS OF BRONCHOSCOPIC
FOREIGN BODY EXTRACTION 158
CHAPTER XVI FOREIGN BODIES IN THE BRONCHI FOR
PROLONGED PERIODS 177
CHAPTER XVII UNSUCCESSFUL BRONCHOSCOPY FOR FOREIGN BODIES 181
CHAPTER XVIII FOREIGN BODIES IN THE ESOPHAGUS 183
CHAPTER XIX ESOPHAGOSCOPY FOR FOREIGN BODY 187
CHAPTER XX PLEUROSCOPY 199
CHAPTER XXI BENIGN GROWTHS IN THE LARYNX 201
CHAPTER XXII BENIGN GROWTHS IN THE LARYNX (Continued) 203
CHAPTER XXIII BENIGN GROWTHS PRIMARY IN THE
TRACHEOBRONCHIAL TREE 207
CHAPTER XXIV BENIGN NEOPLASMS OF THE ESOPHAGUS 209
CHAPTER XXV ENDOSCOPY IN MALIGNANT DISEASE OF THE LARYNX 210
CHAPTER XXVI BRONCHOSCOPY IN MALIGNANT GROWTHS OF
THE TRACHEA 214
CHAPTER XXVII MALIGNANT DISEASE OF THE ESOPHAGUS 216
CHAPTER XXVIII DIRECT LARYNGOSCOPY IN DISEASES OF
THE LARYNX 221
CHAPTER XXIX BRONCHOSCOPY IN DISEASES OF THE TRACHEA
AND BRONCHI 224
CHAPTER XXX DISEASES OF THE ESOPHAGUS 235
CHAPTER XXXI DISEASES OF THE ESOPHAGUS (Continued) 245
CHAPTER XXXII DISEASES OF THE ESOPHAGUS (Continued) 251
CHAPTER XXXIII DISEASES OF THE ESOPHAGUS (Continued) 260
CHAPTER XXXIV DISEASES OF THE ESOPHAGUS (Continued) 268
CHAPTER XXXV GASTROSCOPY 273
CHAPTER XXXVI ACUTE STENOSIS OF THE LARYNX 277
CHAPTER XXXVII TRACHEOTOMY 279
CHAPTER XXXVIII CHRONIC STENOSIS OF THE LARYNX AND TRACHEA 300
CHAPTER XXXIX DECANNULATION AFTER CURE OF LARYNGEAL
STENOSIS 309
BIBLIOGRAPHY 311
INDEX 315
[17] CHAPTER I--INSTRUMENTARIUM
Direct laryngoscopy, bronchoscopy, esophagoscopy and gastroscopy
are procedures in which the lower air and food passages are
inspected and treated by the aid of electrically lighted tubes
which serve as specula to manipulate obstructing tissues out of the
way and to bring others into the line of direct vision.
Illumination is supplied by a small tungsten-filamented, electric,
"cold" lamp situated at the distal extremity of the instrument in a
special groove which protects it from any possible injury during the
introduction of instruments through the tube. The bronchi and the
esophagus will not allow dilatation beyond their normal caliber;
therefore, it is necessary to have tubes of the sizes to fit
these passages at various developmental ages. Rupture or even
over-distention of a bronchus or of the thoracic esophagus is almost
invariably fatal. The armamentarium of the endoscopist must be
complete, for it is rarely possible to substitute, or to improvise
makeshifts, while the bronchoscope is in situ. Furthermore, the
instruments must be of the proper model and well made; otherwise
difficulties and dangers will attend attempts to see them.
_Laryngoscopes_.--The regular type of laryngoscope shown in Fig. I
(A, B, C) is made in adult's, child's, and infant's sizes. The
instruments have a removable slide on the top of the tubular
portion of the speculum to allow the removal of the laryngoscope
after the insertion of the bronchoscope through it. The infant size
is made in two forms, one with, the other without a removable slide;
with either form the larynx of an infant can be exposed in but a few
seconds and a definite diagnosis made, without anesthesia, general or
local; a thing possible by no other method. For operative work on the
larynx of adults, such as the removal of benign growths, particularly
when these are situated in the anterior portion of the larynx, a
special tubular laryngoscope having a heart-shaped lumen and a
beveled tip is used. With this instrument the anterior commissure is
readily exposed, and because of this it is named the anterior
commissure laryngoscope (Fig. 1, D). The tip of the anterior
commissure laryngoscope can be used to expose either ventricle of the
larynx by lifting the ventricular band, or it may be passed through
the adult glottis for work in the subglottic region. This instrument
may also be used as an esophageal speculum and as a pleuroscope. A
side-slide laryngoscope, used with or without the slide, is
occasionally useful.
_Bronchoscopes_.--The regular bronchoscope is a hollow brass tube
slanted at its distal end, and having a handle at its proximal or
ocular extremity. An auxiliary canal on its under surface contains
the light carrier, the electric bulb of which is situated in a recess
in the beveled distal end of the tube. Numerous perforations in the
distal part of the tube allow air to enter from other bronchi when the
tube-mouth is inserted into one whose aerating function may be
impaired. The accessory tube on the upper surface of the bronchoscope
ends within the lumen of the bronchoscope, and is used for the
insufflation of oxygen or anesthetics, (Fig. 2, A, B, C, D).
For certain work such as drainage of pulmonary abscesses, the lavage
treatment of bronchiectasis and for foreign-body or other cases with
abundant secretions, a drainage-bronchoscope is useful The drainage
canal may be on top, or on the under surface next to the light-carrier
canal. For ordinary work, however, secretion in the bronchus is best
removed by sponge-pumping (Q.V.) which at the same time cleans the
lamp. The drainage bronchoscope may be used in any case in which the very
slightly-greater area of cross section is no disadvantage; but in
children the added bulk is usually objectionable, and in cases of
recent foreign-body, secretions are not troublesome.
As before mentioned, the lower air passages will not tolerate
dilatation; therefore, it is necessary never to use tubes larger than
the size of the passages to be examined. Four sizes are sufficient
for any possible case, from a newborn infant to the largest adult.
For infants under one year, the proper tube is the 4 mm. by 30 cm.;
the child's size, 5 mm. by 30 cm., is used for children aged from one
to five years. For children six years or over, the 7 mm. by 40 cm.
bronchoscope (the adolescent size) can be used unless the smaller
bronchi are to be explored. The adult bronchoscope measures 9 mm.
by 40 cm.
The author occasionally uses special sizes, 5 mm. x 45 cm., 6 mm. x 35
cm., 8 mm. x 40 cm.
_Esophagoscopes_.-The esophagoscope, like the bronchoscope, is a
hollow brass tube with beveled distal end containing a small
electric light. It differs from the bronchoscope in that it has no
perforations, and has a drainage canal on its upper surface, or next
to the light-carrier canal which opens within the distal end of the
tube. The exact size, position, and shape of the drainage outlets is
important on bronchoscopes, and to an even greater degree on
esophagoscopes. If the proximal edge of the drainage outlet is too
near the distal end of the endoscopic tube, the mucosa will be drawn
into the outlet, not only obstructing it, but, most important,
traumatizing the mucosa. If, for instance, the esophagoscope were to
be pushed upon with a fold thus anchored in the distal end, the
esophageal wall could easily be torn. To admit the largest sizes of
esophagoscopic bougies (Fig. 40), special esophagoscopes (Fig. 5) are
made with both light canal and drainage canal outside the lumen of the
tube, leaving the full area of luminal cross-section unencroached
upon. They can, of course, be used for all purposes, but the slightly
greater circumference is at times a disadvantage. The esophageal and
stomach secretions are much thinner than bronchial secretions, and, if
free from food, are readily aspirated through a comparatively small
canal. If the canal becomes obstructed during esophagoscopy, the
positive pressure tube of the aspirator is used to blow out the
obstruction. Two sizes of esophagoscopes are all that are required--7
mm. X 45 cm. for children, and 10 mm. X 53 cm. for adults (Fig. 3, A
and B); but various other sizes and lengths are used by the author for
special purposes.* Large esophagoscopes cause dangerous dyspnea in
children. If, it is desired to balloon the esophagus with air, the
window plug shown in Fig. 6, is inserted into the proximal end of the
esophagoscope, and air insufflated by means of the hand aspirator or
with a hand bulb. The window can be replaced by a rubber diaphragm
with a perforation for forceps if desired. It will be noted that none
of the endoscopic tubes are fitted with mandrins. They are to be
introduced under the direct guidance of the eye only. Mandrins are
obtainable, but their use is objectionable for a number of reasons,
chief of which is the danger of overriding a foreign body or a lesion,
or of perforating a lesion, or even the normal esophageal wall. The
slanted end on the esophagoscope obviates the necessity of a mandrin
for introduction. The longer the slant, with consequent acuting of the
angle, the more the introduction is facilitated; but too acute an
angle increases the risk of perforating the esophageal wall, and
necessitates the utmost caution. In some foreign-body cases an acute
angle giving a long slant is useful, in others a short slant is
better, and in a few cases the squarely cut-off distal end is best. To
have all of these different slants on hand would require too many
tubes. Therefore the author has settled upon a moderate angle for the
end of both esophagoscopes and bronchoscopes that is easy to insert,
and serves all purposes in the version and other manipulations
required by the various mechanical problems of foreign-body
extraction. He has, however, retained all the experimental models, for
occasional use in such cases as he falls heir to because of a problem
of extraordinary difficulty.
* A 9 mm. X 45 cm. esophagoscope will reach the stomach of almost all
adults and is somewhat easier to introduce than the 10 mm. X 53 cm.,
which may be omitted from the set if economy must be practiced.
[FIG. I.--Author's laryngoscopes. These are the standard sizes and
fulfill all requirements. Many other forms have been devised by the
author, but have been omitted from the list as unnecessary. The infant
diagnostic laryngoscope (C) is not for introducing bronchoscopes,
and is not absolutely necessary, as the larynx of any infant can be
inspected with the child's size laryngoscope (B).
A Adult's size; B, child's size; C, infant's diagnostic size; D,
anterior commissure laryngoscope; E, with drainage canal; 17,
intubating laryngoscope, large lumen. All the laryngoscopes are
preferred without drainage canals.]
[FIG. 2.--The author's bronchoscopes of the sizes regularly used.
Various other lengths and diameters are on hand for occasional use
for special purposes. With the exception of a 6 mm. X 35 cm. size
for older children, these special bronchoscopes are very rarely
used and none of them can be regarded as necessary. For special
purposes, however, special shapes of tube-mouth are useful, as,
for instance, the oval end to facilitate the getting of both
points of a staple into the tube-mouth The illustrated instruments
are as follows:
A, Infant's size, 4 mm. X 30 cm.; B, child's size, 5 mm. X 30 cm.;
C, adolescent's size, 7 mm. X 40 cm.; D, adult's size, 9 mm. X 40 cm.;
E, aspirating bronchoscope made in all the foregoing sizes, and in a
special size, 5 mm. X 45 cm.]
[FIG. 3.--The author's esophagoscopes of the sizes he has standardized
for all ordinary requirements. He uses various other lengths and sizes
for special purposes, but none of them are really necessary. A
gastroscope, 10 mm. X 70 cm., is useful for adults, especially in
cases of gastroptosis. Drainage canals are placed at the top or at the
side of the tube, next to the light-carrier canal.
A, Adult's size, 10 mm. X 53 cm.; B, child's size, 7 mm. X 45 cm.; C
and D, full lumen, with both light canal and drainage canal outside
the wall of the tube, to be used for passing very large bougies. This
instrument is made in adult, child, and adolescent (8 mm. by 45 cm.)
sizes. Gastroscopes and esophagoscopes of the sizes given above (A)
and (B), can be used also as gastroscopes. A small form of C, 5 mm. X
30 cm. is used in infants, and also as a retrograde esophagoscope in
patients of any age. E, window plug for ballooning gastroscope, F.]
[FIG. 4.--Author's short esophagoscopes and esophageal specula
A, Esophageal speculum and hypopharyngoscope, adult's size; B,
esophageal speculum and hypopharyngoscope, child's size; C, heavy
handled short esophagoscope; D, heavy handled short esophagoscope with
drainage.]
[FIG. 5.--Cross section of full-lumen esophagoscope for the use of
largest bourgies. The canals for the light carrier and for drainage
are so constructed that they do not encroach upon the lumen of the
tube.]
[25] The special sized esophagoscopes most often useful are the 8 mm.
X 30 cm., the 8 mm. X 45 cm., and the 5 mm. X 45 cm. These are made
with the drainage canal in various positions.
For operations on the upper end of the esophagus, and particularly for
foreign body work, the esophageal speculum shown at A and B, in Fig.
4, is of the greatest service. With it, the anterior wall of the
post-cricoidal pharynx is lifted forward, and the upper esophageal
orifice exposed. It can then be inserted deeper, and the upper third
of the esophagus can be explored. Two sizes are made, the adult's and
the child's size. These instruments serve, very efficiently as
pleuroscopes. They are made with and without drainage canals, the
latter being the more useful form.
[FIG. 6.--Window-plug with glass cap interchangeable with a cap having
a rubber diaphragm with a perforation so that forceps may be used
without allowing air to escape. Valves on the canals (E, F, Fig. 3)
are preferable.]
_Gastroscopes_.--The gastroscope is of the same construction as the
esophagoscope, with the exception that it is made longer, in order to
reach all parts of the stomach. In ordinary cases, the regular
esophagoscopes for adults and children respectively will afford a good
view of the stomach, but there are cases which require longer tubes,
and for these a gastroscope 10 mm. X 70 cm. is made, and also one 10
mm. X 80 cm., though the latter has never been needed but once.
[26] _Pleuroscopes_.--As mentioned above the anterior commissure
laryngoscope and the esophageal specula make very efficient
pleuroscopes; but three different forms of pleuroscopes have been
devised by the author for pleuroscopy. The retrograde esophagoscope
serves very well for work through small fistulae.
_Measuring Rule_ (Fig. 7).--It is customary to locate esophageal
lesions by denoting their distance from the incisor teeth. This is
readily done by measuring the distance from the proximal end of the
esophagoscope to the upper incisor teeth, or in their absence, to the
upper alveolar process, and subtracting this measurement from the
known length of the tube. Thus, if an esophagoscope 45 cm. long be
introduced and we find that the distance from the incisor teeth to the
ocular end of the esophagoscope as measured by the rule is 20 cm., we
subtract this 20 cm. from the total length of the esophagoscope (45
cm.) and then know that the distal end of the tube is 25 cm. from the
incisor teeth. Graduation marks on the tube have been used, but are
objectionable.
[FIG. 7.--Measuring rule for gauging in centimeters the depth of any
location by subtraction of the length of the uninserted portion of the
esophagoscope or bronchoscope. This is preferable to graduations
marked on the tubes, though the tubes can be marked with a scale if
desired.]
_Batteries_.--The simplest, best, and safest source of current is a
double dry battery arranged in three groups of two cells each,
connected in series (Fig. 8). Each set should have two binding posts
and a rheostat. The binding posts should have double holes for two
additional cords, to be kept in reserve for use in case a cord becomes
defective.* The commercial current reduced through a rheostat should
never be used, because there is always the possibility of "grounding"
the circuit through the patient; a highly dangerous accident when we
consider that the tube makes a long moist contact in tissues close to
the course of both the vagi and the heart. The endoscopist should
never depend upon a pocket battery as a source of illumination, for it
is almost certain to fail during the endoscopy. The wires connecting
the battery and endoscopic instrument are covered with rubber, so that
they may be cleansed and superficially sterilized with alcohol. They
may be totally immersed in alcohol for any length of time without
injury.
* When this is done care is necessary to avoid attempting to use
simultaneously the two cords from one pair of posts.
[FIG 8.--The author's endoscopic battery, heavily built for
reliability.
It contains 6 dry cells, series-connected in 3 groups of 2 cells each.
Each group has its own rheostat and pair of binding posts.]
_Aspirating Tubes_.--Independent aspirating tubes involve delay in
their use as compared to aspirating canals in the wall of the
endoscopic tube; but there are special cases in which an independent
tube is invaluable. Three forms are used by the author. The "velvet
eye" cannot traumatize the mucosa (Fig. 9). To hold a foreign body by
suction, a squarely cut off end is necessary. For use through the
tracheotomic wound without a bronchoscope a malleable tube (Fig. 10)
is better.
[FIG. 9.--The author's protected-aperture endoscopic aspirating tube
for aspiration of pharyngeal secretions during direct laryngoscopy and
endotracheobronchial secretions at bronchoscopy, also for draining
retropharyngeal abscesses. The laryngoscopes are obtainable with
drainage canals, but for most purposes the independent aspirating tube
shown above is more satisfactory. The tubes are made in 20 30, 40, and
60 cm. lengths. An aperture on both sides prevents drawing in the
mucosa. It can be used for insufflation of ether if desired. An
aspirating tube of the same design, but having a squarely cut off end,
is sometimes useful for removing secretions lying close to a foreign
body; for removing papillomata; and even for withdrawing foreign
bodies of a soft surface consistency. It is not often that the foreign
bodies can be thus withdrawn through the glottis, but closely fitting
foreign bodies can at least be withdrawn to a higher level at which
ample forceps spaces will permit application of forceps. Such
aspirating tubes, however, are not so safe to use as the protected,
double aperture tubes.]
[FIG. 10.--The author's malleable tracheotomic aspirating tube for
removal of secretions, exudates, crusts, etc., from the
tracheobronchial tree through the tracheotomic wound without a
bronchoscope. The tube is made of copper so that it can be bent to any
curve, and the copper wire stylet prevents kinking. The stylet is
removed before using the tube for aspiration.]
[28] _Aspirators_.--The various electric aspirators so universally
used in throat operations should be utilized to withdraw secretions in
the tubes fitted with drainage canals. They, however, have the
disadvantages of not being easily transported, and of occasionally
being out of order. The hand aspirator shown in Fig. 11 is, therefore,
a necessary part of the instrumental equipment. It never fails to
work, is portable, and affords both positive and negative pressures.
The positive pressure is sometimes useful in clearing the drainage
canal of any particles of food, tissue, clots, or secretion which may
obstruct it; and it also serves to fill the stomach or esophagus with
air when the ballooning procedure is used. The mechanical aspirator
(Fig. 12) is highly efficient and is the one used in the Bronchoscopic
Clinic. The positive pressure will quickly clear obstructed drainage
canals, and may be used while the esophagoscope is in situ, by simply
detaching the minus pressure tube and attaching the plus pressure. In
the lungs, however, high plus pressures are so dangerous that the
pressure valve must be lowered.
[Fig. 11--Portable aspirator for endoscopy with additional tube
connected with the plus pressure side for use in case of occlusion of
the drainage canal. This aspirator has the advantage of great power
with portability. Where portability is not required the electrically
operated aspirator is better.]
[FIG. 12.--Robinson mechanical aspirator adapted for bronchoscopic and
esophagoscopic aspiration by the author. The positive pressure is used
for clearing obstructed drainage canals and tubes.]
[FIG. 13.--Apparatus for insufflation of ether or chloroform during
bronchoscopy, for those who may desire to use general anesthesia. The
mechanical methods of intratracheal insufflation anesthesia
subsequently developed by Meltzer and Auer, Elsberg, Geo. P. Muller
and others have rightly superseded this apparatus for all general
surgical purposes.]
_Sponge-pumping_.--While the usually thin, watery esophageal and
gastric secretions, if free from food, are readily aspirated through a
drainage canal, the secretions of the bronchi are often thick and
mucilaginous and aspirated with difficulty. Further-more, bronchial
secretions as a rule are not collected in pools, but are distributed
over the walls of the larger bronchi and continuously well up from
smaller bronchi during cough. The aspirating bronchoscopes should be
used whenever their very slight additional area of cross-section is
unobjectionable. In most cases, however, the most advantageous way to
remove bronchial secretion has been found to be by introducing a gauze
swab on a long sponge carrier (Fig. 14), so that the sponge extends
beyond the distal end of the bronchoscope, causing cough. Then
withdrawal of the sponge carrier will remove all of the secretion in
the tube just as the plunger in a pump will lift all of the water
above it. By this maneuver the walls of the bronchus are wiped free
from secretions, and the lamp itself is cleansed.
[FIG. 14.--Sponge carrier with long collar for carrying the small
sponges shown in Fig. 15. The collar screws down as in the Coolidge
cotton carrier. About a dozen of these are needed and they should all
be small enough to go through the 4 mm. (diameter) bronchoscope and
long enough to reach through the 53 cm. (length) esophagoscope, so
that one set will do for all tubes. The schema shows method of
sponging. The carrier C, armed with the sponge, S, when rotated as
shown by the dart, D, wipes the field, P, at the same time wiping the
lamp, L. The lamp does not need ever to be withdrawn for cleaning
during bronchoscopy. It is protected in a recess so that it does not
catch in the sponges.]
[FIG 15.--Exact size to which the bandage-gauze is cut to make
endoscopic sponges. Each rectangle is the size for the tubal diameter
given. The dimensions of the respective rectangles are not given
because it is easier for the nurse or any one to cut a cardboard
pattern of each size directly from this drawing. The gauze rectangles
are folded up endwise as shown at A, then once in the middle as at B,
then strung one dozen on a safety pin. In America gauze bandages run
about 16 threads to the centimeter. Different material might require a
slightly different size and the pattern could be made to suit.]
