,this book is one of the pioneering works in laryngology4 ,the original text is from the library of ,indiana ,university ,department of ,otolaryngology-,head and ,neck ,surgery1 ,bruce ,matt1 ,,md4 ,it was scanned1 converted to text1 and proofed by ,alex ,tawadros4 ,,bronchoscopy ,,and ,,esophagoscopy ,a ,manual of ,peroral ,endoscopy and ,laryngeal ,surgery by ,,chevalier ,,jackson1 ,m4,d41 ,f4,a4,c4,s4 ,professor of ,laryngology1 ,jefferson ,medical ,college1 ,philadelphia2 ,professor of ,bronchoscopy and ,esophagoscopy1 ,graduate ,school of ,medicine1 ,university of ,pennsylvania2 ,member of the ,american ,laryngological ,association2 ,member of the ,laryngological1 ,rhinological1 and ,otological ,society2 ,member of the ,american ,academy of ,ophthalmology and ,oto-,laryngology2 ,member of the ,american ,bronchoscopic ,society2 ,member of the ,american ,philosophical ,society2 etc41 etc4 ,with #aad ,illustrations and ,four ,color ,plates ,philadelphia ,and ,london ,w4 ,b4 ,saunders ,company #aibb ,copyrights #aibb1 by ,w4 ,b4 ,saunders ,company ,made in ,u4,s4,a4 ,,to ,,my ,,mother ,,to ,,whose ,,interest ,,in ,,medical ,,science ,,the ,,author ,,owes ,,his ,,incentive1 ,,and ,,to ,,my ,,father ,,whose ,,constant ,,advice ,,to ,,educate ,,the ,,eye ,,and ,,the ,,fingers ,,spurred ,,the ,,author ,,to ,,continual ,,effort1 ,,this ,,book ,,is ,,affectionately ,,dedicated4 ,,preface ,this book is based on an abstract of the author's larger work1 ,peroral ,endoscopy and ,laryngeal ,surgery4 ,the abstract was prepared under the author's direction by a reader1 in order to get a reader's point of view on the presentation of the subject in the earlier book4 ,with this abstract as a starting point1 the author has endeavored1 so far as lay within his limited abilities1 to accomplish the difficult task of presenting by written word the various purely manual endoscopic procedures4 ,the large number of corrections and revisions found necessary has confirmed the wisdom of the plan of getting the reader's point of view2 and these revisions1 together with numerous additions1 have brought the treatment of the subject up to date so far as is possible within the limits of a working manual4 ,acknowledgment is due the personnel of the ,w4 ,b4 ,saunders ,company for kindly help4 ,,chevalier ,,jackson4 ,,october1 #aibb4 ,,ii ,,contents ,,page ,,chapter ,i ,,instrumentarium #ag ,,chapter ,,ii ,,anatomy ,,of ,,larynx1 ,,trachea1 ,,bronchi ,,and ,,esophagus1 ,,endoscopically ,,considered #eb ,,chapter ,,iii ,,preparation ,,of ,,the ,,patient ,,for ,,peroral ,,endoscopy #fc ,,chapter ,,iv ,,anesthesia ,,for ,,peroral ,,endoscopy #fe ,,chapter ,v ,,bronchoscopic ,,oxygen ,,insufflation #ga ,,chapter ,,vi ,,position ,,of ,,the ,,patient ,,for ,p,e,r,o,r,al ,,endoscopy #gc ,,chapter ,,vii ,,direct ,,laryngoscopy #hb ,,chapter ,,viii ,,direct ,,laryngoscopy 7,continued7 #ia ,,chapter ,,ix ,,introduction ,,of ,,the ,,bronchoscope #ig ,,chapter ,x ,,introduction ,,of ,,the ,,esophagoscope #ajf ,,chapter ,,xi ,,acquiring ,,skill #aag ,,chapter ,,xii ,,foreign ,,bodies ,,in ,,the ,,air ,,and ,,food ,,passages #abf ,,chapter ,,xiii ,,foreign ,,bodies ,,in ,,the ,,larynx ,,and ,,tracheobronchial ,,tree #adi ,,chapter ,,xiv ,,removal ,,of ,,foreign ,,bodies ,,from ,,the ,,larynx #aef ,,chapter ,,xv ,,mechanical ,,problems ,,of ,,bronchoscopic ,,foreign ,,body ,,extraction #aeh ,,chapter ,,xvi ,,foreign ,,bodies ,,in ,,the ,,bronchi ,,for ,,prolonged ,,periods #agg ,,chapter ,,xvii ,,unsuccessful ,,bronchoscopy ,,for ,,foreign ,,bodies #aha ,,chapter ,,xviii ,,foreign ,,bodies ,,in ,,the ,,esophagus #ahc ,,chapter ,,xix ,,esophagoscopy ,,for ,,foreign ,,body #ahg ,,chapter ,,xx ,,pleuroscopy #aii ,,chapter ,,xxi ,,benign ,,growths ,,in ,,the ,,larynx #bja ,,chapter ,,xxii ,,benign ,,growths ,,in ,,the ,,larynx 7,continued7 #bjc ,,chapter ,,xxiii ,,benign ,,growths ,,primary ,,in ,,the ,,tracheobronchial ,,tree #bjg ,,chapter ,,xxiv ,,benign ,,neoplasms ,,of ,,the ,,esophagus #bji ,,chapter ,,xxv ,,endoscopy ,,in ,,malignant ,,disease ,,of ,,the ,,larynx #baj ,,chapter ,,xxvi ,,bronchoscopy ,,in ,,malignant ,,growths ,,of ,,the ,,trachea #bad ,,chapter ,,xxvii ,,malignant ,,disease ,,of ,,the ,,esophagus #baf ,,chapter ,,xxviii ,,direct ,,laryngoscopy ,,in ,,diseases ,,of ,,the ,,larynx #bba ,,chapter ,,xxix ,,bronchoscopy ,,in ,,diseases ,,of ,,the ,,trachea ,,and ,,bronchi #bbd ,,chapter ,,xxx ,,diseases ,,of ,,the ,,esophagus #bce ,,chapter ,,xxxi ,,diseases ,,of ,,the ,,esophagus 7,continued7 #bde ,,chapter ,,xxxii ,,diseases ,,of ,,the ,,esophagus 7,continued7 #bea ,,chapter ,,xxxiii ,,diseases ,,of ,,the ,,esophagus 7,continued7 #bfj ,,chapter ,,xxxiv ,,diseases ,,of ,,the ,,esophagus 7,continued7 #bfh ,,chapter ,,xxxv ,,gastroscopy #bgc ,,chapter ,,xxxvi ,,acute ,,stenosis ,,of ,,the ,,larynx #bgg ,,chapter ,,xxxvii ,,tracheotomy #bgi ,,chapter ,,xxxviii ,,chronic ,,stenosis ,,of ,,the ,,larynx ,,and ,,trachea #cjj ,,chapter ,,xxxix ,,decannulation ,,after ,,cure ,,of ,,laryngeal ,,stenosis #cji ,,bibliography #caa ,,index #cae #ag ,,chapter ,i--,,instrumentarium ,direct laryngoscopy1 bronchoscopy1 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 vision4 ,illumination is supplied by a small tungsten-filamented1 electric1 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 tube4 ,the bronchi and the esophagus will not allow dilatation beyond their normal caliber2 therefore1 it is necessary to have tubes of the sizes to fit these passages at various developmental ages4 ,rupture or even over-distention of a bronchus or of the thoracic esophagus is almost invariably fatal4 ,the armamentarium of the endoscopist must be complete1 for it is rarely possible to substitute1 or to improvise makeshifts1 while the bronchoscope is in situ4 ,furthermore1 the instruments must be of the proper model and well made2 otherwise difficulties and dangers will attend attempts to see them4 ,laryngoscopes4--,the regular type of laryngoscope shown in ,fig4 ,i 7,a1 ,b1 ,c7 is made in adult's1 child's1 and infant's sizes4 ,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 it4 ,the infant size is made in two forms1 one with1 the other without a removable slide2 with either form the larynx of an infant can be exposed in but a few seconds and a definite diagnosis made1 without anesthesia1 general or local2 a thing possible by no other method4 ,for operative work on the larynx of adults1 such as the removal of benign growths1 particularly when these are situated in the anterior portion of the larynx1 a special tubular laryngoscope having a heart-shaped lumen and a beveled tip is used4 ,with this instrument the anterior commissure is readily exposed1 and because of this it is named the anterior commissure laryngoscope 7,fig4 #a1 ,d74 ,the tip of the anterior commissure laryngoscope can be used to expose either ventricle of the larynx by lifting the ventricular band1 or it may be passed through the adult glottis for work in the subglottic region4 ,this instrument may also be used as an esophageal speculum and as a pleuroscope4 ,a side-slide laryngoscope1 used with or without the slide1 is occasionally useful4 ,bronchoscopes4--,the regular bronchoscope is a hollow brass tube slanted at its distal end1 and having a handle at its proximal or ocular extremity4 ,an auxiliary canal on its under surface contains the light carrier1 the electric bulb of which is situated in a recess in the beveled distal end of the tube4 ,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 impaired4 ,the accessory tube on the upper surface of the bronchoscope ends within the lumen of the bronchoscope1 and is used for the insufflation of oxygen or anesthetics1 7,fig4 #b1 ,a1 ,b1 ,c1 ,d74 ,for certain work such as drainage of pulmonary abscesses1 the lavage treatment of bronchiectasis and for foreign-body or other cases with abundant secretions1 a drainage-bronchoscope is useful ,the drainage canal may be on top1 or on the under surface next to the light-carrier canal4 ,for ordinary work1 however1 secretion in the bronchus is best removed by sponge-pumping 7,q4,v47 which at the same time cleans the lamp4 ,the drainage bronchoscope may be used in any case in which the very slightly-greater area of cross section is no disadvantage2 but in children the added bulk is usually objectionable1 and in cases of recent foreign-body1 secretions are not troublesome4 ,as before mentioned1 the lower air passages will not tolerate dilatation2 therefore1 it is necessary never to use tubes larger than the size of the passages to be examined4 ,four sizes are sufficient for any possible case1 from a newborn infant to the largest adult4 ,for infants under one year1 the proper tube is the #d mm4 by #cj cm42 the child's size1 #e mm4 by #cj cm41 is used for children aged from one to five years4 ,for children six years or over1 the #g mm4 by #dj cm4 bronchoscope 7the adolescent size7 can be used unless the smaller bronchi are to be explored4 ,the adult bronchoscope measures #i mm4 by #dj cm4 ,the author occasionally uses special sizes1 #e mm4 x #de cm41 #f mm4 x #ce cm41 #h mm4 x #dj cm4 ,esophagoscopes4-,the esophagoscope1 like the bronchoscope1 is a hollow brass tube with beveled distal end containing a small electric light4 ,it differs from the bronchoscope in that it has no perforations1 and has a drainage canal on its upper surface1 or next to the light-carrier canal which opens within the distal end of the tube4 ,the exact size1 position1 and shape of the drainage outlets is important on bronchoscopes1 and to an even greater degree on esophagoscopes4 ,if the proximal edge of the drainage outlet is too near the distal end of the endoscopic tube1 the mucosa will be drawn into the outlet1 not only obstructing it1 but1 most important1 traumatizing the mucosa4 ,if1 for instance1 the esophagoscope were to be pushed upon with a fold thus anchored in the distal end1 the esophageal wall could easily be torn4 ,to admit the largest sizes of esophagoscopic bougies 7,fig4 #dj71 special esophagoscopes 7,fig4 #e7 are made with both light canal and drainage canal outside the lumen of the tube1 leaving the full area of luminal cross-section unencroached upon4 ,they can1 of course1 be used for all purposes1 but the slightly greater circumference is at times a disadvantage4 ,the esophageal and stomach secretions are much thinner than bronchial secretions1 and1 if free from food1 are readily aspirated through a comparatively small canal4 ,if the canal becomes obstructed during esophagoscopy1 the positive pressure tube of the aspirator is used to blow out the obstruction4 ,two sizes of esophagoscopes are all that are required--#g mm4 ,x #de cm4 for children1 and #aj mm4 ,x #ec cm4 for adults 7,fig4 #c1 ,a and ,b72 but various other sizes and lengths are used by the author for special purposes499 ,large esophagoscopes cause dangerous dyspnea in children4 ,if1 it is desired to balloon the esophagus with air1 the window plug shown in ,fig4 #f1 is inserted into the proximal end of the esophagoscope1 and air insufflated by means of the hand aspirator or with a hand bulb4 ,the window can be replaced by a rubber diaphragm with a perforation for forceps if desired4 ,it will be noted that none of the endoscopic tubes are fitted with mandrins4 ,they are to be introduced under the direct guidance of the eye only4 ,mandrins are obtainable1 but their use is objectionable for a number of reasons1 chief of which is the danger of overriding a foreign body or a lesion1 or of perforating a lesion1 or even the normal esophageal wall4 ,the slanted end on the esophagoscope obviates the necessity of a mandrin for introduction4 ,the longer the slant1 with consequent acuting of the angle1 the more the introduction is facilitated2 but too acute an angle increases the risk of perforating the esophageal wall1 and necessitates the utmost caution4 ,in some foreign-body cases an acute angle giving a long slant is useful1 in others a short slant is better1 and in a few cases the squarely cut-off distal end is best4 ,to have all of these different slants on hand would require too many tubes4 ,therefore the author has settled upon a moderate angle for the end of both esophagoscopes and bronchoscopes that is easy to insert1 and serves all purposes in the version and other manipulations required by the various mechanical problems of foreign-body extraction4 ,he has1 however1 retained all the experimental models1 for occasional use in such cases as he falls heir to because of a problem of extraordinary difficulty4 99 ,a #i mm4 ,x #de cm4 esophagoscope will reach the stomach of almost all adults and is somewhat easier to introduce than the #aj mm4 ,x #ec cm41 which may be omitted from the set if economy must be practiced4 ,,fig4 ,i4--,author's laryngoscopes4 ,these are the standard sizes and fulfill all requirements4 ,many other forms have been devised by the author1 but have been omitted from the list as unnecessary4 ,the infant diagnostic laryngoscope 7,c7 is not for introducing bronchoscopes1 and is not absolutely necessary1 as the larynx of any infant can be inspected with the child's size laryngoscope 7,b74 ,a ,adult's size2 ,b1 child's size2 ,c1 infant's diagnostic size2 ,d1 anterior commissure laryngoscope2 ,e1 with drainage canal2 #ag1 intubating laryngoscope1 large lumen4 ,all the laryngoscopes are preferred without drainage canals4 ,,fig4 #b4--,the author's bronchoscopes of the sizes regularly used4 ,various other lengths and diameters are on hand for occasional use for special purposes4 ,with the exception of a #f mm4 ,x #ce cm4 size for older children1 these special bronchoscopes are very rarely used and none of them can be regarded as necessary4 ,for special purposes1 however1 special shapes of tube-mouth are useful1 as1 for instance1 the oval end to facilitate the getting of both points of a staple into the tube-mouth ,the illustrated instruments are as follows3 ,a1 ,infant's size1 #d mm4 ,x #cj cm42 ,b1 child's size1 #e mm4 ,x #cj cm42 ,c1 adolescent's size1 #g mm4 ,x #dj cm42 ,d1 adult's size1 #i mm4 ,x #dj cm42 ,e1 aspirating bronchoscope made in all the foregoing sizes1 and in a special size1 #e mm4 ,x #de cm4 ,,fig4 #c4--,the author's esophagoscopes of the sizes he has standardized for all ordinary requirements4 ,he uses various other lengths and sizes for special purposes1 but none of them are really necessary4 ,a gastroscope1 #aj mm4 ,x #gj cm41 is useful for adults1 especially in cases of gastroptosis4 ,drainage canals are placed at the top or at the side of the tube1 next to the light-carrier canal4 ,a1 ,adult's size1 #aj mm4 ,x #ec cm42 ,b1 child's size1 #g mm4 ,x #de cm42 ,c and ,d1 full lumen1 with both light canal and drainage canal outside the wall of the tube1 to be used for passing very large bougies4 ,this instrument is made in adult1 child1 and adolescent 7#h mm4 by #de cm47 sizes4 ,gastroscopes and esophagoscopes of the sizes given above 7,a7 and 7,b71 can be used also as gastroscopes4 ,a small form of ,c1 #e mm4 ,x #cj cm4 is used in infants1 and also as a retrograde esophagoscope in patients of any age4 ,e1 window plug for ballooning gastroscope1 ,f4 ,,fig4 #d4--;,author's short esophagoscopes and esophageal specula ,a1 ,esophageal speculum and hypopharyngoscope1 adult's size2 ,b1 esophageal speculum and hypopharyngoscope1 child's size2 ,c1 heavy handled short esophagoscope2 ,d1 heavy handled short esophagoscope with drainage4 ,,fig4 #e4--;,cross section of full-lumen esophagoscope for the use of largest bourgies4 ,the canals for the light carrier and for drainage are so constructed that they do not encroach upon the lumen of the tube4 #be ,the special sized esophagoscopes most often useful are the #h mm4 ,x #cj cm41 the #h mm4 ,x #de cm41 and the #e mm4 ,x #de cm4 ,these are made with the drainage canal in various positions4 ,for operations on the upper end of the esophagus1 and particularly for foreign body work1 the esophageal speculum shown at ,a and ,b1 in ,fig4 #d1 is of the greatest service4 ,with it1 the anterior wall of the post-cricoidal pharynx is lifted forward1 and the upper esophageal orifice exposed4 ,it can then be inserted deeper1 and the upper third of the esophagus can be explored4 ,two sizes are made1 the adult's and the child's size4 ,these instruments serve1 very efficiently as pleuroscopes4 ,they are made with and without drainage canals1 the latter being the more useful form4 ,,fig4 #f4--,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 escape4 ,valves on the canals 7,e1 ,f1 ,fig4 #c7 are preferable4 ,gastroscopes4--,the gastroscope is of the same construction as the esophagoscope1 with the exception that it is made longer1 in order to reach all parts of the stomach4 ,in ordinary cases1 the regular esophagoscopes for adults and children respectively will afford a good view of the stomach1 but there are cases which require longer tubes1 and for these a gastroscope #aj mm4 ,x #gj cm4 is made1 and also one #aj mm4 ,x #hj cm41 though the latter has never been needed but once4 #bf ,pleuroscopes4--,as mentioned above the anterior commissure laryngoscope and the esophageal specula make very efficient pleuroscopes2 but three different forms of pleuroscopes have been devised by the author for pleuroscopy4 ,the retrograde esophagoscope serves very well for work through small fistulae4 ,measuring ,rule 7,fig4 #g74--;,it is customary to locate esophageal lesions by denoting their distance from the incisor teeth4 ,this is readily done by measuring the distance from the proximal end of the esophagoscope to the upper incisor teeth1 or in their absence1 to the upper alveolar process1 and subtracting this measurement from the known length of the tube4 ,thus1 if an esophagoscope #de cm4 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 #bj cm41 we subtract this #bj cm4 from the total length of the esophagoscope 7#de cm47 and then know that the distal end of the tube is #be cm4 from the incisor teeth4 ,graduation marks on the tube have been used1 but are objectionable4 ,,fig4 #g4--,measuring rule for gauging in centimeters the depth of any location by subtraction of the length of the uninserted portion of the esophagoscope or bronchoscope4 ,this is preferable to graduations marked on the tubes1 though the tubes can be marked with a scale if desired4 ,batteries4--,the simplest1 best1 and safest source of current is a double dry battery arranged in three groups of two cells each1 connected in series 7,fig4 #h74 ,each set should have two binding posts and a rheostat4 ,the binding posts should have double holes for two additional cords1 to be kept in reserve for use in case a cord becomes defective499 ,the commercial current reduced through a rheostat should never be used1 because there is always the possibility of grounding the circuit through the patient2 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 heart4 ,the endoscopist should never depend upon a pocket battery as a source of illumination1 for it is almost certain to fail during the endoscopy4 ,the wires connecting the battery and endoscopic instrument are covered with rubber1 so that they may be cleansed and superficially sterilized with alcohol4 ,they may be totally immersed in alcohol for any length of time without injury4 99 ,when this is done care is necessary to avoid attempting to use simultaneously the two cords from one pair of posts4 ,,fig #h4--,the author's endoscopic battery1 heavily built for reliability4 ,it contains #f dry cells1 series-connected in #c groups of #b cells each4 ,each group has its own rheostat and pair of binding posts4 ,aspirating ,tubes4--,independent aspirating tubes involve delay in their use as compared to aspirating canals in the wall of the endoscopic tube2 but there are special cases in which an independent tube is invaluable4 ,three forms are used by the author4 ,the velvet eye cannot traumatize the mucosa 7,fig4 #i74 ,to hold a foreign body by suction1 a squarely cut off end is necessary4 ,for use through the tracheotomic wound without a bronchoscope a malleable tube 7,fig4 #aj7 is better4 ,,fig4 #i4--,the author's protected-aperture endoscopic aspirating tube for aspiration of pharyngeal secretions during direct laryngoscopy and endotracheobronchial secretions at bronchoscopy1 also for draining retropharyngeal abscesses4 ,the laryngoscopes are obtainable with drainage canals1 but for most purposes the independent aspirating tube shown above is more satisfactory4 ,the tubes are made in #bj #cj1 #dj1 and #fj cm4 lengths4 ,an aperture on both sides prevents drawing in the mucosa4 ,it can be used for insufflation of ether if desired4 ,an aspirating tube of the same design1 but having a squarely cut off end1 is sometimes useful for removing secretions lying close to a foreign body2 for removing papillomata2 and even for withdrawing foreign bodies of a soft surface consistency4 ,it is not often that the foreign bodies can be thus withdrawn through the glottis1 but closely fitting foreign bodies can at least be withdrawn to a higher level at which ample forceps spaces will permit application of forceps4 ,such aspirating tubes1 however1 are not so safe to use as the protected1 double aperture tubes4 ,,fig4 #aj4--,the author's malleable tracheotomic aspirating tube for removal of secretions1 exudates1 crusts1 etc41 from the tracheobronchial tree through the tracheotomic wound without a bronchoscope4 ,the tube is made of copper so that it can be bent to any curve1 and the copper wire stylet prevents kinking4 ,the stylet is removed before using the tube for aspiration4 #bh ,aspirators4--,the various electric aspirators so universally used in throat operations should be utilized to withdraw secretions in the tubes fitted with drainage canals4 ,they1 however1 have the disadvantages of not being easily transported1 and of occasionally being out of order4 ,the hand aspirator shown in ,fig4 #aa is1 therefore1 a necessary part of the instrumental equipment4 ,it never fails to work1 is portable1 and affords both positive and negative pressures4 ,the positive pressure is sometimes useful in clearing the drainage canal of any particles of food1 tissue1 clots1 or secretion which may obstruct it2 and it also serves to fill the stomach or esophagus with air when the ballooning procedure is used4 ,the mechanical aspirator 7,fig4 #ab7 is highly efficient and is the one used in the ,bronchoscopic ,clinic4 ,the positive pressure will quickly clear obstructed drainage canals1 and may be used while the esophagoscope is in situ1 by simply detaching the minus pressure tube and attaching the plus pressure4 ,in the lungs1 however1 high plus pressures are so dangerous that the pressure valve must be lowered4 ,fig4 #aa--,portable aspirator for endoscopy with additional tube connected with the plus pressure side for use in case of occlusion of the drainage canal4 ,this aspirator has the advantage of great power with portability4 ,where portability is not required the electrically operated aspirator is better4 ,,fig4 #ab4--,robinson mechanical aspirator adapted for bronchoscopic and esophagoscopic aspiration by the author4 ,the positive pressure is used for clearing obstructed drainage canals and tubes4 ,,fig4 #ac4--;,apparatus for insufflation of ether or chloroform during bronchoscopy1 for those who may desire to use general anesthesia4 ,the mechanical methods of intratracheal insufflation anesthesia subsequently developed by ,meltzer and ,auer1 ,elsberg1 ,geo4 ,p4 ,muller and others have rightly superseded this apparatus for all general surgical purposes4 ,sponge-pumping4--,while the usually thin1 watery esophageal and gastric secretions1 if free from food1 are readily aspirated through a drainage canal1 the secretions of the bronchi are often thick and mucilaginous and aspirated with difficulty4 ,further-more1 bronchial secretions as a rule are not collected in pools1 but are distributed over the walls of the larger bronchi and continuously well up from smaller bronchi during cough4 ,the aspirating bronchoscopes should be used whenever their very slight additional area of cross-section is unobjectionable4 ,in most cases1 however1 the most advantageous way to remove bronchial secretion has been found to be by introducing a gauze swab on a long sponge carrier 7,fig4 #ad71 so that the sponge extends beyond the distal end of the bronchoscope1 causing cough4 ,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 it4 ,by this maneuver the walls of the bronchus are wiped free from secretions1 and the lamp itself is cleansed4 ,,fig4 #ad4--,sponge carrier with long collar for carrying the small sponges shown in ,fig4 #ae4 ,the collar screws down as in the ,coolidge cotton carrier4 ,about a dozen of these are needed and they should all be small enough to go through the #d mm4 7diameter7 bronchoscope and long enough to reach through the #ec cm4 7length7 esophagoscope1 so that one set will do for all tubes4 ,the schema shows method of sponging4 ,the carrier ,c1 armed with the sponge1 ,s1 when rotated as shown by the dart1 ,d1 wipes the field1 ,p1 at the same time wiping the lamp1 ,l4 ,the lamp does not need ever to be withdrawn for cleaning during bronchoscopy4 ,it is protected in a recess so that it does not catch in the sponges4 ,,fig #ae4--;,exact size to which the bandage-gauze is cut to make endoscopic sponges4 ,each rectangle is the size for the tubal diameter given4 ,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 drawing4 ,the gauze rectangles are folded up endwise as shown at ,a1 then once in the middle as at ,b1 then strung one dozen on a safety pin4 ,in ,america gauze bandages run about #af threads to the centimeter4 ,different material might require a slightly different size and the pattern could be made to suit4 #cb ,the gauze sponges are made by the instrument nurse as directed in ,fig4 #ae1 and are strung on safety pins1 wrapped in paper1 the size indicated by a figure on the wrapper1 and then sterilized in an autoclave4 ,the sterile packages are opened only as needed4 ,these bronchoscopic sponges are also made by ,johnston and ,johnston1 of ,new ,brunswick1 ,n4 ,j4 and are sold in the shops4 ,mouth-gag4--,wide gagging prevents proper exposure of the larynx by forcing the mandible down on the hyoid bone4 ,the mouth should be gently opened and a bite block 7,fig4 #af7 inserted between the teeth on the left side of the patient's mouth1 to prevent closing of the jaws on the delicate bronchoscope or esophagoscope4 ,,fig4 #af4--;,bite block to be inserted between the teeth to prevent closure of the jaws on the endoscopic tube4 ,this is the ,mc,kee-,mc,cready modification of the ,boyce thimble with the omission of the etherizing tube1 which is no longer needed4 ,the block has been improved by ,dr4 ,w4 ,f4 ,moore of the ,bronchoscopic ,clinic4 ,forceps4--,delicacy of touch and manipulation are an absolute necessity if the endoscopist is to avoid mortality2 therefore1 heavily built and spring-opposed forceps are dangerous as well as useless4 ,for foreign-body work in the larynx1 and for the removal of benign laryngeal growths1 the alligator forceps with roughened jaws shown in ,fig4 #ag serve every purpose4 ,,fig4 #ag4--,laryngeal grasping forceps designed by ,mosher4 ,for my own use ,i have taken off the ratchet-locking device for all general work1 to be reapplied on the rare occasions when it is required4 ,bronchoscopic and esophagoscopic grasping forceps are of the tubular type1 that is1 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 tube1 thus causing the blades to approximate4 ,they are very delicate and light1 yet have great grasping power and will sustain any degree of traction that it is safe to exert4 ,they permit of the delicacy of touch of a violin bow4 ,the two types of jaws most frequently used1 are those with the forward-grasping blades shown in ,fig4 #ah1 and those having side-grasping blades shown in ,fig4 #ai4 ,the side-curved forceps are perhaps the most generally useful of all the endoscopic forceps2 the side projection of the jaws makes them readily visible during their closure on an object2 their broader grasp is also an advantage41 ,the projection of the blades in the side-curved grasping forceps should always be directed toward the left4 ,if it is desired that they open in another direction this should be accomplished by turning the handle and not by adjusting the blade itself4 ,if this rule be followed it will always be possible to tell by the position of the handle exactly where the blades are situated2 whereas1 if the jaws themselves are turned1 confusion is sure to result4 ,the forward-grasping forceps are always so adjusted that the jaws open in an up-and-down direction4 ,on rare occasions it may be deemed desirable to turn the stylet of either forceps in some other direction relative to the handle4 ,,fig4 #ah4--,the author's forward grasping tube forceps4 ,the handle mechanism is so simple and delicate that the most exquisite delicacy of touch is possible4 ,two locknuts and a thumbscrew take up all lost motion yet afford perfect adjustability and easy separation for cleansing4 ,at ,a is shown a small clip for keeping the jaws together to prevent injurious bending in the sterilizer1 or carrying case4 ,at the left is shown a handle-clamp for locking the forceps on a foreign body in the solution of certain rarely encountered mechanical problems4 ,the jaws are serrated and cupped4 ,,fig4 #ai4--;,jaws of the author's side-curved endoscopic forceps4 ,these work as shown in the preceding illustration1 each forceps having its own handle and tube4 ,originally the end of the cannula and stylet were squared to prevent rotation of the jaws in the cannula4 ,this was found to be unnecessary with properly shaped jaws1 which wedge tightly4 ,rotation ,forceps4--,it is sometimes desired to make traction on an irregularly shaped foreign body1 and yet to allow the object to turn into the line of least resistance while traction is being made4 ,this can be accomplished by the use of the rotation forceps 7,fig4 #bj71 which have for blades two pointed hooks that meet at their points and do not overlap4 ,rotation forceps made on the model of the laryngeal grasping forceps1 but having opposing points at the end of the blades1 are sometimes very useful for the removal of irregular foreign bodies in the larynx1 or when used through the esophageal speculum they are of great service in the extraction of such objects as bones1 pin-buttons1 and tooth-plates1 from the upper esophagus4 ,these forceps are termed laryngeal rotation forceps 7,fig4 #ca74 ,all the various forms of forceps are made in a very delicate size often called the mosquito or extra light forceps1 #dj cm4 in length1 for use in the #d mm4 and the #e mm4 bronchoscopes4 ,for the #e mm4 bronchoscopes heavier forceps of the #dj cm4 length are made4 ,for the larger tubes the forceps are made in #de cm41 #ej cm41 and #fj cm4 lengths4 ,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 purposes4 ,,fig4 #bj4--,the author's rotation forceps4 ,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 stomach1 turning and withdrawal1 spring up4 ,upper-lobe-bronchus ,forceps4--,foreign bodies rarely lodge in an upper-lobe bronchus1 yet with such a problem it is necessary to have forceps that will reach around a corner4 ,the upper-lobe-bronchus forceps shown in ,fig4 #bg 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 tube1 the radius of curvature being regulated by the extent of emergence permitted4 ,they are made in extra-light pattern1 #dj cm4 long1 and the regular model #de cm4 long4 ,the full-curved model1 giving #ahj degrees and reaching up into the ascending branches1 is made in both light and heavy patterns4 ,forceps with less curve1 and without the spiral1 are used when it is desired to reach only a short distance around the corner anywhere in the bronchi4 ,these are also useful1 as suggested by ,willis ,f4 ,manges1 in dealing with safety pins in the esophagus or tracheobronchial tree4 ,,fig4 #ba4--,tucker jaws for the author's forceps4 ,the tiny lip projecting down from the upper1 and up from the lower jaw prevents sidewise escape of the shaft of a pin1 tack1 nail or needle4 ,the shaft is automatically thrown parallel to the bronchoscopic axis4 ,drawing about four times actual size4 #cf ,tucker ,forceps--,gabriel ,tucker modified the regular side-curved forceps by adding a lip 7,fig4 #ba7 to the left hand side of both upper and lower jaws4 ,this prevents the shaft of a tack1 nail1 or pin1 from springing out of the grasp of the jaws1 and is so efficient that it has brought certainty of grasp never before obtainable4 ,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 extraction4 ,,fig4 #bb4--,the author's down-jaw esophageal forceps4 ,the dropping jaw is useful for reaching backward below the cricopharyngeal fold when using the esophageal speculum in the removal of foreign bodies4 ,posterior forceps-spaces are often scanty in cases of foreign bodies lodged just below the cricopharyngeus4 ,,fig4 #bc4--;,expansile forceps for the endoscopic removal of hollow foreign bodies such as intubation tubes1 tracheal cannulae1 caps1 and cartridge shells4 ,screw forceps4--,for the secure grasp of screws the jaws devised by ,dr4 ,tucker for tacks and pins are excellent 7,fig4 #ba74 ,expanding ,forceps4--,hollow objects may require expanding forceps as shown in ,fig4 #bc4 ,in using them it is necessary to be certain that the jaws are inside the hollow body before expanding them and making traction4 ,otherwise severe1 even fatal1 trauma may be inflicted4 ,,fig4 #bd4--,the author's fenestrated peanut forceps4 ,the delicate construction with long1 springy and fenestrated jaws give in gentle hands a maximum security with a minimum of crushing tendency4 ,,fig4 #be--,the author's bronchial dilators1 useful for dilating strictures above foreign bodies4 ,the smaller size1 shown at the right is also useful as an expanding forceps for removing intubation tubes1 and other hollow objects4 ,the larger size will go over the shaft of a tack4 ,,fig4 #bf4--,the author's self-expanding bronchial dilator4 ,the extent of expansion can be limited by the sense of touch or by an adjustable checking mechanism on the handle4 ,the author frequently used smooth forceps for this purpose1 and found them so efficient that this dilator was devised4 ,the edges of forceps jaws are likely to scratch the epithelium4 ,occasionally the instrument is useful in the esophagus2 but it is not very safe1 unless used with the utmost caution4 ,tissue ,forceps4--,with the forceps illustrated in ,fig4 #bh specimens of tissue may be removed for biopsy from the lower air and food passages with ease and certainty4 ,they have a cross in the outer blade which holds the specimen removed4 ,the action is very delicate1 there being no springs1 and the sense of touch imparted is often of great aid in the diagnosis4 ,,fig4 #bg4--,the author's upper-lobe bronchus forceps4 ,at ,a is shown the full-curved form1 for reaching into the ascending branches of the upper-lobe bronchus ,a number of different forms of jaws are made in this kind of forceps4 ,only #b are shown4 ,,fig #bh--,the author's endoscopic tissue forceps4 ,the laryngeal length is #cj cm4 ,for esophageal use they are made #ej and #fj cm4 long4 ,these are the best forceps for cutting out small specimens of tissue for biopsy4 ,the large basket punch forceps shown in ,fig4 #cc are useful in removing larger growths or specimens of tissue from the pharynx or larynx4 ,a portion or the whole of the epiglottis may be easily and quickly removed with these forceps1 the laryngoscope introduced along the dorsum of the tongue into the glossoepiglottic recess1 bringing the whole epiglottis into view4 ,the forceps may be introduced through the laryngoscope or alongside the tube4 ,in the latter method a greater lateral action of the forceps is obtainable1 the tube being used for vision only4 ,these forceps are #cj cm4 long and are made in two sizes2 one with the punch of the largest size that can be passed through the adult laryngoscope1 and a smaller one for use through the anterior-commissure laryngoscope and the child's size laryngoscope4 ,,fig4 #bi4--,the author's papilloma forceps4 ,the broad blunt nose will scalp off the growths without any injury to the normal basal tissues4 ,voice-destroying and stenosing trauma are thus easily avoided4 ,,fig4 #cj4--,the author's short mechanical spoon 7#cj cm4 long74 ,papilloma ,forceps4--,papillomata do not infiltrate2 but superficial repullulations in many cases require repeated removals4 ,if the basal tissues are traumatized1 an impaired or ruined voice will result4 ,the author designed these forceps 7,fig4 #bi7 to scalp off the growths without injury to the normal tissues4 ,,fig4 #ca4--,the author's laryngeal rotation forceps4 ,,fig4 #cb4--;,enlarged view of the jaws of the author's vocal-nodule forceps4 ,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 users4 ,,fig #cc4-;,extra large laryngeal tissue forceps4 #cj cm4 long1 for removing entire growths or large specimens of tissue4 ,a smaller size is made4 ,bronchial ,dilators4--,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 months4 ,in order to remove the foreign body1 this stricture must be dilated1 and for this the bronchial dilator shown in ,fig4 #be was devised4 ,the channel in each blade allows the closed dilator to be pushed down over the presenting point of such bodies as tacks1 after which the blades are opened and the stricture stretched4 ,a small and a large size are made4 ,for enlarging the bronchial narrowing associated with pulmonary abscess and sometimes found above a bronchiectatic or foreign body cavity1 the expanding dilator shown in ,fig4 #bf is perhaps less apt to cause injury than ordinary forceps used in the same way4 ,the stretching is here produced by the spring of the blades of the forceps and not by manual force4 ,the closed blades are to be inserted through the strictured area1 opened1 and then slowly withdrawn4 ,for cicatricial stenoses of the trachea the metallic bougies1 ,fig4 #dj1 are useful4 ,for the larynx1 those shown in ,fig4 #da are needed4 ,,fig4 #cd4--;,a1 ,mosher's laryngeal curette2 ,b1 author's flat blade cautery electrode2 ,c1 pointed cautery electrode2 ,d1 laryngeal knife4 ,the electrodes are insulated with hard-rubber vulcanized onto the conducting wires4 ,,fig4 #ce4--,retrograde esophageal bougies in graduated sizes devised by ,dr4 ,gabriel ,tucker and the author for dilatation of cicatricial esophageal stenosis4 ,they are drawn upward by an endless swallowed string1 and are therefore only to be used in gastrostomized cases4 ,,fig4 #cf4--;,author's bronchoscopic and esophagoscopic mechanical spoon1 made in #dj1 #ej and #fj cm4 lengths4 ,,fig4 #cg4--,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 ring1 ,r1 is below the pin4 ,the ring is then erected to the position shown dotted at ,m1 by moving the handle1 ,h1 downward to ,l and locking it there with the latch1 ,z4 ,the fork1 ,a1 is then inserted and1 engaging the pin at the spring loop1 ,k1 the pin is pushed into the ring1 thus closing the pin4 ,slight rotation of the pin with the forceps may be necessary to get the point into the keeper4 ,the upper instrument is sometimes useful as a mechanical spoon for removing large1 smooth foreign bodies from the esophagus4 ,esophageal ,dilators4--,the dilatation of cicatricial stenosis of the esophagus can be done safely only by endoscopic methods4 ,blind esophageal bouginage is highly dangerous1 for the lumen of the stricture is usually eccentric and the bougie is therefore apt to perforate the wall rather than find the small opening4 ,often there is present a pouching of the esophagus above a stricture1 in which the bougie may lodge and perforate4 ,bougies should be introduced under visual guidance through the esophagoscope1 which is so placed that the lumen of the stricture is in the center of the endoscopic field4 ,the author's endoscopic bougies 7,fig4 #dj7 are made with a flexible silk-woven tip securely fastened to a steel shaft4 ,this shaft lends rigidity to the instrument sufficient to permit its accurate placement1 and its small size permits the eye to keep the silk-woven tip in view4 ,these endoscopic bougies are made in sizes from #h to #dj1 ,french scale4 ,the larger sizes are used especially for the dilatation of laryngeal and tracheal stenoses4 ,for the latter work it is essential that the bougies be inspected carefully before they are used1 for should a defective tip come off while in the lower air passages a difficult foreign body problem would be created4 ,soft-rubber retrograde dilators to be drawn upward from the stomach by a swallowed string are useful in gastrostomized cases 7,fig4 #ce74 ,,fig #ch4--;,half curved hook1 #de cm4 and #fj cm4 ,full curved patterns are made but caution is necessary to avoid them becoming anchored in the bronchi4 ,spiral forms avoid this4 ,the author makes for himself steel probe-pointed rods out of which he bends hooks of any desired shape4 ,the rod is held in a pin-vise to facilitate bending of the point1 after heating in an alcohol or bunsen flame4 ,hooks4--,no hook greater than a right angle should be used through endoscopic tubes2 for should it become caught in some of the smaller bronchi its extraction might result in serious trauma4 ,the half curved hook shown in ,fig4 #ch is the safest type2 better still1 a spiral twist to the hook will add to its uses1 and by reversing the turning motion it may be unscrewed out if it becomes caught4 ,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 pliers4 ,about #b cm4 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 sight4 ,coil-spring hooks for the upper-lobe-bronchus 7,fig4 #ci7 will reach around the corner into the ascending bronchus of the upper-lobe-bronchus1 but the utmost skill and care are required to make their use justifiable4 ,,fig4 #ci4--;,author's coil-spring hook for the upper-lobe1 bronchus ,safety-pin ,closer4--,there are a number of methods for the endoscopic removal of open safety-pins when the point is up1 one of which is by closing the pin with the instrument shown in ,fig4 #cg in the following manner4 ,the oval ring is passed through the endoscope until it is beyond the spring of the safety-pin1 the ring is then turned upward by depressing the handle1 and by the aid of the prong the pin is pushed into the ring1 which action approximates the point of the pin and the keeper and closes the pin4 ,removal is then less difficult and without danger4 ,this instrument may also be used as a mechanical spoon1 in which case it may be passed to the side of a difficultly grasped foreign body1 such as a pebble1 the ring elevated and the object withdrawn4 ,elsewhere will be found a description of the various safety-pin closers devised by various endoscopists4 ,the author has used ,arrowsmith's closer with much satisfaction4 ,mechanical ,spoon4--,when soft1 friable substances1 such as a bolus of meat1 become impacted in the upper esophagus1 the short mechanical spoon 7,fig4 #cj7 used through the esophageal speculum is of great aid in their removal4 ,the blade in this instrument1 as the name suggests1 is a spoon and is not fenestrated as is the safety-pin closer1 which if used for friable substances would allow them to slip through the fenestration4 ,a longer form for use through bronchoscopes and esophagoscopes is shown in ,fig4 #cf4 ,a laryngeal curette1 cautery electrodes1 cautery handle1 and laryngeal knife are illustrated in ,fig4 #cd4 ,the cautery is to be used with a transformer1 or a storage battery4 ,spectacles4--,if the operator has no refractive error he will need two pairs of plane protective spectacles with very large eyes4 ,if ametropic1 corrective lenses are necessary1 and duplicate spectacles must be in charge of a nurse4 ,for presbyopia two pairs of spectacles for #dj cm4 distance and #fe cm4 distance must be at hand4 ,hook temple frames should be used so that they can be easily changed and adjusted by the nurse when the lenses become spattered4 ,the spectacle nurse has ready at all times the extra spectacles1 cleaned and warmed in a pan of heated water so that they will not be fogged by the patient's breath1 and she changes them without delay as often as they become soiled4 ,the operator should work with both eyes open and with his right eye at the tube mouth4 ,the operating room should be somewhat darkened so as to facilitate the ignoring of the image in the left eye2 any lighting should be at the operator's back1 and should be insufficient to cause reflections from the inner surface of his glasses4 ,,fig4 #dj4--,the author's endoscopic bougies4 ,the end consists of a flexible silk woven tip attached securely to a steel shank4 ,sizes #h to #cj ,french catheter scale4 ,a metallic form of this bougie is useful in the trachea2 but is not so safe for esophageal use4 ,,fig4 #da4--,the author's laryngeal bougie for the dilatation of cicatricial laryngeal stenosis4 ,made in #aj sizes4 ,the shaded triangle shows the cross-section at the widest part4 ,,fig4 #db4--,the author's bronchoscopic and esophagoscopic table4 #df ,endoscopic ,table4--,any operating table may be used1 but the work is facilitated if a special table can be had which allows the placing of the patient in all required positions4 ,the table illustrated in fig4 #db is so arranged that when the false top is drawn forward on the railroad1 the head piece drops and the patient is placed in the correct 7,boyce7 position for esophagoscopy or bronchoscopy1 i4e41 with the head and shoulders extending over the end of the table4 ,by means of the wheel the plane of the table may be altered to any desired angle of inclination or height of head4 ,operating ,room4--,all endoscopic procedures should be performed in a somewhat darkened operating room where all the desired materials are at hand4 ,an endoscopic team consists of three persons3 the operator1 the assistant who holds the head1 and the instrument assistant4 ,another person is required to hold the patient's arms and still another for the changing of the operator's glasses when they become spattered4 ,the endoscopic team of three maintain surgical asepsis in the matter of hands and gowns1 etc4 ,the battery1 on a small table of its own1 is placed at the left hand of the operator4 ,beyond it is the table for the mechanical aspirator1 if one is used4 ,all extra instruments are placed on a sterile table1 within reach1 but not in the way1 while those instruments for use in the particular operation are placed on a small instrument table back of the endoscopist4 ,only those instruments likely to be wanted should be placed on the working table1 so that there shall be no confusion in their selection by the instrument nurse when called for4 ,each moment of time should be utilized when the endoscopic procedure has been started1 no time should be lost in the hunting or separating of instruments4 ,to have the respective tables always in the same position relative to the operator prevents confusion and avoids delay4 ,,fig #dc4--,the author's retrograde esophagoscope4 ,oxygen ,tank and ,tracheotomy ,instruments4--,respiratory arrest may occur from shifting of a foreign body1 pressure of the esophagoscope1 tumor1 or diverticulum full of food4 ,rare as these contingencies are1 it is essential that means for resuscitation be at hand4 ,no endoscopic procedure should be undertaken without a set of tracheotomy instruments on the sterile table within instant reach4 ,in respiratory arrest from the above mentioned causes1 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 larynx4 ,the limpness of the patient renders bronchoscopy so easy that the well-drilled bronchoscopist should have no difficulty in inserting a bronchoscope in #aj or #ae seconds1 if proper preparedness has been observed4 ,it is perhaps relatively rarely that such accidents occur1 yet if preparations are made for such a contingency1 a life may be saved which would otherwise be inevitably lost4 ,the oxygen tank covered with a sterile muslin cover should stand to the left of the operating table4 ,asepsis4--,strict aseptic technic must be observed in all endoscopic procedures4 ,the operator1 first assistant1 and instrument nurse must use the same precautions as to hand sterilization and sterile gowns as would be exercised in any surgical operation4 ,the operator and first assistant should wear masks and sterile gloves4 ,the patient is instructed to cleanse the mouth thoroughly with the tooth brush and a #bj per cent alcohol mouth wash4 ,any dental defects should1 if time permit1 as in a course of repeated treatments1 be remedied by the dental surgeon4 ,when placed on the table with neck bare and the shoulders unhampered by clothing1 the patient is covered with a sterile sheet and the head is enfolded in a sterile towel4 ,the face is wiped with #gj per cent alcohol4 ,it is to be remembered that while the patient is relatively immune to the bacteria he himself harbors1 the implantation of different strains of perhaps the same type of organisms may prove virulent to him4 ,furthermore the transference of lues1 tuberculosis1 diphtheria1 pneumonia1 erysipelas and other infective diseases would be inevitable if sterile precautions were not taken4 ,all of the tubes and forceps are sterilized by boiling4 ,the light-carriers and lamps may be sterilized by immersion in #ie per cent alcohol or by prolonged exposure to formaldehyde gas4 ,continuous sterilization by keeping them put away in a metal box with formalin pastilles or other source of formaldehyde gas is an ideal method4 ,knives and scissors are immersed in #ie per cent alcohol1 and the rubber covered conducting cords are wiped with the same solution4 ,list of ,instruments4--,the following list has been compiled as a convenient basis for equipment1 to which such special instruments as may be needed for special cases can be added from time to time4 ,the instruments listed are of the author's design4 #a adult's laryngoscope4 #a child's laryngoscope4 #a infant's diagnostic laryngoscope4 #a anterior commissure laryngoscope4 #a bronchoscope1 #d mm4 ,x #cj cm4 #a bronchoscope1 #e mm4 ,x #cj cm4 #a bronchoscope1 #g mm4 ,x #dj cm4 #a bronchoscope1 #i mm4 ,x #dj cm4 #a esophagoscope1 #g mm4 ,x #de cm4 #a esophagoscope1 #aj mm4 ,x #ec cm4 #a esophagoscope1 full lumen1 #g mm4 ,x #de cm4 #a esophagoscope1 full lumen1 #i mm4 ,x #de cm4 #a esophageal speculum1 adult4 #a esophageal speculum1 child4 #a forward-grasping forceps1 delicate1 #dj cm4 #a forward-grasping forceps1 regular1 #ej cm4 #a forward-grasping forceps1 regular1 #fj cm4 #a side-grasping forceps1 delicate1 #dj cm4 #a side-grasping forceps1 regular1 #ej cm4 #a side-grasping forceps1 regular1 #fj cm4 #a rotation forceps1 delicate1 #dj cm4 #a rotation forceps1 regular1 #ej cm4 #a rotation forceps1 regular1 #fj cm4 #a laryngeal alligator forceps4 #a laryngeal papilloma forceps4 #aj esophageal bougies1 ,nos4 #h to #ag ,french 7larger sizes to ,no4 #cf may be added74 #a special measuring rule4 #f light sponge carriers4 #a aspirator with double tube for minus and plus pressure4 #b endoscopic aspirating tubes #cj and #ej cm4 #a half curved hook1 #fj cm4 #a triple circuit bronchoscopy battery4 #f rubber covered conducting cords for battery4 #a box bronchoscopic sponges1 size #d4 #a box bronchoscopic sponges1 size #e4 #a box bronchoscopic sponges1 size #g4 #a box bronchoscopic sponges1 size #aj4 #a bite block1 #a adult4 #a bite block1 child4 #b dozen extra lamps for lighted instruments4 #a extra light carrier for each instrument499 #d yards of pipe-cleaning1 worsted-covered wire4 99 ,messrs4 ,george ,p4 ,pilling and ,sons who are now making these instruments supply an extra light carrier and #b extra lamps with each instrument4 ,care of ,instruments4--,the endoscopist must either personally care for his instruments1 or have an instrument nurse in his own employ1 for if they are intrusted to the general operating room routine he will find that small parts will be lost2 blades of forceps bent1 broken1 or rusted2 tubes dinged2 drainage canals choked with blood or secretions which have been coagulated by boiling1 and electric attachments rendered unstable or unservicable1 by boiling1 etc4 ,the tubes should be cleansed by forcing cold water through the drainage canals with the aspirating syringe1 then dried by forcing pipe-cleaning worsted-covered wire through the light and drainage canals4 ,gauze on a sponge carrier is used to clean the main canal4 ,forceps stylets should be removed from their cannulae1 and the cannulae cleansed with cold water1 then dried and oiled with the pipe-cleaning material4 ,the stylet should have any rough places smoothed with fine emery cloth and its blades carefully inspected2 the parts are then oiled and reassembled4 ,nickle plating on the tubes is apt to peel and these scales have sharp1 cutting edges which may injure the mucosa4 ,all tubes1 therefore1 should be unplated4 ,rough places on the tubes should be smoothed with the finest emery cloth1 or1 better1 on a buffing wheel4 ,the dry cells in the battery should be renewed about every #d months whether used or not4 ,lamps1 light carriers1 and cords1 after cleansing1 are wiped with #ie per cent alcohol1 and the light-carriers with the lamps in place are kept in a continuous sterilization box containing formaldehyde pastilles4 ,it is of the utmost importance that instruments be always put away in perfect order4 ,not only are cleaning and oiling imperative1 but any needed repairs should be attended to at once4 ,otherwise it will be inevitable that when gotten out in an emergency they will fail4 ,in general surgery1 a spoon will serve for a retractor and good work can be done with makeshifts2 but in endoscopy1 especially in the small1 delicate1 natural passages of children1 the handicap of a defective or insufficient armamentarium may make all the difference between a success and a fatal failure4 ,a bronchoscopic clinic should at all times be in the same state of preparedness for emergency as is everywhere required of a fire-engine house4 ,,plate ,i--,a ,,working ,,set ,,of ,,the ,,author',s ,,endoscopic ,,tubes ,,for ,,laryngoscopy1 ,,bronchoscopy1 ,,esophagoscopy1 ,,and ,,gastroscopy3 ,a1 ,adult's laryngoscope2 ,b1 child's laryngoscope2 ,c1 anterior commissure laryngoscope2 ,d1 esophageal speculum1 child's size2 ,e1 esophageal speculum1 adult's size2 ,f1 bronchoscope1 infant's size1 #d mm4 ,x #cj cm42 ,g1 bronchoscope1 child's size1 #e mm4 ,x #cj cm42 ,h1 aspirating bronchoscope for adults1 #g mm4 ,x #dj cm42 ,i1 bronchoscope1 adolescent's size1 #g mm4 x #dj cm41 used also for the deeper bronchi of adults2 ,j1 bronchoscope1 adult size1 g mm4 x #dj cm42 ,k1 child's size esophagoscope1 #g mm4 ,x #de cm42 ,l1 adult's size esophagoscope1 full lumen construction1 #i mm4 x #de cm42 ,m1 adult's size gastroscope4 ,c1 ,i1 and ,e are also hypopharyngoscopes4 ,c is an excellent esophageal speculum for children1 and a longer model is made for adults4 ,if the utmost economy must be practised ,d1 ,e1 and ,m may be omitted4 ,the balance of the instruments are indispensable if adults and children are to be dealt with4 ,the instruments are made by ,charles ,j4 ,pilling ,sons1 ,philadelphia4 #eb ,,chapter ,,ii--,,anatomy ,,of ,,larynx1 ,,trachea1 ,,bronchi ,,and ,,esophagus1 ,,endoscopically ,,considered ,the larynx is a cartilaginous box1 triangular in cross-section1 with the apex of the triangle directed anteriorly4 ,it is readily felt in the neck and is a landmark for the operation of tracheotomy4 ,we are concerned endoscopically with four of its cartilaginous structures3 the epiglottis1 the two arytenoid cartilages1 and the cricoid cartilage4 ,the epiglottis1 the first landmark in direct laryngoscopy1 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 sinuses4 ,it does not close the larynx in the trap-door manner formerly taught2 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 removed1 or is destroyed by ulceration4 ,closure of the larynx is accomplished by the approximation of the ventricular bands1 arytenoids and aryepiglottic folds1 the latter having a sphincter-like action1 and by the raising and tilting of the larynx4 ,the arytenoids form the upper posterior boundary of the larynx and our particular interest in them is directed toward their motility1 for the rotation of the arytenoids at the cricoarytenoid articulations determines the movements of the cords and the production of voice4 ,approximation of the arytenoids is a part of the mechanism of closure of the larynx4 ,the cricoid cartilage was regarded by esophagoscopists as the chief obstruction encountered on the introduction of the esophagoscope4 ,as shown by the author1 it is the cricopharyngeal fold1 and the inconceivably powerful pull of the cricopharyngeal muscle on the cricoid cartilage1 that causes the difficulty4 ,the cricoid is pulled so powerfully back against the cervical spine1 that it is hard to believe that this muscles is inserted into the median raphe and not into the spine itself 7,fig4 #fh74 ,the ventricular bands or false vocal cords vicariously phonate in the absence of the true cords1 and assist in the protective function of the larynx4 ,they form the floor of the ventricles of the larynx1 which are recesses on either side1 between the false and true cords1 and contain numerous mucous glands the secretion from which lubricates the cords4 ,the ventricles are not visible by mirror laryngoscopy1 but are readily exposed in their depths by lifting the respective ventricular bands with the tip of the laryngoscope4 ,the vocal cords1 which appear white1 flat1 and ribbon-like in the mirror1 when viewed directly assume a reddish color1 and reveal their true shelf-like formation4 ,in the subglottic area the tissues are vascular1 and1 in children especially1 they are prone to swell when traumatized1 a fact which should be always in mind to emphasize the importance of gentleness in bronchoscopy1 and furthermore1 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 cannula4 ,the trachea just below its entrance into the thorax deviates slightly to the right1 to allow room for the aorta4 ,at the level of the second costal cartilage1 the third in children1 it bifurcates into the right and left main bronchi4 ,posteriorly the bifurcation corresponds to about the fourth or fifth thoracic vertebra1 the trachea being elastic1 and displaced by various movements4 ,the endoscopic appearance of the trachea is that of a tube flattened on its posterior wall4 ,in two locations it normally often assumes a more or less oval outline2 in the cervical region1 due to pressure of the thyroid gland2 and in the intrathoracic portion just above the bifurcation where it is crossed by the aorta4 ,this latter flattening is rhythmically increased with each pulsation4 ,under pathological conditions1 the tracheal outline may be variously altered1 even to obliteration of the lumen4 ,the mucosa of the trachea and bronchi is moist and glistening1 whitish in circular ridges corresponding to the cartilaginous rings1 and reddish in the intervening grooves4 ,the right bronchus is shorter1 wider1 and more nearly vertical than its fellow of the opposite side1 and is practically the continuation of the trachea1 while the left bronchus might be considered as a branch4 ,the deviation of the right main bronchus is about #be degrees1 and its length unbranched in the adult is about #b4e cm4 ,the deviation of the left main bronchus is about #ge degrees and its adult length is about #e cm4 ,the right bronchus considered as a stem1 may be said to give off three branches1 the epiarterial1 upper- or superior-lobe bronchus2 the middle-lobe bronchus2 and the continuation downward1 called the lower- or inferior-lobe bronchus1 which gives off dorsal1 ventral and lateral branches4 ,the left main bronchus gives off first the upper-or superior-lobe bronchus1 the continuation being the lower-or inferior-lobe bronchus1 consisting of a stem with dorsal1 ventral and lateral branches4 ,,fig4 #dd4--,tracheo-bronchial tree4 ,,lm1 ,left main bronchus2 ,,sl1 superior lobe bronchus2 ,,ml1 middle lobe bronchus2 ,,il1 inferior lobe bronchus4 ,the septum between the right and left main bronchi1 termed the carina1 is situated to the left of the midtracheal line4 ,it is recognized endoscopically as a short1 shining ridge running sagitally1 or1 as the patient lies in the recumbent position1 we speak of it as being vertical4 ,on either side are seen the openings of the right and left main bronchi4 ,in ,fig4 #dd1 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 bronchus2 with the carina as a landmark and by displacing with the bronchoscope the lateral wall of the right main bronchus1 a second1 smaller1 vertical spur appears1 and a view of the orifice of the right upper-lobe bronchus is obtained1 though a lumen image cannot be presented4 ,on passing down the right stem bronchus 7patient recumbent7 a horizontal partition or spur is found with the lumen of the middle-lobe bronchus