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