[32] The gauze sponges are made by the instrument nurse as directed in
Fig. 15, and are strung on safety pins, wrapped in paper, the size
indicated by a figure on the wrapper, and then sterilized in an
autoclave. The sterile packages are opened only as needed. These
"bronchoscopic sponges" are also made by Johnston and Johnston, of New
Brunswick, N. J. and are sold in the shops.
_Mouth-gag_.--Wide gagging prevents proper exposure of the larynx by
forcing the mandible down on the hyoid bone. The mouth should be
gently opened and a bite block (Fig. 16) inserted between the teeth on
the left side of the patient's mouth, to prevent closing of the jaws
on the delicate bronchoscope or esophagoscope.
[FIG. 16.--Bite block to be inserted between the teeth to prevent
closure of the jaws on the endoscopic tube. This is the
McKee-McCready modification of the Boyce thimble with the omission of
the etherizing tube, which is no longer needed. The block has been
improved by Dr. W. F. Moore of the Bronchoscopic Clinic.]
_Forceps_.--Delicacy of touch and manipulation are an absolute
necessity if the endoscopist is to avoid mortality; therefore, heavily
built and spring-opposed forceps are dangerous as well as useless. For
foreign-body work in the larynx, and for the removal of benign
laryngeal growths, the alligator forceps with roughened jaws shown in
Fig. 17 serve every purpose.
[FIG. 17.--Laryngeal grasping forceps designed by Mosher. For my own
use I have taken off the ratchet-locking device for all general work,
to be reapplied on the rare occasions when it is required.]
_Bronchoscopic and esophagoscopic grasping forceps_ are of the tubular
type, that is, a stylet carrying the jaws works in a slender tube so
that traction on the stylet draws the V of the open jaws into the
lumen of the tube, thus causing the blades to approximate. They are
very delicate and light, yet have great grasping power and will
sustain any degree of traction that it is safe to exert. They permit
of the delicacy of touch of a violin bow. The two types of jaws most
frequently used, are those with the forward-grasping blades shown in
Fig. 18, and those having side-grasping blades shown in Fig. 19. The
side-curved forceps are perhaps the most generally useful of all the
endoscopic forceps; the side projection of the jaws makes them readily
visible during their closure on an object; their broader grasp is also
an advantage., The projection of the blades in the side-curved
grasping forceps should always be directed toward the left. If it is
desired that they open in another direction this should be
accomplished by turning the handle and not by adjusting the blade
itself. If this rule be followed it will always be possible to tell by
the position of the handle exactly where the blades are situated;
whereas, if the jaws themselves are turned, confusion is sure to
result. The forward-grasping forceps are always so adjusted that the
jaws open in an up-and-down direction. On rare occasions it may be
deemed desirable to turn the stylet of either forceps in some other
direction relative to the handle.
[FIG. 18.--The author's forward grasping tube forceps. The handle
mechanism is so simple and delicate that the most exquisite delicacy
of touch is possible. Two locknuts and a thumbscrew take up all lost
motion yet afford perfect adjustability and easy separation for
cleansing. At A is shown a small clip for keeping the jaws together to
prevent injurious bending in the sterilizer, or carrying case. At the
left is shown a handle-clamp for locking the forceps on a foreign body
in the solution of certain rarely encountered mechanical problems. The
jaws are serrated and cupped.]
[FIG. 19.--Jaws of the author's side-curved endoscopic forceps. These
work as shown in the preceding illustration, each forceps having its
own handle and tube. Originally the end of the cannula and stylet were
squared to prevent rotation of the jaws in the cannula. This was
found to be unnecessary with properly shaped jaws, which wedge
tightly.]
_Rotation Forceps_.--It is sometimes desired to make traction on an
irregularly shaped foreign body, and yet to allow the object to turn
into the line of least resistance while traction is being made. This
can be accomplished by the use of the rotation forceps (Fig. 20),
which have for blades two pointed hooks that meet at their points and
do not overlap. Rotation forceps made on the model of the laryngeal
grasping forceps, but having opposing points at the end of the blades,
are sometimes very useful for the removal of irregular foreign bodies
in the larynx, or when used through the esophageal speculum they are
of great service in the extraction of such objects as bones,
pin-buttons, and tooth-plates, from the upper esophagus. These forceps
are termed laryngeal rotation forceps (Fig. 31). All the various forms
of forceps are made in a very delicate size often called the
"mosquito" or "extra light" forceps, 40 cm. in length, for use in the
4 mm. and the 5 mm. bronchoscopes. For the 5 mm. bronchoscopes heavier
forceps of the 40 cm. length are made. For the larger tubes the
forceps are made in 45 cm., 50 cm., and 60 cm. lengths. A
square-cannula forceps to prevent turning of the jaws was at one time
used by the author but it has since been found that round cannula
pattern serves all purposes.
[FIG. 20.--The author's rotation forceps. Useful to allow turning of an
irregular foreign body to a safer relation for withdrawal and for the
esophagoscopic removal of safety pins by the method of pushing them
into the stomach, turning and withdrawal, spring up.]
_Upper-lobe-bronchus Forceps_.--Foreign bodies rarely lodge in an
upper-lobe bronchus, yet with such a problem it is necessary to have
forceps that will reach around a corner. The upper-lobe-bronchus
forceps shown in Fig. 27 have curved jaws so made as to straighten out
while passing through the bronchoscope and to spring back into their
original shape on up from the lower jaw emerging from the distal end
of the bronchoscopic tube, the radius of curvature being regulated by
the extent of emergence permitted. They are made in extra-light
pattern, 40 cm. long, and the regular model 45 cm. long. The
full-curved model, giving 180 degrees and reaching up into the
ascending branches, is made in both light and heavy patterns. Forceps
with less curve, and without the spiral, are used when it is desired
to reach only a short distance "around the corner" anywhere in the
bronchi. These are also useful, as suggested by Willis F. Manges, in
dealing with safety pins in the esophagus or tracheobronchial tree.
[FIG. 21.--Tucker jaws for the author's forceps. The tiny lip
projecting down from the upper, and up from the lower jaw prevents
sidewise escape of the shaft of a pin, tack, nail or needle. The shaft
is automatically thrown parallel to the bronchoscopic axis. Drawing
about four times actual size.]
[36] _Tucker Forceps_--Gabriel Tucker modified the regular side-curved
forceps by adding a lip (Fig. 21) to the left hand side of both upper
and lower jaws. This prevents the shaft of a tack, nail, or pin, from
springing out of the grasp of the jaws, and is so efficient that it
has brought certainty of grasp never before obtainable. With it the
solution of the safety-pin problem devised by the author many years
ago has a facility and certainty of execution that makes it the method
of choice in safety-pin extraction.
[FIG. 22.--The author's down-jaw esophageal forceps. The dropping jaw
is useful for reaching backward below the cricopharyngeal fold when
using the esophageal speculum in the removal of foreign bodies.
Posterior forceps-spaces are often scanty in cases of foreign bodies
lodged just below the cricopharyngeus.]
[FIG. 23.--Expansile forceps for the endoscopic removal of hollow
foreign bodies such as intubation tubes, tracheal cannulae, caps, and
cartridge shells.]
_Screw forceps_.--For the secure grasp of screws the jaws devised by
Dr. Tucker for tacks and pins are excellent (Fig. 21).
_Expanding Forceps_.--Hollow objects may require expanding
forceps as shown in Fig. 23. In using them it is necessary to be
certain that the jaws are inside the hollow body before expanding them
and making traction. Otherwise severe, even fatal, trauma may be
inflicted.
[FIG. 24.--The author's fenestrated peanut forceps. The delicate
construction with long, springy and fenestrated jaws give in gentle
hands a maximum security with a minimum of crushing tendency.]
[FIG. 25--The author's bronchial dilators, useful for dilating
strictures above foreign bodies. The smaller size, shown at the right
is also useful as an expanding forceps for removing intubation tubes,
and other hollow objects. The larger size will go over the shaft of a
tack.]
[FIG. 26.--The author's self-expanding bronchial dilator. The extent of
expansion can be limited by the sense of touch or by an adjustable
checking mechanism on the handle. The author frequently used smooth
forceps for this purpose, and found them so efficient that this
dilator was devised. The edges of forceps jaws are likely to scratch
the epithelium. Occasionally the instrument is useful in the
esophagus; but it is not very safe, unless used with the utmost
caution.]
_Tissue Forceps_.--With the forceps illustrated in Fig. 28 specimens
of tissue may be removed for biopsy from the lower air and food
passages with ease and certainty. They have a cross in the outer blade
which holds the specimen removed. The action is very delicate, there
being no springs, and the sense of touch imparted is often of great
aid in the diagnosis.
[FIG. 27.--The author's upper-lobe bronchus forceps. At A is shown
the full-curved form, for reaching into the ascending branches of the
upper-lobe bronchus A number of different forms of jaws are made in
this kind of forceps. Only 2 are shown.]
[FIG 28--The author's endoscopic tissue forceps. The laryngeal length
is 30 cm. For esophageal use they are made 50 and 60 cm. long. These
are the best forceps for cutting out small specimens of tissue for
biopsy.]
The large basket punch forceps shown in Fig. 33 are useful in removing
larger growths or specimens of tissue from the pharynx or larynx. A
portion or the whole of the epiglottis may be easily and quickly
removed with these forceps, the laryngoscope introduced along the
dorsum of the tongue into the glossoepiglottic recess, bringing the
whole epiglottis into view. The forceps may be introduced through the
laryngoscope or alongside the tube. In the latter method a greater
lateral action of the forceps is obtainable, the tube being used for
vision only. These forceps are 30 cm. long and are made in two sizes;
one with the punch of the largest size that can be passed through the
adult laryngoscope, and a smaller one for use through the
anterior-commissure laryngoscope and the child's size laryngoscope.
[FIG. 29.--The author's papilloma forceps. The broad blunt nose will
scalp off the growths without any injury to the normal basal tissues.
Voice-destroying and stenosing trauma are thus easily avoided.]
[FIG. 30.--The author's short mechanical spoon (30 cm. long).]
_Papilloma Forceps_.--Papillomata do not infiltrate; but superficial
repullulations in many cases require repeated removals. If the basal
tissues are traumatized, an impaired or ruined voice will result. The
author designed these forceps (Fig. 29) to scalp off the growths
without injury to the normal tissues.
[FIG. 31.--The author's laryngeal rotation forceps.]
[FIG. 32.--Enlarged view of the jaws of the author's vocal-nodule
forceps. Larger cups are made for other purposes but these tiny cups
permit of that extreme delicacy required in the excision of the
nodules from the vocal cords of singers and other voice users.]
[FIG 33.-Extra large laryngeal tissue forceps. 30 cm. long, for
removing entire growths or large specimens of tissue. A smaller size
is made.]
_Bronchial Dilators_.--It is not uncommon to find a stricture of the
bronchus superjacent to a foreign body that has been in situ for a
period of months. In order to remove the foreign body, this stricture
must be dilated, and for this the bronchial dilator shown in Fig. 25
was devised. The channel in each blade allows the closed dilator to be
pushed down over the presenting point of such bodies as tacks, after
which the blades are opened and the stricture stretched. A small and a
large size are made. For enlarging the bronchial narrowing associated
with pulmonary abscess and sometimes found above a bronchiectatic or
foreign body cavity, the expanding dilator shown in Fig. 26 is perhaps
less apt to cause injury than ordinary forceps used in the same way.
The stretching is here produced by the spring of the blades of the
forceps and not by manual force. The closed blades are to be inserted
through the strictured area, opened, and then slowly withdrawn. For
cicatricial stenoses of the trachea the metallic bougies, Fig. 40, are
useful. For the larynx, those shown in Fig. 41 are needed.
[FIG. 34.--A, Mosher's laryngeal curette; B, author's flat blade
cautery electrode; C, pointed cautery electrode; D, laryngeal knife.
The electrodes are insulated with hard-rubber vulcanized onto the
conducting wires.]
[FIG. 35.--Retrograde esophageal bougies in graduated sizes devised by
Dr. Gabriel Tucker and the author for dilatation of cicatricial
esophageal stenosis. They are drawn upward by an endless swallowed
string, and are therefore only to be used in gastrostomized cases.]
[FIG. 36.--Author's bronchoscopic and esophagoscopic mechanical spoon,
made in 40, 50 and 60 cm. lengths.]
[FIG. 37.--Schema illustrating the author's method of endoscopic
closure of open safety pins lodged point upward The closer is passed
down under ocular control until the ring, R, is below the pin. The
ring is then erected to the position shown dotted at M, by moving the
handle, H, downward to L and locking it there with the latch, Z. The
fork, A, is then inserted and, engaging the pin at the spring loop, K,
the pin is pushed into the ring, thus closing the pin. Slight rotation
of the pin with the forceps may be necessary to get the point into the
keeper. The upper instrument is sometimes useful as a mechanical spoon
for removing large, smooth foreign bodies from the esophagus.]
_Esophageal Dilators_.--The dilatation of cicatricial stenosis of the
esophagus can be done safely only by endoscopic methods. Blind
esophageal bouginage is highly dangerous, for the lumen of the
stricture is usually eccentric and the bougie is therefore apt to
perforate the wall rather than find the small opening. Often there is
present a pouching of the esophagus above a stricture, in which the
bougie may lodge and perforate. Bougies should be introduced under
visual guidance through the esophagoscope, which is so placed that the
lumen of the stricture is in the center of the endoscopic field. The
author's endoscopic bougies (Fig. 40) are made with a flexible
silk-woven tip securely fastened to a steel shaft. This shaft lends
rigidity to the instrument sufficient to permit its accurate
placement, and its small size permits the eye to keep the silk-woven
tip in view. These endoscopic bougies are made in sizes from 8 to 40,
French scale. The larger sizes are used especially for the dilatation
of laryngeal and tracheal stenoses. For the latter work it is
essential that the bougies be inspected carefully before they are
used, for should a defective tip come off while in the lower air
passages a difficult foreign body problem would be created.
Soft-rubber retrograde dilators to be drawn upward from the stomach by
a swallowed string are useful in gastrostomized cases (Fig. 35).
[FIG 38.--Half curved hook, 45 cm. and 60 cm. Full curved patterns are
made but caution is necessary to avoid them becoming anchored in the
bronchi. Spiral forms avoid this. The author makes for himself steel
probe-pointed rods out of which he bends hooks of any desired shape.
The rod is held in a pin-vise to facilitate bending of the point,
after heating in an alcohol or bunsen flame.]
_Hooks_.--No hook greater than a right angle should be used through
endoscopic tubes; for should it become caught in some of the smaller
bronchi its extraction might result in serious trauma. The half curved
hook shown in Fig. 38 is the safest type; better still, a spiral twist
to the hook will add to its uses, and by reversing the turning motion
it may be "unscrewed" out if it becomes caught. Hooks may easily be
made from rods of malleable steel by heating the end in a spirit lamp
and shaping the curve as desired by means of a pin-vise and pliers.
About 2 cm. of the proximal end of the rod should be bent in exactly
the opposite direction from that of the hook so as to form a handle
which will tell the position of the hook by touch as well as by sight.
Coil-spring hooks for the upper-lobe-bronchus (Fig. 39) will reach
around the corner into the ascending bronchus of the
upper-lobe-bronchus, but the utmost skill and care are required to
make their use justifiable.
[FIG. 39.--Author's coil-spring hook for the upper-lobe, bronchus]
_Safety-pin Closer_.--There are a number of methods for the endoscopic
removal of open safety-pins when the point is up, one of which is by
closing the pin with the instrument shown in Fig. 37 in the following
manner. The oval ring is passed through the endoscope until it is
beyond the spring of the safety-pin, the ring is then turned upward by
depressing the handle, and by the aid of the prong the pin is pushed
into the ring, which action approximates the point of the pin and the
keeper and closes the pin. Removal is then less difficult and without
danger. This instrument may also be used as a mechanical spoon, in
which case it may be passed to the side of a difficultly grasped
foreign body, such as a pebble, the ring elevated and the object
withdrawn. Elsewhere will be found a description of the
various safety-pin closers devised by various endoscopists. The author
has used Arrowsmith's closer with much satisfaction.
_Mechanical Spoon_.--When soft, friable substances, such as a bolus of
meat, become impacted in the upper esophagus, the short mechanical
spoon (Fig. 30) used through the esophageal speculum is of great aid
in their removal. The blade in this instrument, as the name suggests,
is a spoon and is not fenestrated as is the safety-pin closer, which
if used for friable substances would allow them to slip through the
fenestration. A longer form for use through bronchoscopes and
esophagoscopes is shown in Fig. 36.
A laryngeal curette, cautery electrodes, cautery handle, and laryngeal
knife are illustrated in Fig. 34. The cautery is to be used with a
transformer, or a storage battery.
_Spectacles_.--If the operator has no refractive error he will need
two pairs of plane protective spectacles with very large "eyes." If
ametropic, corrective lenses are necessary, and duplicate spectacles
must be in charge of a nurse. For presbyopia two pairs of spectacles
for 40 cm. distance and 65 cm. distance must be at hand. Hook temple
frames should be used so that they can be easily changed and adjusted
by the nurse when the lenses become spattered. The spectacle nurse has
ready at all times the extra spectacles, cleaned and warmed in a pan
of heated water so that they will not be fogged by the patient's
breath, and she changes them without delay as often as they become
soiled. The operator should work with both eyes open and with his
right eye at the tube mouth. The operating room should be somewhat
darkened so as to facilitate the ignoring of the image in the left
eye; any lighting should be at the operator's back, and should be
insufficient to cause reflections from the inner surface of his
glasses.
[FIG. 40.--The author's endoscopic bougies. The end consists of a
flexible silk woven tip attached securely to a steel shank. Sizes 8 to
30 French catheter scale. A metallic form of this bougie is useful in
the trachea; but is not so safe for esophageal use.]
[FIG. 41.--The author's laryngeal bougie for the dilatation of
cicatricial laryngeal stenosis. Made in 10 sizes. The shaded triangle
shows the cross-section at the widest part.]
[FIG. 42.--The author's bronchoscopic and esophagoscopic table.]
[46] _Endoscopic Table_.--Any operating table may be used, but the
work is facilitated if a special table can be had which allows the
placing of the patient in all required positions. The table
illustrated in fig. 42 is so arranged that when the false top is drawn
forward on the railroad, the head piece drops and the patient is
placed in the correct (Boyce) position for esophagoscopy or
bronchoscopy, i.e., with the head and shoulders extending over the end
of the table. By means of the wheel the plane of the table may
be altered to any desired angle of inclination or height of head.
_Operating Room_.--All endoscopic procedures should be performed in a
somewhat darkened operating room where all the desired materials are
at hand. An endoscopic team consists of three persons: the operator,
the assistant who holds the head, and the instrument assistant.
Another person is required to hold the patient's arms and still
another for the changing of the operator's glasses when they become
spattered. The endoscopic team of three maintain surgical asepsis in
the matter of hands and gowns, etc. The battery, on a small table of
its own, is placed at the left hand of the operator. Beyond it is the
table for the mechanical aspirator, if one is used. All extra
instruments are placed on a sterile table, within reach, but not in
the way, while those instruments for use in the particular operation
are placed on a small instrument table back of the endoscopist. Only
those instruments likely to be wanted should be placed on the working
table, so that there shall be no confusion in their selection by the
instrument nurse when called for. Each moment of time should be
utilized when the endoscopic procedure has been started, no time
should be lost in the hunting or separating of instruments. To have
the respective tables always in the same position relative to the
operator prevents confusion and avoids delay.
[FIG 43.--The author's retrograde esophagoscope.]
_Oxygen Tank and Tracheotomy Instruments_.--Respiratory arrest may
occur from shifting of a foreign body, pressure of the esophagoscope,
tumor, or diverticulum full of food. Rare as these contingencies are,
it is essential that means for resuscitation be at hand. No endoscopic
procedure should be undertaken without a set of tracheotomy
instruments on the sterile table within instant reach. In respiratory
arrest from the above mentioned causes, respiratory efforts are not
apt to return unless oxygen and amyl nitrite are blown into the
trachea either through a tracheotomy opening or better still by means
of a bronchoscope introduced through the larynx. The limpness of the
patient renders bronchoscopy so easy that the well-drilled
bronchoscopist should have no difficulty in inserting a bronchoscope
in 10 or 15 seconds, if proper preparedness has been observed. It is
perhaps relatively rarely that such accidents occur, yet if
preparations are made for such a contingency, a life may be saved
which would otherwise be inevitably lost. The oxygen tank covered with
a sterile muslin cover should stand to the left of the operating
table.
_Asepsis_.--Strict aseptic technic must be observed in all endoscopic
procedures. The operator, first assistant, and instrument nurse must
use the same precautions as to hand sterilization and sterile gowns as
would be exercised in any surgical operation. The operator and first
assistant should wear masks and sterile gloves. The patient is
instructed to cleanse the mouth thoroughly with the tooth brush and a
20 per cent alcohol mouth wash. Any dental defects should, if time
permit, as in a course of repeated treatments, be remedied by the
dental surgeon. When placed on the table with neck bare and the
shoulders unhampered by clothing, the patient is covered with a
sterile sheet and the head is enfolded in a sterile towel. The face is
wiped with 70 per cent alcohol.