extending toward the ventral surface of the body4 ,all below this opening of the right middle-lobe bronchus constitutes the lower-lobe bronchus and its branches4 ,,fig4 #de4--;,bronchoscopic views4 ,s2 ,superior lobe bronchus2 ,,sl1 superior lobe bronchus2 ,i1 inferior lobe bronchus2 ,m1 middle lobe bronchus4 #ef ,coming back to the carina and passing down the left bronchus1 the relatively great distance from the carina to the upper-lobe bronchus is noted4 ,the spur dividing the orifices of the left upper- and lower-lobe bronchi is oblique in direction1 and it is possible to see more of the lumen of the left upper-lobe bronchus than of its homologue on the right4 ,below this are seen the lower-lobe bronchus and its divisions 7,fig4 #de74 ,dimensions of the ,trachea and ,bronchi4--,it will be noted that the bronchi divide monopodially1 not dichotomously4 ,while the lumina of the individual bronchi diminish as the bronchi divide1 the sum of the areas shows a progressive increase in total tubular area of cross-section4 ,thus1 the sum of the areas of cross-section of the two main bronchi1 right and left1 is greater than the area of cross section of the trachea4 ,this follows the well known dynamic law4 ,the relative increase in surface as the tubes branch and diminish in size increases the friction of the passing air1 so that an actual increase in area of cross section is necessary1 to avoid increasing resistance to the passage of air4 ,the cadaveric dimensions of the tracheobronchial tree may be epitomized approximately as follows3 ,adult ,male ,female ,child ,infant ,diameter trachea1 #ad ,x #bj #ab ,x #af #h ,x #aj #f ,x #g ,length trachea1 cm4 #ab4j #aj4j #f4j #d4j ,length right bronchus #b4e #b4e #b4j #a4e ,length left bronchus #e4j #e4j #c4j #b4e ,length upper teeth to trachea #ae4j #bc4j #aj4j #i4j ,length total to secondary bronchus #cb4j #bh4j #ai4j #ae4j ,in considering the foregoing table it is to be remembered that in life muscle tonus varies the lumen and on the whole renders it smaller4 ,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 #ab ,x #bb ,x #bb mm4 and permitting the passage of a tube not over #aj mm4 in diameter without risk of injury4 ,furthermore a tube which filled the trachea would be too large to enter either main bronchus4 ,the normal movements of the trachea and bronchi are respiratory1 pulsatory1 bechic1 and deglutitory4 ,the two former are rhythmic while the two latter are intermittently noted during bronchoscopy4 ,it is readily observed that the bronchi elongate and expand during inspiration while during expiration they shorten and contract4 ,the bronchoscopist must learn to work in spite of the fact that the bronchi dilate1 contract1 elongate1 shorten1 kink1 and are dinged and pushed this way and that4 ,it is this resiliency and movability that make bronchoscopy possible4 ,the inspiratory enlargement of lumen opens up the forceps spaces1 and the facile bronchoscopist avails himself of the opportunity to seize the foreign body4 ,,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 gullet4 ,first and most important is the fact that the esophageal walls are exceedingly thin and delicate and require the most careful manipulation4 ,because of this delicacy of the walls and because the esophagus1 being a constant passageway for bacteria from the mouth to the stomach1 is never sterile1 surgical procedures are associated with infective risks4 ,for some other and not fully understood reason1 the esophagus is1 surgically speaking1 one of the most intolerant of all human viscera4 ,the anterior wall of the esophagus is in a part of its course1 in close relation to the posterior wall of the trachea1 and this portion is called the party wall4 ,it is this party wall that contains the lymph drainage system of the posterior portion of the larynx1 and it is largely by this route that posteriorly located malignant laryngeal neoplasms early metastasize to the mediastinum4 #eh ,,fig #df4--;,esophagoscopic and ,gastroscopic ,chart ,,birth #a yr4 #c yrs4 #f yrs4 #aj yrs4 #ad yrs4,,adults #bc #bg #cj #cc #cf #dc #ec ,cm4 ,,greater ,,curvature #ah #bj #bb #be #bg #cd #dj ,cm4 ,,cardia #ai #ba #bc #bd #be #ca #cf ,cm4 ,,hiatus #ac #ae #af #ah #bj #bd #bg ,cm4 ,,left ,,bronchus #ab #ad #ae #af #ag #ba #bc ,cm4 ,,aorta #g #i #aj #aa #ab #ad #af ,cm4 ,,cricopharyingeus #j #j #j #j #j #j #j ,cm4 ,,incisors ,,fig4 #df4--,the author's esophagoscopic chart of approximate distances of the esophageal narrowings from the upper incisor teeth1 arranged for convenient reference during esophagoscopy in the dorsally recumbent patient4 ,the lengths of the esophagus at different ages are shown diagrammatically in ,fig4 #df4 ,the diameter of the esophageal lumen varies greatly with the elasticity of the esophageal walls2 its diameter at the four points of anatomical constriction is shown in the following table3 ,constriction ,diameter ,vertebra ,cricopharyngeal ,transverse #bc mm4 7#a in47 ,sixth cervical ,antero-posterior #ag mm4 7#c_/d in47 ,aortic ,transverse #bd mm4 7#a in47 ,fourth thoracic ,antero-posterior #ai mm4 7#c_/d in47 ,left-bronchial ,transverse #bc mm4 7#a in47 ,fifth thoracic ,antero-posterior #ag mm4 7#c_/d in47 ,diaphragmatic ,transverse #bc mm4 7#a in7 ,tenth thoracic ,antero-posterior #bc mm4 7in4--7 ,for practical endoscopic purposes it is only necessary to remember that in a normal esophagus1 straight and rigid tubes of #g mm4 diameter should pass freely in infants1 and in adults1 tubes of #aj mm4 ,the #d demonstrable constrictions from above downward are at #a4 ,the crico-pharyngeal fold4 #b4 ,the crossing of the aorta4 #c4 ,the crossing of the left bronchus4 #d4 ,the hiatus esophageus4 ,there is a definite fifth narrowing of the esophageal lumen not easily demonstrated esophagoscopically and not seen during dissection1 but readily shown functionally by the fact that almost all foreign bodies lodge at this point4 ,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 orifice4 ,the crico-pharyngeal constriction1 as already mentioned1 is produced by the tonic contraction of a specialized band of the orbicular fibers of the lowermost portion of the inferior pharyngeal constrictor muscle1 called the cricopharyngeal muscle4 ,as shown by the author it is this muscle and not the cricoid cartilage alone that causes the difficulty in the insertion of an esophagoscope4 ,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 hypopharynx1 thus closing the mouth of the esophagus4 ,its other attachment is in the median posterior raphe4 ,between these circular fibers 7the cricopharyngeal muscle7 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 diverticulum4 ,it is at this weak point that fatal esophagoscopic perforation by inexperienced operators is most likely to occur4 ,the aortic narrowing of the esophagus may not be noticed at all if the patient is placed in the proper sequential high-low position4 ,it is only when the tube-mouth is directed against the left anterior wall that the actively pulsating aorta is felt4 ,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 #bg cm4 from the upper teeth in the adult4 ,the ridge is quite prominent in some patients1 especially those with dilatation from stenoses lower down4 ,the hiatal narrowing is both anatomic and spasmodic4 ,the peculiar arrangement of the tendinous and muscular structure of the diaphragm acts on this hiatal opening in a sphincter-like fashion4 ,there are also special bundles of muscle fibers extending from the crura of the diaphragm and surrounding the esophagus1 which contribute to tonic closure in the same way that a pinch-cock closes a rubber tube4 ,the author has called the hiatal closure the diaphragmatic pinchcock4 ,direction of the ,esophagus4--,the esophagus enters the chest in a decidedly backward as well as downward direction1 parallel to that of the trachea1 following the curves of the cervical and upper dorsal spine4 ,below the left bronchus the esophagus turns forward1 passing through the hiatus in the diaphragm anterior to and to the left of the aorta4 ,the lower third of the esophagus in addition to its anterior curvature turns strongly to the left1 so that an esophagoscope inserted from the right angle of the mouth1 when introduced into the stomach1 points in the direction of the anterior superior spine of the left ileum4 ,it is necessary to keep this general course constantly in mind in all cases of esophagoscopy1 but particularly in those cases in which there is marked dilatation of the esophagus following spasm at the diaphragm level4 ,in such cases the aid of this knowledge of direction will greatly simplify the finding of the hiatus esophageus in the floor of the dilatation4 ,the extrinsic or transmitted movements of the esophagus are respiratory and pulsatory1 and to a slight extent1 bechic4 ,the respiratory movements consist in a dilatation or opening up of the thoracic esophageal lumen during inspiration1 due to the negative intrathoracic pressure4 ,the normal pulsatory movements are due to the pulsatile pressure of the aorta1 found at the #dth thoracic vertebra 7#bd cm4 from the upper teeth in the adult71 and of the heart itself1 most markedly felt at the level of the #gth and #hth thoracic vertebrae 7about #cj cm4 from the upper teeth in adults74 ,as the distances of all the narrowings vary with age1 it is useful to frame and hang up for reference a copy of the chart 7,fig4 #df74 ,the intrinsic movements of the esophagus are involuntary muscular contractions1 as in deglutition and regurgitation2 spasmodic1 the latter usually having some pathologic cause2 and tonic1 as the normal hiatal closure1 in the author's opinion may be considered4 ,swallowing may be involuntary or voluntary4 ,the constrictors are anatomically not considered part of esophagus proper4 ,when the constrictors voluntarily deliver the bolus past the cricopharyngeal fold1 the involuntary or peristaltic contractions of the esophageal mural musculature carry the bolus on downward4 ,there is no sphincter at the cardiac end of the esophagus4 ,the site of spasmodic stenosis in the lower third1 the so-called cardiospasm1 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 esophagus1 and might be termed phrenospasm1 or hiatal esophagismus4 ,regurgitation of food from the stomach is normally prevented by the hiatal muscular diaphragmatic closure 7called by the author the diaphragmatic pinchcock7 plus the kinking of the abdominal esophagus4 ,in the author's opinion there is no spasm in the disease called cardiospasm4 ,it is simply the failure of the diaphragmatic pinchcock to open normally in the deglutitory cycle4 ,a better name is functional hiatal stenosis4 ,at retrograde esophagoscopy the cardia and abdominal esophagus do not seem to exist4 ,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 string4 #fc ,,chapter ,,iii--,,preparation ,,of ,,the ,,patient ,,for ,,peroral ,,endoscopy ,the suggestions of the author in the earlier volumes in regard to preparation of the patient1 as for any operation1 by a bath1 laxative1 etc41 and especially by special cleansing of the mouth with #be per cent alcohol1 have received general endorsement4 ,care should be taken not to set up undue reaction by vigorous scrubbing of gums unaccustomed to it4 ,artificial dentures should be removed4 ,even if no anesthetic is to be used1 the patient should be fasted for five hours if possible1 even for direct laryngoscopy in order to forestall vomiting4 ,except in emergency cases every patient should be gone over by an internist for organic disease in any form4 ,if an endolaryngeal operation is needed by a nephritic1 preparatory treatment may prevent laryngeal edema or other complications4 ,hemophilia should be thought of4 ,it is quite common for the first symptom of an aortic aneurysm to be an impaired power to swallow1 or the lodgment of a bolus of meat or other foreign body4 ,if aneurysm is present and esophagoscopy is necessary1 as it always is in foreign body cases1 to be fore-warned is to be forearmed4 ,pulmonary tuberculosis is often unsuspected in very young children4 ,there is great danger from tracheal pressure by an esophageal diverticulum or dilatation distended with food2 or the food maybe regurgitated and aspirated into the larynx and trachea4 ,therefore1 in all esophageal cases the esophagus should be emptied by regurgitation induced by titillating the fauces with the finger after swallowing a tumblerful of water1 pressure on the neck1 etc4 ,aspiration will succeed in some cases4 ,in others it is absolutely necessary to remove food with the esophagoscope4 ,if the aspirating tube becomes clogged by solid food1 the method of swab aspiration mentioned under bronchoscopy will succeed4 ,of course there is usually no cough to aid1 but the involuntary abdominal and thoracic compression helps4 ,should a patient arrive in a serious state of water-hunger1 as part of the preparation the patient must be given water by hypodermoclysis and enteroclysis1 and if necessary the endoscopy1 except in dyspneic cases1 must be delayed until the danger of water-starvation is past4 ,as pointed out by ,ellen ,j4 ,patterson the size of the thymus gland should be studied before an esophagoscopy is done on a child4 ,every patient should be examined by indirect1 mirror laryngoscopy as a preliminary to peroral endoscopy for any purpose whatsoever4 ,this becomes doubly necessary in cases that are to be anesthetized4 #fe ,,chapter ,,iv--,,anesthesia ,,for ,,peroral ,,endoscopy ,a dyspneic patient should never be given a general anesthetic4 ,cocaine should not be used on children under ten years of age because of its extreme toxicity4 ,to these two postulates always in mind1 a third one1 applicable to both general and local anesthesia1 is to be added--total abolition of the cough-reflex should be for short periods only4 ,general anesthesia is never used in the ,bronchoscopic ,clinic for endoscopic procedures4 ,the choice for each operator must1 however1 be a matter for individual decision1 and will depend upon the personal equation1 and degree of skill of the operator1 and his ability to quiet the apprehensions of the patient4 ,in other words1 the operator must decide what is best for his particular patient under the conditions then existing4 ,children in the ,bronchoscopic ,clinic receive neither local nor general anesthesia1 nor sedative1 for laryngoscopic operations or esophagoscopy4 ,bronchoscopy in the older children when no dyspnea is present has in recent years1 at the suggestion of ,prof4 ,hare1 been preceded by a full dose of morphin sulphate 7i4e41 #a_/h grain for a child of six years7 or a full physiologic dose of sodium bromide4 ,the apprehension is thus somewhat allayed and the excessive cough-reflex quieted4 ,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 desiderata1 not the analgesic effects4 ,dosage is more dependent on temperament than on age or body weight4 ,atropine is advantageously added to morphine in bronchoscopy for foreign bodies1 not only for the usual reasons but for its effect as an antispasmodic1 and especially for its diminution of endobronchial secretions4 ,true1 it does not diminish pus1 but by diminishing the outpouring of normal secretions that dilute the pus the total quantity of fluid encountered is less than it otherwise would be4 ,in cases of large quantities of pus1 as in pulmonary abscess and bronchiectasis1 however1 no diminution is noticeable4 ,no food or water is allowed for #e hours prior to any endoscopic procedure1 whether sedatives or anesthetics are to be given or not4 ,if the stomach is not empty vomiting from contact of the tube in the pharynx will interfere with work4 ,with adults no anesthesia1 general or local1 is given for esophagoscopy4 ,for laryngeal operation and bronchoscopy the following technic is used3 ,one hour before operation the patient is given hypodermatically a full physiologic dose of morphin sulphate 7from #a_/d1 to #c_/h gr47 guarded with atropin sulphate 7gr4 #a_/aej74 ,care must be taken that the injection be not given into a vein4 ,on the operating table the epiglottis and pharynx are painted with #aj per cent solution of cocain4 ,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 applications4 ,the laryngoscope is now introduced and if found necessary a #bj per cent cocain solution is applied to the interior of the larynx and subglottic region1 by means of gauze swabs fastened to the sponge carriers4 ,here also two applications are quite sufficient to produce complete anesthesia in the larynx4 ,if bronchoscopy is to be done the gauze swab is carried down through the exposed glottis to the carina1 thus anesthetizing the tracheal mucosa4 ,if further anesthetization of the bronchial mucosa is required1 cocain may be applied in the same manner through the bronchoscope4 ,in all these local applications prolonged contact of the swab is much more efficient than simply painting the surface4 #fg ,in cases in which cocain is deemed contraindicated morphin alone is used4 ,if given in sufficient dosage cocain can be altogether dispensed with in any case4 ,it is perhaps safer for the beginner in his early cases of esophagoscopy to have the patient relaxed by an ether anesthesia1 provided the patient is not dyspneic to begin with1 or made so by faulty position or by pressure of the esophagoscopic tube mouth on the tracheoesophageal party wall4 ,as proficiency develops1 however1 he will find anesthesia unnecessary4 ,local anesthesia is needless for esophagoscopy1 and if used at all should be limited to the laryngopharynx and never applied to the esophagus1 for the esophagus is without sensation1 as anyone may observe in drinking hot liquids4 ,direct laryngoscopy in children requires neither local nor general anesthesia1 either for diagnosis or for removal of foreign bodies or growths from the larynx4 ,general anesthesia is contraindicated because of the dyspnea apt to be present1 and because the struggles of the patient might cause a dislodgment of the laryngeal intruder and aspiration to a lower level4 ,the latter accident is also prone to follow attempts to cocainize the larynx4 ,technic for ,general ,anesthesia4--,for esophagoscopy and gastroscopy1 if general anesthesia is desired1 ether may be started by the usual method and continued by dropping upon folded gauze laid over the mouth after the tube is introduced4 ,endo-tracheal administration of ether is1 however1 far safer than peroral administration1 for it overcomes the danger of respiratory arrest from pressure of the esophagoscope1 foreign body1 or both1 on the trachea4 ,chloroform should not be used for esophagoscopy or gastroscopy because of its depressant action on the respiratory center4 ,for bronchoscopy1 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 ,fig4 #ac4 ,in case of paralysis of the larynx1 even if only monolateral1 a general anesthetic if needed should be given by intratracheal insufflation4 ,if the apparatus for this is not available the patient should be tracheotomized4 ,hence1 every adult patient should be examined with a throat mirror before general anesthesia for any purpose1 and the necessity becomes doubly imperative before goiter operations4 ,a number of fatalities have occurred from neglect of this precaution4 ,anesthetizing a tracheotomized patient is free from danger so long as the cannula is kept free from secretion4 ,ether is dropped on gauze laid over the tracheotomic cannula and the anesthesia watched in the usual manner4 ,if the laryngeal stenosis is not complete1 ether-saturated gauze is to be placed over the mouth as well as over the tracheotomy tube4 ,endo-tracheal anesthesia is by far the safest way for the administration of ether for any purpose4 ,by means of the silk-woven catheter introduced into the trachea1 ether-laden air from an insufflation apparatus is piped down to the lungs continuously1 and the strong return-flow prevents blood and secretions from entering the lower air-passages4 ,the catheter should be of a size1 relative to that of the glottic chink1 to permit a free return-flow4 ,a number #bd ,french is readily accommodated by the adult larynx and lies well out of the way along the posterior wall of the larynx4 ,because of the little room occupied by the insufflation catheter this method affords ideal anesthesia for external laryngeal operations4 ,operations on the nose1 accessory sinuses and the pharynx1 apt to be attended by considerable bleeding1 are rendered free from the danger of aspiration pneumonia by endotracheal anesthesia4 ,it is the safest anesthesia for goiter operations4 ,endo-tracheal anesthesia has rendered needless the intricate negative pressure chamber formerly required for thoracic surgery1 for by proper regulation of the pressure under which the ether ladened air is delivered1 a lung may be held in any desired degree of expansion when the pleural cavity is opened4 ,it is indicated in operations of the head1 neck1 or thorax1 in which there is danger of respiratory arrest by centric inhibition or peripheral pressure2 in operations in which there is a possibility of excessive bleeding and aspiration of blood or secretions2 and in operations where it is desired to keep the anesthetist away from the operating field4 ,various forms of apparatus for the delivery of the ether-laden vapor are supplied by instrument makers with explicit directions as to their mechanical management4 ,we are concerned here mainly with the technic of the insertion of the intratracheal tube4 ,the larynx should be examined with the mirror1 preferably before the day of operation1 for evidence of disease1 and incidentally to determine the size of the catheter to be introduced1 though the latter can be determined after the larynx is laryngoscopically exposed4 ,the following list of rules for the introduction of the catheter will be of service 7see ,fig4 #ei74 ,,rules ,,for ,,insertion ,,of ,,the ,,catheter ,,for ,,insufflation ,,anesthesia #a4 ,the patient should be fully under the anesthetic by the open method so as to get full relaxation of the muscles of the neck4 #b4 ,the patient's head must be in full extension with the vertex firmly pushed down toward the feet of the patient1 so as to throw the neck upward and bring the occiput down as close as possible beneath the cervical vertebrae4 #c4 ,no gag should be used1 because the patient should be sufficiently anesthetized not to need a gag1 and because wide gagging defeats the exposure of the larynx by jamming down the mandible4 #d4 ,the epiglottis must be identified before it is passed4 #e4 ,the speculum must pass sufficiently far below the tip of the epiglottis so that the latter will not slip4 #f4 ,too deep insertion must be avoided1 as in this case the speculum goes posterior to the cricoid1 and the cricoid is lifted1 exposing the mouth of the esophagus1 which is bewildering until sufficient education of the eye enables the operator to recognize the landmarks4 #g4 ,the patient's head is lifted off the table by the spatular tip of the laryngoscope4 ,actual lifting of the head will not be necessary if the patient is fully relaxed2 but the idea of lifting conveys the proper conception of laryngeal exposure 7,fig4 #ee74 #ga ,,chapter ,v--,,bronchoscopic ,,oxygen ,,insufflation ,bronchoscopic oxygen insufflation is a life-saving measure equalled by no other method known to the science of medicine1 in all cases of asphyxia1 or apnea1 present or impending4 ,its especial sphere of usefulness is in severe cases of electric shock1 hanging1 smoke asphyxia1 strangulation1 suffocation1 thoracic or abdominal pressure1 apnea1 acute traumatic pneumothorax1 respiratory arrest from absence of sufficient oxygen1 or apnea from the presence of quantities of irrespirable or irritant gases4 ,combined with bronchoscopic aspiration of secretions it is the best method of treatment for poisoning by chlorine gas1 asphyxiating1 and other war gases4 ,bronchoscopic oxygen insufflation should be taught to every interne in every hospital4 ,the emergency or accident ward of every hospital should have the necessary equipment and an interne familiar with its use4 ,the method is simple1 once the knack is acquired4 ,the patient being limp and recumbent on a table1 the larynx is exposed with the laryngoscope1 and the bronchoscope is inserted as hereinafter described4 ,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 bronchoscope4 ,it is necessary to be certain that the flow is gentle1 so that1 with a free return flow the introduced pressure does not exceed the capillary pressure2 otherwise the blood will be forced out of the capillaries and the ischemia of the lungs will be fatal4 ,another danger is that overdistension causes inhibition of inspiration resulting in apnea continuing as long as the distension is maintained1 if not longer4 ,the return flow from the bronchoscope should be interrupted for #b or #c seconds several times a minute to inflate the lungs1 but the flow must not be occluded longer than #c seconds1 because the intrapulmonary pressure would rise4 ,a pearl of amyl nitrite may be broken in the wash bottle4 ,slow rhythmic artificial respiratory movements are a useful adjunct1 and unless the operator is very skillful in gauging the alternate pressures and releases with the thumb according to the oxygen pressure1 it is vitally necessary to fill and deflate the lungs rhythmically by one of the well known methods of artificial respiration4 ,anyone skilled in the introduction of the bronchoscope can do bronchoscopy in a few seconds1 and it is especially easy in cases of respiratory arrest1 because of the limp condition of the patient4 ,the foregoing applies to cases in which a pulmotor would be used1 such as apnea from electric shocks1 etc4 ,for obstructive dyspnea and asphyxia1 tracheotomy is the procedure of choice1 and the skillful tracheotomist would be justified in preferring tracheotomy for the other class of cases1 insufflating the oxygen and amyl nitrite through the tracheotomic wound4 ,the pulmotor and similar mechanisms are1 perhaps1 the best things the use of which can be taught to laymen2 but as compared to bronchoscopic oxygen insufflation they are woefully inefficient1 because the intraoral pressure forces the tongue back over the laryngeal orifice1 obstructing the airway in this death zone4 ,by the introduction of the bronchoscope this death zone is entirely eliminated1 and a free airway established for piping the oxygen directly into the lungs4 #gc ,,chapter ,,vi--,,position ,,of ,,the ,,patient ,,for ,,peroral ,,endoscopy ,it is the author's invariable practice to place the patient in the dorsally recumbent position4 ,the sitting position is less favorable4 ,while lying on a well-padded1 flat table the patient is readily controlled1 the head is freely movable1 secretions can be easily removed1 the view obtained by the endoscopist is truly direct 7without reversal of sides71 and1 most important1 the employment of one position only favors smoother and more efficient team work1 and a better endoscopic technic4 ,general ,principles of ,position4--,as will be seen in ,fig4 #dg the trachea and esophagus are not horizontal in the thorax1 but their long axes follow the curves of the cervical and dorsal spine4 ,therefore1 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 table1 and at the same time make extension at the occipito-atloid joint4 ,by this maneuver the cervical spine is brought in line with the upper portion of the dorsal spine as shown in ,fig4 #ee4 ,it was formerly taught1 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 table1 the so-called ,rose position4 ,with the head so placed1 it is impossible to enter the lower air or food passages with a rigid tube1 as will be shown by a study of the radiograph shown in ,fig4 #di4 ,extension of the head on the occipito-atloid joint is for the purpose of freeing the tube from the teeth1 and the amount required will vary with the degree to which the mouth can be opened4 ,whether the head be extended1 flexed1 or kept mid-way1 the fundamental principle in the introduction of all endoscopic tubes is the anterior placing of the cervical spine and the high elevation of the head4 ,the esophagus1 just behind the heart1 turns ventrally and to the left4 ,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 table4 ,this will be further explained in the chapter on esophagoscopy4 ,in all of these procedures1 the nose of the patient should be directed toward the zenith1 and the assistant should prevent rotation of the head as well as prevent lowering of the head4 ,the patient should be urged as follows3 ,don't hold yourself so rigid4 ,let your head and neck go loose4 ,let your head rest in my hand4 ,don't try to hold it4 ,let me hold it4 ,relax4 ,don't raise your chest4 ,,fig4 #dg4--,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 bronchoscopy4 ,when the head is thrown backward 7as in the ,rose position7 the anterior convexity of the cervical spine is transmitted to the trachea and esophagus and their axes deviated4 ,the anterior deviation of the lower third of the esophagus shows the anatomical basis for the high low position for esophagoscopy ,,fig4 #dh4--;,correct position of the cervical spine for esophagoscopy and bronchoscopy4 7,illustration reproduced from author's article ,jour4 ,am4 ,med4 ,assoc41 ,sept4 #be1 #aiji7 ,,fig4 #di4--;,curved position of the cervical spine1 with anterior convexity1 in the ,rose position1 rendering esophagoscopy and bronchoscopy difficult or impossible4 ,the devious course of the pharynx1 larynx and trachea are plainly visible4 ,the extension is incorrectly imparted to the whole cervical spine instead of only to the occipito-atloid joint4 ,this is the usual and very faulty conception of the extended position4 7,illustration reproduced from author's article1 ,jour4 ,am4 ,med4 ,assoc41 ,sept4 #be1 #aiji47 #gf ,for direct laryngoscopy the patient's head is raised above the plane of the table by the first assistant1 who stands to the right of the patient1 holding the bite block on his right thumb inserted in the left corner of the patient's mouth1 while his extended right hand lies along the left side of the patient's cheek and head1 and prevents rotation4 ,his left hand1 placed under the patient's occiput1 elevates the head and maintains the desired degree of extension at the occipito-atloid joint 7,fig4 #ej74 ,,fig #ej4--;,direct laryngoscopy1 recumbent patient4 ,the second assistant is sitting holding the head in the ,boyce position1 his left forearm on his left thigh his left foot on a stool whose top is #fe cm4 lower than the table-top4 ,his left hand is on the patient's sterile-covered scalp1 the thumb on the forehead1 the fingers under the occiput1 making forced extension4 ,the right forearm passes under the neck of the patient1 so that the index finger of the right hand holds the bite-block in the left corner of the patient's mouth4 ,the fingers of the operator's right hand pulls the upper lip out of all danger of getting pinched between the teeth and the laryngoscope4 ,this is a precaution of the utmost importance and the trained habit of doing it must be developed by the peroral endoscopist4 ,position for ,bronchoscopy and ,esophagoscopy4--,the dorsally recumbent patient is so placed that the head and shoulders extend beyond the table1 the edge of which supports the thorax at about the level of the scapulae4 ,during introduction1 the head must be maintained in the same relative position to the table as that described for direct laryngoscopy1 that is1 elevated and extended4 ,the first assistant1 in this case1 sits on a stool to the right of the patient's head1 his left foot resting on a box about #ad inches in height1 the left knee supporting the assistant's left hand1 which being placed under the occiput of the patient maintains elevation and extension4 ,the right arm of the assistant passes under the neck of the patient1 the bite block being carried on the middle finger of the right hand and inserted into the left side of the patient's mouth4 ,the right hand also prevents rotation of the head 7,fig4 #ea74 ,as the bronchoscope or esophagoscope is further inserted1 the head must be placed so that the tube corresponds to the axis of the lumen of the passage to be examined4 ,if the left bronchus is being explored1 the head must be brought strongly to the right4 ,if the right middle lobe bronchus is being searched1 the head would require some left lateral deflection and a considerable degree of lowering1 for this bronchus1 as before mentioned1 extends anteriorly4 ,during esophagoscopy when the level of the heart is reached1 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 esophagus2 at the same time the head must be brought somewhat to the right1 since the esophagus in this region deviates strongly to the left4 ,,fig4 #ea4--,position of patient and assistant for introduction of the bronchoscope and esophagoscope4 ,the middle of the scapulae rest on the edge of the table2 the head and shoulders1 free to move1 are supported by the assistant1 whose right arm passes under the neck2 the right middle finger inserts the bite block into the left side of the mouth4 ,the left hand1 resting on the left knee maintains the desired degree of elevation1 extension and lateral deflection required by the operator4 ,the patient's vertex should be #aj cm4 higher than the level of the top of the table4 ,this is the ,boyce position1 which has never been improved upon for bronchoscopy and esophagoscopy4 ,,fig4 #eb4--,schema of position for endoscopy4 ,a4 ,normal recumbency on the table with pillow supporting the head4 ,the larynx can be directly examined in this position1 but a better position is obtainable4 ,b4 ,head is raised to proper position with head flexed4 ,muscles of front of neck are relaxed and exposure of larynx thus rendered easier2 but1 for most endoscopic work1 a certain amount of extension is desired4 ,the elevation is the important thing4 ,c4 ,the neck being maintained in position ,b1 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 7,b74 ,d4 ,faulty position4 ,unless prevented1 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 head1 thus assuming the same relation of the head to the chest as exists in the ,rose position 7a faulty one for endoscopy7 as will be understood by assuming that the dotted line1 ,e1 represents the table4 ,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 hand4 ,in obtaining the position of high head with occipito-atloid extension1 the easiest and most certain method1 as pointed out to me by my assistant1 ,gabriel ,tucker1 is first to raise the head1 strongly flexed1 as shown in ,fig4 #eb2 then while maintaining it there1 make the occipito-atloid extension4 ,this has proven better than to elevate and extend in a combined simultaneous movement4 ,if the patient would relax to limpness exposure of the larynx would be easily obtained1 simply by lifting the head with the lip of the laryngoscope passed below the tip of the epiglottis 7as in ,fig4 #ee7 and no holding of the head would be necessary4 ,but only rarely is a patient found who can do this4 ,this degree of relaxation is of course1 present in profound general ether anesthesia1 which is not to be thought of for direct laryngoscopy1 except when it is used for the purpose of insertion of intratracheal insufflation anesthetic tubes4 ,for this1 of course1 the patient is already to be deeply anesthetized4 ,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 itself4 ,the tendency of the patient to heave up his chest and assume a false position simulating the opisthotonous position 7,fig4 #eb7 must be overcome by persuasion4 ,this position has all the disadvantages of the ,rose position for endoscopy4 ,,fig4 #ec4--,the author's position for the removal of foreign bodies from the larynx or from any of the upper air or food passages4 ,if dislodged1 the intruder will not be aided by gravity to reach a deeper lodgement4 ,the one exception to these general positions is found in procedures for the removal of foreign bodies from the larynx4 ,in such cases1 while the same relative position of the head to the plane of the table is maintained1 the whole table top is so inclined as to elevate the feet and lower the head1 known as ,jackson's position4 ,this semi-inversion of the patient allows the foreign body to drop into the pharynx if it should be dislodged1 or slip from the forceps 7,fig4 #ec74 #hb ,,chapter ,,vii--,,direct ,,laryngoscopy ,importance of ,mirror ,examination of the ,larynx4--,the presence of the direct laryngoscope incites spasmodic laryngeal reflexes1 and the traction exerted somewhat distorts the tissues1 so that accurate observations of variations in laryngeal mobility are difficult to obtain4 ,the function of the laryngeal muscles and structures1 therefore1 can best be studied with the laryngeal mirror1 except in infants and small children who will not tolerate the procedure of indirect laryngoscopy4 ,a true idea of the depth of the larynx is not obtained with the mirror1 and a view of the ventricles is rarely had4 ,with the introduction of the direct laryngoscope it is found that the larynx is funnel shaped1 and that the adult cords are situated about #c cm4 below the aryepiglottic folds2 the cords also assume their true shelf-like character and take on a pinkish or yellowish tinge1 rather than the pearly white seen in the mirror4 ,they are not to any extent differentiated by color from the neighboring structures4 ,their recognition depends almost wholly on form1 position and movement4 ,accurate observation is stimulated in all pathologic cases by making colored crayon sketches1 however crude1 of the mirror image of the larynx4 ,the location of a growth may be thus graphically recorded1 so that at the time of operation a glance will serve to refresh the memory as to its site4 ,it is to be constantly kept in mind1 however1 that in the mirror image the sides are reversed because of the facing positions of the examiner and patient4 ,direct laryngoscopy is the only method by which the larynx of children can be seen4 ,the procedure need require less than a minute of time1 and an accurate diagnosis of the condition present1 whether papilloma1 foreign body1 diphtheria1 paralysis1 etc41 may be thus obtained4 ,the posterior pharyngeal wall should be examined in all dyspneic children for the possible existence of retropharyngeal abscess4 ,,plate ,,ii--,,direct ,,and ,,indirect ,,laryngeal ,,views ,,from ,,author',s ,,oil-,,color ,,drawings ,,from ,,life3 #a1 ,epiglottis of child as seen by direct laryngoscopy in the recumbent position4 #b1 ,normal larynx spasmodically closed1 as is usual on first exposure without anesthesia4 #c1 ,same on inspiration4 #d1 ,supraglottic papillomata as seen on direct laryngoscopy in a child of two years4 #e1 ,cyst of the larynx in a child of four years1 seen on direct laryngoscopy without anesthesia4 #f1 ,indirect view of larynx eight weeks after thyrotomy for cancer of the right cord in a man of fifty years4 #g1 ,same after two years4 ,an adventitious band indistinguishable from the original one has replaced the lost cord4 #h1 ,condition of the larynx three years after hemilaryngectomy for epithelioma in a patient fifty-one years of age4 ,thyrotomy revealed such extensive involvement1 with an open ulceration which had reached the perichondrium1 that the entire left wing of the thyroid cartilage was removed with the left arytenoid4 ,a sufficiently wide removal was accomplished without removing any part of the esophageal wall below the level of the crico-arytenoid joint4 ,there is no attempt on the part of nature to form an adventitious cord on the left side4 ,the normal arytenoid drew the normal cord over1 approximately to the edge of the cicatricial tissue of the operated side4 ,the voice1 at first a very hoarse whisper1 eventually was fairly loud1 though slightly husky and inflexible4 #i1 ,the pharynx seen one year after laryngectomy for endothelioma in a man aged sixty-eight years4 ,the purple papilla2 anteriorly are at the base of the tongue1 and from this the mucosa slopes downward and backward smoothly into the esophagus4 ,there are some slight folds toward the left and some of these are quite cicatricial4 ,the epiglottis was removed at operation4 ,the trachea was sutured to the skin and did not communicate with the pharynx4 7,direct view47 ,contraindications to ,direct ,laryngoscopy4--,there are no absolute contraindications to direct laryngoscopy in any case where direct laryngoscopy is really needed for diagnosis or treatment4 ,in extremely dyspneic patients1 if the operator is not confident in his ability for a prompt and sure introduction of a bronchoscope1 it may be wise to do a tracheotomy first4 ,instructions to the ,patient4--,before beginning endoscopy the patient should be told that he will feel a very disagreeable pressure on his neck and that he may feel as though he were about to choke4 ,he must be gently but positively made to understand 7#a7 that while the procedure is alarming1 it is absolutely free from danger2 7#b7 that you know just how it feels2 7#c7 that you will not allow his breath to be shut off completely2 7#d7 that he can help you and himself very much by paying close attention to breathing deeply and regularly2 7#e7 and that he must not draw himself up rigidly as though walking on ice1 but must be easy and relaxed4 ,direct ,laryngoscopy4 ,adult ,patient4--,before starting1 every detail in regard to instrumental equipment and operating room assistants1 7including an assistant to hold the arms and legs of the patient7 must be complete4 ,preparation of the patient and the technic of local anesthesia have been discussed in their respective chapters4 ,the dorsally recumbent patient is draped with 7not pinned in7 a sterile sheet4 ,the head1 covered by sterile towels1 is elevated1 and slight extension is made at the occipitoatloid joint by the left hand of the first assistant4 ,the bite block placed on the assistant's right thumb is inserted into the left angle of the patient's open mouth 7see ,fig4 #ej74 ,the laryngoscope must always and invariably be held in the left hand1 and in such a manner that the greatest amount of traction is made at the swell of the horizontal bar of the handle1 rather than on the vertical bar4 ,the right hand is then free for the manipulation of forceps1 and the insertion of the bronchoscope or other instrument4 ,during introduction1 the fingers of the right hand retract the upper lip so as to prevent its being pinched between the laryngoscope and the teeth4 ,the introduction of the direct laryngoscope and exposure of the larynx is best described in two stages4 #a4 ,exposure and identification of the epiglottis4 #b4 ,elevation of the epiglottis and all the tissues attached to the hyoid bone1 so as to expose the larynx to direct view4 ,first ,stage4--,the spatular end of the laryngoscope is introduced in the right side of the patient's mouth1 along the right side of the anterior two-thirds of the tongue4 ,it was the ,german method to introduce the laryngoscope over the dorsum of the tongue but in order to elevate this sometimes powerful muscular organ considerable force may be required1 which exercise of force may be entirely avoided by crowding the tongue over to the left4 ,when the posterior third stage of the tongue is reached1 the tip of the laryngoscope is directed toward the midline and the dorsum of the tongue is elevated by a lifting motion imparted to the laryngoscope4 ,the epiglottis will then be seen to project into the endoscopic field1 as seen in ,fig4 #ed4 ,,fig4 #ed4--;,end of the first of direct laryngoscopy1 recumbent adult patient4 ,the epiglottis is exposed by a lifting motion of the spatular tip on the tongue anterior to the epiglottis4 ,second ,stage4--,the spatular end of the laryngoscope should now be tipped back toward the posterior wall of the pharynx1 passed posterior to the epiglottis1 and advanced about #a cm4 ,the larynx is now exposed by a motion that is best described as a suspension of the head and all the structures attached to the hyoid bone on the tip of the spatular end of the laryngoscope 7,fig4 #ee74 ,particular care must be taken at this stage not to pry on the upper teeth2 but rather to impart a lifting motion with the tip of the speculum without depressing the proximal tubular orifice4 ,it is to be emphasized that while some pressure is necessary in the lifting motion1 great force should never be used2 the art is a gentle one4 ,the first view is apt to find the larynx in state of spasm1 and affords an excellent demonstration of the fact that the larynx can he completely closed without the aid of the epiglottis4 ,usually little more is seen than the two rounded arytenoid masses1 and1 anterior to them1 the ventricular bands in more or less close apposition hiding the cords 7,fig4 #ef74 ,with deep general anesthesia or thorough local anesthesia the spasm may not be present4 ,by asking the patient to take a deep breath and maintain steady breathing1 or perhaps by requesting a phonatory effort1 the larynx will open widely and the cords be revealed4 ,if the anterior commissure of the larynx is not readily seen1 the lifting motion and elevation of the head should be increased1 and if there is still difficulty in exposing the anterior commissure the assistant holding the head should with the index finger externally on the neck depress the thyroid cartilage4 ,if by this technic the larynx fails to be revealed the endoscopist should ask himself which of the following rules he has violated4 ,,fig4 #ee4--,schema illustrating the technic of direct laryngoscopy on the recumbent patient4 ,the motion is imparted to the tip of the laryngoscope as if to lift the patient by his hyoid hone4 ,the portion of the table indicated by the dotted line may be dropped or not1 but the back of the head must never go lower than here shown1 for direct laryngoscopy2 and it is better to have it at least #aj cm4 above the level of the table4 ,the table may be used as a rest for the operator's left elbow to take the weight of the head4 7,note that in bronchoscopy and esophagoscopy the head section of the table must be dropped1 so as to leave the head and neck of the patient out in the air1 supported by the second assistant47 ,,fig4 #ef4--;,endoscopic view at the end of the second stage of direct laryngoscopy4 ,recumbent patient4 ,larynx exposed waiting for larynx to relax its spasmodic contraction4 ,,rules ,,for ,,direct ,,laryngoscopy #a4 ,the laryngoscope must always be held in the left hand1 never in the right4 #b4 ,the operator's right index finger 7never the left7 should be used to retract the patient's upper lip so that there is no danger of pinching the lip between the instrument and the teeth4 #c4 ,the patient's head must always be exactly in the middle line1 not rotated to the right or left1 nor bent over sidewise2 and the entire head must be forward with extension at the occipitoatloid joint only4 #d4 ,the laryngoscope is inserted to the right side of the anterior two-thirds of the tongue1 the tip of the spatula being directed toward the midline when the posterior third of the tongue is reached4 #e4 ,the epiglottis must always be identified before any attempt is made to expose the larynx4 #f4 ,when first inserting the laryngoscope to find the epiglottis1 great care should be taken not to insert too deeply lest the epiglottis be overridden and thus hidden4 #g4 ,after identification of the epiglottis1 too deep insertion of the laryngoscope must be carefully avoided lest the spatula be inserted back of the arytenoids into the hypo-pharynx4 #h4 ,exposure of the larynx is accomplished by pulling forward the epiglottis and the tissues attached to the hyoid bone1 and not by prying these tissues forward with the upper teeth as a fulcrum4 #i4 ,care must be taken to avoid mistaking the ary-epiglottic fold for the epiglottis itself4 7,most likely to occur as the result of rotation of the patient's head47 #aj4 ,the tube should not be retained too long in place1 but should be removed and the patient permitted to swallow the accumulated saliva1 which1 if the laryngoscope is too long in place1 will trickle down the trachea and cause cough4 7,swallowing is almost impossible while the laryngoscope is in position47 ,the secretions may be removed with the aspirator4 #aa4 ,the patient must be instructed to breathe deeply and quietly without making a sound4 #hh ,difficulties of ,direct ,laryngoscopy4--,the larynx can be directly exposed in any patient whose mouth can be opened1 although the ease varies greatly with the type of patient4 ,failure to expose the epiglottis is usually due to too great haste to enter the speculum all the way down4 ,the spatula should glide slowly along the posterior third of the tongue until it reaches the glossoepiglottic fossa1 while at the same time the tongue is lifted2 when this is done the epiglottis will stand out in strong relief4 ,the beginner is apt to insert the speculum too far and expose the hypopharynx rather than the larynx4 ,the elusiveness of the epiglottis and its tendency to retreat downward are very much accentuated in patients who have worn a tracheotomic cannula2 and if still wearing it1 the patient can wait indefinitely before opening his glottis4 ,over extension of the patient's head is a frequent cause of difficulty4 ,if the head is held high enough extension is not necessary1 and the less the extension the less muscular tension there is in the anterior cervical muscles4 ,only one arytenoid eminence may be seen4 ,the right and the left look different4 ,practice will facilitate identification1 so that the endoscopist will at once know which way to look for the glottis4 ,of the difficulties that pertain to the operator himself the greatest is lack of practice4 ,he must learn to recognize the landmarks even though a high degree of spasm be present4 ,the epiglottis and the two rounded eminences corresponding to the arytenoids must be in the mind's eye1 for it is only on deep1 relaxed inspiration that anything like a typical picture of the larynx will be seen4 ,he must know also the right from the left arytenoid when only one is seen in order to know whether to move the lip of the laryngoscope to the right or the left for exposure of the interior of the larynx4 ,instruments for ,direct ,laryngoscopy4--,in undertaking direct laryngoscopy one must always be prepared for bronchoscopy1 esophagoscopy1 and tracheotomy1 as well4 ,preparations for bronchoscopy are necessary because the pathological condition may not be found in the larynx1 and further search of the trachea or bronchi may be required4 ,a foreign body in the larynx may be aspirated to a deeper location and could only be followed with the bronchoscope4 ,sudden respiratory arrest might occur1 from pathology or foreign body1 necessitating the inserting of the bronchoscope for breathing purposes1 and the insufflation of oxygen and amyl nitrite4 ,trachectomy might be required for dyspnea or other reasons4 ,it might be necessary to explore the esophagus for conditions associated with laryngeal lesions1 as for instance a foreign body in the esophagus causing dyspnea by pressure4 ,in short1 when planning for direct laryngoscopy1 bronchoscopy1 or esophagoscopy1 prepare for all three1 and for tracheotomy4 ,a properly done direct laryngoscopy would never precipitate a tracheotomy in an unanesthetized patient2 but direct laryngoscopy has to deal so frequently with laryngeal stenosis1 that routine preparation for tracheotomy a hundred unnecessary times is fully compensated for by the certainty of preparedness when the rare but urgent occasion arises4 ,direct ,laryngoscopy in ,children4--,the epiglottis in children is usually strongly curled1 often omega shaped1 and is very elusive and slippery4 ,the larynx of a child is very freely movable in the neck during respiration and deglutition1 and has a strong tendency to retreat downward during examination1 and thus withdraw the epiglottis after the arytenoids have been exposed4 ,in following down with the laryngoscope the speculum is prone to enter the hypopharynx4 ,lifting in this location will expose the mouth of the esophagus and shut off the larynx1 and may cause respiratory arrest4 ,practice1 however1 will soon develop a technic and ability to recognize the landmarks in state of spasm1 so that on exposing the approximated arytenoid eminences the endoscopist will maintain his position and wait for the larynx to open4 ,the procedure should be done without any form of anesthesia for the following reasons3 #a4 ,anesthesia is unnecessary4 #b4 ,it is extremely dangerous in a dyspneic patient4 #c4 ,it is inadmissable in a patient with diphtheria4 #d4 ,if anesthesia is to be used1 direct laryngoscopy will never reach its full degree of usefulness1 because anesthesia makes a major procedure out of a minor one4 #e4 ,cocain in children is dangerous1 and its application more annoying than the examination4 ,inducing a ,child to ,open its ,mouth 7,author's ,method74--,the wounding of the child's mouth1 gums1 and lips1 in the often inefficacious methods with gags1 hemostats1 raspatories1 etcetera1 are entirely unnecessary4 ,the mouth of any child not unconscious can be opened quickly and without the slightest harm by passing a curved probe between the clenched jaws back of the molars and down back of the tongue toward the laryngopharynx4 ,this will cause the child to gag1 when its mouth invariably opens4 #ia ,,chapter ,,viii--,,direct ,,laryngoscopy 7,continued7 ,technic of ,laryngeal ,operations4--,preparation of the patient and anesthesia have been mentioned under their respective chapters4 ,the prime essential of successful laryngeal operations is perfect mastery of continuous left-handed laryngeal exposure4 ,the right hand must be equally trained in the manipulation of forceps1 and the right eye to gauge depth4 ,blood and secretions are best removed by a suction tube 7,fig4 #i7 inserted through the laryngoscope1 or directly into the pharynx outside the laryngoscope4 ,for the removal of benign growths the author's papilloma forceps1 ,fig4 #bi1 or the laryngeal grasping forceps shown in ,fig4 #ag will prove more satisfactory than any form of cutting forceps4 ,these growths should be removed superficially flush with the normal structure4 ,the crushing of the base incident to the plucking off of the growth causes its recession4 ,by this conservative method damage to the cords and impairment of the voice are avoided4 ,for growths in the anterior portion of the larynx1 and in fact for the removal of most small benign growths1 the anterior commissure laryngoscope is especially adapted4 ,its shape allows its introduction into the vestibule of the larynx1 and if desired it may be introduced through the glottic chink for the treatment of subglottic conditions4 ,it will not infrequently be observed that a pedunculated subglottic growth which is found with difficulty will be pulled upward into view by the gauze swab introduced to remove secretions4 ,the growth is then often held tightly between the approximated cords for a few seconds--perhaps long enough to grasp it with forceps4 #ib ,removal of ,growth from the ,laryngeal ,ventricle4--,after exposing the larynx in the usual manner1 if the head is turned strongly to the right1 the tip of the laryngoscope1 directed from the right side of the mouth1 may be used to lift the left ventricular hand and thus expose the ventricle1 from which a growth may be removed in the usual manner 7,fig4 #eg74 ,the right ventricle is exposed by working from the left side of the mouth4 ,,fig4 #eg4-,schema illustrating the lateral method of exposing a growth in the ventricle of ,morgagni1 by bending the patient's head to the opposite side1 while the second assistant externally fixes the larynx with his hand4 ,m1 ,patient's mouth2 ,t1 thyroid cartilage2 ,r1 right side2 ,l1 left4 ,v1 ,b1 ventricular band4 ,c1 ,c1 vocal cord4 ,the circular drawing indicates the endoscopic view obtainable by this method4 ,the tube1 ,e1 is dropped to the corner of the mouth1 ,b1 and the tube is inserted down to ,r4 ,the lip of the spatula can then be used to lift the ventricular band so as to expose more of the ventricle4 ,the drawing shows an unusually shallow ventricle4 ,taking a ,laryngeal ,specimen for ,diagnosis4--,the diagnosis of carcinoma1 sarcoma1 and some other conditions can be made certain only by microscopic study of tissue removed from the growth4 ,the specimen should be ample but will necessarily be small4 ,if the suspected growth be small it should be removed entire1 together with some of the basal tissues4 ,if it is a large growth1 and there are objections to its entire removal1 the edge of the growth1 including apparently normal as well as neoplastic tissue1 is necessary4 ,if it is a diffuse infiltrative process1 a specimen should be taken from at least two locations4 ,tissue for biopsy is to be taken with the punch forceps shown in ,fig4 #bh or that in ,fig4 #cc4 ,the forceps may be inserted through the tube or from the angle of the mouth2 the extubal method 7see ,fig4 #eh74 ,,fig4 #eh4--,schema illustrating removal of a tumor from the upper part of the larynx by the author's extubal method for large tumors4 ,the large alligator basket punch forceps1 ,f1 is inserted from the right corner of the mouth and the jaws are placed over the tumor1 ,t1 under guidance of the eye looking through the laryngoscope1 ,l4 ,this method is not used for small tumors4 ,it is excellent for amputation of the epiglottis with these same punch forceps or with the heavy snare4 ,removal of large benign tumors above the cords may be done with the snare or with the large laryngeal punch forceps4 ,both are used in the extubal method4 ,amputation of the epiglottis for palliation of odynophagia or dysphagia in tuberculous or malignant disease1 is of benefit when the ulceration is confined to this region2 though as to tuberculosis the author feels rather conservatingly inclined4 ,early malignancy of the extreme tip can be cured by such means4 ,the function of the epiglottis seems to be to split the food bolus and direct its portions laterally into the pyriform sinuses1 rather than to take any important part in the closure of the larynx4 ,following the removal of the epiglottis there is rarely complaint of food entering the larynx4 ,the projecting portion of the epiglottis may be amputated with a heavy snare1 or by means of the large laryngeal punch forceps 7,fig4 #cc74 ,endoscopic ,operations for ,laryngeal ,stenosis4--,web formations may be excised with sliding punch forceps1 or if the web is due to contraction only1 incision of the true band may allow its retraction4 ,in some instances liberation of adhesions will favor the formation of adventitious vocal cords4 ,a sharp anterior commissure is a large factor in good phonation4 ,endoscopic evisceration of the larynx will cure a few cases of laryngeal cicatricial stenosis1 and should be tried before resorting to laryngostomy4 ,a sliding punch forceps is used to remove all the tissue in the larynx out to the perichondrium1 but care should be taken in cicatricial cases to avoid removing any part of either arytenoid cartilage4 ,in cases of posticus paralysis the excision may include portions of the vocal processes of the arytenoids4 ,ventriculocordectomy is preferable to evisceration4 ,the ventricular floor is removed with punch forceps 7,fig4 #cc7 first on one side1 then after two months1 on the other4 ,vocal ,results4--,a whispering voice can always be had as long as air can pass through the larynx1 and this may be developed to a very loud penetrating stage whisper4 ,if the arytenoid motility has been uninjured the repeated pulls on the scar tissue may draw out adventitious bands and develop a loud1 useful1 though perhaps rough and inflexible voice4 ,galvano-cauterization is the best method of treatment for chronic subglottic edema or hyperplasia such as is seen in children following diphtheria1 when the stenosis produced prevents extubation or decannulation4 ,the utmost caution should be used to avoid deep cauterizations2 they are almost certain to set up perichondritis which will increase the stenosis4 ,some of the most difficult cases that have come to the author have been previously cauterized too deeply4 ,galvano-cautery puncture of tuberculous infiltrations of the larynx at times yields excellent results in cases with mild pulmonary lesions1 and has quite replaced the use of the curette1 lactic acid1 and other caustics4 ,the direct method of exposing the larynx renders the application of the cautery point easy and accurate4 ,in severely stenosed tuberculous larynges a tracheotomy should first be done1 for though the reaction is slight it might be sufficient to close a narrowed glottis4 ,the technic is the usual one for laryngeal operations4 ,local anesthesia suffices4 ,the larynx is exposed4 ,the rheostat having been previously adjusted to heat the electrode to nearly white heat1 the circuit is broken and the