It is to be remembered that while the patient is relatively immune to
the bacteria he himself harbors, the implantation of different strains
of perhaps the same type of organisms may prove virulent to him.
Furthermore the transference of lues, tuberculosis, diphtheria,
pneumonia, erysipelas and other infective diseases would be inevitable
if sterile precautions were not taken.
All of the tubes and forceps are sterilized by boiling. The
light-carriers and lamps may be sterilized by immersion in 95 per cent
alcohol or by prolonged exposure to formaldehyde gas. Continuous
sterilization by keeping them put away in a metal box with formalin
pastilles or other source of formaldehyde gas is an ideal method.
Knives and scissors are immersed in 95 per cent alcohol, and the
rubber covered conducting cords are wiped with the same solution.
_List of Instruments_.--The following list has been compiled as a
convenient basis for equipment, to which such special instruments as
may be needed for special cases can be added from time to time. The
instruments listed are of the author's design.
1 adult's laryngoscope.
1 child's laryngoscope.
1 infant's diagnostic laryngoscope.
1 anterior commissure laryngoscope.
1 bronchoscope, 4 mm. X 30 cm.
1 bronchoscope, 5 mm. X 30 cm.
1 bronchoscope, 7 mm. X 40 cm.
1 bronchoscope, 9 mm. X 40 cm.
1 esophagoscope, 7 mm. X 45 cm.
1 esophagoscope, 10 mm. X 53 cm.
1 esophagoscope, full lumen, 7 mm. X 45 cm.
1 esophagoscope, full lumen, 9 mm. X 45 cm.
1 esophageal speculum, adult.
1 esophageal speculum, child.
1 forward-grasping forceps, delicate, 40 cm.
1 forward-grasping forceps, regular, 50 cm.
1 forward-grasping forceps, regular, 60 cm.
1 side-grasping forceps, delicate, 40 cm.
1 side-grasping forceps, regular, 50 cm.
1 side-grasping forceps, regular, 60 cm.
1 rotation forceps, delicate, 40 cm.
1 rotation forceps, regular, 50 cm.
1 rotation forceps, regular, 60 cm.
1 laryngeal alligator forceps.
1 laryngeal papilloma forceps.
10 esophageal bougies, Nos. 8 to 17 French (larger sizes to No. 36
may be added).
1 special measuring rule.
6 light sponge carriers.
1 aspirator with double tube for minus and plus pressure.
2 endoscopic aspirating tubes 30 and 50 cm.
1 half curved hook, 60 cm.
1 triple circuit bronchoscopy battery.
6 rubber covered conducting cords for battery.
1 box bronchoscopic sponges, size 4.
1 box bronchoscopic sponges, size 5.
1 box bronchoscopic sponges, size 7.
1 box bronchoscopic sponges, size 10.
1 bite block, 1 adult.
1 bite block, child.
2 dozen extra lamps for lighted instruments.
1 extra light carrier for each instrument.*
4 yards of pipe-cleaning, worsted-covered wire.
[* Messrs. George P. Pilling and Sons who are now making these
instruments supply an extra light carrier and 2 extra lamps with each
instrument.]
_Care of Instruments_.--The endoscopist must either personally care
for his instruments, or have an instrument nurse in his own employ,
for if they are intrusted to the general operating room routine he
will find that small parts will be lost; blades of forceps bent,
broken, or rusted; tubes dinged; drainage canals choked with blood or
secretions which have been coagulated by boiling, and electric
attachments rendered unstable or unservicable, by boiling, etc. The
tubes should be cleansed by forcing cold water through the drainage
canals with the aspirating syringe, then dried by forcing
pipe-cleaning worsted-covered wire through the light and drainage
canals. Gauze on a sponge carrier is used to clean the main canal.
Forceps stylets should be removed from their cannulae, and the
cannulae cleansed with cold water, then dried and oiled with the
pipe-cleaning material. The stylet should have any rough places
smoothed with fine emery cloth and its blades carefully inspected; the
parts are then oiled and reassembled. Nickle plating on the tubes is
apt to peel and these scales have sharp, cutting edges which may
injure the mucosa. All tubes, therefore, should be unplated. Rough
places on the tubes should be smoothed with the finest emery cloth,
or, better, on a buffing wheel. The dry cells in the battery should be
renewed about every 4 months whether used or not. Lamps, light
carriers, and cords, after cleansing, are wiped with 95 per cent
alcohol, and the light-carriers with the lamps in place are kept in a
continuous sterilization box containing formaldehyde pastilles. It is
of the utmost importance that instruments be always put away in
perfect order. Not only are cleaning and oiling imperative, but any
needed repairs should be attended to at once. Otherwise it will be
inevitable that when gotten out in an emergency they will fail. In
general surgery, a spoon will serve for a retractor and good work can
be done with makeshifts; but in endoscopy, especially in the small,
delicate, natural passages of children, the handicap of a defective or
insufficient armamentarium may make all the difference between a
success and a fatal failure.
A bronchoscopic clinic should at all times be in the same state of
preparedness for emergency as is everywhere required of a fire-engine
house.
[PLATE I--A WORKING SET OF THE AUTHOR'S ENDOSCOPIC TUBES FOR LARYNGOSCOPY,
BRONCHOSCOPY, ESOPHAGOSCOPY, AND GASTROSCOPY:
A, Adult's laryngoscope; B, child's laryngoscope; C, anterior
commissure laryngoscope; D, esophageal speculum, child's size; E,
esophageal speculum, adult's size; F, bronchoscope, infant's size, 4
mm. X 30 cm.; G, bronchoscope, child's size, 5 mm. X 30 cm.; H,
aspirating bronchoscope for adults, 7 mm. X 40 cm.; I, bronchoscope,
adolescent's size, 7 mm. x 40 cm., used also for the deeper bronchi of
adults; J, bronchoscope, adult size, g mm. x 40 cm.; K, child's size
esophagoscope, 7 mm. X 45 cm.; L, adult's size esophagoscope, full
lumen construction, 9 mm. x 45 cm.; M, adult's size gastroscope. C,
I, and E are also hypopharyngoscopes. C is an excellent esophageal
speculum for children, and a longer model is made for adults.
If the utmost economy must be practised D, E, and M may be omitted.
The balance of the instruments are indispensable if adults and
children are to be dealt with. The instruments are made by Charles J.
Pilling & Sons, Philadelphia.]
[52] CHAPTER II--ANATOMY OF LARYNX, TRACHEA, BRONCHI AND ESOPHAGUS,
ENDOSCOPICALLY CONSIDERED
The _larynx_ is a cartilaginous box, triangular in cross-section, with
the apex of the triangle directed anteriorly. It is readily felt in
the neck and is a landmark for the operation of tracheotomy. We are
concerned endoscopically with four of its cartilaginous structures:
the epiglottis, the two arytenoid cartilages, and the cricoid
cartilage. The _epiglottis_, the first landmark in direct
laryngoscopy, is a leaf-like projection springing from the
anterointernal surface of the larynx and having for its function the
directing of the bolus of food into the pyriform sinuses. It does not
close the larynx in the trap-door manner formerly taught; a fact
easily demonstrated by the simple insertion of the direct laryngoscope
and further demonstrated by the absence of dysphagia when the
epiglottis is surgically removed, or is destroyed by ulceration.
Closure of the larynx is accomplished by the approximation of the
ventricular bands, arytenoids and aryepiglottic folds, the latter
having a sphincter-like action, and by the raising and tilting of the
larynx. The _arytenoids_ form the upper posterior boundary of the
larynx and our particular interest in them is directed toward their
motility, for the rotation of the arytenoids at the cricoarytenoid
articulations determines the movements of the cords and the production
of voice. Approximation of the arytenoids is a part of the mechanism
of closure of the larynx.
The _cricoid cartilage_ was regarded by esophagoscopists as the chief
obstruction encountered on the introduction of the esophagoscope. As
shown by the author, it is the cricopharyngeal fold, and the
inconceivably powerful pull of the cricopharyngeal muscle on the
cricoid cartilage, that causes the difficulty. The cricoid is pulled
so powerfully back against the cervical spine, that it is hard to
believe that this muscles is inserted into the median raphe and not
into the spine itself (Fig. 68).
The _ventricular bands_ or false vocal cords vicariously phonate in
the absence of the true cords, and assist in the protective function
of the larynx. They form the floor of the _ventricles_ of the larynx,
which are recesses on either side, between the false and true cords,
and contain numerous mucous glands the secretion from which lubricates
the cords. The ventricles are not visible by mirror laryngoscopy, but
are readily exposed in their depths by lifting the respective
ventricular bands with the tip of the laryngoscope. The _vocal cords_,
which appear white, flat, and ribbon-like in the mirror, when viewed
directly assume a reddish color, and reveal their true shelf-like
formation. In the subglottic area the tissues are vascular, and, in
children especially, they are prone to swell when traumatized, a fact
which should be always in mind to emphasize the importance of
gentleness in bronchoscopy, and furthermore, the necessity of avoiding
this region in tracheotomy because of the danger of producing chronic
laryngeal stenosis by the reaction of these tissues to the presence of
the tracheotomic cannula.
The _trachea_ just below its entrance into the thorax deviates
slightly to the right, to allow room for the aorta. At the level of
the second costal cartilage, the third in children, it bifurcates into
the right and left main bronchi. Posteriorly the bifurcation
corresponds to about the fourth or fifth thoracic vertebra, the
trachea being elastic, and displaced by various movements. The
endoscopic appearance of the trachea is that of a tube flattened on
its posterior wall. In two locations it normally often assumes a more
or less oval outline; in the cervical region, due to pressure of the
thyroid gland; and in the intrathoracic portion just above the
bifurcation where it is crossed by the aorta. This latter flattening
is rhythmically increased with each pulsation. Under pathological
conditions, the tracheal outline may be variously altered, even to
obliteration of the lumen. The mucosa of the trachea and bronchi is
moist and glistening, whitish in circular ridges corresponding to the
cartilaginous rings, and reddish in the intervening grooves.
The right bronchus is shorter, wider, and more nearly vertical than
its fellow of the opposite side, and is practically the continuation
of the trachea, while the left bronchus might be considered as a
branch. The deviation of the right main bronchus is about 25 degrees,
and its length unbranched in the adult is about 2.5 cm. The deviation
of the left main bronchus is about 75 degrees and its adult length is
about 5 cm. The right bronchus considered as a stem, may be said to
give off three branches, the epiarterial, upper- or superior-lobe
bronchus; the middle-lobe bronchus; and the continuation downward,
called the lower- or inferior-lobe bronchus, which gives off dorsal,
ventral and lateral branches. The left main bronchus gives off first
the upper-or superior-lobe bronchus, the continuation being the
lower-or inferior-lobe bronchus, consisting of a stem with dorsal,
ventral and lateral branches.
[FIG. 44.--Tracheo-bronchial tree. LM, Left main bronchus; SL,
superior lobe bronchus; ML, middle lobe bronchus; IL, inferior lobe
bronchus.]
The septum between the right and left main bronchi, termed the carina,
is situated to the left of the midtracheal line. It is recognized
endoscopically as a short, shining ridge running sagitally, or, as the
patient lies in the recumbent position, we speak of it as being
vertical. On either side are seen the openings of the right and left
main bronchi. In Fig. 44, it will be seen that the lower border of the
carina is on a level with the upper portion of the orifice of the
right superior-lobe bronchus; with the carina as a landmark and by
displacing with the bronchoscope the lateral wall of the right main
bronchus, a second, smaller, vertical spur appears, and a view of the
orifice of the right upper-lobe bronchus is obtained, though a lumen
image cannot be presented. On passing down the right stem bronchus
(patient recumbent) a horizontal partition or spur is found with the
lumen of the middle-lobe bronchus extending toward the ventral surface
of the body. All below this opening of the right middle-lobe bronchus
constitutes the lower-lobe bronchus and its branches.
[FIG. 45.--Bronchoscopic views.
S; Superior lobe bronchus; SL, superior lobe bronchus; I, inferior
lobe bronchus; M, middle lobe bronchus.]
[56] Coming back to the carina and passing down the left bronchus, the
relatively great distance from the carina to the upper-lobe bronchus
is noted. The spur dividing the orifices of the left upper- and
lower-lobe bronchi is oblique in direction, and it is possible to see
more of the lumen of the left upper-lobe bronchus than of its
homologue on the right. Below this are seen the lower-lobe bronchus
and its divisions (Fig. 45).
_Dimensions of the Trachea and Bronchi_.--It will be noted that the
bronchi divide monopodially, not dichotomously. While the lumina of
the individual bronchi diminish as the bronchi divide, the sum of the
areas shows a progressive increase in total tubular area of
cross-section. Thus, the sum of the areas of cross-section of the two
main bronchi, right and left, is greater than the area of cross
section of the trachea. This follows the well known dynamic law. The
relative increase in surface as the tubes branch and diminish in size
increases the friction of the passing air, so that an actual increase
in area of cross section is necessary, to avoid increasing resistance
to the passage of air.
The cadaveric dimensions of the tracheobronchial tree may be
epitomized approximately as follows:
Adult
Male Female Child Infant
Diameter trachea, 14 X 20 12 X 16 8 X 10 6 X 7
Length trachea, cm. 12.0 10.0 6.0 4.0
Length right bronchus 2.5 2.5 2.0 1.5
Length left bronchus 5.0 5.0 3.0 2.5
Length upper teeth to trachea 15.0 23.0 10.0 9.0
Length total to secondary bronchus 32.0 28.0 19.0 15.0
In considering the foregoing table it is to be remembered that in life
muscle tonus varies the lumen and on the whole renders it smaller. In
the selection of tubes it must be remembered that the full diameter of
the trachea is not available on account of the glottic aperture which
in the adult is a triangle measuring approximately 12 X 22 X 22 mm.
and permitting the passage of a tube not over 10 mm. in diameter
without risk of injury. Furthermore a tube which filled the trachea
would be too large to enter either main bronchus.
The normal movements of the trachea and bronchi are respiratory,
pulsatory, bechic, and deglutitory. The two former are rhythmic while
the two latter are intermittently noted during bronchoscopy. It is
readily observed that the bronchi elongate and expand during
inspiration while during expiration they shorten and contract. The
bronchoscopist must learn to work in spite of the fact that the
bronchi dilate, contract, elongate, shorten, kink, and are dinged and
pushed this way and that. It is this resiliency and movability that
make bronchoscopy possible. The inspiratory enlargement of lumen opens
up the forceps spaces, and the facile bronchoscopist avails himself of
the opportunity to seize the foreign body.
THE ESOPHAGUS
A few of the anatomical details must be kept especially in mind when
it is desired to introduce straight and rigid instruments down the
lumen of the gullet. First and most important is the fact that the
esophageal walls are exceedingly thin and delicate and require the
most careful manipulation. Because of this delicacy of the walls and
because the esophagus, being a constant passageway for bacteria from
the mouth to the stomach, is never sterile, surgical procedures are
associated with infective risks. For some other and not fully
understood reason, the esophagus is, surgically speaking, one of the
most intolerant of all human viscera. The anterior wall of the
esophagus is in a part of its course, in close relation to the
posterior wall of the trachea, and this portion is called the party
wall. It is this party wall that contains the lymph drainage system of
the posterior portion of the larynx, and it is largely by this route
that posteriorly located malignant laryngeal neoplasms early
metastasize to the mediastinum.
[58] [FIG 46.--Esophagoscopic and Gastroscopic Chart
BIRTH 1 yr. 3 yrs. 6 yrs. 10 yrs. 14 yrs.ADULTS
23 27 30 33 36 43 53 Cm. GREATER CURVATURE
18 20 22 25 27 34 40 Cm. CARDIA
19 21 23 24 25 31 36 Cm. HIATUS
13 15 16 18 20 24 27 Cm. LEFT BRONCHUS
12 14 15 16 17 21 23 Cm. AORTA
7 9 10 11 12 14 16 Cm. CRICOPHARYINGEUS
0 0 0 0 0 0 0 Cm. INCISORS
FIG. 46.--The author's esophagoscopic chart of approximate distances
of the esophageal narrowings from the upper incisor teeth, arranged
for convenient reference during esophagoscopy in the dorsally
recumbent patient.]
The lengths of the esophagus at different ages are shown
diagrammatically in Fig. 46. The diameter of the esophageal lumen
varies greatly with the elasticity of the esophageal walls; its
diameter at the four points of anatomical constriction is shown in the
following table:
Constriction Diameter Vertebra
Cricopharyngeal Transverse 23 mm. (1 in.) Sixth cervical
Antero-posterior 17 mm. (3/4 in.)
Aortic Transverse 24 mm. (1 in.) Fourth thoracic
Antero-posterior 19 mm. (3/4 in.)
Left-bronchial Transverse 23 mm. (1 in.) Fifth thoracic
Antero-posterior 17 mm. (3/4 in.)
Diaphragmatic Transverse 23 mm. (1 in+) Tenth thoracic
Antero-posterior 23 mm. (in.--)
For practical endoscopic purposes it is only necessary to remember
that in a normal esophagus, straight and rigid tubes of 7 mm. diameter
should pass freely in infants, and in adults, tubes of 10 mm.
The 4 demonstrable constrictions from above downward are at
1. The crico-pharyngeal fold.
2. The crossing of the aorta.
3. The crossing of the left bronchus.
4. The hiatus esophageus.
There is a definite fifth narrowing of the esophageal lumen not easily
demonstrated esophagoscopically and not seen during dissection, but
readily shown functionally by the fact that almost all foreign bodies
lodge at this point. This narrowing occurs at the superior aperture of
the thorax and is probably produced by the crowding of the numerous
organs which enter or leave the thorax through this orifice.
_The crico-pharyngeal constriction_, as already mentioned, is produced
by the tonic contraction of a specialized band of the orbicular fibers
of the lowermost portion of the inferior pharyngeal constrictor
muscle, called the cricopharyngeal muscle. As shown by the author it
is this muscle and not the cricoid cartilage alone that causes the
difficulty in the insertion of an esophagoscope.
This muscle is attached laterally to the edges of the signet of the
cricoid which it pulls with an incomprehensible power against the
posterior wall of the hypopharynx, thus closing the mouth of the
esophagus. Its other attachment is in the median posterior raphe.
Between these circular fibers (the cricopharyngeal muscle) and the
oblique fibers of the inferior constrictor muscle there is a weakly
supported point through which the esophageal wall may herniate to form
the so-called pulsion diverticulum. It is at this weak point that
fatal esophagoscopic perforation by inexperienced operators is most
likely to occur.
_The aortic narrowing_ of the esophagus may not be noticed at all if
the patient is placed in the proper sequential "high-low" position. It
is only when the tube-mouth is directed against the left anterior wall
that the actively pulsating aorta is felt.
The bronchial narrowing of the esophagus is due to backward
displacement caused by the passage of the left bronchus over the
anterior wall of the esophagus at about 27 cm. from the upper teeth in
the adult. The ridge is quite prominent in some patients, especially
those with dilatation from stenoses lower down.
The hiatal narrowing is both anatomic and spasmodic. The peculiar
arrangement of the tendinous and muscular structure of the diaphragm
acts on this hiatal opening in a sphincter-like fashion. There are
also special bundles of muscle fibers extending from the crura of the
diaphragm and surrounding the esophagus, which contribute to tonic
closure in the same way that a pinch-cock closes a rubber tube. The
author has called the hiatal closure the "diaphragmatic pinchcock."
_Direction of the Esophagus_.--The esophagus enters the chest in a
decidedly backward as well as downward direction, parallel to that of
the trachea, following the curves of the cervical and upper dorsal
spine. Below the left bronchus the esophagus turns forward, passing
through the hiatus in the diaphragm anterior to and to the left of the
aorta. The lower third of the esophagus in addition to its anterior
curvature turns strongly to the left, so that an esophagoscope
inserted from the right angle of the mouth, when introduced into the
stomach, points in the direction of the anterior superior spine of the
left ileum.
It is necessary to keep this general course constantly in mind in all
cases of esophagoscopy, but particularly in those cases in which there
is marked dilatation of the esophagus following spasm at the diaphragm
level. In such cases the aid of this knowledge of direction will
greatly simplify the finding of the hiatus esophageus in the floor of
the dilatation.
The extrinsic or transmitted movements of the esophagus are
respiratory and pulsatory, and to a slight extent, bechic. The
respiratory movements consist in a dilatation or opening up of the
thoracic esophageal lumen during inspiration, due to the negative
intrathoracic pressure. The normal pulsatory movements are due to the
pulsatile pressure of the aorta, found at the 4th thoracic vertebra
(24 cm. from the upper teeth in the adult), and of the heart itself,
most markedly felt at the level of the 7th and 8th thoracic vertebrae
(about 30 cm. from the upper teeth in adults). As the distances of all
the narrowings vary with age, it is useful to frame and hang up for
reference a copy of the chart (Fig. 46).