electrode introduced cold4 ,when the point is in contact with the desired location the current is turned on and the point thrust in as deeply as desired4 ,usually it should penetrate until a firm resistance is felt2 but care must be used not to damage the cricoarytenoid joint4 ,the circuit is broken at the instant of withdrawal4 ,punctures should be made as nearly as possible perpendicular to the surface1 so as to minimize the destruction of epithelium and thus lessen the reaction4 ,a minute gray fibrous slough detaches itself in a few days4 ,cautery puncture should be repeated every two or three weeks1 selecting a new location each time1 until the desired result is obtained4 ,great caution1 as mentioned above1 must be used to avoid setting up perichondritis4 ,many cases of laryngeal tuberculosis will recover as quickly by silence and a general antituberculous regime4 ,radium1 in form of capsules or of needles inserted in the tissues may be applied with great accuracy2 but the author is strongly impressed with pyriform sinus applications by the ,freer method4 ,after-care of endolaryngeal operations includes careful cleansing of the teeth and mouth2 and if the extrinsic area of the larynx is involved in the wound1 sterile liquid food and water should be given for four days4 ,the patient should be watched for complications by a special nurse who is familiar with the signs of laryngeal dyspnea 7q4v474 ,complications during endolaryngeal operations are rare4 ,dyspnea may require tracheotomy4 ,idiosyncrasy to cocain1 or the sight or taste of blood may nauseate the patient and cause syncope4 ,serious hemorrhage could occur only in a hemophile4 ,the careless handling of a bite block might damage a frail tool or dental fixture4 ,complications after endolaryngeal operations are unusual4 ,carelessness in asepsis has been known to cause cervical cellulitis4 ,emphysema of the neck has occurred4 ,edema of the larynx occasionally occurs1 and might necessitate tracheotomy4 ,serious bleeding after operation is very rare except in bleeders4 ,hemorrhage within the larynx can be stopped by the introduction of a roll of gauze from above1 tracheotomy having been previously performed4 ,morphin subcutaneously administered1 has a constricting action on the vessels which renders it of value in controlling hemorrhage4 #ig ,,chapter ,,ix--,,introduction ,,of ,,the ,,bronchoscope ,no one should do bronchoscopy until he is able to expose the glottis by left-handed direct laryngoscopy in less than one minute4 ,when he has mastered this1 one minute more should be sufficient to introduce the bronchoscope into the trachea4 ,,technic ,,of ,,bronchoscopy ,local anesthesia is usually employed in the adult4 ,the patient is placed in the ,boyce position shown in ,fig4 #ea1 with head and shoulders projecting over the edge of the table and supported by an assistant4 ,the glottis is exposed by left-handed laryngoscopy4 ,the instrument-assistant now inserts the distal end of the bronchoscope into the lumen of the laryngoscope1 the handle being directed to the right in a horizontal position4 ,the operator now grasps the bronchoscope1 his eye is transferred from the laryngoscope to the bronchoscope1 and the bronchoscope is advanced and so directed that a good view of the glottis is obtained4 ,the slanted end of the bronchoscope should then be directed to the left1 so as clearly to expose the left cord4 ,in this position it will be found that the tip of the slanted end is in the center of the glottic chink and will slip readily into the trachea4 ,no great force should be used1 because if the bronchoscope does not go through readily1 either the tube is too large a size or it is not correctly placed 7,fig4 #fj74 ,normally1 however1 there is some slight resistance1 which in cases of subglottic laryngitis may be considerable4 ,the trained laryngologist will readily determine by sense of touch the degree of pressure necessary to overcome it4 ,when the bronchoscope has been inserted to about the second or third tracheal ring1 the heavy laryngoscope is removed by rotating the handle to the left1 removing the slide1 and withdrawing the instrument4 ,care must be taken that the bronchoscope is not withdrawn or coughed out during the removal of the laryngoscope2 this can be avoided by allowing the ocular end to rest against the gown-covered chest of the operator4 ,if preferred the operator may train his instrumental assistant to take off the laryngoscope1 while the operator devotes his attention to preventing the withdrawal of the bronchoscope by holding the handle with his right hand4 ,at the moment of insertion of the bronchoscope through the glottis1 an especially strong upward lift on the beak of the spatula will facilitate the passage4 ,it is necessary to be certain that the axis of the bronchoscope corresponds to the axis of the trachea1 in order to avoid injury to the subglottic tissue which might be followed by subglottic edema 7,fig4 #dg74 ,if the subglottic region is already edematous and causes resistance1 slight rotation to the laryngoscope1 and bronchoscope will cause the bronchoscope to enter more easily4 ,,fig4 #ei4--;,insufflation anesthesia with ,elsberg apparatus4 ,anesthetist has exposed the larynx and is about to introduce the silk-woven catheter4 ,note the full extension of the head on the table4 ,,fig4 #fj4--,schema illustrating the introduction of the bronchoscope through the glottis1 recumbent patient4 ,the handle1 ,h1 is always horizontally to the right4 ,when the glottis is first seen through the tube it should be centrally located as at ,k4 ,at the next inspiration the end ,b1 is moved horizontally to the left as shown by the dart1 ,m1 until the glottis shows at the right edge of the field1 ,c4 ,this means that the point of the lip1 ,b1 is at the median line1 and it is then quickly 7not violently7 pushed through into the trachea4 ,at this same moment or the instant before1 the hyoid bone is given a quick additional lift with the tip of the laryngoscope4 ,,fig4 #fa4--,schema illustrating oral bronchoscopy4 ,the portion of the table here shown under the head is1 in actual work1 dropped all the way down perpendicularly4 ,it appears in these drawings as a dotted line to emphasize the fact that the head must be above the level of the table during introduction of the bronchoscope into the trachea4 ,a1 ,exposure of larynx2 ,b1 bronchoscope introduced2 ,c1 slide removed2 ,d1 laryngoscope removed leaving bronchoscope alone in position4 ,difficulties in the ,introduction of the ,bronchoscope4--,the beginner may enter the esophagus instead of the trachea3 this might be a dangerous accident in a dyspneic case1 for the tube could1 by pressure on the trachea1 cause respiratory arrest4 ,a bronchoscope thus misplaced should be resterilized before introducing it into the air passages1 for while the lower air passages are usually free from bacteria1 the esophagus is a septic canal4 ,if the given technic is carefully carried out the bronchoscope will not be contaminated with mouth secretions4 ,the trachea is recognized as an open tube1 with whitish rings1 and the expiratory blast can be felt and tubular breathing heard2 while if by mistake the bronchoscope has entered the gullet it will be observed that the cervical esophagus has collapsed walls4 ,a puff of air may be felt and a fluttering sound heard when the tube is in the esophagus1 but these lack the intensity of the tracheal blast4 ,usually a free flow of secretion is met with in the esophagus4 ,in diseased states the tracheal rings may not be visible because of swollen mucosa1 or the trachea itself may be in partial collapse from external pressure4 ,the true expiratory blast will1 however1 always be recognized when the tube is in the trachea4 ,wide gagging of the mouth renders exposure of the larynx difficult4 ,,fig4 #fb4--;,insertion of the bronchoscope4 ,note direction of the trachea as indicated by the bronchoscope4 ,note that the patient's head is held above the level of the table4 ,the assistant's left hand should be at the patient's mouth holding the bite-block4 ,this is removed and the assistant is on the wrong side of the table in the illustration in order not to hide the position of the operator's hands4 ,note the handle of the bronchoscope is to the right4 ,,fig4 #fc4--,the heavy laryngoscope has been removed leaving the light bronchoscope in position4 ,the operator is inserting forceps4 ,note how the left hand of the operator holds the tube lightly between the thumb and first two fingers of the left hand1 while the last two fingers are hooked over the upper teeth of the patient anchoring the tube to prevent it moving in or out or otherwise changing the relation of the distal tube-mouth to a foreign body or a growth while forceps are being used4 ,thus1 also1 any desired location of the tube can be maintained in systematic exploration4 ,the assistant's left hand is dropped out of the way to show the operator's method4 ,the assistant during bronchoscopy holds the bite-block like a thimble on the index finger of the left hand1 and the assistant should be on the right side of the patient4 ,he is here put wrongly on the left side so as not to hide the instruments and the manner of holding them4 ,examination of the ,trachea and ,bronchi4--,all bronchial orifices must be identified seriatim2 because this is the only way by which the bronchoscopist can know what part of the tree he is examining4 ,appearances alone are not enough4 ,it is the order in which they are exposed that enables the inexperienced operator to know the orifices4 ,after the removal of the laryngoscope1 the bronchoscope is to be held by the left hand like a billiard cue1 the terminal phalanges of the left middle and ring fingers hooking over the upper teeth1 while the thumb and index finger hold the bronchoscope1 clamping it to the teeth tightly or loosely as required 7,fig4 #fc74 ,thus the tube may be anchored in any position1 or at any depth1 and the right hand which was directing the tube may be used for the manipulation of instruments4 ,the grasp of the bronchoscope in the right hand should be similar to that of holding a pen1 that is1 the thumb1 first1 and second fingers1 encircle the shaft of the tube4 ,the bronchoscope should never be held by the handle 7,fig4 #fd7 for this grasp does not allow of tactile sense transmission1 is rigid1 awkward1 and renders rotation of the tube a wrist motion instead of but a gentle finger action4 ,any secretion in the trachea is to be removed by sponge pumping before the bronchoscope is advanced4 ,the inspection of the walls of the trachea is accomplished by weaving from side to side and1 if necessary1 up and down2 the head being deflected as required during the search of the passages1 so that the larynx be not made the fulcrum in the lever-like action4 ,,fig4 #fd4--;,at ,a is shown an incorrect manner of holding the bronchoscope4 ,the grasp is too rigid and the position of the hand is awkward4 ,b1 ,correct manner1 the collar being held lightly between the finger and the thumb ,the thumb must not occlude the tube mouth4 ,the ,fulcrum of the ,bronchoscopic ,lever is at the ,upper ,thoracic ,aperture2 ,never at the ,larynx4--,disregard of this rule will cause subglottic edema and will limit the lateral motion of the tip of the bronchoscope4 ,it is the function of the assistant to make the head and neck follow the direction of the proximal end of the bronchoscope and thus avoid any pressure on the larynx 7see ,peroral ,endoscopy1 ,fig4 #ace1 p4 #afd74 ,in passing down the trachea the following two rules must be kept in mind3 #a4 ,before attempting to enter either main bronchus the carina must be identified4 #b4 ,before entering either main bronchus the orifices of both should be identified and inspected4 ,the carina is identified as a sharp vertical spur 7recumbent patient7 at the distal end of the trachea1 on either side of which are the openings of the main bronchi4 ,as the carina is situated to the left of the midline of the trachea1 the lip of the bronchoscope should be turned toward the left1 and slight lateral pressure should be made on the left tracheal wall while the head of the patient is held slightly to the right4 ,this will expose the left bronchial orifice and carina4 ,entering the ,bronchi4--,the lip of the bronchoscope should be turned in the direction of the bronchus to be explored1 and the axis of the bronchoscope should be made to correspond as nearly as possible to the axis of this bronchus4 ,the position of the lip is designated by the direction taken by the handle4 ,upon entering the right bronchus1 the handle of the bronchoscope is turned horizontally to the right1 and at the same time the assistant deflects the head to the left4 ,the right upper-lobe bronchus is recognized by its vertical spur2 the orifice is exposed by displacing the right lateral wall of the right main bronchus at the level of the carina4 ,usually this orifice will be thus brought into view4 ,if not the bronchoscope may be advanced downward #a or #b cm41 carefully to avoid overriding4 ,this branch is sometimes found coming off the trachea itself1 and even if it does not1 the overriding of the orifice is certain if the right bronchus is entered before search is made for the upper-lobe-bronchial orifice4 ,the head must be moved strongly to the left in order to view the orifice4 ,a lumen image of the right upper-lobe bronchus is not obtainable because of the sharp angles at which it is given off4 ,the left upper-lobe bronchus is entered by keeping the handle of the bronchoscope 7and consequently the lip7 to the left1 and1 by keeping the head of the patient strongly to the right as the bronchoscopist goes down the left main bronchus4 ,this causes the lip of the bronchoscope to bear strongly on the left wall of the left main bronchus1 consequently the left upper-lobe-bronchial orifice will not be overridden4 ,the spur separating the upper-lobe-bronchial orifice from the stem bronchus is at an angle approximately from two to eight o'clock1 as usually seen in the recumbent patient4 ,a lumen image of a descending branch of the upper-lobe bronchus is often obtained1 if the patient's head be borne strongly enough to the right4 ,,fig4 #fe4--,schema illustrating the entering of the anteriorly branching middle lobe bronchus4 ,t1 ,trachea2 ,b1 orifice of left main bronchus at bifurcation of trachea4 ,the bronchoscope1 ,s1 is in the right main bronchus1 pointing in the direction of the right inferior lobe bronchus1 ,i4 ,in order to cause the lip to enter the middle lobe bronchus1 ,m1 it is necessary to drop the head so that the bronchoscope in the trachea ,,tt1 will point properly to enable the lip of the tube mouth to enter the middle lobe bronchus1 as it is seen to have done at ,,ml4 ,branches of the stem bronchus in either lung are exposed1 or their respective lumina presented1 by manipulation of the lip of the bronchoscope1 with movement of the head in the required direction4 ,posterior branches require the head quite high4 ,a large one in the left stem just below the left upper-lobe bronchus is often invaded by foreign bodies4 ,anterior branches require lowering the head4 ,the middle-lobe bronchus is the largest of all anterior branches4 ,its almost horizontal spur is brought into view by directing the lip of the bronchoscope upward1 and dropping the head of the patient until the lip bears strongly on the anterior wall of the right bronchus 7see ,fig4 #fe74 #ajf ,,chapter ,x--,,introduction ,,of ,,the ,,esophagoscope ,the esophagoscope is to be passed only with ocular guidance1 never blindly with a mandrin or obturator1 as was done before the bevel-ended esophagoscope was developed4 ,blind introduction of the esophagoscope is equally as dangerous as blind bouginage4 ,it is almost certain to cause over-riding of foreign bodies and disease4 ,in either condition perforation of the esophagus is possible by pushing a sharp foreign body through the normal wall or by penetrating a wall weakened by disease4 ,landmarks must be identified as reached1 in order to know the locality reached4 ,the secretions present form sufficient lubrication for the instrument4 ,a clear conception of the endoscopic anatomy1 the narrowings1 direction1 and changes of direction of the axis of the esophagus1 are necessary4 ,the services of a trained assistant to place the head in the proper sequential high-low positions are indispensible 7,figs4 #eb and #gj74 ,introduction may be divided into four stages4 #a4 ,entering the right pyriform sinus4 #b4 ,passing the cricopharyngeus4 #c4 ,passing through the thoracic esophagus4 #d4 ,passing through the hiatus4 ,the patient is placed in the ,boyce position as described in ,chapter ,,vi4 ,as previously stated1 the esophagus in its upper portion follows the curves of the cervical and dorsal spine4 ,it is necessary1 therefore1 to bring the cervical spine into a straight line with the upper portion of the dorsal spine and this is accomplished by elevation of the head--the high position 7,figs4 #ff-ga74 ,,plate ,,iii--,,esophagoscopic ,,views ,,from ,,oil-,,color ,,drawings ,,from ,,life1 ,,by ,,the ,,author3 #a1 ,direct view of the larynx and laryngopharynx in the dorsally recumbent patient1 the epiglottis and hyoid bone being lifted with the direct laryngoscope or the esophageal speculum4 ,the spasmodically adducted vocal cords are partially hidden by the over-hang of the spasmodically prominent ventricular hands4 ,posterior to this the aryepiglottic folds ending posteriorly in the arytenoid eminences are seen in apposition4 ,the esophagoscope should be passed to the right of the median line into the right pyriform sinus1 represented here by the right arm of the dark crescent4 #b1 ,the right pyriform sinus in the dorsally recumbent patient1 the eminence at the upper left border1 corresponds to the edge of the cricoid cartilage4 #c1 ,the cricopharyngeal constriction of the esophagus in the dorsally recumbent patient1 the cricoid cartilage being lifted forward with the esophageal speculum4 ,the lower 7posterior7 half of the lumen is closed by the fold corresponding to the orbicular fibers of the cricopharyngeus which advances spasmodically from the posterior wall4 7,compare ,fig4 #aj47 ,this view is not obtained with an esophagoscope4 #d1 ,passing through the right pyriform sinus with the esophagoscope2 dorsally recumbent patient4 ,the walls seem in tight apposition1 and1 at the edges of the slit-like lumen1 bulge toward the observer4 ,the direction of the axis of the slit varies1 and in some instances it is like a rosette1 depending on the degree of spasm4 #e1 ,cervical esophagus4 ,the lumen is not so patulent during inspiration as lower down2 and it closes completely during expiration4 #f1 ,thoracic esophagus2 dorsally recumbent patient4 ,the ridge crossing above the lumen corresponds to the left bronchus4 ,it is seldom so prominent as in this patient1 but can always be found if searched for4 #g1 ,the normal esophagus at the hiatus4 ,this is often mistaken for the cardia by esophagoscopists4 ,it is more truly a sphincter than the cardia itself4 ,in the author's opinion there is no truly sphincteric action at the cardia4 ,it is the failure of this hiatal sphincter to open as in the normal deglutitory cycle that produces the syndrome called cardiospasm4 #h1 ,view in the stomach with the open-tube gastroscope4 ,the form of the folds varies continually4 #i1 ,sarcoma of the posterior wall of the upper third of the esophagus in a woman of thirty-one years4 ,seen through the esophageal speculum1 patient sitting4 ,the lumen of the mouth of the esophagus1 much encroached upon by the sarcomatous infiltration1 is seen at the lower part of the circle4 #aj1 ,coin 7half-dollar7 wedged in the upper third of the esophagus of a boy aged fourteen years4 ,seen through the esophageal speculum1 recumbent patient4 ,forceps are retracting the posterior lip of the esophageal mouth preparatory to removal4 #aa1 ,fungating squamous-celled epithelioma in a man of seventy-four years4 ,fungations are not always present1 and are often pale and edematous4 #ab1 ,cicatricial stenosis of the esophagus due to the swallowing of lye in a boy of four years4 ,below tile upper stricture is seen a second stricture4 ,an ulcer surrounded by an inflammatory areola and the granulation tissue together illustrates the etiology of cicatricial tissue4 ,the fan-shaped scar is really almost linear1 but it is viewed in perspective4 ,patient was cured by esophagoscopic dilatation4 #ac1 ,angioma of the esophagus in a man of forty years4 ,the patient had hemorrhoids and varicose veins of the legs4 #ad1 ,luetic ulcer of the esophagus #bf cm4 from the upper teeth in a woman of thirty-eight years4 ,two scars from healed ulcerations are seen in perspective on the anterior wall4 ,branching vessels are seen in the livid areola of the ulcers4 #ae1 ,tuberculosis of the esophagus in a man of thirty-four years4 #af1 ,leukoplakia of the esophagus near the hiatus in a man aged fifty-six years4 ,the hypopharynx tapers down to the gullet like a funnel1 and the larynx is suspended in its lumen from the anterior wall4 ,the larynx is attached only to the anterior wall1 but is held closely against the posterior pharyngeal wall by the action of the inferior constrictor of the pharynx1 and particularly by its specialized portion--the cricopharyngeus muscle4 ,a bolus of food is split by the epiglottis and the two portions drifted laterally into the pyriform sinuses1 the recesses seen on either side of the larynx4 ,but little of the food bolus passes posterior to the larynx during the act of swallowing4 ,it is through the pyriform sinus that the esophagoscope is to be inserted1 thereby following the natural food passage4 ,to insert the esophagoscope in the midline1 posterior to the arytenoids1 requires a degree of force dangerous to exert and almost certain to produce damage to the cricoarytenoid joint or to the pharyngeal wall1 or to both4 ,the esophagoscope is steadied by the left hand like a billiard cue1 the terminal phalanges of the left middle and ring fingers hooked over the upper teeth1 while the left index finger and thumb encircle the tube and retract the upper lip to prevent its being pinched between the tube and upper teeth4 ,the right hand holds the tube in pen fashion at the collar of the handle1 not by the handle4 ,during introduction the handle is to be pointed upward toward the zenith4 ,stage ,i4 ,entering the ,right ,pyriform ,sinus4--,the operator standing 7as in ,fig4 #ff71 inserts the esophagoscope along the right side of the tongue as far as and down the posterior pharyngeal wall4 ,a lifting motion imparted to the tip of the esophagoscope by the left thumb will bring the rounded right arytenoid eminence into view 7,a1 ,fig4 #fi74 ,this is the landmark of the pyriform sinus1 and care must be taken to avoid injury by hooking the tube mouth over it or its fellow4 ,the tip of the tube should now be directed somewhat toward the midline1 remembering the funnel shape of the hypopharynx4 ,it will then be found to glide readily through the right pyriform sinus for #b or #c cm41 when it comes to a full stop1 and the lumen disappears4 ,this is the spasmodically closed cricopharyngeal constriction4 ,,fig4 #ff4--;,esophagoscopy by the author's high-low method4 ,first stage4 ,high position4 ,finding the right pyriform sinus4 ,in this and the second stage the patient's vertex is about #ae cm4 above the level of the table4 ,stage #b4 ,passing the cricopharyngeus is the most difficult part of esophagoscopy1 especially if the patient is unanesthetized4 ,local anesthesia helps little1 if at all4 ,the handle of the esophagoscope is still pointing upward and consequently we are sure that the lip of the esophagoscope is directed anteriorly4 ,force must not be used1 but steady firm pressure against the tonically contracted cricopharyngeus is made1 while at the same time the distal end of the esophagoscope is lifted by the left thumb4 ,at the first inspiration a lumen will usually appear in the upper portion of the endoscopic field4 ,the tip of the esophagoscope enters this lumen and the slanted end slides over the fold of the cricopharyngeus into the cervical esophagus4 ,there is usually from #a to #c cm4 of this constricted lumen at the level of the cricopharyngeus and the subjacent orbicular esophageal fibers4 #aji ,,fig4 #fg4--,schematic illustration of the author's high-low method of esophagoscopy4 ,in the first and second stages the patient's head fully extended is held high so as to bring it in line with the thoracic esophagus1 as shown above4 ,the ,rose position is shown by way of accentuation4 ,,fig4 #fh4--,schematic illustration of the anatomic basis for difficulty in introduction of the esophagoscope4 ,the cricoid cartilage is pulled backward against the cervical spine1 by the cricopharyngeus1 so strongly that it is difficult to realize that the cricopharyngeus is not inserted into the vertebral periosteum instead of into the median raphe4 ,,fig4 #fi4--,the upper illustration shows movements necessary for passing the cricopharyngeus4 ,the lower illustration shows schematically the method of finding the pyriform sinus in the author's method of esophagoscopy4 ,the large circle represents the cricoid cartilage4 ,g1 ,glottic chink1 spasmodically closed2 ,,vb1 ventricular band2 ,a1 right arytenoid eminence2 ,p1 right pyriform sinus1 through which the tube is passed in the recumbent posture4 ,the pyriform sinuses are the normal food passages4 ,stage #c4 ,passing ,through the ,thoracic ,esophagus4--,the thoracic esophagus will be seen to expand during inspiration and contract during expiration1 due to the change in thoracic pressure4 ,the esophagoscope usually glides easily through the thoracic esophagus if the patient's position is correct4 ,after the levels of the aorta and left bronchus are passed the lumen of the esophagus seems to have a tendency to disappear anteriorly4 ,the lumen must be kept in axial view and the head lowered as required for this purpose4 ,stage #d4 ,passing ,through the ,hiatus ,esophageus4--,when the head is dropped1 it must at the same time be moved horizontally to the right in order that the axis of the tube shall correspond to the axis of the lower third of the esophagus1 which deviates to the left and turns anteriorly4 ,the head and shoulders at this time will be found to be considerably below the plane of the table top 7,fig4 #ga74 ,the hiatal constriction may assume the form of a slit or rosette4 ,if the rosette or slit cannot be promptly found1 as may be the case in various degrees of diffuse dilatation1 the tube mouth must be shifted farther to the left and anteriorly4 ,when the tube mouth is centered over the hiatal constriction moderately firm pressure continued for a short time will cause it to yield4 ,then the tube1 maintaining this same direction will1 without further trouble glide into and through the abdominal esophagus4 ,the cardia will not be noticed as a constriction1 but its appearance will be announced by the rolling in of reddish gastric mucosal folds1 and by a gush of fluid from the stomach4 ,,fig4 #gj4--,schematic illustration of the author's high-low method of esophagoscopy1 fourth stage4 ,passing the hiatus4 ,the head is dropped from the position of the #ast and #bnd stages1 ,,cl1 to the position ,t1 and at the same time the head and shoulders are moved to the right 7without rotation7 which gives the necessary direction for passing the hiatus4 ,,fig4 #ga4--;,esophagoscopy by the author's high-low method4 ,stage #d4 ,passing the hiatus ,the patient's vertex is about #e cm4 below the top of the table4 ,normal esophageal mucosa under proper illumination is glistening and of a yellowish or bluish pink4 ,the folds are soft and velvety1 rendering infiltration quickly noticeable4 ,the cricoid cartilage shows white through the mucosa4 ,the gastric mucosa is a darker pink than that of the esophagus and when actively secreting1 its color in some cases tends toward crimson4 ,secretions in the esophagus are readily aspirated through the drainage canal by a negative pressure pump4 ,food particles are best removed by sponge pumping1 or with forceps4 ,should the drainage canal become obstructed positive pressure from the pump will clear the canal4 ,difficulties of ,esophagoscopy4--,the beginner may find the esophagoscope seemingly rigidly fixed1 so that it can be neither introduced nor withdrawn4 ,this usually results from a wedging of the tube in the dental angle1 and is overcome by a wider opening of the jaws1 or perhaps by easing up of the bite block1 but most often by correcting the position of the patient's head4 ,if the beginner cannot start the tube into the pyriform sinus in an adult1 it is a good plan to expose the arytenoid eminence with the laryngoscope and then to insert the #g mm4 esophagoscope into the right pyriform sinus by direct vision4 ,passing the cricopharyngeal and hiatal spasmodically contracted narrowings will prove the most trying part of esophagoscopy2 but with the head properly held1 and the tube properly placed and directed1 patient waiting for relaxation of the spasm with gentle continuous pressure will usually expose the lumen ahead4 ,in his first few esophagoscopies the novice had best use general anesthesia to avoid these difficulties and to accustom himself to the esophageal image4 ,in the first favorable subject--an emaciated individual with no teeth--esophagoscopy without anesthesia should be tried4 ,in cases of kyphosis it is a mistake to try to straighten the spine4 ,the head should be held correspondingly higher at the beginning1 and should be very slowly and cautiously lowered4 ,once inserted1 the esophagoscope should not be removed until the completion of the procedure1 unless respiratory arrest demands it4 ,occasionally in stenotic conditions the light may become covered by the upwelling of a flood of fluid1 and it will be thought the light has gone out4 ,as soon as the fluid has been aspirated the light will be found burning as brightly as before4 ,if a lamp should fail it is unnecessary to remove the tube1 as the light carrier and light can be withdrawn and quickly adjusted4 ,a complete instrument equipment with proper selection of instruments for the particular case are necessary for smooth working4 ,ballooning ,esophagoscopy4--,by inserting the window plug shown in ,fig4 #f the esophagus may be inflated and studied in the distended state4 ,the folds are thus smoothed out and constrictions rendered more marked4 ,ether anesthesia is advocated by ,mosher4 ,the danger of respiratory arrest from pressure1 should the patient be dyspneic1 is always present unless the anesthetic be given by the intratracheal method4 ,if necessary to use forceps the window cap is removed4 ,if the perforated rubber diaphragm cap be substituted the esophagus can be reballooned1 but work is no longer ocularly guided4 ,the fluoroscope may be used but is so misleading as to render perforation and false passage likely4 ,specular ,esophagoscopy4--,inspection of the hypopharynx and upper esophagus is readily made with the esophageal speculum shown in ,fig4 #d4 ,high lesions and foreign bodies lodged behind the larynx are thus discovered with ease1 and such a condition as a retropharyngeal abscess which has burrowed downward is much less apt to be overlooked than with the esophagoscope4 ,high strictures of the esophagus may be exposed and treated by direct visual bouginage until the lumen is sufficiently dilated to allow the passage of the esophagoscope for bouginage of the deeper strictures4 ,technic of ,specular ,esophagoscopy4--,recumbent patient4 ,boyce position4 ,the larynx is to be exposed as in direct laryngoscopy1 the right pyriform sinus identified1 the tip of the speculum inserted therein1 and gently insinuated to the cricopharyngeal constriction4 ,too great extension of the head is to be avoided--even slight flexion at the occipito-atloid joint may be found useful at times4 ,moderate anterior or upward traction pulls the cricoid away from the posterior pharyngeal wall and the lumen of the esophagus opens above a crescentic fold 7the cricopharyngeus74 ,the speculum readily slides over this fold and enters the cervical esophagus4 ,in searching for foreign bodies in the esophagus the speculum has the disadvantage of limited length1 so that should the foreign body move downward it could not be followed4 ,complications ,following ,esophagoscopy4--,these are to be avoided in large measure by the exercise of gentleness1 care1 and skill that are acquired by practice4 ,if the instructions herein given are followed1 esophagoscopy is absolutely without mortality apart from the conditions for which it is done4 ,injury to the crico-arytenoid joint may simulate recurrent paralysis4 ,posticus paralysis may occur from recurrent or vagal pressure by a misdirected esophagoscope4 ,these conditions usually recover but may persist4 ,perforation of the esophageal wall may cause death from septic mediastinitis4 ,the pleura may be entered1--pyopneumothorax will result and demand immediate thoracotomy and gastrostomy4 ,aneurysm of the aorta may be ruptured4 ,patients with tuberculosis1 decompensating cardiovascular lesions1 or other advanced organic disease1 may have serious complications precipitated by esophagoscopy4 ,retrograde ,esophagoscopy4--,the first step is to get rid of the gastric secretions4 ,there is always fluid in the stomach1 and this keeps pouring out of the tube in a steady stream4 ,fold after fold is emptied of fluid4 ,once the stomach is empty1 the search begins for the cardial opening4 ,the best landmark is a mark with a dermal pencil on the skin at a point corresponding to the level of the hiatus esophageus4 ,when it is desired to do a retrograde esophagoscopy and the gastrostomy is done for this special purpose1 it is wise to have it very high4 ,once the cardia is located and the esophagus entered1 the remainder of the work is very easy4 ,bouginage can be carried out from below the same as from above and may be of advantage in some cases4 ,strictural lumina are much more apt to be concentric as approached from below because there has been no distortion by pressure dilatation due to stagnation of the food operating through a long period of time4 ,at retrograde esophagoscopy there seems to be no abdominal esophagus and no cardia4 ,the esophagoscope encounters only the diaphragmatic pinchcock which seems to be at the top of the stomach like the puckering string at the top of a bag4 ,retrograde esophagoscopy is sometimes useful for stringing the esophagus in cases in which the patient is unable to swallow a string because he is too young or because of an epithelial scaling over of the upper entrance of the stricture4 ,in such cases the smallest size of the author's filiform bougies 7,fig4 #dj7 is inserted through the retrograde esophagoscope 7,fig4 #dc7 and insinuated upward through the stricture4 ,when the tip reaches the pharynx coughing1 choking and gagging are noticed4 ,the filiform end is brought out the mouth sufficiently far to attach a silk braided cord which is then pulled down and out of the gastrostomic opening4 ,the braided silk string must be long enough so that the oral and the abdominal ends can be tied together to make it endless2 but before doing so the oral end should be drawn through nose where it will be less annoying than in the mouth4 ,the purpose of the string is to pull up the retrograde bougies 7,fig4 #ce7 #aag ,,chapter ,,xi--,,acquiring ,,skill ,endoscopic ability cannot be bought with the instruments4 ,as with all mechanical procedures1 facility can be obtained only by educating the eye and the fingers in repeated exercise of a particular series of maneuvers4 ,as with learning to play a musical instrument1 a fundamental knowledge of technic1 positions1 and landmarks is necessary1 after which only continued manual practice makes for proficiency4 ,for instance1 efficient use of forceps requires that they be so familiar to the grasp that their use is automatic4 ,endoscopy is a purely manual procedure1 hence to know how is not enough3 manual practice is necessary4 ,even in the handling of the electrical equipment1 practice in quickly locating trouble is as essential as theoretic knowledge4 ,there is no mystery about electric lighting4 ,no source of illumination other than electricity is possible for endoscopy4 ,therefore a small amount of electrical knowledge1 rendered practical by practice1 is essential to maintain the simple lighting system in working order4 ,it is an insult to the intelligence of the physician to say that he cannot master a simple problem of electric testing involving the locating of one or more of five possibilities4 ,it is simply a matter of memorizing five tests4 ,it is repeated for emphasis that a commercial current reduced by means of a rheostat should never be used as a source of current for endoscopy with any kind of instrument1 because of the danger to the patient of a possible grounding of the circuit during the extensive moist contact of a metallic endoscopic tube in the mediastinum4 ,the battery shown in ,fig4 #h should be used4 ,the most frequent cause of trouble is the mistake of over-illuminating the lamps4 ,the lamp should not be over-illuminated to the dazzling whiteness usually used in flash lights4 ,excessive illumination alters the proper perception of the coloring of the mucosa1 besides shortening the life of the lamps4 ,the proper degree of brightness is obtained when1 as the current is increased1 the first change from yellow to white light is obtained4 ,never turn up the rheostat without watching the lamp4 ,testing for ,electric ,defects4--,these tests should be made beforehand2 not when about to commence introduction4 ,if the first lamp lights up properly1 use it with its light-carrier to test out the other cords4 ,if the lamp lights up1 but flickers1 locate the trouble before attempting to do an endoscopy4 ,if shaking the carrier cord-terminal produces flickering there may be a film of corrosion on the central contact of the light carrier that goes into the carrier cord-terminal4 ,if the lamp fails to show a light1 the trouble may be in one of five places which should be tested for in the following order and manner4 #a4 ,the lamp may not be firmly screwed into the light-carrier4 ,withdraw the light-carrier and try screwing it in1 though not too strongly1 lest the central wire terminal in the lamp be bent over4 #b4 ,the light-carrier may be defective4 #c4 ,the cord may be defective or its terminals not tight in the binding posts4 ,if screwing down the thumb nuts does not produce a light1 test the light-carrier with lamp on the other cords4 ,reserve cords in each pair of binding posts are for use instead of the defective cords4 ,the two sets of cords from one pair of binding posts should not be used simultaneously4 #d4 ,the lamp may be defective4 ,try another lamp4 #e4 ,the battery may be defective4 ,take a cord and light-carrier with lamp that lights up1 detaching the cord-terminals at the binding posts1 and attach the terminals to the binding posts of the battery to be tested4 ,efficient use of forceps requires previous practice in handling of the forceps until it has become as natural and free from thought as the use of knife and fork4 ,indeed the coordinate use of the bronchoscopic tube-mouth and the forceps very much resembles the use of knife and fork4 ,yet only too often a practitioner will telegraph for a bronchoscope and forceps1 and without any practice start in to remove an entangled or impacted foreign body from the tiny bronchi of a child4 ,failure and mortality are almost inevitable4 ,a few hundred hours spent in working out1 on a bit of rubber tubing1 the various mechanical problems given in the section on that subject will save lives and render easily successful many removals that would otherwise be impossible4 ,it is often difficult for the beginner to judge the distance the forceps have been inserted into the tube4 ,this difficulty is readily solved if upon inserting the forceps slowly into the tube1 he observes that as the blades pass the light they become brightly illuminated4 ,by this light reflex it is known1 therefore1 that the forceps blades are at the tube-mouth1 and distance from this point can be readily gauged4 ,excellent practice may be had by picking up through the bronchoscope or esophagoscope black threads from a white background1 then white threads from a black background1 and finally white threads on a white background and black threads on a black background4 ,this should be done first with the #i mm4 bronchoscope4 ,it is to be remembered that the majority of foreign body accidents occur in children1 with whom small tubes must be used2 therefore1 practice work1 after say the first #ajj hours1 should be done with the #e mm4 bronchoscope and corresponding forceps rather than adult size tubes1 so that the operator will be accustomed to work through a small calibre tube when the actual case presents itself4 #abj ,cadaver ,practice4--,the fundamental principles of peroral endoscopy are best taught on the cadaver4 ,it is necessary that a specially prepared subject be had1 in order to obtain the required degree of flexibility4 ,injecting fluid of the following formula worked out by ,prof4 ,j4 ,parsons ,schaeffer for the ,bronchoscopic ,clinic courses1 has proved very satisfactory3 ,sodium carbonate--#a #a_/b lbs4 ,white arsenic--#b #a_/b lbs4 ,potassium nitrate--#c lbs4 ,water--#e gal4 ,boil until arsenic is dissolved4 ,when cold add3 ,carbolic acid #aejj c4c4 ,glycerin #abej c4c4 ,alcohol 7#ie7 #abej c4c4 ,for each body use about #c gal4 of fluid4 ,the method of introduction of the endoscopic tube1 and its various positions can be demonstrated and repeatedly practiced on the cadaver until a perfected technic is developed in both the operator and assistant who holds the head1 and the one who passes the instruments to the operator4 ,in no other manner can the landmarks and endoscopic anatomy be studied so thoroughly and practically1 and in no other way can the pupil be taught to avoid killing his patient4 ,the danger-points in esophagoscopy are not demonstrable on the living without actually incurring mortality4 ,laryngeal growths may be simulated1 foreign body problems created and their mechanical difficulties solved and practice work with the forceps and tube perfected4 ,practice on the ,rubber-tube ,manikin4--,this must be carried out in two ways4 #a4 ,general practice with all sorts of objects for the education of the eye and the fingers4 #b4 ,before undertaking a foreign body case1 practice should be had with a duplicate of the foreign body4 ,it is not possible to have a cadaver for daily practice1 but fortunately the eye and fingers may be trained quite as effectually by simulating foreign body conditions in a small red rubber tube and solving these mechanical problems with the bronchoscope and forceps4 ,the tubing may be placed on the desk and held by a small vise 7,fig4 #gb7 so that at odd moments during the day or evening the fascinating work may be picked up and put aside without loss of time4 ,complicated rubber manikins are of no value in the practice of introduction1 and foreign body problems can be equally well studied in a piece of rubber tubing about #aj inches long4 ,no endoscopist has enough practice on the living subject1 because the cases are too infrequent and furthermore the tube is inserted for too short a space of time4 ,practice on the rubber tube trains the eye to recognize objects and to gauge distance2 it develops the tactile sense so that a knowledge of the character of the object grasped or the nature of the tissues palpated may be acquired4 ,before attempting the removal of a particular foreign body from a living patient1 the anticipated problem should be simulated with a duplicate of the foreign body in a rubber tube4 ,in this way the endoscopist may precede each case with a practical experience equivalent to any number of cases of precisely the same kind of foreign body4 ,if the object cannot be removed from the rubber tube without violence1 it is obvious that no attempt should be made on the patient until further practice has shown a definite method of harmless removal4 ,during practice work the value of the beveled lip of the bronchoscope and esophagoscope in solving mechanical problems will be evidenced4 ,with it alone1 a foreign body may be turned into favorable positions for extraction1 and folds can always be held out of the way4 ,sufficient combined practice with the bronchoscope and the forceps enable the endoscopist easily to do things that at first seem impossible4 ,it is to be remembered that lateral motion of the long slender tube-forceps cannot be controlled accurately by the handle1 this is obtained by a change in position of the endoscopic tube1 the object being so centered that it is grasped without side motion of the forceps4 ,when necessary1 the distal end of the forceps may be pushed laterally by the manipulation of the bronchoscope4 ,,fig4 #gb4--;,a simple manikin4 ,the weight of the small vise serves to steady the rubber tubing4 ,by the use of tubing of the size of the invaded bronchus and a duplicate of the foreign body1 any mechanical problem can he simulated for solution or for practice1 study of all possible presentations1 etc4 ,practice on the ,dog4--,having mastered the technic of introduction on the cadaver and trained the eye and fingers by practice work on the rubber tube1 experience should be had in the living lower air and food passages with their pulsatory1 respiratory1 bechic and deglutitory movements1 and ever-present secretions4 ,it is not only inhuman but impossible to obtain this experience on children4 ,fortunately the dog offers a most ready subject and need in no way be harmed nor pained by this invaluable and life-saving practice4 ,a small dog the size of a terrier 7say #f to #aj pounds in weight7 should be chosen and anesthetized by the hypodermic injection of morphin sulphate in dosage of approximately one-sixth of a grain per pound of body weight1 given about #de minutes before the time of practice4 ,dogs stand large doses of morphin without apparent ill effect1 so that repeated injection may be given in smaller dosage until the desired degree of relaxation results4 ,the first effect is vomiting which gives an empty stomach for esophagoscopy and gastroscopy4 ,vomiting is soon followed by relaxation and stupor4 ,the dog is normal and hungry in a few hours4 ,dosage must be governed in the clog as in the human being by the susceptibility to the drug and by the temperament of the animal4 ,other forms of anesthesia have been tried in my teaching1 and none has proven so safe and satisfactory4 ,phonation may be prevented during esophagoscopy by preventing approximation of the cords1 through inserting a silk-woven cathether in the trachea4 ,the larynx and trachea may be painted with cocain solution if it is found necessary for bronchoscopy4 ,a very comfortable and safe mouth gag is shown in ,fig4 #gc4 ,great gentleness should be exercised1 and no force should be used1 for none is required in endoscopic work2 and the endoscopist will lose much of the value of his dog practice if he fails to regard the dog as a child4 ,he should remember he is not learning how to do endoscopy on the dog2 but learning on the dog how safely to do bronchoscopy on a human being4 ,the degree of resistance during introduction can be gauged and the color of the mucosa studied1 while that interesting phenomenon1 the dilatation and lengthening of the bronchi during inspiration and their contraction and shortening during expiration1 is readily observed and always forms subject for thought in its possible connection with pathological conditions4 ,foreign body problems are now to be solved under these living conditions1 and it is my feeling that no one should attempt the removal of a foreign body from the bronchus of a child until he has removed at least #ajj foreign bodies from the dog without harming the animal4 ,dogs have the faculty of easily ridding their air-passages of foreign objects1 so that one need not be alarmed if a foreign body is lost during practice removal4 ,it is to be remembered that dogs swallow very large objects with apparent ease4 ,the dog's esophagus is relatively much larger than that of human beings4 ,therefore a small dog 7of six to eight pounds' weight7 must be used for esophagoscopic practice1 if practice is to be had with objects of the size usually encountered in human beings4 ,the bronchi of a dog of this weight will be about the size of those of a child4 ,,fig4 #gc4--;,author's mouth gag for use on the dog4 ,the thumb-nut serves to prevent an uncomfortable degree of expansion of the gag4 ,a bandage may be wound around the dog's jaws to prevent undue spread of the jaws4 ,endoscopy on the ,human ,being4--,dog work offers but little practice in laryngoscopy4 ,because of the slight angle at which the dog's head joins his spine1 the larynx is in a direct line with the open mouth2 hence little displacement of the anterior cervical tissues is necessary4 ,moreover the interior of the larynx of the dog is quite different from that of the human larynx4 ,the technic of laryngoscopy in the human subject is best perfected by a routine direct examination of the larynx of anesthetized patients after such an operation as1 for instance1 tonsillectomy1 to see that the larynx and laryngopharynx are free of clots4 ,to perform a bronchoscopy or esophagoscopy under these conditions would be reprehensible2 but direct laryngoscopy for the seeking and removal of clots serves a useful purpose as a preventative of pulmonary abscess and similar complications499 ,diagnosis of laryngeal conditions in young children is possible only by direct laryngoscopy and is neglected in almost all of the cases4 ,no anesthesia1 general or local1 is required4 ,much clinical material is neglected4 ,all cases of dyspnea or dysphagia should be studied endoscopically if the cause of the condition cannot be definitely found and treated by other means4 ,invaluable practice in esophagoscopy is found in the treatment of strictures of the esophagus by weekly or biweekly esophagoscopic bouginage4 99 ,dr4 ,william ,frederick ,moore1 of the ,bronchoscopic ,clinic1 has recently collected statistics of #bjb cases of post-tonsillectomic pulmonary abscess that point strongly to aspiration of infected clots and other infective materials as the most frequent etiologic mechanism 7,moore1 ,w4 ,f41 ,pulmonary ,abscess4 ,journ4 ,am4 ,med4 ,assn41 ,april #bi1 #aibb1 ,vol4 #gh1 pp4 #abgi-abha74 ,in acquiring skill as an endoscopist the following paraphrased aphorisms afford food for thought4 ,,aphorisms ,educate your eye and your fingers4 ,be sure you are right1 but not too sure4 ,follow your judgment1 never your impulse4 ,cry over spilled milk enough to memorize how you spilled it4 ,let your mistakes worry you enough to prevent repetition4 ,let your left hand know what your right hand does and how to do it4 ,nature helps1 but she is no more interested in the survival of your patient than in the survival of the attacking pathogenic bacteria4 #abf ,,chapter ,,xii--,,foreign ,,bodies ,,in ,,the ,,air ,,and ,,food ,,passages ,the air and food passages may be invaded by any foreign substance of solid1 liquid or gaseous nature1 from the animal1 vegetable1 or mineral kingdoms4 ,its origin may be from within the body 7blood1 pus1 secretion1 broncholiths1 sequestra1 worms72 introduced from without by way of the natural passages 7aspirated or swallowed objects72 or it may enter by penetration 7bullet1 dart1 drainage tube from the neck74 ,prophylaxis4--,if one put into his mouth nothing but food1 foreign body accidents would be rare4 ,the habit of holding tacks1 pins and whatnot in the mouth is quite universal and deplorable4 ,children are prone to follow the bad example of their elders4 ,no small objects such as safety pins1 buttons1 and coins should be left within a baby's reach2 children should be watched and taught not to place things in their mouths4 ,mothers should be specially cautioned not to give nuts or nut candy of any kind to a child whose powers of mastication are imperfect1 because the molar teeth are not erupted4 ,it might be made a dictum that3 ,no child under #c years of age should be allowed to eat nuts1 unless ground finely as in peanut butter4 ,digital efforts at removal of foreign bodies frequently force the object downward1 or may hook it forward into the larynx1 whereas if not meddled with digitally the intruder might be spat out4 ,before general anesthesia the mouth should be searched for loose teeth1 removable dentures1 etc41 and all unconscious individuals should be likewise examined4 ,when working in the mouth precautions should be taken against the possible inhalation or swallowing of loose objects or instruments4 #abf ,objects that have lodged in the esophagus1 larynx1 trachea1 or bronchi should be endoscopically removed4 ,foreign ,bodies in the ,insane4--,foreign bodies may be introduced voluntarily and in great numbers by the insane4 ,hysterical individuals may assert the presence of a foreign body1 or may even volitionally swallow or aspirate objects4 ,it is a mistake to do a bronchoscopy in order to cure by suggestion the delusion of foreign body presence4 ,such cures are ephemeral4 ,foreign ,bodies in the ,stomach4--,gastroscopy is indicated in cases of a foreign body that refuses to pass after a month or two4 ,foreign bodies in very large numbers in the stomach1 as in the insane1 may be removed by gastrostomy4 ,the symptomatology of foreign bodies may be epitomized as given below2 but it must be kept in mind1 that certain symptoms may not be manifest immediately after intrusion1 and others may persist for a time after the passage1 removal1 or expulsion of a foreign body4 ,,esophageal ,,foreign ,,body ,,symptoms #a4 ,there are no absolutely diagnostic symptoms4 #b4 ,dysphagia1 however1 is the most constant complaint1 varying with the size of the foreign body1 and the degree of inflammatory or spasmodic reaction produced4 #c4 ,pain may be caused by penetration of a sharp foreign body1 by inflammation secondary thereto1 by impaction of a large object1 or by spasmodic closure of the hiatus esophageus4 #d4 ,the subjective sensation of foreign body is usually present1 but cannot be relied upon as assuring the presence of a foreign body for this sensation often remains for a time after the passage onward of the intruder4 #e4 ,all of these symptoms may exist1 often in the most intense degree1 as the result of previous violent attempts at removal2 and the foreign body may or may not be present4 ,,symptoms ,,of ,,laryngeal ,,foreign ,,body #a4 ,initial laryngeal spasm followed by wheezing respiration1 croupy cough1 and varying degrees of impairment of phonation4 #b4 ,pain may be a symptom4 ,if so1 it is usually located in the laryngeal region1 though in some cases it is referred to the ears4 #c4 ,the larynx may tolerate a thin1 flat1 foreign body for a relatively long period of time1 a month or more2 but the development of increasing dyspnea renders early removal imperative in the majority of cases4 ,,symptoms ,,of ,,tracheal ,,and ,,bronchial ,,foreign ,,body #a4 ,tracheal foreign bodies are usually movable and their movements can usually be felt by the patient4 #b4 ,cough is usually present at once1 may disappear for a time and recur1 or may be continuous1 and may be so violent as to induce vomiting4 ,in recent cases fixed foreign bodies cause little cough2 shifting foreign bodies cause violent coughing4 #c4 ,sudden shutting off of the expiratory blast and the phonation during paroxysmal cough is almost pathognomonic of a movable tracheal foreign body4 #d4 ,dyspnea is usually present in tracheal foreign bodies1 and is due to the bulk of the foreign body plus the subglottic swelling caused by the traumatism of the shiftings of the intruder4 #e4 ,dyspnea is usually absent in bronchial foreign bodies4 #f4 ,the respiratory rate is increased only if a considerable portion of lung is out of function1 by the obstruction of a main bronchus1 or if inflammatory sequelae are extensive4 #g4 ,the asthmatoid wheeze is usually present in tracheal foreign bodies1 and is often louder and of lower pitch than the asthmatoid wheeze of bronchial foreign bodies4 ,it is heard at the open mouth1 not at the chest wall2 and prolonged expiration as though to rid the lungs of all residual air1 may be necessary to elicit it4 #h4 ,pain is not a common symptom1 but may occur and be accurately localized by the patient1 in case of either tracheal or bronchial foreign body4 ,,early ,,symptoms ,,of ,,irritating ,,foreign ,,body ,,such ,,as ,a ,,peanut ,,kernel ,,in ,,the ,,bronchus #a4 ,initial laryngeal spasm is almost invariably present with foreign bodies of organic nature1 such as nut kernels1 peas1 beans1 maize1 etc4 #b4 ,a diffuse purulent laryngo-tracheo-bronchitis develops within #bd hours in children under #b years4 #c4 ,fever1 toxemia1 cyanosis1 dyspnea and paroxysmal cough are promptly shown4 #d4 ,the child is unable to cough up the thick mucilaginous pus through the swollen larynx and may drown in its own secretions unless the offender be removed4 #e4 ,drowned lung1 that is to say natural passages idled with pus and secretions1 rapidly forms4 #f4 ,pulmonary abscess develops sooner than in case of mineral foreign bodies4 #g4 ,the older the child the less severe the reaction4 ,,symptoms ,,of ,,prolonged ,,foreign ,,body ,,sojourn ,,in ,,the ,,bronchus #a4 ,the time of inhalation of a foreign body may be unknown or forgotten4 #b4 ,cough and purulent expectoration ultimately result1 although there may be a delusive protracted symptomless interval4 #acj #c4 ,periodic attacks of fever1 with chills and sweats1 and followed by increased coughing and the expulsion of a large amount of purulent1 usually more or less foul material1 are so nearly diagnostic of foreign body as to call for exclusion of this probability with the utmost care4 #d4 ,emaciation1 clubbing of the fingers and toes1 night sweats1 hemoptysis1 in fact all of the symptoms of tuberculosis are in most cases simulated with exactitude1 even to the gain in weight by an out-door regime4 #e4 ,tubercle bacilli have never been found1 in the cases at the ,bronchoscopic ,clinic1 associated with foreign body in the bronchus499 ,in cases of prolonged sojourn this has been the only element lacking in a complete clinical picture of advanced tuberculosis4 ,one point of difference was the almost invariably rapid recovery after removal of the foreign body4 ,the statement in all of the text-books1 that foreign body is followed by phthisis pulmonalis is a relic of the days when the bacillary origin of true tuberculosis was unknown1 hence the foreign-body phthisis pulmonalis1 or pseudo tuberculosis1 was confused with the true pulmonary tuberculosis of bacillary origin4 #f4 ,the subjective sensation of pain may allow the patient accurately to localize a foreign body4 #g4 ,foreign bodies of metallic or organic nature may cause their peculiar taste in the sputum4 #h4 ,offensive odored sputum should always suggest bronchial foreign body2 but absence of sputum1 odorous or not1 should not exclude foreign body4 #i4 ,sudden complete obstruction of one main bronchus does not cause noticeable dyspnea provided its fellow is functionating4 #aca #aj4 ,complete obstruction of a bronchus is followed by rapid onset of symptoms4 #aa4 ,the physical signs usually show limitation of expansion on the affected side1 impairment of percussion1 and lessened trans-mission or absence of breath-sounds distal to the foreign body4 99 ,the exceptional case has at last been encountered4 ,a boy with a tack in the bronchus was found to have pulmonary tuberculosis4 ,,symptoms ,,of ,,gastric ,,foreign ,,body ,foreign body in the stomach ordinarily produces no symptoms4 ,the roentgenogram and the fluoroscopic study with an opaque mixture are the chief means of diagnosis4 ,,diagnosis ,,of ,,foreign ,,body ,,in ,,the ,,air ,,or ,,food ,,passages ,the questions arising are3 ,i4 ,is a foreign body present8 #b4 ,where is it located8 #c4 ,is a peroral endoscopic procedure indicated8 #d4 ,are there any contraindications to endoscopy8 ,in order to answer these questions the definite routine given below is followed unvaryingly in the ,bronchoscopic ,clinic4 #a4 ,history4 #b4 ,complete physical examination1 including mirror laryngoscopy4 #c4 ,roentgenologic study4 #d4 ,endoscopy4 ,the history should note the date of1 and should delve into the details of the accident2 special note being made of the occurrence of laryngeal spasm1 wheezing respiration heard by the patient or others 7asthmatoid wheeze71 fever1 cough1 pain1 dyspnea1 dysphagia1 odynphagia1 regurgitation1 etc4 ,the amount1 character and odor of sputum are important4 ,increasing amounts of purulent1 foul-odored1 sometimes blood-tinged sputum