The intrinsic movements of the esophagus are involuntary muscular
contractions, as in deglutition and regurgitation; spasmodic, the
latter usually having some pathologic cause; and tonic, as the normal
hiatal closure, in the author's opinion may be considered. Swallowing
may be involuntary or voluntary. The constrictors are anatomically not
considered part of esophagus proper. When the constrictors voluntarily
deliver the bolus past the cricopharyngeal fold, the involuntary or
peristaltic contractions of the esophageal mural musculature carry the
bolus on downward. There is no sphincter at the cardiac end of the
esophagus. The site of spasmodic stenosis in the lower third, the
so-called cardiospasm, was first demonstrated by the author to be
located at the hiatus esophageus and the spasmodic contractions are of
the specialized muscle fibers there encircling the esophagus, and
might be termed "phrenospasm," or "hiatal esophagismus." Regurgitation
of food from the stomach is normally prevented by the hiatal muscular
diaphragmatic closure (called by the author the "diaphragmatic
pinchcock") plus the kinking of the abdominal esophagus.
In the author's opinion there is no spasm in the disease called
"cardiospasm." It is simply the failure of the diaphragmatic pinchcock
to open normally in the deglutitory cycle. A better name is functional
hiatal stenosis.
At retrograde esophagoscopy the cardia and abdominal esophagus do not
seem to exist. The top of the stomach seems to be closed by the
diaphragmatic pinchcock in the same way that the top of a bag is
closed by a puckering string.
[63] CHAPTER III--PREPARATION OF THE PATIENT FOR PERORAL ENDOSCOPY
The suggestions of the author in the earlier volumes in regard to
preparation of the patient, as for any operation, by a bath, laxative,
etc., and especially by special cleansing of the mouth with 25 per
cent alcohol, have received general endorsement. Care should be taken
not to set up undue reaction by vigorous scrubbing of gums
unaccustomed to it. Artificial dentures should be removed. Even if no
anesthetic is to be used, the patient should be fasted for five hours
if possible, even for direct laryngoscopy in order to forestall
vomiting. Except in emergency cases every patient should be gone over
by an internist for organic disease in any form. If an endolaryngeal
operation is needed by a nephritic, preparatory treatment may prevent
laryngeal edema or other complications. Hemophilia should be thought
of. It is quite common for the first symptom of an aortic aneurysm to
be an impaired power to swallow, or the lodgment of a bolus of meat or
other foreign body. If aneurysm is present and esophagoscopy is
necessary, as it always is in foreign body cases, "to be fore-warned
is to be forearmed." Pulmonary tuberculosis is often unsuspected in
very young children. There is great danger from tracheal pressure by
an esophageal diverticulum or dilatation distended with food; or the
food maybe regurgitated and aspirated into the larynx and trachea.
Therefore, in all esophageal cases the esophagus should be emptied by
regurgitation induced by titillating the fauces with the finger after
swallowing a tumblerful of water, pressure on the neck, etc. Aspiration
will succeed in some cases. In others it is absolutely necessary to
remove food with the esophagoscope. If the aspirating tube becomes
clogged by solid food, the method of swab aspiration mentioned under
bronchoscopy will succeed. Of course there is usually no cough to aid,
but the involuntary abdominal and thoracic compression helps. Should a
patient arrive in a serious state of water-hunger, as part of the
preparation the patient must be given water by hypodermoclysis and
enteroclysis, and if necessary the endoscopy, except in dyspneic
cases, must be delayed until the danger of water-starvation is past.
As pointed out by Ellen J. Patterson the size of the thymus gland
should be studied before an esophagoscopy is done on a child.
Every patient should be examined by indirect, mirror laryngoscopy as a
preliminary to peroral endoscopy for any purpose whatsoever. This
becomes doubly necessary in cases that are to be anesthetized.
[65] CHAPTER IV--ANESTHESIA FOR PERORAL ENDOSCOPY
A dyspneic patient should never be given a general anesthetic. Cocaine
should not be used on children under ten years of age because of its
extreme toxicity. To these two postulates always in mind, a third one,
applicable to both general and local anesthesia, is to be added--total
abolition of the cough-reflex should be for short periods only.
General anesthesia is never used in the Bronchoscopic Clinic for
endoscopic procedures. The choice for each operator must, however, be
a matter for individual decision, and will depend upon the personal
equation, and degree of skill of the operator, and his ability to
quiet the apprehensions of the patient. In other words, the operator
must decide what is best for his particular patient under the
conditions then existing.
_Children_ in the Bronchoscopic Clinic receive neither local nor
general anesthesia, nor sedative, for laryngoscopic operations or
esophagoscopy. Bronchoscopy in the older children when no dyspnea is
present has in recent years, at the suggestion of Prof. Hare, been
preceded by a full dose of morphin sulphate (i.e., 1/8 grain for a
child of six years) or a full physiologic dose of sodium bromide. The
apprehension is thus somewhat allayed and the excessive cough-reflex
quieted. The morphine should be given not less than an hour and a half
before bronchoscopy to allow time for the onset of the soporific and
antispasmodic effects which are the desiderata, not the analgesic
effects. Dosage is more dependent on temperament than on age or body
weight. Atropine is advantageously added to morphine in bronchoscopy
for foreign bodies, not only for the usual reasons but for its effect
as an antispasmodic, and especially for its diminution of
endobronchial secretions. True, it does not diminish pus, but by
diminishing the outpouring of normal secretions that dilute the pus
the total quantity of fluid encountered is less than it otherwise
would be. In cases of large quantities of pus, as in pulmonary abscess
and bronchiectasis, however, no diminution is noticeable. No food or
water is allowed for 5 hours prior to any endoscopic procedure,
whether sedatives or anesthetics are to be given or not. If the
stomach is not empty vomiting from contact of the tube in the pharynx
will interfere with work.
With _adults_ no anesthesia, general or local, is given for
esophagoscopy. For laryngeal operation and bronchoscopy the following
technic is used:
One hour before operation the patient is given hypodermatically a full
physiologic dose of morphin sulphate (from 1/4, to 3/8 gr.) guarded
with atropin sulphate (gr. 1/150). Care must be taken that the
injection be not given into a vein. On the operating table the
epiglottis and pharynx are painted with 10 per cent solution of
cocain. Two applications are usually sufficient completely to
anesthetize the exterior and interior of the larynx by blocking of the
superior laryngeal nerve without any endolaryngeal applications. The
laryngoscope is now introduced and if found necessary a 20 per cent
cocain solution is applied to the interior of the larynx and
subglottic region, by means of gauze swabs fastened to the sponge
carriers. Here also two applications are quite sufficient to produce
complete anesthesia in the larynx. If bronchoscopy is to be done the
gauze swab is carried down through the exposed glottis to the carina,
thus anesthetizing the tracheal mucosa. If further anesthetization of
the bronchial mucosa is required, cocain may be applied in the same
manner through the bronchoscope. In all these local applications
prolonged contact of the swab is much more efficient than simply
painting the surface.
[67] In cases in which cocain is deemed contraindicated morphin alone
is used. If given in sufficient dosage cocain can be altogether
dispensed with in any case.
It is perhaps _safer for the beginner_ in his early cases of
esophagoscopy to have the patient relaxed by an ether anesthesia,
provided the patient is not dyspneic to begin with, or made so by
faulty position or by pressure of the esophagoscopic tube mouth on the
tracheoesophageal "party wall." As proficiency develops, however, he
will find anesthesia unnecessary. Local anesthesia is needless for
esophagoscopy, and if used at all should be limited to the
laryngopharynx and never applied to the esophagus, for the esophagus
is without sensation, as anyone may observe in drinking hot liquids.
_Direct laryngoscopy in children_ requires neither local nor general
anesthesia, either for diagnosis or for removal of foreign bodies or
growths from the larynx. General anesthesia is contraindicated because
of the dyspnea apt to be present, and because the struggles of the
patient might cause a dislodgment of the laryngeal intruder and
aspiration to a lower level. The latter accident is also prone to
follow attempts to cocainize the larynx.
_Technic for General Anesthesia_.--For esophagoscopy and gastroscopy,
if general anesthesia is desired, ether may be started by the usual
method and continued by dropping upon folded gauze laid over the mouth
after the tube is introduced. Endo-tracheal administration of ether
is, however, far safer than peroral administration, for it overcomes
the danger of respiratory arrest from pressure of the esophagoscope,
foreign body, or both, on the trachea. Chloroform should not be used
for esophagoscopy or gastroscopy because of its depressant action on
the respiratory center.
For bronchoscopy, ether or chloroform may be started in the usual way
and continued by insufflating through the branch tube of the
bronchoscope by means of the apparatus shown in Fig. 13.
In case of paralysis of the larynx, even if only monolateral, a
general anesthetic if needed should be given by intratracheal
insufflation. If the apparatus for this is not available the patient
should be tracheotomized. Hence, every adult patient should be
examined with a throat mirror before general anesthesia for any
purpose, and the necessity becomes doubly imperative before goiter
operations. A number of fatalities have occurred from neglect of this
precaution.
_Anesthetizing a tracheotomized patient_ is free from danger so long
as
the cannula is kept free from secretion. Ether is dropped on gauze
laid over the tracheotomic cannula and the anesthesia watched in the
usual manner. If the laryngeal stenosis is not complete,
ether-saturated gauze is to be placed over the mouth as well as over
the tracheotomy tube.
_Endo-tracheal anesthesia_ is by far the safest way for the
administration of ether for any purpose. By means of the silk-woven
catheter introduced into the trachea, ether-laden air from an
insufflation apparatus is piped down to the lungs continuously, and
the strong return-flow prevents blood and secretions from entering the
lower air-passages. The catheter should be of a size, relative to that
of the glottic chink, to permit a free return-flow. A number 24 French
is readily accommodated by the adult larynx and lies well out of the
way along the posterior wall of the larynx. Because of the little room
occupied by the insufflation catheter this method affords ideal
anesthesia for external laryngeal operations. Operations on the nose,
accessory sinuses and the pharynx, apt to be attended by considerable
bleeding, are rendered free from the danger of aspiration pneumonia by
endotracheal anesthesia. It is the safest anesthesia for goiter
operations. Endo-tracheal anesthesia has rendered needless the
intricate negative pressure chamber formerly required for thoracic
surgery, for by proper regulation of the pressure under which the
ether ladened air is delivered, a lung may be held in any desired
degree of expansion when the pleural cavity is opened. It is indicated
in operations of the head, neck, or thorax, in which there is danger
of respiratory arrest by centric inhibition or peripheral pressure; in
operations in which there is a possibility of excessive bleeding and
aspiration of blood or secretions; and in operations where it is
desired to keep the anesthetist away from the operating field. Various
forms of apparatus for the delivery of the ether-laden vapor are
supplied by instrument makers with explicit directions as to their
mechanical management.
We are concerned here mainly with the technic of the insertion of the
intratracheal tube. The larynx should be examined with the mirror,
preferably before the day of operation, for evidence of disease, and
incidentally to determine the size of the catheter to be introduced,
though the latter can be determined after the larynx is
laryngoscopically exposed. The following list of rules for the
introduction of the catheter will be of service (see Fig. 59).
RULES FOR INSERTION OF THE CATHETER FOR INSUFFLATION
ANESTHESIA
1. The patient should be fully under the anesthetic by the open
method so as to get full relaxation of the muscles of the neck.
2. The patient's head must be in full extension with the vertex
firmly pushed down toward the feet of the patient, so as to throw the
neck upward and bring the occiput down as close as possible beneath
the cervical vertebrae.
3. No gag should be used, because the patient should be sufficiently
anesthetized not to need a gag, and because wide gagging defeats the
exposure of the larynx by jamming down the mandible.
4. The epiglottis must be identified before it is passed.
5. The speculum must pass sufficiently far below the tip of the
epiglottis so that the latter will not slip.
6. Too deep insertion must be avoided, as in this case the speculum
goes posterior to the cricoid, and the cricoid is lifted, exposing the
mouth of the esophagus, which is bewildering until sufficient
education of the eye enables the operator to recognize the landmarks.
7. The patient's head is lifted off the table by the spatular tip of
the laryngoscope. Actual lifting of the head will not be necessary if
the patient is fully relaxed; but the idea of lifting conveys the
proper conception of laryngeal exposure (Fig. 55).
[71] CHAPTER V--BRONCHOSCOPIC OXYGEN INSUFFLATION
Bronchoscopic oxygen insufflation is a life-saving measure equalled by
no other method known to the science of medicine, in all cases of
asphyxia, or apnea, present or impending. Its especial sphere of
usefulness is in severe cases of electric shock, hanging, smoke
asphyxia, strangulation, suffocation, thoracic or abdominal pressure,
apnea, acute traumatic pneumothorax, respiratory arrest from absence
of sufficient oxygen, or apnea from the presence of quantities of
irrespirable or irritant gases. Combined with bronchoscopic aspiration
of secretions it is the best method of treatment for poisoning by
chlorine gas, asphyxiating, and other war gases.
Bronchoscopic oxygen insufflation should be taught to every interne in
every hospital. The emergency or accident ward of every hospital
should have the necessary equipment and an interne familiar with its
use. The method is simple, once the knack is acquired. The patient
being limp and recumbent on a table, the larynx is exposed with the
laryngoscope, and the bronchoscope is inserted as hereinafter
described. The oxygen is turned on at the tank and the flow regulated
before the rubber tube from the wash-bottle of tank is attached to the
side-outlet of the bronchoscope. It is necessary to be certain that
the flow is gentle, so that, with a free return flow the introduced
pressure does not exceed the capillary pressure; otherwise the blood
will be forced out of the capillaries and the ischemia of the lungs
will be fatal. Another danger is that overdistension causes inhibition
of inspiration resulting in apnea continuing as long as the distension
is maintained, if not longer. The return flow from the bronchoscope
should be interrupted for 2 or 3 seconds several times a minute to
inflate the lungs, but the flow must not be occluded longer than 3
seconds, because the intrapulmonary pressure would rise. A pearl of
amyl nitrite may be broken in the wash bottle. Slow rhythmic
artificial respiratory movements are a useful adjunct, and unless the
operator is very skillful in gauging the alternate pressures and
releases with the thumb according to the oxygen pressure, it is
vitally necessary to fill and deflate the lungs rhythmically by one of
the well known methods of artificial respiration. Anyone skilled in
the introduction of the bronchoscope can do bronchoscopy in a few
seconds, and it is especially easy in cases of respiratory arrest,
because of the limp condition of the patient.
The foregoing applies to cases in which a pulmotor would be used, such
as apnea from electric shocks, etc. For obstructive dyspnea and
asphyxia, tracheotomy is the procedure of choice, and the skillful
tracheotomist would be justified in preferring tracheotomy for the
other class of cases, insufflating the oxygen and amyl nitrite through
the tracheotomic wound. The pulmotor and similar mechanisms are,
perhaps, the best things the use of which can be taught to laymen; but
as compared to bronchoscopic oxygen insufflation they are woefully
inefficient, because the intraoral pressure forces the tongue back
over the laryngeal orifice, obstructing the airway in this "death
zone." By the introduction of the bronchoscope this death zone is
entirely eliminated, and a free airway established for piping the
oxygen directly into the lungs.
[73] CHAPTER VI--POSITION OF THE PATIENT FOR PERORAL ENDOSCOPY
It is the author's invariable practice to place the patient in the
dorsally recumbent position. The sitting position is less favorable.
While lying on a well-padded, flat table the patient is readily
controlled, the head is freely movable, secretions can be easily
removed, the view obtained by the endoscopist is truly direct (without
reversal of sides), and, most important, the employment of one
position only favors smoother and more efficient team work, and a
better endoscopic technic.
_General Principles of Position_.--As will be seen in Fig. 47 the
trachea and esophagus are not horizontal in the thorax, but their long
axes follow the curves of the cervical and dorsal spine. Therefore, if
we are to bring the buccal cavity and pharynx in a straight line with
the trachea and esophagus it will be found necessary to elevate the
whole head above the plane of the table, and at the same time make
extension at the occipito-atloid joint. By this maneuver the cervical
spine is brought in line with the upper portion of the dorsal spine as
shown in Fig. 55. It was formerly taught, and often in spite of my
better knowledge I am still unconsciously prone to allow the head and
cervical spine to assume a lower position than the plane of the table,
the so-called Rose position. With the head so placed, it is impossible
to enter the lower air or food passages with a rigid tube, as will be
shown by a study of the radiograph shown in Fig. 49. Extension of the
head on the occipito-atloid joint is for the purpose of freeing the
tube from the teeth, and the amount required will vary with the degree
to which the mouth can be opened. Whether the head be extended,
flexed, or kept mid-way, the fundamental principle in the introduction
of all endoscopic tubes is the anterior placing of the cervical spine
and the high elevation of the head. The esophagus, just behind the
heart, turns ventrally and to the left. In order to pass a rigid tube
through this ventral curve the dorsal spine is now extended by
lowering the head and shoulders below the plane of the table. This
will be further explained in the chapter on esophagoscopy. In all of
these procedures, the nose of the patient should be directed toward
the zenith, and the assistant should _prevent rotation of the head_ as
well as _prevent lowering of the head_. The patient should be urged as
follows:
"Don't hold yourself so rigid."
"Let your head and neck go loose."
"Let your head rest in my hand."
"Don't try to hold it."
"Let me hold it."
"Relax."
"Don't raise your chest."
[FIG. 47.--Schematic illustration of normal position of the
intra-thoracic trachea and esophagus and also of the entire trachea
when the patient is in the correct position for peroral bronchoscopy.
When the head is thrown backward (as in the Rose position) the
anterior convexity of the cervical spine is transmitted to the trachea
and esophagus and their axes deviated. The anterior deviation of the
lower third of the esophagus shows the anatomical basis for the "high
low" position for esophagoscopy]
[FIG. 48.--Correct position of the cervical spine for esophagoscopy
and
bronchoscopy. (_Illustration reproduced from author's article Jour.
Am. Med. Assoc., Sept. 25, 1909_)]
[FIG. 49.--Curved position of the cervical spine, with anterior
convexity, in the Rose position, rendering esophagoscopy and
bronchoscopy difficult or impossible. The devious course of the
pharynx, larynx and trachea are plainly visible. The extension is
incorrectly imparted to the whole cervical spine instead of only to
the occipito-atloid joint. This is the usual and very faulty
conception of the extended position. (_Illustration reproduced from
author's article, Jour. Am. Med. Assoc., Sept. 25, 1909._)]
[76] For _direct laryngoscopy_ the patient's head is raised above the
plane of the table by the first assistant, who stands to the right of
the patient, holding the bite block on his right thumb inserted in the
left corner of the patient's mouth, while his extended right hand lies
along the left side of the patient's cheek and head, and prevents
rotation. His left hand, placed under the patient's occiput, elevates
the head and maintains the desired degree of extension at the
occipito-atloid joint (Fig. 50).
[FIG 50.--Direct laryngoscopy, recumbent patient. The second assistant
is sitting holding the head in the Boyce position, his left forearm on
his left thigh his left foot on a stool whose top is 65 cm. lower than
the table-top. His left hand is on the patient's sterile-covered
scalp, the thumb on the forehead, the fingers under the occiput,
making forced extension. The right forearm passes under the neck of
the patient, so that the index finger of the right hand holds the
bite-block in the left corner of the patient's mouth. The fingers of
the operator's right hand pulls the upper lip out of all danger of
getting pinched between the teeth and the laryngoscope. This is a
precaution of the utmost importance and the trained habit of doing it
must be developed by the peroral endoscopist.]
_Position for Bronchoscopy and Esophagoscopy_.--The dorsally recumbent
patient is so placed that the head and shoulders extend beyond the
table, the edge of which supports the thorax at about the level of the
scapulae. During introduction, the head must be maintained in the same
relative position to the table as that described for direct
laryngoscopy, that is, elevated and extended. The first assistant, in
this case, sits on a stool to the right of the patient's head, his
left foot resting on a box about 14 inches in height, the left knee
supporting the assistant's left hand, which being placed under the
occiput of the patient maintains elevation and extension. The right
arm of the assistant passes under the neck of the patient, the bite
block being carried on the middle finger of the right hand and
inserted into the left side of the patient's mouth. The right hand
also prevents rotation of the head (Fig. 51). As the bronchoscope or
esophagoscope is further inserted, the head must be placed so that the
tube corresponds to the axis of the lumen of the passage to be
examined. If the left bronchus is being explored, the head must be
brought strongly to the right. If the right middle lobe bronchus is
being searched, the head would require some left lateral deflection
and a considerable degree of lowering, for this bronchus, as before
mentioned, extends anteriorly. During esophagoscopy when the level of
the heart is reached, the head and upper thorax must be strongly
depressed below the plane of the table in order to follow the axis of
the lumen of the ventrally turning esophagus; at the same time the
head must be brought somewhat to the right, since the esophagus in
this region deviates strongly to the left.
[FIG. 51.--Position of patient and assistant for introduction of the
bronchoscope and esophagoscope. The middle of the scapulae rest on the
edge of the table; the head and shoulders, free to move, are supported
by the assistant, whose right arm passes under the neck; the right
middle finger inserts the bite block into the left side of the mouth.
The left hand, resting on the left knee maintains the desired degree
of elevation, extension and lateral deflection required by the
operator. The patient's vertex should be 10 cm. higher than the level
of the top of the table. This is the Boyce position, which has never
been improved upon for bronchoscopy and esophagoscopy.]
[FIG. 52.--Schema of position for endoscopy.
A. Normal recumbency on the table with pillow supporting the head.
The larynx can be directly examined in this position, but a better
position is obtainable.