strongly suggest prolonged bronchial foreign body sojourn4 ,the mode of onset of the persisting symptoms1 whether immediately following the supposed accident or delayed in their occurrence1 is to be noted4 ,do attacks of sudden dyspnea and cyanosis occur8 ,what has been the previous treatment and what attempts at removal have been made8 ,the nature of the foreign body is to be determined1 and if possible a duplicate thereof obtained4 ,general physical examination should be complete including inspection of the eyes1 ears1 nose1 pharynx1 and mirror inspection of the naso-pharynx and larynx4 ,special attention is paid to the chest for the localization of the object4 ,in order to discover conditions rendering endoscopy unusually hazardous1 all parts of the body are to be examined4 ,aneurysm of the aorta1 excessive blood pressure1 serious cardiac and renal conditions1 the presence of a hernia and the existence of central nervous disease1 as tabes dorsalis1 should be at least known before attempting any endoscopic procedure4 ,dysphagia might result from the pressure of an unknown aneurysm1 the symptoms being attributed to a foreign body1 and aortic aneurysm is a definite contraindication to esophagoscopy unless there be foreign body present also4 ,there is no absolute contraindication to the endoscopic removal of a foreign body1 though many conditions may render it wise to post-pone endoscopy4 ,laryngeal crises of tabes might1 because of their sudden onset1 be thought due to foreign body4 ,,physical ,,signs ,,in ,,esophageal ,,foreign ,,body ,there are no constant physical signs associated with uncomplicated impaction of a foreign body in the esophagus4 ,should perforation of the cervical esophagus occur1 subcutaneous emphysema1 and perhaps cellulitis1 may be found2 while a perforation of the thoracic region causing mediastinitis is manifested by toxemia1 fever1 and rapid sinking4 ,perforation of the pleura1 with the development of pyopneumothorax1 is manifested by the usual signs4 ,it is to be emphasized that blind bouginage has no place in the diagnosis of any esophageal condition4 ,the roentgenologist will give the information we desire without danger to the patient1 and with far greater accuracy4 ,,foreign ,,bodies ,,in ,,the ,,larynx ,laryngeally lodged foreign bodies produce a wheezing respiration1 the quality of which is peculiar to the larynx and is readily localized to this organ4 ,if swelling or the size of the foreign body be sufficient to produce dyspnea1 inspiratory indrawing of the suprasternal notch1 supraclavicular fossae1 costal interspaces and lower sternum will be present4 ,cyanosis is only an accompaniment of suddenly produced dyspnea2 the facies will therefore usually be anxious and pale1 unless the patient is seen immediately after the aspiration of the foreign body4 ,if labored breathing has been prolonged1 and exhaustion threatened1 the heart's action will be irregular and weak4 ,the foreign body can be seen with the mirror1 but a roentgenograph must nevertheless be made1 for the object may be of another nature than was first thought4 ,the roentgenograph will show its position1 and from this knowledge the plan of removal can be formulated4 ,for example1 a straight pin may be so placed in the larynx that only a portion of its shaft will be visible1 the roentgenogram will tell where the head and point are located1 and which of these will be the more readily disengaged4 7,see ,chapter on ,mechanical ,problems47 ,,physical ,,signs ,,of ,,tracheal ,,foreign ,,body ,if fixed in the trachea the only objective sign of foreign body may be a wheezing respiration1 the site of which may be localized with the stethoscope1 by the intensity of the sound4 ,movable foreign bodies may produce a palpatory thrill1 and the rumble and sudden stop can be heard with the stethoscope and often with the naked ear4 ,the lungs will show equal aeration1 but there may be marked dyspnea without the indrawing of the fossae1 if the object be of large size and located below the manubrium4 ,to the peculiar sound of the sudden subglottic1 expiratory or bechic arrest of the foreign body the author has given the name audible slap2 when felt by the thumb on the trachea he calls it the palpatory thud4 ,these signs can be produced by no condition other than the arrest of some substance by the subglottic taper4 ,once heard and felt they are unmistakable4 ,,physical ,,signs ,,of ,,bronchial ,,foreign ,,body ,in most cases there will be limitation of expansion on the invaded side1 even though the foreign body is of such a shape as to cause no bronchial obstruction4 ,it has been noted frequently in conjunction with the presence of such objects as a common straight pin in a small branch bronchus4 ,this peculiar phenomenon was first noted by ,thomas ,mc,crae in one of the author's cases and has since been abundantly corroborated by ,mc,crae and others as one of the most constant physical signs4 ,to understand the peculiar physical findings in these cases it is necessary to remember that the bronchi are not tubes of constant caliber2 there occurs a dilatation during inspiration1 and a contraction of the lumen during expiration2 furthermore1 the lumen may be narrowed by swollen mucosa if the foreign body be of an irritant nature4 ,the signs vary with the degree of obstruction of the bronchus1 and with the consequent degree of interference with aeration and drainage of the subjacent portion of the lung4 ,we have three definite types which show practically constant signs in the earlier stages of foreign body invasion4 #a4 ,complete bronchial occlusion4 #b4 ,obstruction complete during expiration1 but allowing the passage of air during the bronchial dilatation incident to inspiration1 constituting an expiratory valve-like obstruction4 #c4 ,partial bronchial obstruction1 allowing to-and-fro passage of air4 #a4 ,complete bronchial obstruction is manifested by limitation of expansion1 markedly impaired percussion note1 particularly at the base1 absence of breath-sounds1 and rales on the invaded side4 ,an atelectasis here exists2 the air imprisoned in the lung is soon absorbed1 and secretions rapidly accumulate4 ,on the free side a compensatory emphysema is present4 #b4 ,expiratory ,valve-like ,obstruction4--,the obstructed side shows marked limitation of expansion4 ,percussion is of a tympanitic character4 ,the duration of the vibrations may be shortened giving a muffled tympany4 ,various grades and degrees of tympany may be noted4 ,breath sounds are markedly diminished or absent4 ,no rales are heard on the invaded side1 although rales of all types may be present on the free side4 ,in some cases it is possible to hear a short inspiratory sound4 ,vocal resonance and fremitus are but little altered4 ,the heart will be found displaced somewhat to the opposite side4 ,these signs are explained by the passage of some air past the foreign body during inspiration with its trapping during expiration1 so that there is air under pressure constantly maintained in the obstructed area4 ,this type of obstruction is most frequently observed when the foreign body is of an organic nature such as nut kernels1 beans1 corn1 seed1 etc4 ,the localized swelling about the irritating foreign body completes the expiratory obstruction4 ,it may also be present with any foreign body whose size and shape are such as to occlude the lumen of the bronchus during its contracted expiratory phase4 ,it was present in cases of pebbles1 cylindrical metallic objects1 thick tough balls of secretion etcetera4 ,the valvular action is here produced most often by a change in the size of the valve seat and not by a movement of the foreign body plug4 ,in other cases ,i have found at bronchoscopy1 a regular ball-valve mechanism4 ,pneumothorax is the only pathologic condition associated with signs similar to those of expiratory1 valve-like bronchial obstruction by a foreign body4 #c4 ,partial bronchial obstruction by an object such as a nail allows air to pass to and fro with some degree of retardation1 and impairs the drainage of the subjacent lung4 ,limitation of expansion will be found on the invaded side4 ,the area below the foreign body will give an impaired percussion note4 ,breath-sounds are diminished in the area of dullness1 and vocal resonance and fremitus are impaired4 ,rales are of great diagnostic import2 the passage of air past the foreign body is accompanied by blowing1 harsh breathing1 and snoring2 snapping rales are heard usually with greatest intensity posteriorly over the site of the foreign body 7usually about the scapular angle74 ,a knowledge of the topographical lung anatomy1 the bronchial tree1 and of endoscopic pathology99 should enable the examiner of the chest to locate very accurately a bronchial foreign body by physical signs alone1 for all the significant signs occur distal to the foreign body lodgment4 99 ,jackson1 ,chevalier4 ,pathology of ,foreign ,bodies in the ,air and ,food ,passages4 ,mutter ,lecture1 #aiah4 ,surgery1 ,gynecology and ,obstetrics1 ,march1 #aiai4 ,also1 by the same author1 ,mechanism of the ,physical ,signs of ,foreign ,bodies in the ,lungs4 ,proceedings of the ,college of ,physicians1 ,philadelphia1 #aibb4 ,the asthmatoid wheeze has been found by the author a valuable confirmatory sign of bronchial foreign body4 ,it is a wheezing heard by placing the observer's ear at the open mouth of the patient 7not at the chest wall7 during a prolonged forced expiration4 ,thomas ,mc,crae elicits this sign by placing the stethoscope bell at the patient's open mouth4 ,the quality of the sound is dryer than that heard in asthma and the wheeze is clearest after all secretion has been removed by coughing4 ,the mechanism of production is1 probably1 the passage of air by a foreign body which narrows the lumen of a large bronchus4 ,as the foreign body works downward the wheeze lessens4 ,the wheeze is often so loud as to be heard at some distance from the patient4 ,it is of greatest value in the diagnosis of non-roentgenopaque foreign body but its absence in no way negates foreign body4 ,its presence or absence should be recorded in every case4 ,prolonged bronchial obstruction by foreign body is followed by bronchiectasis and lung abscess usually in a lower lobe4 ,the symptoms may with exactitude simulate tuberculosis1 but this disease should be readily excluded by the basal1 unilateral site of the lesion1 absence of tubercle bacilli in the sputum1 and roentgenographic study4 ,chest examination in the foreign body cases reveals limitation of expansion1 often some retraction1 flat percussion note1 and greatly diminished or absent breath-sounds over the site of the pulmonary lesion4 ,rales vary with the amount of secretion present4 ,these physical signs suggest empyema2 and rib resection had been done before admission in a number of cases only to find the pleura normal4 ,,roentgenray ,,study ,,in ,,foreign ,,body ,,cases ,roentgenography4--,all cases of chest disease should have the benefit of a roentgenologic study to exclude bronchial foreign body as an etiological factor4 ,negative opinions should never be based upon any plates except the best that the wonderful modern development of the art and science of roentgenology can produce4 ,in doubtful cases1 the negative opinion should not be conclusive until a roentgenologist of long experience in chest work1 and especially in foreign body cases1 has been called in consultation4 ,even then there will be an occasional case calling for diagnostic bronchoscopy4 ,antero-posterior and lateral roentgenograms should always be made4 ,in an antero-posterior film a flat foreign body lying in the lateral body plane might be invisible in the shadow of the spine1 heart1 and great vessels2 but would be revealed in the lateral view because of the greater edgewise density of the intruder and the absence of other confusing shadows4 ,fluoroscopic examination will often discover the best angle from which to make a plate2 but foreign bodies casting a very faint shadow on a plate may be totally invisible on the fluoroscopic screen4 ,the value of a roentgenogram after the removal of a foreign body cannot be too strongly emphasized4 ,it is evidence of removal and will exclude the presence of a second intruder which might have been overlooked in the first study4 ,fluoroscopic study of the swallowing function with barium mixture1 or a barium-filled capsule1 will give the location of a nonroentgenopaque object 7such as bone1 meat1 etc47 in the esophagus4 ,if a flat or disc-shaped object located in the cervical region is seen to be lying in the lateral body plane1 it will be found to be in the esophagus1 for it assumed that position by passing down flatwise behind the larynx4 ,if1 however1 the object is seen to be in the sagittal plane it must lie in the trachea4 ,this position was necessary for it to pass through the glottic chink1 and can be maintained because of the yielding of the posterior membranous wall of the trachea4 ,,the ,,roentgenographic ,,signs ,,of ,,expiratory-,,valve-,,like ,,bronchial ,,obstruction ,the roentgenray signs in expiratory valve-like obstruction of a bronchus are those of an acute obstructive emphysema 7,fig4 #gd71 namely1 #a4 ,greater transparency on the obstructed side 7,iglauer74 #b4 ,displacement of the heart to the free side 7,iglauer74 #c4 ,depression and flattening of the dome of the diaphragm on the invaded side 7,iglauer74 #d4 ,limitation of the diaphragmatic excursion on the obstructed side 7,manges74 ,it is very important to note that1 as discovered by ,manges1 the differential emphysema occurs at the end of expiration and the plate must be exposed at that time1 before inspiration starts4 ,he also noted that at fluoroscopy the heart moved laterally toward the uninvaded side during expiration499 99 ,dr4 ,manges has developed such a high degree of skill in the fluoroscopic diagnosis of non-opaque foreign bodies by the obstructive emphysema they produce that he has located peanut kernels and other vegetable substances with absolute accuracy and unfailing certainty in dozens of cases at the ,bronchoscopic ,clinic4 ,,fig4 #gd--;,expiratory valve-like bronchial obstruction by non-radiopaque foreign body1 producing an acute obstructive emphysema4 ,peanut kernel in right main bronchus4 ,note 7a7 depression of right diaphragm2 7b7 displacement of heart and mediastinum to left2 7c7 greater transparency of the invaded side4 ,ray-plate made by ,willis ,f4 ,manges4 ,complete bronchial obstruction shows a density over the whole area the aeration and drainage of which has been cut off 7,fig4 #ge74 ,pulmonary abscess formation and drowned lung 7accumulated secretion in the bronchi and bronchioli7 are shown by the definite shadows produced 7,fig4 #gf74 #adj ,dense and metallic objects will usually be readily seen in the roentgenograms and fluoroscope1 but many foreign bodies are of a nature which will produce no shadow2 the roentgenologist should1 therefore1 be prepared to interpret the pulmonary pathology1 and should not dismiss the case as negative for foreign body because one is not seen4 ,even metallic objects are in rare cases exceedingly difficult to demonstrate4 ,,fig4 #ge4--,radiograph showing pathology resulting from complete obstruction of a bronchus with atelectasis and drowned lung resulting4 ,foot of an alarm clock in left bronchus of #d year old child4 ,present #be days4 ,plate made by ,johnston and ,grier4 ,positive ,films of the ,tracheo-bronchial ,tree as an ,aid to ,localization4--,in order to localize the bronchus invaded by a small foreign body the positive film is laid over the negative of the patient showing the foreign body4 ,the shadow of the foreign body will then show through the overlying positive film4 ,these positive films are made in twelve sizes1 and the size selected should be that corresponding to the size of the patient as shown by the roentgenograph4 ,the dome of the diaphragm and the dome of the pleura are taken as visceral landmarks for placing the positive films which have lines indicating these levels4 ,if the shadow of the foreign body be faint it may be strengthened by an ink mark on the uncoated side of the plate4 ,,fig4 #gf4--,partial bronchial obstruction for long period of time ,pathology1 bronchiectasis and pulmonary abscess1 produced by the presence for #d years of a nail in the left lung of a boy of #aj years ,bronchial mapping is readily accomplished by the author's method of endobronchial insufflation of a roentgenopaque inert powder such as bismuth subnitrate or subcarbonate 7,fig4 #gg74 ,the roentgenopaque substance may be injected in a fluid mixture if preferred1 but the walls are better outlined with the powder 7,fig4 #gg74 ,,fig4 #gg4--,roentgenogram showing the author's method of bronchial mapping or lung-mapping by the bronchoscopic introduction of opaque substances 7in this instance powdered bismuth subnitrate7 into the lung of the patient4 ,plate made by ,david ,r4 ,bowen4 7,illustration1 strengthened for reproduction1 is from author's article in ,american ,journal of ,roentgenology1 ,oct41 #aiah47 ,,errors ,,to ,,avoid ,,in ,,suspected ,,foreign ,,body ,,cases #a4 ,do not reach for the foreign body with the fingers1 lest the foreign body be thereby pushed into the larynx1 or the larynx be thus traumatized4 #b4 ,do not hold up the patient by the heels1 lest a tracheally lodged foreign body be dislodged and asphyxiate the patient by becoming jammed in the glottis4 #adc #c4 ,do not fail to have a roentgenogram made1 if possible1 whether the foreign body in question is of a kind dense to the ray or not4 #d4 ,do not fail to search endoscopically for a foreign body in all cases of doubt4 #e4 ,do not pass blindly an esophageal bougie1 probang1 or other instrument4 #f4 ,do not tell the patient he has no foreign body until after roentgenray examination1 physical examination1 indirect examination1 and endoscopy have all proven negative4 ,,summary ,,symptomatology ,,and ,,diagnosis ,,of ,,foreign ,,bodies ,,in ,,the ,,air ,,and ,,food ,,passages ,initial symptoms are choking1 gagging1 coughing1 and wheezing1 often followed by a symptomless interval4 ,the foreign body may be in the larynx1 trachea1 bronchi1 nasal chambers1 nasopharynx1 fauces1 tonsil1 pharynx1 hypopharynx1 esophagus1 stomach1 intestinal canal1 or may have been passed by bowel1 coughed out or spat out1 with or without the knowledge of the patient4 ,initial choking1 etcetera may have escaped notice1 or may have been forgotten4 ,laryngeal ,foreign ,body4--,one or more of the following laryngeal symptoms may be present3 ,hoarseness1 croupy cough1 aphonia1 odynphagia1 hemoptysis1 wheezing1 dyspnea1 cyanosis1 apnea1 subjective sensation of foreign body4 ,croupiness in foreign body cases1 as in diphtheria1 usually means subglottic swelling4 ,obstructive foreign body may be quickly fatal by laryngeal impaction on aspiration1 or on abortive bechic expulsion4 ,lodgement of a non-obstructive foreign body may be followed by a symptomless interval4 ,direct laryngoscopy for diagnosis is indicated in every child having laryngeal diphtheria without faucial membrane4 7,no anesthetic1 general or local is needed47 ,in the presence of laryngeal symptoms1 think of the following3 #a4 ,a foreign body in the larynx4 #b4 ,a foreign body loose or fixed in the trachea4 #c4 ,digital efforts at removal4 #d4 ,instrumentation4 #e4 ,overflow of food into the larynx from esophageal obstruction due to the foreign body4 #f4 ,esophagotracheal fistula from ulceration set up by a foreign body in the esophagus1 followed by the leakage of food into the air-passages4 #g4 ,laryngeal symptoms may persist from the trauma of a foreign body that has passed on into the deeper air or food passages or that has been coughed or spat out4 #h4 ,laryngeal symptoms 7hoarseness1 croupiness1 etcetera7 may be due to digital or instrumental efforts at the removal of a foreign body that never was present4 #i4 ,laryngeal symptoms may be due to acute or chronic laryngitis1 diphtheria1 pertussis1 infective laryngotracheitis1 and many other diseases4 #aj4 ,deductive decisions are dangerous4 #aa4 ,if the roentgenray is negative1 laryngoscopy 7direct in children1 indirect in adults7 without anesthesia1 general or local1 is the only way to make a laryngeal diagnosis4 #ab4 ,before doing a diagnostic laryngoscopy1 preparation should be made for taking a swab-specimen and for bronchoscopy and esophagoscopy4 ,tracheal ,foreign ,body4--7#a7 ,audible slap1 7#b7 palpatory thud1 and 7#c7 asthmatoid wheeze are pathognomonic4 ,the tracheal flutter has been observed by ,mc,crae in a case of watermelon seed4 ,cough1 hoarseness1 dyspnea1 and cyanosis are often present4 ,diagnosis is by roentgenray1 auscultation1 palpation1 and bronchoscopy4 ,listen long for audible slap1 best heard at open mouth during cough4 ,the asthmatoid wheeze is heard with the ear or stethoscope bell 7,mc,crae7 at the patient's open mouth4 ,history of initial choking1 gagging1 and wheezing is important if elicited1 but is valueless negatively4 ,bronchial ,foreign ,body4--,initial symptoms are coughing1 choking1 asthmatoid wheeze1 etc4 noted above4 ,there may be a history of these or of tooth extraction4 ,at once1 or after a symptomless interval1 cough1 blood-streaked sputum1 metallic taste1 or special odor of foreign body may be noted4 ,non-obstructive metallic foreign bodies afford few symptoms and few signs for weeks or months4 ,obstructive foreign bodies cause atelectasis1 drowned lung1 and eventually pulmonary abscess4 ,lobar pneumonia is an exceedingly rare sequel4 ,vegetable organic foreign bodies as peanut-kernels1 beans1 watermelon seeds1 etcetera1 cause at once violent laryngotracheobronchitis1 with toxemia1 cough and irregular fever1 the gravity and severity being inversely to the age of the child4 ,bones1 animal shells and inorganic bodies after months or years produce changes which cause chills1 fever1 sweats1 emaciation1 clubbed fingers1 incurved nails1 cough1 foul expectoration1 hemoptysis1 in fact1 all the symptoms of chronic pulmonary sepsis1 abscess1 and bronchiectasis4 ,these symptoms and some of the physical signs may suggest pulmonary tuberculosis1 but the apices are normal and bacilli are absent from the sputum4 ,every acute or chronic chest case calls for the exclusion of foreign body4 ,the physical signs vary with conditions present in different cases and at different times in the same case4 ,secretions1 normal and pathologic1 may shift from one location to another2 the foreign body may change its position admitting more1 less1 or no air1 or it may shift to a new location in the same lung or even in the other lung4 ,a recently aspirated pin may produce no signs at all4 ,the signs of diagnostic importance are chiefly those of partial or complete bronchial obstruction1 though a non-obstructive foreign body1 a pin for instance1 may cause limited expansion 7,mc,crae7 or1 rarely1 a peculiar rale or a peculiar auscultatory sound4 ,the most nearly characteristic physical signs are3 7#a7 ,limited expansion2 7#b7 decreased vocal fremitus2 7#c7 impaired percussion note2 7#d7 diminished intensity of the breath-sounds distal to the foreign body4 ,complete obstruction of a bronchus followed by drowned lung adds absence of vocal resonance and vocal fremitus1 thus often leading to an erroneous diagnosis of empyema4 ,varying grades of tympany are obtained over areas of obstructive or compensatory emphysema4 ,with complete obstruction there may be tympany from the collapsed lung for a time4 ,rales in case of complete obstruction are usually most intense on the uninvaded side4 ,in partial obstruction they are most often found on the invaded side distal to the foreign body1 especially posteriorly1 and are most intense at the site corresponding to that of the foreign body4 ,a foreign body at the bifurcation of the trachea may give signs in both lungs4 ,early in a foreign body case1 diminished expansion of one side1 with dulness1 may suggest pneumonia in the affected side2 but absence of1 or decreased1 vocal resonance1 and absence of typical tubular breathing should soon exclude this diagnosis4 ,bronchial obstruction in pneumonia is exceedingly rare4 ,memorize these signs suggestive of foreign body3 #a4 ,expansion--diminished4 #b4 ,percussion note--impaired 7except in obstructive emphysema74 #c4 ,vocal fremitus--diminished4 #d4 ,breath sounds--diminished4 ,the foregoing is only for memorizing1 and must be considered in the light of the following fundamental note by ,prof4 ,mc,crae ,there is no one description of physical signs which covers all cases4 ,if the student will remember that complete obstruction of a bronchus leads to a shutting off of this area1 there should be little difficulty in understanding the signs present4 ,the diagnosis of empyema may be made1 but the outline of the area of dulness1 the fact that there is no shifting dulness1 and the greater resistance which is present in empyema nearly always clear up any difficulty promptly4 ,the absence of the frequent change in the voice sounds1 so significant in an early small empyema1 is of value4 ,a large empyema should give no difficulty4 ,if difficulty remains the use of the needle should be sufficient4 ,in thickened pleura vocal fremitus is not entirely absent1 and the breath-sounds can usually be heard1 even if diminished4 ,in case of partial obstruction of a bronchus1 it is evident that air will still be present1 hence the dulness may be only slight4 ,the presence of air and secretion will probably result in the breath-sounds being somewhat harsh1 and will cause a great variety of rales1 principally coarse1 and many of them bubbling4 ,difficulty may be caused by signs in the other lung or in a lobe other than the one affected by the foreign body4 ,if it is remembered that these signs are likely to be only on auscultation1 and to consist largely in the presence of rales1 while the signs in the area supplied by the affected bronchus will include those on inspection1 palpation1 and percussion1 there should be little difficulty4 ,the roentgenray is the most valuable diagnostic means2 but careful notation of physical signs by an expert should be made in all cases preferably without knowledge of ray findings4 ,expert ray work will show all metallic foreign bodies and many of less density1 such as teeth1 bones1 shells1 buttons1 etcetera4 ,if the ray is negative1 a diagnostic bronchoscopy should be done in all cases of unexplained bronchial obstruction4 ,peanut kernels and watermelon seeds and1 rarely1 other foreign bodies in the bronchi produce obstructive emphysema of the invaded side4 ,fluoroscopy shows the diaphragm flattened1 depressed and of less excursion on the invaded side2 at the end of expiration1 the heart and the mediastinal wall move over toward the uninvaded side and the invaded lung becomes less dense than the uninvaded lung1 from the trapping of the air by the expiratory1 valve-like effect of obliteration of the forceps spaces that during inspiration afford air ingress between the foreign body and the swollen bronchial wall4 ,this partial obstruction causes obstructive emphysema1 which must be distinguished from compensatory emphysema1 in which the ballooning is in the unobstructed lung1 because its fellow is wholly out of function through complete corking of the main bronchus of the invaded side4 ,esophageal ,foreign ,body4--,after initial choking and gagging1 or without these1 there may be a subjective sense of a foreign body1 constant or1 more often1 on swallowing4 ,odynphagia and dysphagia or aphagia may or may not be present4 ,pain1 sub-sternal or extending to the back is sometimes present4 ,hematemesis and fever may occur from the foreign body or from rough instrumentation4 ,symptoms referable to the air-passages may be present due to3 7#a7 ,overflow of the secretions on attempts to swallow through the obstructed esophagus2 7#b7 erosion of the foreign body through from the esophagus into the trachea2 or 7#c7 trauma inflicted on the larynx during attempts at removal1 digital or instrumental1 the foreign body still being present or not4 ,diagnosis is by the roentgenray1 first without1 then1 if necessary1 with a capsule filled with an opaque mixture4 ,flat objects1 like coins1 always lie with their greatest diameter in the coronal plane of the body1 when in the esophagus2 in the sagittal plane1 when in the trachea or larynx4 ,lateral1 anteroposterior1 and sometimes also quartering roentgenograms are necessary4 ,one taken laterally1 low down on the neck but clear of the shoulder1 will often show a bone or other semiopaque object invisible in the anteroposterior exposure4 #adi ,,chapter ,,xiii--,,foreign ,,bodies ,,in ,,the ,,larynx ,,and ,,tracheobronchial ,,tree ,the protective reflexes preventing the entrance of foreign bodies into the lower air passages are3 7#a7 ,the laryngeal closing reflex and 7#b7 the bechic reflex4 ,laryngeal closing for normal swallowing consists chiefly in the tilting and the closure of the upper laryngeal orifice4 ,the ventricular bands help but slightly2 and the epiglottis and the vocal cords little1 if at all4 ,the gauntlet to be run by foreign bodies entering the tracheobronchial tree is composed of3 #a4 ,epiglottis4 #b4 ,upper laryngeal orifice4 #c4 ,ventricular bands4 #d4 ,vocal cords4 #e4 ,bechic blast4 ,the epiglottis acts somewhat as a fender4 ,the superior laryngeal aperture1 composed of a pair of movable ridges of tissue1 has almost a sphincteric action1 in addition to a tilting movement4 ,the ventricular bands can approximate under powerful stimuli4 ,the vocal cords act similarly4 ,the one defect in the efficiency of this barrier1 is the tendency to take a deep inspiration preparatory to the cough excited by the contact of a foreign body4 ,site of ,lodgment4--,the majority of foreign bodies in the air passages occur in children4 ,the right bronchus is more frequently invaded than the left because of the following factors3 ,i4 ,its greater diameter4 #b4 ,its lesser angle of deviation from the tracheal axis4 #c4 ,the situation of the carina to the left of the mid-line of the trachea4 #d4 ,the action of the trachealis muscle4 #e4 ,the greater volume of air going into the right bronchus on inspiration4 ,the middle lobe bronchus is rarely invaded by foreign body1 and1 fortunately1 in less than one per cent of the cases is the object in an upper lobe bronchus4 ,spontaneous ,expulsion of ,foreign ,bodies from the ,air ,passages4 ,a large1 light1 foreign body in the larynx or trachea may occasionally be coughed out1 but the frequent newspaper accounts of the sudden death of children known to have aspirated objects should teach us never to wait for this occurrence4 ,the cause of death in these cases is usually the impaction of a large foreign body in the glottis producing sudden asphyxiation1 and in a certain proportion of these cases the impaction has occurred on the reverse journey1 when cough forced the intruder upward from below4 ,the danger of subglottic impaction renders it imperative that attempts to aid spontaneous expulsion by inverting the patient should be discouraged4 ,sharp objects1 such as pins1 are rarely coughed out4 ,the tendency of all foreign bodies is to migrate down and out to the periphery as their size and shape will allow4 ,most of the reported cases of bechic expulsion of bronchially lodged foreign bodies have occurred after a prolonged sojourn of the object1 associated which much lung pathology2 and in some cases the object has been carried out along with an accumulation of pus suddenly liberated from an abscess cavity1 and expelled by cough4 ,this is a rare sequence compared to the usual formation of fibrous stricture above the foreign body that prevents the possibility of bechic expulsion4 ,to delay bronchoscopy with the hope of such a solution of the problem is comparable to the former dependence on nature for the cure of appendiceal abscess4 ,we do our full duty when we tell the patient or parents that while the foreign body may be coughed up1 it is very dangerous to wait2 and1 further1 that the difficulty of removal usually increases with the time the foreign body is allowed to remain in the air passages4 ,mortality and morbidity of bronchoscopy vary directly with the degree of skill and experience of the operator1 and the conditions for which the endoscopies are performed4 ,the simple insertion of the bronchoscope is devoid of harm if carefully done4 ,the danger lies in misdirected efforts at removal of the intruder and in repeating bronchoscopies in children at too frequent intervals1 or in prolonging the procedure unduly4 ,in children under one year endoscopy should be limited to twenty minutes1 and should not be repeated sooner than one week after1 unless urgently indicated4 ,a child of #e years will bear #dj to #fj minutes work1 while the adult offers no unvarying time limit4 ,more can be ultimately accomplished1 and less reaction will follow short endoscopies repeated at proper intervals than in one long procedure4 ,indications for bronchoscopy for suspected foreign body may be thus summarized3 #a4 ,the appearance of a suspicious shadow in the radiograph1 in the line of a bronchus4 #b4 ,in any case in which lung symptoms followed a clear history of the patient having choked on a foreign body4 #c4 ,in any case showing signs of obstruction in the trachea or of a bronchus4 #d4 ,in suspected bronchiectasis4 #e4 ,symptoms of pulmonary tuberculosis with sputum constantly negative for tubercle bacilli4 ,if the physical signs are at the base1 particularly the right base1 the indication becomes very strong even in the absence of any foreign body circumstance in the history4 #f4 ,in all cases of doubt1 bronchoscopy should be done anyway4 ,there is no absolute contraindication to bronchoscopy for foreign bodies4 ,extreme exhaustion or reaction from previous efforts at removal may call for delay for recuperation1 but pulmonary abscess and even the rarer complications1 bronchopneumonia and gangrene of the lung1 are improved by the early removal of the foreign body4 ,choice of ,time to do ,bronchoscopy for ,foreign ,body4--,the difficulties of removal usually increase from the time of aspiration of the object4 ,it tends to work downward and outward1 while the mucosa becomes edematous1 partly closing over the foreign body1 and even completely obliterating the lumen of smaller bronchi4 ,later1 granulation tissue and the formation of stricture further hide the object4 ,the patient's health deteriorates with the onset of pulmonary pathology1 and renders him a less favorable subject for bronchoscopy4 ,organic foreign bodies1 which produce early and intense inflammatory reaction and are liable to swell1 call for prompt bronchoscopy4 ,when a bronchus is completely obstructed by the bulk of the foreign body itself immediate removal is urgently demanded to prevent serious lung changes1 resulting from atelectasis and want of drainage4 ,in short1 removal of the foreign body should be accomplished as soon as possible after its entrance4 ,this1 however1 does not justify hasty1 ill-planned1 and poorly equipped bronchoscopy1 which in most cases is doomed to failure in removal of the object4 ,the bronchoscopist should not permit himself to be stampeded into a bronchoscopy late at night1 when he is fatigued after a hard day's work4 ,bronchoscopic finding of a foreign body is not especially difficult if the aspiration has been recent4 ,if secondary processes have developed1 or the object be small and in a bronchus too small to admit the tube-mouth1 considerable experience may be necessary to discover it4 ,there is usually inflammatory reaction around the orifice of the invaded bronchus1 which in a measure serves to localize the intruder4 ,we must not forget1 however1 that objects may have moved to another location1 and also that the irritation may have been the result of previous efforts at removal4 ,care must be exercised not to mistake the sharp1 shining1 interbronchial spurs for bright thin objects like new pins just aspirated2 after a few days pins become blackened4 ,if these spurs be torn pneumothorax may ensue4 ,if a number of small bronchi are to be searched1 the bronchoscope must be brought into the line of the axis of the bronchus to be examined1 and any intervening tissue gently pushed aside with the lip of the bronchoscope4 ,blind probing for exploration is very dangerous unless carefully done4 ,the straight forceps1 introduced closed1 form the best probe and are ready for grasping if the object is felt4 ,once the bronchoscope has been introduced1 it should not be withdrawn until the procedure is completed4 ,the light carrier alone may be removed from its canal if the illumination be faulty4 ,,complications ,,and ,,after-,,effects ,,of ,,bronchoscopy ,all foreign body cases should be watched day and night by special nurses until all danger of complications is passed4 ,complications are rare after careful work1 but if they do occur1 they may require immediate attention4 ,this applies especially to the subglottic edema associated with arachidic bronchitis in children under #b years of age4 ,general ,reaction4--,there is usually no elevation in temperature following a short bronchoscopy for the removal of a recently lodged metallic foreign body4 ,if1 however1 an inflammatory condition of the bronchi existed previous to the bronchoscopy1 as for instance the intense diffuse1 purulent laryngotracheobronchitis associated with the aspiration of nut kernels1 or in the presence of pulmonary abscess from long retained foreign bodies1 a moderate temporary rise of temperature may be expected4 ,these cases almost always have had irregular fever before bronchoscopy4 ,disturbance of the epithelium in the presence of pus without abscess usually permits enough absorption to elevate the temperature slightly for a few days4 ,surgical shock in its true form has never followed a carefully performed and time-limited bronchoscopy4 ,severe fatigue resulting in deep sleep may be seen in children after prolonged work4 ,local reaction is ordinarily noted by slight laryngeal congestion causing some hoarseness and disappearing in a few days4 ,if dyspnea occur it is usually due to 7#a7 ,drowning of the patient in his own secretions4 7#b7 ,subglottic edema4 7#c7 ,laryngeal edema4 ,drowning of the ,patient in ,his ,own ,secretions4--,the accumulation of secretions in the bronchi due to faulty bechic powers and seen most frequently in children1 is quickly relievable by bronchoscopic sponge-pumping or aspiration through the tracheotomic wound1 in cases in which the tracheotomy may be deemed necessary4 ,in other cases1 the aspirating bronchoscope with side drainage canal 7,fig4 #a1 ,e7 may be used through the larynx4 ,frequent peroral passage of the bronchoscope for this purpose is contraindicated only in case of children under #c years of age1 because of the likelihood of provoking subglottic edema4 ,in such cases instead of inserting a bronchoscope the aspirating tube 7,fig4 #i7 should be inserted through the direct laryngoscope1 or a low tracheotomy should be done4 ,supraglottic edema is rarely responsible for dyspnea except when associated with advanced nephritis4 ,subglottic edema is a complication rarely seen except in children under #c years of age4 ,they have a peculiar histologic structure in this region1 as is shown by ,logan ,turner4 ,even at the predisposing age subglottic edema is a very unusual sequence to bronchoscopy if this region was previously normal4 ,the passage of a bronchoscope through an already inflamed subglottic area is liable to be followed by a temporary increase in the swelling4 ,if the foreign body be associated with but slight amount of secretion1 the child can usually obtain sufficient air through the temporarily narrowed lumen4 ,if1 however1 as in cases of arachidic bronchitis1 large amounts of purulent secretion must be expelled1 it will be found in certain cases that the decreased glottic lumen and impaired laryngeal motility will render tracheotomy necessary to drain the lungs and prevent drowning in the retained secretions4 ,subglottic edema occurring in a previously normal larynx may result from3 #a4 ,the use of over-sized tubes4 #b4 ,prolonged bronchoscopy4 #c4 ,faulty position of the patient1 the axis of the tube not being in that of the trachea4 #d4 ,trauma from undue force or improper direction in the insertion of the bronchoscope4 #e4 ,the manipulation of instruments4 #f4 ,trauma inflicted in the extraction of the foreign body4 ,diagnosis must be made without waiting for cyanosis which may never appear4 ,pallor1 restlessness1 startled awakening after a few minutes sleep1 occurring in a child with croupy cough1 indrawing around the clavicles1 in the intercostal spaces1 at the suprasternal notch and at the epigastrium1 call for tracheotomy which should always be low4 ,such a case should not be left unwatched4 ,the child will become exhausted in its fight for air and will give up and die4 ,the respiratory rate naturally increases because of air hunger1 accumulating secretions that cannot be expelled because of impaired glottic motility give signs wrongly interpreted as pneumonia4 ,many children whose lives could have been saved by tracheotomy have died under this erroneous diagnosis4 ,treatment4--,intubation is not so safe because the secretions cannot easily be expelled through the tube and postintubational stenosis may be produced4 ,low tracheotomy1 the tracheal incision always below the second ring1 is the safest and best method of treatment4 #aef ,,chapter ,,xiv--,,removal ,,of ,,foreign ,,bodies ,,from ,,the ,,larynx ,symptoms and ,diagnosis4--,the history of a sudden choking attack followed by impairment of voice1 wheezing1 and more or less dyspnea can be usually elicited4 ,laryngeal diphtheria is the condition most frequently thought of when these symptoms are present1 and antitoxin is rightly given while waiting for a positive diagnosis4 ,extreme dyspnea may render tracheotomy urgently demanded before any attempts at diagnosis are made4 ,further consideration of the symptomatology and diagnosis of laryngeal foreign body will be found on pages #abh1 #acc and #adc4 ,preliminary ,examination4--,in the adult1 mirror examination of the larynx should be done1 the patient being placed in the recumbent position4 ,whenever time permits roentgenograms1 lateral and anteroposterior1 should be made1 the lateral one as low in the neck as possible4 ,one might think this an unnecessary procedure because of the visibility of the larynx in the mirror2 but a child's larynx cannot usually be indirectly examined1 and even in the adult a pin may be so situated that neither head nor point is visible1 only a portion of the shaft being seen4 ,the roentgenogram will give accurate information as to the position1 and will thus allow a planning of the best method for removal of the foreign body4 ,a bone in the larynx usually is visible in a good roentgenogram4 ,accurate diagnosis in children is made by direct laryngoscopy without anesthesia1 but direct laryngoscopy should not be done until one is prepared to remove a foreign body if found1 to follow it into the bronchus and remove it if it should be dislodged and aspirated1 and to do tracheotomy if sudden respiratory arrest occur4 #aeg ,technic of ,removal of ,foreign ,bodies from the ,larynx4--,the patient is to be placed in the author's position1 shown in ,fig4 #ec4 ,no general anesthesia should be given1 and the application of local anesthesia is usually unnecessary and further1 is liable to dislodge and push down the foreign body499 ,because of the risk of loss downward it is best to seize the foreign body as soon as seen2 then to determine how best to disimpact it4 ,the fundamental principles are that a pointed object must either have its point protected by the forceps grasp or be brought out point trailing1 and that a flat object must be so rotated that its plane corresponds to the sagittal plane of the glottic chink4 ,the laryngeal grasping forceps 7,fig4 #ec7 will be found the most useful1 although the alligator rotation forceps 7,fig4 #ca7 may occasionally be required4 99 ,in adolescents or adults a few drops of a #d per cent solution of cocain applied to the laryngopharynx with an atomizer or a dropper will afford the minimum risk of dislodgement2 but the author's personal preference is for no anesthesia1 general or local4 #aeh ,,chapter ,,xv--,,mechanical ,,problems ,,of ,,bronchoscopic ,,foreign ,,body ,,extraction99 99 ,for more extensive consideration of mechanical problems than is here possible the reader is referred to the ,bibliography1 page #caa1 especially reference numbers #a1 #aa1 #cg and #ef4 ,the endoscopic extraction of a foreign body is a mechanical problem pure and simple1 and must be studied from this viewpoint4 ,hasty1 ill-equipped1 ill-planned1 or violent endoscopy on the erroneous principle that if not immediately removed the foreign body will be fatal1 is never justifiable4 ,while the lodgement of an organic foreign body 7such as a nut kernel7 in the bronchus calls for prompt removal and might be included under the list of emergency operations1 time is always available for complete preparation1 for thorough study of the patient1 and localization of the intruder4 ,the patient is better off with the foreign body in the lung than if in its removal a mediastinitis1 rupture into the pleura1 or tearing of a thoracic blood vessel has resulted4 ,the motto of the endoscopist should be ,i will do no harm4 ,if no harm be inflicted1 any number of bronchoscopies can be done at suitable intervals1 and eventually success will be achieved1 whereas if mortality results1 all opportunity ceases4 ,the first step in the solution of the mechanical problem is the study of the roentgenograms made in at least three planes2 7#a7 anteroposterior1 7#b7 lateral1 and 7#c7 the plane corresponding to the greatest plane of the foreign body4 ,the next step is to put a duplicate of the foreign body into the rubber-tube manikin previously referred to1 and try to simulate the probable position shown by the ray1 so as to get an idea of the bronchoscopic appearance of the probable presentation4 ,then the duplicate foreign body is turned into as many different positions as possible1 so as to educate the eye to assist in the comprehension of the largest possible number of presentations that may be encountered at the bronchoscopy on the patient4 ,for each of these presentations a method of disimpaction1 disengagement1 disentanglement or version and seizure is worked out1 according to the kind of foreign body4 ,prepared by this practice and the radiographic study1 the bronchoscope is introduced into the patient4 ,the location of the foreign body is approached slowly and carefully to avoid overriding or displacement4 ,a study of the presentation is as necessary for the bronchoscopist as for the obstetrician4 ,it should be made with a view to determining the following points3 #a4 ,the relation of the presenting part to the surrounding tissues4 #b4 ,the probable position of the unseen portion1 as determined by the appearance of the presenting part taken in connection with the knowledge obtained by the previous ray study1 and by inspection of the ray plate upside down on view in front of the bronchoscopist4 #c4 ,the version or other manipulation necessary to convert an unfavorable into a favorable presentation for grasping and disengagement4 #d4 ,the best instruments to use1 and which to use first1 as1 hook1 pincloser1 forceps1 etc4 #e4 ,the presence and position of the forceps spaces of which there must be two for all ordinary forceps1 one for each jaw1 or the insertion space for any other instrument4 ,until all of these points are determined it is a grave error to insert any kind of instrument4 ,if possible even swabbing of the foreign body should be avoided by swabbing out the bronchus1 when necessary1 before the region of the intruder is reached4 ,when the operator has determined the instrument to be used1 and the method of using it1 the instrument is cautiously inserted1 under guidance of the eye4 #afj ,the lip of the bronchoscope is one of the most valuable aids in the solution of foreign-body problems4 ,with it partial or complete version of an object can be accomplished so as to convert an unfavorable presentation into one favorable for grasping with the forceps2 edematous mucosa may be displaced1 angles straightened and space made at the side of the foreign body for the forceps' jaw4 ,it forms a shield or protector that can be slipped under the point of a sharp foreign body and can make counterpressure on the tissues while the forceps are disembedding the point of the foreign body4 ,with the bronchoscopic lip and the forceps or other instrument inserted through the tube1 the bronchoscopist has bimanual1 eye-guided control1 which if it has been sufficiently practiced to afford the facility in coordinate use common to everyone with knife and fork1 will accomplish maneuvers that seem marvelous to anyone who has not developed facility in this coordinate use of the bronchoscopic instruments4 ,the relation of the tube mouth and foreign body is of vital importance4 ,generally considered1 the tube mouth should be as near the foreign body as possible1 and the object must be placed in the center of the bronchoscopic field1 so that the ends of the open jaws of the forceps will pass sufficiently far over the object4 ,but little lateral control is had of the long instruments inserted through the tube2 sidewise motion is obtained by a shifting of the end of the bronchoscope4 ,when the foreign body has been centered in the bronchoscopic field and placed in a position favorable for grasping1 it is important that this position be maintained by anchoring the tube to the upper teeth with the left1 third1 and fourth fingers hooked over the patient's upper alveolus 7,fig4 #fc7 ,the ,light ,reflex on the ,forceps4--,it is often difficult for the beginner to judge to what depth an instrument has been inserted through the tube4 ,on slowly inserting a forceps through the tube1 as the blades come opposite the distal light they will appear brightly illuminated2 or should the blades lie close to the light bulb1 a shadow will be seen in the previously brilliantly lighted opposite wall4 ,it is then known that the forceps are at the tube mouth1 and the endoscopist has but to gauge the distance from this to the foreign body4 ,this assistance in gauging depth is one of the great advances in foreign body bronchoscopy obtained by the development of distal illumination4 ,hooks are useful in the solution of various mechanical problems1 and may be turned by the operator himself into various shapes by heating small probe-pointed steel rods in a spirit lamp1 the proximal end being turned over at a right angle for a controlling handle4 ,hooks with a greater curve than a right angle are prone to engage in small orifices from which they are with difficulty removed4 ,a right angle curve of the distal end is usually sufficient1 and a corkscrew spiral is often advantageous1 rendering removal easy by a reversal of the twisting motion 7,bib4 #aa1 p4 #caa74 ,the ,use of ,forceps in ,endoscopic ,foreign ,body ,extraction4--,two different strengths of forceps are supplied1 as will be seen in the list in ,chapter #a4 ,the regular forceps have a powerful grasp and are used on dense foreign bodies which require considerable pressure on the object to prevent the forceps from slipping off4 ,for more delicate manipulation1 and particularly for friable foreign bodies1 the lighter forceps are used4 ,spring-opposed forceps render any delicacy of touch impossible4 ,forceps are to be held in the right hand1 the thumb in one ring1 and the third1 or ring finger1 in the other ring4 ,these fingers are used to open and close the forceps1 while all traction is to be made by the right index finger1 which has its position on the forceps handle near the stylet1 as shown in ,fig4 #gh4 ,it is absolutely essential for accurate work1 that the forceps jaws be seen to close upon the foreign body4 ,the impulse to seize the object as soon as it is discovered must be strongly resisted4 ,a careful study of its size1 shape1 and position and relation to surrounding structures must be made before any attempt at extraction4 ,the most favorable point and position for grasping having been obtained1 the closed forceps are inserted through the bronchoscope1 the light reflex obtained1 the forceps blades now opened are turned in such a position that1 on advancing1 the foreign body will enter the open ,v1 a sufficient distance to afford a good grasp4 ,the blades are then closed and the foreign body is drawn against the tube mouth4 ,few foreign bodies are sufficiently small to allow withdrawal through the tube1 so that tube1 forceps and foreign body are usually withdrawn together4 ,,fig4 #gh4--,proper hold of forceps4 ,the right thumb and third fingers are inserted into the rings while the right index finger has its place high on the handle4 ,all traction is made with the index finger1 the ring fingers being used only to open and close the forceps4 ,if any pushing is deemed safe it may be done by placing the index finger back of the thumb-nut on the stylet4 ,anchoring the ,foreign ,body ,against the ,tube ,mouth4--,if withdrawal be made a bimanual procedure it is almost certain that the foreign body will trail a centimeter or more beyond the tube mouth1 and that the closure of the glottic chink as soon as the distal end of the bronchoscope emerges will strip the foreign body from the forceps grasp1 when the foreign body reaches the cords4 ,this is avoided by anchoring the foreign body against the tube mouth as soon as the foreign body is grasped1 as shown in ,fig4 #gi4 ,the left index finger and thumb grasp the shaft of the forceps close to the ocular end of the tube1 while the other fingers encircle the tube2 closure of the forceps is maintained by the fingers of the right hand1 while all traction for withdrawal is made with the left hand1 which firmly clamps forceps and bronchoscope as one piece4 ,thus the three units are brought out as one2 the bronchoscope keeping the cords apart until the foreign body has entered the glottis4 ,,fig4 #gi--,method of anchoring the foreign body against the tube mouth ,after the object has been drawn firmly against the lip of the endoscopic tube the left finger and thumb grasp the forceps cannula and lock it against the ocular end of the tube1 the other fingers of the left hand encircle the tube4 ,withdrawal is then done with the left hand2 the fingers of the right hand maintaining closure of the forceps4 #afd ,bringing the ,foreign ,body ,through the ,glottis4--,stripping of the foreign body from the forceps at the glottis may be due to3 #a4 ,not keeping the object against the tube mouth as just mentioned4 #b4 ,not bringing the greatest diameter of the foreign body into the sagittal plane of the glottic chink4 #c4 ,faulty application of the forceps on the foreign body4 #d4 ,mechanically imperfect forceps4 ,should the foreign body be lost at the glottis it may1 if large become impacted and threaten asphyxia4 ,prompt insertion of the laryngoscope will usually allow removal of the object by means of the laryngeal grasping forceps4 ,the object may be dropped or expelled into the pharynx and be swallowed4 ,it may even be coughed into the naso-pharynx or it may be re-aspirated4 ,in the latter event the bronchoscope is to be re-inserted and the trachea carefully searched4 ,care must be used not to override the object4 ,if much inflammatory reaction has occurred in the first invaded bronchus1 temporarily suspending the aerating function of the corresponding lung1 reaspiration of a dislodged foreign body is liable to carry it into the opposite main bronchus1 by reason of the greater inspiratory volume of air entering that side4 ,this may produce sudden death by blocking the only aerating organ4 ,extraction of ,pins1 ,needles and ,similar ,long ,pointed ,objects4--,when searching for such objects especial care must be taken not to override them4 ,pins are almost always found point upward1 and the dictum can therefore be made1 ,search not for the pin1 but for the point of the pin4 ,if the point be found free1 it should be worked into the lumen of the bronchoscope by manipulation with the lip of the tube4 ,it may then be seized with the forceps and withdrawn4 ,should the pin be grasped by the shaft1 it is almost certain to turn crosswise of the tube mouth1 where one pull may cause the point to perforate1 enormously increasing the difficulties by transfixation1 and perhaps resulting fatally 7,fig4 #hj74 ,,fig4 #hj4--,schematic illustration of a serious phase of the error of hastily seizing a transfixed pin near its middle1 when first seen as at ,m4 ,traction with the forceps in the direction of the dart in ,schema ,b will rip open the esophagus or bronchus inflicting fatal trauma1 and probably the pin will be stripped off at the glottic or the cricopharyngeal level1 respectively4 ,the point of the pin must be disembedded and gotten into the tube mouth as at ,a1 to make forceps traction safe4 ,,fig4 #ha4--,schema illustrating the mechanical problem of extracting a pin1 a large part of whose shaft is buried in the bronchial wall1 ,b4 ,the pin must be pushed downward and if the orifice of the branches1 ,c1 ,d1 are too small to admit the head of the pin some other orifice 7as at ,a7 must be found by palpation 7not by violent pushing7 to admit the head1 so that the pin can be pushed downward permitting the point to emerge 7,e74 ,the point is then manipulated into the bronchoscopic tube-mouth by means of co-ordinated movements of the bronchoscopic lip and the side-curved forceps1 as shown at ,f4 ,inward ,rotation ,method4--,when the point is found to be buried in the mucosa1 the best and usually successful method is to grasp the pin as near the point as possible with the side-grasping forceps1 then with a spiral motion to push the pin downward while rotating the forceps about ninety degrees4 ,the point is thus disengaged1 and the shaft of the pin is brought parallel with that of the forceps1 after which the point may be drawn into the tube mouth4 ,the lips added to the side-curved forceps by my assistant ,dr4 ,gabriel ,tucker ,i now use exclusively for this inward rotation method4 ,they are invaluable in preventing the escape of the pin during the manipulation4 ,a hook is sometimes useful in disengaging a buried point4 ,the method of its use is illustrated in ,fig4 #hb4 ,,fig4 #hb4--,mechanical problem of pin1 needle1 tack or nail with embedded point4 ,if the forceps are pulled upon the pin point will be buried still deeper4 ,the side curved forceps grasp the pin as near the point as possible then with a corkscrew motion the pin is pushed downward and rotated to the right when the pin will be found to be parallel with the shaft of the forceps and can be drawn into the tube4 ,if the pin is prevented by its head from being pushed downward the point may be extracted by the hook as shown above ,the side curved forceps may be used instead of the hook for freeing the point1 the author's inward rotation method4 ,the very best instrument for the purpose is the forceps devised by my assistant1 ,dr4 ,gabriel ,tucker 7,fig4 #ba74 ,the lips prevent all risk of losing the pin from the grasp1 and at the same time bring the long axis of the pin parallel to that of the bronchoscope4 ,pins are very prone to drop into the smaller bronchi and disappear completely from the ordinary field of endoscopic exploration4 ,at other times1 pins not dropping so deeply may show the point only during expiration or cough1 at which times the bronchi are shortened4 ,in such instances the invaded bronchial orifice should be clearly exposed as near the axis of its lumen as possible2 the forceps are now inserted1 opened1 and the next emergence watched for1 the point being grasped as soon as seen4 ,extraction of ,tacks1 ,nails and ,large ,headed ,foreign ,bodies from the ,tracheobronchial ,tree4--,in cases of this sort the point presents the same difficulty and requires solution in the same manner as mentioned in the preceding paragraphs on the extraction of pins4 ,the author's inward-rotation method when executed with the ,tucker forceps is ideal4 ,the large head1 however1 presents a special problem because of its tendency to act as a mushroom anchor when buried in swollen mucosa or in a fibrous stenosis 7,fig4 #hc74 ,the extraction problems of tacks are illustrated in ,figs4 #hd1 #he1 and #hf4 ,nails1 stick pins1 and various tacks are dealt with in the same manner by the author's inward rotation method4 ,hollow metallic bodies presenting an opening toward the observer may be removed with a grooved expansile forceps as shown in ,figs #bc and #be1 or its edge may be grasped by the regular side-grasping forceps4 ,the latter hold is apt to be very dangerous because of the trauma inflicted by the catching of the free edge opposite