B. Head is raised to proper position with head flexed. Muscles of
front of neck are relaxed and exposure of larynx thus rendered easier;
but, for most endoscopic work, a certain amount of extension is
desired. The elevation is the important thing.
C. The neck being maintained in position B, the desired amount of
extension of the head is obtained by a movement limited to the
occipito-atloid articulation by the assistant's hand placed as shown
by the dart (B).
D. Faulty position. Unless prevented, almost all patients will heave
up the chest and arch the lumbar spine so as to defeat the object and
to render endoscopy difficult by bringing the chest up to the
high-held head, thus assuming the same relation of the head to the
chest as exists in the Rose position (a faulty one for endoscopy) as
will be understood by assuming that the dotted line, E, represents the
table. If the pelvis be not held down to the table the patient may
even assume the opisthotonous position by supporting his weight on his
heels on the table and his head on the assistant's hand.]
In obtaining the position of high head with occipito-atloid extension,
the easiest and most certain method, as pointed out to me by my
assistant, Gabriel Tucker, is first to raise the head, strongly
flexed, as shown in Fig. 52; then while maintaining it
there, make the occipito-atloid extension. This has proven better
than to elevate and extend in a combined simultaneous movement.
If the patient would relax to limpness exposure of the larynx would be
easily obtained, simply by lifting the head with the lip of the
laryngoscope passed below the tip of the epiglottis (as in Fig. 55)
and no holding of the head would be necessary. But only rarely is a
patient found who can do this. This degree of relaxation is of course,
present in profound general ether anesthesia, which is not to be
thought of for direct laryngoscopy, except when it is used for the
purpose of insertion of intratracheal insufflation anesthetic tubes.
For this, of course, the patient is already to be deeply anesthetized.
The muscular tension exerted by some patients in assuming and holding
a faulty position is almost as much of a hindrance to peroral
endoscopy as is the position itself. The tendency of the patient to
heave up his chest and assume a false position simulating the
opisthotonous position (Fig. 52) must be overcome by persuasion. This
position has all the disadvantages of the Rose position for endoscopy.
[FIG. 53.--The author's position for the removal of foreign bodies
from the larynx or from any of the upper air or food passages. If
dislodged, the intruder will not be aided by gravity to reach a deeper
lodgement.]
The one exception to these general positions is found in procedures
for the removal of foreign bodies from the larynx. In such cases,
while the same relative position of the head to the plane of the table
is maintained, the whole table top is so inclined as to elevate the
feet and lower the head, known as Jackson's position. This
semi-inversion of the patient allows the foreign body to drop into the
pharynx if it should be dislodged, or slip from the forceps (Fig. 53).
[82] CHAPTER VII--DIRECT LARYNGOSCOPY
_Importance of Mirror Examination of the Larynx_.--The presence of
the direct laryngoscope incites spasmodic laryngeal reflexes, and the
traction exerted somewhat distorts the tissues, so that accurate
observations of variations in laryngeal mobility are difficult to
obtain. The function of the laryngeal muscles and structures,
therefore, can best be studied with the laryngeal mirror, except in
infants and small children who will not tolerate the procedure of
indirect laryngoscopy. A true idea of the depth of the larynx is not
obtained with the mirror, and a view of the ventricles is rarely had.
With the introduction of the direct laryngoscope it is found that the
larynx is funnel shaped, and that the adult cords are situated about 3
cm. below the aryepiglottic folds; the cords also assume their true
shelf-like character and take on a pinkish or yellowish tinge, rather
than the pearly white seen in the mirror. They are not to any extent
differentiated by color from the neighboring structures. Their
recognition depends almost wholly on form, position and movement.
Accurate observation is stimulated in all pathologic cases by making
colored crayon sketches, however crude, of the mirror image of the
larynx. The location of a growth may be thus graphically recorded, so
that at the time of operation a glance will serve to refresh the
memory as to its site. It is to be constantly kept in mind, however,
that in the mirror image the sides are reversed because of the facing
positions of the examiner and patient. Direct laryngoscopy is the only
method by which the larynx of children can be seen. The procedure need
require less than a minute of time, and an accurate diagnosis of the
condition present, whether papilloma, foreign body, diphtheria,
paralysis, etc., may be thus obtained. The posterior pharyngeal wall
should be examined in all dyspneic children for the possible existence
of retropharyngeal abscess.
[PLATE II--DIRECT AND INDIRECT LARYNGEAL VIEWS FROM AUTHOR'S OIL-COLOR
DRAWINGS FROM LIFE:
1, Epiglottis of child as seen by direct laryngoscopy in the
recumbent position.
2, Normal larynx spasmodically closed, as is usual on first exposure
without anesthesia.
3, Same on inspiration.
4, Supraglottic papillomata as seen on direct laryngoscopy in a
child of two years.
5, Cyst of the larynx in a child of four years, seen on direct
laryngoscopy without anesthesia.
6, Indirect view of larynx eight weeks after thyrotomy for cancer of
the right cord in a man of fifty years.
7, Same after two years. An adventitious band indistinguishable from
the original one has replaced the lost cord.
8, Condition of the larynx three years after hemilaryngectomy for
epithelioma in a patient fifty-one years of age. Thyrotomy revealed
such extensive involvement, with an open ulceration which had reached
the perichondrium, that the entire left wing of the thyroid cartilage
was removed with the left arytenoid. A sufficiently wide removal was
accomplished without removing any part of the esophageal wall below
the level of the crico-arytenoid joint. There is no attempt on the
part of nature to form an adventitious cord on the left side. The
normal arytenoid drew the normal cord over, approximately to the edge
of the cicatricial tissue of the operated side. The voice, at first a
very hoarse whisper, eventually was fairly loud, though slightly husky
and inflexible.
9, The pharynx seen one year after laryngectomy for endothelioma in
a man aged sixty-eight years. The purple papilla; anteriorly are at
the base of the tongue, and from this the mucosa slopes downward and
backward smoothly into the esophagus. There are some slight folds
toward the left and some of these are quite cicatricial. The
epiglottis was removed at operation. The trachea was sutured to the
skin and did not communicate with the pharynx. (Direct view.)]
_Contraindications to Direct Laryngoscopy_.--There are no absolute
contraindications to direct laryngoscopy in any case where direct
laryngoscopy is really needed for diagnosis or treatment. In extremely
dyspneic patients, if the operator is not confident in his ability for
a prompt and sure introduction of a bronchoscope, it may be wise to do
a tracheotomy first.
_Instructions to the Patient_.--Before beginning endoscopy the
patient should be told that he will feel a very disagreeable pressure
on his neck and that he may feel as though he were about to choke. He
must be gently but positively made to understand (1) that while the
procedure is alarming, it is absolutely free from danger; (2) that you
know just how it feels; (3) that you will not allow his breath to be
shut off completely; (4) that he can help you and himself very much by
paying close attention to breathing deeply and regularly; (5) and that
he must not draw himself up rigidly as though "walking on ice," but
must be easy and relaxed.
_Direct Laryngoscopy. Adult Patient_.--Before starting, every detail
in regard to instrumental equipment and operating room assistants,
(including an assistant to hold the arms and legs of the patient) must
be complete. Preparation of the patient and the technic of local
anesthesia have been discussed in their respective chapters. The
dorsally recumbent patient is draped with (not pinned in) a sterile
sheet. The head, covered by sterile towels, is elevated, and slight
extension is made at the occipitoatloid joint by the left hand of the
first assistant. The bite block placed on the assistant's right thumb
is inserted into the left angle of the patient's open mouth (see Fig.
50).
The laryngoscope must always and invariably be held in the left hand,
and in such a manner that the greatest amount of traction is made at
the swell of the horizontal bar of the handle, rather than on the
vertical bar.
The right hand is then free for the manipulation of forceps, and the
insertion of the bronchoscope or other instrument. During
introduction, the fingers of the right hand retract the upper lip so
as to prevent its being pinched between the laryngoscope and the
teeth. The introduction of the direct laryngoscope and exposure of the
larynx is best described in two stages.
1. Exposure and identification of the epiglottis.
2. Elevation of the epiglottis and all the tissues attached to the
hyoid bone, so as to expose the larynx to direct view.
_First Stage_.--The spatular end of the laryngoscope is introduced in
the right side of the patient's mouth, along the right side of the
anterior two-thirds of the tongue. It was the German method to
introduce the laryngoscope over the dorsum of the tongue but in order
to elevate this sometimes powerful muscular organ considerable force
may be required, which exercise of force may be entirely avoided by
crowding the tongue over to the left. When the posterior third stage
of the tongue is reached, the tip of the laryngoscope is directed
toward the midline and the dorsum of the tongue is elevated by a
lifting motion imparted to the laryngoscope. The epiglottis will then
be seen to project into the endoscopic field, as seen in Fig. 54.
[FIG. 54.--End of the first of direct laryngoscopy, recumbent adult
patient. The epiglottis is exposed by a lifting motion of the spatular
tip on the tongue anterior to the epiglottis.]
_Second Stage_.--The spatular end of the laryngoscope should now be
tipped back toward the posterior wall of the pharynx, passed posterior
to the epiglottis, and advanced about 1 cm. The larynx is now exposed
by a motion that is best described as a suspension of the head and all
the structures attached to the hyoid bone on the tip of the spatular
end of the laryngoscope (Fig. 55). Particular care must be taken at
this stage not to pry on the upper teeth; but rather to impart a
lifting motion with the tip of the speculum without depressing the
proximal tubular orifice. It is to be emphasized that while some
pressure is necessary in the lifting motion, great force should never
be used; the art is a gentle one. The first view is apt to find the
larynx in state of spasm, and affords an excellent demonstration of
the fact that the larynx can he completely closed without the aid of
the epiglottis. Usually little more is seen than the two rounded
arytenoid masses, and, anterior to them, the ventricular bands in more
or less close apposition hiding the cords (Fig. 56). With deep
general anesthesia or thorough local anesthesia the spasm may not be
present. By asking the patient to take a deep breath and maintain
steady breathing, or perhaps by requesting a phonatory effort, the
larynx will open widely and the cords be revealed. If the anterior
commissure of the larynx is not readily seen, the lifting motion and
elevation of the head should be increased, and if there is still
difficulty in exposing the anterior commissure the assistant holding
the head should with the index finger externally on the neck depress
the thyroid cartilage. If by this technic the larynx fails to be
revealed the endoscopist should ask himself which of the following
rules he has violated.
[FIG. 55.--Schema illustrating the technic of direct laryngoscopy on
the recumbent patient. The motion is imparted to the tip of the
laryngoscope as if to lift the patient by his hyoid hone. The portion
of the table indicated by the dotted line may be dropped or not, but
the back of the head must never go lower than here shown, for direct
laryngoscopy; and it is better to have it at least 10 cm. above the
level of the table. The table may be used as a rest for the operator's
left elbow to take the weight of the head. (Note that in bronchoscopy
and esophagoscopy the head section of the table must be dropped, so as
to leave the head and neck of the patient out in the air, supported by
the second assistant.)]
[FIG. 56.--Endoscopic view at the end of the second stage of direct
laryngoscopy. Recumbent patient. Larynx exposed waiting for larynx to
relax its spasmodic contraction.]
RULES FOR DIRECT LARYNGOSCOPY
1. The laryngoscope must always be held in the left hand, never in
the right.
2. The operator's right index finger (never the left) should be used
to retract the patient's upper lip so that there is no danger of
pinching the lip between the instrument and the teeth.
3. The patient's head must always be exactly in the middle line, not
rotated to the right or left, nor bent over sidewise; and the entire
head must be forward with extension at the occipitoatloid joint only.
4. The laryngoscope is inserted to the right side of the anterior
two-thirds of the tongue, the tip of the spatula being directed toward
the midline when the posterior third of the tongue is reached.
5. The epiglottis must always be identified before any attempt is
made to expose the larynx.
6. When first inserting the laryngoscope to find the epiglottis,
great care should be taken not to insert too deeply lest the
epiglottis be overridden and thus hidden.
7. After identification of the epiglottis, too deep insertion of the
laryngoscope must be carefully avoided lest the spatula be inserted
back of the arytenoids into the hypo-pharynx.
8. Exposure of the larynx is accomplished by pulling forward the
epiglottis and the tissues attached to the hyoid bone, and not by
prying these tissues forward with the upper teeth as a fulcrum.
9. Care must be taken to avoid mistaking the ary-epiglottic fold for
the epiglottis itself. (Most likely to occur as the result of rotation
of the patient's head.)
10. The tube should not be retained too long in place, but should be
removed and the patient permitted to swallow the accumulated saliva,
which, if the laryngoscope is too long in place, will trickle down the
trachea and cause cough. (Swallowing is almost impossible while the
laryngoscope is in position.) The secretions may be removed with the
aspirator.
11. The patient must be instructed to breathe deeply and quietly
without making a sound.
[88] _Difficulties of Direct Laryngoscopy_.--The larynx can be
directly exposed in any patient whose mouth can be opened, although
the ease varies greatly with the type of patient. Failure to expose
the epiglottis is usually due to too great haste to enter the speculum
all the way down. The spatula should glide slowly along the posterior
third of the tongue until it reaches the glossoepiglottic fossa, while
at the same time the tongue is lifted; when this is done the
epiglottis will stand out in strong relief. The beginner is apt to
insert the speculum too far and expose the hypopharynx rather than the
larynx. The elusiveness of the epiglottis and its tendency to retreat
downward are very much accentuated in patients who have worn a
tracheotomic cannula; and if still wearing it, the patient can wait
indefinitely before opening his glottis. Over extension of the
patient's head is a frequent cause of difficulty. If the head is held
high enough extension is not necessary, and the less the extension the
less muscular tension there is in the anterior cervical muscles. Only
one arytenoid eminence may be seen. The right and the left look
different. Practice will facilitate identification, so that the
endoscopist will at once know which way to look for the glottis.
Of the difficulties that pertain to the operator himself the greatest
is lack of practice. He must learn to recognize the landmarks even
though a high degree of spasm be present. The epiglottis and the two
rounded eminences corresponding to the arytenoids must be in the
mind's eye, for it is only on deep, relaxed inspiration that anything
like a typical picture of the larynx will be seen. He must know also
the right from the left arytenoid when only one is seen in order to
know whether to move the lip of the laryngoscope to the right or the
left for exposure of the interior of the larynx.
_Instruments for Direct Laryngoscopy_.--In undertaking direct
laryngoscopy one must always be prepared for bronchoscopy,
esophagoscopy, and tracheotomy, as well. Preparations for bronchoscopy
are necessary because the pathological condition may not be found in
the larynx, and further search of the trachea or bronchi may be
required. A foreign body in the larynx may be aspirated to a deeper
location and could only be followed with the bronchoscope. Sudden
respiratory arrest might occur, from pathology or foreign body,
necessitating the inserting of the bronchoscope for breathing
purposes, and the insufflation of oxygen and amyl nitrite. Trachectomy
might be required for dyspnea or other reasons. It might be necessary
to explore the esophagus for conditions associated with laryngeal
lesions, as for instance a foreign body in the esophagus causing
dyspnea by pressure. In short, when planning for direct laryngoscopy,
bronchoscopy, or esophagoscopy, prepare for all three, and for
tracheotomy. A properly done direct laryngoscopy would never
precipitate a tracheotomy in an unanesthetized patient; but direct
laryngoscopy has to deal so frequently with laryngeal stenosis, that
routine preparation for tracheotomy a hundred unnecessary times is
fully compensated for by the certainty of preparedness when the rare
but urgent occasion arises.
_Direct Laryngoscopy in Children_.--The epiglottis in children is
usually strongly curled, often omega shaped, and is very elusive and
slippery. The larynx of a child is very freely movable in the neck
during respiration and deglutition, and has a strong tendency to
retreat downward during examination, and thus withdraw the epiglottis
after the arytenoids have been exposed. In following down with the
laryngoscope the speculum is prone to enter the hypopharynx. Lifting
in this location will expose the mouth of the esophagus and shut off
the larynx, and may cause respiratory arrest. Practice, however, will
soon develop a technic and ability to recognize the landmarks in state
of spasm, so that on exposing the approximated arytenoid eminences the
endoscopist will maintain his position and wait for the larynx to
open. The procedure should be done without any form of anesthesia for
the following reasons:
1. Anesthesia is unnecessary.
2. It is extremely dangerous in a dyspneic patient.
3. It is inadmissable in a patient with diphtheria.
4. If anesthesia is to be used, direct laryngoscopy will never reach
its full degree of usefulness, because anesthesia makes a major
procedure out of a minor one.
5. Cocain in children is dangerous, and its application more
annoying than the examination.
_Inducing a Child to Open its Mouth (Author's Method)_.--The wounding
of the child's mouth, gums, and lips, in the often inefficacious
methods with gags, hemostats, raspatories, etcetera, are entirely
unnecessary. The mouth of any child not unconscious can be opened
quickly and without the slightest harm by passing a curved probe
between the clenched jaws back of the molars and down back of the
tongue toward the laryngopharynx. This will cause the child to gag,
when its mouth invariably opens.
[91] CHAPTER VIII--DIRECT LARYNGOSCOPY (_Continued_)
_Technic of Laryngeal Operations_.--Preparation of the patient and
anesthesia have been mentioned under their respective chapters. The
prime essential of successful laryngeal operations is perfect mastery
of continuous left-handed laryngeal exposure. The right hand must be
equally trained in the manipulation of forceps, and the right eye to
gauge depth. Blood and secretions are best removed by a suction tube
(Fig. 9) inserted through the laryngoscope, or directly into the
pharynx outside the laryngoscope.
_For the removal of benign growths_ the author's papilloma forceps,
Fig. 29, or the laryngeal grasping forceps shown in Fig. 17 will prove
more satisfactory than any form of cutting forceps. These growths
should be removed superficially flush with the normal structure. The
crushing of the base incident to the plucking off of the growth causes
its recession. By this conservative method damage to the cords and
impairment of the voice are avoided. For growths in the anterior
portion of the larynx, and in fact for the removal of most small
benign growths, the anterior commissure laryngoscope is especially
adapted. Its shape allows its introduction into the vestibule of the
larynx, and if desired it may be introduced through the glottic chink
for the treatment of subglottic conditions. It will not infrequently
be observed that a pedunculated subglottic growth which is found with
difficulty will be pulled upward into view by the gauze swab
introduced to remove secretions. The growth is then often held tightly
between the approximated cords for a few seconds--perhaps long enough
to grasp it with forceps.
[92] _Removal of Growth from the Laryngeal Ventricle_.--After exposing
the larynx in the usual manner, if the head is turned strongly to the
right, the tip of the laryngoscope, directed from the right side of
the mouth, may be used to lift the left ventricular hand and thus
expose the ventricle, from which a growth may be removed in the usual
manner (Fig. 57). The right ventricle is exposed by working from the
left side of the mouth.
[FIG. 57.-Schema illustrating the lateral method of exposing a growth
in the ventricle of Morgagni, by bending the patient's head to the
opposite side, while the second assistant externally fixes the larynx
with his hand. M, Patient's mouth; T, thyroid cartilage; R, right
side; L, left. V, B, ventricular band. C, C, vocal cord. The circular
drawing indicates the endoscopic view obtainable by this method. The
tube, E, is dropped to the corner of the mouth, B, and the tube is
inserted down to R. The lip of the spatula can then be used to lift
the ventricular band so as to expose more of the ventricle. The
drawing shows an unusually shallow ventricle.]
_Taking a Laryngeal Specimen for Diagnosis_.--The diagnosis of
carcinoma, sarcoma, and some other conditions can be made certain only
by microscopic study of tissue removed from the growth. The specimen
should be ample but will necessarily be small. If the suspected growth
be small it should be removed entire, together with some of the basal
tissues. If it is a large growth, and there are objections to its
entire removal, the edge of the growth, including apparently normal as
well as neoplastic tissue, is necessary. If it is a diffuse
infiltrative process, a specimen should be taken from at least two
locations. Tissue for biopsy is to be taken with the punch forceps
shown in Fig. 28 or that in Fig. 33. The forceps may be inserted
through the tube or from the angle of the mouth; the "extubal" method
(see Fig. 58).
[FIG. 58.--Schema illustrating removal of a tumor from the upper part
of the larynx by the author's "extubal" method for large tumors. The
large alligator basket punch forceps, F, is inserted from the right
corner of the mouth and the jaws are placed over the tumor, T, under
guidance of the eye looking through the laryngoscope, L. This method
is not used for small tumors. It is excellent for amputation of the
epiglottis with these same punch forceps or with the heavy snare.]
_Removal of large benign tumors above the cords_ may be done with the
snare or with the large laryngeal punch forceps. Both are used in the
extubal method.
_Amputation of the epiglottis_ for palliation of odynophagia or
dysphagia in tuberculous or malignant disease, is of benefit when the
ulceration is confined to this region; though as to tuberculosis the
author feels rather conservatingly inclined. Early malignancy of the
extreme tip can be cured by such means. The function of the epiglottis
seems to be to split the food bolus and direct its portions laterally
into the pyriform sinuses, rather than to take any important part in
the closure of the larynx. Following the removal of the epiglottis
there is rarely complaint of food entering the larynx. The projecting
portion of the epiglottis may be amputated with a heavy snare, or by
means of the large laryngeal punch forceps (Fig. 33).
_Endoscopic Operations for Laryngeal Stenosis_.--Web formations may be
excised with sliding punch forceps, or if the web is due to
contraction only, incision of the true band may allow its retraction.
In some instances liberation of adhesions will favor the formation of
adventitious vocal cords. A sharp anterior commissure is a large
factor in good phonation.
_Endoscopic evisceration of the larynx_ will cure a few cases of
laryngeal cicatricial stenosis, and should be tried before resorting
to laryngostomy. A sliding punch forceps is used to remove all the
tissue in the larynx out to the perichondrium, but care should be
taken in cicatricial cases to avoid removing any part of either
arytenoid cartilage. In cases of posticus paralysis the excision may
include portions of the vocal processes of the arytenoids.
Ventriculocordectomy is preferable to evisceration. The ventricular
floor is removed with punch forceps (Fig. 33) first on one side, then
after two months, on the other.
_Vocal Results_.--A whispering voice can always be had as long as air
can pass through the larynx, and this may be developed to a very loud
penetrating stage whisper. If the arytenoid motility has been
uninjured the repeated pulls on the scar tissue may draw out
adventitious bands and develop a loud, useful, though perhaps rough
and inflexible voice.
_Galvano-cauterization_ is the best method of treatment for chronic
subglottic edema or hyperplasia such as is seen in children following
diphtheria, when the stenosis produced prevents extubation or
decannulation. The utmost caution should be used to avoid deep
cauterizations; they are almost certain to set up perichondritis which
will increase the stenosis. Some of the most difficult cases that have
come to the author have been previously cauterized too deeply.
_Galvano-cautery puncture_ of tuberculous infiltrations of the larynx
at times yields excellent results in cases with mild pulmonary
lesions, and has quite replaced the use of the curette, lactic acid,
and other caustics. The direct method of exposing the larynx renders
the application of the cautery point easy and accurate. In severely
stenosed tuberculous larynges a tracheotomy should first be done, for
though the reaction is slight it might be sufficient to close a
narrowed glottis. The technic is the usual one for laryngeal
operations. Local anesthesia suffices. The larynx is exposed. The
rheostat having been previously adjusted to heat the electrode to
nearly white heat, the circuit is broken and the electrode introduced
cold. When the point is in contact with the desired location the
current is turned on and the point thrust in as deeply as desired.
Usually it should penetrate until a firm resistance is felt; but care
must be used not to damage the cricoarytenoid joint. The circuit is
broken at the instant of withdrawal. Punctures should be made as
nearly as possible perpendicular to the surface, so as to minimize the
destruction of epithelium and thus lessen the reaction. A minute gray
fibrous slough detaches itself in a few days. Cautery puncture should
be repeated every two or three weeks, selecting a new location each
time, until the desired result is obtained. Great caution, as
mentioned above, must be used to avoid setting up perichondritis. Many
cases of laryngeal tuberculosis will recover as quickly by silence and
a general antituberculous regime.
_Radium_, in form of capsules or of needles inserted in the tissues
may be applied with great accuracy; but the author is strongly
impressed with pyriform sinus applications by the Freer method.
_After-care of endolaryngeal operations_ includes careful cleansing of
the teeth and mouth; and if the extrinsic area of the larynx is
involved in the wound, sterile liquid food and water should be given
for four days. The patient should be watched for complications by a
special nurse who is familiar with the signs of laryngeal dyspnea
(q.v.). _Complications during endolaryngeal operations_ are rare.
Dyspnea may require tracheotomy. Idiosyncrasy to cocain, or the sight
or taste of blood may nauseate the patient and cause syncope. Serious
hemorrhage could occur only in a hemophile. The careless handling of a
bite block might damage a frail tool or dental fixture.
_Complications after endolaryngeal operations_ are unusual.
Carelessness in asepsis has been known to cause cervical cellulitis.
Emphysema of the neck has occurred. Edema of the larynx occasionally
occurs, and might necessitate tracheotomy. Serious bleeding after
operation is very rare except in bleeders. Hemorrhage within the
larynx can be stopped by the introduction of a roll of gauze from
above, tracheotomy having been previously performed. Morphin
subcutaneously administered, has a constricting action on the vessels
which renders it of value in controlling hemorrhage.
[97] CHAPTER IX--INTRODUCTION OF THE BRONCHOSCOPE
No one should do bronchoscopy until he is able to expose the glottis
by left-handed direct laryngoscopy in less than one minute. When he
has mastered this, one minute more should be sufficient to introduce
the bronchoscope into the trachea.
TECHNIC OF BRONCHOSCOPY
Local anesthesia is usually employed in the adult. The patient is
placed in the Boyce position shown in Fig. 51, with head and shoulders
projecting over the edge of the table and supported by an assistant.
The glottis is exposed by left-handed laryngoscopy. The
instrument-assistant now inserts the distal end of the bronchoscope
into the lumen of the laryngoscope, the handle being directed to the
right in a horizontal position. The operator now grasps the
bronchoscope, his eye is transferred from the laryngoscope to the
bronchoscope, and the bronchoscope is advanced and so directed that a
good view of the glottis is obtained. The slanted end of the
bronchoscope should then be directed to the left, so as clearly to
expose the left cord. In this position it will be found that the tip
of the slanted end is in the center of the glottic chink and will slip
readily into the trachea. No great force should be used, because if
the bronchoscope does not go through readily, either the tube is too
large a size or it is not correctly placed (Fig. 60). Normally,
however, there is some slight resistance, which in cases of subglottic
laryngitis may be considerable. The trained laryngologist will readily
determine by sense of touch the degree of pressure necessary to
overcome it. When the bronchoscope has been inserted to about the
second or third tracheal ring, the heavy laryngoscope is removed by
rotating the handle to the left, removing the slide, and withdrawing
the instrument. Care must be taken that the bronchoscope is not
withdrawn or coughed out during the removal of the laryngoscope; this
can be avoided by allowing the ocular end to rest against the
gown-covered chest of the operator. If preferred the operator may
train his instrumental assistant to take off the laryngoscope, while
the operator devotes his attention to preventing the withdrawal of the
bronchoscope by holding the handle with his right hand. At the moment
of insertion of the bronchoscope through the glottis, an especially
strong upward lift on the beak of the spatula will facilitate the
passage. It is necessary to be certain that the axis of the
bronchoscope corresponds to the axis of the trachea, in order to avoid
injury to the subglottic tissue which might be followed by subglottic
edema (Fig. 47). If the subglottic region is already edematous and
causes resistance, slight rotation to the laryngoscope, and
bronchoscope will cause the bronchoscope to enter more easily.
[FIG. 59.--Insufflation anesthesia with Elsberg apparatus. Anesthetist
has exposed the larynx and is about to introduce the silk-woven
catheter. Note the full extension of the head on the table.]
[FIG. 60.--Schema illustrating the introduction of the bronchoscope
through the glottis, recumbent patient. The handle, H, is always
horizontally to the right. When the glottis is first seen through the
tube it should be centrally located as at K. At the next inspiration
the end B, is moved horizontally to the left as shown by the dart, M,
until the glottis shows at the right edge of the field, C. This means
that the point of the lip, B, is at the median line, and it is then
quickly (not violently) pushed through into the trachea. At this same
moment or the instant before, the hyoid bone is given a quick
additional lift with the tip of the laryngoscope.]
[FIG. 61.--Schema illustrating oral bronchoscopy. The portion of the
table here shown under the head is, in actual work, dropped all the
way down perpendicularly. It appears in these drawings as a dotted
line to emphasize the fact that the head must be above the level of
the table during introduction of the bronchoscope into the trachea. A,
Exposure of larynx; B, bronchoscope introduced; C, slide removed; D,
laryngoscope removed leaving bronchoscope alone in position.]
_Difficulties in the Introduction of the Bronchoscope_.--The beginner
may enter the esophagus instead of the trachea: this might be
a dangerous accident in a dyspneic case, for the tube could, by
pressure on the trachea, cause respiratory arrest. A bronchoscope thus
misplaced should be resterilized before introducing it into the air
passages, for while the lower air passages are usually free from
bacteria, the esophagus is a septic canal. If the given technic is
carefully carried out the bronchoscope will not be contaminated with
mouth secretions. The trachea is recognized as an open tube, with
whitish rings, and the expiratory blast can be felt and tubular
breathing heard; while if by mistake the bronchoscope has entered the
gullet it will be observed that the cervical esophagus has collapsed
walls. A puff of air may be felt and a fluttering sound heard when the
tube is in the esophagus, but these lack the intensity of the tracheal
blast. Usually a free flow of secretion is met with in the esophagus.
In diseased states the tracheal rings may not be visible because of
swollen mucosa, or the trachea itself may be in partial collapse from
external pressure. The true expiratory blast will, however, always be
recognized when the tube is in the trachea. Wide gagging of the mouth
renders exposure of the larynx difficult.
[FIG. 62.--Insertion of the bronchoscope. Note direction of the
trachea as indicated by the bronchoscope. Note that the patient's head
is held above the level of the table. The assistant's left hand should
be at the patient's mouth holding the bite-block. This is removed and
the assistant is on the wrong side of the table in the illustration in
order not to hide the position of the operator's hands. Note the
handle of the bronchoscope is to the right.]
[FIG. 63.--The heavy laryngoscope has been removed leaving the light
bronchoscope in position. The operator is inserting forceps. Note how
the left hand of the operator holds the tube lightly between the thumb
and first two fingers of the left hand, while the last two fingers are
hooked over the upper teeth of the patient "anchoring" the tube to
prevent it moving in or out or otherwise changing the relation of the
distal tube-mouth to a foreign body or a growth while forceps are
being used. Thus, also, any desired location of the tube can be
maintained in systematic exploration. The assistant's left hand is
dropped out of the way to show the operator's method. The assistant
during bronchoscopy holds the bite-block like a thimble on the index
finger of the left hand, and the assistant should be on the right side
of the patient. He is here put wrongly on the left side so as not to
hide the instruments and the manner of holding them.]
_Examination of the Trachea and Bronchi_.--All bronchial orifices must
be identified _seriatim_; because this is the only way by which the
bronchoscopist can know what part of the tree he is examining.
Appearances alone are not enough. It is the order in which they are
exposed that enables the inexperienced operator to know the orifices.
After the removal of the laryngoscope, the bronchoscope is to be held
by the left hand like a billiard cue, the terminal phalanges of the
left middle and ring fingers hooking over the upper teeth, while the
thumb and index finger hold the bronchoscope, clamping it to the teeth
tightly or loosely as required (Fig. 63). Thus the tube may be
anchored in any position, or at any depth, and the right hand which
was directing the tube may be used for the manipulation of
instruments. The grasp of the bronchoscope in the right hand should be
similar to that of holding a pen, that is, the thumb, first, and
second fingers, encircle the shaft of the tube. The bronchoscope
should never be held by the handle (Fig. 64) for this grasp does not
allow of tactile sense transmission, is rigid, awkward, and renders
rotation of the tube a wrist motion instead of but a gentle finger
action. Any secretion in the trachea is to be removed by sponge
pumping before the bronchoscope is advanced. The inspection of the
walls of the trachea is accomplished by weaving from side to side and,
if necessary, up and down; the head being deflected as required during
the search of the passages, so that the larynx be not made the fulcrum
in the lever-like action.
[FIG. 64.--At A is shown an incorrect manner of holding the
bronchoscope. The grasp is too rigid and the position of the hand is
awkward. B, Correct manner, the collar being held lightly between the
finger and the thumb The thumb must not occlude the tube mouth.]
_The Fulcrum of the Bronchoscopic Lever is at the Upper Thoracic
Aperture; Never at the Larynx_.--Disregard of this rule will cause
subglottic edema and will limit the lateral motion of the tip of the
bronchoscope. It is the function of the assistant to make the head and
neck follow the direction of the proximal end of the bronchoscope and
thus avoid any pressure on the larynx (see Peroral Endoscopy, Fig.
135, p. 164).
In passing down the trachea the following two rules must be kept in
mind:
1. Before attempting to enter either main bronchus the carina must
be identified.
2. Before entering either main bronchus the orifices of both should
be identified and inspected.
_The carina_ is identified as a sharp vertical spur (recumbent
patient) at the distal end of the trachea, on either side of which are
the openings of the main bronchi. As the carina is situated to the
left of the midline of the trachea, the lip of the bronchoscope should
be turned toward the left, and slight lateral pressure should be made
on the left tracheal wall while the head of the patient is held
slightly to the right. This will expose the left bronchial orifice and
carina.
_Entering the Bronchi_.--The lip of the bronchoscope should be turned
in the direction of the bronchus to be explored, and the axis of the
bronchoscope should be made to correspond as nearly as possible to the
axis of this bronchus. The position of the lip is designated by the
direction taken by the handle. Upon entering the right bronchus, the
handle of the bronchoscope is turned horizontally to the right, and at
the same time the assistant deflects the head to the left.
_The right upper-lobe bronchus_ is recognized by its vertical spur;
the orifice is exposed by displacing the right lateral wall of the
right main bronchus at the level of the carina. Usually this orifice
will be thus brought into view. If not the bronchoscope may be
advanced downward 1 or 2 cm., carefully to avoid overriding. This
branch is sometimes found coming off the trachea itself, and even if
it does not, the overriding of the orifice is certain if the right
bronchus is entered before search is made for the upper-lobe-bronchial
orifice. The head must be moved strongly to the left in order to view
the orifice. A lumen image of the right upper-lobe bronchus is not
obtainable because of the sharp angles at which it is given off. _The
left upper-lobe bronchus_ is entered by keeping the handle of the
bronchoscope (and consequently the lip) to the left, and, by keeping
the head of the patient strongly to the right as the bronchoscopist
goes down the left main bronchus. This causes the lip of the
bronchoscope to bear strongly on the left wall of the left main
bronchus, consequently the left upper-lobe-bronchial orifice will not
be overridden. The spur separating the upper-lobe-bronchial orifice
from the stem bronchus is at an angle approximately from two to eight
o'clock, as usually seen in the recumbent patient. A lumen image of a
descending branch of the upper-lobe bronchus is often obtained, if the
patient's head be borne strongly enough to the right.
[FIG. 65.--Schema illustrating the entering of the anteriorly
branching middle lobe bronchus. T, Trachea; B, orifice of left main
bronchus at bifurcation of trachea. The bronchoscope, S, is in the
right main bronchus, pointing in the direction of the right inferior
lobe bronchus, I. In order to cause the lip to enter the middle lobe
bronchus, M, it is necessary to drop the head so that the bronchoscope
in the trachea TT, will point properly to enable the lip of the tube
mouth to enter the middle lobe bronchus, as it is seen to have done at
ML.]
Branches of the stem bronchus in either lung are exposed, or their
respective lumina presented, by manipulation of the lip of the
bronchoscope, with movement of the head in the required direction.
Posterior branches require the head quite high. A large one in the
left stem just below the left upper-lobe bronchus is often invaded by
foreign bodies. Anterior branches require lowering the head. The
_middle-lobe bronchus_ is the largest of all anterior branches. Its
almost horizontal spur is brought into view by directing the lip of
the bronchoscope upward, and dropping the head of the patient until
the lip bears strongly on the anterior wall of the right bronchus (see
Fig. 65).
[106] CHAPTER X--INTRODUCTION OF THE ESOPHAGOSCOPE
The esophagoscope is to be passed only with ocular guidance, never
blindly with a mandrin or obturator, as was done before the
bevel-ended esophagoscope was developed. Blind introduction of the
esophagoscope is equally as dangerous as blind bouginage. It is almost
certain to cause over-riding of foreign bodies and disease. In either
condition perforation of the esophagus is possible by pushing a sharp
foreign body through the normal wall or by penetrating a wall weakened
by disease. Landmarks must be identified as reached, in order to know
the locality reached. The secretions present form sufficient
lubrication for the instrument. A clear conception of the endoscopic
anatomy, the narrowings, direction, and changes of direction of the
axis of the esophagus, are necessary. The services of a trained
assistant to place the head in the proper sequential "high-low"
positions are indispensible (Figs. 52 and 70). Introduction may be
divided into four stages.
1. Entering the right pyriform sinus.
2. Passing the cricopharyngeus.
3. Passing through the thoracic esophagus.
4. Passing through the hiatus.
The patient is placed in the Boyce position as described in Chapter
VI. As previously stated, the esophagus in its upper portion follows
the curves of the cervical and dorsal spine. It is necessary,
therefore, to bring the cervical spine into a straight line with the
upper portion of the dorsal spine and this is accomplished by
elevation of the head--the "high" position (Figs. 66-71).
[PLATE III--ESOPHAGOSCOPIC VIEWS FROM OIL-COLOR DRAWINGS FROM LIFE, BY
THE AUTHOR:
1, Direct view of the larynx and laryngopharynx in the dorsally
recumbent patient, the epiglottis and hyoid bone being lifted with the
direct laryngoscope or the esophageal speculum. The spasmodically
adducted vocal cords are partially hidden by the over-hang of the
spasmodically prominent ventricular hands. Posterior to this the
aryepiglottic folds ending posteriorly in the arytenoid eminences are
seen in apposition. The esophagoscope should be passed to the right of
the median line into the right pyriform sinus, represented here by the
right arm of the dark crescent. 2, The right pyriform sinus in the
dorsally recumbent patient, the eminence at the upper left border,
corresponds to the edge of the cricoid cartilage. 3, The
cricopharyngeal constriction of the esophagus in the dorsally
recumbent patient, the cricoid cartilage being lifted forward with the
esophageal speculum. The lower (posterior) half of the lumen is closed
by the fold corresponding to the orbicular fibers of the
cricopharyngeus which advances spasmodically from the posterior wall.
(Compare Fig. 10.) This view is not obtained with an esophagoscope. 4,
Passing through the right pyriform sinus with the esophagoscope;
dorsally recumbent patient. The walls seem in tight apposition, and,
at the edges of the slit-like lumen, bulge toward the observer. The
direction of the axis of the slit varies, and in some instances it is
like a rosette, depending on the degree of spasm. 5, Cervical
esophagus. The lumen is not so patulent during inspiration as lower
down; and it closes completely during expiration. 6, Thoracic
esophagus; dorsally recumbent patient. The ridge crossing above the
lumen corresponds to the left bronchus. It is seldom so prominent as
in this patient, but can always be found if searched for. 7, The
normal esophagus at the hiatus. This is often mistaken for the cardia
by esophagoscopists. It is more truly a sphincter than the cardia
itself. In the author's opinion there is no truly sphincteric action
at the cardia. It is the failure of this hiatal sphincter to open as
in the normal deglutitory cycle that produces the syndrome called
"cardiospasm." 8, View in the stomach with the open-tube gastroscope.
The form of the folds varies continually. 9, Sarcoma of the posterior
wall of the upper third of the esophagus in a woman of thirty-one
years. Seen through the esophageal speculum, patient sitting. The
lumen of the mouth of the esophagus, much encroached upon by the
sarcomatous infiltration, is seen at the lower part of the circle. 10,
Coin (half-dollar) wedged in the upper third of the esophagus of a boy
aged fourteen years. Seen through the esophageal speculum, recumbent
patient. Forceps are retracting the posterior lip of the esophageal
"mouth" preparatory to removal. 11, Fungating squamous-celled
epithelioma in a man of seventy-four years. Fungations are not always
present, and are often pale and edematous. 12, Cicatricial stenosis of
the esophagus due to the swallowing of lye in a boy of four years.
Below tile upper stricture is seen a second stricture. An ulcer
surrounded by an inflammatory areola and the granulation tissue
together illustrates the etiology of cicatricial tissue. The
fan-shaped scar is really almost linear, but it is viewed in
perspective. Patient was cured by esophagoscopic dilatation. 13,
Angioma of the esophagus in a man of forty years. The patient had
hemorrhoids and varicose veins of the legs. 14, Luetic ulcer of the
esophagus 26 cm. from the upper teeth in a woman of thirty-eight
years. Two scars from healed ulcerations are seen in perspective on
the anterior wall. Branching vessels are seen in the livid areola of
the ulcers. 15, Tuberculosis of the esophagus in a man of thirty-four
years. 16, Leukoplakia of the esophagus near the hiatus in a man aged
fifty-six years.]
The hypopharynx tapers down to the gullet like a funnel, and the
larynx is suspended in its lumen from the anterior wall. The larynx is
attached only to the anterior wall, but is held closely against the
posterior pharyngeal wall by the action of the inferior constrictor of
the pharynx, and particularly by its specialized portion--the
cricopharyngeus muscle. A bolus of food is split by the epiglottis and
the two portions drifted laterally into the pyriform sinuses, the
recesses seen on either side of the larynx. But little of the food
bolus passes posterior to the larynx during the act of swallowing. It
is through the pyriform sinus that the esophagoscope is to be
inserted, thereby following the natural food passage. To insert the
esophagoscope in the midline, posterior to the arytenoids, requires a
degree of force dangerous to exert and almost certain to produce
damage to the cricoarytenoid joint or to the pharyngeal wall, or to
both.
The esophagoscope is steadied by the left hand like a billiard cue, the
terminal phalanges of the left middle and ring fingers hooked over the
upper teeth, while the left index finger and thumb encircle the tube
and retract the upper lip to prevent its being pinched between the
tube and upper teeth. The right hand holds the tube in pen fashion at
the collar of the handle, not by the handle. During introduction the
handle is to be pointed upward toward the zenith.