the forceps2 but with care it is the best method4 ,should the closed end be uppermost1 however1 it may be necessary to insert a hook beyond the object1 and to coax it upward to a point where it may be turned for grasping and removal with forceps4 ,,fig4 #hc4--,mushroom anchor problem of the upholstery tack4 ,if the tack has not been in situ more than a few weeks the stenosis at the level of the darts is simply edematous mucosa and the tack can be pulled through with no more than slight mucosal trauma1 provided axis-traction only be used4 ,if the tack has been in situ a year or more the fibrous stricture may need dilatation with the divulsor4 ,otherwise traction may rupture the bronchial wall4 ,the stenotic tissue in cases of a few months' sojourn maybe composed of granulations1 in which case axis-traction will safely withdraw it4 ,the point of a tack rarely projects freely into the lumen as here shown4 ,more often it is buried in the wall4 #afh ,,fig4 #hd4-,schema illustrating the mushroom anchor problem of the brass headed upholstery tack4 ,at ,a the tack is shown with the head bedded in swollen mucosa4 ,the bronchoscopist1 looking through the bronchoscope1 ,e1 considering himself lucky to have found the point of the tack1 seizes it and starts to withdraw it1 making traction as shown by the dart in drawing ,b4 ,the head of the tack catches below a chondrial ring and rips in1 tearing its way through the bronchial wall 7,d7 causing death by mediastinal emphysema4 ,this accident is still more likely to occur if1 as often happens1 the tack-head is lodged in the orifice of the upper lobe bronchus1 ,f4 ,but if the bronchoscopist swings the patient's head far to the opposite side and makes axis-traction1 as shown at ,c1 the head of the tack can be drawn through the swollen mucosa without anchoring itself in a cartilage4 ,if necessary1 in addition1 the lip of the bronchoscope can be used to repress the angle1 h1 and the swollen mucosa1 ,h4 ,if the swollen mucosa1 ,h1 has been replaced by fibrous tissue from many months' sojourn of the tack1 the stenosis may require dilatation with the divulsor4 ,,fig4 #he4--,problem of the upholstery tack with buried point4 ,if pulled upon1 the imminent perforation of the mediastinum1 as shown at ,a will be completed1 the bronchus will be torn and death will follow even if the tack be removed1 which is of doubtful possibility4 ,the proper method is gently to close the side curved forceps on the shank of the tack near the head1 push downward as shown by the dart1 in ,b1 until the point emerges4 ,then the forceps are rotated to bring the point of the tack away from the bronchial wall4 #afi ,removal of ,open ,safety ,pins from the ,trachea and ,bronchi4-- ,removal of a closed safety pin presents no difficulty if it is grasped at one or the other end4 ,a grasp in the middle produces a toggle and ring action which would prevent extraction4 ,when the safety pin is open with the point downward care must be exercised not to override it with the bronchoscope or to push the point through the wall4 ,the spring or near end is to be grasped with the side-curved or the rotation forceps 7,figs4 #ai1 #bj and #ca7 and pulled into the bronchoscope1 thus closing the pin4 ,an open safety pin lodged point up presents an entirely different and a very difficult problem4 ,if traction is made without closing the pin or protecting the point severe and probably fatal trauma will be produced4 ,the pin may be closed with the pin-closer as illustrated in ,fig4 #cg1 and then removed with forceps4 ,arrowsmith's pin-closer is excellent4 ,another method 7,fig4 #hg7 consists in bringing the point of the safety pin into the bronchoscope1 after disengaging the point with the side curved forceps1 by the author's inward rotation method4 ,the forceps-jaws 7,fig4 #ba7 devised recently by my assistant1 ,dr4 ,gabriel ,tucker1 are ideal for this maneuver4 ,as the point is now protected1 the spring1 seen just off the tube mouth1 is best grasped with the rotation forceps1 which afford the securest hold4 ,the keeper and its shaft are outside the bronchoscope1 but its rounded portion is uppermost and will glide over the tissues without trauma upon careful withdrawal of the tube and safety pin4 ,care must be taken to rotate the pin so that it lies in the sagittal plane of the glottis with the keeper placed posteriorly1 for the reason that the base of the glottic triangle is posterior1 and that the posterior wall of the larynx is membranous above the cricoid cartilage1 and will yield4 ,a small safety-pin may be removed by version1 the point being turned into a branch bronchial orifice4 ,no one should think of attempting the extraction of a safety pin lodged point upward without having practiced for at least a hundred hours on the rubber tube manikin4 ,this practice should be carried out by anyone expecting to do endoscopy1 because it affords excellent education of the eye and the fingers in the endoscopic manipulation of any kind of foreign body4 ,then1 when a safety pin case is encountered1 the bronchoscopist will be prepared to cope with its difficulties1 and he will be able to determine which of the methods will be best suited to his personal equation in the particular case4 ,,fig4 #hf4--,schema illustrating the upper-lobe-bronchus problem1 combined with the mushroom-anchor problem and the author's method for their solution4 ,the patient being recumbent1 the bronchoscopist looking down the right main bronchus1 ,m1 sees the point of the tack projecting from the right upper-lobe-bronchus1 ,a4 ,he seizes the point with the side-curved forceps2 then slides down the bronchoscope to the position shown dotted at ,b4 ,next he pushes the bronchoscopic tube-mouth downward and medianward1 simultaneously moving the patient's head to the right1 thus swinging the bronchoscopic level on its fulcrum1 and dragging the tack downward and inward out of its bed1 to the position1 #a74 ,traction1 as shown at ,c1 will then safely and easily withdraw the tack4 ,a very small bronchoscope is essential4 ,the lip of the bronchoscopic tube-mouth must be used to pry the forceps down and over1 and the lip must be brought close to the tack just before the prying-pushing movement4 ,s1 right stem-bronchus4 ,,fig4 #hg4--,one method of dealing with an open safety pin without closing it4 ,removal of ,double ,pointed ,tacks4--,if the tack or staple be small1 and lodged in a relatively large trachea a version may be done4 ,that is1 the staple may be turned over with the hook or rotation forceps and brought out with the points trailing4 ,with a long staple in a child's trachea the best method is to coax the intruder along gently under ocular guidance1 never making traction enough to bury the point deeply1 and lifting the point with the hook whenever it shows any inclination to enter the wall4 ,great care and dexterity are required to get the intruder through the glottis4 ,in certain locations1 one or both points may be turned into branch bronchi as illustrated in ,fig4 #hh1 or over the carina into the opposite main bronchus4 ,another method is to get both points into the tube-mouth4 ,this may be favored1 as demonstrated by my assistant1 ,dr4 ,gabriel ,tucker1 by tilting the staple so as to get both points into the longest diameter of the tube-mouth4 ,in some cases ,i have squeezed the bronchoscope in a vise to create an oval tube-mouth4 ,in other cases ,i have used expanding forceps with grooved blades4 ,,fig4 #hh4-,schema illustrating podalic version of bronchially-lodged staples or double-pointed tacks4 ,h1 bronchoscope4 ,a1 swollen mucosa covering points of staple4 ,at ,e the staple has been manipulated upward with bronchoscopic lip and hooks until the points are opposite the branch bronchial orifices1 ,b1 ,c4 ,traction being made in the direction of the dart 7,f71 by means of the rotation forceps1 and counterpressure being made with the bronchoscopic lip on the points of the staple1 the points enter the branch bronchi and permit the staple to be turned over and removed with points trailing harmlessly behind 7,k74 ,the ,extraction of ,tightly ,fitting ,foreign ,bodies from the ,bronchi4 ,annular ,edema4--,such objects as marbles1 pebbles1 corks1 etc41 are drawn deeply and with force by the inspiratory blast into the smallest bronchus they can enter4 ,the air distal to the impacted foreign body is soon absorbed1 and the negative pressure thus produced increases the impaction4 ,a ring of edematous mucosa quickly forms and covers the presenting part of the object1 leaving visible only a small surface in the center of an acute edematous stenosis4 ,a forceps with narrow1 stiff1 expansive-spring jaws may press back a portion of the edema and may allow a grasp on the sides of the foreign body2 but usually the attempt to apply forceps when there are no spaces between the presenting part of the foreign body and the bronchial wall1 will result only in pushing the foreign body deeper499 ,a better method is to use the lip of the bronchoscope to press back the swollen mucosa at one point1 so that a hook may be introduced below the foreign body1 which then can be worked up to a wider place where forceps may be applied 7,fig4 #hi74 ,sometimes the object may even be held firmly against the tube mouth with the hook and thus extracted4 ,for this the unslanted tube-mouth is used4 99 ,the author's new ball forceps are very successful with ball-bearing balls and marbles4 ,,fig4 #hi4--,schema illustrating the use of the lip of the bronchoscope in disimpaction of foreign bodies4 ,a and ,b show an annular edema above the foreign body1 ,f4 ,at ,c the edematous mucosa is being repressed by the lip of the tube mouth1 permitting insinuation of the hook1 ,h1 past one side of the foreign body1 which is then withdrawn to a convenient place for application of the forceps4 ,this repression by the lip is often used for purposes other than the insertion of hooks4 ,the lip of the esophagoscope can be used in the same way4 ,extraction of ,soft ,friable ,foreign ,bodies from the ,tracheobronchial ,tree4--,the difficulties here consist in the liability of crushing or fragmenting the object1 and scattering portions into minute bronchi1 as well as the problem of disimpaction from a ring of annular edema1 with little or no forceps space4 ,there is usually in these cases an abundance of purulent secretion which further hinders the work4 ,the great danger of pushing the foreign body downward so that the swollen mucosa hides it completely from view1 must always be kept in mind4 ,extremely delicate forceps with rather broad blades are required for this work4 ,the fenestrated peanut forceps are best for large pieces in the large bronchi4 ,the operator should develop his tactile sense with forceps by repeated practice in order to acquire the skill to grasp peanut kernels sufficiently firmly to hold them during withdrawal1 yet not so firmly as to crush them4 ,nipping off an edge by not inserting the forceps far enough is also to be avoided4 ,small fragments under #b mm4 in diameter may be expelled with the secretions and fragments may be found on the sponges and in the secretions aspirated or removed by sponge pumping4 ,it is1 however1 never justifiable deliberately to break a friable foreign body with the hope that the fragments will be expelled1 for these may be aspirated into small bronchi1 and cause multiple abscesses4 ,a hook may be found useful in dealing with round1 friable1 foreign bodies2 and in some cases the mechanical spoon or safety-pin closer may be used to advantage4 ,the foreign body is then brought close to1 but not crushed against the tube mouth4 #agd ,removal of animal objects from the tracheobronchial tree is readily accomplished with the side-curved forceps4 ,leeches are not uncommon intruders in ,european countries4 ,small insects are usually coughed out4 ,worms and larvae may be found4 ,cocaine or salt solution will cause a leech to loosen its hold4 ,foreign bodies in the upper-lobe bronchi are fortunately not common4 ,if the object is not too far out to the periphery it may be grasped by the upper-lobe-bronchus forceps 7,fig4 #ij71 guided by the collaboration of the fluoroscopist4 ,these forceps are made so as to reach high into the ascending branches of the upper-lobe bronchus4 ,full-curved coil-spring hooks will reach high1 but must be used with the utmost caution1 and the method of their disengagement must be practiced beforehand4 ,penetrating ,projectiles4--,foreign bodies that have penetrated the chest wall and lodged in the lung may be removed by oral bronchoscopy if the intruder is not larger than the lumen of the corresponding main bronchus 7see ,bibliography1 #dc7 ,,fig4 #ij4--,schematic illustration of the author's upper-lobe-bronchus forceps in position grasping a pin in an anteriorly ascending branch of the upper-lobe bronchus4 ,t1 ,trachea2 ,,ul1 upper-lobe bronchus2 ,,lb1 left bronchus2 ,,sb1 stem bronchus4 ,these forceps are made to extend around #ahj degrees4 ,,rules ,,for ,,endoscopic ,,foreign ,,body ,,extraction #a4 ,never endoscope a foreign body case unprepared1 with the idea of taking a preliminary look4 #b4 ,approach carefully the suspected location of a foreign body1 so as not to override any portion of it4 #age #c4 ,avoid grasping a foreign body hastily as soon as seen4 #d4 ,the shape1 size and position of a foreign body1 and its relations to surrounding structures1 should be studied before attempting to apply the forceps4 7,exception cited in ,rule #aj47 #e4 ,preliminary study of a foreign body should be from a distance4 #f4 ,as the first grasp of the forceps is the best1 it should be well planned beforehand so as to seize the proper part of the intruder4 #g4 ,with all long foreign bodies the motto should be ,search1 not for the foreign body1 but for its nearer end4 ,with pins1 needles1 and the like1 with point upward1 search always for the point4 ,try to see it first4 #h4 ,remember that a long foreign body grasped near the middle becomes1 mechanically speaking1 a toggle and ring4 #i4 ,remember that the mortality to follow failure to remove a foreign body does not justify probably fatal violence during its removal4 #aj4 ,laryngeally lodged foreign bodies1 because of the likelihood of dislodgment and loss1 may be seized by any part first presented1 and plan of withdrawal can be determined afterward4 #aa4 ,for similar reasons1 laryngeal cases should be dealt with only in the author's position 7,fig4 #ec74 #ab4 ,an esophagoscopy may be needed in a bronchoscopic case1 or a bronchoscopy in an esophageal case4 ,in every case both kinds of tubes should be sterile and ready before starting4 ,it is the unexpected that happens in foreign body endoscopy4 #ac4 ,do not pull on a foreign body unless it is properly grasped to come away readily without trauma4 ,then do not pull hard4 #ad4 ,do no harm1 if you cannot remove the foreign body4 #ae4 ,full-curved hooks are to be used in the bronchi with greatest caution1 if used at all1 lest they catch inextricably in branch bronchi4 #agf #af4 ,don't force a foreign body downward4 ,coax it back4 ,the deeper it gets the greater your difficulties4 #ag4 ,the watchword of the bronchoscopist should be1 ,if ,i can do no good1 ,i will at least do no harm4 ,fluoroscopic bronchoscopy is so deceptively easy from a superficial1 theoretical1 point of view that it has been used unsuccessfully in cases easily handled in the regular endoscopic way with the eye at the proximal tube-mouth4 ,in a collected series of cases by various operators the object was removed in #ff4g per cent with a mortality of #da4f per cent4 ,in the problem of a pin located out of the field of bronchoscopic vision1 the fluoroscopist will yield invaluable aid4 ,an extremely delicate forceps is to be inserted closed into the invaded bronchus1 the grasp on the object being confirmed by the fluoroscopist4 ,it is to be kept in mind that while the object itself may be in the grasp of the forceps1 the fluoroscope will not show whether there may not be included in the forceps' grasp a bronchial spur or other tissue1 the tearing of which may be fatal4 ,therefore traction must not be sufficient to lacerate tissue4 ,if the foreign body does not come readily it must be released1 and a new grasp may then be taken4 ,all of the cautions in faulty seizure already mentioned1 apply with particular force to fluoroscopic bronchoscopy4 ,the fluoroscope is of aid in finding foreign bodies held in abscess cavities4 ,the fluoroscope should show both the lateral and anteroposterior planes4 ,to accomplish this quickly1 two ,coolidge tubes and two screens are necessary4 ,fluoroscopic bronchoscopy1 because of its high mortality and low percentage of successes1 should be tried only after regular1 ocularly guided1 peroral bronchoscopy has failed1 and only by those who have had experience in ocularly guided bronchoscopy4 #agg ,,chapter ,,xvi--,,foreign ,,bodies ,,in ,,the ,,bronchi ,,for ,,prolonged ,,periods ,the sojourn of an inorganic foreign body in the bronchus for a year or more is followed by the development of bronchiectasis1 pulmonary abscess1 and fibrous changes4 ,the symptoms of tuberculosis may all be presented1 but tubercle bacilli have never been found associated with any of the many cases that have come to the ,bronchoscopic ,clinic499 ,the history of repeated attacks of malaise1 fever1 chills1 and sweats lasting for a few days and terminated by the expulsion of an amount of foul pus1 suggests the intermittent drainage of an abscess cavity1 and special study should be made to eliminate foreign body as the cause of the condition1 in all such cases1 whether there is any history of a foreign body accident or not4 ,bronchoscopy for diagnosis is to be done unless the etiology can be definitely proven by other means4 ,in all cases of chronic chest disease foreign body should be eliminated as a matter of routine4 99 ,one exception has recently come to the ,clinic4 #ab ,the time of aspiration of a foreign body may be unknown1 having possibly occurred in infancy1 during narcosis1 or the object may even enter the lower air passages without the patient being aware of the accident1 as happened with a particularly intelligent business man who unknowingly aspirated the tip of an atomizer while spraying his throat4 ,in many other cases the accident had been forgotten4 ,in still others1 in spite of the patient's statement of a conviction that the trouble was due to a foreign body he had aspirated1 the physician did not consider it worthy of sufficient consideration to warrant a roentgenray examination4 ,it is curious to note the various opinions held in regard to the gravity of the presence of a bronchial foreign body4 ,one patient was told by his physician that the presence of a staple in his bronchus was an impossibility1 for he would not have lived five minutes after the accident4 ,others consider the presence of a foreign body in the bronchus as comparatively harmless1 in spite of the repeated reports of invalidism and fatality in the medical literature of centuries4 ,the older authorities state that all cases of prolonged bronchial foreign body sojourn died from phthisis pulmonalis1 and it is still the opinion of some practitioners that the presence of a foreign body in the lung predisposes to the development of true tuberculosis4 ,with the dissemination of knowledge regarding the possibility of bronchial foreign body1 and the marvellous success in their removal by bronchoscopy1 the cases of prolonged foreign body sojourn should decrease in number4 ,it should be the recognized rule1 and not the exception1 that all chest conditions1 acute or chronic1 should have the benefit of roentgenographic study1 even apart from the possibility of foreign body4 ,often even with the clear history of foreign-body aspiration1 both patient and physician are deluded by a relatively long period of quiescence in which no symptoms are apparent4 ,this symptomless interval is followed sooner or later by ever increasing cough and expectoration of sputum1 finally by bronchiectasis and pulmonary abscess1 chronic sepsis1 and invalidism4 ,pathology4--,if the foreign body completely obstructs a main bronchus1 preventing both aeration and drainage1 such rapid destruction of lung tissue follows that extensive pathologic changes may result in a few months1 or even in a few weeks1 in the case of irritating foreign bodies such as peanut kernels and soft rubber4 ,very minute1 inorganic foreign bodies may become encysted as in anthracosis4 ,large objects1 however1 do not become encysted4 ,the object is drawn down by gravity and aspirated into the smallest bronchus it can enter4 ,later the negative pressure below from absorption of air impacts it still further4 ,swelling of the bronchial mucosa from irritation plus infection completes the occlusion of the bronchus4 ,retention of secretions and bacterial decomposition thereof produces first a drowned lung 7natural passages full of pus72 then sloughing or ulceration in the tissues plus the pressure of the pus1 causes bronchiectasis2 further destruction of the cartilaginous rings results in true abscess formation below the foreign body4 ,the productive inflammation at the site of lodgement of the foreign body results in cicatricial contraction and the formation of a stricture at the top of the cavity1 in which the foreign body is usually held4 ,the abscess may extend to the periphery and rupture into the pleural cavity4 ,it may drain intermittently into a bronchus4 ,certain irritating foreign bodies1 such as soft rubber1 may produce gangrenous bronchitis and multiple abscesses4 ,for observations on pathology 7see ,bibliography1 #ch74 ,prognosis4--,if the foreign body be not removed1 the resulting chronic sepsis or pulmonary hemorrhage will prove fatal4 ,removal of the foreign body usually results in complete recovery without further local treatment4 ,occasionally1 secondary dilatation of a bronchial stricture may be required4 ,all cases will need1 besides removal of the foreign body1 an antituberculous regimen1 and offer a good prognosis if this be followed4 ,treatment4--,bronchoscopy should be done in all cases of chronic pulmonary abscess and bronchiectasis even though radiographic study reveals no shadow of foreign body4 ,the patient by assuming a posture with the head lowered is urged to expel spontaneously all the pus possible1 before the bronchoscopy4 ,the aspirating bronchoscope 7,fig4 #b1 ,e7 is often useful in cases where large amounts of secretion may be anticipated4 ,granulations may require removal with forceps and sponging4 ,disturbed granulations result in bleeding which further hampers the operation2 therefore1 they should not be touched until ready to apply the forceps1 unless it is impossible to study the presentation without disturbing them4 ,for this reason secretions hiding a foreign body should be removed with the aspirating tube 7,fig4 #i7 rather than by swabbing or sponge-pumping1 when the bronchoscopic tube-mouth is close to the foreign body4 ,it is inadvisable1 however1 to insert a forceps into a mass of granulations to grope blindly for a foreign body1 with no knowledge of the presentation1 the forceps spaces1 or the location of branch-bronchial orifices into which one blade of the forceps may go4 ,dilatation of a stricture may be necessary1 and may be accomplished by the forms of bronchial dilators shown in ,fig4 #be4 ,the hollow type of dilator is to be used in cases in which the foreign body is held in the stricture 7,fig4 #hc74 ,this dilator may be pushed down over the stem of such an object as a tack1 and the stricture dilated without the risk of pushing the object downward4 ,it is only rarely1 however1 that the point of a tack is free4 ,dense cicatricial tissue may require incision or excision4 ,internal bronchotomy is doubtless1 a very dangerous procedure1 though no fatalities have occurred in any of the three cases in the ,bronchoscopic ,clinic4 ,it is advisable only as a last resort4 #aha ,,chapter ,,xvii--,,unsuccessful ,,bronchoscopy ,,for ,,foreign ,,bodies ,the limitations of bronchoscopic removal of foreign bodies are usually manifested in the failure to find a small foreign body which has entered a minute bronchus far down and out toward the periphery4 ,when localization by means of transparent films1 fluoroscopy1 and endobronchial bismuth insufflation has failed1 the question arises as to the advisability of endoscopic excision of the tissue intervening between the foreign body and bronchoscope with the aid of two fluoroscopes1 one for the lateral and the other the vertical plane4 ,with foreign bodies in the larger bronchi near the root of the lung such a procedure is unnecessary1 and injury to a large vessel would be almost certain4 ,at the extreme periphery of the lung the danger is less1 for the vessels are smaller and serious hemorrhage less probable1 through the retention and decomposition of blood in small bronchi with later abscess formation is a contingency4 ,the nature of the bridge of tissue is to be considered2 should it be cicatricial1 the result of prolonged inflammatory processes1 it may be carefully excised without very great risk of serious complications4 ,the blood vessels are diminished in size and number by the chronic productive inflammation1 which more than offsets their lessened contractility4 ,the possibility of the foreign body being coughed out after suppurative processes have loosened its impaction is too remote2 and the lesions established may result fatally even after the expulsion of the object4 ,pulmonary abscess formation and rupture into the pleura should not be awaited1 for the foreign body does not often follow the pus into the pleural cavity4 ,it remains in the lung1 held in a bed of granulation tissue4 ,furthermore1 to await the development is to subject the patient to a prolonged and perhaps fatal sepsis1 or a fatal pulmonary hemorrhage from the erosion of a vessel by the suppurative process4 ,the recent developments in thoracic surgery have greatly decreased the operative mortality of thoracotomy1 so that this operation is to be considered when bronchoscopy has failed4 ,bronchoscopy can be considered as having failed1 for the time being1 when two or more expert bronchoscopists on repeated search have been unable to find the foreign body or to disentangle it2 but the art of bronchoscopy is developing so rapidly that the failures of a few years ago would be easy successes today4 ,before considering thoracotomy months of study of the mechanical problem are advisable4 ,it is probable that any foreign body of appreciable size that has gone down the natural passages can be brought back the same way4 ,in the event of a foreign body reaching the pleura1 either with or without pus1 it should be removed immediately by pleuroscopy or by thoracotomy1 without waiting for adhesive pleuritis4 ,the problem may be summarized thus3 #a4 ,large foreign bodies in the trachea or large bronchi can always be removed by bronchoscopy4 #b4 ,the development of bronchoscopy having subsequently solved the problems presented by previous failures1 it seems probable that by patient developmental endeavor1 any foreign body of appreciable size that has gone down through the natural passages1 can be bronchoscopically removed the same way1 provided fatal trauma is avoided4 ,at the author's ,bronchoscopic ,clinics #ih4g per cent of foreign bodies have been removed4 ,,chapter ,,xviii--,,foreign ,,bodies ,,in ,,the ,,esophagus ,etiology4--,the lodgement of foreign bodies in the esophagus is influenced by3 #a4 ,the shape of the foreign body 7disc-shaped1 pointed1 irregular74 #b4 ,resiliency of the object 7safety pins74 #c4 ,the size of the foreign body4 #d4 ,narrowing of the esophagus1 spasmodic or organic1 normal1 or pathologic4 #e4 ,paralysis of the normal esophageal propulsory mechanism4 ,the lodgement of a bolus of ordinary food in the esophagus is strongly suggestive of a preexisting narrowing of the lumen of either a spasmodic or organic nature2 a large bolus of food1 poorly masticated and hurriedly swallowed1 may1 however1 become impacted in a perfectly normal esophagus4 ,carelessness is the cause of over #hj per cent of the foreign bodies in the esophagus 7see ,bibliography1 #bi74 ,site of ,lodgement4--,almost all foreign bodies are arrested in the cervical esophagus at the level of the superior aperture of the thorax4 ,a physiologic narrowing is present at this level1 produced in part by muscular contraction1 and mainly by the crowding of the adjacent viscera into the fixed and narrow upper thoracic aperture4 ,if dislodged from this position the foreign body usually passes downward to be arrested at the next narrowing or to pass into the stomach4 ,the esophagoscopist who encounters the difficulty of introduction at the cricopharyngeal fold expects to find the foreign body above the fold4 ,such1 however1 is almost never the case4 ,the cricopharyngeus muscle functionates in starting the foreign body downward as if it were food2 but the narrowing at the upper thoracic aperture arrests it because the esophageal peristaltic musculature is feeble as compared to the powerful inferior constrictor4 ,symptoms4--,dysphagia is the most frequent complaint in cases of esophageally lodged foreign bodies4 ,a very small object may excite sufficient spasm to cause aphagia1 while a relatively large foreign body may be tolerated1 after a time1 so that the swallowing function may seem normal4 ,intermittent dysphagia suggests the tilting or shifting of a foreign body in a valve-like fashion2 but may be due to occlusion of the by-passages by food arrested by the foreign body4 ,dyspnea may be present if the foreign body is large enough to compress the trachea4 ,cough may be excited by reflex irritation1 overflow of secretions into the larynx1 or by perforation of the posterior tracheal wall1 traumatic or ulcerative1 allowing leakage of food or secretion into the trachea4 7,see ,chapter ,,xii for discussion of symptomatology and diagnosis47 ,prognosis4--,a foreign body lodged in the esophagus may prove quickly fatal from hemorrhage due to perforation of a large vessel2 from asphyxia by pressure on the trachea2 or from perforation and septic mediastinitis4 ,slower fatalities may result from suppuration extending to the trachea or bronchi with consequent edema and asphyxia4 ,sooner or later1 if not removed1 the foreign body causes death4 ,it may be tolerated for a long period of time1 causing abscess1 cervical cellulitis1 fistulous tracts1 and ultimately extreme stenosis from cicatricial contraction4 ,perichondritis of the laryngeal or tracheal cartilages may follow1 and result in laryngeal stenosis requiring tracheotomy4 ,the damage produced by the foreign body is often much less than that caused by blind and ill-advised attempts at removal4 ,if the foreign body becomes dislodged and moves downward1 the danger of intestinal perforation is encountered4 ,the prognosis1 therefore1 must be guarded so long as the intruder remains in the body4 ,treatment4--,it is a mistake to try to force a foreign body into the stomach with the stomach tube or bougie4 ,sounding the esophagus with bougies to determine the level of the obstruction1 or to palpate the nature of the foreign body1 is unnecessary and dangerous4 ,esophagoscopy should not be done without a previous roentgenographic and fluoroscopic examination of the chest and esophagus1 except for urgent reasons4 ,the level of the stenosis1 and usually the nature of the foreign body1 can thus be decided4 ,blind instrumentation is dangerous1 and in view of the safety and success of esophagoscopy1 reprehensible4 ,if for any reason removal should be delayed1 bismuth sub-nitrate1 gramme #j4f1 should be given dry on the tongue every four hours4 ,it will adhere to the denuded surfaces4 ,the addition of calomel1 gramme #j4jjc1 for a few doses will increase the antiseptic action4 ,should swallowing be painful1 gramme #j4b of orthoform or anesthesin will be helpful4 ,emetics are inefficient and dangerous4 ,holding the patient up by the heels is rarely1 if ever1 successful if the foreign body is in the esophagus4 ,in the reported cases the intruder was probably in the pharynx4 ,external esophagotomy for the removal of foreign bodies is unjustifiable until esophagoscopy has failed in the hands of at least two skillful esophagoscopists4 ,it has been the observation in the ,bronchoscopic ,clinic that every foreign body that has gone down through the mouth into the esophagus can be brought back the same way1 unless it has already perforated the esophageal wall1 in which event it is no longer a case of foreign body in the esophagus4 ,the mortality of external esophagotomy for foreign bodies is from twenty to forty-two per cent1 while that of esophagoscopy is less than two per cent1 if the foreign body has not already set up a serious complication before the esophagoscopy4 ,furthermore1 external esophagotomy can be successful only with objects lodged in the cervical esophagus and1 moreover1 it has happened that after the esophagus has been opened1 the foreign body could not be found because of dislodgement and passage downward during the relaxation of the general anesthesia4 ,should this occur during esophagoscopy1 the foreign body can be followed with the esophagoscope1 and even if it is not overtaken and removed1 no risk has been incurred4 ,esophagoscopy is the one method of removal worthy of serious consideration4 ,should it repeatedly fail in the hands of two skillful endoscopists1 which will be very rarely1 if ever1 then external operation is to be considered in cervically lodged foreign bodies4 #ahg ,,chapter ,,xix--,,esophagoscopy ,,for ,,foreign ,,body ,indications4--,esophagoscopy is demanded in every case in which a foreign body is known to be1 or suspected of being1 in the esophagus4 ,contraindications4--,there is no absolute contraindication to careful esophagoscopy for the removal of foreign bodies1 even in the presence of aneurism1 serious cardiovascular disease1 hypertension or the like1 although these conditions would render the procedure inadvisable4 ,should the patient be in bad condition from previous ill-advised or blind attempts at extraction1 endoscopy should be delayed until the traumatic esophagitis has subsided and the general state improved4 ,it is rarely the foreign body itself which is producing these symptoms1 and the removal of the object will not cause their immediate subsidence2 while the passage of the tube through the lacerated1 infected1 and inflamed esophagus might further harm the patient4 ,moreover1 the foreign body will be difficult to find and to remove from the edematous and bleeding folds1 and the risk of following a false passage into the mediastinum or overriding the foreign body is great4 ,water starvation should be relieved by means of proctoclysis and hypodermoclysis before endoscopy is done4 ,the esophagitis is best treated by placing dry on the tongue at four-hour intervals the following powder3 ,rx4 ,anesthesin444gramme #j4ab ,bismuth subnitrate444gramme #j4f ,calomel1 gramme #j4jjf to #j4jjc may be added to each powder for a few doses to increase the antiseptic effect4 ,if the patient can swallow liquids it is best to wait one week from the time of the last attempt at removal before any endoscopy for extraction be done4 ,this will give time for nature to repair the damage and render the removal of the object more certain and less hazardous4 ,perforation of the esophagus by the foreign body1 or by blind instrumentation1 is a contraindication to esophagoscopy4 ,it is manifested by such signs as subcutaneous emphysema1 swelling of the neck1 fever1 irritability1 increase in pulsatory and respiratory rates1 and pain in the neck or chest4 ,gaseous emphysema is present in some cases1 and denotes a dangerous infection4 ,esophagoscopy should be postponed and the treatment mentioned at the end of this chapter instituted4 ,after the subsidence of all symptoms other than esophageal1 esophagoscopy may be done safely4 ,pleural perforation is manifested by the usual signs of pneumothorax1 and will be demonstrated in the roentgenogram4 ,,esophagoscopic ,,extraction ,,of ,,foreign ,,bodies ,it is unwise to do an endoscopy in a foreign-body case for the sole purpose of taking a preliminary look4 ,everything likely to be needed for extraction of the intruder should be sterile and ready at hand4 ,furthermore1 all required instruments for laryngoscopy1 bronchoscopy or tracheotomy should be prepared as a matter of routine1 however rarely they may be needed4 ,sponging should be done cautiously lest the foreign body be hidden in secretions or food accumulation1 and dislodged4 ,small food masses often lodge above the foreign body and are best removed with forceps4 ,the folds of the esophagus are to be carefully searched with the aid of the lip of the esophagoscope4 ,if the mucosa of the esophagus is lacerated with the forceps all further work is greatly hampered by the oozing2 if the laceration involve the esophageal wall the accident may be fatal3 and at best the tendency of the tube-mouth to enter the laceration and create a false passage is very great4 ,overriding or failure to find a foreign body known to be present is explained by the collapsed walls and folds covering the object1 since the esophagoscope cannot be of sufficient size to smooth out these folds1 and still be of small enough diameter to pass the constricted points of the esophagus noted in the chapter on anatomy4 ,objects are often hidden just distal to the cricopharyngeal fold1 which furthermore makes a veritable chute in throwing the end of the tube forward to override the foreign body and to interpose a layer of tissue between the tube and the object1 so that the contact at the side of the tube is not felt as the tube passes over the foreign body 7,fig4 #ia74 ,the chief factors in overriding an esophageal foreign body are3 #a4 ,the chute-like effect of the plica cricopharyngeus4 #b4 ,the chute-like effect of other folds4 #c4 ,the lurking of the foreign body in the unexplored pyriform sinus4 #d4 ,the use of an esophagoscope of small diameter4 #e4 ,the obscuration of the intruder by secretion or food debris4 #f4 ,the obscuration of the intruder by its penetration of the esophageal wall4 #g4 ,the obscuration of the intruder by inflammatory sequelae4 ,,fig4 #ia4--;,illustrating the hiding of a coin by the folding downward of the plica cricopharyngeus4 ,the muscular contraction throws the beak of the esophagoscope upward while the interposed tissue prevents the tactile appreciation of contact of the foreign body with the side of the tube after the tip has passed over the foreign body4 ,other folds may in rare instances act similarly in hiding a foreign body from view4 ,this overriding of a foreign body is apt to cause dangerous dyspnea by compression of the party wall4 ,the esophageal speculum for the removal of foreign bodies is useful when the object is not more than #b cm4 below the cricoid in a child1 and #c cm4 in the adult4 ,the fold of the cricopharyngeus can be repressed posteriorward by the forceps which are then in position to grasp the object when it is found4 ,the author's down-jaw forceps 7,fig4 #bb7 are very useful to reach down back of the cricopharyngeal fold1 because of the often small posterior forceps space4 ,the speculum has the disadvantage of not allowing deeper search should the foreign body move downward4 ,in infants1 the child's size laryngoscope may be used as an esophageal speculum4 ,general anesthesia is not only unnecessary but dangerous1 because of the dyspnea created by the endoscopic tube4 ,local anesthesia is unnecessary as well as dangerous in children2 and its application is likely to dislodge the foreign body unless used as a troche4 ,forbes esophageal speculum is excellent4 ,,mechanical ,,problems ,,of ,,esophagoscopic ,,removal ,,of ,,foreign ,,bodies ,the bronchoscopic problems considered in the previous chapter should be studied4 ,the extraction of transfixed foreign bodies presents much the same problem as those in the bronchi1 though there is no limit here to the distance an object may be pushed down to free the point4 ,thin1 sharp foreign bodies such as bones1 dentures1 pins1 safety-pins1 etcetera1 are often found to lie crosswise in the esophagus1 and it is imperative that one end be disengaged and the long axis of the object be made to correspond to that of the esophagus before traction for removal is made 7,fig4 #ib74 ,should the intruder be grasped in the center and traction exerted1 serious and perhaps fatal trauma might ensue4 #aia ,,fig4 #ib4--,the problem of the horizontally transfixed foreign body in the esophagus4 ,the point1 ,d1 had caught as the bone1 ,a1 was being swallowed4 ,the end1 ,e1 was forced down to ,c1 by food or by blind attempts at pushing the bone downward4 ,the wall1 ,f1 should be laterally displaced to ,j1 with the esophagoscope1 permitting the forceps to grasp the end1 ,m1 of the bone4 ,traction in the direction of the dart will disimpact the bone and permit it to rotate4 ,the rotation forceps are used as at ,k4 ,,fig4 #ic4--,solution of the mechanical problem of the broad foreign body having a sharp point by version4 ,if withdrawn with plain forceps as applied at ,a1 the point ,b1 will rip open the esophageal wall4 ,if grasped at ,c1 the point1 ,d1 will rotate in the direction of ,f and will trail harmlessly4 ,to permit this version the rotation forceps are used as at ,h4 ,on this principle flat foreign bodies with jagged or rough parts are so turned that the potentially traumatizing parts trail during withdrawal4 ,the extraction of broad1 flat foreign bodies having a sharp point or a rough place on part of their periphery is best accomplished by the method of rotation as shown in ,fig4 #ic4 ,extraction of ,open ,safety-pins from the ,esophagus4--,an open safety pin with the point down offers no particular mechanical difficulty in removal4 ,great care must be exercised1 however1 that it be not overridden or pushed upon1 as either accident might result in perforation of the esophagus by the pin point4 ,the coiled spring is to be sought1 and when found1 seized with the rotation forceps and the pin thus drawn into the esophagoscope to effect closure4 ,an open safety-pin lodged point upward in the esophagus is one of the most difficult and dangerous problems4 ,a roentgenogram should always be made in the plane showing the widest spread of the pin4 ,it is to be remembered that the endoscopist can see but one portion of the pin at a time 7except in cases of very small safety-pins7 and that if he grasps the part first showing1 which is almost invariably the keeper1 fatal trauma will surely be inflicted when traction is made4 ,it may be best to close the safety pin with the safety-pin closer1 as illustrated in ,fig4 #cg4 ,for this purpose ,arrowsmith's closer is excellent4 ,in other cases it may prove best to disengage the point of the pin and to bring the pointed shaft into the esophagoscope with the ,tucker forceps and withdraw the pin1 forceps1 and esophagoscope1 with the keeper and its shaft sliding alongside the tube4 ,the rounded end of the keeper lying outside the tube allows it to slip along the esophageal walls during withdrawal without inflicting trauma2 however1 should resistance be felt1 withdrawal must immediately cease and the pin must be rotated into a different plane to release the keeper from the fold in which it has probably caught4 ,the sense of touch will aid the sense of sight in the execution of this maneuver 7,fig4 #hg74 ,when the pin reaches the cricopharyngeal level the esophagoscope1 forceps1 and pin should be turned so that the keeper will be to the right1 not so much because of the cricopharyngeal muscle as to escape the posteriorly protuberant cricoid cartilage4 ,in certain cases in which it is found that the pointed shaft of a small safety pin has penetrated the esophageal wall1 the pin has been successfully removed by working the keeper into the tube mouth1 grasping the keeper with the rotation forceps or side-curved forceps1 and pulling the whole pin into the tube by straightening it4 ,this1 however1 is a dangerous method and applicable in but few cases4 ,it is better to disengage the point by downward and inward rotation with the ,tucker forceps4 ,version of a ,safety ,pin4--,a safety pin of very small size may be turned over in a direction that will cause the point to trail4 ,an advancing point will puncture4 ,this is a dangerous procedure with a large safety pin4 ,endogastric ,version4--,a very useful and comparatively safe method is illustrated in ,figs4 #id and #ie4 ,in the execution of this maneuver the pin is seized by the spring with a rotation forceps1 and thus passed along with the esophagoscope into the stomach where it is rotated so that the spring is uppermost4 ,it can then be drawn into the tube mouth so as to protect the tissues during withdrawal of the pin1 forceps1 and esophagoscope as one piece4 ,only very small safety-pins can be withdrawn through the esophagoscope4 ,spatula-protected ,method4--,safety-pins in children1 point upward1 when lodged high in the cervical esophagus may be readily removed with the aid of the laryngoscope1 or esophageal speculum4 ,the keeper end is grasped with the alligator forceps1 while the spatular tip of the laryngoscope is worked under the point4 ,instruments and foreign body are then removed together4 ,often the pin point will catch in the light-chamber where it is very safely lodged4 ,if the pin be then pulled upon it will straighten out and may be withdrawn through the tube4 ,,fig4 #id4--;,endogastric version4 ,one of the author's methods of removal of upward pointed esophageally lodged open safety-pins by passing them into stomach1 where they are turned and removed4 ,the first illustration 7,a7 shows the rotation forceps before seizing pin by the ring of the spring end4 7,forceps jaws are shown opening in the wrong diameter47 ,at ,b is shown the pin seized in the ring by the points of the forceps4 ,at ,c is shown the pin carried into the stomach and about to be rotated by withdrawal4 ,d1 the withdrawal of the pin into the esophagoscope which will thereby close it4 ,if withdrawn by flat-jawed forceps as at ,f1 the esophageal wall would be fatally lacerated4 ,double pointed tacks and staples1 when lodged point upward1 must be turned so that the points trail on removal4 ,this may be done by carrying them into the stomach and turning them1 as described under safety-pins4 ,the extraction of foreign bodies of very large size from the esophagus is greatly facilitated by the use of general anesthesia1 which relaxes the spasmodic contractions of the esophagus often occurring when attempt is made to withdraw the foreign body4 ,general anesthesia1 though entirely unnecessary for introduction of the esophagoscope1 in any case may be used if the body is large1 sharp1 and rough1 in order to prevent laceration through the muscular contractions otherwise incident to withdrawal499 ,in exceptional cases it may be necessary to comminute a large foreign body such as a tooth plate4 ,a large smooth foreign body may be difficult to seize with forceps4 ,in this case the mechanical spoon or the author's safety-pin closer may be used4 99 ,it must always be remembered that large foreign bodies are very prone to cause dyspnea that renders general anesthesia exceedingly dangerous especially in children4 ,,fig4 #ie4--,lateral roentgenogram of a safety-pin in a child aged #aa months1 demonstrating the esophageal location of the pin in this case and the great value of the lateral roentgenogram in the localization of foreign bodies4 ,the pin was removed by the author's method of endogastric version4 7,plate made by ,george ,c4 ,johnston 7 ,the extraction of meat and other foods from the esophagus at the level of the upper thoracic aperture is usually readily accomplished with the esophageal speculum and forceps4 ,in certain cases the mechanical spoon will be found useful4 ,should the bolus of food be lodged at the lower level the esophagoscope will be required4 ,extraction of ,foreign ,bodies from the ,strictured ,esophagus4--,foreign bodies of relatively small size will lodge in a strictured esophagus4 ,removal may be rendered difficult when the patient has an upper stricture relatively larger than the lower one1 and the foreign body passing the first one lodges at the second4 ,still more difficult is the case when the second stricture is considerably below the first1 and not concentric4 ,under these circumstances it is best to divulse the upper stricture mechanically1 when a small tube can be inserted past the first stricture to the site of lodgement of the foreign body4 ,prolonged sojourn of foreign bodies in the esophagus1 while not so common as in the bronchi is by no means of rare occurrence4 ,following their removal1 stricture of greater or less extent is almost certain to follow from contraction of the fibrous-tissue produced by the foreign body4 ,fluoroscopic esophagoscopy is a questionable procedure1 for the esophagus can be explored throughout by sight4 ,in cases in which it is suspected that a foreign body1 such as pin1 has partially escaped from the esophagus1 the fluoroscope may aid in a detailed search to determine its location1 but under no circumstances should it be the guide for the application of forceps1 because the transparent but vital tissues are almost certain to be included in the grasp4 #aig ,complications and ,dangers of ,esophagoscopy for ,foreign ,bodies4 ,asphyxia from the pressure of the foreign body1 or the foreign body plus the esophagoscope1 is a possibility 7,fig4 #ia74 ,faulty position of the patient1 especially a low position of the head1 with faulty direction of the esophagoscope may cause the tube mouth to press the membranous tracheo-esophageal wall into the trachea1 so as temporarily to occlude the tracheal lumen1 creating a very dangerous situation in a patient under general anesthesia4 ,prompt introduction of a bronchoscope1 with oxygen and amyl nitrite insufflation and artificial respiration1 may be necessary to save life4 ,the danger is greater1 of course1 with chloroform than with ether anesthesia4 ,cocain poisoning may occur in those having an idiosyncrasy to the drug4 ,cocain should never be used with children1 and is of little use in esophagoscopy in adults4 ,its application is more annoying and requires more time than the esophagoscopic removal of the foreign bodies without local anesthesia4 ,traumatic esophagitis1 septic mediastinitis1 cervical cellulitis1 and1 most dangerous1 gangrenous esophagitis may be present1 caused by the foreign body itself or ill-advised efforts at removal4 ,perforation of the esophagus with the esophagoscope is rare1 in skillful hands1 if the esophageal wall is sound4 ,the esophageal wall1 however1 may be weakened by ulceration1 malignant disease1 or trauma1 so that the possibility of making a false passage should always deter the endoscopist from advancing the tube beyond a visible point of weakening4 ,to avoid entering a false passage previously created1 is often exceedingly difficult1 and usually it is better to wait for obliterative adhesive inflammation to seal the tissue layers together4 ,treatment4--,acute esophagitis calls for rest in bed1 sterile liquid food1 and the administration of bismuth powder mentioned in the paragraph on contraindications4 ,an ice bag applied to the neck may afford some relief4 ,the mouth should be hourly cleansed with the following solution3 ,dakin's solution #a part ,cinnamon water #e parts4 ,emphysema unaccompanied by pyogenic processes usually requires no treatment1 though an occasional case may require punctures of the skin to liberate the air4 ,gaseous emphysema and pus formation urgently demand early external drainage1 preferably behind the sternomastoid4 ,should the pleura be perforated by sudden puncture pyo-pneumothorax is inevitable4 ,prompt thoracotomy for drainage may save the patient's life if the mediastinum has not also been infected4 ,foreign bodies ulcerating through may reach the lung without pleural leakage because of the sealing together of the visceral and parietal pleurae4 ,in the serious degrees of esophageal trauma1 particularly if the pleura be perforated1 gastrostomy is indicated to afford rest of the esophagus1 and for alimentation4 ,a duodenal feeding tube may be placed through an esophagoscope passed into the stomach in the usual way through the mouth1 avoiding by ocular guidance the perforation into which a blindly passed stomach tube would be very likely to enter1 with probably dangerous results4 #aii ,,chapter ,,xx--,,pleuroscopy ,foreign bodies in the pleural cavity should be immediately removed4 ,the esophageal speculum inserted through a small intercostal incision makes an excellent pleuroscope1 its spatular tip being of particular value in moving the lung out of the way4 ,this otherwise dark cavity is thus brilliantly illuminated without the necessity of making a large flap resection1 an important factor in those cases in which there is no infection present4 ,the pleura and wound may be immediately closed without drainage1 if the pleura is not infected4 ,excessive plus pressure or pus may require reopening4 ,in one case in which the author removed a foreign body by pleuroscopy1 healing was by first intention and the lung filled in a few days4 ,drainage tubes that have slipped up into the empyemic cavity are foreign bodies4 ,they are readily removed with the retrograde esophagoscope even through the smallest fistula4 ,the aspirating canal keeps a clear field while searching for the drain4 ,pleuroscopy for ,disease4--,most pleural diseases require a large external opening for drainage1 and even here the pleuroscope may be of some use in exploring the cavities4 ,usually there are many adhesions and careful ray study may reveal one or more the breaking up of which will improve drainage to such an extent as to cure an empyema of long standing4 ,repeated severing of adhesions1 aspiration and sometimes incision of the thickened visceral pleura may be necessary4 ,the author is so strongly imbued with the idea that local examination under full illumination has so revolutionized the surgery of every region of the body to which it has been applied1 that every accessible region should be thus studied4 ,the pleural cavity is quite accessible with or without rib-resection1 and there is practically no risk in careful pleuroscopy4 #bja ,,chapter ,,xxi--,,benign ,,growths ,,in ,,the ,,larynx ,benign growths in the larynx are easily and accurately removable by direct laryngoscopy2 but perhaps no method has been more often misused and followed by most unfortunate results4 ,it should always be remembered that benign growths are benign1 and that hence they do not justify the radical work demanded in dealing with malignancy4 ,the larynx should be worked upon with the same delicacy and respect for the normal tissues that are customary in dealing with the eye4 ,granulomata in the larynx1 while not true neoplasms1 require extirpation in some instances4 ,vocal nodules1 when other methods of cure such as vocal rest1 various vocal exercises1 etcetera have failed may require surgical excision4 ,this may be done with the laryngeal tissue forceps or with the author's vocal nodule forceps4 ,sessile vocal nodules may be cured by touching them with a fine galvanocautery point1 but all work on the vocal cords must be done with extreme caution and nicety4 ,it is exceedingly easy to ruin a fine voice4 ,fibromata1 often of inflammatory genesis1 are best removed with the laryngeal grasping forceps1 though the small laryngeal punch or tissue forceps may be used4 ,if very large1 they may be amputated with the snare1 the base being treated with galvanocautery though this is seldom advisable4 ,strong traction should be avoided as likely to do irreparable injury to the laryngeal motility4 ,cystomata may get well after simple excision or galvanopuncture of a part of the wall of the sac1 but complete extirpation of the sac is often required for cure4 ,the same is true of adenomata4 #bjb ,angiomata1 if extensive and deeply seated1 may require deep excision1 but usually cure results from superficial removal4 ,usually no cauterization of the vessels at the base is necessary1 either to arrest hemorrhage or to lessen the tendency to recurrence4 ,a diffuse telangiectasis1 should it require treatment1 may be gently touched with a needle-pointed galvanocaustic electrode at a number of sittings4 ,the galvanonocautery is a dangerous method to use in the larynx4 ,radium offers the best results in this latter form of angioma1 applied either internally or to the neck4 ,lymphoma1 enchondroma and osteoma1 if not too extensively involving the laryngeal walls1 may be excised with basket punch forceps1 but lymphoma is probably better treated by radium499 ,true myxomata and lipomata are very rare4 ,amyloid tumors are occasionally met with1 and are very resistant to treatment4 ,aberrant thyroid tumors do not require very radical excision of normal base1 but should be removed as completely as possible4 ,in a general way1 it may be stated that with benign growths in the larynx the best functional results are obtained by superficial rather than radical1 deep extirpation1 remembering that it is easier to remove tissue than to replace it1 and that cicatrices impair or ruin the voice and may cause stenosis4 99 ,in a case reported by ,delavan a complete cure with perfect restoration of voice resulted from radium after ,i had failed to cure by operative methods4 7,proceedings ,american ,laryngological ,association1 #aiba47 #bjc ,,chapter ,,xxii--,,benign ,,growths ,,in ,,the ,,larynx 7,continued7 ,,papillomata ,,of ,,the ,,larynx ,,in ,,children ,of all benign growths in the larynx papilloma is the most frequent4 ,it may occur at any age of childhood and may even be congenital4 ,the outstanding fact which necessarily influences our treatment is the tendency to recurrences1 followed eventually in practically all cases by a tendency to disappearance4 ,in the author's opinion multiple papillomata constitute a benign1 self-limited disease4 ,there are two classes of cases4 #a4 ,those in which the growth gets well spontaneously1 or with slight treatment1 surgically or otherwise2 and1 #b1 those not readily amenable to any form of treatment1 recurrences appearing persistently at the old sites1 and in entirely new locations4 ,in the author's opinion these two classes of case represent not two different kinds of growths1 but stages in the disease4 ,those that get well after a single removal are near the end of the disease4 ,papillomata are of inflammatory origin and are not true neoplasms in the strictest sense4 ,methods of ,treatment4--,irritating applications probably provoke recurrences1 because the growths are of inflammatory origin4 ,formerly laryngostomy was recommended as a last resort when all other means had failed4 ,the excellent results from the method described in the foregoing paragraph has relegated laryngostomy to those cases that come in with a severe cicatricial stenosis from an injudicious laryngofissure2 and even in these cases cure of the stenosis as well as the papillomata can usually be obtained by endoscopic methods alone1 using superficial scalping off of the papillomata with subsequent laryngoscopic bouginage for the stenosis4 ,thyrotomy for papillomata is mentioned only to be condemned4 ,fulguration has been satisfactory in the hands of some1 disappointing to others4 ,it is easily and accurately applied through the direct laryngoscope1 but damage to normal tissues must be avoided4 ,radium1 mesothorium1 and the roentgenray are reported to have had in certain isolated cases a seemingly beneficial action4 ,in my experience1 however1 ,i have never seen a cure of papillomata which could be attributed to the radiation4 ,i have seen cases in which no effect on the growths or recurrence was apparent1 and in some cases the growths seemed to have been stimulated to more rapid repullulations4 ,in other most unfortunate cases ,i have seen perichondritis of the laryngeal cartilages with subsequent stenosis occurring after the roentgenotherapy4 ,possibly the disastrous results were due to overdosage2 but ,i feel it a duty to state the unfavorable experience1 and to call attention to the difference between cancer and papillomata4 ,multiple papillomata involve no danger to life other than that of easily obviated asphyxia1 and it is moreover a benign self-limited disease that repullulates on the surface4 ,in cancer we have an infiltrating process that has no limits short of life itself4 ,endolaryngeal extirpation of papillomata in children requires no anesthetic1 general or local2 the growths are devoid of sensibility4 ,if1 for any reason1 a general anesthetic is used it should be only in tracheotomized cases1 because the growths obstruct the airway4 ,obstructed respiration introduces into general anesthesia an enormous element of danger4 ,concerning the treatment of multiple papillomata it has been my experience in hundreds of cases that have come to the ,bronchoscopic ,clinic1 that repeated superficial removals with blunt non-cutting forceps 7see ,chapter ,i7 will so modify the soil as to make it unfavorable for repullulation4 ,the removals are superficial and do not include the subjacent normal tissue4 ,radical removal of a papilloma situated1 for instance1 on the left ventricular band or cord1 can in no way prevent the subsequent occurrence of a similar growth at a different site1 as upon the epiglottis1 or even in the fauces4 ,furthermore1 radical removal of the basal tissues is certain to impair the phonatory function4 ,excellent results as to voice and freedom from recurrence have always followed repeated superficial removal4 ,the time required has been months or a year or two4 ,only rarely has a cure followed a single extirpation4 ,if the child is but slightly dyspneic1 the obstructing part of the growth is first removed without anesthesia1 general or local2 the remaining fungations are extirpated subsequently at a number of brief seances4 ,the child is thus not terrified1 soon loses dread of the removals1 and appreciates the relief4 ,should the child be very dyspneic when first seen1 a low tracheotomy is immediately done1 and after an interim of ten days1 laryngoscopic removal of the growth is begun4 ,tracheotomy probably has a beneficial effect on the disease4 ,tracheal growths require the insertion of the bronchoscope for their removal4 ,papillomata in the larynx of adults are1 on the whole1 much more amenable to treatment than similar growths in children4 ,tracheotomy is very rarely required1 and the tendency to recurrence is less marked4 ,many are cured by a single extirpation4 ,the best results are obtained by removal of the growths with the laryngeal grasping-forceps1 taking the utmost care to avoid including in the bite of the forceps any of the subjacent normal tissue4 ,radical resection or cauterization of the base is unwise because of the probable impairment of the voice1 or cicatricial stenosis1 without in anyway insuring against repullulation4 ,the papillomata are so soft that they give no sensation of traction to the forceps4 ,they can readily be scalped off without any impairment of the sound tissues1 by the use of the author's papilloma forceps 7,fig4 #bi74 ,cutting forceps of all kinds are objectionable because they may wound the normal tissues before the sense of touch can give warning4 ,a gentle hand might be trusted with the cup forceps 7,fig4 #cb1 large size47 ,sir ,felix ,semon proved conclusively by his collective investigations that cancer cannot be caused by the repeated removals of benign growths4 ,therefore1 no fear of causing cancer need give rise to hesitation in repeatedly removing the repullulations of papillomata or other benign growths4 ,indeed there is much clinical evidence elsewhere in the body1 and more than a little such evidence as to the larynx1 to warrant the removal of benign growths1 repeated if necessary1 as a prophylactic of cancer 7,bibliography1 #ai74 #bjg ,,chapter ,,xxiii--,,benign ,,growths ,,primary ,,in ,,the ,,tracheobronchial ,,tree ,extension of papillomata from the larynx into the cervical trachea1 especially about the tracheotomy wound1 is of relatively common occurrence4 ,true primary growths of the tracheobronchial tree1 though not frequent1 are by no means rare4 ,these primary growths include primary papillomata and fibromata as the most frequent1 aberrant thyroid1 lipomata1 adenomata1 granulomata and amyloid tumors4 ,chondromata and osteochondromata may be benign but are prone to develop malignancy1 and by sarcomatous or other changes1 even metaplasia4 ,edematous polypi and other more or less tumor-like inflammatory sequelae are occasionally encountered4 ,symptoms of ,benign ,tumors of the ,tracheobronchial ,tree4--,cough1 wheezing respiration1 and dyspnea1 varying in degree with the size of the tumor1 indicate obstruction of the airway4 ,associated with defective aeration will be the signs of deficient drainage of secretions4 ,roentgenray examination may show the shadow of enchondromata or osteomata1 and will also show variations in aeration should the tumor be in a bronchus4 ,bronchoscopic removal of benign growths is readily accomplished with the endoscopic punch forceps shown in ,figs4 #bh and #cc4 ,quick action may be necessary should a large tumor producing great dyspnea be encountered1 for the dyspnea is apt to be increased by the congestion1 cough1 and increased respiration and spasm incidental to the presence of the bronchoscope in the trachea4 ,general anesthesia1 as in all cases showing dyspnea1 is contraindicated4 ,the risks of hemorrhage following removal are very slight1 provided fungations on an aneurismal erosion be not mistaken for a tumor4 ,multiple papillomata when very numerous are best removed by the author's coring method4 ,this consists in the insertion of an aspirating bronchoscope with the mechanical aspirator working at full negative pressure4 ,the papillomata are removed like coring an apple2 though the rounded edge of the bronchoscope does not even scratch the tracheal mucosa4 ,many of the papillomata are taken off by the holes in the bronchoscope4 ,aspiration of the detached papillomata into the lungs is prevented by the corking of the tube-mouth with the mass of papillomata held by the negative pressure at the canal inlet orifice4 ,,chapter ,,xxiv--,,benign ,,neoplasms ,,of ,,the ,,esophagus ,as a result of prolonged inflammation edematous polypi and granulomata are not infrequently seen1 but true benign tumors of the esophagus are rare affections4 ,keloidal changes in scar tissue may occur4 ,cases of retention1 epithelial and dermoid cysts have been observed2 and there are isolated reports of the finding of papillomata1 fibromata1 lipomata1 myomata and adenomata4 ,the removal of these is readily accomplished with the tissue forceps 7,fig4 #bh71 if the growths are small and projecting into the esophageal lumen4 ,the determination of the advisability of the removal of keloidal scars would require careful consideration of the particular case1 and the same may be said of very large growths of any kind4 ,the extreme thinness of the esophageal walls must be always in the mind of the esophagoscopist if he would avoid disaster4 #baj ,,chapter ,,xxv--,,endoscopy ,,in ,,malignant ,,disease ,,of ,,the ,,larynx ,the general surgical rule applying to individuals past middle life1 that benign growths exposed to irritation should be removed1 probably applies to the larynx as well as to any other epithelialized structure4 ,the facility1 accuracy and thoroughness afforded by skilled1 direct1 laryngeal operation offers a means of lessening the incidence of cancer4 ,to a much greater extent the facility1 accuracy1 and thoroughness contribute to the cure of cancer by establishing the necessary early diagnosis4 ,well-planned1 careful1 external operation 7laryngofissure7 followed by painstaking after-care is the only absolute cure so far known for malignant neoplasms of the larynx2 and it is a cure only in those intrinsic cases in which the growth is small1 and is located in the anterior two-thirds of the intrinsic area4 ,by limiting operations strictly to this class of case1 eighty-five per cent of cures may be obtained499 ,in determining the nature of the growth and its operability the limits of the usefulness of direct endoscopy are reached4 ,it is very unwise to attempt the extirpation of intrinsic laryngeal malignancy by the endoscopic method1 for the reason that the full extent of the growth cannot be appreciated when viewed only from above1 and the necessary radical removal cannot be accurately or completely accomplished4 99 ,the author's results in laryngofissure have recently fallen to #gi per cent of relative cures by thyrochondrotomy4 ,malignant disease of the epiglottis1 in those rare cases where the lesion is strictly limited to the tip is1 however1 an exception4 ,if amputation of the epiglottis will give a sufficiently wide removal1 this may be done en masse with a heavy snare1 and has resulted in complete cure4 ,very small growths may be removed sufficiently widely with the punch forceps 7,fig4 #cc72 but piece meal removal of malignancy is to be avoided4 ,differential ,diagnosis of ,laryngeal ,growths in the ,larynx of ,adults4--,determination of the nature of the lesion in these cases usually consists in the diagnosis by exclusion of the possibilities1 namely1 #a4 ,lues4 #b4 ,tuberculosis1 including lupus4 #c4 ,scleroma4 #d4 ,malignant neoplasm4 ,in the ,bronchoscopic ,clinic the following is the routine procedure3 #a4 ,a ,wassermann test is made4 ,if negative1 and there remains a suspicion of lues1 a therapeutic test with mercury protoiodid is carried out by keeping the patient just under the salivation point for eight weeks2 during which time no potassium iodid is given1 lest its reaction upon the larynx cause an edema necessitating tracheotomy4 ,if no improvement is noticed lues is excluded4 ,if the ,wassermann is positive1 malignancy and the other possibilities are not considered as excluded until the patient has been completely cured by mercury1 because1 for instance1 a leutic or tuberculous patient may have cancer2 a tuberculous patient may have lues2 or a leutic patient1 tuberculosis4 #b4 ,pulmonary tuberculosis is excluded by the usual means4 ,if present the laryngeal lesion may or may not be tuberculous2 if the laryngoscopic appearances are doubtful a specimen is taken4 ,lupoid laryngeal tuberculosis so much resembles lues that both the therapeutic test and biopsy may be required for certainty4 #c4 ,in all cases in which the diagnosis is not clear a specimen is taken4 ,this is readily accomplished by direct laryngoscopy under local anesthesia1 using the regular laryngoscope or the anterior commissure laryngoscope4 ,the best forceps in case of large growths are the alligator punch forceps 7,fig4 #cc74 ,smaller growths require tissue forceps 7,fig4 #bh74 ,in case of small growths1 it is best to remove the entire growth2 but without any attempt at radical extirpation of the base2 because1 if the growth prove benign it is unnecessary2 if malignant1 it is insufficient4 ,inspection of the ,party ,wall in ,cases of ,suspected ,laryngeal ,malignancy4--,when taking a specimen the party wall should be inspected by passing a laryngoscope or1 if necessary1 an esophageal speculum down through the laryngopharynx and beyond the cricopharyngeus4 ,if this region shows infiltration1 all hope of cure by operation1 however radical1 should be abandoned4 ,radium and the therapeutic roentgenray have given good results1 but not such as would warrant their exclusive use in any case of malignancy in the larynx operable by laryngofissure4 ,with inoperable cases1 excellent palliative results are obtained4 ,in some cases an almost complete disappearance of the growth has occurred1 but ultimately there has been recurrence4 ,the method of application of the radium1 dosage1 and its screening1 are best determined by the radiologist in consultation with the laryngologist4 ,radium may be applied externally to the neck1 or suspended in the larynx2 radium-containing needles may be buried in the growth1 or the emanations1 imprisoned in glass pearls or capillary tubes1 may be inserted deeply into the growth by means of a small trocar and cannula4 ,for all of these procedures direct laryngoscopy affords a ready means of accurate application4 ,tracheotomy is necessary however1 because of the reactionary swelling1 which may be so great as to close completely the narrowed glottic chink4 ,where this is the case1 the endolaryngeal application of the radium may be made by inserting the container through the tracheotomic wound1 and anchoring it to the cannula4 ,the author is much impressed with ,freer's method of radiation from the pyriform sinus in such cases as those in which external radiation alone is deemed insufficient4 ,the work of ,drs4 ,d4 ,bryson ,delavan and ,douglass ,m4 ,quick forms one of the most important contributions to the subject of the treatment of radium by cancer4 7,see ,proceedings of the ,american ,laryngological ,association1 #aibb2 also ,proceedings of the ,tenth ,international ,otological ,congress1 ,paris1 #aibb47 #bad ,,chapter ,,xxvi--,,bronchoscopy ,,in ,,malignant ,,growths ,,of ,,the ,,trachea ,the trachea is often secondarily invaded by malignancy of the esophagus1 thyroid gland1 peritracheal or peribronchial glands4 ,primary malignant neoplasms of the trachea or bronchus have not infrequently been diagnosticated by bronchoscopy4 ,peritracheal or peribronchial malignancy may produce a compressive stenosis covered with normal mucosa4 ,endoscopically1 the wall is seen to bulge in from one side causing a crescentic picture1 or compression of opposite walls may cause a scabbard or pear shaped lumen4 ,endotracheal and endobronchial malignancy ulcerate early1 and are characterized by the bronchoscopic view of a bleeding mass of fungating tissue bathed in pus and secretion1 usually foul4 ,the diagnosis in these cases rests upon the exclusion of lues1 and is rendered certain by the removal of a specimen for biopsy4 ,sarcoma and carcinoma of the thyroid when perforating the trachea may become pedunculated4 ,in such cases aberrant non-pathologic thyroid must be excluded by biopsy4 ,endothelioma of the trachea or bronchus may also assume a pedunculated form1 but is more often sessile4 ,treatment4--,pedunculated malignant growths are readily removed with snare or punch forceps4 ,cure has resulted in one case of the author following bronchoscopic removal of an endothelioma from the bronchus2 and a limited carcinoma of the bronchus has been reported cured by bronchoscopic removal1 with cauterization of the base4 ,most of the cases1 however1 will be subjects for palliative tracheotomy and radium therapy4 ,it will be found necessary in many of the cases to employ the author's long1 cane-shaped tracheal cannula 7,fig4 #ajd1 ,a71 in order to pipe the air down to one or both bronchi past the projecting neoplasm4 ,it has recently been demonstrated that following the intravenous injection of a suspension of the insoluble salt1 radium sulphate1 that the suspended particles are held in the capillaries of the lung for a period of one year4 ,intravenous injections of a watery suspension1 and endobronchial injections of a suspension of radium sulphate in oil1 have had definite beneficial action4 ,while as yet1 no relatively permanent cures of pulmonary malignancy have been obtained1 the amelioration and steady improvement noted in the technic of radium therapy are so encouraging that every inoperable case should be thus treated1 if the disease is not in a hopelessly advanced stage4 ,in a case under the care of ,dr4 ,robert ,m4 ,lukens at the ,bronchoscopic ,clinic1 a primary epithelioma of the trachea was retarded for #b years by the use of radium applied by ,dr4 ,william ,s4 ,newcomet1 radium-therapist1 and ,miss ,katherine ,e4 ,schaeffer1 technician4 #baf ,,chapter ,,xxvii--,,malignant ,,disease ,,of ,,the ,,esophagus ,cancer of the esophagus is a more prevalent disease than is commonly thought4 ,in the male it usually develops during the fourth and fifth decades of life4 ,there is in some cases the history of years of more or less habitual consumption of strong alcoholic liquors4 ,in the female the condition often occurs at an earlier age than in the male1 and tends to run a more protracted course1 preceeded in some cases by years of precancerous dysphagia4 ,squamous-celled epithelioma is the most frequent type of neoplasm4 ,in the lower third of the esophagus1 cylindric cell carcinoma may be found associated with a like lesion in the stomach4 ,sarcoma of the esophagus is relatively rare 7,bibliography #a1 p4 #ddi74 ,the sites of the lesion are those of physiologic narrowing of the esophagus4 ,the middle third is most frequently involved2 and the lower third1 near the cardia1 comes next in frequency4 ,cancer of the lower third of the esophagus preponderates in men1 while cancer of the upper orifice is1 curiously1 more prevalent in women4 ,the lesion is usually single1 but multiple lesions1 resulting from implantation metastases have been observed 7,bibliography #a1 p4 #cia74 ,bronchoesophageal fistula from extension is not uncommon4 ,symptoms4--,malignant disease of the esophagus is rarely seen early1 because of the absence1 or mildness1 of the symptoms4 ,dysphagia1 the one common symptom of all esophageal disease1 is often ignored by the patient until it becomes so marked as to prevent the taking of solid food2 therefore1 the onset may have the similitude of abruptness4 ,any well masticated solid food can be swallowed through a lumen #e millimeters in diameter4 ,the inability to maintain the nutrition is evidenced by loss of weight and the rapid development of cachexia4 ,when the stenosis becomes so severe that the fluid intake is limited1 rapid decline occurs from water starvation4 ,pain is usually a late symptom of the disease4 ,it may be of an aching character and referred to the vertebral region or to the neck2 or it may only accompany the act of swallowing4 ,blood-streaked1 regurgitated material1 and the presence of odor1 are late manifestations of ulceration and secondary infection4 ,in some cases1 constant oozing of blood from the ulcerated area adds greatly to the cachexia4 ,if the recurrent laryngeal nerves are involved1 unilateral or bilateral paralysis of the larynx may complicate the symptoms by cough1 dyspnea1 aphonia1 and possibly septic pneumonia4 ,diagnosis4--,it has been estimated that #gj per cent of stenoses of the esophagus in adults are malignant in nature4 ,this should stimulate the early and careful investigation of every case of dysphagia4 ,when all cases of persistent dysphagia1 however slight1 are endoscopically studied1 precancerous lesions may be discovered and treated1 and the limited malignancy of the early stages may be afforded surgical treatment while yet there is hope of complete removal4 ,luetic and tuberculous ulceration of the esophagus are to be eliminated by suitable tests1 supplemented in rare instances by biopsy4 ,aneurysm of the aorta must in all cases of dysphagia be excluded1 for the dilated aorta may be the sole cause of the condition1 and its presence contraindicates esophagoscopy because of the liability of rupture4 ,foreign body is to be excluded by history and roentgenographic study4 ,spasmodic stenosis of the esophagus may or may not have a malignant origin4 ,esophagoscopy and removal of a specimen for biopsy renders the diagnosis certain4 ,it is to be especially remembered1 however1 that it is very unwise to bite through normal mucosa for the purpose of taking a specimen from a periesophageal growth4 ,fungations and polypoid protuberances afford safe opportunities for the removal of specimens of tissue4 ,the esophagoscopic appearances of malignant disease1 varying with the stage and site of origin of the growth1 may present as follows3-- #a4 ,submucosal infiltration covered by perfectly normal membrane1 usually associated with more or less bulging of the esophageal wall1 and very often with hardness and infiltration4 #b4 ,leucoplakia4 #c4 ,ulceration projecting but little above the surface at the edges4 #d4 ,rounded nodular masses grouped in mulberry-like form1 either dark or light red in color4 #e4 ,polypoid masses4 #f4 ,cauliflower fungations4 ,in considering the esophagoscopic appearances of cancer1 it is necessary to remember that after ulceration has set in1 the cancerous process may have engrafted upon it1 and upon its neighborhood1 the results of inflammation due to the mixed infections4 ,cancer invading the wall from without may for a long time be covered with perfectly normal mucous membrane4 ,the significant signs at this early stage are3 #a4 ,absence of one or more of the normal radial creases between the folds4 #b4 ,asymmetry of the inspiratory enlargement of lumen4 #c4 ,sensation of hardness of the wall on palpation with the tube4 #d4 ,the involved wall will not readily be made to wrinkle when pushed upon with the tube mouth4 ,in all the later forms of lesions the two characteristics are 7a7 the readiness with which oozing of blood occurs2 and 7b7 the sense of rigidity1 or fixation1 of the involved area as palpated with the esophagoscope1 in contrast to the normally supple esophageal wall4 ,esophageal dilatation above a malignant lesion is rarely great1 because the stenosis is seldom severely obstructive until late in the course of the disease4 ,treatment4--,the present #ajj per cent mortality in cancer of the esophagus will be lowered and a certain percentage of surgical cures will be obtained when patients with esophageal symptoms are given the benefit of early esophagoscopic study4 ,the relief or circumvention of the dysphagia requires early measures to prevent food and water starvation4 ,bouginage of a malignant esophagus to increase temporarily the size of the stenosed lumen is of questionable advisability1 and is attended with the great risk of perforating the weakened esophageal wall4 ,esophageal intubation may serve for a time to delay gastrostomy but it cannot supplant it1 nor obviate the necessity for its ultimate performance4 ,the ,charters-,symonds or ,guisez esophageal intubation tube is readily inserted after drawing the larynx forward with the laryngoscope4 ,the tube must be changed every week or two for cleaning1 and duplicate tubes must be ready for immediate reinsertion4 ,eventually1 a smaller1 and then a still smaller tube are needed1 until finally none can be introduced2 though in some cases the tube can be kept in the soft mass of fungations until the patient has died of hemorrhage1 exhaustion1 complications or intercurrent disease4 ,gastrostomy is always indicated as the disease progresses1 and it should be done before nutrition is greatly impaired4 ,surgeons often hesitate thus to operate on an inoperable case2 but it must be remembered that no one should be allowed to die of hunger and thirst4 ,the operation should be done before inanition has made serious inroads4 ,as in the case of tracheotomy1 we always preach doing it early1 and always do it late4 ,if postponed too long1 water starvation may proceed so far that the patient will not recover1 because the water-starved tissues will not take up water put in the stomach4 ,radiotherapy4--,radium and the therapeutic roentgenray are today our only effective means of retarding the progress of esophageal malignant neoplasms4 ,no permanent cures have been reported1 but marked temporary improvement in the swallowing function and prolongation of life have been repeatedly observed4 ,the combination of radium treatment applied within the esophageal lumen and the therapeutic roentgenray through the chest wall1 has retarded the progress of some cases4 ,the dosage of radium or the therapeutic ray must be determined by the radiologist for the particular individual case2 its method of application should be decided by consultation of the radiologist and the endoscopist4 ,two fundamental points are to be considered1 however4 ,the radium capsule1 if applied within the esophagus1 should be so screened that the soft1 irritating1 beta rays1 and the secondary rays1 are both filtered out to prevent sloughing of the esophageal mucosa4 ,the dose should be large enough to have a lethal effect upon the cancer cells at the periphery of the growth as well as in the center4 ,if the dose be insufficient1 development of the cells at the outside of the growth is stimulated rather than inhibited4 ,it is essential that the radium capsule be accurately placed in the center of the malignant strictured area and this can be done only by visual control through the esophagoscope 7,fig4 #ie7 ,drs4 ,henry ,k4 ,pancoast1 ,george ,e4 ,pfahler and ,william ,s4 ,newcomet have obtained very satisfactory palliative effects from the use of radium in esophageal cancer4 #bba ,,chapter ,,xxviii--,,direct ,,laryngoscopy ,,in ,,diseases ,,of ,,the ,,larynx ,the diagnosis of laryngeal disease in young children1 impossible with the mirror1 has been made easy and precise by the development of direct laryngoscopy4 ,no anesthetic1 local or general1 should be used1 for the practised endoscopist can complete the examination within a minute of time and without pain to the patient4 ,the technic for doing this should be acquired by every laryngologist4 ,anesthesia is absolutely contraindicated because of the possibility of the presence of diphtheria1 and especially because of the dyspnea so frequently present in laryngeal disease4 ,to attempt general anesthesia in a dyspneic case is to invite disaster 7see ,tracheotomy74 ,it is to be remembered that coughing and straining produce an engorgement of the laryngeal mucosa1 so that the first glance should include an estimation of the color of the mucosa1 which1 as a result of the engorgement1 deepens with the prolongation of the direct laryngoscopy4 ,chronic subglottic edema1 often the result of perichondritis1 may require linear cauterization at various times1 to reduce its bulk1 after the underlying cause has been removed4 ,perichondritis and abscess1 and their sequelae are to be treated on the accepted surgical precepts4 ,they may be due to trauma1 lues1 tuberculosis1 enteric fever1 pneumonia1 influenza1 etc4 ,tuberculosis of the larynx calls for conservatism in the application of surgery4 ,ulceration limited to the epiglottis may justify amputation of the projecting portion or excision of only the ulcerated area4 ,in either case1 rapid healing may be expected1 and relief from the odynphagia is sometimes prompt4 ,amputation of the epiglottis is1 however1 not to be done if ulceration in other portions of the larynx coexist4 ,the removal of tuberculomata is sometimes indicated1 and the excision of limited ulcerative lesions situated elsewhere than on the epiglottis may be curative4 ,these measures as well as the galvanocautery are easily executed by the facile operator2 but their advisability should always be considered from a conservative viewpoint4 ,they are rarely justifiable until after months of absolute silence and a general antituberculous regime have failed of benefit4 ,galvanopuncture for laryngeal tuberculosis has yielded excellent results in reducing the large pyriform edematous swellings of the aryepiglottic folds when ulceration has not yet developed4 ,deep punctures at nearly a white heat1 made perpendicular to the surface1 are best4 ,care must be exercised not to injure the cricoarytenoid joint4 ,fungating ulcerations may in some cases be made to cicatrize by superficial cauterization4 ,excessive reactions sometimes follow1 so that a light application should be made at the first treatment4 ,congenital laryngeal stridor is produced by an exaggeration of the infantile type of larynx4 ,the epiglottis will be found long and tapering1 its lateral margins rolled backward so as to meet and form a cylinder above4 ,the upper edges of the aryepiglottic folds are approximated1 leaving a narrow chink4 ,the lack of firmness in these folds and the loose tissue in the posterior portion of the larynx1 favors the drawing inward of the laryngeal aperture by the inspiratory blast4 ,the vibration of the margins of this aperture produces the inspiratory stridor4 ,diagnosis is quickly made by the inspection of the larynx with the infant diagnostic laryngoscope4 ,no anesthetic1 general or local1 is needed4 ,stridorous respiration may also be due to the presence of laryngeal papillomata1 laryngeal spasm1 thymic compression1 congenital web1 or an abnormal inspiratory bulging into the trachea of the posterior membranous tracheo-esophageal wall4 ,the term congenital laryngeal stridor should be limited to the first described condition of exaggerated infantile larynx4 ,treatment of congenital laryngeal stridor should be directed to the relief of dyspnea1 and to increasing the nutrition and development of the infant4 ,the insertion of a bronchoscope will temporarily relieve an urgent dyspneic attack precipitated by examination2 but this rarely happens if the examination is not unduly prolonged4 ,tracheotomy may be needed to prevent asphyxia or exhaustion from loss of sleep2 but very few cases require anything but attention to nutrition and hygiene4 ,recovery can be expected with development of the laryngeal structures4 ,congenital webs of the larynx require incision or excision1 or perhaps simply bouginage4 ,congenital goiter and congenital laryngeal paralysis1 both of which may cause stertorous breathing1 are considered in connection with other forms of stenosis of the air passages4 ,aphonia due to cicatricial webs of the larynx may be cured by plastic operations that reform the cords1 with a clean1 sharp anterior commissure1 which is a necessity for clear phonation4 ,the laryngeal scissors and the long slender punch are often more useful for these operations than the knife4 #bbd ,,chapter ,,xxix--,,bronchoscopy ,,in ,,diseases ,,of ,,the ,,trachea ,,and ,,bronchi ,the indications for bronchoscopy in disease are becoming increasingly numerous4 ,among the more important may be mentioned3 #a4 ,bronchiectasis4 #b4 ,chronic pulmonary abscess4 #c4 ,unexplained dyspnea4 #d4 ,dyspnea unrelieved by tracheotomy calls for bronchoscopic search for deeper obstruction4 #e4 ,paralysis of the recurrent laryngeal nerve1 the cause of which is not positively known4 #f4 ,obscure thoracic disease4 #g4 ,unexplained hemoptysis4 #h4 ,unexplained cough4 #i4 ,unexplained expectoration4 ,contraindications to bronchoscopy in disease do not exist if the bronchoscopy is really needed4 ,serious organic disease such as aneurysm1 hypertension1 advanced cardiac disease1 might render bronchoscopy inadvisable except for the removal of foreign bodies4 ,bronchoscopic ,appearances in ,disease4--,the first look should note the color of the bronchial mucosa1 due allowance being made for the pressure of tubal contact1 secretions1 and the engorgement incident to continued cough4 ,the carina trachealis normally moves slowly forward as well as downward during deep inspiration1 returning quickly during expiration4 ,impaired movement of the carina indicates peritracheal and peribronchial pathology1 the fixation being greatest in advanced cancer4 ,in children and in the smaller tubes of the adult1 the lengthening and dilatation of the bronchi during inspiration1 and their shortening and contraction during expiration are readily seen4 ,anomalies of the ,tracheobronchial ,tree4--,tracheobronchial anomalies are relatively rare4 ,congenital esophagotracheal and esophagobronchial fistulae are occasionally seen1 and cases of cervicotracheal fistulae have been reported4 ,congenital webs and diverticula of the trachea are cited infrequently4 ,laryngoptosis and deviation of the trachea may be congenital4 ,substernal goitre1 aneurysm1 malignant growths1 and various mediastinal adenopathies may displace the trachea from its normal course4 ,the emphysematous chest fixed in the deep voluntary inspiratory position produces in some cases an elevation of the superior thoracic aperture simulating laryngoptosis 7,bibliography r1 pp4 #dfh1 #eid74 ,compression ,stenosis of the ,trachea and ,bronchi4--,compression of the trachea is most commonly caused by goiter1 substernal or cervical1 aneurysm1 malignancy1 or1 in children1 by enlarged thymus4 ,less frequently1 enlarged mediastinal tuberculous1 leukemic1 leutic or ,hodgkin's glands compress the airway4 ,the left bronchus may be stenosed by pressure from a hypertrophied cardiac auricle4 ,compression stenosis of the trachea associated with pulmonary emphysema accounts for the dyspnea during attacks of coughing4 ,the endoscopic picture of compression stenosis is that of an elliptical or scabbard-shaped lumen when the bronchus is at rest or during inspiration4 ,concentric funnel-like compression stenosis1 while rare1 may be produced by annular growths4 ,treatment of ,compression ,stenoses of the ,trachea4--,if the thymus be at fault1 rapid amelioration of symptoms follows roentgenray or radium therapy4 ,tracheotomy and the insertion of the long cane-shaped cannula 7,fig4 #ajd7 past the compressed area is required in the cases caused by conditions less amenable to treatment than thymic enlargement4 ,permanent cure depends upon the removability of the compressive mass4 ,should the bronchi be so compressed by a benign condition as to prevent escape of secretions from the subjacent air passages1 bronchial intubation tubes may be inserted1 and1 if necessary1 worn constantly4 ,they should be removed weekly for cleansing and oftener if obstructed4 ,influenzal ,laryngotracheobronchitis4--,influenzal infection1 not always by the same organism1 sweeps over the population1 attacking the air passages in a violent and quite characteristic way4 ,bronchoscopy shows the influenzal infection to be characterized by intense reddening and swelling of the mucosa4 ,in some cases the swelling is so great as to necessitate tracheotomy1 or intubation of the larynx2 and if the edema involve the bronchi1 occlusion may be fatal4 ,hemorrhagic spots and superficial erosions are commonly seen1 and a thick1 tenacious exudate1 difficult of expectoration1 lies in patches in the trachea4 ,infants may asphyxiate from accumulation of this secretion which they are unable to expel4 ,the differential diagnosis from diphtheria is sometimes difficult4 ,the absence of true membrane and the failure to find diphtheria bacilli in smears taken from the trachea are of aid but are not infallible4 ,in doubtful cases1 the administration of diphtheria antitoxin is a wise precaution pending the establishment of a definite diagnosis4 ,the pseudomembrane sometimes present in influenzal tracheobronchitis is thinner and less pulpy than that of the earlier stages of diphtheria4 ,the casts of the later stages do not occur in influenzal tracheobronchitis 7,bibliography ,i1 p4 #dhj74 ,edematous ,tracheobronchitis4--,this is chiefly observed in children4 ,the most frequently encountered form is the epidemic disease to which the name ,influenza has been given 7q4v4 supra74 ,the only noticeable difference between the epidemic and the sporadic cases is in the more general susceptibility to the infective agent1 which gives the influenzal form an appearance of being more virulently infective4 ,possibly the sporadic form is simply the attack of children not immunized by a previous attack during an epidemic4 ,there is another form of edematous tracheobronchitis often of great severity and grave prognosis1 that results from the aspiration of irritating liquids or vapors1 or of certain organic substances such as peanut kernels1 watermelon seeds1 etcetera4 ,tracheotomy should be done if marked dyspnea be present4 ,secretions can then be easily removed and medication in the form of oily solutions be instilled at will into the trachea4 ,in the ,bronchoscopic ,clinic many children have been kept alive for days1 and their lives finally saved by aspiration of thick1 tough1 sometimes clotted and crusted secretions1 with the aspirating tube 7,fig4 #aj74 ,it is better in these cases not to pass the bronchoscope repeatedly4 ,if1 however1 evidences of obstruction remain1 after aspiration1 it is necessary to see the nature of the obstruction and relieve it by removal1 dilatation1 or bronchial intubation as the case may require4 ,it is all a matter of plumbing i4e41 clearing out the pipes1 and maintaining a patulous airway4 ,tracheobronchial ,diphtheria4--,urgent dyspnea in diphtheria when no membrane and but slight lessening of the laryngeal airway is seen1 calls for bronchoscopy4 ,many lives have been saved by the bronchoscopic removal of membrane obstructing the trachea or bronchi4 ,in the early stages1 pulpy masses looking like mother of vinegar are very obstructive4 ,later casts of membrane may simulate foreign bodies4 ,the local application of diphtheria antitoxin to the trachea and bronchi has also been recommended4 ,a preparation free from a chemical irritant should be selected4 ,abscess of the ,lung4--,if of foreign-body origin1 pulmonary abscess almost invariably heals after the removal of the object and a regime of fresh air and rest1 without local measures of any kind4 ,acute pulmonary abscess from other causes may require bronchoscopic drainage and gentle dilatation of the swollen and narrowed bronchi leading to it4 ,some of these bronchi are practically fistulae4 ,obstructive granulations should be removed with crushing1 not biting forceps4 ,the regular foreign-body forceps are best for this purpose4 ,caution should be used as to removal of the granulations with which the abscess cavity is filled in chronic cases4 ,the term abscess is usually loosely applied to the condition of drowned lung in which the pus has accumulated in natural passages1 and in which there is neither a new wall nor a breaking down of normal walls4 ,chronic lung-abscess is often successfully treated by weekly bronchoscopic lavage with #bj cc4 or more of a warm1 normal salt solution1 a #a3ajjj watery potassium permanganate solution1 or a weak iodine solution as in the following formula3 ,rx4 ,monochlorphenol 7,merck7 4#ab ,lugol's solution #h4jj ,normal salt solution #ejj4 ,perhaps the best procedure is to precede medicinal applications by the clearing out of the purulent secretions by aspiration with the aspirating bronchoscope and the independent aspirating tube1 the latter being inserted into passages too small to enter with the bronchoscope1 and the endobronchial instillation of from #aj to #cj cc4 of the medicament4 ,the following have been used3 ,argyrol1 #a per cent watery solution2 ,silvol1 #a per cent watery solution2 ,iodoform1 oil emulsion #aj per cent2 ,guaiacol1 #aj per cent solution in paraffine oil2 ,gomenol1 #bj per cent solution in oil2 or a bismuth subnitrate suspension in oil4 ,robert ,m4 ,lukens and ,william ,f4 ,moore of the ,bronchoscopic ,clinic report excellent results in post-tonsillectomy abscesses from one tenth of one per cent phenol in normal salt solution with the addition of #b per cent ,lugol's solution4 ,chlorinated solutions are irritating1 and if used1 require copious dilution4 ,liquid petrolatum with a little oil of eucalyptus has been most often the medium4 ,gangrene of the ,lung4--,pulmonary gangrene has been followed by recovery after the endobronchial injection of oily solutions of gomenol and guaiacol 7,guisez74 ,the injections are readily made through the laryngoscope without the insertion of a bronchoscope4 ,a silk woven catheter may be used with an ordinary glass syringe or a long-nozzled laryngeal syringe1 or a bronchoscopic syringe may be used4 ,lung-mapping by a roentgenogram taken promptly after the bronchoscopic insufflation of bismuth subnitrate powder or the injection of a suspension of bismuth in liquid petrolatum is advisable in most cases of pulmonary abscess before beginning any kind of treatment4 ,bronchial ,stenosis4--,stenosis of one or more bronchi results at times from cicatricial contraction following secondary infection of leutic1 tuberculous or traumatic lesions4 ,the narrowing resulting from foreign body traumatism rarely requires secondary dilatation after the foreign body has been removed4 ,tuberculous bronchial stenoses rarely require local treatment1 but are easily dilated when necessary4 ,luetic cicatricial stenosis may require repeated dilatation1 or even bronchial intubation4 ,endobronchial neoplasms may cause a subjacent bronchiectasis1 and superjacent stenosis2 the latter may require dilatation4 ,cicatricial stenoses of the bronchi are readily recognizable by the scarred wall and the absence of rings at or near the narrowing4 ,bronchiectasis4--,in most cases of bronchiectasis there are strong indications for a bronchoscopic diagnosis1 to eliminate such conditions as foreign body1 cicatricial bronchial stenosis1 or endobronchial neoplasm as etiologic factors4 ,in the idiopathic types considerable benefit has resulted from the endobronchial lavage and endobronchial oily injections mentioned under lung abscess4 ,it is probable that if bronchoscopic study were carried out in every case1 definite causes for many so-called idiopathic cases would be discovered4 ,lung-mapping as elsewhere herein explained is invaluable in the study of bronchiectasis4 ,bronchial asthma affords a large field for bronchoscopic study4 ,as yet1 sufficient data to afford any definite conclusions even as to the endoscopic picture of this disease have not been accumulated4 ,of the cases seen in the ,bronchoscopic ,clinic some showed no abnormality of the bronchi in the intervals between attacks1 others a chronic bronchitis4 ,in cases studied bronchoscopically during an attack1 the bronchi were found filled with bubbling secretions and the mucosa was somewhat cyanotic in color4 ,the bronchial lumen was narrowed only as much as it would be1 with the same degree of cough1 in any patient not subject to asthma4 ,the secretions were removed and the attack quickly subsided2 but no influence on the recurrence of attacks was observed4 ,it is essential that the bronchoscopic studies be made1 as were these1 without anesthesia1 local or general1 for it is known that the application of cocain or adrenalin to the larynx1 or even in the nose1 will1 with some patients1 stop the attack4 ,when done without local anesthesia1 allowance must be made for the reaction to the presence of the tube4 ,in those cases in which other means have failed to give relief1 the endobronchial application of novocain and adrenalin1 orthoform1 propaesin or anesthesin emulsion may be tried4 ,cures have been reported by this treatment4 ,argentic nitrate applied at weekly intervals has proven very efficient in some cases4 ,associated infective disease of the bronchial mucosa brings with it the questions of immunity1 allergy1 anaphylaxis1 and vaccine therapy2 and the often present defective metabolism has to be considered4 ,autodrownage4--,autodrownage is the name given by the author to the drowning of the patient in his own secretions4 ,tracheobronchial secretions in excess of the amount required to moisten the inspired air1 become1 in certain cases1 a mechanical menace to life1 unless removed4 ,the cough reflex1 forced expiration1 and ciliary action1 normally remove the excess4 ,when these mechanisms are impaired1 as in profound asthenia1 laryngeal paralysis1 laryngeal or tracheal stenosis1 etc42 and especially when in addition to a mild degree of glottic stenosis or impaired laryngeal mobility1 the secretions become excessive1 the accumulation may literally drown the patient in his own secretions4 ,this is illustrated frequently in influenza and arachidic bronchitis4 ,infants cannot expectorate1 and their cough reflex is exceedingly ineffective in raising secretion to the pharynx2 furthermore they are easily exhausted by bechic efforts2 so that age may be cited as one of the most frequent etiologic factors in the condition of autodrownage4 ,bronchoscopic sponge-pumping 7q4v47 and bronchoscopic aspiration are quite efficient and can save any patient not afflicted with conditions that are fatal by other pathologic processes4 ,lues of the ,tracheobronchial ,tree4--,compared to laryngeal involvement1 syphilis of the tracheobronchial tree is relatively rare4 ,the lesions may be gummatous1 ulcerative1 or inflammatory1 or there may be compressive granulomatous masses4 ,hemoptysis may have its origin from a luetic ulceration4 ,excision of fungations or of a portion of the margin of the ulceration for biopsy is advisable4 ,the ,wassermann and therapeutic tests1 and the elimination of tuberculosis will be required for confirmation4 ,luetic stenoses are referred to above4 ,tuberculosis of the ,tracheobronchial ,tree4--,the bronchoscopic study of tuberculosis is very interesting1 but only a few cases justify bronchoscopy4 ,the subglottic infiltrations from extensions of laryngeal disease are usually of edematous appearance1 though they are much more firm than in ordinary inflammatory edema4 ,ulcerations in this region are rare1 except as direct extensions of ulceration above the cord4 ,the trachea is relatively rarely involved in tuberculosis1 but we may have in the trachea the pale swelling of the early stage of a perichondritis1 or the later ulceration and all the phenomena following the mixed pyogenic infections4 ,these same conditions may exist in the bronchi4 ,in a number of instances1 the entire lumen of the bronchus was occluded by cheesy pus and debris of a peribronchial gland which had eroded through4 ,as a rule1 the mucosa of tuberculosis is pale1 and the pallor is accentuated by the rather bluish streak of vessels1 where these are visible4 ,erosion through of peri-bronchial or peri-tracheal lymph masses may be associated with granulation tissue1 usually of pale color1 but occasionally reddish2 and sometimes oozing of blood is noticed4 ,a most common picture in tuberculosis is a broadening of the carina1 which may be so marked as to obliterate the carina and to bulge inward1 producing deformed lumina in both bronchi4 ,sometimes the lumina are crescentic1 the concavity of the crescent being internal1 that is1 toward the median line4 ,absence of the normal anterior and downward movement of the carina on deep inspiration is almost pathognomonic of a mass at the bifurcation1 and such a mass is usually tuberculous1 though it may be malignant1 and1 very rarely1 luetic4 ,the only lesion visible in a tuberculous case may be cicatrices from healed processes4 ,in a number of cases there has been a discharge of pus coming from the upper-lobe bronchus4 ,fig4 #if4--,the author's tampons for pulmonary hemostasis by bronchoscopic tamponade4 ,the folded gauze is #aj cm4 long2 the braided silk cord #fj cm4 long4 ,hemoptysis4--,in cases not demonstrably tuberculous1 hemoptysis may require bronchoscopic examination to determine the origin4 ,varices or unsuspected luetic1 malignant1 or tuberculous lesions may be found to be the cause4 ,it is mechanically easy to pack off one bronchus with the author's packs 7,fig4 #if7 introduced through the bronchoscope1 but the advisability of doing so requires further clinical tests4 ,angioneurotic ,edema4--,angioneurotic edema manifests itself by a pale or red swollen mucosa producing stenosis of the lumen4 ,the temporary character of the lesion and its appearance in other regions confirm the diagnosis4 ,scleroma of the trachea is characterized by infiltration of the tracheal mucosa1 which greatly narrows the lumen4 ,the infiltration may be limited in area and produce a single stricture1 or it may involve the entire trachea and even close a bronchial orifice4 ,drying and crusting of secretions renders the stenosis still more distressing4 ,this disease is but rarely encountered in ,america but is not infrequent in some parts of ,europe4 ,treatment consists in the prevention of crusts and their removal4 ,limited stenotic areas may yield to bronchoscopic bouginage4 ,urgent dyspnea calls for tracheotomy4 ,radium and roentgenray therapy have been advised1 and cure has been reported by intravenous salvarsan treatment 7see article by ,s4 ,shelton ,watkins1 on ,scleroma in ,surg4 ,gynecol4 and ,obst41 ,july1 #aiba1 p4 #dg74 ,atrophic tracheitis1 with symptoms quite similar to atrophic rhinitis is a not unusual accompaniment of the nasal condition4 ,it may also exist without nasal involvement4 ,on tracheoscopy the mucosa is thinned1 pale and dry1 and is covered with patches of thick mucilaginous secretion and crusts4 ,decomposition of secretion produces tracheal ozena1 while the accumulated crusts give rise to the sensation of a foreign body and may seriously interfere with respiration1 making bronchoscopic removal imperative4 ,the associated development of tracheal nodular enchondromata has been described4 ,the internal administration of iodine and the intratracheal injection of bland oily solutions of menthol1 guaiacol1 or gomenol are helpful4 #bce ,,chapter ,,xxx--,,diseases ,,of ,,the ,,esophagus ,the more frequent causes of the one common symptom of esophageal disease1 dysphagia1 are included in the list given below4 ,to avoid elaboration and to obtain maximum usefulness as a reminder1 overlapping has not been eliminated4 #a4 ,anomalies4 #b4 ,esophagitis1 acute4 #c4 ,esophagitis1 chronic4 #d4 ,erosion4 #e4 ,ulceration4 #f4 ,trauma4 #g4 ,stricture1 congenital4 #h4 ,stricture1 spasmodic1 including cramp of the diaphragmatic pinchcock4 #i4 ,stricture1 inflammatory4 #aj4 ,stricture1 cicatricial4 #aa4 ,dilatation1 local4 #ab4 ,dilatation1 diffuse4 #ac4 ,diverticulum4 #ad4 ,compression stenosis4 #ae4 ,mediastinal tumor4 #af4 ,mediastinal abscess4 #ag4 ,mediastinal glandular mass4 #ah4 ,aneurysm4 #ai4 ,malignant neoplasm4 #bj4 ,benign neoplasm4 #ba4 ,tuberculosis4 #bb4 ,lues4 #bc4 ,actinomycosis4 #bd4 ,varix4 #be4 ,angioneurotic edema4 #bf4 ,hysteria4 #bg4 ,functional antiperistalsis4 #bh4 ,paralysis4 #bi4 ,foreign body in 7a7 pharynx1 7b7 larynx1 7c7 trachea1 7d7 esophagus4 #bcf ,diagnosis4--,the swallowing function can be studied only with the fluoroscope2 esophagoscopy for diagnosis1 should therefore always be preceded by a fluoroscopic study of deglutition with a barium or other opaque mixture and examination of the thoracic organs to eliminate external pressure on the esophagus as the cause of stenosis4 ,complete physical examination and ,wassermann reaction are further routine preliminaries to any esophagoscopy4 ,special laboratory tests are done as may be indicated4 ,the physical examination is meant to include a careful examination of the lips1 tongue1 palate1 pharynx1 and a mirror examination of the larynx when age permits4 ,indications for ,esophagoscopy in ,disease4--,any persistent abnormal sensation or disturbance of function of the esophagus calls for esophagoscopy4 ,vague stomach symptoms may prove to be esophageal in origin1 for vomiting is often a complaint when the patient really regurgitates4 ,contraindications to ,esophagoscopy4--,in the presence of aneurysm1 advanced organic disease1 extensive esophageal varicosities1 acute necrotic or corrosive esophagitis1 esophagoscopy should not be done except for urgent reasons1 such as the lodgment of a foreign body2 and in this case the esophagoscopy may be postponed1 if necessary1 unless the patient is unable to swallow fluids4 ,esophagoscopy should be deferred1 in cases of acute esophagitis from swallowing of caustics1 until sloughing has ceased and healing has strengthened the weak places4 ,the extremes of age are not contraindications to esophagoscopy4 ,a number of newborn infants have been esophagoscoped by the author2 and he has removed foreign bodies from patients over #hj years of age4 ,water starvation makes the patient a very bad surgical subject1 and is a distinct contraindication to esophagoscopy4 ,water must be supplied by means of proctoclysis and hypodermoclysis before any endoscopic or surgical procedure is attempted4 ,if the esophageal stenosis is not readily and quickly remediable1 gastrostomy should be done immediately4 ,rectal feeding will supply water for a limited time1 but for nutrient purposes rectal alimentation is dangerously inefficient4 ,preliminary examination of the pharynx and larynx with tongue depressor should always precede esophagoscopy1 for any purpose1 because the symptoms may be due to laryngeal or pharyngeal disease that might be overlooked in passing the esophagoscope4 ,a high degree of esophageal stenosis results in retention in the suprajacent esophagus of the fluids which normally are continually flowing downward4 ,the pyriform sinuses in these cases are seen with the laryngeal mirror to be filled with frothy secretion 7,jackson's sign of esophageal stenosis7 and this secretion may sometimes be seen trickling into the larynx4 ,this overflow into the larynx and lower air passages is often the cause of pulmonary symptoms1 which are thus strictly secondary to the esophageal disease4 ,,anomalies ,,of ,,the ,,esophagus ,congenital esophagotracheal fistulae are the most frequent of the embryonic developmental errors of this organ4 ,septic pneumonia from the entrance of fluids into the lungs usually causes death within a few weeks4 ,imperforate esophagus usually shows an upper esophageal segment ending in a blind pouch4 ,a lower segment is usually present and may be connected with the upper segment by a fistula4 ,congenital stricture of the esophagus may be single or multiple1 and may be thin and weblike1 or it may extend over a third or more of the length of the esophagus4 ,it may not become manifest until solids are added to the child's diet2 often not for many months4 ,the lodgment of an unusually large bolus of unmasticated food may set up an esophagitis the swelling of which may completely close the lumen of the congenitally narrow esophagus4 ,it is not uncommon to meet with cases of adults who have never swallowed as well as other people1 and in whom cicatricial and spasmodic stenosis can be excluded by esophagoscopy1 which demonstrates an obvious narrowing of the esophageal lumen4 ,these cases are doubtless congenital4 ,webs in the upper third of the esophagus are best determined by the passage of a large esophagoscope which puts the esophagus on the stretch4 ,the webs may be broken by the insertion of a closed alligator forceps1 which is then withdrawn with opened blades4 ,better still is the dilator shown in ,fig4 #bf4 ,this retrograde dilatation is relatively safe4 ,a silk-woven esophagoscopic bougie or the metallic tracheal bougie may be used1 with proper caution4 ,subsequent dilatation for a few times will be required to prevent a reproduction of the stenosis4 ,treatment of ,esophageal ,anomalies4--,gastrostomy is required in the imperforate cases4 ,esophagoscopic bouginage is very successful in the cure of all cases of congenital stenosis4 ,any sort of lumen can be enlarged so any well masticated food can be swallowed4 ,careful esophagoscopic work with the bougies 7,fig4 #dj7 will ultimately cure with little or no risk of mortality4 ,any form of rapid dilatation is dangerous4 ,congenital stenosis1 if not an absolute atresia1 yields more readily to esophagoscopic bouginage than cicatricial stenosis4 ,,rupture ,,and ,,trauma ,,of ,,the ,,esophagus ,these may be spontaneous or may ensue from the passage of an instrument1 or foreign body1 or of both combined1 as exemplified in the blind attempts to remove a foreign body or to push it downwards4 ,digestion of the esophagus and perforation may result from the stagnation of regurgitated gastric juice therein4 ,this condition sometimes occurs in profound toxic and debilitated states4 ,rupture of the thoracic esophagus produces profound shock1 fever1 mediastinal emphysema1 and rapid sinking4 ,pneumothorax and empyema follow perforation into the pleural cavity4 ,rupture of the cervical esophagus is usually followed by cervical emphysema and cervical abscess1 both of which often burrow into the mediastinum along the fascial layers of the neck4 ,lesser degrees of trauma produce esophagitis usually accompanied by fever and painful and difficult swallowing4 ,the treatment of traumatic esophagitis consists in rest in bed1 sterile liquid food1 and the administration of bismuth subnitrate 7about one gramme in an adult71 dry on the tongue every #d hours4 ,rupture of the esophagus requires immediate gastrostomy to put the esophagus at rest and supply necessary alimentation4 ,thoracotomy for drainage is required when the pleural cavity has been involved1 not only for pleural secretions1 but for the constant and copious esophageal leakage4 ,it is not ordinarily realized how much normal salivary drainage passes down the esophagus4 ,the customary treatment of shock is to be applied4 ,no attempt should be made to remove a foreign body until the traumatic lesions have healed4 ,this may require a number of weeks4 ,decision as to when to remove the intruder is determined by esophagoscopic inspection4 ,subcutaneous emphysema does not require puncture unless gaseous1 or unless pus forms4 ,in the latter event free external drainage becomes imperative4 ,,acute ,,esophagitis ,this is usually of traumatic or cauterant origin4 ,if severe or extensive1 all the symptoms described under ,rupture of the ,esophagus may be present4 ,the endoscopic appearances are unmistakable to anyone familiar with the appearance of mucosal inflammations4 ,the pale1 bluish pink color of the normal mucosa is replaced by a deep-red velvety swollen appearance in which individual vessels are invisible4 ,after exudation of serum into the tissues1 the color may be paler and in some instances a typical edema may be seen4 ,this may diminish the lumen temporarily4 ,folds of swollen mucosa crowd into the lumen if the inflammation is intense4 ,these folds are sometimes demonstrable in the roentgenogram by the bismuth or barium in the creases between which the prominence of the folds show as islands as beautifully demonstrated by ,david ,r4 ,bowen in one of the author's cases4 ,if the inflammation is due to corrosives1 a grayish exudate may be visible early1 sloughs later4 ,,ulceration ,,of ,,the ,,esophagus ,superficial erosions of the esophagus are by no means an uncommon accompaniment of the stagnation of food and secretions4 ,from the irritation they produce1 spastic stenosis may occur1 thus constituting a vicious circle2 the spasm of the esophagus increases the stagnation which in turn results in further inflammation and ultimate ulceration4 ,healing of such ulcers may result in cicatricial contraction and organic stenosis4 ,ulceration may follow trauma by instrument1 foreign body1 or corrosive4 ,,differential ,,diagnosis ,,of ,,ulcer ,,of ,,the ,,esophagus ,simple ulcer requires the exclusion of lues1 tuberculosis1 epithelioma1 endothelioma1 sarcoma1 and actinomycosis4 ,simple ulcer of the esophagus is usually associated with stenosis1 spastic or organic4 ,luetic ulcers commonly show a surrounding inflammatory areola1 and they usually have thickened elevated edges1 generally free from granulation tissue1 with a pasty center not bleeding readily when sponged4 ,the ,wassermann reaction may contribute to the diagnosis2 but if negative1 a thorough and prolonged test with mercury is imperative4 ,it must be remembered that a person with lues may have a simple1 mixed1 or malignant ulceration of the esophagus1 or the three lesions may even be combined4 ,it may be in some cases possible to demonstrate the treponema pallidum in scrapings taken from the ulcer4 ,the single tuberculous ulcer is usually pale1 superficial1 and granular in base4 ,if it is a continuation from more extensive extra-esophageal tuberculous ulceration1 pale cauliflower granulations may be present4 ,slight cicatrices may be seen4 ,tuberculosis in other organs can almost always be demonstrated by roentgenographic1 physical1 or laboratory studies4 ,tuberculin tests and animal injection with an emulsion of a specimen of tissue may be required4 ,the specimen must be taken very superficially to avoid risk of perforation4 ,sarcomatous ulcers do not differ materially in appearance from those of carcinoma1 but they are much more rare4 ,carcinomatous ulcer is usually characterized by the very vascular bright red zone1 raised edges1 fungations1 granulation tissue that bleeds freely on the lightest touch1 and above all1 it is almost invariably situated on an infiltrated base which communicates a feeling of hardness to the pressure of sponges or the esophagoscope itself4 ,a scar may be from the healing of an ulcer from stasis1 or one of specific or precancerous character4 ,it may be a cancerous process developing on the site of a scar1 so that the presence of scar tissue does not absolutely negative malignancy4 ,as a rule1 however1 scars are absent in cancer of the esophagus4 ,the firm and sometimes prominent ridge of the crossing of the left bronchus must not be mistaken for infiltration1 and the esophagoscopist must be familiar with the normal rigidity of the cricopharyngeus4 #bdb ,mixed infection gives to all esophageal ulceration a certain uniformity of appearance1 so that laboratory studies of smears or histologic and bacteriologic study of tissue specimens taken from fungations or thickened edges are often required to confirm the endoscopic diagnosis4 ,if the edges are thin and flat1 the taking of a specimen involves some risk2 fungations can be removed without risk2 so can nodules1 but care must be taken that projecting folds are not mistaken for nodules4 ,it is always wise to push the therapeutic test with potassium iodid and especially mercury in any case of esophageal ulceration unassociated with stasis4 ,treatment of ,acute and ,subacute ,inflammation and ,ulceration of the ,esophagus4--,bismuth subnitrate in doses of about one gramme1 given dry on the tongue and swallowed without water1 has a local antiseptic and protective action4 ,its antiseptic power