_Stage I. Entering the Right Pyriform Sinus_.--The operator standing
(as in Fig. 66), inserts the esophagoscope along the right side of the
tongue as far as and down the posterior pharyngeal wall. A lifting
motion imparted to the tip of the esophagoscope by the left thumb will
bring the rounded right arytenoid eminence into view (A, Fig. 69).
This is the landmark of the pyriform sinus, and care must be taken to
avoid injury by hooking the tube mouth over it or its fellow. The tip
of the tube should now be directed somewhat toward the midline,
remembering the funnel shape of the hypopharynx. It will then be found
to glide readily through the right pyriform sinus for 2 or 3 cm., when
it comes to a full stop, and the lumen disappears. This is the
spasmodically closed cricopharyngeal constriction.
[FIG. 66.--Esophagoscopy by the author's "high-low" method. First
stage. "High" position. Finding the right pyriform sinus. In this and
the second stage the patient's vertex is about 15 cm. above the level
of the table.]
_Stage 2. Passing the cricopharyngeus_ is the most difficult part of
esophagoscopy, especially if the patient is unanesthetized. Local
anesthesia helps little, if at all. The handle of the esophagoscope is
still pointing upward and consequently we are sure that the lip of the
esophagoscope is directed anteriorly. Force must not be used, but
steady firm pressure against the tonically contracted cricopharyngeus
is made, while at the same time the distal end of the esophagoscope is
lifted by the left thumb. At the first inspiration a lumen will
usually appear in the upper portion of the endoscopic field. The tip
of the esophagoscope enters this lumen and the slanted end slides over
the fold of the cricopharyngeus into the cervical esophagus. There is
usually from 1 to 3 cm. of this constricted lumen at the level of the
cricopharyngeus and the subjacent orbicular esophageal fibers.
[109] [FIG. 67.--Schematic illustration of the author's "high-low"
method of esophagoscopy. In the first and second stages the patient's
head fully extended is held high so as to bring it in line with the
thoracic esophagus, as shown above. The Rose position is shown by way
of accentuation.]
[FIG. 68.--Schematic illustration of the anatomic basis for difficulty
in introduction of the esophagoscope. The cricoid cartilage is pulled
backward against the cervical spine, by the cricopharyngeus, so
strongly that it is difficult to realize that the cricopharyngeus is
not inserted into the vertebral periosteum instead of into the median
raphe.]
[FIG. 69.--The upper illustration shows movements necessary for
passing the cricopharyngeus.
The lower illustration shows schematically the method of finding the
pyriform sinus in the author's method of esophagoscopy. The large
circle represents the cricoid cartilage. G, Glottic chink,
spasmodically closed; VB, ventricular band; A, right arytenoid
eminence; P, right pyriform sinus, through which the tube is passed in
the recumbent posture. The pyriform sinuses are the normal food
passages.]
_Stage 3. Passing Through the Thoracic Esophagus_.--The thoracic
esophagus will be seen to expand during inspiration and contract
during expiration, due to the change in thoracic pressure. The
esophagoscope usually glides easily through the thoracic esophagus if
the patient's position is correct. After the levels of the aorta and
left bronchus are passed the lumen of the esophagus seems to have a
tendency to disappear anteriorly. The lumen must be kept in axial view
and the head lowered as required for this purpose.
_Stage 4. Passing Through the Hiatus Esophageus_.--When the head is
dropped, it must at the same time be moved horizontally to the right
in order that the axis of the tube shall correspond to the axis of the
lower third of the esophagus, which deviates to the left and turns
anteriorly. The head and shoulders at this time will be found to be
considerably below the plane of the table top (Fig. 71). The hiatal
constriction may assume the form of a slit or rosette. If the rosette
or slit cannot be promptly found, as may be the case in various
degrees of diffuse dilatation, the tube mouth must be shifted farther
to the left and anteriorly. When the tube mouth is centered over the
hiatal constriction moderately firm pressure continued for a short
time will cause it to yield. Then the tube, maintaining this same
direction will, without further trouble glide into and through the
abdominal esophagus. The cardia will not be noticed as a constriction,
but its appearance will be announced by the rolling in of reddish
gastric mucosal folds, and by a gush of fluid from the stomach.
[FIG. 70.--Schematic illustration of the author's "high-low" method of
esophagoscopy, fourth stage. Passing the hiatus. The head is dropped
from the position of the 1st and 2nd stages, CL, to the position T,
and at the same time the head and shoulders are moved to the right
(without rotation) which gives the necessary direction for passing the
hiatus.]
[FIG. 71.--Esophagoscopy by the author's "high-low" method. Stage 4.
Passing the hiatus The patient's vertex is about 5 cm. below the top
of the table.]
_Normal esophageal mucosa_ under proper illumination is glistening and
of a yellowish or bluish pink. The folds are soft and velvety,
rendering infiltration quickly noticeable. The cricoid cartilage shows
white through the mucosa. The gastric mucosa is a darker pink than
that of the esophagus and when actively secreting, its color in some
cases tends toward crimson.
_Secretions_ in the esophagus are readily aspirated through the
drainage canal by a negative pressure pump. Food particles are best
removed by "sponge pumping," or with forceps. Should the drainage
canal become obstructed positive pressure from the pump will clear the
canal.
_Difficulties of Esophagoscopy_.--The beginner may find the
esophagoscope seemingly rigidly fixed, so that it can be neither
introduced nor withdrawn. This usually results from a wedging of the
tube in the dental angle, and is overcome by a wider opening of the
jaws, or perhaps by easing up of the bite block, but most often by
correcting the position of the patient's head. If the beginner cannot
start the tube into the pyriform sinus in an adult, it is a good plan
to expose the arytenoid eminence with the laryngoscope and then to
insert the 7 mm. esophagoscope into the right pyriform sinus by direct
vision. Passing the cricopharyngeal and hiatal spasmodically
contracted narrowings will prove the most trying part of
esophagoscopy; but with the head properly held, and the tube properly
placed and directed, patient waiting for relaxation of the spasm with
gentle continuous pressure will usually expose the lumen ahead. In his
first few esophagoscopies the novice had best use general anesthesia
to avoid these difficulties and to accustom himself to the esophageal
image. In the first favorable subject--an emaciated individual with no
teeth--esophagoscopy without anesthesia should be tried.
In cases of kyphosis it is a mistake to try to straighten the spine.
The head should be held correspondingly higher at the beginning, and
should be very slowly and cautiously lowered.
Once inserted, the esophagoscope should not be removed until the
completion of the procedure, unless respiratory arrest demands it.
Occasionally in stenotic conditions the light may become covered by
the upwelling of a flood of fluid, and it will be thought the light
has gone out. As soon as the fluid has been aspirated the light will
be found burning as brightly as before. If a lamp should fail it is
unnecessary to remove the tube, as the light carrier and light can be
withdrawn and quickly adjusted. A complete instrument equipment with
proper selection of instruments for the particular case are necessary
for smooth working.
_Ballooning Esophagoscopy_.--By inserting the window plug shown in
Fig. 6 the esophagus may be inflated and studied in the distended
state. The folds are thus smoothed out and constrictions rendered more
marked. Ether anesthesia is advocated by Mosher. The danger of
respiratory arrest from pressure, should the patient be dyspneic, is
always present unless the anesthetic be given by the intratracheal
method. If necessary to use forceps the window cap is removed. If the
perforated rubber diaphragm cap be substituted the esophagus can be
reballooned, but work is no longer ocularly guided. The fluoroscope
may be used but is so misleading as to render perforation and false
passage likely.
_Specular Esophagoscopy_.--Inspection of the hypopharynx and upper
esophagus is readily made with the esophageal speculum shown in Fig.
4. High lesions and foreign bodies lodged behind the larynx are thus
discovered with ease, and such a condition as a retropharyngeal
abscess which has burrowed downward is much less apt to be overlooked
than with the esophagoscope. High strictures of the esophagus may be
exposed and treated by direct visual bouginage until the lumen is
sufficiently dilated to allow the passage of the esophagoscope for
bouginage of the deeper strictures.
_Technic of Specular Esophagoscopy_.--Recumbent patient. Boyce
position. The larynx is to be exposed as in direct laryngoscopy, the
right pyriform sinus identified, the tip of the speculum inserted
therein, and gently insinuated to the cricopharyngeal constriction.
Too great extension of the head is to be avoided--even slight flexion
at the occipito-atloid joint may be found useful at times. Moderate
anterior or upward traction pulls the cricoid away from the posterior
pharyngeal wall and the lumen of the esophagus opens above a
crescentic fold (the cricopharyngeus). The speculum readily slides
over this fold and enters the cervical esophagus. In searching for
foreign bodies in the esophagus the speculum has the disadvantage of
limited length, so that should the foreign body move downward it could
not be followed.
_Complications Following Esophagoscopy_.--These are to be avoided in
large measure by the exercise of gentleness, care, and skill that are
acquired by practice. If the instructions herein given are followed,
esophagoscopy is absolutely without mortality apart from the
conditions for which it is done.
Injury to the crico-arytenoid joint may simulate recurrent paralysis.
Posticus paralysis may occur from recurrent or vagal pressure by a
misdirected esophagoscope. These conditions usually recover but may
persist. Perforation of the esophageal wall may cause death from
septic mediastinitis. The pleura may be entered,--pyopneumothorax will
result and demand immediate thoracotomy and gastrostomy. Aneurysm of
the aorta may be ruptured. Patients with tuberculosis, decompensating
cardiovascular lesions, or other advanced organic disease, may have
serious complications precipitated by esophagoscopy.
_Retrograde Esophagoscopy_.--The first step is to get rid of the
gastric secretions. There is always fluid in the stomach, and this
keeps pouring out of the tube in a steady stream. Fold after fold is
emptied of fluid. Once the stomach is empty, the search begins for the
cardial opening. The best landmark is a mark with a dermal pencil on
the skin at a point corresponding to the level of the hiatus
esophageus. When it is desired to do a retrograde esophagoscopy and
the gastrostomy is done for this special purpose, it is wise to have
it very high. Once the cardia is located and the esophagus entered,
the remainder of the work is very easy. Bouginage can be carried out
from below the same as from above and may be of advantage in some
cases. Strictural lumina are much more apt to be concentric as
approached from below because there has been no distortion by pressure
dilatation due to stagnation of the food operating through a long
period of time. At retrograde esophagoscopy there seems to be no
abdominal esophagus and no cardia. The esophagoscope encounters only
the diaphragmatic pinchcock which seems to be at the top of the
stomach like the puckering string at the top of a bag.
Retrograde esophagoscopy is sometimes useful for "stringing" the
esophagus in cases in which the patient is unable to swallow a string
because he is too young or because of an epithelial scaling over of
the upper entrance of the stricture. In such cases the smallest size
of the author's filiform bougies (Fig. 40) is inserted through the
retrograde esophagoscope (Fig. 43) and insinuated upward through the
stricture. When the tip reaches the pharynx coughing, choking and
gagging are noticed. The filiform end is brought out the mouth
sufficiently far to attach a silk braided cord which is then pulled
down and out of the gastrostomic opening. The braided silk "string"
must be long enough so that the oral and the abdominal ends can be
tied together to make it "endless;" but before doing so the oral end
should be drawn through nose where it will be less annoying than in
the mouth. The purpose of the "string" is to pull up the retrograde
bougies (Fig. 35)
[117] CHAPTER XI--ACQUIRING SKILL
Endoscopic ability cannot be bought with the instruments. As with all
mechanical procedures, facility can be obtained only by educating the
eye and the fingers in repeated exercise of a particular series of
maneuvers. As with learning to play a musical instrument, a
fundamental knowledge of technic, positions, and landmarks is
necessary, after which only continued manual practice makes for
proficiency. For instance, efficient use of forceps requires that they
be so familiar to the grasp that their use is automatic. Endoscopy is
a purely manual procedure, hence to know how is not enough: manual
practice is necessary. Even in the handling of the electrical
equipment, practice in quickly locating trouble is as essential as
theoretic knowledge. There is no mystery about electric lighting. No
source of illumination other than electricity is possible for
endoscopy. Therefore a small amount of electrical knowledge, rendered
practical by practice, is essential to maintain the simple lighting
system in working order. It is an insult to the intelligence of the
physician to say that he cannot master a simple problem of electric
testing involving the locating of one or more of five possibilities.
It is simply a matter of memorizing five tests. It is repeated for
emphasis that a commercial current reduced by means of a rheostat
should never be used as a source of current for endoscopy with any
kind of instrument, because of the danger to the patient of a possible
"grounding" of the circuit during the extensive moist contact of a
metallic endoscopic tube in the mediastinum. The battery shown in Fig.
8 should be used. The most frequent cause of trouble is the mistake of
over-illuminating the lamps. _The lamp should not be over-illuminated
to the dazzling whiteness usually used in flash lights_. Excessive
illumination alters the proper perception of the coloring of the
mucosa, besides shortening the life of the lamps. The proper degree of
brightness is obtained when, as the current is increased, the first
change from yellow to white light is obtained. Never turn up the
rheostat without watching the lamp.
_Testing for Electric Defects_.--These tests should be made
beforehand; not when about to commence introduction.
If the first lamp lights up properly, use it with its light-carrier to
test out the other cords.
If the lamp lights up, but flickers, locate the trouble before
attempting to do an endoscopy. If shaking the carrier cord-terminal
produces flickering there may be a film of corrosion on the central
contact of the light carrier that goes into the carrier cord-terminal.
If the lamp fails to show a light, the trouble may be in one of five
places which should be tested for in the following order and manner.
1. The lamp may not be firmly screwed into the light-carrier.
Withdraw the light-carrier and try screwing it in, though not too
strongly, lest the central wire terminal in the lamp be bent over.
2. The light-carrier may be defective.
3. The cord may be defective or its terminals not tight in the
binding posts. If screwing down the thumb nuts does not produce a
light, test the light-carrier with lamp on the other cords. Reserve
cords in each pair of binding posts are for use instead of the
defective cords. The two sets of cords from one pair of binding posts
should not be used simultaneously.
4. The lamp may be defective. Try another lamp.
5. The battery may be defective. Take a cord and light-carrier with
lamp that lights up, detaching the cord-terminals at the binding
posts, and attach the terminals to the binding posts of the battery to
be tested.
_Efficient use of forceps_ requires previous practice in handling of
the forceps until it has become as natural and free from thought as
the use of knife and fork. Indeed the coordinate use of the
bronchoscopic tube-mouth and the forceps very much resembles the use
of knife and fork. Yet only too often a practitioner will telegraph
for a bronchoscope and forceps, and without any practice start in to
remove an entangled or impacted foreign body from the tiny bronchi of
a child. Failure and mortality are almost inevitable. A few hundred
hours spent in working out, on a bit of rubber tubing, the various
mechanical problems given in the section on that subject will save
lives and render easily successful many removals that would otherwise
be impossible.
It is often difficult for the beginner to judge the distance the
forceps have been inserted into the tube. This difficulty is readily
solved if upon inserting the forceps slowly into the tube, he observes
that as the blades pass the light they become brightly illuminated. By
this _light reflex_ it is known, therefore, that the forceps blades
are at the tube-mouth, and distance from this point can be readily
gauged. Excellent practice may be had by picking up through the
bronchoscope or esophagoscope black threads from a white background,
then white threads from a black background, and finally white threads
on a white background and black threads on a black background. This
should be done first with the 9 mm. bronchoscope. It is to be
remembered that the majority of foreign body accidents occur in
children, with whom small tubes must be used; therefore, practice
work, after say the first 100 hours, should be done with the 5 mm.
bronchoscope and corresponding forceps rather than adult size tubes,
so that the operator will be accustomed to work through a small
calibre tube when the actual case presents itself.
[120] _Cadaver Practice_.--The fundamental principles of peroral
endoscopy are best taught on the cadaver. It is necessary that a
specially prepared subject be had, in order to obtain the required
degree of flexibility. Injecting fluid of the following formula worked
out by Prof. J. Parsons Schaeffer for the Bronchoscopic Clinic
courses, has proved very satisfactory:
Sodium carbonate--1 1/2 lbs.
White arsenic--2 1/2 lbs.
Potassium nitrate--3 lbs.
Water--5 gal.
Boil until arsenic is dissolved. When cold add:
Carbolic acid 1500 c.c.
Glycerin 1250 c.c.
Alcohol (95%) 1250 c.c.
For each body use about 3 gal. of fluid.
The method of introduction of the endoscopic tube, and its various
positions can be demonstrated and repeatedly practiced on the cadaver
until a perfected technic is developed in both the operator and
assistant who holds the head, and the one who passes the instruments
to the operator. In no other manner can the landmarks and endoscopic
anatomy be studied so thoroughly and practically, and in no other way
can the pupil be taught to avoid killing his patient. The
danger-points in esophagoscopy are not demonstrable on the living
without actually incurring mortality. Laryngeal growths may be
simulated, foreign body problems created and their mechanical
difficulties solved and practice work with the forceps and tube
perfected.
_Practice on the Rubber-tube Manikin_.--This must be carried out in
two ways.
1. General practice with all sorts of objects for the education of
the eye and the fingers.
2. Before undertaking a foreign body case, practice should be had
with a duplicate of the foreign body.
It is not possible to have a cadaver for daily practice, but
fortunately the eye and fingers may be trained quite as effectually by
simulating foreign body conditions in a small red rubber tube and
solving these mechanical problems with the bronchoscope and forceps.
The tubing may be placed on the desk and held by a small vise (Fig.
72) so that at odd moments during the day or evening the fascinating
work may be picked up and put aside without loss of time. Complicated
rubber manikins are of no value in the practice of introduction, and
foreign body problems can be equally well studied in a piece of rubber
tubing about 10 inches long. No endoscopist has enough practice on the
living subject, because the cases are too infrequent and furthermore
the tube is inserted for too short a space of time. Practice on the
rubber tube trains the eye to recognize objects and to gauge distance;
it develops the tactile sense so that a knowledge of the character of
the object grasped or the nature of the tissues palpated may be
acquired. Before attempting the removal of a particular foreign body
from a living patient, the anticipated problem should be simulated
with a duplicate of the foreign body in a rubber tube. In this way the
endoscopist may precede each case with a practical experience
equivalent to any number of cases of precisely the same kind of
foreign body. If the object cannot be removed from the rubber tube
without violence, it is obvious that no attempt should be made on the
patient until further practice has shown a definite method of harmless
removal. During practice work the value of the beveled lip of the
bronchoscope and esophagoscope in solving mechanical problems will be
evidenced. With it alone, a foreign body may be turned into favorable
positions for extraction, and folds can always be held out of the way.
Sufficient combined practice with the bronchoscope and the forceps
enable the endoscopist easily to do things that at first seem
impossible. It is to be remembered that lateral motion of the long
slender tube-forceps cannot be controlled accurately by the handle,
this is obtained by a change in position of the endoscopic tube, the
object being so centered that it is grasped without side motion of the
forceps. When necessary, the distal end of the forceps may be pushed
laterally by the manipulation of the bronchoscope.
[FIG. 72.--A simple manikin. The weight of the small vise serves to
steady the rubber tubing. By the use of tubing of the size of the
invaded bronchus and a duplicate of the foreign body, any mechanical
problem can he simulated for solution or for practice, study of all
possible presentations, etc.]
_Practice on the Dog_.--Having mastered the technic of introduction on
the cadaver and trained the eye and fingers by practice work on the
rubber tube, experience should be had in the living lower air and food
passages with their pulsatory, respiratory, bechic and deglutitory
movements, and ever-present secretions. It is not only inhuman but
impossible to obtain this experience on children. Fortunately the dog
offers a most ready subject and need in no way be harmed nor pained by
this invaluable and life-saving practice. A small dog the size of a
terrier (say 6 to 10 pounds in weight) should be chosen and
anesthetized by the hypodermic injection of morphin sulphate in dosage
of approximately one-sixth of a grain per pound of body weight, given
about 45 minutes before the time of practice. Dogs stand large doses
of morphin without apparent ill effect, so that repeated injection may
be given in smaller dosage until the desired degree of relaxation
results. The first effect is vomiting which gives an empty stomach for
esophagoscopy and gastroscopy. Vomiting is soon followed by relaxation
and stupor. The dog is normal and hungry in a few hours. Dosage must
be governed in the clog as in the human being by the susceptibility to
the drug and by the temperament of the animal. Other forms of
anesthesia have been tried in my teaching, and none has proven so safe
and satisfactory. Phonation may be prevented during esophagoscopy by
preventing approximation of the cords, through inserting a silk-woven
cathether in the trachea. The larynx and trachea may be painted with
cocain solution if it is found necessary for bronchoscopy. A very
comfortable and safe mouth gag is shown in Fig. 73. Great gentleness
should be exercised, and no force should be used, for none is required
in endoscopic work; and the endoscopist will lose much of the value of
his dog practice if he fails to regard the dog as a child. He should
remember he is not learning how to do endoscopy on the dog; but
learning on the dog how safely to do bronchoscopy on a human being.