may be enhanced by the addition of calomel to the powder1 in such amount as may be tolerated by the bowels4 ,if pain be present the combination of a grain or two of anesthesin or orthoform with the bismuth will be grateful4 ,the local application of argyrol in #be per cent watery solution is also of great value4 ,the mouth and teeth are to be kept clean with a mouth wash of ,dakin's solution1 #a part1 to peppermint water1 #f parts4 ,the esophagus must be placed at rest as far as possible by liquid diet or1 if need be1 by gastrostomy4 ,,chronic ,,esophagitis ,this is usually a result of stagnation of food or secretion1 and will be considered under spasmodic stenosis and diffuse dilatation of the esophagus4 ,a very marked case with local distress and pain extending through to the back was seen by the author in consultation with ,dr4 ,john ,b4 ,wright who had made the diagnosis4 ,the patient was a sufferer from ankylostomiasis4 #bdc ,,compression ,,stenosis ,,of ,,the ,,esophagus ,the esophagus may be narrowed by the pressure of any periesophageal disease or anomaly4 ,the lesions most frequently found are3 #a4 ,goiter1 cervical or thoracic4 #b4 ,malignancy of any of the intrathoracic viscera4 #c4 ,aneurysm4 #d4 ,cardiac and aortic enlargement4 #e4 ,lymphadenopathies4 ,hodgkins' disease4 ,leukemia4 ,lues4 ,tuberculosis4 ,simple infective adenitis4 #f4 ,lordosis4 #g4 ,enlargement of the left hepatic lobe4 ,endoscopically1 compression stenosis of the esophagus is manifested by a slit-like crevice which occupies the place of the lumen and which does not open up readily before the advancing tube4 ,the long axis of the slit is almost always at right angles to the compressive mass1 if the esophageal wall be uninvolved4 ,the covering mucosa may be normal or it may show signs of chronic inflammation4 ,malignant compressions are characterized by their hardness when palpated with the tube4 ,associated pressure on the recurrent laryngeal nerve often makes laryngeal paralysis coexistent4 ,the nature of the compressive mass will require for its determination the aid of the roentgenologist1 internist1 and clinical laboratory4 ,compression by the enlarged left auricle has been observed a number of times4 ,the presence of aneurysm is a distinct contraindication to esophagoscopy for diagnosis except in case of suspected foreign body4 ,treatment of compressive stenosis of the esophagus depends upon the nature of the compressive lesion and is without the realm of endoscopy4 ,in uncertain cases potassium iodid1 and especially mercury1 should always be given a thorough and prolonged trial2 an occasional cure will result4 ,esophageal intubation is indicated in all conditions except aneurysm4 ,gastrostomy should be done early when necessary4 ,,diffuse ,,dilatation ,,of ,,the ,,esophagus ,this is practically always due to stagnation ectasia1 which is invariably associated with either organic or spasmodic stricture1 existing at the time of observation or at some time prior thereto4 ,the dilating effect of the repeatedly accumulated food results in a permanent enlargement1 so that the esophagus acts as the reservoir of a large funnel with a very small opening4 ,when food is swallowed the esophagus fills1 and the contents trickle slowly through the opening4 ,gases due to fermentation increase the distension and cause substernal pressure1 discomfort1 and belching4 ,a very large dilatation of the thoracic esophagus indicates spastic stenosis4 ,cicatricial stenoses do not result in such large dilatations and the dilatation above a malignant stenosis is usually slight1 probably because of its relatively shorter duration4 ,the treatment of diffuse esophageal dilatation consists in dilating the diaphragmatic pinchcock that is1 the hiatal esophagus4 ,chronic esophagitis is to be controlled by esophageal lavage1 the regulation of the diet to liquefiable foods and the administration of bismuth subnitrate4 ,the patient can be taught to do the lavage4 ,the local esophagoscopic application of a small quantity of a #be per cent watery solution of argyrol may be required for the static esophagitis4 ,the redundancy probably never disappears2 but functional and subjective cures are usually obtainable4 #bde ,,chapter ,,xxxi--,,diseases ,,of ,,the ,,esophagus 7,continued7 ,,spasmodic ,,stenosis ,,of ,,the ,,esophagus ,etiology4--,the functional activity of the esophagus is dependent upon reflex action4 ,the food is propulsed in a peristaltic wave by the same mechanism as1 and through an innervation 7,auerbach and ,meissner plexus7 similar to that which controls intestinal movements4 ,the vagus also is directly concerned with the deglutitory act1 for swallowing is impossible if both vagi are cut4 ,anything which unduly disturbs this reflex arc may serve as an exciting cause of spasmodic stenosis4 ,bolting of food1 superficial erosions1 local esophageal disease1 or a small foreign body1 may produce spasmodic stenosis4 ,spasm secondary to disease of the stomach1 liver1 gall bladder1 appendix1 or other abdominal organ is clinically well recognized4 ,a perpetuating cause in established cases is undoubtedly nerve cell habit1 and in many cases there is an underlying neurotic factor4 ,shock as an exciting cause has been well exemplified by the number of cases of phrenospasm developing in soldiers during the ,world ,war4 ,cricopharyngeal spasmodic stenosis usually presents the subjective symptom of difficulty in starting the bolus of food downward4 ,once started1 the food passes into the stomach unimpeded4 ,regurgitation1 if it occurs1 is immediate4 ,the condition consists in a tonic contraction1 ahead of the bolus1 of the circular fibers of the inferior constrictor known as the cricopharyngeus muscle1 or in a failure of this muscle to relax so as to allow the bolus to pass4 ,in either case the disorder may be secondary to an organic lesion4 ,local malignant disease or foreign bodies may be the cause4 ,globus hystericus1 lump in the throat1 and the sense of constriction and choking during emotion are due to the same spasmodic condition4 ,diagnosis4--,at esophagoscopy there will be found marked exaggeration of the usual spasm which occurs at the cricopharyngeus during the introduction of the tube4 ,the lumen may assume various shapes1 or be so tightly closed that the folds form a mammilliform projection in the center4 ,if the spasm gradually yields1 and a full-sized esophagoscope passes without further resistance1 it may be stated that the esophagus is of normal calibre1 and a diagnosis of spasmodic stenosis can be made4 ,considerable experience is required to distinguish between normal and pathologic spasm in an unanesthetized individual4 ,to the less experienced esophagoscopist1 examination under ether anesthesia is recommended4 ,deep anesthesia will relax the normal cricopharyngeal reflex closure as well as any abnormal spasm1 thus assisting in the differentiation between an organic stricture and one of functional character4 ,under deep general anesthesia1 however1 it is impossible to differentiate between the normal reflex and a spasmodic condition1 since both are abolished4 ,many cases of intermittent esophageal stenosis supposed to be spasmodic are due to organic narrowness of lumen plus lodgement of food1 obstructive in itself and in the esophagitis resulting from its presence4 ,the organic narrowing1 congenital or pathologic1 is readily recognizable esophagoscopically4 ,treatment4--,the fundamental cause of the disturbance of the reflex should be searched for1 and treated according to its nature4 ,purely functional cases are often cured by the passage of a large esophagoscope4 ,recurrences may require similar treatment4 #bdg ,,functional ,,hiatal ,,stenosis4 ,,hiatal ,,esophagismus4 ,,phrenospasm1 ,,diaphragmatic ,,pinchcock ,,stenosis4 7,,so-,,called ,,cardiospasm7 ,there is no sphincteric muscular arrangement at the cardiac orifice of the esophagus1 so that spasmodic stenosis at this level is not possible and the term cardiospasm is1 therefore1 a misnomer4 ,it was first demonstrated by the author that in so-called cardiospasm the functional closure of the esophagus occurred at the diaphragmatic level1 and that it was due to the diaphragmatic pinchcock4 ,anatomical studies have corroborated this finding by demonstrating a definite sphincteric mechanism consisting of muscle bands springing from the crura of the diaphragm and surrounding the esophagus at the under surface of the hiatus4 ,an inspection of the cadaveric diaphragm from below will demonstrate an arrangement like double shears admirably adapted to this pinchcock action4 ,further confirmation is the fact that all dilatation of the esophagus incident to spasm at its lower extremity is situated above the diaphragm4 ,in passing it may be stated that the pinchcock action1 plus the kinking of the esophagus normally prevents regurgitation when a man with a full stomach stands on his head or inverts his body4 ,for the upward escape of food from the stomach an involuntary co-ordinated antiperistaltic cycle is necessary4 ,the dilatation resulting from phrenospasm may reach great size 7,fig4 #if;a71 and the capacity of the sac may be as much as two liters4 ,while the esophagus is usually dilated1 the stomach on the other hand is often contracted1 largely from lack of distention by food1 but possibly also because of a spastic state due to the same causes as the phrenospasm4 ,recently ,mosher has demonstrated that hepatic abnormality may furnish an organic cause in many cases formerly considered spasmodic4 ,the symptoms of hiatal esophagismus are variable in degree4 ,substernal distress1 with a feeling of fullness and pressure followed by eructations of gas and regurgitation of food within a period of a quarter of an hour to several hours after eating1 are present4 ,if the esophageal dilatation be great1 regurgitation may occur only after an accumulation of several days1 when large quantities of stale food will be expelled4 ,the general nutrition is impaired1 and there is usually the history of weight loss to a certain level at which it is maintained with but slight variation4 ,this is explained by the trickling of liquified food from the esophageal reservoir into the stomach as the spasm intermittently relaxes1 this occurring usually before a serious state of inanition supervenes4 ,at times the hiatal spasms are extremely violent and painful1 the pain being referred from the xiphoid region to the back1 or upward into the neck4 ,patients are often conscious of the times of patulency of the esophagus2 they will know the esophagus to be open and will eat without hesitation1 or will refuse food with the certain knowledge that it will not pass into the stomach4 ,periods of remission of symptoms for months and years are noted4 ,the neurotic character of the lesion in some cases is evidenced by the occasionally sudden and startling cures following a single dilatation1 as well as by the tendency to relapse when the individual is subject to what is for him undue nervous tension4 ,in a very few cases1 with patients of rather a stolid type1 all neurotic tendencies seem to be absent4 ,the diagnosis of hiatal esophagismus requires the exclusion of local organic esophageal lesions4 ,in the typical case with marked dilatation1 the esophagoscopic findings are diagnostic4 ,a white1 pasty1 macerated mucosa1 and normally contracted hiatus esophageus which when found permits the large esophagoscope to pass into the stomach1 will be recognized as characteristic by anyone who has seen the condition4 ,in the cases with but little esophageal distension the diagnosis is confirmed by the constancy of the obstruction to a barium mixture at the phrenic level1 while at esophagoscopy the usual resistance at the hiatus esophageus is found not to be increased1 and no other local lesion is found as the esophagoscope enters the stomach4 ,it is the failure of the diaphragmatic pinchcock to open1 as in the normal deglutitory cycle1 rather than a spasmodic tightness1 that obstructs the food4 ,the presence of organic stenosis at the hiatus may remove the case altogether from the spasmodic class1 or a cicatricial or infiltrated narrowing may be the result of static esophagitis4 ,a compressive stenosis due to hepatic abnormality may simulate spasmodic stenosis as shown by ,mosher1 who believes that #ge per cent of so-called cardiospasms are organic4 ,treatment of hiatal esophagismus 7so-called cardiospasm7 consists in the over-dilatation of the diaphragmatic pinchcock or hiatus esophageus1 and in proper remedial measures for the removal of the underlying neurosis4 ,the simple passage of the esophagoscope suffices to cure some cases4 ,further dilatation by endoscopic guidance may be obtained by the introduction of ,mosher's divulsor through the esophagoscope1 by which accurate placement is obtained4 ,the distension should not usually exceed #be mm4 ,numerous water and air bags have been devised for stretching the hiatus1 and excellent results have been obtained by their use4 ,possibly some of the cures have been due to the dilatation of organic lesions1 or to the crowding back of an enlarged malposed1 or otherwise abnormal left lobe of the liver1 which ,mosher has shown to be an etiologic factor4 ,certain cases prove very obstinate of cure1 and require esophageal lavage for the esophagitis1 and feedings through the stomach tube to increase nutrition and to dilate the contracted stomach4 ,gastrostomy for feeding rarely becomes necessary1 for a stomach tube can always be placed with the esophagoscope if it will not pass otherwise4 ,retrograde dilatation with the fingers through a gastrostomy opening has been done1 but seems hardly warranted in view of the excellent results obtainable from above4 ,instructions should be given concerning the proper mastication of food1 and during treatment the frequent partaking of small quantities of liquid foods is recommended4 ,liquids and foods should be neither hot nor cold4 ,the neurologist should be consulted in cases deemed neurotic4 #if;a4-,functional hiatal stenosis4 ,cramp of the diaphragmatic pinchcock 7so-called cardiospasm74 ,endocrine imbalance should be investigated and treated1 as urged by ,mac,nab4 ,esophageal antiperistalsis is the name given by the author to a heretofore undescribed disease associated with regurgitation of food from the esophagus1 the food not having reached the stomach4 ,it may be continuous or paroxysmal and may be of so serious a degree as to threaten starvation4 ,the best treatment in severe cases is gastrostomy to put the esophagus at rest4 ,milder cases get well under liquid diet1 rest in bed1 endocrine therapy1 cure of associated abdominal disease1 etcetera4 #bea ,,chapter ,,xxxii--,,diseases ,,of ,,the ,,esophagus 7,continued7 ,,cicatricial ,,stenosis ,,of ,,the ,,esophagus ,etiology4--,the accidental swallowing of caustic alkali in solutions of lye or proprietary washing and cleansing powders1 is the most frequent cause of cicatricial stenosis4 ,commercial lye preparations are about #ie per cent sodium hydroxide4 ,the cleansing and washing powders contain from eight to fifty per cent of caustic alkali1 usually soda ash1 and are sold by grocers everywhere4 ,the labels on their containers not only give no warning of the dangerous nature of the contents nor antidotal advice1 but have such directly misleading statements as 3 ,will not injure the most delicate fabric1 ,will not injure the hands1 etc4 ,utensils used to measure or dissolve the powders are afterward used for drinking1 without rinsing1 and thus the residue of the powder remaining is swallowed in strong solution4 ,at other times solutions of lye are drunk in mistake for water1 coffee1 or wine4 ,these entirely preventable accidents would be rare if they were as conspicuously labelled ,poison as is required by law in the case of these and any other poisons1 when sold by druggists4 ,the necessity for such labelling is even greater with the lye preparations because they go into the kitchen1 whereas the drugs go to the medicine shelf1 out of the reach of children4 ,household ammonia1 salts of tartar 7potassium carbonate71 washing soda 7sodium carbonate71 mercuric chloride1 and strong acids are also1 though less frequently1 the cause of cicatricial esophageal stricture4 ,tuberculosis1 lues1 scarlet fever1 diphtheria1 enteric fever and pyogenic conditions may produce ulceration followed by cicatrices of the esophagus4 ,spasmodic stenosis with its consequent esophagitis and erosions1 and1 later1 secondary pyogenic infection1 may result in serious cicatrices4 ,peptic ulcer of the lower esophagus may be a cause4 ,the prolonged sojourn of a foreign body is likely to result in cicatricial narrowing4 ,,fig4 #ig4--,schematic illustration of a series of eccentric strictures with interstrictural sacculations1 in the esophagus of a boy aged four years4 ,the strictures were divulsed seriatim from above downward with the divulsor1 the esophageal wall1 ,d1 being moved sidewise to the position of the dotted line by means of a small esophagoscope inserted through the upper stricture1 ,a1 after divulsion of the latter4 ,location of ,cicatricial ,esophageal ,strictures4--,the strictures are often multiple and their lumina are rarely either central or concentric 7,fig4 #ig74 ,in order of frequency the sites of cicatricial stenosis are3 #a4 ,at the crossing of the left bronchus2 #b4 ,in the region of the cricopharyngeus2 #c4 ,at the hiatal level4 ,stricture at the cardia has rarely been encountered in the ,bronchoscopic ,clinic4 ,stenosis of the pylorus has been noted1 but is rare4 ,prognosis4--,spontaneous recovery from cicatricial stenosis probably never occurs1 and the mortality of untreated small lumen strictures is very high4 ,blind methods of dilatation are almost certain to result in death from perforation of the esophageal wall1 because some pressure is necessary to dilate a stricture1 and the point of the bougie1 not being under guidance of the eye1 is certain at sometime or other to be engaged in a pocket instead of in the stricture4 ,pressure then results in perforation of the bottom of the pocket 7,fig4 #ih74 ,this accident is contributed to by dilatation with the wrinkled1 scarred floor which usually develops above the stricture4 ,rapid divulsion and internal esophagotomy are mechanically very easily and accurately done through the esophagoscope1 and would yield a few prompt cures2 but the mortality would be very high4 ,under certain circumstances1 to be explained below1 gentle divulsion of the proximal one of a series of strictures has to be done4 ,with proper precautions and a gentle hand1 the risk is slight4 ,under esophagoscopic bouginage the prognosis is favorable as to ultimate cure1 the duration of the treatment varying with the number of strictures1 the tightness1 and the extent of the fibrous tissue-changes in the esophageal wall4 ,mortality from the endoscopic procedure is almost nil1 and if gastrostomy is done early in the tightly stenosed cases1 ultimate cure may be confidently expected with careful though prolonged treatment4 ,,fig4 #ih4--,schema illustrating the mechanism of perforation by blind bouginage4 ,on encountering resilient resistance the operator1 having a false conception1 pushes on the bougie4 ,perforation results because in reality the bougie is in a pocket of the suprastrictural eccentric dilatation4 ,symptoms4--,dysphagia1 regurgitation1 distress after eating1 and loss of weight1 vary with the degree of the stenosis4 ,the intermittency of the symptoms is sometimes confusing1 for the lodgment of relatively large particles of food often simulates a spasmodic stenosis1 and in fact there is often an element of spasm which holds the foreign body in the strictured area until it relaxes4 ,static esophagitis results in a swelling of the esophageal walls and a narrowing of the lumen1 so that swallowing is more or less troublesome until the esophagitis subsides4 ,esophagoscopic ,appearances of ,cicatricial ,stenosis4--,the color of the cicatricial area is usually paler than the normal mucosa4 ,the scars may be very white and elevated1 or they may be flush with the normal mucosa1 or even depressed4 ,occasionally the cicatrix is annular1 but more often it is eccentric and involves only a part of the circumference of the wall4 ,if the amount of scar tissue is small1 the lumen maintains its mobility2 opens and closes during respiration1 cough1 and vomiturition4 ,between two strictures there is often a pouch containing food remnants4 ,it is rarely possible to see the lumen of the second stricture1 because it is usually eccentric to the first4 ,stagnation of food results in superjacent dilatation and esophagitis4 ,erosions and ulcerations which follow the stagnation esophagitis increase the cicatricial stenosis in their healing4 ,differential ,diagnosis4--,when the underlying condition is masked by inflammation and ulceration1 these lesions must be removed by frequent lavage1 the administration of bismuth subnitrate with the occasional addition of calomel powder1 and the limitation of the diet to strained liquids4 ,the cicatricial nature of the stenosis can then be studied to better advantage4 ,in most cases the cicatrices are unmistakably conspicuous4 ,spasmodic stenoses are differentiated by the absence of cicatrices and the yielding of the stenosis to gentle but continuous pressure of the esophagoscope4 ,while it is possible that spasmodic stenosis may supplement cicatricial stenosis1 it is certainly exceedingly rare4 ,nearly all of the occasions in which a temporary increase of the stenosis in a cicatricial case is attributed to an element of spasm1 the real cause of the intermittency is not spasm but obstruction caused by food4 ,this occurs in three ways3 #a4 ,actual corking of the strictured lumen by a fragment of food1 in which case intermittency may be due to partial regurgitation of the corking mass with subsequent sinking tightly into the stricture4 #b4 ,the cork may dissolve and pass on through to be later replaced by another4 #c4 ,reactionary swelling of the esophageal mucosa due to stagnation4 ,here again the obstruction may be prolonged1 or it may be quite intermittent1 due to a valve-like action of the swollen mucosal surfaces or folds intermittently coming in contact4 ,cancerous stenosis is accompanied by infiltration of the periesophageal tissue1 and usually by projecting bleeding fungations4 ,cancer may1 however1 develop on a cicatrix1 favored no doubt by chronic inflammation in tissue of low resistance4 ,compression stenosis of the esophagus is characterized by the sudden transition of the lumen to a linear or crescentic outline1 while the covering mucosa is normal unless esophagitis be present4 ,the compressive mass can be detected by the sensation transmitted to the touch by the esophagoscope4 ,treatment4--,blind bouginage should be discarded as an obsolete and very dangerous procedure4 ,if the stenosis be so great as to interfere with the ingestion of the required amount of liquids1 gastrostomy should be done at once and esophagoscopic treatment postponed until water hunger has been relieved4 ,gastrostomy aids in the treatment by putting the esophagus at rest1 and by affording the means of maintaining a high degree of nutrition unhampered by the variability or efficiency of the swallowing function4 ,careful diet and gentle treatment will1 however1 usually avoid gastrostomy4 ,the diet in the gastrostomy-fed patients should be as varied as in oral alimentation2 even solids of the consistency of mashed potatoes1 if previously forced through a wire gauze strainer1 may be forced through the tube with a glass injector4 ,liquids and readily liquefiable foods are to be given the non-gastrostomized patient1 solids being added when demonstrated that no stagnation above the stricture occurs4 ,thorough mastication and the slow partaking of small quantities at a time are imperative4 ,should food accumulation occur1 the esophagus should be emptied by regurgitation1 following which a glassful of warm sodium bicarbonate solution is to be taken1 and this also regurgitated if it does not go through promptly4 ,the esophagus is thus lavaged and emptied4 ,in all these cases1 whether being fed through the mouth or the gastrostomic tube1 it is very important to remember that milk and eggs are not a complete dietary4 ,a pediatrist should be consulted4 ,prof4 ,graham has saved the lives of many children by solving the nutritive problems in the cases at the ,bronchoscopic ,clinic4 ,fruit and vegetable juices are necessary4 ,vegetable soups and mashed fruits should be strained through a wire gauze coffee strainer4 ,if the saliva is spat out by the child because it will not go through the stricture the child should be taught to spit the saliva into the funnel of the abdominal tube4 ,this method of improving nutrition was discovered by ,miss ,groves at the ,bronchoscopic ,clinic4 ,esophagoscopic bouginage with the author's silk-woven steel-shank endoscopic bougies 7,fig4 #dj7 has proven the safest and most successful method of treatment4 ,the strictured lumen is to be centered in the esophagoscopic field1 and three successively increasing sizes of bougies are used under direct vision4 ,larger and larger bougies are used at the successive treatments which are given at intervals of from four to seven days4 ,no anesthesia1 general or local1 is used for esophagoscopic bouginage4 ,the tightness of the grasping of the bougie by the stricture on withdrawal1 determines the limitation of sizes to be used4 ,when the upper stricture is dilated1 lower ones in the series are taken seriatim4 ,if concentric1 two or more closely situated strictures may be simultaneously dilated4 ,for the use of bougies of the larger sizes1 the special esophagoscopes with both the light-carrier canal and the drainage canal outside the lumen of the tube are needed4 ,functional cure is obtained with a relatively small lumen at the point of stenosis4 ,a lumen of #g mm4 will allow the passage of any well masticated food4 ,it is unwise and unsafe to attempt to restore the lumen to its normal anatomic size4 ,in cicatricial stricture cases it is advisable to examine the esophagus at monthly periods for a time after a functional cure has been obtained1 in order that tendency to recurrence may be early detected4 ,divulsion of an upper stricture may be deemed advisable in order to reach others lower down1 especially in cases of multiple eccentric strictures 7,fig4 #ig74 ,this procedure is best done with the author's esophagoscopic divulser1 accurately placed by means of the esophagoscope2 but divulsion requires the utmost care1 and a gentle hand4 ,even then it is not so safe as esophagoscopic bouginage4 ,internal esophagotomy by the string-cutting instruments and esophagotome are relatively dangerous methods1 and perhaps yield in the end no quicker results than the slower and safe bouginage per tubam4 ,electrolysis has been used with varying results in the treatment of cicatricial stenosis4 ,thermic bouginage with electrically heated bougies has been found useful in some cases by ,dean and ,imperatori4 #beh ,string-swallowing1 with the passage of olives threaded over the string has yielded good results in the hands of some operators4 ,the string may be used to pull up dilators in increasing sizes1 introduced through a gastrostomic fistula4 ,the string stretched across the stomach from the cardia to the pylorus1 is fished out with the author's pillar retractor1 or is found with the retrograde esophagoscope 7,fig4 #dc74 ,the string is attached to a dilator 7,fig4 #ce71 and a fresh string is pulled in to replace the one pulled out4 ,this is the safest of the blind methods4 ,it is rarely possible to get a child under two years of age to swallow and tolerate a string4 ,it is better after each treatment to draw the upper end of the string through the nose1 as it is not so likely to be chewed off and is less annoying4 ,with the esophagoscope1 the string is not necessary1 because the lumen of the stricture can be exposed to view by the esophagoscope4 ,retrograde esophagoscopy through a gastrostomy wound offers some advantages over peroral treatment2 but unless the gastrostomy is high1 the procedure is undoubtedly more difficult4 ,the approach to the lowest stricture from below is usually funnel shaped and free from dilatation and redundancy4 ,it must be remembered the stricture seen from below may not be the same one seen from above4 ,roentgenray examination with barium mixture or esophagoscopes simultaneously in situ above and below are useful in the study of such cases4 ,impermeable strictures of the cervical esophagus are amenable to external esophagotomy1 with plastic reformation of the esophagus4 ,those in the middle third have not been successfully treated by surgical methods1 though various ingenious operations for the formation of an extrathoracic esophagus have been suggested as means of securing relief4 ,impermeable strictures of the lower third can with reasonable safety be treated by the ,brenneman method1 which consists in passing the esophagoscope down to the stricture while the surgeon1 inserting his finger up into the esophagus from the stomach1 can feel the end of the esophagoscope4 ,an incision through the tissue barrier is then made from below1 passing the knife along the finger as a guide4 ,a soft rubber stomach-tube is pulled up from below and left in situ1 being replaced at intervals by a fresh one1 pulled up from the stomach1 until epithelialization of the new lumen is complete4 ,catheters are used in children4 ,in replacing the catheter or stomach tube the fresh one is attached to the old one by stitching in a loop of braided silk4 ,frequent esophagoscopic bouginage will be required to maintain the more or less fistulous lumen until it is epithelialized1 and in occasional cases1 for a long time thereafter4 ,in cases of absolute atresia the saliva does not reach the stomach4 ,no one realizes the quantity of normal salivary drainage1 nor its importance in nutritive processes4 ,oral insalivation is of little consequence compared to esophagogastric drainage4 ,gastrostomized children with absolute atresia of the esophagus do not thrive unless they regurgitate the salivary accumulations into the funnel of the gastrostomic feeding tube4 ,this has been abundantly proven by observations at the ,bronchoscopic ,clinic4 ,my attention was first called to this clinical fact by ,miss ,frances ,groves who has charge of these cases4 ,intubation of the esophagus with soft rubber tubes has occasionally proven useful4 #bfj ,,chapter ,,xxxiii--,,diseases ,,of ,,the ,,esophagus 7,continued7 ,,diverticulum ,,of ,,the ,,esophagus ,diverticula may1 and usually do1 consist in a pouching by herniation1 of the whole thickness of the esophageal wall2 or they may be herniations of the mucosa between the muscular layers4 ,they are classified according to their etiology1 as traction and pulsion diverticula4 ,,fig4 #ii4--,traction diverticulum of the esophagus rendered visible in the roentgenogram by a swallowed opaque mixture4 ,case of ,h4 ,w4 ,dachtler1 ,am4 ,journ4 ,roentgenology4 ,traction diverticulum of the esophagus 7,fig4 #ii7 is a rare condition1 usually occurring in the thorax1 and as a rule constituting a one-sided enlargement of the gullet rather than a true pouch formation4 ,it is supposed to be formed by the pulling during cough1 respiration1 and swallowing1 on localized adhesions of the esophagus to periesophageal structures1 such as inflammatory peribronchial glands4 ,diagnosis is often incidental to examination of the gastrointestinal tract for other conditions1 because traction diverticula usually cause no symptoms4 ,unless a very large esophagoscope be used1 a traction diverticulum may easily be overlooked in the mucosal folds4 ,careful lateral search1 however1 will reveal the dilatation1 and the localized periesophageal fixation may be demonstrated4 ,the subdiverticular esophagus is readily followed1 its lumen opening during inspiration unless very close to the diaphragm1 which is very rare4 ,perhaps most cases will be discovered by the roentgenologist4 ,it has been said that traction diverticula are more readily demonstrated in the roentgenologic examination1 if the patient be placed with pelvis elevated4 ,pulsion diverticulum of the esophagus is an acquired hernia of the mucosa between the circular and oblique fibers of the inferior constrictor muscle of the pharynx4 ,a congenital anatomic basic factor in etiology probably exists4 ,the pouching develops in the middle part of the posterior wall1 between the orbicular and oblique fibers of the cricopharyngeus muscle1 at which point there is a gap1 leaving the mucosa supported only by a not very resistant fascia 7,fig4 #ajj74 ,when small1 the sac is in the midline1 but with increase in size1 it presents either to the right or the left side1 commonly the latter4 ,the sac may be very small1 or it may be sufficiently large to hold a pint or more1 and to cause the neck to bulge when filled4 ,when large1 the pouch extends into the mediastinum4 ,it will be seen that anatomically the pulsion diverticulum has its origin in the pharynx2 the symptoms1 however1 are referable to the esophagus and the subdiverticular esophagus is stenosed by compression of the pouch2 therefore1 it is properly classified as an esophageal disease4 ,,fig4 #ajj4--,schema illustrative of the etiology of pressure diverticula4 ,o1 oblique fibers of the cricopharyngeus attached to the thyroid cartilage1 ,t4 ,the fundiform fibers1 ,f1 encircle the mouth of the esophagus4 ,between the two sets of fibers is a gap in the support of the esophageal wall1 through which the wall herniates owing to the pressure of food propelled by the oblique fibers1 ,o1 advance of the bolus being resisted by spasmodic contraction of the orbicular fibers1 ,f4 ,etiology4--,pressure diverticula occur after middle life1 and more often in men than in women4 ,the hasty swallowing of unmasticated food1 too large a bolus1 defective or artificial teeth1 flaccidity of tissues1 and spasm of the cricopharyngeus muscle1 are etiologic factors4 ,cicatricial stenosis below the level of the inferior constrictor is a contributory cause in some cases4 ,prognosis4--,after the pouch is formed1 it steadily increases in size1 since the swallowed food first fills and distends the sac before the overflow passes down the esophagus4 ,when a pendulous sac becomes filled with food1 it presses on the subdiverticular esophagus1 and produces compression stenosis2 so that there exists a vicious circle4 ,the enlargement of the sac produces increasing stenosis with consequent further distension of the pouch4 ,this explains the clinically observed fact1 that unless treated1 pulsion diverticula increase progressively in size1 and consequently in distressing symptoms4 ,the sac becomes so large in some cases as to contribute to the occurrence of cerebral apoplexy by interference with venous return4 ,practically all cases can be cured by radical operation4 ,the operative mortality varies with the age1 state of nutrition1 and general health of the patient4 ,in general it may be said to have a mortality of at least #aj per cent1 largely due to the fact that most cases are poor surgical subjects4 ,recurrences after radical operation are due to a persistence of the original causes1 i4e41 bolting of food2 stenosis1 spasmodic or organic1 of the esophageal lumen2 and weakness in the support of the esophageal wall1 which1 unsupported1 has little strength of its own4 ,symptoms4--,dysphagia1 regurgitation1 a gurgling sound and subjective bubbling sensation on swallowing1 sour odor to the breath1 and cough1 are the chief symptoms4 ,with larger pouches1 emaciation1 pressure sensation in the neck and upper mediastinum1 and the presence of a mass in the neck when the sac is filled1 are present4 ,tracheal compression by the filled pouch may produce dyspnea4 ,the sac may be emptied by pressure on the neck1 this means of relief being often discovered by the patient4 ,the sac sometimes spontaneously empties itself by contraction of its enveloping muscular layer1 and one of the most annoying symptoms is the paroxysm of coughing1 waking the patient1 when during the relaxation of sleep the sac empties itself into the pharynx and some of its contents are aspirated into the larynx4 ,there are no pathognomonic symptoms4 ,those recited are common to other forms of esophageal stenosis1 and are urgent indications for diagnostic esophagoscopy4 ,diagnosis4--,roentgenray study with barium mixtures1 is the first step in the diagnosis 7,fig4 #aja74 ,this is to be followed by diagnostic esophagoscopy4 ,malignant1 spasmodic1 cicatricial1 and compression stenosis are to be excluded by esophagoscopic appearances4 ,aneurysm is to be eliminated by the usual means4 ,the ,boyce sign is almost invariably present1 and is diagnostic4 ,it is elicited by telling the patient to swallow1 which action imprisons air in the sac4 ,the imprisoned air is forced out by finger-pressure on the neck1 over the sac4 ,the exit of the air bubble produces a gurgling sound audible at the open mouth of the patient4 ,esophagoscopic ,appearances in ,pulsion ,diverticulum4--,the esophagoscope will without difficulty enter the mouth of the sac which is really the whole bottom of the pharynx1 and will be arrested by the blind end of the pouch1 the depth of which may be from #d to #aj cm4 ,in some cases the bottom of the pouch is in the mediastinum4 ,the walls are often pasty1 and may be eroded1 or ulcerated1 and they may show vessels or cicatrices4 ,on withdrawing the tube and searching the anterior wall1 the subdiverticular slit-like opening of the esophagus will be found1 though perhaps not always easily4 ,the esophageal speculum will be found particularly useful in exposing the subdiverticular orifice1 and through this a small esophagoscope may be passed into the esophagus1 thus completing the diagnosis4 ,care must be exercised not to perforate the bottom of the diverticular pouch by pressure with the esophagoscope or esophageal speculum4 ,the walls of the sac are surprisingly thin4 ,,fig4 #aja4--,pulsion diverticulum filled with bismuth mixture in a man of fifty years4 ,treatment of ,pulsion ,diverticulum4--,if the pouch is small1 the subdiverticular esophageal orifice may be dilated with esophagoscopic bougies1 thus overcoming the etiologic factor of spastic or organic stenosis4 ,the redundancy remains1 however1 though the symptoms may be relieved4 ,cutting the common wall between the esophagus and the sac by means of scissors passed through the endoscopic tube1 has been successfully done by ,mosher4 ,various methods of external operation have been devised1 among which are3 7#a7 ,freeing the sac through an external cervical incision and suturing its fundus upward against the pharynx1 which has proved successful in some cases4 7#b7 ,inversion of the sac into the pharynx and suture of the mouth of the pouch4 ,in a case so treated the pouch was blown out again during a fit of sneezing eight months after operation4 7#c7 ,plication of the walls of the sac by catgut sutures1 as in the ,matas obliterative operation for aneurysm4 7#d7 ,freeing and removing the sac1 with suture of the esophageal wound4 7#e7 ,removal of the sac by a two-stage operation1 in which method the initial step is the deliverance of the sac into the cervical wound1 where it remains surrounded by gauze packing until adhesions have walled off the mediastinum4 ,the work is completed by cutting off the sac and either suturing the esophageal wound or touching it with the cautery1 and allowing it to heal by granulation4 ,external exposure and amputation of the sac has been more frequently done than any other operation4 ,unless the pouch is large1 it is extremely difficult to find after the surgeon has exposed the esophagus1 for the reasons that at operation it is empty and that when the adhesions about it are removed the walls of the sac contract4 ,after removal1 the sac is disappointingly small as compared with its previous size in the roentgenogram1 which shows it distended with opaque material4 ,it has been the chagrin of skilled surgeons to find the diverticulum present functionally and roentgenographically precisely the same as before the performance of the very trying and difficult operation4 ,the time of operation may be shortened at least by one-half by the aid of the esophagoscopist in the ,gaub-,jackson operation4 ,intratracheally insufflated ether is the anesthesia of choice4 ,after the surgeon has exposed the esophagus by dissection1 the endoscopist introduces the esophagoscope into the sac1 and delivers it into the wound1 while the surgeon frees it from adhesions4 ,the esophagoscope is now withdrawn from the pouch and entered into the esophagus proper1 below the diverticulum1 while the surgeon cuts off the hernial sac and sutures the esophagopharyngeal wound over the esophagoscope4 ,the presence of the esophagoscope prevents too tight suture and possible narrowing of the lumen 7,fig4 #ajb74 ,,fig4 #ajb4--,schematic representation of esophagoscopic aid in the excision of a diverticulum in the ,gaub-,jackson operation4 ,at ,a the esophagoscope is represented in the bottom of the pouch after the surgeon has cut down to where he can feel the esophagoscope4 ,then the esophagoscopist causes the pouch to protrude as shown by the dotted line at ,b4 ,after the surgeon has dissected the sac entirely loose from its surroundings1 traction is made upon the sac as shown at ,h and the esophagoscope is inserted down the lumen of the esophagus as shown at ,c4 ,the esophagoscope now occupies the lumen which the patient will need for swallowing4 ,it only remains for the surgeon to remove the redundancy1 without risk of removing any of the normal wall4 ,the esophagoscope here shown is of the form squarely cut off at the end4 ,the standard form of instrument with slanted end will serve as well4 ,after-care4--,feeding may be carried on by the placing of a small nasal feeding tube into the stomach at the time of operation4 ,gastrostomy for feeding as a preliminary to the esophageal operation has been suggested1 and is certainly ideal from the viewpoint of nutrition and esophageal rest4 ,the decision of its performance may perhaps be best made by the patient himself4 ,should leakage through the neck occur1 the fistula should be flushed by the intake of sterile water by mouth4 ,oral sepsis should1 of course1 be treated before operation and combated after operation by frequent brushing of the teeth and rinsing of the mouth with ,dakin's solution1 one part1 to ten parts of peppermint water4 ,a postoperative barium roentgenogram should be made in every case as a matter of record and to make certain the proper functioning of the esophagus4 #bfh ,,chapter ,,xxxiv--,,diseases ,,of ,,the ,,esophagus 7,continued7 ,,paralysis ,,of ,,the ,,esophagus ,the passage of liquids and solids through the esophagus is a purely muscular act1 controlled1 after the propulsive usually voluntary start given to the bolus by the inferior constrictor1 by a reflex arc having connection with the central nervous system through the vagus nerve4 ,gravity plays little or no part in the act of deglutition1 and alone will not carry food or drink to the stomach4 ,paralysis of the esophagus may be said to be motor or sensory4 ,it is rarely if ever unassociated with like lesions of contiguous organs4 ,motor paralysis of the esophagus is first manifested by inability to swallow4 ,this is associated with the accumulation of secretion in the pyriform sinuses 7the author's sign of esophageal stenosis7 which overflows into the larynx and incites violent coughing4 ,motor paralysis may affect the constrictors or the esophageal muscular fibers or both4 ,sensory paralysis of the esophagus by breaking the continuity of the reflex arc1 may so impair the peristaltic movements as to produce aphagia4 ,the same filling of the pyriform sinuses will be noted1 but as the larynx is usually anesthetic also1 it may be that no cough is produced when secretions overflow into it4 ,etiology4--#a4 ,toxic paralysis as in diphtheria4 #b4 ,functional paralysis as in hysteria4 #c4 ,peripheral paralysis from neuritis4 #d4 ,central paralysis1 usually of bulbar origin4 ,embolism or thrombosis of the posterior cerebral artery is a reported cause in two cases4 ,lues is always to be excluded as the fundamental factor in the groups #c and #d4 ,esophageal paralysis is not uncommon in myasthenia gravis4 ,esophagoscopic findings are those of absence of the normal resistance at the cricopharyngeus1 flaccidity and lack of sensation of the esophageal walls1 and perhaps adherence of particles of food to the folds4 ,the hiatal contraction is usually that normally encountered1 for this is accomplished by the diaphragmatic musculature4 ,in paralysis of sensation1 the reflexes of coughing1 vomiturition and vomiting are obtunded4 ,diagnosis4--,hysteria must not be decided upon as the cause of dysphagia1 until after esophagoscopy has eliminated paralysis4 ,dysphagia after recent diphtheria should suggest paralysis of the esophagus4 ,the larynx1 lips1 tongue1 and pharynx also1 are usually paralyzed in esophageal paralysis of bulbar origin4 ,the absence of the cricopharyngeal resistance to the esophagoscope passed without anesthesia1 general or local1 is diagnostic4 ,treatment4--,the internist and neurologist should govern the basic treatment4 ,nutrition can be maintained by feeding with the stomach-tube1 which meets no resistance to its passage4 ,should this be contraindicated by ulceration of the esophagus1 gastrostomy should be done4 ,,lues ,,of ,,the ,,esophagus ,esophageal syphilis is a rather rare affection1 and may show itself as a mucous plaque1 a gumma1 an ulceration1 or a cicatrix4 ,cicatricial stenosis developing late in life without history of the swallowing of escharotics or ulcerative lesions is strongly suggestive of syphilis1 though the late manifestation of a congenital stenosis is a possibility4 ,esophagoscopic appearances of lues are not always characteristic4 ,as in any ulcerative lesion1 the inflammatory changes of mixed infections mask the basic nature4 ,the mucous plaque has the same appearance as one situated on the velum1 and gummata resemble those seen in the mucosa elsewhere4 ,there is nothing characteristic in luetic cicatrices4 ,the diagnosis of luetic lesions of the esophagus1 therefore1 depends upon the history1 presence of luetic lesions elsewhere1 the serologic reaction1 therapeutic test1 examination of tissue1 and the demonstration of the treponema pallidum4 ,the therapeutic test by prolonged saturation of the system with mercury is imperative in all suspected cases and no other negative result should be deemed sufficient4 ,the treatment of luetic esophagitis is systemic1 not local4 ,luetic cicatrices contract strongly1 and are very resistant to treatment1 so that esophagoscopic bouginage should be begun as early as possible after the healing of a luetic ulceration1 in order to prevent stenosis4 ,a silk-woven endoscopic bougie placed in position by ocular guidance1 and left in situ for from half to one hour daily1 may prevent severe contraction1 if used early in the stage of cicatrization4 ,prolonged treatment is required for the cure of established luetic cicatricial stenosis4 ,if gastrostomy has been done retrograde bouginage 7,fig4 #ce7 may be used4 ,,tuberculosis ,,of ,,the ,,esophagus ,esophageal tuberculosis is not commonly met1 but is probably not infrequently associated with the dysphagia of tuberculous laryngitis4 ,it may rarely occur as a primary infection1 but usually the esophagus is involved in an extension from a tuberculous process in the larynx1 mediastinal lymphatics1 pleura1 bronchi1 or lungs4 ,primary lesions appear as superficial erosions or ulcerations1 with a surrounding yellowish granular zone1 or the granules may alone be present4 ,the mucosa in tuberculous lesions is usually pallid1 the absence of vascularity being marked4 ,invasion from the periesophageal organs produces more or less localized compression and fixation of the esophagus4 ,the character of open ulceration is modified by the mixed infections4 ,healed tuberculous lesions1 sometimes resulting from the evacuation of tuberculous mediastinal lymph nodes into the esophagus may be encountered4 ,the local fixation and cicatricial contraction may be the site of a traction diverticulum4 ,tuberculous esophago-bronchial fistulae are occasionally seen4 ,diagnosis1 to be certain1 requires the demonstration of the tubercule bacilli and the characteristic cell accumulation of the tubercle in a specimen of tissue removed from the lesion4 ,actinomycosis must be excluded1 and the possibility of mixed luetic and tuberculous lesions is to be kept in mind4 ,post-tuberculous cicatrices have no recognizable characteristics4 ,treatment4--,the maintenance of nutrition to the highest degree1 and the institution of a strict antituberculous regime are demanded4 ,local applications are of no avail4 ,gastrostomy for feeding should be done if dysphagia be severe1 and has the advantage of putting the esophagus at rest4 ,the passage of a stomach-tube for feeding purposes may be done1 but it is often painful1 and is dangerous in the presence of ulceration4 ,pain is not marked if the lesion be limited to the esophagus1 though if it is present orthoform1 anesthesin1 or apothesin1 in powder form1 swallowed dry1 may prove helpful4 ,,varix ,,and ,,angioma ,,of ,,the ,,esophagus ,these lesions are sometimes the cause of esophageal hemorrhage1 the regurgitated blood being bright red1 and alkaline in reaction1 in contradistinction to the acid coffee ground blood of gastric origin4 ,esophageal varices may coexist with the common dilatation of the venous system in which the veins of the rectum1 scrotum1 and legs are most conspicuously affected4 ,cirrhosis and cancer of the liver may1 by interference with the portal circulation1 produce dilatation of the veins in the lower third of the esophagus4 ,angioma of the esophagus is amenable to radium treatment4 ,,actinomycosis ,,of ,,the ,,esophagus ,esophageal actinomycosis has been autoptically discovered4 ,its diagnosis1 and differentiation from tuberculosis1 would probably rest upon the microscopic study of tissue removed esophagoscopically1 though as yet no such case has been reported4 ,,angioneurotic ,,edema ,angioneurotic edema involving the esophagus1 may produce intermittent and transient dysphagia4 ,the lesions are rarely limited to the esophagus alone2 they may occur in any portion of the gastrointestinal1 genitourinary1 or respiratory tracts1 and concomitant cutaneous manifestations usually render the diagnosis clear4 ,the treatment is general4 ,,deviation ,,of ,,the ,,esophagus ,deviation of the esophagus may be marked in the presence of a deformed vertebral column1 though dysphagia is a very uncommon symptom4 ,the lack of esophageal symptoms in deviation of spinal production is probably explained by the longitudinal shortening of the spine which accompanies the deflection4 ,compression stenosis of the esophagus is commonly associated with deviations produced by a thoracic mass4 ,,plate ,,iv ,a1 ,gastroscopic view of a gastrojejunostomy opening drawn patulous by the tube mouth4 7,gastrojejunostomy done by ,dr4 ,george ,l4 ,hays47 ,b1 ,carcinoma of the lesser curvature4 7,patient afterward surgically explored and diagnosis verified by ,dr4 ,john ,j4 ,buchanan47 ,c1 ,healed perforated ulcer4 7,patient referred by ,dr4 ,john ,w4 ,boyce47 ,drawn from a case of postdiphtheric subglottic stenosis cured by the author's method of direct galvanocauterization of the hypertrophies4 ,a1 ,immediately after removal of the intubation tube2 hypertrophies like turbinals are seen projecting into the subglottic lumen4 ,b1 ,five minutes later2 the masses have now closed the lumen almost completely4 ,the patient became so cyanotic that a bronchoscope was at once introduced to prevent asphyxia4 ,c1 ,the left mass has been cauterized by a vertical application of the incandescent knife4 ,d1 ,completely and permanently cured after repeated cauterizations4 ,direct view2 recumbent patient4 ,,photoprocess ,,reproductions ,,of ,,the ,,author',s ,,oil-,,color ,,drawings ,,from ,,life #bgc ,,chapter ,,xxxv--,,gastroscopy ,the stomach of any individual having a normal esophagus and normal spine can be explored with an open-tube gastroscope4 ,the adult size esophagoscope being #ec cm4 long will reach the stomach of the average individual4 ,longer gastroscopes are used1 when necessary1 to explore a ptosed stomach4 ,various lens-system gastroscopes have been devised1 which afford an excellent view of the walls of the air-inflated stomach4 ,the optical system1 however1 interferes with the insertion of instruments1 so that the open-tube gastroscope is required for the removal of gastric foreign bodies1 the palpation of1 or sponging secretions from1 gastric lesions4 ,the open-tube gastroscope may be closed with a window plug 7,fig4 #f7 having a rubber diaphragm with a central perforation for forceps1 when it is desired to inflate the stomach4 ,technic4--,relaxation by general anesthesia permits lateral displacement of the dome of the diaphragm along with the esophagus1 and thus makes possible a wider range of motion of the distal end of the gastroscope4 ,all of the recent gastroscopies in the ,bronchoscopic ,clinic1 however1 have been performed without anesthesia4 ,the method of introduction of the gastroscope through the esophagus is precisely the same as the introduction of the esophagoscope 7q4v474 ,it should be emphasized that with the lens-system gastroscopes1 the tube should be introduced into the stomach under direct ocular guidance1 without a mandrin1 and the optical apparatus should be inserted through the tube only after the stomach has been entered4 ,blind insertion of a rigid metallic tube into the esophagus is an extremely dangerous procedure4 ,the descriptions and illustrations of the stomach in anatomical works must be disregarded as cadaveric4 ,in the living body1 the empty stomach is usually found1 on endoscopic inspection1 to be a collapsed tube of such shape as to fit whatever space is available at the particular moment1 with folds and rugae running in all directions1 the impression given as to form being strikingly like searching among a mass of earth worms or boiled spaghetti4 ,the color is pink1 under proper illumination1 if no food is present4 ,poor illumination may make the color appear deep crimson4 ,if food is present1 or has just been regurgitated1 the color is bright red4 ,to appreciate the appearance of gastritis1 the eye must have been educated to the endoscopic appearances under a degree of illumination always the same4 ,the left two-thirds of the stomach is most easily examined4 ,the stomach wall can be pushed by the tube into almost any position1 and with the aid of gentle external abdominal manipulation to draw over the pylorus it is possible to examine directly almost all of the gastric walls except the pyloric antrum1 which is reachable in relatively few cases4 ,a lateral motion of from #aj to #ag cm4 can be imparted to the gastroscope1 provided the diaphragmatic musculature is relaxed by deep anesthesia4 ,the stomach is explored by progressive traverse4 ,that is1 after exploring down to the greater curvature1 the tube-mouth is moved laterally about #b centimeters1 and the withdrawing travel explores a new field4 ,then a lateral movement affords a fresh field during the next insertion4 ,this is repeated until the entire explorable area has been covered4 ,ballooning the stomach with air or oxygen is sometimes helpful1 but the distension fixes the stomach1 lessens the mobility of the arch of the diaphragm1 and thus lessens the lateral range of gastroscopic vision4 ,furthermore1 ballooning pushes the gastric walls far away from the reach of the tube-mouth4 ,a window plug 7,fig4 #f7 is inserted into the ocular end of the gastroscope for the ballooning procedure4 #bge ,like many other valuable diagnostic means1 gastroscopy is very valuable in its positive findings4 ,negative results are entitled to little weight except as to the explorable area4 ,the gastroscopist working in conjunction with the abdominal surgeon should be able to render him invaluable assistance in his work on the stomach4 ,the surgeon with his gloved hand in the abdomen1 by manipulating suspected areas of the stomach in front of the tube-mouth can receive immediately a report of its interior appearance1 whether cancerous1 ulcerated1 hemorrhagic1 etc4 ,lens-system ballooning gastroscopy may possibly afford additional information after all possible data from open-tube gastroscopy has been obtained4 ,care must be exercised not to exert an injurious degree of air-pressure4 ,the distended portion of the stomach assumes a funnel-like form ending at the apex in a depression with radiating folds1 that leads the observer to think he is looking at the pylorus4 ,the foreshortening produced by the lens system also contributes to this illusion4 ,the best lens-system gastroscope is that of ,henry ,janeway1 which combines the open-tube and the lens system4 ,gastroscopy for ,foreign ,bodies4--,the great majority of foreign bodies that reach the stomach unassisted are passed per rectum1 provided the natural protective means are not impaired by the administration of cathartics1 changes in diet1 etcetera4 ,this1 however1 does not mean that esophageal foreign bodies should be pushed into the stomach by blind methods1 or by esophagoscopy1 because a swallowed object lodged in the esophagus can always be returned through the mouth4 ,foreign bodies in the stomach and intestines should be fluoroscopically watched each second day4 ,if an object is seen to lodge five days in one location in the intestines1 it should be removed by laparotomy1 since it will almost certainly perforate4 ,certain objects reaching the stomach may be judged too large to pass the pylorus and intestinal angles4 ,these should be removed by gastroscopy when such decision is made4 ,it is to be remembered that gastric foreign bodies may be regurgitated and may lodge in the esophagus1 whence they are easily removed by esophagoscopy4 ,the double-planed fluoroscope of ,manges is helpful in the removal of gastric foreign bodies1 but there is great danger of injury to the stomach walls1 and even the peritoneum1 unless forceps are used with the utmost caution4 #bgg ,,chapter ,,xxxvi--,,acute ,,stenosis ,,of ,,the ,,larynx ,etiology4--,causes of a relatively sudden narrowing of the lumen of the larynx and subjacent trachea are included in the following list4 ,two or more may be combined4 #a4 ,foreign body4 #b4 ,accumulation of secretions or exudate in the lumen4 #c4 ,distension of the tissues by air1 inflammatory products1 serum1 pus1 etc4 #d4 ,displacement of relatively normal tissues1 as in abductor paralysis1 congenital laryngeal stridor1 etcetera4 #e4 ,neoplasms4 #f4 ,granulomata4 ,edema of the larynx may be at the glottic level1 or in the supraglottic or subglottic regions4 ,the loose cellular tissue is most frequently concerned in the process rather than the mucosal layer alone4 ,in children the subglottic area is very vascular1 and swelling quickly results from trauma or inflammation1 so that acute stenosis of the larynx in children commonly has its point of narrowing below the cords4 ,dyspnea1 and croupy1 barking1 cough with no change in the tone or pitch of the speaking voice are characteristic signs of subglottic stenosis4 ,edema may accompany inflammation of either the superficial or deep structures of the larynx4 ,the laryngeal lesion may be primary1 or may complicate general diseases2 among the latter1 typhoid fever deserves especial mention4 ,acute laryngeal stenosis complicating typhoid fever is frequently overlooked and often fatal1 for the asthenic patient makes no fight for air1 and hoarseness1 if present1 is very slight4 ,the laryngeal lesion may be due to cordal immobility from either paralysis or inflammatory arytenoid fixation1 in the absence of edema4 ,perichondritis and chondritis of the laryngeal cartilages often follow typhoid ulceration of the larynx1 chronic stenosis resulting4 ,laryngeal stenosis in the newborn may be due to various anomalies of the larynx or trachea1 or to traumatism of these structures during delivery4 ,the normal glottis in the newborn is relatively narrow1 so that even slight encroachment on its lumen produces a serious degree of dyspnea4 ,the characteristic signs are inspiratory indrawing of the supraclavicular fossae1 the suprasternal notch1 the epigastrium1 and the lower sternum and ribs4 ,cyanosis is seen at first1 later giving place to pallid asphyxia when cardiac failure occurs4 ,little air is heard to enter the lungs1 during respiratory efforts and the infant1 becoming exhausted by the great muscular exertion1 soon ceases to breathe4 ,paralytic stenosis of the larynx sometimes follows difficult forceps deliveries during which stretching or compression of the recurrent nerves occur4 ,acute laryngeal stenosis in infants1 from laryngeal perichondritis1 may be a delayed result of traumatism to the laryngeal cartilages during delivery4 ,the symptoms usually develop within four weeks after birth4 ,lues and tuberculosis are possible factors to be eliminated by the usual methods4 ,surgical ,treatment of ,acute ,laryngeal ,stenosis4--,multiple puncture of acute inflammatory edema1 while readily performed with the laryngeal knife used through the direct laryngoscope1 is an uncertain measure of relief4 ,tracheotomy1 if done low in the neck1 will completely relieve the dyspnea4 ,by its therapeutic effect of rest1 it favors the rapid subsidence of the inflammation in the larynx and is the treatment to be preferred4 ,intubation is treacherous and unreliable except in diphtheritic cases2 but in the diphtheritic cases it is ideal1 if constant skilled watching can be had4 #bgi ,,chapter ,,xxxvii--,,tracheotomy ,indications4--,tracheotomy is indicated in dyspnea of laryngotracheal origin4 ,the cardinal signs of this form of dyspnea are3 #a4 ,indrawing at the suprasternal notch4 #b4 ,indrawing around the clavicles4 #c4 ,indrawing of the intercostal spaces4 #d4 ,restlessness4 #e4 ,choking and waking as soon as the aid of the voluntary respiratory muscles ceases in falling to sleep4 #f4 ,cyanosis is a dangerously late symptom4 ,as a therapeutic measure in diseases of the larynx its place has been thoroughly established4 ,marked improvement of the laryngeal lesions has been observed to follow tracheotomy in advanced laryngeal tuberculosis1 and in cancer of the larynx4 ,it has proven1 in some cases1 a useful adjunct in the treatment of luetic laryngitis1 though it cannot be regarded as indicated1 in the absence of dyspnea4 ,perichondritis and other inflammations are benefited by tracheotomy4 ,a marked therapeutic effect on multiple laryngotracheal papillomata in children has been noted by the author in hundreds of cases4 ,tracheotomy for foreign body is no longer indicated either for the removal of the intruder1 or for the insertion of the bronchoscope4 ,tracheotomy may be urgently indicated for foreign body dyspnea1 but not for foreign body removal4 ,subcutaneous rupture of the trachea from external trauma may produce dyspnea and generalized emphysema1 both of which will be relieved by tracheotomy4 #bhj ,acromegalic stenosis of the larynx is a rare but urgent indication for tracheotomy4 ,contraindications4--,there are no contraindications to tracheotomy for dyspnea4 ,the instruments required for an orderly tracheotomy are3 ,headlight ,scalpels #b ,retractors ,trousseau dilator #f ,hemostats ,scissors 7dissecting7 ,tracheal cannulae 7six sizes7 ,curved needles ,needle holder ,hypodermic syringe for local anesthesia ,no4 #a plain catgut ligatures ,linen tape ,gauze sponges ,these are sterilized and kept in a sterile copper box ready for instant use4 ,beside the patient's bed following the tracheotomy the following sterile materials are placed3 ,sterile gloves #a ,hemostat ,sterile new gauze ,trousseau dilator ,scissors ,duplicate tracheotomy tube ,silver probe ,basin of ,bichloride of mercury solution1 #a 3 #aj1jjj ,tracheotomy is one of the oldest operations known to surgery1 yet strange to say1 it is probably more often improperly performed today1 and more often followed by needless mortality1 than any other operation4 ,the two chief preventable sequelae are death from improper routine surgical care and wrongly fitted tube1 and stenosis from too high an operation4 ,the classical descriptions of crico-thyroidotomy and high and low tracheotomy have been handed down to generations of medical students without revision4 ,every medical graduate has been taught that there are two kinds of tracheotomy1 high and low1 the low operation being very difficult1 the high operation very easy4 ,when he is suddenly called upon to do an emergency tracheotomy1 this erroneous teaching is about all that remains in the dim recesses of his memory2 consequently he makes sure of doing the operation high enough1 and goes in through the larynx1 usually dividing the cricoid cartilage1 the only complete ring in the trachea4 ,as originally made the distinction between high and low as applied to tracheotomy referred to operations above and below the isthmus of the thyroid gland1 in a day when primitive surgery attached too much importance to operations upon the thyroid gland4 ,the isthmus is entitled to absolutely no consideration whatever in deciding the location at which to incise so vital a structure as the trachea4 ,students are taught different short skin incisions for these two operations1 and it is no wonder that they1 as did their predecessors1 find tracheotomy a difficult1 bloody1 and often futile operation4 ,the trachea is searched for at the bottom of a short1 deep wound filled with blood1 the source of which is difficult to find and impossible to control4 ,tracheotomic cannulae should be made of sterling silver4 ,german silver plated with pure silver is good enough for temporary use1 but the plating soon wears off under the galvanic action set up between the two metals4 ,aluminum becomes roughened by boiling and contact with secretions1 and causes the formation of granulations which in time lead to stenosis4 ,hard rubber tubes cannot be boiled1 the walls are so thick as to leave too little lumen1 and the rubber is irritating to the tissues4 ,all tracheotomy tubes should be fitted with pilots4 ,many of the tubes furnished to patients have no pilots to facilitate the introduction1 and the tubes are inserted with somewhat the effect of a cheese tester1 and with great pain and suffering on the part of the patient4 ,most of the the tubes in the shops are too short to allow for the swelling of the tissues of the neck following the operation4 ,they may reach the trachea at the time of the operation1 but as soon as the reactionary swelling occurs1 the end of the tube is pulled out 7,fig4 #ajc7 of the tracheal incision2 the air hissing along the tube is considered by the attendant to indicate that the tube is still in place1 and the increasing dyspnea and accelerated respiratory rate are attributed to supposed pneumonia or edema of the lungs1 under which erroneous diagnosis the patient is buried4 ,in all cases in which it is reported that in spite of tracheotomy the dyspnea was only temporarily relieved1 the fault is the lack of a plumber4 ,that is1 an attendant who will make sure that there is at all times a clear airway all the way down to the lungs4 ,with a bronchoscope and aspirator he will see that the airway is clear4 ,to begin with1 a proper sized cannula must be selected4 ,the series of different sized1 full curved tubes1 one of which is illustrated in ,fig4 #ajd1 will under all conditions reach the trachea4 ,if the tube seems to be too long in any given case1 it will usually be found that the tracheotomy has been done too high1 and a lower one should be done at once4 ,if the operation has not been done too high1 and the cannula is too long1 a pad of gauze under the shield will take up the surplus length4 ,in cases of tracheal compression from new growth1 thymus or other such cases1 in which the ordinary tube will not pass the obstruction1 the author's long cane-shaped cannula 7see ,fig4 #ajd7 can be inserted past the obstruction1 and if necessary into either bronchus4 ,the fenestrum placed in the cannula in many of the older tubes1 with the supposed function of allowing partial breathing through the larynx1 is a most pernicious thing4 ,a properly fitted tube should not take up more than half of the cross section of the trachea1 and should allow the passage of sufficient air for free laryngeal breathing when it is completely corked4 ,the fenestrum is1 moreover1 rarely so situated that air can pass through it2 the fenestral edges act as a constant irritant to the wound1 producing bleeding and granulation tissue4 ,,fig4 #ajc4--,schema showing thick pad of gauze dressing1 filling the space1 ,a1 and used to hold out the author's full-curved cannula when too long1 prior to reactionary swelling1 and after subsidence of the latter4 ,at the right is shown the manner in which the ordinary cannula of the shops permits a patient to asphyxiate1 though some air is heard passing through the tracheal opening1 ,h1 after the cannula has been partially withdrawn by swelling of the tissues1 ,t4 ,,fig4 #ajd4--,the author's tracheotomic cannulae4 ,a1 shows cane-shaped cannula for use in intrathoracic compressive or other stenoses4 ,b1 shows full curved cannula for regular use4 ,pilots are made to fit the outer cannula2 the inner cannula not being inserted until after withdrawal of the pilot4 ,anesthesia4--,no dyspneic patient should be given a general anesthetic2 because any patient dyspneic enough to need a tracheotomy for dyspnea is depending largely upon the action of the accessory respiratory muscles4 ,when this action is stopped by beginning unconsciousness1 respiration ceases4 ,if the trachea is not immediately opened1 artificial respiration instituted1 and oxygen insufflated1 the patient dies on the table4 ,skin infiltration along the line of incision with a very weak cocaine solution 7#a_/aj of #a per cent71 apothesine 7#b per cent71 novocaine1 ,schleich's fluid or other local anesthetic1 suffices to render the operation painless4 ,the deeper structures have little sensation and do not require infiltration4 ,it has been advocated that an interannular injection of cocaine solution with a hypodermic syringe be done just prior to incision of the trachea for the purpose of preventing cough after the incision of the trachea and the insertion of the cannula4 ,it would seem1 however1 that this introduces the risk of aspiration pneumonia and pulmonary abscess1 by permitting the aspiration and clotting of blood in small bronchi1 followed by subsequent breaking down of the clots4 ,as the author has so often said1 ,the cough reflex is the watch dog of the lungs1 and if not drugged asleep by local or general anesthesia can safely be relied upon to prevent all possibility of the blood or the pus which nearly always is present in acute or chronic conditions calling for tracheotomy1 being aspirated into the deeper air-passages4 ,cocaine in any form1 by any method1 and in any dosage1 is dangerous in very young children4 ,technic4--,the patient should be placed in the recumbent position1 with the extended head held in the midline by an assistant4 ,the shoulders1 not the neck1 should be slightly raised with a sand bag4 ,the head should be somewhat lower than the feet1 to lessen the danger of aspiration of blood4 ,a midline incision dividing the skin and fascia is made from the thyroid notch to just above the suprasternal notch4 ,the cricoid is now located1 and the deeper dissection is continued from below this point4 ,the ribbon muscles are separated with dissecting scissors or knife1 and held apart with retractors4 ,if the isthmus of the thyroid gland is in the way1 it may be retracted upward2 if large1 however1 it should be divided and ligated1 for it is apt to slip over the tracheal incision afterward1 and render difficult the quick finding of the incision during after-care4 ,this covering of the tracheal incision by the slipping back of the drawn-aside thyroidal isthmus is one of the most frequent avoidable causes of mortality1 because it deflects the cannula off into the tissues when it is replaced after cleaning during the early postoperative period4 ,the corrugated surface of the trachea can be felt1 and its exact location can be determined by the index finger4 ,if the tracheotomy is proceeding in an orderly manner1 all bleeding points should be caught and tied with plain catgut 7,no4 #a7 before the trachea is opened4 ,because of distension of vessels during cough1 all but the tiniest vessels should be ligated4 ,side-cut veins are particularly treacherous4 ,they should be freed of tissue1 cut across and the divided ends ligated4 ,the incision in the trachea should be as low as possible1 and should never be made through the first ring4 ,the incision should be through the third1 fourth and fifth rings4 ,only in cases of laryngoptosis will it be necessary to incise the trachea higher than this4 ,the incision must be made in the midline1 and in the long axis of the trachea1 and care must be exercised that the point of the knife does not perforate the posterior tracheal wall4 ,stab incisions are always to be avoided4 ,if the incision in the trachea is found to be of insufficient length1 the original incision must be found and elongated4 ,a second incision must not be made1 for the portion of cartilage between the two incisions will die and will almost certainly make a site of future tracheal stenosis4 ,the cricoid should never be cut1 for stenosis is almost sure to follow the wearing of a cannula in this position4 ,a ,trousseau dilator should now be inserted in the tracheal incision1 its blades gently separated4 ,with the tracheal lumen thus opened1 a cannula of proper size is introduced with absolute certainty of its having entered the trachea4 ,a quadruple-folded square of gauze in the form of a pad about four inches square is moistened with mercuric chloride solution 7#a3aj1jjj7 and is slit from the lower border to its midpoint4 ,this pad is slipped from above downward under the tape holder of the cannula1 the slit permitting the tubal part of the cannula to reach the central part of the pad 7,fig4 #ajh71 and completely covers the wound4 ,no attempt should be made to suture the skin wound1 for this tends to form a pocket in which lodge the bronchial secretions that escape alongside the tube1 resulting in infection of the wound4 ,furthermore it renders the daily changing of the tube much more difficult4 ,in fact it prevents the attendant from being certain that the tube is actually placed in the trachea4 ,suturing of the skin to the trachea should never be done1 for the sutures soon tear out and often set up a perichondritis of the tracheal cartilages1 with resulting difficult decannulation4 ,,fig4 #aje4--,schema of practical gross anatomy to be memorized for emergency tracheotomy4 ,the middle line is the safety line1 the higher the wider4 ,below1 the safety line narrows to the vanishing point ,,vp4 ,the upper limit of the safety line is the thyroid notch until the trachea is bared1 when the limit falls below the first tracheal ring4 ,in practice the two-dark danger lines are pushed back with the left thumb and middle finger as shown in ,fig4 #ajf1 thus throwing the safety line into prominence4 ,this is generally known as ,jackson's tracheotomic triangle4 ,,fig4 #ajf4--,schema showing the author's method of rapid tracheotomy4 ,first stage4 ,the hands are drawn ungloved for the sake of clearness4 ,the upper hand is the left1 of which the middle finger 7,m7 and the thumb are used to repress the sterno-cleido-mastoid muscles1 the finger and thumb being close to the trachea in order to press backward out of the way the carotid arteries and the jugular vein4 ,this throws the trachea forward into prominence1 and one deep slashing cut will incise all of the soft tissues down to the trachea4 ,emergency ,tracheotomy4--,stabbing of the cricothyroid membrane1 or an attempted stabbing of the trachea1 so long taught as an emergency tracheotomy1 is a mistake4 ,the author's two stage1 finger guided method is safer1 quicker1 more efficient1 and not likely to be followed by stenosis4 ,to execute this promptly1 the operator is required to forget his textbook anatomy and memorize the schema 7,fig4 #aje74 ,the larynx and trachea are steadied by the thumb and middle finger of the left hand1 which at the same time push back the important nerves and vessels which parallel the trachea1 and render the central safety line more prominent 7,fig4 #ajf74 ,a long incision is now made from the thyroid notch almost to the suprasternal notch1 and deep enough to reach the trachea4 ,this completes the first stage4 ,,fig4 #ajg4--;,illustrating the author's method of quick tracheotomy4 ,second stage4 ,the fingers are drawn ungloved for the sake of clearness4 ,in operating the whole wound is full of blood1 and the rings of the trachea are felt with the left index which is then moved slightly to the patient's left1 while the knife is slid down along the left index to exactly the middle line when the trachea is incised4 ,second stage4 ,the entire wound is full of blood and the trachea cannot be seen1 but its corrugations can be very readily felt by the tip of the free left index finger4 ,the left index finger is now moved a little to the patient's left in order that the knife shall come precisely in the midline of the trachea1 and three rings of the trachea are divided from above downward 7,fig4 #ajg74 ,the ,trousseau dilator should now be inserted1 the head of the table should be lowered1 and the patient should be turned on the side to allow the blood to run away from the wound4 ,if respiration has ceased1 a cannula is slipped in1 and artificial respiration is begun4 ,oxygen insufflation will aid in the restoration of respiration1 and a pearl of amyl nitrite should be crushed in gauze and blown in with the oxygen4 ,in all such cases1 excessive pressure of oxygen should be avoided because of the danger of producing ischemia of the lungs4 ,hope of restoring respiration should not be abandoned for half an hour at least4 ,one of the author's assistants1 ,dr4 ,phillip ,stout1 saved a patient's life by keeping up artificial respiration for twenty minutes before the patient could do his own breathing4 ,the after-care of the tracheotomic wound is of the utmost importance4 ,a special day and night nurse are required4 ,the inner tube of the cannula must be removed and cleaned as soon as it contains secretion4 ,secretion coughed out must be wiped away quickly1 but gently1 before it is again aspirated4 ,the gauze dressing covering the wound must be changed as soon as soiled with secretions from the wound and the air-passages4 ,each fresh pad should be moistened with very weak bichloride of mercury solution 7#a3aj1jjj74 ,the outer tube must be changed every twenty-four hours1 and oftener if the bronchial secretion is abundant4 ,student-physicians who have been taught my methods and who have seen the cases in care of our nurses have often expressed amazement at the neglect unknowingly inflicted on such cases elsewhere1 in the course of ordinary routine surgery4 ,it is not unusual for a patient to be sent to the ,bronchoscopic ,clinic who has worn his cannula without a single changing for one or two years4 ,in some cases the tube had broken and a portion had been aspirated into the trachea4 ,,fig4 #ajh4--,method of dressing a tracheotomic wound4 ,a broad quadruple1 in-folded pad of gauze is cut to its centre so that it can be slipped astride of the tube of the cannula back of the shield4 ,no strings1 ravellings or strips of gauze are permissible because of the risk of their getting down into the trachea4 ,if the respiratory rate increases1 instead of attributing it to pulmonary complications1 the entire cannula should be removed1 the wound dilated with the ,trousseau forceps1 the interior of the trachea inspected1 and all secretions cleaned away4 ,then the tracheal mucosa below the wound should be gently touched with a sterile bent probe1 to induce cough to rid the lower air passages of accumulated secretions4 ,in many cases it is a life-saving procedure to insert a sterile long malleable aspirating tube to remove secretions from the lower air-passages4 ,when all is clear1 a fresh sterile cannula which has been carefully inspected to see that its lumen has been thoroughly cleaned1 is inserted1 and its tapes tied4 ,good plumbing1 that is1 the maintenance at all times of a clear1 clean passage in all the pipes1 natural and artificial1 is the reason why the mortality in the ,bronchoscopic ,clinic has been less than half of one per cent1 while in ordinary routine surgical care in all hospitals collectively it ranges from #aj to #bj per cent4 ,bronchial ,aspiration4--,as mentioned above1 bronchial aspiration is often necessary4 ,when the patient is unable to get up secretions1 he will1 as demonstrated by the author many years ago1 drown in his own secretions4 ,in some cases bronchoscopic aspiration is required 7,peroral ,endoscopy1 p4 #dhc74 ,occasionally1 very thick secretions will require removal with forceps4 ,pus may become very thick and gummy from the administration of morphin4 ,opiates do not lessen pus formation1 but they do lessen the normal secretions that ordinarily increase the quantity and fluidity of the pus4 ,when to this is added the dessicating effect of the air inhaled through the cannula1 unmoistened by the upper air-passages1 the secretions may be so thick as to form crusts and plugs that are equivalent to foreign bodies and require removal with forceps4 ,diphtheritic membrane in the trachea may require removal with bronchoscope and forceps4 ,thinner secretions may be removed by sponge-pumping4 ,in most cases1 however1 secretions can be brought up through an aspirating tube1 connected to a bronchoscopic aspirating syringe 7,fig4 #aa71 an ordinary aspirating bottle1 or preferably1 a mechanical aspirator such as that shown in ,fig4 #ab4 ,in this1 combined with bronchoscopic oxygen insuflation 7q4v471 we have a life-saving measure of the highest efficiency in cases of poisoning by chlorine and other irritant and asphyxiating gases4 ,an aspirating tube for insertion into the deeper air passages should be of copper1 so that it can be bent to the proper curve to reach into the various parts of the tracheobronchial tree1 and it should have a removable copper-wire core to prevent kinking1 and collapse of the lumen4 ,the distal end should be thickened1 and also perforated at the sides1 to prevent drawing-in of the mucosa and trauma thereto4 ,a rubber tube may be used1 but is not so satisfactory4 ,the one shown in ,fig4 #aj ,i had made by ,mr4 ,pilling1 and it has proved very satisfactory4 ,decannulation4--,when the tracheal incision is placed below the first ring1 no difficulty in decannulation should result from the operation per se4 ,when by temporarily occluding the cannula with the finger it is evident that the laryngeal aperture has regained sufficient size to allow free breathing1 a smaller-sized tracheotomic tube should be substituted to allow free passage of air around the cannula in the trachea4 ,in doing this1 the amount of secretion and the handicap of impaired glottic mobility in the expulsion of thick secretions must be borne in mind4 ,babies labor under a special handicap in their inefficient bechic expulsion and especially in their small cannulae which are so readily occluded4 ,if breathing is not free and quiet with the smaller tube2 the larger one must be replaced4 ,if1 however1 there is no trouble with secretions1 and the breathing is free and quiet1 the inner cannula should be removed1 and the external orifice of the outer cannula firmly closed with a rubber cork4 ,if the laryngeal condition has been acute1 decannulation can usually be safely done after the patient has been able to sleep quietly for three nights with a corked cannula4 ,if free breathing cannot be obtained when the cannula is corked1 the larynx is stenosed1 and special work will be required to remove the tube4 ,children sometimes become panic stricken when the cannula is completely corked at once and they are forced to breathe through the larynx instead of the easier shortcut through the neck4 ,in such a case1 the first step is partially to cork the cannula with a half or two-thirds plug made from a pure rubber cord fashioned in the desired shape by grinding with an emery wheel 7,fig4 #aab74 ,thus the patient is gradually taught to use the natural air-way1 still feeling that he has an anchor to windward in the opening in the cannula4 ,when some swelling of the laryngeal structures still exists1 this gradual corking has a therapeutic effect in lessening the stenosis by exercising the muscles of abduction of the cords and mobilizing the cricoarytenoid articulation during the inspiratory effort4 ,the forced respiration keeps the larynx freed from secretions1 which are more or less purulent and hence irritating4 ,after removing the cannula1 in order that healing may proceed from the bottom upward1 the wound should be dressed in the following manner3 ,a single thickness of gauze should be placed over the wound and the front of the neck1 and a gauze wedge firmly inserted over this to the depths of the tracheotomic wound1 all of this dressing being held in place by a bandage4 ,if the skin-wound heals before the fibrous union of the tracheal cartilages is complete1 exuberant granulations are apt to form and occlude the trachea1 perhaps necessitating a new tracheotomy for dyspnea4 ,it is so important to fix indelibly in the mind the cardinal points concerning tracheotomy that ,i have appended to this chapter the teaching notes that ,i have been for years giving my classes of students and practitioners1 hundreds of whom have thanked me for giving them the clear-cut conception of tracheotomy that enabled them1 when their turn came to do an emergency tracheotomy1 to save human life4 ,,resume ,,of ,,tracheotomy ,instruments4 ,headlight ,sandbag ,scalpel ,hemostats ,small retractors ,tenaculum ,tracheotomic cannulae 7proper kind7 ,long4 ,half area cross-section trachea4 ,proper curve3 ,radius too short will press ant4 tracheal wall2 too long1 post4 wall4 ,sterling ,silver ,tracheobronchial aspirator4 ,probe4 ,tapes for cannulae ,trousseau dilator ,sponges ,infiltration syringe and solution ,oxygen tank4 ,indications3 ,laryngeal dyspnea4 7,indrawing guttural and clavicular fossae and at epigastrium4 ,pallor4 ,restlessness4 ,drowning in his own secretions47 ,do it early4 ,don't wait for cyanosis4 #bid ,never use general anesthesia on dyspneic patient4 ,forget about high and low distinctions until trachea is exposed4 ,memorize ,jackson's tracheotomic triangle4 ,patient recumbent1 sand bag under shoulders or neck4 ,nose to zenith4 ,infiltration1 ,intradermatic4 ,incise from ,adam's apple to guttural fossa4 ,hemostasis4 ,keep in middle line4 ,feel for trachea4 ,expose isthmus of thyroid gland4 ,draw it upward or downward or cut it4 ,ligature1 torsion1 etc4 before incising trachea4 ,hold trachea with tenaculum4 ,incise trachea below first ring4 ,avoid cutting cricoid or first ring4 ,cut #c rings vertically4 ,don't hack4 ,don't cut posterior wall which almost touches the anterior wall during cough4 ,spread carefully1 with ,trousseau dilator4 ,insert cannula2 see it enter tracheal lumen2 remove pilot2 tie tapes4 ,don't suture wound4 ,dress with large squares4 ,don't give morphine4 ,decannulation by corking partially1 after changing to smaller cannula4 ,do not remove cannula permanently until patient sleeps without indrawing with corked cannula4 ,,resume ,,of ,,emergency ,,tracheotomy ,the following notes should be memorized4 #a4 ,essentials3 ,knife and pair of hands 7but full equipment better74 #bie #b4 ,don't do a laryngotomy1 or stabbing4 #c4 ,two stage1 finger guided operation better4 #d4 ,sand bag or substitute4 #e4 ,press back danger lines with left thumb and middle finger1 making safety line and trachea prominent4 #f4 ,memorize ,jackson's tracheotomic triangle4 #g4 ,incise exactly in middle line from ,adam's apple to sternum4 #h4 ,feel for tracheal corrugations with left index in pool of blood1 following trachea with finger downward from superficial ,adam's apple4 #i4 ,pass knife along index and incise trachea 7not too deeply1 may cut posterior wall74 #aj4 ,don't mind bleeding2 but keep middle line and keep head straight2 keep head low2 don't bother about thyroid gland4 #aa4 ,don't expect hiss when trachea is cut if patient has stopped breathing4 #ab4 ,start artificial respiration4 #ac4 ,amyl nitrite4 ,oxygen4 #ad4 ,practice palpation of the neck until the tracheal landmarks are familiar4 #ae4 ,practice above technic1 up to point of incision1 at every opportunity4 #af4 ,jackson's tracheotomic triangle3 ,a triangulation of the front of the neck intended to facilitate a proper emergency tracheotomy4 ,apex at suprasternal notch4 ,sides anterior edge sternomastoids4 ,base horizontal line lower edge cricoid4 ,,resume ,,of ,,after-,,care ,,of ,a ,,tracheotomic ,,case #a4 ,always bear in mind that tracheotomy is not an ultimate object4 ,the ultimate object is to pipe air down into the lungs4 ,tracheotomy is only a means to that end4 #b4 ,sterile tray beside bed should contain duplicate 7exact7 tracheotomy tube1 ,trousseau dilator1 hemostat1 thumb forceps1 silver probe1 scissors1 scalpel1 probe-pointed curved bistoury4 ,sterile gloves ready4 #c4 ,special nursing necessary for safety4 #d4 ,laxative4 #e4 ,sponge away secretions before they are drawn in4 #f4 ,cover wound with wide large gauze square slit so it fits around cannula under the tape holder4 ,pull off ravelings4 ,keep wet with #a 3 #aj1jjj ,bichloride solution4 #g4 ,change dressing every hour or oftener4 #h4 ,abundance of fresh air1 temperature preferably about #gj degrees4 #i4 ,nurse should remove inner cannula as often as needed and clean it with pipe cleaner before boiling4 #aj4 ,outer cannula should be changed every day by the surgeon or long-experienced tracheotomy nurse4 ,a pilot should be used and care should be taken not to injure the cut ends of the tracheal cartilage4 #aa4 ,a sterile1 bent probe may be inserted downward in the trachea with both cannulae out to excite cough if necessary to expel secretions4 ,an aspirating tube should be used1 when necessary4 #ab4 ,a patient with a properly fitted cannula free of secretions breathes noiselessly4 ,any sound demands immediate attention4 #ac4 ,if the respiratory rate increase it is much more likely to be due to obstruction in1 malposition of1 or shortness of the cannula than to lung complications4 #ad4 ,be sure that3 7a7 ,the cannula is clear and clean4 7b7 ,the cannula is long enough to reach well down into the trachea4 ,a cannula that was long enough when the operation was done may be too short after the cervical tissues swell4 7c7 ,the distal end of the cannula actually is deeply in the trachea4 ,the only way to be sure is1 when inserting the cannula1 to spread the wound and the tracheal incision with a ,trousseau dilator1 then see the interior of the tracheal lumen and see the cannula enter therein4 #ae4 ,if after attending to the above mentioned details there are still signs of obstructive dyspnea1 a bronchoscopy should be done for finding and removal of the obstruction in the trachea or main bronchi4 #af4 ,if all the pipes1 natural and instrumental1 are clear there can be no such thing as obstructive dyspnea4 #ag4 ,pneumonia and pulmonary edema may exist before tracheotomy1 but they are rare sequelae4 #ah4 ,decannulation1 in cases of tracheotomy done for temporary conditions should not be attempted until the patient has slept at least #c nights with his cannula tightly corked4 ,a properly fitted cannula 7i4e4 one not larger than half the area of cross section of the trachea7 permits the by-passage of plenty of air4 ,a partial cork should be worn for a few days first for testing and weaning a child away from the easier breathing through the neck4 ,in cases of chronic laryngeal stenosis a prolonged test is necessary before attempting decannulation4 #ai4 ,a tracheotomic case may be aphonic1 hence unable to call for help4 #bj4 ,the foregoing rules apply to the post-operative periods4 ,after the wound has healed and a fistula is established1 the patient1 if not a child1 may learn to care for his own cannula4 #bih #ba4 ,do not give cough-sedatives or narcotics4 ,the cough reflex is the watch dog of the lungs4 ,,notes ,,on ,,nursing ,,tracheotomized ,,patients ,bedside tray should contain3 ,duplicate cannula ,scalpel ,trousseau dilator ,hemostat ,dressing forceps ,sterile vaseline ,scissors ,tape ,probe ,gauze sponges ,gauze squares ,probe-pointed curved bistoury4 #a4 ,room should be abundantly ventilated1 as free from dust and lint as possible1 and the air should be moistened by steam in winter4 #b4 ,keep mouth clean4 ,tooth brush4 ,rinse alcohol #a3aj4 #c4 ,sponge away secretion after the cough before drawn in4 #d4 ,remove inner cannula 7not outer7 as often as needed4 ,not less often than every hour4 ,replace immediately4 ,never boil a cannula until you have thoroughly cleaned it4 #e4 ,obstruction of cannula calling for cleaning indicated by3 ,blue or ashy color4 ,indrawing at clavicles1 sternal notch1 epigastrium4 ,noisy breathing4 7,learn sound47 #f4 ,surgeon 7in our cases7 will change outer cannula once daily or oftener4 #g4 ,duplicate cannulae4 #h4 ,be careful in cleaning cannulae not to damage4 #i4 ,watch for loose parts on cannula4 #aj4 ,change dressing 7in our cases7 as often as soiled4 ,not less often than every hour4 ,large squares4 ,never narrow strips4 #aa4 ,watch color of lips and ears and face4 #bii #ab4 ,report at once if food or water leaks through wound4 7,coughing and choking74 #ac4 ,never leave a tracheotomized patient unwatched during the first days or weeks1 according to case4 #ad4 ,remember ,trousseau dilator or hemostat will spread the tracheal wound or fistula when cannula is out4 #ae4 ,remember life depends on a clear cannula if the patient gets no air through the mouth4 #af4 ,remember it takes very little to clog the small cannula of a child4 #ag4 ,remember a tracheotomized patient cannot call for help4 #ah4 ,decannulation4 ,testing by corking partially4 ,watch corks not too small1 or broken4 ,attach them by braided silk thread4 ,pure rubber cord ground down makes best cork4 #cjj ,,chapter ,,xxxviii--,,chronic ,,stenosis ,,of ,,the ,,larynx ,,and ,,trachea ,the various forms of laryngeal stenosis for which tracheotomy or intubation has been performed1 and the difficulties encountered in restoring the natural breathing1 may be classified into the following types3 #a4 ,panic #b4 ,spasmodic #c4 ,paralytic #d4 ,ankylotic 7arytenoid7 #e4 ,neoplastic #f4 ,hyperplastic #g4 ,cicatricial 7a7 ,loss of cartilage 7b7 ,loss of muscular tissue 7c7 ,fibrous ,panic4--,nothing so terrifies a child as severe dyspnea2 and the memory of previous struggles for air1 together with the greater ease of breathing through the tracheotomic cannula than through even a normal larynx1 incites in some cases so great a degree of fear that it may properly be called panic1 when attempts at decannulation are made4 ,crying and possibly glottic spasm increase the difficulties4 ,spasmodic stenosis may be associated with panic1 or may be excited by subglottic inflammation4 ,prolonged wearing of an intubation tube1 by disturbing the normal reciprocal equilibrium of the abductors and adductors1 is one of the chief causes4 ,the treatment for spasmodic stenosis and panic is similar4 ,the use of a special intubation tube having a long antero-posterior lumen and a narrow neck1 which form allows greater action of the musculature1 has been successful in some cases4 ,repeated removal and replacement of the intubation tube when dyspnea requires it may prove sufficient in the milder cases4 ,very rarely a tracheotomy may be required2 if so1 it should be done low4 ,the wearing of a tracheotomic cannula permits a restoration of the muscle balance and a subsidence of the subglottic inflammation4 ,corking the cannula with a slotted cork 7,fig4 #aaa7 will now restore laryngeal breathing1 after which the tracheotomic cannula may be removed4 ,,plate ,v--,,photoprocess ,,reproductions ,,of ,,the ,,author',s ,,oil-,,color ,,drawings ,,from ,,life--,,laryngeal ,,and ,,tracheal ,,stenoses3 #a1 ,indirect view1 sitting position2 postdiphtheric cicatricial stenosis permanently cured by endoscopic evisceration4 7,see ,fig4 #e47 #b1 ,indirect view1 sitting position2 posttyphoid cicatricial stenosis4 ,mucosa was very cyanotic because cannula was re-moved for laryngoscopy and bronchoscopy4 ,cured by laryngostomy4 7,see ,fig4 #f47 #c1 ,indirect view1 sitting position2 posttyphoid infiltrative stenosis1 left arytenoid destroyed by necrosis4 ,cured by laryngostomy2 failure to form adventitious band 7,fig4 #g7 because of lack of arytenoid activity4 #d1 ,indirect view1 recumbent position2 posttyphoid cicatricial stenosis4 ,cured of stenosis by endoscopic evisceration with sliding punch forceps4 ,anterior commissure twice afterward cleared of cicatricial tissue as in the other case shown in ,fig4 #ae4 ,ultimate result shown in ,fig4 #h4 #e1 ,same patient as ,fig4 #a2 sketch made two years after decannulation and plastic4 #f1 ,same patient as ,fig4 #b2 sketch made four years after decannulation and plastic4 #g1 ,same patient as ,fig4 #c2 sketch made three years after decannulation and plastic4 #h1 ,same patient as ,fig4 #d2 sketch made one year after decannulation1 fourteen months after clearing of the anterior commissure to form adventitious cords4 #i1 ,direct view1 recumbent patient2 web postdiphtheric 787 or congenital 7874 ,rough voice since birth1 but larynx never examined until stenosed after diphtheria4 ,web removed and larynx eviscerated with punch forceps2 recurrence of stenosis 7not of web74 ,cure by laryngostomy4 ,this view also illustrates the true depth of the larynx which is often overlooked because of the misleading flatness of laryngeal illustrations4 #aj1 ,direct laryngoscopic view2 postdiphtheric hypertrophic subglottic stenosis4 ,cured by galvanocauterization4 #aa1 ,direct laryngoscopic view2 postdiphtheric hypertrophic supraglottic stenosis4 ,forceps excision2 extubation one month later2 still well after four years4 #ab1 ,bronchoscopic view of posttracheotomic stenosis following a plastic flap tracheotomy done for acute edema4 #ac1 ,direct laryngoscopic view2 anterolateral thymic compression stenosis in a child of eighteen months4 ,cured by thymopexy4 #ad1 ,indirect laryngoscopic 7mirror7 view2 laryngostomy rubber tube in position in treatment of post-typhoid stenosis4 #ae1 ,direct view2 posttyphoid stenosis after cure by laryngostomy4 ,dotted line shows place of excision for clearing out the anterior commissure to restore the voice4 #af1 ,endoscopic view of posttracheotomic tracheal stenosis from badly placed incision and chondrial necrosis4 ,tracheotomy originally done for influenzal tracheitis4 ,cured by tracheostomy4 ,paralysis4--,bilateral abductor laryngeal paralysis causes severe stenosis1 and usually tracheotomy is urgently required4 ,in cadaveric paralysis both cords are in a position midway between abduction and adduction1 and their margins are crescentic1 so that sufficient airway remains4 ,efforts to produce the cadaveric position of the cords by division or excision of a portion of the recurrent laryngeal nerves1 have been failures4 ,the operation of ventriculocordectomy consists in removing a vocal cord and the portion or all of the ventricular floor by means of a punch forceps introduced through the direct laryngoscope4 ,usually it is better to remove only the portion of the floor anterior to the vocal process of the arytenoid4 ,in some cases monolateral ventriculocordectomy is sufficient2 in most cases1 however1 operation on both sides is needed4 ,an interval of two months between operations is advisable to avoid adhesions4 ,in almost all cases1 ventriculocordectomy will result in a sufficient increase in the glottic chink for normal respiration4 ,the ultimate vocal results are good4 ,evisceration of the larynx1 either by the endoscopic or thyrotomic method1 usually yields excellent results when no lesion other than paralysis exists4 ,only too often1 however1 the condition is complicated by the results of a faultily high tracheotomy4 ,a rough1 inflexible voice is ultimately obtained after this operation1 especially if the arytenoid cartilage is unharmed4 ,in recent bilateral recurrent paralysis1 it may be worthy of trial to suture the recurrent to the pneumogastric4 ,operations on the larynx for paralytic stenosis should not be undertaken earlier than twelve months from the inception of the condition1 this time being allowed for possible nerve regeneration1 the patient being made safe and comfortable1 meanwhile1 by a low tracheotomy4 ,ankylosis4--,fixation of the crico-arytenoid joints with an approximation of the cords may require evisceration of the larynx4 ,this1 however1 should not be attempted until after a year's lapse1 and should be preceded by attempts to improve the condition by endoscopic bouginage1 and by partial corking of the tracheotomic cannula4 ,neoplasms4--,decannulation in neoplastic cases depends upon the nature of the growth1 and its curability4 ,cicatricial contraction following operative removal of malignant growths is best treated by intubational dilatation1 provided recurrence has been ruled out4 ,the stenosis produced by benign tumors is usually relieved by their removal4 ,papillomata4--,decannulation after tracheotomy done for papillomata should be deferred at least #f months after the discontinuance of recurrence4 ,not uncommonly the operative treatment of the growths has been so mistakenly radical as to result in cicatricial or ankylotic stenoses which require their appropriate treatments4 ,it is the author's opinion that recurrent papillomata constitute a benign self-limited disease and are best treated by repeated superficial removals1 leaving the underlying normal structures uninjured4 ,this method will yield ultimately a perfect voice and will avoid the unfortunate complications of cicatricial hypertrophic and ankylotic stenosis4 ,compression ,stenosis of the ,trachea4--,decannulation in these cases can only follow the removal of the compressive mass1 which may be thymic1 neoplastic1 hypertrophic or inflammatory4 ,glandular disease may be of the ,hodgkins' type4 ,thymic compression yields readily to radium and the roentgenray1 and the tuberculous and leukemic adenitides are sometimes favorably influenced by the same agents4 ,surgery will relieve the compression of struma and benign neoplasms1 and may be indicated in certain neoplasms of malignant origin4 ,the possible coexistence of laryngeal paralysis with tracheal compression is frequently overlooked by the surgeon4 ,monolateral or bilateral paralysis of the larynx is by no means an uncommon postoperative sequel to thyroidectomy1 even though the recurrent nerves have been in no way injured at operation4 ,probably a localized neuritis1 a cicatricial traction1 or inclusion of a nerve trunk accounts for most of these cases4 ,hyperplastic and cicatricial chronic stenoses preventing decannulation may be classified etiologically as follows3 #a4 ,tuberculosis #b4 ,lues #c4 ,scleroma #d4 ,acute infectious diseases 7a7 ,diphtheria 7b7 ,typhoid fever 7c7 ,scarlet fever 7d7 ,measles 7e7 ,pertussis #e4 ,decubitus 7a7 ,cannular 7b7 ,tubal #f4 ,trauma 7a7 ,tracheotomic 7b7 ,intubational 7c7 ,operative 7d7 ,suicidal and homicidal 7e7 ,accidental 7by foreign bodies1 external violence1 bullets1 etc47 ,most of the organic stenoses1 other than the paralytic and neoplastic forms1 are the result of inflammation1 often with ulceration and secondary changes in the cartilages or the soft tissues4 #cjd ,tuberculosis4--,in the non-cicatricial forms1 galvanocaustic puncture applied through the direct laryngoscope will usually reduce the infiltrations sufficiently to provide a free airway4 ,should the pulmonary and laryngeal tuberculosis be fortunately cured1 leaving1 however1 a cicatricial stenosis of the larynx1 decannulation may be accomplished by laryngostomy4 ,lues4--,active and persistent antiluetic medication must precede and accompany any local treatment of luetic laryngeal stenosis4 ,prolonged stretching with oversized intubation tubes following excision or cauterization may sometimes be successful1 but laryngostomy is usually required to combat the vicious contraction of luetic cicatrices4 ,scleroma is rarely encountered in ,america4 ,radiotherapy has been advocated and good results have been reported from the intravenous injection of salvarsan4 ,radium may be tried1 and its application is readily made through the direct laryngoscope4 ,diphtheria4--,chronic postdiphtheritic stenosis may be of the panic1 spasmodic or1 rarely1 the paralytic types2 but more often it is of either the hypertrophic or cicatricial forms4 ,only too frequently the stenosis should be called posttracheotomic rather than postdiphtheritic1 since decannulation after the subsidence of the acute stenosis would have been easy had it not been for the sequelae of the faulty tracheotomy4 ,prolonged intubation may induce either a supraglottic or subglottic tissue hyperplasia4 ,the supraglottic type consists in an edematous thickening around the base of the epiglottis1 sometimes involving also the glossoepiglottic folds and the ventricular bands4 ,an improperly shaped or fitted tube is the usual cause of this condition1 and a change to a correct form of intubation tube may be all that is required4 ,excessive polypoid tissue hypertrophy should be excised4 ,the less redundant cases subside under galvanocaustic treatment1 which may be preceded by tracheotomy and extubation1 or the intubation tube may be replaced after the application of the cautery4 ,the former method is preferable since the patient is far safer with a tracheotomic cannula and1 further1 the constant irritation of the intubation tube is avoided4 ,subglottic hypertrophic stenosis consists in symmetrical turbinal-like swellings encroaching on the lumen from either side4 ,cautious galvanocauterant treatment accurately applied by the direct method will practically always cure this condition4 ,preliminary tracheotomy is required in those cases in which it has not already been done1 and in the cases in which a high tracheotomy has been done1 a low tracheotomy must be the first step in the cure4 ,cicatricial types of postdiphtheritic stenosis may be seen as webs1 annular cicatrices of funnel shape1 or masses of fibrous tissue causing fixation of the arytenoids as well as encroachment on the glottic lumen4 7,see color plates47 ,as a rule1 when a convalescent diphtheritic patient cannot be extubated two weeks after three negative cultures have been obtained the advisability of a low tracheotomy should be considered4 ,if a convalescent intubated patient cough up a tube and become dyspneic a low tracheotomy is usually preferable to forcing in an oversized intubation tube4 ,typhoid ,fever4--,ulcerative lesions in the larynx during typhoid fever are almost always the result of mixed infection1 though thrombosis of a small vessel1 with subsequent necrosis is also seen4 ,if the ulceration reaches the cartilage1 cicatricial stenosis is almost certain to follow4 ,trauma4--,the chief traumatic factors in chronic laryngeal stenosis are3 7a7 prolonged presence of a foreign body in the larynx 7b7 unskilled attempts at intubation and the wearing of poorly fitting intubation tubes2 7c7 a faulty tracheotomy2 7d7 a badly fitting cannula2 7e7 war injuries2 7f7 attempted suicide2 7g7 attempted homicide2 7h7 neglect of cleanliness and care of either intubation tubes or tracheotomic cannulae allowing incrustation and roughening which traumatize the tissues at each movement of the ever-moving larynx and trachea4 ,treatment of ,cicatricial ,stenosis4--,a careful direct endoscopic examination is essential before deciding on the method of treatment for each particular case4 ,granulations should be removed4 ,intubated cases are usually best treated by tracheotomy and extubation before further endoscopic treatment is undertaken4 ,a certain diagnosis as to the cause of the condition must be made by laboratory and therapeutic tests1 supplemented by biopsy if necessary4 ,vigorous antiluetic treatment1 especially with protiodide of mercury1 must precede operation in all luetic cases4 ,necrotic cartilage is best treated by laryngostomy4 ,intubational dilatation will succeed in some cases4 ,,fig4 #aji4--,schema showing the author's method of laryngostomy4 ,the hollow upward metallic branch 7,n7 of the cannula 7,c7 holds the rubber tube 7,r7 back firmly against the spur usually found on the back wall of the trachea4 ,moreover1 the air passing up through the rubber tube 7,r7 permits the patient to talk in a loud whisper1 the external orifice of the cannula being occluded most of the time with the cork 7,k74 ,the rubber tubing1 when large sizes are reached may extend down to the lower end of the cannula1 the part ,c coming out through a large hole cut in the tubing at the proper distance from the lower end4 ,laryngoscopic bouginage once weekly with the laryngeal bougies 7,fig4 #db7 will cure most cases of laryngeal stenosis4 ,for the trachea1 round1 silk-woven1 or metallic bougies 7,fig4 #dj7 are better4 #cjg ,laryngostomy consists in a midline division of the laryngeal and tracheal cartilages as low as the tracheotomic fistula1 excision of thick cicatricial tissue1 very cautious incision of the scar tissue on the posterior wall1 if necessary1 and the placing of the author's laryngostomy tube for dilatation 7,fig4 #aji74 ,over the upward branch of the laryngostomy tube is slipped a piece of rubber tubing which is in turn anchored to the tape carrier by braided silk thread4 ,progressively larger sizes of rubber tubing are used as the laryngeal lumen increases in size under the absorptive influence of the continuous elastic pressure of the rubber4 ,several months of wearing the tube are required until dilatation and epithelialization of the open trough thus formed are completed4 ,painstaking after-care is essential to success4 ,when dilatation and healing have taken place1 the laryngostomy wound in the neck is closed by a plastic operation to convert the trough into a trachea by supplying an anterior wall4 ,intubational treatment of chronic laryngeal stenosis may be tried in certain forms of stenosis in which the cicatrices do not seem very thick4 ,the tube is a silver-plated brass one of large size 7,fig4 #aaj74 ,a post which screws into the anterior surface of the tube prevents its expulsion4 ,over the post is slipped a block which serves to keep open the tracheal fistula4 ,detailed discussion of these operative treatments is outside the scope of this work1 but mention is made for the sake of completeness4 ,before undertaking any of the foregoing procedures1 a careful study of the complete descriptions in ,peroral ,endoscopy is necessary1 and a practical course of training is advisable4 ,,fig4 #aaj4--,the author's retaining intubation tube for treatment of chronic laryngeal stenosis4 ,the tube 7,a7 is introduced through the mouth1 then the post 7,b7 is screwed in through the tracheal wound4 ,then the block 7,c7 is slid into the wound1 the square hole in the block guarding the post against all possibility of unscrewing4 ,if the threads of the post are properly fitted and tightly screwed up with a hemostat1 however1 there is no chance of unscrewing and gauze packing is used instead of the block to maintain a large fistula4 ,the shape of the intubation tube has been arrived at after long clinical study and trials1 and cannot be altered without risk of falling into errors that have been made and eliminated in the development of this shape4 #cji ,,chapter ,,xxxix--,,decannulation ,,after ,,cure ,,of ,,laryngeal ,,stenosis ,in order to train the patient to breathe again through the larynx it is necessary to occlude the cannula4 ,this is best done by inserting a rubber cork in the inner cannula4 ,at first it may be necessary to make a slot in the cork so as to permit some air to enter through the tube to supplement the insufficient supply obtainable through the insufficiently patulous glottis1 new corks with smaller grooves being substituted as laryngeal breathing becomes easier4 ,corking the cannula is an excellent orthopedic treatment in certain cases where muscle atrophy and partial inflammatory fixation of the cricoarytenoid joints are etiological factors in the stenosis4 ,the added pull of the posterior cricoarytenoid muscles during the slight effort at inspiration restores their tone and increases the mobility of all the attached structures4 ,by no other method can panic and spasmodic stenosis be so efficiently cured4 ,,fig4 #aaa4--;,illustration of corks used to occlude the cannula in training patients to breathe through the mouth again1 before decannulation4 ,the corks allow air leakage1 the amount of which is regulated by the use of different shapes4 ,a smaller and still smaller air leak is permitted until finally an ungrooved cork is tolerated4 ,a central hole is sometimes used instead of a slot4 ,a1 one-third cork2 ,b1 half cork2 ,c1 three-quarter cork2 ,d1 whole cork4 ,following the subsidence of an acute laryngeal stenosis1 it is my rule to decannulate after the patient has been able to breathe through the larynx with the cannula tightly corked for #c days and nights4 ,this rule does not apply to chronic laryngeal stenosis1 for while the lumen under ordinary conditions might be ample1 a slight degree of inflammation might render it dangerously small4 ,in these cases1 many weeks are sometimes required to determine when decannulation is safe4 ,a test period of a few months is advisable in most cases of chronic laryngeal stenosis4 ,recurrent contractions after closure of the wound are best treated by endoscopic bouginage4 ,the corks are best made of pure rubber cord1 cut and ground to shape1 and grooved1 if desired1 on a small emery wheel 7,fig4 #aab74 ,the ordinary rubber corks and those made of cork-bark should not be used because of their friability1 and the possible aspiration of a fragment into the bronchus1 where rubber particles form very irritant foreign bodies4 ,,fig4 #aab4--,this illustration shows the method of making safe corks for tracheotomic cannulae by grinding pure rubber cord to shape on an emery wheel4 ,after grinding the taper1 if a partial cork is desired1 a groove is ground on the angle of the wheel4 ,if a half-cork is desired half of the cork is ground away on the side of the wheel4 ,reliable corks made in this way are now obtainable from ,messers ,charles ,j4 ,pilling and ,son4 ,,bibliography ,the following list of publications of the author may be useful for reference3 #a4 ,peroral ,endoscopy and ,laryngeal ,surgery1 ,textbook1 #aiad4 7,contains full bibliography to date of publication47 #b4 ,acromegaly of the ,larynx4 ,journ4 ,amer4 ,med4 ,asso41 ,nov4 #cj1 #aiah1 ,vol4 ,,lxxi1 pp4 #aghg-aghi4 #c4 ,a ,fence ,staple in the ,lung4 ,a ,new ,method of ,bronchoscopic ,removal4 ,journ4 ,amer4 ,med4 ,asso41 ,vol4 ,,lxiv1 ,june #e1 #aiag1 pp4 #aijf-g4 #d4 ,amalgam ,tooth-filling ,aspirated into ,lung ,during ,extraction4 ,dental ,cosmos1 ,vol4 ,,lix1 ,may1 #aiag1 pp4 #ejj-ejb4 #e4 ,amalgam ,filling ,removed from ,lung after a ,seven ,months' ,sojourn3 ,case ,report4 ,dental ,cosmos1 ,april1 #aibj4 #f4 ,a ,mechanical ,spoon for ,esophagoscopic ,use4 ,the ,laryngoscope1 ,january1 #aiah1 ,,pp4 #dg-dh4 #g4 ,an ,anterior ,commissure ,laryngoscope4 ,the ,laryngoscope1 ,vol4 ,,xxv1 ,aug41 #aiae1 ,p4 #ehi4 #h4 ,ancient ,foreign ,body ,cases4 ,editorial4 ,the ,laryngoscope1 ,vol4 ,,xxvii1 ,july1 #aiag1 ,,pp4 #ehc-ehd4 #i4 ,an ,esophagoscopic ,forceps4 ,the ,laryngoscope1 ,jan41 #aiah1 p4 #di4 #aj4 ,a ,new ,diagnostic ,sign of ,foreign ,body in ,trachea or ,bronchi1 the ,asthmatoid ,wheeze4 ,amer4 ,journ4 ,med4 ,sciences1 ,vol4 ,,clvi1 ,no4 #e1 ,nov41 #aiah1 p4 #fbe4 #aa4 ,a ,new ,method of ,working ,out ,difficult ,mechanical ,problems of ,bronchoscopic ,foreign-body ,extraction4 ,the ,laryngoscope1 ,vol4 ,,xxvii1 ,oct41 #aiag1 p4 #gbe4 #ab4 ,arachidic ,bronchitis4 ,journ4 ,amer4 ,med4 ,asso41 ,aug4 #cj1 #aiai1 ,vol4 ,,lxxiii1 pp4 #fgb-fgg4 #ac4 ,band of a ,gold ,crown in the ,bronchus3 ,report of a ,case4 ,dental ,cosmos4 ,vol4 ,,lx1 ,oct41 #aiah1 p4 #ije4 #ad4 ,bronchiectasis and ,bronchiectatic ,symptoms ,due to ,foreign ,bodies4 ,penn4 ,med4 ,journ41 ,vol4 ,,xix1 ,aug41 #aiaf1 pp4 #hjg-had4 #ae4 ,bronchoscopic and ,esophagoscopic ,postulates4 ,annals of ,otology1 ,rhinology and ,laryngology1 ,june1 #aiaf1 pp4 #dad-daf4 #af4 ,bronchoscopic ,removal of a ,collar ,button after ,twenty-six ,years ,sojourn in the ,lung4 ,annals of ,otology1 ,rhinology and ,laryngology1 ,june1 #aiac4 #ag4 ,bronchoscopy4 ,keen's ,surgery1 #aiba1 ,vol4 ,,viii4 #ah4 ,caisson ,bronchoscopy in ,lung-abscess ,due to ,foreign ,body4 ,surg41 ,gyn4 and ,obstet41 ,oct41 #aiag1 pp4 #dbd-dbh4 #ai4 ,cancer of the ,larynx4 ,is it ,preceded by a ,recognizable ,precancerous ,condition8 ,proceedings ,amer4 ,laryngol4 ,soc41 #aibb4 #bj4 ,din4 ,editorial4 ,the ,laryngoscope1 ,vol4 ,,xxvi1 ,dec41 #aiaf1 pp4 #ache-achg4 #bc4 ,endoscopie ,perorale et ,chirurgie ,laryngienne4 ,arch4 de ,laryngol41 ,t4 ,,xxxvii1 ,no4 #c1 #aiad1 pp4 #fdi-fhj4 #bd4 ,endoscopy and the ,war4 ,editorial4 ,the ,laryngoscope1 ,vol4 ,,xxvi1 ,june1 #aiaf1 p4 #iib4 #be4 ,endothelioma of the ,right ,bronchus ,removed by ,peroral ,bronchoscopy4 ,amer4 ,journ4 of ,med4 ,sci41 ,no4 #c1 ,vol4 ,,clii1 ,march1 #aiag1 p4 #cga4 #bf4 ,esophageal ,stenosis ,following the ,swallowing of ,caustic ,alkalies1 ,journ4 ,amer4 ,med4 ,asso41 ,july #b1 #aiba1 ,vol4 ,,lxxvii1 pp4 #bb-bc4 #bg4 ,esophagoscopic ,radium ,screens4 ,the ,laryngoscope1 ,feb41 #aiad4 #bh4 ,foreign ,bodies in the ,insane4 ,editorial4 ,the ,laryngoscope1 ,vol4 ,,xxvii1 ,june1 #aiag1 pp4 #eac-eae4 #bi4 ,foreign ,bodies in the ,larynx1 ,trachea1 ,bronchi and ,esophagus ,etiologically ,considered4 ,trans4 ,sec4 ,laryn41 ,otol4 and ,rhin41 ,amer4 ,med4 ,asso41 #aiag1 pp4 #cf-ef4 #cj4 ,gold ,three-tooth ,molar ,bridge ,removal from the ,right ,bronchus3 ,case ,report4 ,dental ,cosmos1 ,oct41 #aiai4 #ca4 ,high ,tracheotomy and ,other ,errors the ,chief ,causes of ,chronic ,laryngeal ,stenosis4 ,surg41 ,gyn4 and ,obstet41 ,may1 #aiba1 pp4 #cib-cih4 #cb4 ,inducing a ,child to ,open ,its ,mouth4 ,editorial4 ,the ,laryngoscope1 ,vol4 ,,xxvi1 ,nov41 #aiag1 p4 #gie4 #cc4 ,intestinal ,foreign ,bodies4 ,editorial4 ,the ,laryngoscope1 ,vol4 ,,xxvi1 ,may1 #aiaf1 p4 #ibi4 #cd4 ,laryngoscopic1 ,esophagoscopic and ,bronchoscopic ,clinic4 ,international ,clinics1 ,vol4 ,,iv1 #aiah4 ,j4 ,b4 ,lippincott ,co4 #ce4 ,local ,application of ,radium ,supplemented by ,roentgen ,therapy 7,discussion74 ,amer4 ,journ4 of ,roentgenology4 #cf4 ,localization of the ,lobes of the ,lungs by ,means of ,transparent ,outline ,films4 ,amer4 ,journ4 ,roent41 ,vol4 ,v1 ,oct41 #aiah1 p4 #def4 ,also ,proc4 ,amer4 ,laryn41 ,rhin4 and ,otol4 ,soc41 #aiah4 #cg4 ,mechanical ,problems of ,bronchoscopic and ,esophagoscopic ,foreign ,body ,extraction1 ,journ4 ,am4 ,med4 ,assn41 ,jan4 #bg1 #aiag4 #ch4 ,observation on the ,pathology of ,foreign ,bodies in the ,air and ,food ,passages ,based on the ,analysis of #fbh ,cases4 ,mutter ,lecture1 #aiag1 ,surg4 ,gyn4 and ,obstet41 ,mar41 #aiai1 pp4 #bja-bfa4 #ci4 ,orthopedic ,treatment by ,corking4 ,journ4 of ,laryn4 and ,otol41 ,london1 ,vol4 ,,xxxii1 ,feb41 #aiag4 #dj4 ,peroral ,endoscopy4 ,journ4 of ,laryn4 and ,otol41 ,edinburgh1 ,nov41 #aiba4 #da4 ,peroral ,endoscopy and ,laryngeal ,surgery4 ,the ,laryngoscope1 ,feb41 #aiai4 #db4 ,postulates on the ,cough ,reflex in ,some of its ,medical and ,surgical ,phases4 ,therapeutic ,gazette1 ,sept4 #ae1 #aibj4 #dc4 ,prognosis of ,foreign ,body in the ,lung4 ,journ41 ,amer4 ,med4 ,asso41 ,oct4 #h1 #aiba1 ,vol4 ,,lxxvii1 pp4 #aagh-aaha4 #dd4 ,pulsion ,diverticulum of the ,esophagus4 ,surg41 ,gyn4 and ,obstet41 ,vol4 ,,xxi1 ,july1 #aiae1 ,,pp4 #eb-ee4 #de4 ,radium4 ,editorial4 ,the ,laryngoscope1 ,vol4 ,,xxvi1 ,aug41 #aiaf1 pp4 #aaaa-aaac4 #df4 ,reaction after ,bronchoscopy4 ,penn4 ,med4 ,journ41 ,april1 #aiai4 ,vol4 ,,xxii ,p4 #dcd4 #dg4 ,root-canal ,broach ,removed from the ,lung by ,bronchoscopy4 ,the ,dental ,cosmos1 ,vol4 ,,lvii1 ,march1 #aiae1 p4 #bdg4 #dh4 ,safety ,pins in ,stomach1 ,peroral ,gastroscopic ,removal without ,anesthesia4 ,journ4 ,amer4 ,med4 ,asso41 ,feb4 #bf1 #aiba1 ,vol4 ,,lxxvi1 pp4 #egg-egi4 #di4 ,symptomatology and ,diagnosis of ,foreign ,bodies in the ,air and ,food ,passages4 ,am4 ,journ4 ,med4 ,sci41 ,may1 #aiba1 ,vol4 ,,clxi1 ,no4 #e1 p4 #fbe4 #ej4 ,the ,bronchial ,tree1 ,its ,study by ,insufllation of ,opaque ,substances in the ,living4 ,amer4 ,journ4 ,roentgenology1 ,vol4 #e1 ,oct41 #aiah1 p4 #ded4 ,also ,proc4 ,amer4 ,laryn41 ,rhinol4 and ,otol4 ,soc41 #aiah4 #ea4 ,thymic ,death4 ,editorial4 ,the ,laryngoscope1 ,vol4 ,,xxvi1 ,may1 #aiaf1 p4 #ibi4 #eb4 ,tracheobronchitis ,due to ,nitric ,acid ,fumes4 ,new ,york ,med4 ,journ41 ,nov4 #d1 #aiaf1 ,,pp4 #hih-hii4 #ec4 ,treatment of ,laryngeal ,stenosis by ,corking the ,tracheotomic ,cannula1 ,the ,laryngoscope1 ,jan41 #aiai4 #ed4 ,ventriculocordectomy4 ,proceedings ,amer4 ,laryngol4 ,soc41 #aiba4 #ee4 ,new ,mechanical ,problems in the ,bronchoscopic ,extraction of ,foreign ,bodies from the ,lungs and ,esophagus4 ,annals of ,surgery1 ,jan41 #aibb4 #ef4 ,the ,diaphragmatic ,pinchcock in ,so-called ,cardiospasm4 ,laryngoscope1 ,jan41 #aibb4