The degree of resistance during introduction can be gauged and the
color of the mucosa studied, while that interesting phenomenon, the
dilatation and lengthening of the bronchi during inspiration and their
contraction and shortening during expiration, is readily observed and
always forms subject for thought in its possible connection with
pathological conditions. Foreign body problems are now to be solved
under these living conditions, and it is my feeling that no one should
attempt the removal of a foreign body from the bronchus of a child
until he has removed at least 100 foreign bodies from the dog without
harming the animal. Dogs have the faculty of easily ridding their
air-passages of foreign objects, so that one need not be alarmed if a
foreign body is lost during practice removal. It is to be remembered
that dogs swallow very large objects with apparent ease. The dog's
esophagus is relatively much larger than that of human beings.
Therefore a small dog (of six to eight pounds' weight) must be used
for esophagoscopic practice, if practice is to be had with objects of
the size usually encountered in human beings. The bronchi of a dog of
this weight will be about the size of those of a child.
[FIG. 73.--Author's mouth gag for use on the dog. The thumb-nut serves
to prevent an uncomfortable degree of expansion of the gag. A bandage
may be wound around the dog's jaws to prevent undue spread of the
jaws.]
_Endoscopy on the Human Being_.--Dog work offers but little practice
in laryngoscopy. Because of the slight angle at which the dog's head
joins his spine, the larynx is in a direct line with the open mouth;
hence little displacement of the anterior cervical tissues is
necessary. Moreover the interior of the larynx of the dog is quite
different from that of the human larynx. The technic of laryngoscopy
in the human subject is best perfected by a routine direct examination
of the larynx of anesthetized patients after such an operation as, for
instance, tonsillectomy, to see that the larynx and laryngopharynx are
free of clots. To perform a bronchoscopy or esophagoscopy under these
conditions would be reprehensible; but direct laryngoscopy for the
seeking and removal of clots serves a useful purpose as a preventative
of pulmonary abscess and similar complications.* Diagnosis of
laryngeal conditions in young children is possible only by direct
laryngoscopy and is neglected in almost all of the cases. No
anesthesia, general or local, is required. Much clinical material is
neglected. All cases of dyspnea or dysphagia should be studied
endoscopically if the cause of the condition cannot be definitely
found and treated by other means. Invaluable practice in esophagoscopy
is found in the treatment of strictures of the esophagus by weekly or
biweekly esophagoscopic bouginage.
* Dr. William Frederick Moore, of the Bronchoscopic Clinic, has
recently collected statistics of 202 cases of post-tonsillectomic
pulmonary abscess that point strongly to aspiration of infected clots
and other infective materials as the most frequent etiologic mechanism
(Moore, W. F., Pulmonary Abscess. Journ. Am. Med. Assn., April 29,
1922, Vol. 78, pp. 1279-1281).
In acquiring skill as an endoscopist the following paraphrased
aphorisms afford food for thought.
APHORISMS
Educate your eye and your fingers.
Be sure you are right, but not too sure.
Follow your judgment, never your impulse.
Cry over spilled milk enough to memorize how you spilled it.
Let your mistakes worry you enough to prevent repetition.
Let your left hand know what your right hand does and how
to do it.
Nature helps, but she is no more interested in the survival of your
patient than in the survival of the attacking pathogenic bacteria.
[126] CHAPTER XII--FOREIGN BODIES IN THE AIR AND FOOD PASSAGES
The air and food passages may be invaded by any foreign substance of
solid, liquid or gaseous nature, from the animal, vegetable, or
mineral kingdoms. Its origin may be from within the body (blood, pus,
secretion, broncholiths, sequestra, worms); introduced from without by
way of the natural passages (aspirated or swallowed objects); or it
may enter by penetration (bullet, dart, drainage tube from the neck).
_Prophylaxis_.--If one put into his mouth nothing but food, foreign
body accidents would be rare. The habit of holding tacks, pins and
whatnot in the mouth is quite universal and deplorable. Children are
prone to follow the bad example of their elders. No small objects such
as safety pins, buttons, and coins should be left within a baby's
reach; children should be watched and taught not to place things in
their mouths. Mothers should be specially cautioned not to give nuts
or nut candy of any kind to a child whose powers of mastication are
imperfect, because the molar teeth are not erupted. It might be made a
dictum that: "No child under 3 years of age should be allowed to eat
nuts, unless ground finely as in peanut butter." Digital efforts at
removal of foreign bodies frequently force the object downward, or may
hook it forward into the larynx, whereas if not meddled with digitally
the intruder might be spat out. Before general anesthesia the mouth
should be searched for loose teeth, removable dentures, etc., and all
unconscious individuals should be likewise examined. When working in
the mouth precautions should be taken against the possible inhalation
or swallowing of loose objects or instruments.
[126] Objects that have lodged in the esophagus, larynx, trachea, or
bronchi should be endoscopically removed.
_Foreign Bodies in the Insane_.--Foreign bodies may be introduced
voluntarily and in great numbers by the insane. Hysterical individuals
may assert the presence of a foreign body, or may even volitionally
swallow or aspirate objects. It is a mistake to do a bronchoscopy in
order to cure by suggestion the delusion of foreign body presence.
Such "cures" are ephemeral.
_Foreign Bodies in the Stomach_.--Gastroscopy is indicated in cases of
a foreign body that refuses to pass after a month or two. Foreign
bodies in very large numbers in the stomach, as in the insane, may be
removed by gastrostomy.
_The symptomatology of foreign bodies_ may be epitomized as given
below; but it must be kept in mind, that certain symptoms may not be
manifest immediately after intrusion, and others may persist for a
time after the passage, removal, or expulsion of a foreign body.
ESOPHAGEAL FOREIGN BODY SYMPTOMS
1. There are no absolutely diagnostic symptoms.
2. Dysphagia, however, is the most constant complaint, varying with
the size of the foreign body, and the degree of inflammatory or
spasmodic reaction produced.
3. Pain may be caused by penetration of a sharp foreign body, by
inflammation secondary thereto, by impaction of a large object, or by
spasmodic closure of the hiatus esophageus.
4. The subjective sensation of foreign body is usually present, but
cannot be relied upon as assuring the presence of a foreign body for
this sensation often remains for a time after the passage onward of
the intruder.
5. All of these symptoms may exist, often in the most intense
degree, as the result of previous violent attempts at removal; and the
foreign body may or may not be present.
SYMPTOMS OF LARYNGEAL FOREIGN BODY
1. Initial laryngeal spasm followed by wheezing respiration, croupy
cough, and varying degrees of impairment of phonation.
2. Pain may be a symptom. If so, it is usually located in the
laryngeal region, though in some cases it is referred to the ears.
3. The larynx may tolerate a thin, flat, foreign body for a
relatively long period of time, a month or more; but the development
of increasing dyspnea renders early removal imperative in the majority
of cases.
SYMPTOMS OF TRACHEAL AND BRONCHIAL FOREIGN BODY
1. Tracheal foreign bodies are usually movable and their movements
can usually be felt by the patient.
2. Cough is usually present at once, may disappear for a time and
recur, or may be continuous, and may be so violent as to induce
vomiting. In recent cases fixed foreign bodies cause little cough;
shifting foreign bodies cause violent coughing.
3. Sudden shutting off of the expiratory blast and the phonation
during paroxysmal cough is almost pathognomonic of a movable tracheal
foreign body.
4. Dyspnea is usually present in tracheal foreign bodies, and is due
to the bulk of the foreign body plus the subglottic swelling caused by
the traumatism of the shiftings of the intruder.
5. Dyspnea is usually absent in bronchial foreign bodies.
6. The respiratory rate is increased only if a considerable portion
of lung is out of function, by the obstruction of a main bronchus, or
if inflammatory sequelae are extensive.
7. The asthmatoid wheeze is usually present in tracheal foreign
bodies, and is often louder and of lower pitch than the asthmatoid
wheeze of bronchial foreign bodies. It is heard at the open mouth, not
at the chest wall; and prolonged expiration as though to rid the lungs
of all residual air, may be necessary to elicit it.
8. Pain is not a common symptom, but may occur and be accurately
localized by the patient, in case of either tracheal or bronchial
foreign body.
EARLY SYMPTOMS OF IRRITATING FOREIGN BODY SUCH AS A PEANUT KERNEL IN
THE BRONCHUS
1. Initial laryngeal spasm is almost invariably present with foreign
bodies of organic nature, such as nut kernels, peas, beans, maize,
etc.
2. A diffuse purulent laryngo-tracheo-bronchitis develops within 24
hours in children under 2 years.
3. Fever, toxemia, cyanosis, dyspnea and paroxysmal cough are
promptly shown.
4. The child is unable to cough up the thick mucilaginous pus
through the swollen larynx and may "drown in its own secretions"
unless the offender be removed.
5. "Drowned lung," that is to say natural passages idled with pus
and secretions, rapidly forms.
6. Pulmonary abscess develops sooner than in case of mineral foreign
bodies.
7. The older the child the less severe the reaction.
SYMPTOMS OF PROLONGED FOREIGN BODY SOJOURN IN THE BRONCHUS
1. The time of inhalation of a foreign body may be unknown or
forgotten.
2. Cough and purulent expectoration ultimately result, although
there may be a delusive protracted symptomless interval.
[130] 3. Periodic attacks of fever, with chills and sweats, and
followed by increased coughing and the expulsion of a large amount of
purulent, usually more or less foul material, are so nearly diagnostic
of foreign body as to call for exclusion of this probability with the
utmost care.
4. Emaciation, clubbing of the fingers and toes, night sweats,
hemoptysis, in fact all of the symptoms of tuberculosis are in most
cases simulated with exactitude, even to the gain in weight by an
out-door regime.
5. Tubercle bacilli have never been found, in the cases at the
Bronchoscopic Clinic, associated with foreign body in the bronchus.*
In cases of prolonged sojourn this has been the only element lacking
in a complete clinical picture of advanced tuberculosis. One point of
difference was the almost invariably rapid recovery after removal of
the foreign body. The statement in all of the text-books, that foreign
body is followed by phthisis pulmonalis is a relic of the days when
the bacillary origin of true tuberculosis was unknown, hence the
foreign-body phthisis pulmonalis, or pseudo tuberculosis, was confused
with the true pulmonary tuberculosis of bacillary origin.
6. The subjective sensation of pain may allow the patient accurately
to localize a foreign body.
7. Foreign bodies of metallic or organic nature may cause their
peculiar taste in the sputum.
8. Offensive odored sputum should always suggest bronchial foreign
body; but absence of sputum, odorous or not, should not exclude
foreign body.
9. Sudden complete obstruction of one main bronchus does not cause
noticeable dyspnea provided its fellow is functionating.
[131] 10. Complete obstruction of a bronchus is followed by rapid
onset of
symptoms.
11. The physical signs usually show limitation of expansion on the
affected side, impairment of percussion, and lessened trans-mission or
absence of breath-sounds distal to the foreign body.
* The exceptional case has at last been encountered. A boy with a tack
in the bronchus was found to have pulmonary tuberculosis.
SYMPTOMS OF GASTRIC FOREIGN BODY
Foreign body in the stomach ordinarily produces no symptoms. The
roentgenogram and the fluoroscopic study with an opaque mixture are
the chief means of diagnosis.
DIAGNOSIS OF FOREIGN BODY IN THE AIR OR FOOD PASSAGES
The questions arising are:
I. Is a foreign body present?
2. Where is it located?
3. Is a peroral endoscopic procedure indicated?
4. Are there any contraindications to endoscopy?
In order to answer these questions the definite routine given below is
followed unvaryingly in the Bronchoscopic Clinic.
1. History.
2. Complete physical examination, including mirror laryngoscopy.
3. Roentgenologic study.
4. Endoscopy.
The history should note the date of, and should delve into the details
of the accident; special note being made of the occurrence of
laryngeal spasm, wheezing respiration heard by the patient or others
(asthmatoid wheeze), fever, cough, pain, dyspnea, dysphagia,
odynphagia, regurgitation, etc. The amount, character and odor of
sputum are important. Increasing amounts of purulent, foul-odored,
sometimes blood-tinged sputum strongly suggest prolonged bronchial
foreign body sojourn. The mode of onset of the persisting symptoms,
whether immediately following the supposed accident or delayed in
their occurrence, is to be noted. Do attacks of sudden dyspnea and
cyanosis occur? What has been the previous treatment and what attempts
at removal have been made? The nature of the foreign body is to be
determined, and if possible a duplicate thereof obtained.
_General physical examination_ should be complete including inspection
of the eyes, ears, nose, pharynx, and mirror inspection of the
naso-pharynx and larynx. Special attention is paid to the chest for
the localization of the object. In order to discover conditions
rendering endoscopy unusually hazardous, all parts of the body are to
be examined. Aneurysm of the aorta, excessive blood pressure, serious
cardiac and renal conditions, the presence of a hernia and the
existence of central nervous disease, as tabes dorsalis, should be at
least known before attempting any endoscopic procedure. Dysphagia
might result from the pressure of an unknown aneurysm, the symptoms
being attributed to a foreign body, and aortic aneurysm is a definite
contraindication to esophagoscopy unless there be foreign body present
also. There is no absolute contraindication to the endoscopic removal
of a foreign body, though many conditions may render it wise to
post-pone endoscopy. Laryngeal crises of tabes might, because of their
sudden onset, be thought due to foreign body.
PHYSICAL SIGNS IN ESOPHAGEAL FOREIGN BODY
There are no constant physical signs associated with uncomplicated
impaction of a foreign body in the esophagus. Should perforation of
the cervical esophagus occur, subcutaneous emphysema, and perhaps
cellulitis, may be found; while a perforation of the thoracic region
causing mediastinitis is manifested by toxemia, fever, and rapid
sinking. Perforation of the pleura, with the development of
pyopneumothorax, is manifested by the usual signs. It is to be
emphasized that blind bouginage has no place in the diagnosis of any
esophageal condition. The roentgenologist will give the information we
desire without danger to the patient, and with far greater accuracy.
FOREIGN BODIES IN THE LARYNX
Laryngeally lodged foreign bodies produce a wheezing respiration, the
quality of which is peculiar to the larynx and is readily localized to
this organ. If swelling or the size of the foreign body be sufficient
to produce dyspnea, inspiratory indrawing of the suprasternal notch,
supraclavicular fossae, costal interspaces and lower sternum will be
present. Cyanosis is only an accompaniment of suddenly produced
dyspnea; the facies will therefore usually be anxious and pale, unless
the patient is seen immediately after the aspiration of the foreign
body. If labored breathing has been prolonged, and exhaustion
threatened, the heart's action will be irregular and weak. The foreign
body can be seen with the mirror, but a roentgenograph must
nevertheless be made, for the object may be of another nature than was
first thought. The roentgenograph will show its position, and from
this knowledge the plan of removal can be formulated. For example, a
straight pin may be so placed in the larynx that only a portion of its
shaft will be visible, the roentgenogram will tell where the head and
point are located, and which of these will be the more readily
disengaged. (See Chapter on Mechanical Problems.)
PHYSICAL SIGNS OF TRACHEAL FOREIGN BODY
If fixed in the trachea the only objective sign of foreign body may be
a wheezing respiration, the site of which may be localized with the
stethoscope, by the intensity of the sound. Movable foreign bodies may
produce a palpatory thrill, and the rumble and sudden stop can be
heard with the stethoscope and often with the naked ear. The lungs
will show equal aeration, but there may be marked dyspnea without the
indrawing of the fossae, if the object be of large size and located
below the manubrium.
To the peculiar sound of the sudden subglottic, expiratory or bechic
arrest of the foreign body the author has given the name "audible
slap;" when felt by the thumb on the trachea he calls it the
"palpatory thud." These signs can be produced by no condition other
than the arrest of some substance by the subglottic taper. Once heard
and felt they are unmistakable.
PHYSICAL SIGNS OF BRONCHIAL FOREIGN BODY
In most cases there will be limitation of expansion on the invaded
side, even though the foreign body is of such a shape as to cause no
bronchial obstruction. It has been noted frequently in conjunction
with the presence of such objects as a common straight pin in a small
branch bronchus. This peculiar phenomenon was first noted by Thomas
McCrae in one of the author's cases and has since been abundantly
corroborated by McCrae and others as one of the most constant physical
signs.
To understand the peculiar physical findings in these cases it is
necessary to remember that the bronchi are not tubes of constant
caliber; there occurs a dilatation during inspiration, and a
contraction of the lumen during expiration; furthermore, the lumen may
be narrowed by swollen mucosa if the foreign body be of an irritant
nature. The signs vary with the degree of obstruction of the bronchus,
and with the consequent degree of interference with aeration and
drainage of the subjacent portion of the lung. We have three definite
types which show practically constant signs in the earlier stages of
foreign body invasion.
1. Complete bronchial occlusion.
2. Obstruction complete during expiration, but allowing the passage
of air during the bronchial dilatation incident to inspiration,
constituting an expiratory valve-like obstruction.
3. Partial bronchial obstruction, allowing to-and-fro passage of
air.
1. _Complete bronchial obstruction_ is manifested by limitation of
expansion, markedly impaired percussion note, particularly at the
base, absence of breath-sounds, and rales on the invaded side. An
atelectasis here exists; the air imprisoned in the lung is soon
absorbed, and secretions rapidly accumulate. On the free side a
compensatory emphysema is present.
2. _Expiratory Valve-like Obstruction_.--The obstructed side shows
marked limitation of expansion. Percussion is of a tympanitic
character. The duration of the vibrations may be shortened giving a
muffled tympany. Various grades and degrees of tympany may be noted.
Breath sounds are markedly diminished or absent. No rales are heard on
the invaded side, although rales of all types may be present on the
free side. In some cases it is possible to hear a short inspiratory
sound. Vocal resonance and fremitus are but little altered. The heart
will be found displaced somewhat to the opposite side. These signs are
explained by the passage of some air past the foreign body during
inspiration with its trapping during expiration, so that there is air
under pressure constantly maintained in the obstructed area. This type
of obstruction is most frequently observed when the foreign body is of
an organic nature such as nut kernels, beans, corn, seed, etc. The
localized swelling about the irritating foreign body completes the
expiratory obstruction. It may also be present with any foreign body
whose size and shape are such as to occlude the lumen of the bronchus
during its contracted expiratory phase. It was present in cases of
pebbles, cylindrical metallic objects, thick tough balls of secretion
etcetera. The valvular action is here produced most often by a change
in the size of the valve seat and not by a movement of the foreign
body plug. In other cases I have found at bronchoscopy, a regular
ball-valve mechanism. Pneumothorax is the only pathologic condition
associated with signs similar to those of expiratory, valve-like
bronchial obstruction by a foreign body.
3. _Partial bronchial obstruction_ by an object such as a nail allows
air to pass to and fro with some degree of retardation, and impairs
the drainage of the subjacent lung. Limitation of expansion will be
found on the invaded side. The area below the foreign body will give
an impaired percussion note. Breath-sounds are diminished in the area
of dullness, and vocal resonance and fremitus are impaired. Rales are
of great diagnostic import; the passage of air past the foreign body
is accompanied by blowing, harsh breathing, and snoring; snapping
rales are heard usually with greatest intensity posteriorly over the
site of the foreign body (usually about the scapular angle).
A knowledge of the topographical lung anatomy, the bronchial tree, and
of endoscopic pathology* should enable the examiner of the chest to
locate very accurately a bronchial foreign body by physical signs
alone, for all the significant signs occur distal to the foreign body
lodgment.
* Jackson, Chevalier. Pathology of Foreign Bodies in the Air and Food
Passages. Mutter Lecture, 1918. Surgery, Gynecology and Obstetrics,
March, 1919. Also, by the same author, Mechanism of the Physical Signs
of Foreign Bodies in the Lungs. Proceedings of the College of
Physicians, Philadelphia, 1922.
_The asthmatoid wheeze_ has been found by the author a valuable
confirmatory sign of bronchial foreign body. It is a wheezing heard by
placing the observer's ear at the open mouth of the patient (not at
the chest wall) during a prolonged forced expiration. Thomas McCrae
elicits this sign by placing the stethoscope bell at the patient's
open mouth. The quality of the sound is dryer than that heard in
asthma and the wheeze is clearest after all secretion has been removed
by coughing. The mechanism of production is, probably, the passage of
air by a foreign body which narrows the lumen of a large bronchus. As
the foreign body works downward the wheeze lessens. The wheeze is
often so loud as to be heard at some distance from the patient. It is
of greatest value in the diagnosis of non-roentgenopaque foreign body
but its absence in no way negates foreign body. Its presence or
absence should be recorded in every case.
_Prolonged bronchial obstruction_ by foreign body is followed by
bronchiectasis and lung abscess usually in a lower lobe. The symptoms
may with exactitude simulate tuberculosis, but this disease should be
readily excluded by the basal, unilateral site of the lesion, absence
of tubercle bacilli in the sputum, and roentgenographic study. Chest
examination in the foreign body cases reveals limitation of expansion,
often some retraction, flat percussion note, and greatly diminished or
absent breath-sounds over the site of the pulmonary lesion. Rales vary
with the amount of secretion present. These physical signs suggest
empyema; and rib resection had been done before admission in a number
of cases only to find the pleura normal.
ROENTGENRAY STUDY IN FOREIGN BODY CASES
_Roentgenography_.--All cases of chest disease should have the benefit
of a roentgenologic study to exclude bronchial foreign bod
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